il^eference  Hibxavp 


AN    i\dp:x    of 
DIFFERENTIAL    DIAGNOSIS 

Ol'     MAIN     S^'^I1'T()MS 


I'lllNTKD   IS    ESOLAND   BY 
JOHN   WRIGHT  AXn  SONS  LTD..   BHISTOL 


PKHFACK     TO     THE     SECOND     EDITION 

Little  need  be  said  by  way  of  preface  to  the  second  edition  of  this  worlv  •  ti.e 
jrratity.ng  sale  of  the  first  edition  and  the  necessity  there  has  been  to  reprint  it 
several  t.mes  ,s  .sufficient  evidence  tliat  the  book  is  one  wliiel,  the  medical  profession 
welcomes  and  ajipreciates. 

In  this  edition  every  article  has  been  re^■ised  and  several  new  ones  have  been 
added. 

The  elaborate-  nuicx.  which  has  been  nmeh  appreciated,  has  l,een  made  if 
possible,  even  more  complete,  and  at  the  same  time  it  has  been  simplified  in  some 
particulars  :  the  relative  importance  of  the  entries  in  it  are  indicated  more  clearlv 
perhaps  than  was  the  case  in  the  first  edition,  by  the  use  of  three  deorees  of  type 

The  dlustrations  are  nearly  doubled  in  number  ;  the  coloured  plates  especiallv 
havng  been  mcreased  from  sixteen  to  thirty-seven,  and  neither  time  nor  expensV 
has  been  spared  m  the  endeavour  to  make  them  characteristic  of  the  conditions 
they  represent. 

The  size  of  the  type-  en.ployed  is  larger  than  before,  m  response  to  sug-vestions 
Irom  readers,  and  consequently  the  pages  have  had  to  be  enlarged  also 

It  became  a  question,  therefore,  whether  the  book  should  be  published  m  tvvo 
.•olumes  ;  in  the  belief,  however,  that  in  a  work  in  which  numerous  cross-references 
ire  unavoidable  it  is  advantageous  to  confine  it  within  one  cover,  it  has  been 
lec.ded  to  keep  it  as  a  single  book.  The  general  character  of  the  volume  remains 
"tJierwise  unchanged. 

It  is  hoped  that  this  second  edition  will  be  as  widelv  welcomed  as  was  the  first  • 
.nd  that  It  will  prove  even  more  helpful  in  its  primary  purpose,  namelv,  to  be  of 
.SS.S  anec  in  arriving  at  the  diagnosis  of  the  exact  cause  of  particular  symptoms. 

Cordial  thanks  are  extended  to  many  helpers  who.  whilst  not  eoutrihutinrv 
vritten  articles  to  the  volume,  have  n,-verthelcss  assisted  g.vatlx-  u,  ^  ariuus  wavs^ 
specially  to  Dr.  J).  S.  Davies.  Mr.  C.  Thurstan  Holland.  Dr.  A.  C.  .Jordan  Dr"  t' 
Vanier  Laeey  Dr.  T.  M.  L.,.,.  ,),  ,,„dsay  Locke,  Professor  Rutherlbrd  Moriso.K 
'.r  .Malcolm  Morns.  1),-.  II.  J{.  Xcuham,  Dr.  G.  W.  Nicholson.  Dr.  .1.  II  HylTc.l 
•  .-.  S.  CillHi-t  Scot..  Dr.  W.  P.  Saunders,  Dr.  A.  Reudle  Short.  Dr.  Hugh  Walsham" 
)r.  S.  A  K.  \\,isoM  :  .,lso  to  the  ]{nyal  Society  of  M,.lieinr.  I|,..  (;„nio„  Mnsenn, 
•uys  Jlosp.tal,  ,1„.  Sonll,  K.-.t.-n,  fVv.r  ]|.,s,.„al.  and  ll„.  London  .School  .,r 
ropieal  M.-d,,.,,,,..  Also  ,..  tl„.  publishers  and  proprietors  of  various  journals  and 
••r..t hea  s  lor  unl-nhng  courtesy  n,  giving  laeilities  lor  the  use  of  copyright  material 
■  un  illnsi  rations. 

Jli;ui'.i;Kr     l''Hi-'.Neu. 
Liindiin. 

I''rliniiui/.   I!) 1 7. 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/indexofdifferentOOfren 


PREFACE     TO     THl-L     FIRST     EDmON 

Tins  book  is  a  treatise  on  the  application  ot  differential  diagnosis  to  all  the  main 
signs  and  symptoms  of  disease.  It  aims  at  being  of  practical  utility  to  medical 
men  whenever  difficulty  arises  in  deciding  the  precise  cause  of  any  particular 
symptom  of  which  a  patient  may  complain.  It  covers  the  whole  ground  of  medicine, 
surgery,  gynaecology,  ophthalmology,  dermatology,  and  neurology. 

Whatever  the  disease  from  which  a  patient  is  suffering,  the  importance  of 
diagnosing  it  as  early  as  possible  can  hardly  be  over-rated.  The  present  volume 
deals  with  diagnosis  from  a  standpoint  which  is  different  from  that  of  most  text- 
books, having  been  written  in  response  to  requests  for  an  Index  oj  Diagnosis  as  a 
companion  to  the  publishers'  Index  oj  Treatment,  issued  in  1907.  The  book  is  an 
index  in  the  sense  that  its  articles  on  the  various  symptoms  are  arranged  in  al]jha- 
betical  order  ;  at  the  same  time  it  is  a  work  upon  differential  diagnosis  in  that  it 
discusses  the  methods  of  distinguishing  between  the  various  diseases  in  which  each 
individual  symptom  may  be  observed.  Whilst  the  body  of  the  book  thus  deals 
with  symptoms,  the  general  index  at  the  end  gathers  these  together  under  the 
headings  of  the  various  diseases  in  which  they  occur. 

The  Editor  lays  jiarticular  stress  upon  the  importance  of  using  these  two  parts 
of  the  book  together.  Unless  reference  is  made  freely  to  the  general  index,  the 
reader  may  miss  a  number  of  the  places  in  which  is  discussed  the  diagnosis  of  the 
disease  with  which  he  has  to  deal  :  for  while  each  symptom  is  considered  but  once, 
each  disease  is  likely  to  come  uj)  for  diseussioii  inider  the  heading  of  each  of  its  more 
important  symptoms. 

The  guiding  princijile  throughout  has  been  to  suppose  that  a  particular 
syini)tom  attracts  special  notice  in  a  gi\en  case,  and  that  the  diagnosis  has  to  be 
established  by  tlifferentiating  between  the  various  diseases  to  which  this  symptom 
may  be  due.  One  of  many  difficulties  arising  during  the  construction  of  the  work 
was  that  of  deciding  where  to  draw  the  line  as  regards  symptoms  themselves.  The 
<-xcIusion  of  many  borderline  headings  such  as  "  Dullness  at  the  base  of  one  lung." 
■  Inability  to  breathe  through  the  nose."'  and  various  signs  such  as  Romberg's. 
Stcllwag's,  Von  Graefe's,  and  so  forth,  nuiy  ])erhaps  seem  arbitrary  ;  but  reference 
to  the  minor  symptoms  and  physical  signs  which  have  not  been  thought  sufficiently 
miportant  to  merit  se|)arate  articles  will  be  found  in  the  general  index  a  I  I  lie  end 
of  the  volume. 

Tre;itnieiit.  patliology.  uiid  |)rognosis  .uc  uol  dcall  willi  cxcci.l  ui  so  far  as  tlii-y 
may  bear  upon  (liff<Tential  diagnosis  tlic  euiploynicul  of  salieylnlcs.  for  instance. 
in  distinguishing  acute  rheiimatie  from  other  forms  of  ,iil  hiil  is  :  Ihc  us,-  of  (In- 
microscope  in  distinguishing  malignant  neoplasins  Iroin  iiilJ.uMui.ihn  \  or  oilier 
tumours:  the  value  of  the  hipse  of  lime  in  .lislinguisliing  l)el\ve<u  I  nlHirulous  ;uid 
ineningoeoeeal  meningitis. 

Coloured  plates  and  other  illustrations  have  been  introduced  freely  wherever 
It  was  thought  they  might  be  helpful  in  diagnosis.     .Most  of  them  are  original,  but 


^riii  PREFACE 

a  few  are  ivprocUiccd  Ironi  other  sources,  and  thanks  are  due  to  the  authors  and 
publishers  who  have  kindly  lent  them. 

So  iar  as  the  Editor  is  aware,  although  there  exist  indices  of  symptoms,  and 
medical  works  in  which  various  maladies  are  discussed  in  alphabetical  order,  the 
present  Index  of  Differential  Diagnosis  of  Main  Symptoms  is  unique  in  medical 
literature.  It  rests  with  the  medical  profession  to  decide  whether  it  strikes  the 
mark  at  which  it  aims.  There  must  be  room  for  improvement  in  many  respects, 
notwithstanding  the  great  amount  of  time  and  labour  that  have  been  bestowed 

upon  it. 

IIowe\cr  this  may  be,  the  work  undoubtedly  owes  much  of  what  value  it 
possesses  to  the  suggestions  and  kindly  help  of  the  many  contributors  who  have 
assisted  in  its  making  ;  and  to  the  practitioners  and  the  authorities  of  various  insti- 
tutions who  have  generously  lent  the  material  for  many  of  the  illustrations.  Indeed, 
it  is  difficult  to  see  how  the  book  could  have  been  produced  in  its  present  complete- 
ness without  their  willing  collaboration  :  they  are  enumerated  elsewhere,  and  to  all 
of  them  the  Editor  tenders  his  sincere  thanks. 

Criticisms  and  suggestions  are  invited,  and  will  hi'  received  with  gratitude  by 
tlie  Editor. 

Hkkbf.rt    French. 

62,  Wiinpole  Street,  Londnu.   W. 
March,  1912. 


LIST     OF 
CONTRIBUTORS     AND     THEIR     SUBJECTS 

VViLLiAM  C'kcii.  Bosanquet,  m.a.  Oxon.,  m.d.,  p.r.c.p.  ;  Pliysician,  Brompton  Hospitiil  lur 
Consumption  and  Diseases  ol'  tlic  Chest ;    Pliysician,  Charing  Cross  Hospital. 

Blood  per  anum,  75. — Colic,  114. — Glycosuria,  260. — Meleena,  385. 

K.  Farquiiar  Buzzard,  m.a.,  m.ij.  Oxon.,  b.ch.,  f.r.c.p.  ;  Physichiri  In  Out-Patieiits  at  St.  Tliomas's 
Hospital  and  at  the  National  Hospital  for  the  Paralyzed  and  I'.pili  ptie.  Queen  Square  ;  Con- 
sulting Neurologist  to  the  Royal  Free  Hospital  and  to  the  llospitid  Inr  Diseases  of  the  Throat, 
Golden  Square. 

Amnesia,  19. — Ataxy  55. — -Aura,  67. — Claw-foot,  109. — Claw-hand,  109. — Facies,  abnormalities  of,  233. — 
Girdle-pain,  260. — Incontinence  of  faeces,  313. — Irritability,  323. — Knee-jerk,  abnormalities  of  the,  357. — 
Pain  in  the  extremity  (lower),  438. — Pain  in  the  extremity  (upper),  442. — Pain  in  the  face,  446. — 
Paralysis,  facial,  491. — Paralysis  of  one  extremity  (lower),  4  '6. — Paralysis  of  one  extremity  (upper),  500. 
— Sensation,  some  abnormalities  of,  604. ^Speech,  abnormalities  of,  623 

Pkrcv  .John  Ca.mmidge,  m.d.  Loud..  n.iMi.  (anil). 
Cammidge's  pancreatic  reaction,   100. 

IIerbkrt  I..  E.vso.v.  m.d..  m.^.  I-ond.  :    .Senior  Ophtliahiiie  .Surgeon.  (Juv's  Hospital. 

Diplopia.  174.  Enopblhalmos,  217. — Epiphora,  220 — Exophthalmos,  229. — Eye,  acute  inflammation  of, 
231. — Nystagmus,  407. — Ophthalmoscopic  appearances,  notes  on,  415. — Ptosis,  540. — Pupil,  abnormalities 
or  the,  551. — Strabismus,  649.     Ulceration  of  the  cornea,  733. — Vision,  defects  of.  757. 

.loiiN  W.  H.  KviiE.  M.I).,  M.S.  Diirli.,  D.i'.ii.  (anil).:  Direetor  of  the  Baeteriologic  al  Depaitinent, 
(Juy's  Hospital  :  I.eetiiicr  on  IJaeleriologv  to  the  .Medieal  .School  and  Dental  .Sehool,  (iiiv's 
Hospital. 

Bacteriuria,  69. 

Carev  F.  CoOMns,  M.D.,  M.ii.i-.i".  :    Assistant   I'hysieiaii,  Bristol  (iciieral  Hospital:    (  liiiieal  l.iitnrer 
in  Meilieine,  I'uiveisity  of  Bristol. 
Pulse,  Irregular,  544. 

Ili;iiiii;iir  .^I()lll.I.^•   Fi.i;nnEic,  m.a..  m.d.  Canil).,  i  .R.c.i-.  ;    Physician,  St.  Bartholomew's  Hospital  : 
Physician  in  Charge  of  Diseases  of  Children   Department,  .St.  Bartholomew's   Hospital  ;    Con- 
sulting Physician,  h'-ast  l.oiiilou  H<)s])ital  for  Childien. 
Hoad.T,cho,  293.      Vomiting.  763. 

IlKitiiEiiT  l'"iti;N(ii.  M.A.,  M.D.  Oxoii,,  i.u.c.i'.  ;    I'hysiciaii,  I'athologisl ,  and  I.eeliircr,  (Jny's  Hospital. 

Accentuation  of  heart  sounds.  1.  Accoucheur's  hand,  2.  Acetonuria.  3. — Albuminuria,  4.  — Albumosuria. 
16. — Allocholria.  17.  Aniemla,  20.  -Ankle  clonus,  39. — Ascites,  43. — Atrophy,  muscular,  59. — Atrophy, 
testicular,  66.  Babinski's  sign,  68.-  Bl.ack  specks  before  the  eyes,  71.  -Bleeding  gums,  72.  Blood- 
pressure,  .abnormal,  81.  Borborygml,  82. — Br.adycardia,  82.  Bnadypnooa,  84.  Breath,  foulness  of  the, 
86.  -BuIlX",  96.  Richexla,  99.  Charcot  Loydoii  crystals.  102.  Chest,  bloody  oflusion  in,  102.  Chost, 
pus  In,  103.  Chost,  serous  effusion  in.  104.  Cheyne  Stokes  rosplr.ation,  107.  Chordee,  108.  Chyluria. 
108.  Clubbed  Angers,  111.  Coma,  117.  Cr.ackling,  egg-.shell.  161.  Crepitus,  152.  Curschmann's 
spirals,  153.  Cyanosis,  extreme,  161.  — Cystliiurl.a,  1>)1.  Dead  lingers,  162.  DlaceturLa,  170.  Diazo- 
reaction,  173.     Dilatation  of  the  stom.ach,  173.     Discharge,  naa.al.  178.      Dysphagia,  194.      Dyspncea.  199. 

Emphysema,  surgical.   203.     Enlargomont  of  the  forehead.   203.      Enlargement  ol   tho  heart.  206, 
Eoslnophllla.   218.      Ei-ylhoma,    222.      Fa-'cos  passed  per  urethram.   238.      Fatty  stools,   239.      Fr.acture, 
spontaneous.   242      O.-ill  bladder  onlargomont,   262.     Grinding  of  tho  tooth  during  sleep,     65.      Haima- 
tamosls.    2G6,       Hoemogloblnurla,    284.      Hajmoptysis,    286.     -Heartburn,    296.       Homiiinopsia,    300. 
Hemiplegia.   302.-  -Hiccough,  307.      Hyperacusls,  308.      Hyperpyrexia,  309. — Hypothermia,  310.     Impo 
tenoe,    3  2.      IndlcanurLa,    314.      Jaundice.    324.      Leucocytosls,    359.     I  oucopenia,    361.     Limping    in 
children,  362.     Lymphatic  gland  enlargement,  376.     Mar.asmus,  384.     Moryoism,  388      Meteorism,  388. 
Mucus  in  the  urine,   399.     Nightmares,    402.     Noises  in   tho  ho.ad,   405.     Obesity.   408.     (Edema,   sym- 
metrical, 410.     Opisthotonos,  417.     Orthopna).a,  418.     Ox,-iIurla,  423.     P.-vln  in  tho  breast,  429.     P.aln  in 
the  eye,   445.     P.aln    In   the   lll.ac  fossa  (loft),  462.     Pain  In  the  lilac  fossa  (i-ightl,  454.     Pain,  inter- 


X  tX)XTRIBUTORS    AND    THEIR     SUBJPX'TS 

scapular,  461.  Pain  in  the  shoulder,  474.  -Palpitation,  484.  Paralysis,  laryngeal,  494.  Paraplegia, 
510.  -Parasites,  intestinal,  519.  Peristalsis,  visible,  521.  Phosphaturia,  522.  Photophobia,  S24. 
Pigmentation  in  the  mouth,  526.-  Pneumaturia,  52&.  Pneumothorax.  530.  Polycythaemia,  532. 
Polyuria,  534.  Priapism,  537.  Ptyalism,  542.  Pulsation,  undue  abdominal  aortic,  543.  Pulses,  unequal. 
550.  Purpui-a,  552.  Pus  in  the  stools,  657.  Reaction  of  degeneration,  583.  Reduplication  of  heart 
sound,  587.  Regurgitation  of  food  through  the  nose,  588.  -Retraction  of  the  gums,  589.  -Retraction  of 
the  head,  589.  Risus  sardonicus,  598.  Skodalc  resonance,  611.  Smell,  abnormalities  of,  611.  Snoring, 
613.  Sore  throat,  613.  -Spleen,  enlargement  of  the,  628.  Sputum,  641.  Stertor,  647.  Strangury,  649. 
-Stridor,  650.-  Succussion  sounds,  651.  Swelling,  pulsatile,  693.  Swelling  of  the  tongue,  698.  Tache 
cer^brale,  702.—  Tachycardia,  702.  Taste,  abnormalities  of,  705.  Tenesmus,  716.  Thirst,  extreme,  719.- 
Trismus,  729.  —Urate  deposit  in  the  urine,  740.  Dric  acid  deposit  in  the  urine,  741.  Veins,  varicose 
abdominal,  748.     Veins,  varicose  thoracic,  750.     Weight,  loss  of,  768. 

AiiCiiiBALD  Edwu.  Gaiikoij,  C.M.G.,  .M.A.,  .M.i).  Oxoii..  1  .K.c.i>.,  1  .U.S.  :    I'livsiciitii.  St.  BarthoIomcwV 
Hospital  :    Consulting  Physician  to  the  Hospital  for  Sick  Children,  (Jreat  Ornioiid  Street. 
Urine,  abnormal  coloration  of,  742. 

(;i;ouGE  Ernest  Gask.  i  .k.c.s.  :  Sin-oeon  with  Charge  of  Out-iiatients,  St.  Bartholomc\\  "s  Hospital  : 
.Toint  Lecturer  in  Siiroci\  .  .St.  Bartholomew'.s  Hospital  Medical  School. 

Discharge  from  the  nipple,  131. — CEdema,  asynunetrical,  410.     Pain  in  the  jaw,  462. — Pain  in  the  umbilical 
region,   483.     Rectum,  abnormalities  felt  per,  584.     Rigidity   of  the  abdomen,  592.     Stiff  neck.  647. 
Swelling,  axillary,  666.     Swelling  on  a  bone,  (67. — Swelling  of  the  face,  673. — Swelling,  femoral,  674. — 
Swelling  in  the  iliac  fossa,  676.     Swelling  of  the  jaw  (lower),  683.-    Swelling  of  the  jaw  (upper),  685. 
Swelling,   popliteal,  691.--  Swelling  of  the  salivary  glands,  694.    -Swelling,  scrotal,  695. — Thyroid  gland 
enlargement,  721.     Ulceration  of  the  leg,  736.     Ulceration  of  the  tongue,  738. 

Hastings  CiiLFOBD,  f.ii.c.s.  ;    Considting  .Surgeon.  Kiugvvood  Saiiatoriuiii.  Heading. 
Dwarfism,  186. 

.Artiiuk    Fkedi;iuck   Hihst,   m.a..   .m.d.   Oxon.,   f.r.c.p.  :     I'hysieian   and    I'hysician    Tor   Nervous 
Diseases  and  Lecturer  on  Therapeutics,  Guy's  Hospital. 
Constipation,  121. — Fullness,  sense  of,  243. 

Robert  HiiTCHisoN,  m.ij.,  cm.  Kdin.,  i-.r.c.p.  ;  Physician  to  tlie  London  Hospital  :  Physician  with 
Charge  of  Out-patients  to  the  Hospital  for  Sick  Children,  Gicat  Orniond  Street. 

Appetite,  abnormal,  42.     Diarrhoaa,  170.     Flatulence,  240.     Indigestion,   315.     Pain  in  ihe  epigasti-ium, 
436.     Pain  in  the  hypochondrium  Heft),  450.     Pain  in  the  hypochondrlum  (right),  450. 

Arthi  K  John  Jex-Blake.  m.a.,  m.b.,  b.ch.  Oxon.  m.r.c.p.  :  Senior  Assistant  Pliysician,  St.  GeoigcV 
Hosjjital  :    Assistant  Physician.  Brompton  Hos])ital  for  Consumption. 

Contractions,  131.     Contractures,  139.     Convulsions,  143.     Cramps,  150.-    Epistaxis,  221.     Gangrene,  255. 
Gangrene  of  the  lung,  259.     Insomnia,  320.     Pain  in  the  chest,  430.  -Pain  in  the  limbs,  463,-  -Rigors, 
or  chills,  694.     Swelling,  abdominal,  656.     Tenderness  in  the  chest,  706.  -  Tenderness  in  the  scalp,  710. 
Tenderness  in  the  spine,  712.    -Tremor,  724. 

Sir  i\L\lcolm  Morris,  Bart.,  K.c.v.o.,  i-.r.c.s.  Edin.  ;  Consulting  Surgeon.  Skin  Department. 
St.  Mary's  Ho.spital ;   Surgeon,  Skin  Department,  Seamen's  Ho.spital. 

Baldness,  70.     Sore  finger,  239.     Flushing,  241.     Futigous  affections  of  the  skin,  246.     Lips,  affections  of 
the  red  part  of  the,  365.     Macules,  382.     Nails,  affections  of  the,  399.     Napkin  region  eruptions,  400.- 
Nodules,  402.     Papules,  487.     Pigmentation  of  the  skin,  527.     Prm-itus,  540.     Pustules,  557.     Scabs,  599. 
Scaly  eruptions,  601.     Sweating,  abnormalities  of,  t54.     Tiunours  of  the  skin,  731.     Ulceration  of  the 
face,  735.     Ulceration  of  the  foot,  735.     Vesicles,  753.     Wheals,  771. 

HoBEin  P,  l{o\M.ANi)s.  M.B.,  M.S.  Loud.,  1  .R.c.s.  :    Surgeon.  Guv's  Hospital  :   Lecturer  on  Anatomy. 

Guy's  Hosjiitiil  .^ledical  School. 

Club  foot,  or  talipes.  111.     Curvature,  spinal,  153.     Swelling,  inguinal,  678.     Swelling,  Inguinoscrotal,  682- 

.I.vMES  K.  H.  S.\wvEH,  .M.A..  M.D..  ii.cii.  Oxon.  :   Assistant  Physician,  General  Hospital.  Birmingham. 

Bruits,  cardiac,  89.     Deformity  of  the  chest,  167.     Heart  impulse,  displaced,  297.     Thrills,  precordial,  720. 

Frkderick  John  Smith,  m.a.,  .m.o.  Oxon.,  f.r.c.p.,  f.r.c.s.  :  Physician  and  Senior  Pathologist. 
London  Ho.«pital  :  Consulting  Physician  to  the  City  of  London  Dispensary  and  to  the  National 
Orthopjedic  Hospital. 

Breath,  shortness  of,  87,     Cough,  148.     Delirium,  169.— Gait,  abnormalities  of,  261.     Lineffi  albicantes, 
365.     Pain  in  the  back,  427.     Pyrexia  without  obvious  cause,  571. 


CONTRIBUTORS    AND    THEIR     SUBJECTS  xi 

'I'lioMAS  George  Stevens,  m.d.,  b.s.  Lond.,  m.r.c.p.,  f.r.c.s.  :  Obstetric  Surgeon,  St.  Mary's 
Hospital  ;  Gyna^eolooical  Surgeon,  Hospital  for  Women,  Soho  Square  :  Physician  to  In- 
patients, Queen  Charlotte's  Hospital. 

Amenorrhcea,  17.     Discharge,  vaginal,  185.     Dysmenorrhcea,  192.     Dyspareunia,  193.     Dystocia,  199. 
Menorrhagia,  385.     Metrorrhagia,  390.     Metrostaxis,  392.     Pain,  bearing  down,  427.     Pain  in  the  pelvis, 
467.     Prolapse  of  the  uterus,  538.     Sterility,  645.     Swelling,  mammary,  685.     Swelling,  vulval,  699. 

Id  ■<-,i;i.!.  H.  .JocKi.vN  S\v.\x.  .m.is..  .-m.s.  LoiuI.,  i  .it.c'.s.  :    Suri;coii,  t'aiiccr  Ilosjiitai,  Bioiiiptoii. 

Anuria,  39.     Discharge,  urethral,  181.     Enuresis,  218.     Hasmaturia,  276.     Kidney,  enlargement  of,  352. 
Micturition,  abnormalities  of,  393.     Pain  in  the  Penis,  469.-  Pain  in  the  perineum,  474.     Pain  in  the 
testicle,  477.     Pyuria,  674.     Sores,  penile,  617.     Sores,  perineal,  619.     Sores,  scrotal,  621. 

Ki(KiJi;uitK   T.ivi.oit,   M.D.    Lund.,   i.r.c.p.  ;     Coiisultiiiy    Physician,   Guy's   Hospital,   and    Kvelina 
Hospital  for  .Sicl;  C'liikhen  :    Physician,  .Seamen's  Hospital,  Greenwich. 
Pyrexia,  prolonged,  563. 

Philip  Tlrner,  b.sc,  m.b.,  M.S.  Lond.,  f.r.c.s.  :  .\ssistant  Surgeon,  Guy's  Hospital  :  Drmoastrator 
of  Operative  Surgery,  Guy's  Hospital  Medical  School. 

Deafness,  163.     Earache,  202.     Otorrhoea,  421.     Tinnitus,  723.     Vertigo.  750- 

\Vii.i.iA.\i  Half.  Wuite,  .m.d.  Lond.,  m.d.  Dub.,  f.r.c.p,  :  Senior  Physician  and  Lecturer  on  Medicine, 
Guy's  Hospital, 

Joints,  affections  of  the,  337.     Liver  dullness,  deficient,  366.     Livei-,  enlargements  of  the,  366.     Mucus  in 
the  stools,  398.     Pain,  abdominal,  426.     Sand,  intestinal,  599. 


LIST     OF     COLOURED     PLATES 

Platk  I. — Renal  tube  casts  __--_-.- 

A,  Hyaline;  B^  Waxy;  C)  Uynline  cast  containiug  small  ciystals  of  cnlcium  oxalate;  D,  Blood; 
E,  Leucocyte  ;    F.  Epithelial ;    G,  Granular  ;    H,  Fatty. 

Plate  II.— Red  and  wliite  blood  corpuscles  ,.--.- 

A,  Xormal  red  ;  B,  Megalooytes  and  microcytes  ;  C,  Normal  red  corpuscles  made  angular  by  imperfect' 
fixation;  D,  Crenated  red  coi-puscles  ;  F,  Poikilocytes  ;  F,  Nucleated  red  corpuscles — (1)  Normoblasts, 
(2)  Mefjaloblasts.  (3)  Gigantoblasts ;  G,  Punctate  basophilia  and  polychromasia ;  H,  Small  lymphocyte: 
I,  Indeterminate  lymphocyte  ;  j.  Large  hyaline  lymphocyte  ;  K,  Polymorphonuclear  corpuscle  ;  L,  Coarsely 
granular  eosinophile  coipuscle  ;    M,  Myelocyte  ;   N.  Eosinophiie  myelocyte  ;  o,  Easophile  corpuscle. 

Plate  III.  —Blood  film  in  pernicious  antemia  _.---. 

showing  poikilocytes,  microcytes,  megalocytes,  nucleated  red  cells,  and  punctate  basophilia. 

Plate  IV. — Blood  film  in  spltnnincdiillary  leuktemia  _  .  .  .  , 

Showing  five  neui  in|.!iil.>  tm  .In,  \  ti.-^,  one  eosuiophile  myelocyte,  three  basophile  cells,  and  one  binucleated 
red  cell,  in  addition  to  im.iui.W  ."■mi  pu>.'les. 

Plate  V. — Blood  film  in  lymphatic  leukaemia  ...... 

Sliowing  a  lai^e  increa-se  in  the  small  lymphocytes. 
Plate  VI. — Blood  film  in  malaria  ._..__, 

Showing  three  malarial  panisites  of  the  ring  type. 
Plate  VII. — Pigmentation  of  the  skin  due  to  arsenic  .  .  .  _  . 

Plate  VIII.—Koplik's  spots  .  .  ,  .  ... 

Plate  IX.—Pellaora  _....._.. 

Plate  X. — The  hand  of  u  i)ellagrin  -.-,_.. 

Plate  XI. ^ — ^Acute  inflammations  of  the  eye  -._,_. 

A,  Acute  conjunctivitis  ;  B,  Acute  iritis  ;  C,  Glaucoma ;  D,  Phl^'ctenular  conjunctivitis  :  e.  FoIUcuUir 
conjunctivitis. 

Pl.\te  XII. — Acute  inflammations  of  the  eye  .--_-- 

F,  Chi-onic  blepharitis  ;   G)  Interetitial  keratitis  ;    H,  Ti'aclioma  ;    |,  Hypopyon  and  ulcer  of  cornea. 
Pi^\TK  XIII. — ^Symmetrical  gangrene  of  the  fingers  in  Raynaud's  disease 
Plate  XIV. — Gangrene  of  the  foot  _  -  .  .  .  . 

Plate  XV. — Bladder  appearances  seen   thrtniiih  the   cystoscope      ...  - 

A,  Blood-stained  urine  issuing  fi-om  the  ureter ;  8»  Pmnleut  urine  issmng  from  the  ureter ;  C,  Conges- 
tion round  a  ureteric  orifice  in  calculous  pyehtis ;  d,  The  reti-acted  ureter  common  with  descending  renal 
tuberculosis  ;   E,  Tuberculous  ulceration  around  the  ureteric  orifice  in  descending  tuberculosis. 

Plati:  XVI. — Bladder  appearances  seen  through  the  cystoscope     -  _  -  - 

F,  Pedunculated  carcinoma  of  bladder;  G-,  Pedunculated  bald  carcinoma  of  bladder;  h,  L'ric  acid 
calculus  in  bladder;  |,  Appearance  at  tlie  urethral  orifice  in  bilateral  adenomatous  enlargement  of  the 
jirostate  ;    K,  Bilhaiv.ia  hasmatohia. 

Plate  XVII.— Multiple  bleeding  narvi  of  tlu-  tongue,  niuutii.  and  ehtek 

Plate  XVIII. — Familial    acholuric    jaundice  _-_.-. 

Plate  XlX.—Ophthalmoscopic  appearances  _-,-.. 

a.  Physiological  cup ;  &,  Congenital  crescent ;  c.  Pigmented  crescent  in  disc  mai^gin  ;  d,  Colobomu 
of  choroid  ;  e,  /,  Opaque  nerve  fibres ;  y,  Advanced  syphilitic  choroiditis ;  A,  t",  The  myopic  crescent ; 
k,  I,  Eecent  optic  neuritis. 

Plate  XX. — ^Ophthalmoscopic  appearances  -  -  .  .  _ 

7«,  11,  Primary  optic  atrophy  ;  o,  Tln-ombosis  of  the  central  retinal  vein  ;  p,  q,  i\  .Vlbuminnric  retinitis  ; 
.V.  Embolism  of  the  central  retinal  artery  ;  r,  Detachnipnt  of  the  retina  :  r,  Glaucomatous  discs  ;  ir.  Tubercles 
in  the  choroid  ;   x.  Hypermetropic  astigmatism. 

i*LATE  XXI.^Pigmentation  of  the  tongue  and  nioutli  in  Addison's  disease 

Plate   XXII.      Picnicntation   of  tlic  mouth   in   j)ei'nicrous  aniemia 


LIST    OF    I'OLOUREI)     PLATES 

PL.vn;  XXIII. — Intestinal  sand  -------- 

1.  True  intestinal  sand  ;   2.  False  intestinal  sami. 

PLiVTE  XXIV. — Pityriasis  rubra  ------- 

Plate  XXV. — Diagram  showino  tlie  radicular  sensory  areas  of  the  human  body    - 
Plate  XXVI.— .Sore  throats  -_.,._-- 

I.  Ordinary  hypenemio  sore  throat ;  II.  Jlild  follioular  tonsillitis  ;  III.  .Severe  follicular  tonsillitis ; 
IV.  Left-sided  quinsy  ;   \.  Syphilitic  sore  throat. 

Plate  XXVII. — Sore  throats  _--.---- 

VI.  Mild  diphtheria,  simulating  follicular  tonsillitis  ;  VII.  Diphtheritic  sore  throat,  of  medium  severity  ; 
VIII.  Diphtheritic  sore  throat,  severe,  showing  spread  of  membranous  exudate  to  palate  ;  IX.  Phlegmonous 
diphtheria  ;    X.  Vincent's  angina. 

PL.\rE  XXVIII. — Bacteria  and  blood  parasites         _  .  .  -  -  - 

A,  ilalaria,  early  ring  form  ;  B,  Malaria,  ordinary  ring  form  ;  C,  Malaria,  m,ature  tertian  ;  D,  Malaria, 
tertain,  ready  to  sporulate ;  E,  Malaria,  crescentic ;  F,  Filaria  embryo;  G,  Trypanosoma  Gambiense ; 
H,  Leishman-Donovan  bodies  obtained  by  splenic  puncture;  I,  Spirochaeta  Obermeieri  of  relapsing  fever; 
J,  Spirochaeta  palhda  of  syphilis;  K.  Tubercle  bacilli  and  pus  cells;  L,  Diphtheria  brcilli ;  M,  Vincent's 
angina.  Spirilla  and  fusiform  bacilli ;  N,  Meningococci  within  a  leucocyte  ;  o.  Pneumococci  and  pus  cells  ; 
p.  Staphylococci  and  pus  cells ;  Q,  Streptococci  and  pus  cells ;  R,  Gonococci.  in  and  outside  of  pus  cells ; 
S,  -A.ctinomyces  ;  T,  Tetanus  bacilli. 

Pl-vte  XXIX. — Splenomegalic  polycytliBcmia  ------ 

Plati-:  XXX. — Po])liteal  aneurysm  ..-.--- 

Plate  XXXI. — Cirsoid  aneurysm       -------- 

Plate  XXXII. — Cancer  of  the  tongue  :    very  early  conditions         .  -  -  - 

P1.ATE  XXXIII.-    Ochronosis  --------- 

Plate  XXXIV. — Urine  tests  --------- 

1,2,3.  The  three  stages  of  the  sodium  nitroprusside  test  for  acetone.  4,  5,  6.  The  same  in  a  urine 
containing  no  obvious  acetone.  (I  and  4,  noi-mal  urine  ;  2  and  5,  the  appearance  after  adding  caustic  soda 
and  sodium  nitroprusside  :  3  and  6,  the  appearance  after  adding  acetic  acid,  3  being  positive,  6  negative,  for 
acetone).  7,  Kothera's  test  for  acetone,  p.  Ferric  chloride  reaction  of  diacetic  acid.  9,  Indicanuria  test. 
to,  Melanuria-     1  1,  Diabetic  urine.     12,  The  fluorescent  reaction  of  urobilin. 

Pi..\TE  XXXV. — Urine  tests  and  Gunsberg's  test      ----- 

1 ,  Iodine  test  for  bile  pigment  in  urine.  2,  Gmelin's  reaction  for  bile  pigment  in  urine.  3,  Gunsberg's 
test  for  free  HCI  in  gastric  juice. 

Pl.vti:  XXXVI. — TuJ)erculin  reactions  ------- 

Cutaneous  reaction  (von  Pirquel)  ;  Dermal  reaction  {Woodcock). 
Pi..\iK  XXXVII. — Tuberculin  reactions  ------- 

Dnroinl  reaction  (.Vor«)  :    Oplithalmo-test  iCulmellf). 


ILLUSTRATIONS     IN     THE     TEXT 


F7G. 

1. — Accoucheurs  luind 
2. — Method  of  making  a  blood-film 
•i. — Miculicz's  syndrome 
4. — Temperature  chart  in  leukiemia 
■>■ —  ..  ,,  relapsing  fever 

<),  7. —      ..  „  malaria 

'i- —  ..  ,,  quotidian   ma- 

laria    - 
'■>■ —  ..  ..  double  tertian 

malaria 
10. —  ,.  ,,  complex     ma 

laria     - 
11. —  ,,  ,.      to    illustrate    ir- 

regular pyrexia 
in  chronic  ma- 
laria 
12. — Pyrexia  in  cirrhosis         _         _         , 
13. — Pseudoleukaemia  infantum 
14. — Facies  previous  to  myxa-dema 
15. — Myxirdema   facies   -  - 

Ifi. — Hands  in  iiiyxcrdcnia 
17. — Maliyiiant  kit  supraclavicular  glands 
18.— Hydatid  hookkts  - 

m. — Infantile  paralysis  - 
20. — Tooth's  peroneal  palsv  (bov) 
21.—       „  .,  '    (girl) 

22. — Wrist-drop  from  diphtheria 
23. — E.'itragenital  chancre 
24. — Cancrimi  oris  -  -  -  - 

25. — Ama?ba  histolytica  and  A.  coli 

26. — Ova  of  bilharzia  ha>matobia   - 

27. — Ankylostomum  duodenale 

28-9.—    ■     „  ova 

30. — Spectrum  of  oxyhjemoglobin  - 

31. —  „  reduced  hiemoglobin 

32. —  ,,  carboxyha;moglobin    - 

33. —  „  alkaline  ha^matiii 

34. —  ,,  acid    haematin     - 

35. —  .,  methicmoglobin  - 

36. —  ..  urobilin 

37—8. — Heart-block  electrocardiogram 

39. — Bruits  of  mitral  stenosis  - 

40. — Flint's  murmur        -  -  -  - 

41. — Skiagram  of  phthisis 

42. —         „  sarcoma  of  lung  - 

43. — Cheyne-Stokes  breathing 

44. — Claw-foot         ----- 

45. — Syringomyelic  claw-hand 
46. — Clubbed     fingers     with     pulmonary 
stenosis        ----- 

47. — Habitual   constipation 
48. — Dyschezia         -         .  -         .  - 

49. — Time  relations  of  food  in  large  bowel 
■)0. — Post-dysenteric  atony  and  paresis  of 
colon   ------ 

51. — Constipation  due  to  lead  poisoning 

52. —  ,,  with  mucomembranous 

colitis       -  -         - 

53. — .Skiagram  of  carcinoma    of    splenic 

4   flexure 
54. —  ..  bismuth     enema     and 

carcinoma  coli 


PAGE 

3 
21 


60.— ( 
61. 


68.—' 
69. 


79 

85 

80 

86 

80 

87 

80 

88 

80 

89 

80 

90 

80 

91 

80 

92 

95 

96 

103 

105 

97 

107 

98 

109 

99 

110 

100 

111 

101 

122 

102 

122 

103 

123 

104 

105 

123 

106- 

124 

108 

109 

124 

110 

in- 

125 

ns 

114 

126 

115 

PAGi: 
The  colon  in  Hirschs])rung's  disease  127 
Visceroptosis  -  -  -  -  -  127 
Athetotic  hand         -  -  -  132 

Volkmann's  paralysis       -         -  141 

Dupuytren's   contracture  -  142 

Contracture  after  a  burn         -  -     142 

Skiagram  of  caseous  bronchial  gland      149 
,,  carcinoma  of  bone        -     152 

— Osteitis  deformans        -  -  -     155 

Deal-porter's  bursa  -  156 

Myopathic  lordosis  -  -  -     156 

Morbus  coeruleus,  pulmonary  stenosis  157 
Caseous  gland  seen  with  bronchoscope  158 
-Vena  cava  superior  obstructed  by 

aneurysm  -         -         -         - 

-Skiagram  of  miner's  phthisis    - 
•Temperature    chart    of    pneumonia 

and  empyema     -         .         - 
■Cystin  crystals 
■Politzer's  acoumeter 
■Tuning-fork  with  foot-piece 
Galton's  whistle 
-Rickety  chest  outline 
Normal  adult  chest  outline 
Pigeon  chest  outline 
Fibroid  lung,  chest  outline 
Knipliyscniatous  chest  outline 
Hoiniiiiynious  double  images 
Criissctl  doidjie  images    - 
Effects  of  paralyses  of  ocular  muscles 
Transillumination  of  the  antrum 
Rickety  dwarfism 
Achondroplasia 
Osteogenesis  imperfecta 
•Cretinism         -         -         .         . 
Pituitary  infantilism 
•Mongolism       -         -         -         - 
Anangioplastie  infantilism 
Ateliosis  - 

Progeria  -  - 

Tooth-plate  im])actcd  in  larynx 
Bean  in  oesophagus 
Bismuth  skiagram  with  epithelioma 

of  a?sopliagus      -  -  -  - 

Stcuoscd  cardiac  end  of  tesophagus 
Ididpaihic  ililatation  of  oesophagus 
Vena  cava  superior  obstruction  by 

aneinysm  -  .  -  -     208 

Skiagram  of  aneurysm   -  -     209 

Temperature  chart  in  pellagra  225 

Meningocele  of  face  -  -  -     230 

Cretin  with  frog-belly  -  -  -  233 
Jlyxffidema     -         -         -  234 

Face  previous  to  myxoedcma  -     234 

— Congenital  syphilis       -  -     234 

Hutchinsonian  notched  teeth  234 

.Myopathic    facies    -         -  -     235 

Rirc  en   travers        -  -  -     235 

— Myastlicnic  facies  235 

F.xojilitliahnic  goitre  236 

I'aralvsis  aaitans     -  -  .     230 

Tabetic  facies  -  -  -  -     236 


158 
159 

160 
161 
164 
164 
165 
167 
167 
167 
167 
167 
176 
176 
177 
180 
186 
187 
187 
189 
189 
190 
190 
190 
191 
195 
195 

190 
197 
198 


LIST    OF    ILLUSTRATIONS 


FIG. 

PAGE 

116. 

—Acromegaly     ----- 

237 

117.- 

—.Achondroplasia        -         .         .         - 

237 

118- 
120.- 

9. — Mongolian  idiot  -         -         -         - 
— Facies  of  familial  lenticular  degenera- 

237 

tion              _         .         -         -         - 

238 

121. 

— Sarcina:  ventriculi 

241 

122.- 

—Skiagram  of  normal  stomach  - 

245 

123.- 

— Favus               _         .         -         -         - 

246 

124.- 

— Cholcsterin  crystals 

254 

125.- 

—Local  asphyxia  in  Raynaud's  disease 

256 
257 

126. 

—Raynaud's  disease,  fingers 

127. 

— Phenyl-glucosazonc  crystals    - 

262 

128. 

—Skiagram  of  hour-glass  stomach 

268 

129.- 

—           ..            normal  stomach 

269 

130. 

—           ..            carcinoma  of  stomach 

269 

131 . 

—            ..                      ..                ,.  pyloric 

270 

132.- 

.,  diffuse 

270 

133. 

-            ..             renal  calculus     - 

279 

134. 

—           ..             tuberculous  kidney 

280 

13.3. 

vesical  calculus  - 

282 

136. 

—           ..             pneumonia 

289 

137.- 

—Hydatid  cyst  of  lung 

291 

138. 

—Connections    of    optic    ner\-es    and 

tracts           ----- 

300 

139.- 

—Bilateral  temporal  hemianopsia 

300 

140- 

1. —     „       homonymous  hemianopsia 

301 

142.- 

-Temperature  chart  of  hypothermia 

with  mitral  stenosis     - 

311 

143.- 

—Hypothermia  in  malignant  cachexia 

312 

144.- 

—Skiagram,   bismuth    shadow    of    a 

dropped  and  dilated  stomach 

318 

14.5.- 

-Pyrexia  with  carcinoma  of  liver 

326 

146.- 

—Skiagram  of  gall-stones  - 

327 

147. 

— Leucin  crystals        -         -         -         - 

333 

148. 

-Tyrosin   crystals      -         .         -         - 

333 

149. 

-Temperature  chart  showing  effect  of 
salicylates      in 
acute  rheuma- 

tism 

338 

150.- 

..     of  gonococcal  ar- 

thritis     - 

338 

151. 

—              .,               ..in  acute  gout 

339 

152.- 

—             .,              ..     in       rhcumatoi'l 

arthritis 

341 

153. 

— .\cutc  rluinnaloid  arthritis 

342 

154.- 

—.Skiagram  of  hands  in  acute  rheuma- 

toid arthritis        -          .          -          . 

342 

155. 

— HebcrdcM's   nodes    -          -          -          - 

343 

156.- 

— Hhcuinaldid   arthritis,  transparency 

of  bones  in 

344 

157. 

—Henoch's  purjmni 

345 

158.- 

—Gout 

345 

159. 

—Skiagram  of  chniiiic  gciul 

346 

160- 

1. — Pads  (m  fingers   - 

347 

162. 

—  Charcot's  joint 

349 

163. 

—Skiagram  of  Charcot's  hip 

3.-.0 

164- 

5. — Pulmonary  osteo-arthropattiy 

3.-,1 

166. 

— Pyelogra])liy 

3.1C, 

167. 

-Pvrexia  in  cirrhosis 

371 

168. 

-Ilodgkin's   disease 

377 

169. 

Still's  disease 

.•f77 

170. 

Macular  sypliili.lcs 

383 

171. 

-    Hirschsprung's  disease 

3H9 

172. 

Mucous  <ast  of  iiitcstiuc 

3ilK 

173. 

-  Nodular  leprosy        - 

101- 

174- 

5.      Ilypcriieplironia   patient 

MIH 

176. 

-  DvstropiiiM  adiposogenilalis 

K)9 

177. 

-   Milr.,y's  diseas..        - 

HI 

178. 

.\ngioneurolic    (cdcma 

412 

17U. 

-  .Meige's  disease 

414 

180. 

SUiagiani  of  large  lliviiiiis  gland 

419 

181. 

(al.-iMiii  nxMlale  crystals 

423 

FIG.  PAGE 

182. — Skiagram  of  bismuth  in  normal  colon  426 
183. —          ,,                    ,,              dropped  colon  426 

184. —         „              aneurysm      -          -          -  435 

185. —         „              spine  on  os  calcis  440 

186. —         „             cervical  rib  in  child     -  443 

187. —          ..                      ,,         „          adult     -  443 
188-91. — Sensory  areas  of  face,  head,  and 

neck  -----  448 
192. — Skiagram  of  ureteral  calculus  -  -  455 
193. — Temperature  chart  in  coli  bacilluria  4,56 
194. — Tuberculous  ea;cum  -  -  458 
195. — Skiagram  of  lumbar  caries  -  -  460 
196. — Electrocardiogram  of  auricular  fibril- 
lation -  .  -  -  .  4gg 
197-200. — Facial  paralysis  -  -  491-2 
201 . — Bilateral  facial  palsy  -  -  493 
202. — Hemiatrophy  of  face  -  -  -  494 
203—4. — Diagrams      of     Brown  -  Sequard 

paralysis  -  -  -  .  497 
205. — Diagram  of  lumbosacral  plexus  -  500 
206. — Peripheral  neuritis  in  leprosy  -  505 
207. — Serratus  magnus  paralysis  -  -  506 
208. — Diagram  of  cervicobrachial  plexus  -  507 
209. — Atrophy  in  hand  from  cervical  rib  -  508 
210. — Sensory  localization  in  the  cord  -  518 
211. — Reflex  centres  in  the  cord  -  518 
212-3. — Head  of  tienia  solium  -  519 
214. —  ,,  „  mediocanellata  -  519 
215. — •  ,,  Bothriocephalus  latus  -  519 
216. — Ovum  of  taenia  solium  -  -  520 
217. —  ,,  ascaris  lumbricoides  -  520 
218. — Trichocephalus  dispar  in  the  colon  -  520 
219. — Ovum  of  trichocephalus  dispar  -  521 
220. — Ankylostomiasis  of  the  duodenum  -  521 
221. — Triple  phosphate  crystals  -  -  524 
222. — Pigmentation  in  exophthalmic  goitre  527 
223-4. — Sypliilitie  leukomelanodermia  -  528 
225. — Pigmentation  of  skin  from  arsenic  -  529 
226. — Skiagram  of  pyopneumothorax  -  531 
227. — Ptosis  and  healed  gumma  of  face  541 
228. — Paralysis  of  internal  rectus  -  -  541 
229. — Ptosis  from  syphilis  -  -  -  541 
230. — Facial  paralysis  from  syphilis  -  -  541 
231. — Klcctrocardiogram  showing  extra- 
systoles  -----  544 
232.-  Polygraj)!!     tracing    of    incomplete 

heart-block        -  545 
233.-            ..                 ,,         showing    heart- 
block              -  546 
234.              .,                ,,           of     ventricular 

extrasystolc  -  547 

235. — Pulsus  bisfcriens     -         -         -         .  .5,50 

236. — Purpura  in  fungating  endocarditis  -  555 

237.  Discrete  small  pox  -          -                    -  561 

238.  Conllueiit  smallpox                      -          -  561 

239.  Se|itic  dermatitis  wrongly  diagnosed 

as  small-pox     -                              -  562 
2K).     Temperature     chart 


241 . 


in     prolonged 

inilucnza      -     564 
in  typhoid  fever  565 

of     iMediter- 

ranean  fever     565 
in     malignant 

endocarditis 
in  lateral  sinus 

thrombosis 
11    erysipelas 
I  pernicious  an- 


r>66 


:>(M 


Ilodgkin's 
.lisease  - 
sarcoma 


LIST    OF    ILLUSTRATIONS 


IIG. 

•249 
250 


2G0 
201 


262 

2()3 


266 
267 
268 


. — Rectum  oiKuing  into  virctlira  - 
, — Malformations    of   rectum    in    male 
-2. —  ,,  ,,  ,,  female 

. — Temperature  chart  in  cerebrospinal 
meningitis 

—  ..  ..  rat-bite  fever 
— Distribution    of   sensory    nerves    in 

the  skin  -     - 
— Glove   and   stockini;   ana>sthesia   in 

peripheral  neuritis 
, — Sensory     effects     of     ulnar     nerve 

division        .         .         -         .         . 
— Sensory  tracts  in  cord 
, — Ansesthesia  from  fracture  of  sacrum 

—  ..  myelitis 

—  ..  fracture  of  cervical 

spine 
— Sensory  changes  in  syringomyelia 

—  ..  ,,  tabes  dorsalis  - 
— Dissociative  ana-sthesia  from  throm 

bosis  of  posterior  inferior  cere- 
bellar artery         _  .  _  . 

— Temperature  chart  in  Kirkland"s 
disease  -         - 

— Speech  centres 

— Splenic  anemia       -         .         .         . 

— ^Temperature  chart  of  typhus  ending 
by  lysis        ----- 

— Temperature  chart  of  typhus  ending 
by  crisis       ----- 

— Enlarged  liver  and  spleen  in  fun- 
gating  endocarditis 

— Elastic  fibres  -  -  - 

— Temperature   chart    in    lobar   pneii- 


FIG. 

273 
274 


598 

278 

279 

605 

280 

281 

606 

282 

283 

606 

284 

607 

288 

608 

608 

289 

608 

290 

609 

291 

609 

292- 

294 

615 

297 

624 

298 

633 

299 

300 

638 

301 

302 

639 

303 

304 

640 

642 

305 

306. 

PAOE 

. — Calcareous  concretions  in  sputum  -  644 

. — Spondylitis  deformans     -          -          -  648 

. — Regions  of  the  abdomen           -         -  659 

. — Idiopathic  dilatation  of  stomach     -  664 

.—          „                  „                 bladder      -  665 

. — Skiagram  of  chronic  periostitis        -  668 

. —         ,.              tuberculous  dactylitis  -  669 

. —          ..               syphilitic  radius  -          -  669 

. —          ..                exostosis  of  femur       -  670 

. —         ..               cnchondroma  of  hand  671 

. —  ..  sarcoma  of  tibia  -  671 
-7. —  ..  .,  radius  672-;j 
. — Carcinoma    of   stomach    simulating 

aneurysm  -----  694 
. — Electrocardiogram     in   ■  paroxysmal 

tachycardia           -          -          .          -  703 

. — Cutaneous  nerve-supply  of  the  scalp  710 

. — Molluscum  fibrosum         -          -          -  711 

-3. — Segmental  areas  of  the  scalp  -  712 
. — Areas   of  referred   spinal  pain   and 

tenderness    -----  716 

. — Movements  in  intention  tremor       -  728 

. —  -            .,               ataxy       -          -          -  728 

. — Perforating  ulcer  of  foot          -         -  736 

. — Diagram  of  a  gummatous  ulcer       -  737 

. —            ..            a  tuberculous  ulcer       -  737 

. —           .,           an  ei)itheliomatous  ulcer  737 

, —            ,,            a  rodent  iilcer       -          -  737 

, — Uric  acid  crystals  -         -                    -  741 

, — Varicose  abdominal  veins  -  749 
— Renal  growth  extending  into  vena 

cava    ------  750 

— Small-pox  eruption           -          -          -  757 

— Ridging  of  nails  after  pneumonia  -  769 


ILLUSTRATIONS,     ALPH.^BETICALLY     ARRANGED 


Abdomen,  the  regions  of  -  -  - 

Abdominal   varicose  veins 
Accoucheur's  liand  -  -  .  - 

Achondroplasia  .         -         -         -         - 

,.  facies  of  -         .         - 

Acoumetcr,  Politzer"s        -  -  -  - 

Acroiiicu:il\  .  larirs  of         -  -  -  - 

.\m(rli;i  li\slol\  lira  and  coli 
Anaemia,  iicrLiicious  (tem])erature  cliart)    - 
,,        splenic         -         -         -         .         - 
.\na?sthesia  from  fracture  of  cervical  spine 
,.       injury  to  sacrum  - 
myelitis 
syringomyelia 
thrombosis  of  post.  inf. 
cerebellar  artery 
Aivangioplastic  infantilism 
Aiicinysm,  large  saccular  (skiagram) 

obstructing  the  superior  vena 
cava  -         - 

skiagram   of  - 
Angioneurotic  oedema        -  -  -  . 

.Ankylostomiasis  of  the  duodemun     - 
.\nkylostomum  duodenale 

,,         ova  of  (2  figs.) 
Antrum,  transillumination  of    - 
Aortic  aneurysm  obstructing  the  vena  cava 
.\reas  of  referred  spinal  pain     - 
.\rsenic,  pigmentation  of  skin  from  - 


I'AUK 

659 
749 
3 
187 
237 
164 
237 

569 
633 
008 
608 
608 
609 

610 
190 
209 


180 
208 
716 


.\scaris  lumbricoidcs.  ovum  of  - 

Ataxy,  movements  in        - 

Atelciosis  ------ 

Athetotic  hand  -  .  .  -  - 

.Atiiny  and  jjaresis  of  colon,  post-dysenteric 
.Atrophy  in  hand  from  cervical  rib  - 

muscular  -         -         -         . 

Auricular   fibrillation    (electrocardiogram) 
Bean  in  opsophagus  (skiagram) 
Bilateral  facial  palsy         -         -  -  - 

homonymous  hemianopsia  (2  figs. 

temporal  hemianopsia 
Bilharzia  lucmatobia,  ova  of     - 
Bismuth  l)loekcd  by  epithelioma  in   nso- 
phagus  (skiagram) 
,.  in  normal  colon  (skiagram) 

Bladilcr.  idiopathic  dilatation  of 
Blood-film,  method  of  making 
Botliridcephahis  lalus.  head  of 
Brcincliial  caMous  f^ianil  (skiagram) 
Brown-Si(|uar(l  jiaialysis  (2  diagrams) 
Bruits  of  mitral  stenosis  (6  diagrams) 
Csecimi.  tuberculous  -         -  - 

Calcareous  concretions  in  phthisical  sputum 
Calcium  oxalate  crystals 
Calcidus,  renal  (skiagram) 

ureteral  (skiagram)    - 

vesical  (skiagram) 
t'ancrum   oris  -  -  .  .  . 


PAGE 

520 

728 

190 

132 

123 

508 

59 

486 

195 

493 

)  301 

300 

79 

196 
426 
665 

21 
519 
149 
497 

94 
458 
I  644 
423 
279 
455 
282 

74 


LIST    OF    ILLUSTRATIONS 


C'arboxylifeniofiloljiu,  spectrum  of    - 

Carcinoma  of  bone  (skiagram) 

coli   with    bismuth   (skiauram) 
of  liver,  pyrexia  in  (chart) 
splenic  Hexurc  (skiagram)  - 


320 

125 

stomach  simulating  aneurysm  694 


Caries  of  lumbar  vertebra?  (skiagram)        -  460 

Caseous  gland  seen  witli  Ijronchoscope       -  158 
Cerebrospinal       meningitis      (temperatme 

chart)                        -----  591 

Cervical  rib  in  adult  (skiagram)  443 

„       child  (skiaurain)        -          -  443 

,.          spine,  anasthcsia  In  mi  injury  to  608 

C'ervicobrachial  plexus  (iliagrani)                 -  507 

Chancre  of  lower  lip         -         -         -         -  73 

Charcofs  hip-joint  (skiagram)                      -  350 

knee-joint           .          -          -          .  349 

Chest  outlines   ------  167 

Cheyue-Stokes'  l>reathing  (diagram)            -  107 

Cholcsterin  crystals             _          _          .          _  254. 
Cirrhosis,  pyrexia  in  (temperature  charts)  35,  371 

Claw-foot   -------  109 

Claw-hand         -         -         -         -         -         -  110 

Clubbed  fingers  in  pulmonary  stenosis        -  111 

Coli  bacilluria  (tem])erature  chart)    -  456 

Colon,  dropped  (skiiigram)         -          -  426 

.,       in  Hirschspiung's  disease        -          -  127 

,,       normal  (skiagraiu)            -          -          -  426 

Complex  malaria  (temperature  chart)       -  31 

Concretions  in  phthisical  sputum       -  644 

Confluent  small-pox            .          .          -          -  .-jei 

Congenital  svi>hilis,  faeies  in  (2  figs.)  234 

notched  teeth  (2  figs.)  234 

Connections  of  optic  nerves  and  tracts       -  300 

Constipation,  habitual  (diagram)                 -  122 

from  lead  poisoning  (diagram)  124 

with  miicomembranous  colitis  124 


Contracture  after  a  burn 
Dupuytren's 
Cretin,  showing  a  'frog-belly"  - 
Cretinism  .         .         .         .         , 

Crystals,  calcium  oxalate 

cholcsterin 

cysfin  -  .  .  . 

leufin  -  .  -  - 

plicnylglueosazonc 

triple  ])liosi)hatc 

ly  rosin 

uric  acid 
Cutaneous  nerve  supply  of  the  scalp 
Cyrtometrie  tracings  of  various   forms 

chest  -  - 

Cyst  (hydatid)  of  Imig  (skiagram) 
Cystin    crystals  -  -  . 

Dactylitis,  tu^crculous  (skiagram) 
Deal-porter's  bursa 
Diphtheria,  wristdrop  riilluwiiig 
Diplopia,  crossed  double  iinngcs 

hotnouyninus  doulilc  images 
Discrete  smail-poN 
Dissociative  aiinsthesiii  Ironi  I  liiciinbosis 

posterior  iulcrior  ccrcbeiliir  ;irlery 
Distribution  of  sensory  uerxis  jr]   liic  si 
Dropped  colon  (skiagliun) 
Dupuytren's  contracture 
Dwarfism,   riekelv 
Dysclie/.ia 

Dvstrophia  adiposogenilalis 
Keliinricoecal    booklets 
l-;i:islii-  tibr<'s  from  spuluru 
l';iectiocar<liograni  oraurjeuhir     lilirilhili 
cstmsvstclcs 


142 
142 
233 
189 
423 
254 
161 
333 
262 
524 
333 
741 
710 


161 
660 


616 
605 
426 
I  1-2 


r.vGi; 
Electrocardiogram  of  heart-block    (2   figs.)  83 
paroxysmal      tachy- 
cardia            -         -  703 
Emphysematous  chest  outline            -  167 
Enchondroma  of  hand  (skiagram)     -         -  671 
Endocarditis,  fungating,  enlarged  liver  and 

spleen  in     -          -  640 

(temperature  chart)  566 

KpitheJiiiiuMtiJus  ulcer  (diagram)       -          -  737 

l-a-ysipijiis  (tiuipcrature  chart)           -          -  568 

ExopiitliaJMiic  goitre,  faeies  of           -          -  236 

pigmentation  of  skin 

in         -         -         -  527 

Exostosis  of  femur  (skiagram)            -          -  670 

Extrasystoles  (electrocardiogram)      -         -  544 

Face,    head,    and   neck,   sensory  areas  of 

(4  diagrams)           -         -         _         .         _  44,s 

Facial  paralysis  (4  figs.)  -     491,  492 

bilateral                             -  49;> 

from  syphilis                      -  541 

Faeies  of  achondroplasia                              -  237 

acromegaly        -         .         .         .  237 

congenital  syphilis  (2  figs.)  234 

exophthalmic  goitre            -          -  23*> 

familial  lenticular  degeneration  23H 

locomotor  ataxy         -          -          -  23(i 

a  Mongolian  idiot  (2  figs.)            -  23H 

myxu-iUrna  (2  figs.)             -  38 

myasthenic  (2  ligs.)             -          -  235 

myopathic  (2   figs.)   -          -          -  235 

paralysis  agitans        -          -          -  236 

Familial  lenticular  degeneration,  faeies  of  238 

Favus        ------_  246 

Fibrosis  of  left  lung,  chest  outline       -  167 

Fingers,  pads  on  (2  figs.)            -         -         -  347 

Flint's  murmur          -----  95 

'  Frog-belly  '  in  a  cretin  -         -         -         -  223 

Gall-stones   (skiagram)      -         -         -         .  327 

Gallon's  whi.stlc        -----  105 

Glands,  malignant,  left  supraclavicular      -  49 
'  Glove  and  stocking '  anaesthesia  in  peri- 
pheral   neuritis      ----- 

Gonococcal   arthritis   (temperature   chart) 
Gout,  acute  (temperature  chart) 

chronic  -         .         .         .  . 

„        (skiagram) 
Gummatous  ulcer  (diagram)     - 
HuMuatin,  acid,  spectrum  of    - 

in  alkaline  solution,  spectrum  of  80 
Hirmoglobin,  re<luced,  spectrum  of  -          -  80 
Hand.  the.  in  tetany         -                    .          .  3 
in   niyxiedcma                                       -  38 
Heart  block,  electrocardiogram  of  (2  figs.)  83 
incoiuplete,   polygraph    trac- 
ing of        -       "  -          -  545 
polygraph  tracing  of              -  .546 
Ileberdeu's   node's      -----  .•}43 

Ileiuialrophy  of  face          -          .          -          -  494 

Henoch's  purpura     -----  34.5 

Hirschsprung's  disease  ;J89 

colon   iu  127 

Hodgkin's  di.seasc     -----  377 

(temperaliirr  cliinl)     -  ,570 

Hooklets,  hydatid  49 

Hour-glass  stonuich  (skiagram)  268 

Hydatid   cyst   of  lung  (skiiigram)                -  291 

booklets  49 

Hyperncplironia  palieul   (2  ligs.)  1.08 
ll\  piitlicriiiia    ill  lualignaiit  caclicxia  (tem- 

pcialuic    chart)  312 
Willi    iiiilral    stenosis    (Iciii- 

pciatiiie   (hart)  311 


LIST    OP    ILLUSTRATIONS 


pa(;e 

Idiopathic  dilatation   of  llic  bladder          -  6G5 

colon     -         -  389 

stomach         -  664 

Infantile  ])aralysis    -----  59 

Infantilism,  anangioplastic                           -  190 

,,             pituitary         -          -                    -  189 

Influenza,   prolonijed   (temperature   cliart)  564 

Inteutiiiii  Irciiiipr,  rnovemeuts  in          -          -  728 

Ki(hic\  ,  liil.(  I.  iilous  (sl<iayrain)                     -  280 

Kirl^laiid's  ihsease  (tcmpeiature  chart)       -  615 

Larynx  with  tooth-plate  impacted  in          -  195 
Lateral     sinus     thrombosis     (temperature 

chart)              -----  .567 

Leprosy,  nodular  -         - 

,,         peripheral  neuritis  in  - 
Lencin   crystals  .  .  .  - 

Lencomelaiiodcmiia.  sypliiliHe  (2  figs.) 
Leuka'inia   (tenipciature   chart) 

Lobar  piuunKinia  (tcin|)cratMre  chart)  642 

Lordosis,  myopathic           -          -          -          -  156 

Luml)ar  caries  (skiagram)           -          -          -  460 

Lunil>osacral  plexus  (diaijram)                      -  500 

iMacular  syphilides              -          -          _          -  383 

Malaria,  double  tertian  (temperature  chart)  30 

,,         chronic  (temperature  chart)         -  31 

,,         quartan  (temperature  chart)  29 

„         (|UOtitlian  (temperature  chart)  30 

„         tertian  (temperature  chart)        .  .  28 

Malformations  of  rectimi  (4  figs.)       -          -  586 

Malignant  endocardititis  (temperature  chart)  566 

cachexia  (tem])erature  chart)     -  312 

,,          left  supraclavicular  glands        -  49 

Mediterranean    fever   (temperature   chart)  565 

Meige's  disease  (2  figs.)     -         -         -    411,  414 

Meningocele  of  face             -          -          -          .  230 

Metha-mrglobin,  spectrum  of                         -  80 

Miculicz's  syndrome           -          -                    -  25 

Milrov's  dis'iMM-  (•_>  fios.)    -          -          .     411,  414 

Miners'  i>h(lii-.is  (ski:mram)        -          -          -  159 

iMitral  stenosis,  diagram  of  bruits  of  -           -  94 

,,            „          (temperature  chart)   -          -  311 

Molluscum  fibrosimi,  early         -                    -  711 

Mongolian  idiot,  facies  of  a  (2  figs.)              -  238 

Mongolism  (2  figs.)              -          -          -          -  190 

:\Iorbus  ctrriUeus,  pulmonary  stenosis  157 

Movements  in  ataxy          .          -          -          -  728 

„               intention  tremor                   -  728 

Mucous  cast  of  intestine  -                   -         -  398 

Muscular  atrophy     -          -                              -  59 

Myasthcni.'  laciei  (2  ligs.)                               -  235 

Myelitis,  ana-stlicsia  from                               -  608 

Myoi)atliic  lacics  (2  figs.)                       -          -  235 

lordosis              _          _          -          -  155 
Myxci'dema,  facies   before   and    during   (2 

_^        M^-)           -         -          -          -  234 

facies  in  (2  figs.)           -         -  38 

hands  in        -          -          -          -  38 

Nails,  ridged  after  pneumonia  -         -         -  769 

Nod\dar  leprosy        -----  404 

Notched  teeth  in  congenital  syphilis  (2  figs.)  234 
Ocular  muscles,  double  images  in  paralysis 

of           -------  177 

(Esophagus  blocked  by  a  bean  (skiagram)  195 
idio])atliic  dilatation  of  (skia- 
gram)          -          -          -          -  198 

.,            stenosis  of  (skiagram)  197 

OiJtic  nerves  and  tracts,  connections  of     -  300 

Osteitis  deformans  (2  figs.)         -          -          -  155 

O.steo-arthropatliy.  pulmonary  (2  ligs.)      -  351 

Osteogenesis    impcrlccta   -          -          -          -  187 

Oxyhajmoglobin,  spectrum  of  -                    -  80 

Pad.?  on  fingers  (2  figs.)    -          -          -         -  347 


PAGi; 

Paralysis  agitans,  facies  of       -          •          -  236 

facial  (4  figs.)              -          -      491,  492 

infantile              -         -         -         -  59 

of  internal  rectus      -                   -  541 

of  right  serratus  magnus  -  506 

Volkmann's        -          .          .          -  14] 

Pellagra  (temperature  chart) 

Perforating  ulcer  of  foot 

Periostitis,  chronic  (skiagram)  66K 

Peripheral  neuritis,   'glove   and  stocking' 

anaesthesia  in          -  60(i 

in  leprosy           -          -  ,50.") 

Pernicious  ana'uiia  (temperature  chart)     -  56i> 

Peroneal  palsy.  Tooth's  (2  figs.)         -           -  60 

PlicTivliiliiicsa/.onc    crvstals        -           -          -  262 

Phthisis,  mottling  of  the  hmg  in  (skiagram)  lO.T 

Pigeon-chest  outline           -          .          -          .  167 

Pigmentation  from  arsenic         -         -         -  529 

in  exophthalmic  goitre  527 

Pituitary  infantilism          -          .          .          -  189 

Pnemnonia  (skiagram)       -          -          -          -  289 

with    empyema    (temperature 

chart)          -         -         .         .  160 
ridging  of  nails  after  769 
Politzer's  acoumeter           -         -                    -  164 
Polygra])h  tracing  of  heart-block      -          -  546 
..of    incomplete     heart- 
block        -          -          -  54.-, 
.,        of    ventricular    extra- 
systole               -         -  547 
Progeria              --.-..  190 
Pseudoleukamia  infantum          -                    -  37 
Ptosis  and  healed  gumma  of  lace        -          -  .541 
Pulmonary   osteoarthropathy   (2   figs.)     -  351 
Pulsus  bisferiens        -         -         -         -         .  550 
Purpura  in  fungating  endocarditis    -  555 
Pyelogra|)hy  (skiagram)   -         -         -         -  356 
Pyopneumothorax  (skiagram)  -                    -  531 
Hat  liiti-  fcyer  (temperature  chart)              -  598 
Haynauds  disease,  fingers         -                    -  257 
,,        local  asphyxia    -         -  256 
Rectum,  malformations  of  (4  figs.)            -  586 
Reflex  centres  in  spinal  cord  -          -          -  518 
Regions  of  the  abdomen  -          -          -          -  659 
Relapsing  fever  (temperature  chart )           -  27 
Renal  calciUus  (skiagram)          -                    -  279 
,,       growth  into  vena  cava  -         -         -  750 
Rheumatoid  arthritis,  acute      -          -          -  342 
,,     hands  in  (skia- 
gram)        -  342 
(temperature     chart)  341 
transparency  of  bones 


(skiagram) 

Rickety  chest  outline        -         -         -         - 
,,         dwarfism      -  -  -  - 

Ridging  of  nails  after  pneumonia     - 
Rigors    and    pyrexia    from    lateral    sinus 

thrombosis  (temperatiu'e  chart) 
RodcTit  ulcer,  diagram  of  -  -  - 

Sacrum,  anasthcsia  from  injury  to - 
Salicylates  in  acute  rheumatism,  effects^of 
(temperatme   chart)       -  -  -  - 

Sarcini  ventriculi      -         - 
Sarcoma  of  lung  (skiagram)     - 
radius  (skiagram 
(temperature  chart) 
of  til)ia   (skiagram) 
Seal]),  cutaneous  nerve  supply  of 

segmental  areas  of  -  -  - 

Sensory  areas    of    face,   head,    and     neck 
(4  diagrams)     -  -  -  - 

disturbances  in  tabes  - 


344 
167 
186 
769 

507 
737 
608 


-  338 
241 

-  105 
i  figs.  I  672,  673 

-  570 

-  (>71 

-  710 


448 
6(»il 


LIST    OK    ILLUSTRATIONS 


TACK 

Seii.'ory  olTccts  of  ulnar  luivc  divisioii     -  (■,{)(; 
localization  in  spinal  cortl  -          -  518 
nerves  in  the  skin,  distribution  of  ()()5 
traets  in  cord      -          -          -          _  007 
Septic  dermatitis  wrongly  diaijnosed  small- 
pox       -          -          -          -          -          -          -  -.f.2 

Serratus  niaKUUs  paralysis         -          -          .  .-;()(; 
Skiagram  of  aneurysm       -          -          .          .  (,3.-, 
Iiean  in  the  u'sopliajius-          -  lo.'j 
bismntli  blocked  by  epitheli- 
oma in  (esophajius  l!)f> 
in   dropped   colon     -  420 
in  normal  colon         -  -1.2(i 
eareinoma   of  bone           -          -  ],'52 
coli    with    bisnmth 

enema         -          -  12(1 

of  s])lenie    llexiire-  I2.j 

stomaeli  -          -  200 

[)ylorie  270 

cardiospasm   -          -          -          .  19^ 

caseous   bronchial    jrland          -  149 

cervical  rib  in  adult                  -  4J.;{ 

child        -          -  443 

Charcot's  hip-joint          -         -  350 

chronic  frout                     -         _  345 

periostitis             -          -  0O8 

dropped  and  dilated  stomach  318 

enchondroma  of  hand     -          -  071 

exostosis  of  femur  -          -          -  070 

^'a  1 1 -stones       -          -          -          _  ;j27 

hands     in    acute     rheumatoid 

arthritis       -          -          .          .  342 

hour-glass  stomach                    -  2(>8 

hydatid  cyst  of  lung       -          -  29] 

large  thynms  gland                    -  41 9 

leatlier-liottlc   ston)aeli  27() 
lobar  pneumonia 
lumbar   caries 
lung  in  ])htliisis 

,,           sarcoma               -          -  lo.^ 

miner's  phthisis                          -  l-,9 

normal  stomach                      24.";.  20il 

perl.isteal  sarcoma  of  tibia         "  7i'\ 

pyelography              -          -           .  ;;.-,() 

pyopneumolhoraN  ^                    .  r,:U 

renal   calculus           -           .           .  27!) 

saccular  aneurysm                     -  2()!» 

sarcoma  of  radius  (4  figs.)  072,  (i7;i 

tibia     -  (171 
■  spine  '  on  os  calcis 
stenosis   of  the   lesophagu 
syphilitic   radius      - 
sliowing  transpareiu-v  of  In 
Jn    rheiUTiatoid   arlhiilis 
Ihymcis  gland  crdarged 
tuberculous  daelylilis 

,.  kidney 

ureteral  calculus   '• 
v<'sical  c'aleulus 
Sinall-po\.  corilluenl 
.liser.le 
eruption 
>pcelral  absorption  bands 

V'O'lrimi   or  aei.l    lia-irialirj  HO 

'■•"■'"'^^yl'''- tilobin  80 

'licmalui  in  alkaline  solution  80 

niell,a-n,og|,,lMn     -                      ,  80 

oxyha-moglobin                -  80 

reduced   ha-moglobin      -  80 

,'•  .  "r<-l)ilin  -  -  80 
pceeli  centres  -  -  .  .  _  ,.., , 
pinal   cord,   rellex   eenlres   in   -           -           .      ,'Xh 


28!t 
4<iO 

io:j 


41.0 
1!»7 
(i(i!) 

.■(44 
H!) 
(iO!) 
280 


-.57 


Spinal  cord,  sensory  localization   in  -     518 

„      pain  referred,  areas  of  -         -         -     710 

■  Spine  '  on  os  calcis         -         -         .         -     440 

Splenic  ana;mia  -  -         .  (;;j;j 

Spondylitis  deformans       -  -  -  -     (i48 

Sputum,  elastic  libres  in  -         -         -         -     042 

Still's  disease    -----_     377 

Stomach,  eareinoma   of  (skiagram)   -  -     20!) 

dilfuse  (skiagram)     270 

pyloric  (skiagram)     270 

dropi)ed  and  dilated  (skiagram)     ;il8 

idiopathic  dilatation  of     -         -     (J64 

normal  (skiagram)     -  -      243,  20!) 

.Sy])hilides,  macular  -----     ^s!! 

Syphilis,  congenital,  faeics  in  (2  ligs.)         -     234 

uotehed  teeth  in  (2  figs.)  234 

facial  paral.Nsis  from    -  -  -     541 

|)tosis  and   paralysis  from  (Migs.)      541 

Syphilitic  leucomelauodermia  (2  ligs.)        -     528 

„  radius  (skiagram)       -  -  -     (i(j9 

Syringomyelia,  ana;sthcsia  from         -         -     009 

Syringomyelic  claw-hand  -         -         -     110 

Tabes  dorsalis,  faeics  of  -         -         -     230 

„  sensory  changes  in  009 

Tachycardia,    paroxysmal     (electiocajilio- 

gram)  -----.     703 

Ticnia  mediocanellata,  head  of  -         -     519 

,,      solium,  head  of  (2  ligs.)         -         -     5i<) 

ovum  of    -  -  -  -     520 

Temperature  chart  in  carcinoma  of  li\er, 

pyrexia  of  -         -     320 
cerebrospinal  menin- 
gitis    -         -         -     591 
cirrhosis, pvrexia  of 

3.5,  371 
coli  baeilluria  -  450 
erysipelas        -  -     508 

gonococcal  arthritis     338 
gout,  acute    -  -     33!) 

Hodgkin's  disease  -     570 
hyi)othermia  in  ma- 

ligiumt    cachexia      312 
hypotherntia     with 

mitral  stenosis     -     311 

iidluenza,  prolonged    504 

Kirkland's  disease       015 

•  .  ..  leuka'inia        -  -        25 

!>  „  malaria,  chronic      -       31 

,.  .,        complex     -        31 

..        double  Icr- 

liau  30 

(pi.artau  29 

ipjolidiau  -        .'iO 

!.  !,  ..         Iciliau        -        28 

>.  ,.  malignaid  cudoear 

ilitis  -     500 

„  ,,  .Mcdilerrauc.-m  fever    50.5 

"  >,  pellagra  -      223 

pernicious  auaiuia       5(i9 

,,  pneumonia         willi 

empyema   -  -      KiO 

,.  pneumonia,  lobar  -     (i42 

pya-mia  -     507 

rat-bile  fever  598 

rela|)siiig  fever        -        27 

..  ..  I'hcumatism,  acute, 

eireel ofsalieylales  3.38 

:.  ..  rheumatoid  arllirilis    341 

<-ase  of  sarcoma      -      .570 

typhoid   fever         -     505 

I  \phus  fever  ending 

bv  crisis     (i39 


LIST    OF    ILLUSTRATIONS 


TerajH-niturc  i-liarr  in  typluis  lever  cixliiis 

by  lysis  -         -         - 

Tetany,  tlie  liaiiil   in 
Thymus  ■.land  cnlaificd  (skia<.n-am) 
Tiiiie    relations    iit    food    in    lar^e 

(diaiirani)       -  -  -  - 

Tooth-plate  iinpaetcd  in  larynx 
Tootirs  |)eroneal  palsy  (2  figs.) 
Transillumination  of  the  antrum 
Triehnccphalus  dispar  in  the  colon 

.,       ovum  of 
Triple  (ihosphate  crystals 
Tuliere\dons  ea-eimi - 

kidney  (skiagram) 
iilcer  (diagram) 
Tuniny-fork  with  foot-jjicce 
Tyjihoid  fever  (temperature  chart)   - 
Typhus  fever  ending  by  crisis  (temperalui 
'chart) 


I'AGE 

038 
3 

n9 

1 23 
19.5 


458 
280 


of 


Typhus  fever  ending  by  lysis  (tempcrati 

chart)    ----"' 
Tvrosln  crystals         - 
lUcer  of  foot,  perforating 
T 'leers,  typical  (diagrams) 
Ulnar  nerve  division,  sensory  elTcet 
Ureteral  calculus  (skiagram)     - 
Uric  acid  crystals     - 
Urobilin,  spectrum  of 
Varicose  abdominal  veins 
Vena  cava  obstructed  by  aortic  aneurysm 

superior,  obstructed  by  aneurysm 
Ve'iitrieu'lar  extrasystole  (polygraph  tracing) 
Vesical  calculus  (skiagram) 
Visceroiitosis     -         -         - 
Volkmann's  paralysis 
Xon  .Jaksch's  disease 
Whip-worms  in  the  colon 
Wrist-drop  after  di])htlieria 


638 
333 


(iOO 
45.5 


208 
1;58 
547 

282 


AN     INDEX     OF 

DIFFERENTIAL    DIAGNOSIS 
OF    MAIN    SYMPTOMS 


ACCENTUATION  OF  HEART  SOUNDS.— It  may  be  that,  without  cardiac  bruit, 
me  or  other  of  tlie  heart  sounds  is  much  louder  tlian  it  ouglit  to  be.  Such  accentuation 
eneraily  has  important  clinical  significance.  It  is  the  first  sound  that  is  likely  to  be  accen- 
uated  or  prolonged  at  the  impulse  ;  whilst  in  the  second  right,  or  second  and  third  left 
ntcrcostal  spaces  close  to  the  sternum,  it  is  the  second  sound  that  is  likely  to  be  accentuated 
athcr  than  the  first.  It  is  very  unusual  to  find  the  first  sound  accentuated  at  the  base 
ir  the  second  sound  at  the  impulse,  unless  there  is  at  the  same  time  still  greater  accen- 
uation  of  the  first  sound  at  the  impulse,  and  of  the  second  sound  at  the  base  respectively, 
lence  the  three  conditions  under  which  accentuation  of  a  cardiac  sound  becomes  clinically 
mportant  are:  (1)  When  the  second  sound  is  unduly  loud  in  Ihc  second  right  intercostal 
pace  close  to  the  sternum  ;  (2)  When  there  is  accentuation  of  the  second  sound  ivith 
nadimum  of  inleuaiti/  in  the  second  or  third  left  intercostal  space  close  to  the  sternum  ; 
:j)   When  there  /.v  accentuationof  the  first  sound  icith  maximum  intensiti/  at  or  near  the  impulse. 

Accentuation  of  the  second  sound  witli  maximum  intensity  in  the  second  right 
ntercostal  space  close  to  the  sternum  nearly  always  indicates  that  the  systemic  hlood- 
)ressurc  is  above  the  normal.  The  latter  can  only  be  determined  with  certainty  by  actual 
neasuremcnt  of  Ihe  systemic  blood-pressure  instrumentally.  The  causes  of  the  increase 
vill  probably  be  one  or  other  of  the  following  : — 

-Irtf. — Even  liealthy  jjcrsons  over  fifty  begin  to  show  sliglit  increase  of  Blood- 
RKSSuitK  (p.  81)  :    and  their  aortic  second  sound  begins  to  get  louder  than  the  first. 

Arteriosclerosis  or  granular  kidney. — These  can  be  discussed  together,  because  it 
s  extremely  dillieult  to  tell  where  the  one  ends  and  the  other  begins.  In  both  there  is 
ardiae  liyperlniphy,  increase  in  the  blood-i)ressiire,  prolongation  of  the  first  soimd  at 
he  impulse,  possibly  a  blowing  systolic  bruit  there,  a  ringing  or  clanging  aortic  second 
;oun(l,  albuinimiria.  a  tendency  to  heart  failure  as  time  goes  on,  with  all  its  concomitant 
lyniptoms,  and  albuminuric  retinitis.  It  is  sometimes  stated  that  the  accentuation  of 
he  aortic  second  sound  is  due  to  local  atheroma  ;  but  this  is  inaccurate,  for  atheroma 
)y  itself,  though  it  may  easily  produce  an  aortic  systolic  bruit,  does  not  accentuate  the 
iccond  soun(^:  and  when  in  the  second  right  intercostal  space  there  is  a  soft  systolic  bruit 
•eplacing  the  lirst  sound,  and  a  clanging  second  somul,  the  former  indictites  atheroma  of 
he  aortic  valves,  and  the  latter  arteriosclerosis.  These  two  absolutely  <listinct  vascular 
esions  often  coincide  in  the  same  j)atient.  atheroma  affecting  the  aorta,  and  the  coronary 
md  cerebral  arliries,  whilst  arteriosclerosis  affects  the  middle-sized  arteries,  especially 
)f  the  splanchnic  area.  There  is  often  extensive  visceral  arteriosclerosis  when  the  radiid 
irtcry  docs  iiol    IVcl  alini)rm:d  to  the  fingers. 

Accentuation  of  the  second  sound  with  maximum  intensity  in  the  second  or 
third  left  intercostal  space  close  to  llu-  slcrnum.  generally  spoken  of  as  acccnl  nation 
f  the  pulmonary  second  sound,  indicates  a   higher  pressutc  lliaii   I  heir  sliould   be  in   Ihe 

(ulmonary  circulation,  except  in  children,  in  wliorn  it    is  not    imicoii ii   lo  liiicl   llir  pul- 

iionary  second  sound  normally  nuich  louder  than  the  aortic.  The  most  important  cause 
)f  pathological  aeccntMalion  of  the  pulmonary  second  sound  is  disease  of  Ihe  mitral  valve  ; 
t,occurs  more  markedly  willi  milial  slenosis  than  with  inilral  regurgitation.  It  may 
ionietimcs  he  a  niaikcd  fcaluic  oi  Ihr  lallcf.  ulicllici'  iliic  lo  oiLiaiiic  cliaiiges  In  llic  mitral 
n  1 


•2  ACCENTUATION    OP    HEART    SOUNDS 

valve  itself,  or  secondary  to  dihitatioii  of  the  otherwise  normal  orifice  as  the  result  of  heart 
failure  from  aortic  disease,  niyocanlial  diueneration,  arteriosclerosis,  or  granular  kidney. 
Sometimes,  instead  of  accentuation  of  the  pulmonary  second  sound,  the  latter  may  be 
reduplicated  ;  the  significance  of  its  reduplication  is  identical  with  that  of  its  accentuation, 
the  probable  reason  for  the  reduplication  being  that  when  the  pressure  in  the  jjulmonary 
circulation  is  relatively  very  much  above  the  normal,  the  pulmonary  semilunar  valves 
close  sooner  than  the  aortic,  the  first  part  of  the  reduplicated  second  sound  being  due  to 
closure  of  the  pulmonary  valves,  whilst  its  second  part  is  due  to  closure  of  the  aortic  valves. 
The  cause  of  an  accentuated  or  reduplicated  pulmonary  second  sound  will  generally  be 
obvious  if  the  other  cardiac  physical  signs  are  observed  carefully  ;  one  way  in  which  it 
may  have  particular  significance  is  in  distinguishing  between  old  and  recent  changes  in 
the  mitral  valve  ;  when,  for  instance,  a  systolic  and  mid-diastolic  bruit  at  the  impulse  are 
due  to  recent  endocarditis  which  may  jiosslbly  clear  up,  there  is  very  much  less  accentua- 
tion of  the  pulmonary  second  sound  than  there  would  be  if  the  same  bruits  were  due  to 
mitral  stenosis  and  regurgitation  due  to  old  lil)rotic  changes.  The  greater  the  accentuation 
of  the  |)ulmonary  second  sound,  the  greater  the   mitral  leakage  or  obstruction. 

Accentuation  of  the  first  sound  at  the  impulse  may  have  one  or  other  of  two 
entirely  different  characters  ;  it  may  be  an  accentuation  of  very  short  duration,  difficult 
to  describe  in  words,  though  obvious  enough  when  heard,  and  often  spoken  of  as  a 
■  slapping  '  first  sound  at  the  impulse  :  this  is  one  of  the  most  characteristic  physical 
signs  in  many  cases  of  mitral  stenosis.  It  may  occur  when  there  is  neither  a  presystolic 
nor  a  mid-diastolic  bruit,  though  even  when  there  is  a  bruit  the  slapping  character  of  the 
first  sound  is  still  to  be  distinguished.  When  there  is  failure  of  compensation  in  a  mitral 
case,  the  driving  power  of  the  heart  may  become  so  feeble  that  bruits  are  no  longer  audible, 
and  the  heart's  action  is  quite  irregular  ;  in  such  cases,  the  occurrence  of  this  slapping 
character  of  the  first  sound,  clearly  audible  here  and  there  in  an  otherwise  tumbling 
rhythm,  is  highly  suggestive  of  mitral  stenosis. 

The  second  variety  of  accentuation  of  the  first  sound  at  the  impulse  consists  in  its 
being  very  much  longer  tlian  it  ought  to  be — a  marked  prolongation  of  the  first  sound 
as  distinct  from  there  being  any  bruit.  This  prolongation  is  obvious  enough  when  heard. 
It  indicates  that  there  is  considerable  hyi)ertro])hy  of  the  left  ventricle,  and  therefore, 
in  the  absence  of  bruits,  nearly  always  points  to  a  high  blood-pressure  such  as  results  from 
either  arteriosclerosis,  granular  kidney,  or  the  two  combined  ;  it  is  repeatedly  met  with 
in  cases  in  which  there  is  accentuation  of  the  aortic  second  sound  at  the  same  time.  In 
a  ])crson  of  middle  age  or  over,  in  whom  there  is  a  prolonged  first  sound  at  the  impulse 
— sometimes  spoken  of  as  a  •  lumpy  '  first  sound — and  a  clanging  aortic  second  sound, 
with  or  without  Albuminuria  (p.  11),  a  diagnosis  of  arteriosclerosis  or  of  granular  kidney 
is  very  probably  correct,  and  instrinnental  determination  of  the  blood-pressure  will 
generally  sliow  that  it  has  risen  from  the  normal  120-150  mm.  Hg  to  something  between 
l.S()  and  300  mm.  Hg,  or  even  more. 

It  is  noteworthy  that  transient  accentuation  of  the  first  sound  at  the  impulse  may 
occur  in  nervous  young  patients  examined  while  their  hearts  are  acting  rapidly  ;  it  vanishes 
in  a  few  minutes  when  the  patient  becomes  less  nervous  and  the  heart  slower.  The 
phenomenon  is  common  in  connection  with  life  insurance  examinations.        Herbert  French. 

ACCOUCHEUR'S  HAND  is  seen  most  characteristically  in  tetany  (Fig.  1),  though 
it  may  also  occur  in  a  few  cases  of  other  spasmodic  neuro-museular  affections  such  as 
<itlictr>sis.  In  a  typical  case,  the  attitude  of  the  fingers  is  almost  pathognomonic.  There 
is  full  extension  of  all  tlie  fingers  and  of  the  thumb  at  the  interphalangeal  joints,  the  four 
fino-ers  are  adducted  firmly  towards  the  middle  finger,  so  as  to  form  a  cone,  they  are  semi- 
flexed at  the  metacarpo-phalangeal  joints,  and  the  thumb  is  strongly  adducted  and  opposed 
to  the  cone  of  which  the  middle  finger  forms  the  apex,  or  else  into  the  palm  of  the  hand. 
The  spasmodic  muscular  contraction  seldom  ceases  here,  but  generally  affects  the  rest  of 
the  arm  also,  the  wrist  being  flexed  and  abducted  towards  the  ulnar  side.  The  elbov/^  is 
flexed  to  a  right  angle,  and  the  arm  rotated  inward  and  adducted  so  as  to  lie  in  contact 
with  the  trunk.  The  affection  is  symmetrical.  The  feet  and  ankles  are  apt  to  show 
similar  spasmodic  contractions,  the  ankle  being  fidly  nlantar-flexed,  the  toes  and  the  distal 
iialt  of  the  feet  rotated  inward,  the  knees  extended  rigidly,  and  generally  the  thighs  also. 


ACETONURIA  3 

Tlie  contractions  may  be  limited  to  tlie  liands  and  feet — the  so-called  carpo-pedal  spasm 
— especially  in  the  tetany  of  young  children  suffering  from  rickets  or  from  gastro-intestinal 
disorder  such  as  diarrhoea.  AVhen  adults  are  affected,  the  symptoms  spread  from  the 
limbs  to  the  trunk,  the  whole  body  being  kept  rigidly  extended,  the  paroxysms  lasting 
from  a  few  minutes  to  many  hours,  and  recurring  for^ays.  weeks,  or  even  months.  So 
far  as  the  tetany  itself  is  concerned  recovery  is 
invariable,  though  the  patient  may  sometimes 
succumb  to  tlie  associated  malady,  tetany  itself 
being  generally  not  a  primary  disease  but  a  com- 
plication of  gastric  ulcer,  gastrectasis,  colitis, 
intestinal  fermentation  or  putrefaction,  thyroidec- 
tomy,   or    jircgnancy.     The    diagnosis    is    seldom 

dillicult.  - 

One  remarkable  feature  of  the  case  is  that 
in  the  intervals  between  the  spasms,  if  the  upper 
ami  is  grasped  firmly  between  the  observer's  two 

hands,  and  the  pressure  maintained,  the  hand  and  wrist  may  be  forthwith  sent  into  the 
typical  spasm,  a  sign  described  as  Trousseau's.  If  the  cheek  close  to  the  front  of  the  ear 
is  percussed  gently  but  sharply  from  above  downwards,  the  different  groups  of  muscles 
supplied  by  the  branches  of  the  pes  anserinus  of  the  seventh  nerve  can  be  made  to 
twitch  successively — Chvostek"s  sign.  The  muscles  of  the  limbs  often  show  altered 
electrical  reactions  in  that,  though  still  responding  to  faradism,  with  galvanism  .\.C.C.  is 
greater  than  K.C.C. — Erb's  sign.  Herbert  Freiieli. 

ACETONURIA  denotes  the  occurrence  of  acetone  in  the  urine  in  amounts  to  be 
(lilcitcd  by  (iiiliiuiry  clinical  tests.  In  ])ractice  the  lalxiratory  method  of  distilling  a 
(|uantity  of  urine  to  get  a  concentrated  solution  of  any  acetone  that  may  be  present  takes 
too  long,  and  yet  without  distillation  it  is  dillicult  to  apply  the  iodoform  test  for  acetone. 
An  easier  and  more  useful  plan  is  Legal's  nitroprussidc  test,  or  Rothera's  modification  of  it. 
Legal's  test  consists  in  taking  5  c.c.  of  urine  in  a  test-tube,  adding  a  few  drops  of  liquor 
sodic,  then  a  few  drops  of  fresh  sodium  nitroprussidc  solution,  and  finally  acidifying  with 
strong  acetic  acid.  The  li(|Uor  soda-  causes  no  change  of  colour,  or  at  most  an  opalescence 
from  the  prccii)itation  of  j)hosphates  ;  the  sodium  nitroprussidc  produces  a  reddish-brown 
colour  in  almost  all  urines  owing  to  the  presence  of  creatinine  :  if  the  red  colour  is  due  to 
creatinine  only  it  is  discharged  on  adding  acetic  acid,  whereas  when  acetone  is  present 
the  red  deepens  into  a  rich  burgundy  that  is  unmistakable.  Kothera's  modification  of  this 
test  consists  in  adding  a  few  dro|)s  of  fresh  nilroprusside  solution  to  .5  c.c.  r)f  urine,  li(|U()r 
anun(>ni;c  till  the  tnixlure  is  decidedly  alkaline,  and  llieii  ainnioniuin  sulphate  cryslals 
in  excess  :  as  the  solution  bcc(jiiies  saturated  willi  llie  latter,  a  colour  like  that  ol'  polassiuni 
permanganate  develops  if  acetone  is  present,  the  maximum  being  reached  in  about  fifteen 
minutes. 

.\cetone  is  often  ass{)ciatcd  with  diaeetic  acid,  oxybutyric  acid,  and  ainido-oxybulyric 
acid  ;  the  rietcction  of  these, 'however,  affords  no  clinical  inl'orinalion  that  is  not  alTorded 
by  the  acetone  alone,  so  that  it  generally  sullices  to  tesi  for  the  latter,  and  jxissibly  for 
diaeetic  acid  also.  The  tests  for  the  butyric  acids  are  clilliculf.  When  these  subslances 
are  being  proilueed,  the  patient  is  said  to  be  suffering  from  miilosis.  the  result  of  unnatural 
metabolism,  .\cetonuria  is  indeed  the  chief  i>ractical  evitlenee  of  acidosis.  It  occurs  in 
the  most  extreme  degree  in  certain  cases  of  diabetes  mellilus  ;  from  the  point  of  view  of 
prognosis  all  cases  of  glycosuria  may  be  di\idcd  broadly  into  two  classes,  namely,  those 
with,  and  those  without,  acetomnia.  'I'lie  same  patient  may.  of  course,  l)e  jiassing  acetone 
in  his  urine  at  one  time  and  not  at  another  :  the  |)rognosis  is  always  graver,  howevir.  when 
acetone  is  present,  for  it  is  tlic  acidosis  that  causes  the  serious  results  of  diahctis  and 
glycosuria.  .\  |)atient  witimut  acelonuria  is  in  no  immediate  danger  of  enma.  wliiiias. 
when  acetone  is  present  as  well  as  sugar,  coma  may  siiperx  iiie  at  aii\  linic.  Uroadly 
speaking,  once  glycosuria  has  been  diagnosed,  it  is  more  iiiip(jrlarit  to  list  the  urine  for 
acetone   from  time  to  time  than   it   is   for  sugar,   and    thai    t  ic:it  iiiriil    wliieli   ir(hiees   the 

acetone  to  a  miniinum   is,   ijciierally  speaking,   lining   most    g I,    wliati\ir  (|uaiililies  of 

sugar  may  be  passed. 


4  ACETOXURIA 

Acetontiria  may  occur,  however,  without  glycosuria  ;  even  a  healtliy  person  who 
is  starved  oi^  carbohydrate  food  is  apt  to  pass  acetone  and  diacetic  acid  in  the  urine.  Tliis 
explains  why  it  is  that  acetonuria  occurs  in  such  conditions  as  gastric  ulcer  :  gastric  carci- 
noma ;  gastrectasis  :  oesophageal  stenosis  :  intestinal  obstruction  :  cachexia,  whether 
tuberculous,  malignant,  syphilitic  or  malarial  :  in  cases  of  persistent  vomiting  of  pregnancy  : 
ura>mia  ;  severe  migraine  ;  infantile  diarrhoea  and  vomiting  :  cyclical  vomiting  of  children 
(p.  765)  ;  and  probably  in  many  other  conditions  in  which  there  is  either  actual  or  virtual 
starvation.  The  same  applies  to  surgical  operations  under  ansestheties — the  patient  is 
often  starved  beforehand,  and  may  then  be  persistently  sick  afterwards  :  almost  all  patients 
who  have  been  under  a  general  anicsthetic  for  any  length  of  time  have  acetonuria.  and  in 
some  the  acidosis  increases  instead  of  being  transient,  this  being  to  a  large  extent,  perhaps, 
the  pathology  of  so-called  delayed  chloroform  poisoning.  It  may  also  result  from  gross 
intracranial  lesions,  especially  those  of  an  inflammatory  nature  ;  thus,  acetonuria  may 
be  pronounced  even  as  early  as  the  first  two  or  three  days  in  acute  epidemic  cerebro- 
spinal meningitis. 

The  chief  importance  of  acetonuria  therefore  from  a  diagnostic  point  of  view  lies, 
not  so  much  in  distinguishing  one  disease  from  another,  as  in  detecting  the  existence  of 
acidosis.  The  importance  of  this  from  the  point  of  view  of  prophylaxis  and  treatment 
will  be  obvious  when  it  is  remembered  that  acidosis  does  not  occur  until  the  liver  and  tissues 
have  lost  their  glycogen,  and  that  glycogen  storage  depends  largely  upon  the  ingestion 
of  carbohydrates  either  by  the  mouth,  the  rectum,  or  hj^DOdermically.  Herbert   Freiieli. 

ACIDOSIS.— (See  Acetonuria,  p.  3.) 

ACROPARiCSTHESIA.— (See  Pain  in  the  Extrejiitv,  Upper,  p.  442.) 

ALBUMINURIA. — This  term  is  used  to  denote  the  passage  in  the  urine  of  proteid 
that  is  coagulablc  on  boiling.  More  than  one  substance  is  included  in  this  sense,  and  there 
are  varying  proportions  of  albumin  and  globulin  in  different  cases.  So  variable  may  be 
the  relative  amounts  of  these,  not  only  in  different  diseases,  but  also  in  different  cases  of 
the  same  disease,  and  in  the  same  patient  at  different  times,  that  little  useful  clinical  infor- 
mation is  to  be  obtained  by  dealing  with  them  separately,  at  any  rate  so  far  as  present 
knowledge  goes.     Nucleo-albumin  (p.  424)  comes  in  quite  a  different  category. 

Although  numbers  of  tests  for  albumin  have  been  devised  and  advocated,  for  clinical 
purposes  there  is  little  need  to  trouble  about  more  than  the  two  common  ones,  namely 
the  acetic  acid  and  boiling,  and  the  cold  nitric  acid  tests.  It  is  true  that  each  of  these  has 
fallacies  ;  but  the  latter  are  not  common  to  both,  and  therefore  if  there  is  doubt  in  the 
interpretation  of  one  of  the  two  tests,  it  can  be  confirmed  or  otherwise  by  the  other.  More 
delicate  tests  exist,  but  there  is  such  a  thing  as  too  great  delicacy  in  a  clinical  method. 
One  does  not  want  to  find  albumin  in  minute  traces  where  it  does  not  matter  ;  and  it 
seldom  matters  until  its  amount  is  sufficient  to  give  both  the  common  tests. 

The  Acetic  Acid  and  Boiling  Test. — A  test-tube  three  parts  full  of  urine — cleared 
by  filtration  if  need  be — is  held  by  its  lower  end  whilst  its  upper  part  is  heated  carefully 
to  boiling  point.  It  is  best  not  to  add  any  acetic  acid  before  boiling  unless  the  specimen 
is  distinctly  alkaline,  in  which  case  it  may  be  just  acidulated  with  a  drop  of  acetic  acid. 
After  boiling,  the  tube  should  be  held  in  a  good  surface-light  against  a  dark  background, 
such  as  the  sleeve  of  one's  coat  :  any  opalescence  will  be  obvious,  and  there  may  be  a  dense 
white  cloud.  Except  in  rare  cases  of  Bence-Jones  albumosuria  (p.  16),  this  will  be  due 
to  one  or  more  of  three  things,  namely,  calcium  and  magnesium  phosphate,  calcium  car- 
bonate, or  coagulated  albumin.  One.  two.  or  more  drops  of  acetic  acid  solution  (B.P.)  arc 
now  added  :  if  the  cloud  disappears  entirely,  quickly,  and  at  once,  it  was  due  to  earthy 
phosphates,  and  no  albumin  is  present  :  if  it  disappears  entireh-  but  with  brisk  efferves- 
cence, the  latter  is  due  to  calcium  carbonates  amongst  the  phosphates,  and  no  albumin  is 
present  ;  if,  on  the  other  hand,  the  cloud  clears  up  but  partially,  or  remains  imaltered,  or 
actually  increases  and  becomes  more  flocculent,  albumin  is  almost  certainly  present.  There 
is  only  one  serious  fallacy  remaining,  and  that  is  in  regard  to  nucleo-proteid  :  this  is  preci- 
pitated by  acetic  acid,  and  it  is  possible  for  a  cloud  of  phosphates  to  be  cleared  up  by  the 
latter  and  yet  for  a  faint  cloud  of  nucleo-proteid  to  come  down  in  the  place  of  the  phosphates 
in  such  a  way  as  to  suggest  that  the  original  cloud  was  not  wholly  soluble  in  the  acid,  and 


ALBUMINURIA  5 

therefore  that  albumin  is  present  when  it  is  not.  There  are  three  ways  of  obviating  this 
soiirce  of  fallacy  :  the  first  is  to  add  a  single  drop  of  dilute  non-fuming  nitric  acid  to  the 
suspicious  cloud  that  remains  after  adding  the  acetic  acid  ;  if  it  is  due  to  albumin  it  will 
persist  or  even  increase,  whilst  if  it  is  due  to  nucleo-proteid  the  nitric  acid  will  disperse 
it  ;  the  second  is  to  perform  the  cold  nitric  acid  test  for  albumin  as  described  below — 
nucleo-proteid  will  not  give  a  definite  localized  white  ring  with  it  ;  and  thirdly,  a  control 
test  may  be  done,  acetic  acid  being  added  to  another  specimen  of  the  urine  without  boiling, 
and  the  cloud  due  to  any  nucleo-proteid  present  compared  with  the  cloud  in  the  acidulated 
and  boiled  specimen. 

Heller's  Cold  Nitric  Acid  Test. — About  an  inch  and  a  half  of  urine  is  poured  into 
a  test-tube,  the  latter  is  held  much  inclined,  and  colourless  nitric  acid  is  allowed  to  flow 
gently  down  the  side  until  about  one-third  as  much  as  the  urine  has  been  added.  The 
nitric  acid  is  heavier  than  urine  and  goes  to  the  bottom  :  if  albumin  is  present  a  white 
ring  lorms  at  the  jimction  of  the  two  fluids.  Some  prefer  to  pour  the  nitric  acid  into  the 
test-tube  first,  and  then  add  the  urine  with  a  pipette.  It  is  important  not  to  shake  the 
tube,  or  the  nitric  acid  and  urine  will  mix  and  there  will  be  no  definite  junction  line  between 
them.  Fuming  nitric  acid  must  be  avoided  because  the  nitrous  oxide  fumes  decompose 
the  urea  and  the  resultant  bubbles  mix  the  fluids  ;  sometimes  there  is  bubbling  even  when 
the  nitric  acid  is  colourless,  in  which  case  this  is  due  tc  CO..  set  free  from  carbonates.  The 
test  is  very  delicate  ;  if  any  large  quantity  of  albumin  is  present,  the  ring  appears  at  once  ; 
it  there  is  only  a  trace,  the  white  ring  may  not  appear  for  a  little,  and  the  tube  should  be 
set  aside  and  looked  at  again  in  a  few  minutes.  Broadly  speaking  it  takes  three  minutes 
for  it  to  develop  when  the  amount  of  albumin  is  1  part  in  30,000.  This  test  is  open  to 
more  fallacies,  however,  than  the  acetic  acid  and  boiling  test,  so  that  it  should  not  be 
trusted  to  alone  unless  it  is  negative.  In  concentrated  urines  it  is  common  to  get  a  dark- 
brown,  reddish-brown,  or  violet  brown  ring  of  colour  at  the  junction  ;  this  is  nothing  to 
do  witli  albumin  :  it  is  generally  most  marked  in  eases  of  Indicanuria  (p.  314).  White 
rings,  more  or  less  like  that  due  to  albumin,  may  also  be  due  to  any  of  the  following  : — 

1.  Resin. — If  the  patient  is  taking  copaiba  or  other  similar  drug,  enough  of  the  resin 
may  be  excreted  in  the  urine  to  form  a  diffuse  white  cloud  above  the  nitric  acid.  This 
fallacy  is  best  avoided  by  bearing  it  in  mind  and  checking  the  nitric  acid  test  by  the  heat 
test  ;    this  latter  safeguard  applies  to  all  cases  of  suspected  albuminuria. 

2.  Albumoses. — These  generally  occur  in  association  with  albumin  ;  should  they 
occur  alone  the  ring  will  disappear  with  warming,  to  reappear  with  cooling,  and  there  will 
be  no  cloud  with  the  heat  test. 

3.  Tinici-.JoiHs'.i  Albnntnse. — This  occurs  without  albumin,  gives  a  white  ring  with 
nitric  acid  that  disappears  on  warming,  to  reapjiear  on  cooling  ;  with  the  heat  test,  a 
dense  cloud  appears  about  GO^  C,  to  disappear  on  further  heating  to  boiling-point  (p.  l(i). 

t.  Xiirlro-iilhiimiii. — The  ring  with  this  is  not  in  contact  with  the  nitric  acid,  but 
higluT  up,  and  diffuse  ;  it  may  be  a  real  difficulty  in  diagnosis  from  albumin,  for  it  is  also 
precipitated  by  acetic  acid,  and  may  therefore  give  a  haze  with  the  boiling  test  (see  above). 

5.  I'raJcs. — These  may  form  a  cloud  near  the  nitric  acid  if  the  urine  is  very  concen- 
trated ;  the  cloud  will  disappear  on  gentle  warming,  to  reappear  on  cooling,  so  that  it 
mav  also  be  mistaken  for  albumose  ;  the  fallacy  may  be  avoided  by  diluting  the  urine- 
with  plain  water  before  the  nitric  acid  test  is  employed. 

0.  Urea  Xilrale. — If  the  urine  contains  a  large  percentage  of  urea  a  crystalline  deposit 
of  urea  nitrate  may  form  at  the  junction  ;  as  a  rule  the  crystalline  nature  of  the  ring  is 
obvious  on  inspcelioii  ;  but  in  case  of  doubt  the  urine  should  be  dilulcd  and  Ihc  (est 
repeated. 

It  docs  not  niatler  whicn  lest  is  most  relied  upon  when  Ihc  result  is  lugalivc  ;  bul 
before  the  positive  deduction  that  a  urine  contains  albumin  is  drawn,  both  the  acetic  acid 
and  boiling,  and  ttie  cold  nitric  acid  tests,  should  be  positive. 

In  aiiiving  al  a  diagnosis  of  the  precise  cause  of  .'dliuiniiiiiiia  in  an\-  gi\(ii  ease,  it  is 
rssciiliiil  Ihul  a  mirroscnpiral  ci'diiiiiHitioii  of  the  iiiitrijiiildliud  ilcjiiisit  (i(i)n  Ihc  mine  slioiilil 
hr  made.  Whatever  else  niay  be  ff)und,  the  first  (piestioii  to  be  answered  is  :  Are  renal 
tul)e-easts  present  as  well  as  albiunin.  or  not  r  All  cases  of  albumiimria  may  be  divided 
into  two  iimin  ^'voups,  namely  :  (I)  Crisis  nilli  loinl  liihi-iasis  :  (II)  Cases  liilhijut  rnuil 
liihe-(iis'\. 


6  ALBUMINURIA 

Renal  Tube-casts. — AVhen  one  speaks  of  renal  tube-casts,  however,  one  has  to  bear 
in  mind  tliat  modern  methods  of  centiifugahzing  with  electrically-driven  machinery  have 
reached  such  perfection  that  hardly  anything  that  a  specimen  of  urine  contains  escapes 
detection  ;  technique  has  become  almost  too  perfect  ;  for  when  clinical  methods  become 
too  delicate  they  begin  to  lose  some  of  their  clinical  value.  The  result,  in  connection  with 
casts,  is  that  even  in  a  great  many  normal  urines  an  occasional  renal  tube-cast  and  an 
occasional  red  blood  corpuscle  are  found  ;  therefore  when  one  speaks  of  cases  of  "'  albumin- 
uria witn  tube-casts."  one  means  ""  witli  enough  renal  tube-casts  to  be  pathological."  The 
observer  learns  from  experience  to  know  when  the  '  occasional '  tube-cast  is  inside  or 
outside  the  normal  limits.  More  than  one  examination  may  be  rccjuired,  and  the  urine 
should  be  as  fresh  as  possible,  for  casts  disintegrate  on  standing,  especially  in  hot  weather 
and  in  alkaline  urines. 

Renal  tube-casts  are  of  various  sorts  (Plate  I),  and  a  certain  amount  of  help  can  be 
derived  from  a  knowledge  of  the  particular  kinds  of  casts  present  in  a  given  case.  Their 
matrix  or  foundation  is  a  structureless  material  whose  origin  is  obscure,  thougli  thought 
to  be  due  to  some  kind  of  proteid  coagulation.  Sometimes  the  casts  consist  of  this 
structureless  matrix  only,  and  according  as  they  are  then  less  or  more  highly  retractile, 
they  are  spoken  of  as  hyaline  casts  or  ivaxy  casts  respectively.  The  hyaline  is  commoner 
than  the  waxy,  but  neither  is  characteristic  of  any  particular  disease.  Embedded  in  the 
hyaline  matrix  there  may  be  various  substances  or  structures  ;  and  according  to  the  main 
features  of  the  embedded  substances  the  casts  receive  different  descriptive  names.  If 
renal  epithelial  cells  predominate,  the  cast  is  an  epithelial  cast :  if  leueocj-tes  or  pus  corpuscles, 
a  leucoci/tic  cast  ;  if  red  blood  corpuscles,  a  blood  cast  :  if  bacteria,  bacterial  casts  ;  if  fat 
globules,  probably  derived  from  degenerated  renal  cells  or  leucocytes,  fatit/  casts  ;  if  non- 
fatty  granular  debris,  granular  casts.  It  is  not  at  all  imcommon  to  find  a  long  cast  which 
in  one  part  is  simply  hyaline,  at  one  end  is  granular,  and  at  the  other  epithelial — a  mixed 
cast.  Upon  the  whole  one  may  say  that  the  hyaline  cast  occurs  in  all  forms  of  nephritic 
conditions,  whether  acute  or  chronic  ;  that  epithelial  and  leucoc\-tic  easts  indicate  active 
catarrh  ;  that  granular  easts  tend  to  occur  along  with  epithelial  casts,  but  that  when  they 
occur  alone  or  in  association  with  hyaline  casts  they  are  evidence  of  at  least  less  acute 
mischief  than  are  epithelial  casts  ;  whilst  fatty  casts  come  between  the  two.  Blood  casts 
may  occur  in  almost  any  variety  of  renal  ha?morrhage.  and  by  themselves  they  are  not 
evidence  of  inflammation,  though  in  association  with  other  easts  they  indicate  very  acute 
inflammatory  changes. 

I.  -ALBUMINURIA    WITH     RENAL     TUBE-CASTS. 

When  it  nas  been  decided  that  there  are  a  jiathologieal  lumiber  of  renal  tube  casts 
as  well  as  albumin  in  the  urine,  it  is  almost  certain  that  there  is  an  inflammatory  lesion 
of  the  kidney.  The  next  step  in  the  diagnosis  is  to  decide  by  microscopical  examination 
whether  pus  is  present  also  ;  in  other  words,  the  cases  may  be  subdivided  into  two  main 
sub-groups,  namely  :  (A)  Albuminuria  -cvith  renal  tube-casts  tcithout  obiious  ])us  :  and 
(li)  Albuminuria  with  renal  tube  casts  and  obvious  pus.  There  are  border-line  cases  in 
which  leucocytes  are  present  in  excess,  and  yet  not  in  sufficient  numbers  to  constitute 
pus  ;  other  points  about  such  a  case  will  generally  lead  one  to  decide  whether  it  come- 
in  the  apyurie  or  in  the  ])yuric  group.  The  differential  diagnosis  of  the  latter  is  discussed 
under  Pviria  (p.  'i'i).  so  that  it  only  remains  lure  tt)  discuss  : — 

(.1)  The  Differential  Diagnosis  of  Albuminuria  lvHIi  Tube-easts  without  Obvious  Pus. — 
The  causes  of  tliis  condition  may  be  classilied  as  folk)ws  : — 

1.  The  Various  Forms  of  Bright's  Disease: — 

(a)  .\  primary  acute  nephritis. 

(b)  \n  acute  exacerbation  upon  an  underlying  chronic  ne|)hritis. 

(c)  Chronic  nephritis  of  young    ]K(iple  :    (i)    Arising  out    of  a  known    attack  of 

acute  nephritis  :    (ii)  Arising   without   any   known  prexious  attack  of  acute 
nephritis. 

((/)  Chronic  nephritis  of  old   ])CO])le  :     (i)  cirrhosis  of  tlie  kidneys  ;     (ii)  Arterio- 
sclerosis. 

((')  Cystic  disease  of  llie  kidneys. 
•2.  Nephritis  of  Pregnancy. 


PLATE     I 


RENAL      TUBE      CASTS 


4. 


/•- 


A.  Il.vniiiiorasis;    B,  Wnxy  casts:    c    Myaliiic  MLst  coritiiiuintr  siniill  crystals  of  raloiiim  oxiihitc;    D,  Hloucl  cints; 
E,  A  Icuc'or-ytc  init ;    F,  Hpitlidiiil  wists;    G,  <in""ilur  casts;    H,  Futty  ciiats. 


iMii:x    III-    iiiMiXosis— 7'«  jure  />. 


ALBUMINURIA  7 

3.  Chronic  Ascending  Nephritis,  leadino;  to  scarred  contracted  kidneys,  the  result  of 

{(!}  ()l)structii)n  to  urine  outflow  by  : — 
(i)  Urethral  stenosis, 
(ii)  Enlarged  prostate, 
(iii)  Displacement  of  the  womb. 
■     (iv)  Fibromyonia.   ovarian  cyst,  or  other  |)elvic  tiunour. 
(v)  Pregnancies. 

(vi)  Undue  mobility  of  the  kidney  and  kinkinw  of  the  ureter, 
(vii)  Rarities,  such  as  abdominal  aneurysm  obstructing  a  ureter. 
(h)  Irritation  ascending  from  the  pelvis  of    the  kidney,  the  result  especially  of 
calculus,  but  also  sometimes  of  chronic  tuberculous  lesions, 

4,  Lardaceous  Disease  of  the  Kidneys. 

'>.  Infarction    of    the    Kidneys,    esi)ecially    when   the  result  of  embolism  in  cases  of 
fungatiiig  endocarditis  :     Imt   also  due  to  thrombosis,  as  in   some  blood  diseases, 
(i.  Thrombosis  i>f  tlie  inferior  vena  cava  involving  the  renal  veins. 
T.  New  Growth  of  the  Kidney,  some  cases. 

In  many  cases  the  diagnosis  soon  becomes  obvious,  but  in  some  there  may  be  great 
dilliculty.     The  two  following  may  serve  to  illustrate  how  such  difficulties  may  arise  : 

A  patient  of  middle  age,  who  had  not  been  strong  for  a  long  time,  began  to  suffer  from 
tt'dema  of  the  ankles,  which  increased  rapidly  and  spread  to  her  legs,  thighs,  genital  organs, 
and  back.  Within  a  few  days  her  abdomen  began  to  swell,  and  she  began  to  pass  very 
little  water,  the  colour  of  blood.  Upon  examination  the  urine  had  a  sp.  gr.  of  1030.  wa.s 
loaded  with  albumin  and  blood,  and  microscopically  there  was  an  abundance  of  red 
corpuscles,  renal  epithelial  cells,  leucocytes,  and  epithelial,  fatty,  granular,  and  blood 
casts,  without  ])us,  crystals,  or  bacteria.  It  seemed  almost  obvious  that  she  must  be 
suffering  frf)m  acute  Bright's  disease  :  but  there  was  no  oedema  of  the  eyelids,  and  there 
was  delinite  enlargement  of  the  left  supraclavicular  lymphatic  gland  ;  the  discovery  of 
the  latter  led  to  a  very  careful  examination  for  malignant  disease  ;  and  a  latent  and  <|uitc 
unsuspected  carc'inoma  of  the  rectum  was  foimd.  'I'lu-  diagnosis  was  carcinoma  recti, 
secondary  dcjiosits  in  the  retroperitoneal  glands,  obstruction  and  thrombosis  of  the  inferior 
vena  cava  and  of  the  renal  veins,  with  consequent  albumiimria,  hematuria,  and  renal 
tube-casts  from  as])liyxial  nephritis,  sinnilating  acute  Bright's  disease. 

Another  case  was  that  of  a  girl  of  !(!,  suffering  from  increasing  ana-mia,  shortness  of 
breath,  (edema  of  her  ankles  and  lac  c,  and  slight  pyrexia.  The  heart  was  a  little  enlarged, 
and  there  were  soft  systolic  bruits  that  were  regarded  as  secondary  to  the  anaemia.  The 
urine  contained  blood  and  albumin,  willi  renal  e|)itlielial  cells  and  tube-casts  in  abundance. 
Ascites  developed,  with  increasing  general  (edema  :  there  were  also  retinal  ha'morrhages 
and  neuro-retinitis.  'I'he  diagnosis  of  acute  nephritis,  however,  was  only  in  small  degree 
correct  :  for  she  was  really  suffering  from  maliiinani  endocarditis  of  a  subacute  type, 
the  nephritis  being  due  to  iidccted  crTilioli  of  llie  Uidney  pnidueing  intlammatory  changes 
around  nuiUipic  renal  itilarcts. 

'I'hese  cases  will  serve  to  show  how  it  nia\  be  impossible  to  arrive  at  a  correct  diagnosis 
excci)t  by  thorough  examination  of  all  the  systems,  by  watching  the  case  carefullw  and 
by  repeating  the  fidl  systemic  examination  at  intervals.  We  will  now  deal  witli  I  lie 
headings  in  the  abo\c  table  in  their  reversed  order. 

If  there  is  New  Growth  in  a  kidney  the  munber  of  renal  lube-easts  is  likely  to  be 
small  ;  sooner  or  later  a  microscopic  fragment  of  new  growth  may  be  detected  in  the  ccntri- 
fugali/cd  urinary  deposit.  .Mbuminuria  will  not  be  extreme  unless  the  renal  veins  and 
the  inferior  vena  cava  become  invohcd  (/•'/;,'.  ;iO  f.  p.  7.50).  the  same  ap|)lying  also  to  the 
nedema  of  the  legs  and  trunk  :  h:iiiial  uiia  is  liUclx  to  occur  at  iidervals,  the  attacks  being 
separated  by  many  weeks  soniclinies.  and  liiing  r(laliv<'l\  painless  :  there  may  be  an  in- 
creasing renal  tumour:  cystoscopic  cxaminal  ion  may  show  blood-slaincd  mine  (see  Philc 
.Vr.  Fifi.  .1,  p.  -jHti)  coming  from  one  ureter  only  ;  and  finally,  when  suspicion  of  new  growth 
has  been   aroused,    laparotomy   may   be   indicated   and   the  diagnosis  conlirmed   thereby. 

Thrombosis  of  the  Renal  Veins  and  Inferior  Vena  Cava  has  been  rchrred  to 
above  as  a  conditioTi  that  may  simulate  acute  nephritis.  I'oinis  lo  lay  stress  on  in  nrri\  ing 
at   the  diagnosis  are  :    (I)  To  make  a   Ncrv  careful  and   svstcmatic  examination,   including 


8  ALBUMINURIA 

that  of  rectum  and  vaiiina,  in  order  not  to  miss  anything,  sueli  as  some  latent  growtli.  wliose 
secondary  deposits  are  obstructing  the  veins  ;  (2)  To  enquire  carefully  into  the  history 
— many  cases  of  inferior  vena  caval  thrombosis  are  due  to  extension  vipwards  i'rom  iliac 
or  saphenous  clots,  in  which  case  there  will  nearly  always  have  been  swelling  of  one  leg 
only  to  start  with,  followed  later  by  extension  to  the  back  and  to  the  other  leg  :  (3)  To 
note  that  although  the  oedema  of  the  legs  and  back  may  be  extreme,  there  is  a  delinite 
upper  level  to  it  and  no  swelling  of  the  eyelids  or  scalp  :  and  (4)  To  note  that  if  there  are 
any  distended  or  varicose  veins  upon  the  abdominal  wall  (see  Veins,  Varicose  Abdominal, 
Fig.  303,  p.  749),  the  current  in  them  has  become  reversed — to  being  from  below 
upwards  instead  of  from  above  downwards. 

Infarction  of  the  Kidneys  may  be  either  embolic  or  thrombotic.  The  commonest 
cause  of  embolic  renal  infarction  is  fungating  endocarditis.  Each  embolus  gives  rise  to 
the  sudden  appearance  of  blood  in  the  urine  which  may  have  contained  none  previously, 
or  to  increase  in  any  existent  hasmaturia  ;  there  may  or  may  not  have  been  a  sudden  pain 
in  the  back  at  the  same  time.  Around  each  infarct  acute  nephritis  develops,  so  that  in 
some  cases  all  the  characters  of  the  latter  malady  may  be  superposed  upon  those  of  the 
fungating  endocarditis.  If  the  patient  is  already  known  to  have  heart  disease  the  diagnosis 
is  easy  enough  ;  the  difliculties  arise  in  cases  in  which,  notwithstanding  the  endocarditis 
there  is  no  bruit.  If  fimgating  endocarditis  is  suspected,  the  points  that  confirm  the 
diagnosis  arc  those  mentioned  on  p.  34. 

Thrombotic  infarcts  are  less  severe  in  their  effects  ;  they  may  produce  no  haematuria 
at  all,  and  the  albuminuria  may  be  slight,  and  unaccompanied  by  tube-casts.  They 
generally  arise  in  cachetic  conditions,  or  in  blood  diseases  such  as  leukaemia  or  pernicious 
anaemia,  in  whieli  cases  the  diagnosis  will  be  arrived  at  on  other  grounds,  albuminuria 
not  being  the  ]>nMiiineut  feature  of  the  ease. 

Lardaceous  Disease  of  the  Kidneys  used  to  be  common  in  the  days  of  septic 
surgery,  but  it  is  uncommon  now.  It  is  a  risky  diagnosis  to  make,  therefore,  unless  there 
is  some  obvious  cause  for  it,  such  as  long-standing  suppuration  in  association  with  a  .spinal, 
hip-joint,  or  empyema  sinus,  bronchiectasis,  phthisis  with  cavitation,  or  the  like  ;  or  clear 
evidence  of  tertiary  syphilis  with  cachexia.  There  is  nothing  characteristic  about  the 
urine.  In  the  earlier  stages  there  may  be  but  a  trace  of  albumin  in  an  otherwise  normal 
urine  ;  later,  the  albumin  increases  and  it  may  reach  very  large  amounts,  such  as  20  parts 
per  1000,  casts  being  very  few  in  proportion,  the  total  amount  of  urine  increased,  its  colour 
pale,  and  its  sp.  gr.  low — 1005  to  1012  :  later  still,  possibly  as  the  result  of  superposed 
nephritis,  the  amount  of  urine  falls  until  only  a  few  ounces  may  be  passed  each  day,  of 
high  colour  and  sp.  gr.  1020  to  1035,  loaded  with  albumin,  and  now  containing  hvaline, 
waxy,  granular,  fatty,  and  epithelial  casts.  Lardaceous  easts  may  or  may  not  occur,  but 
they  are  not  diagnostic,  for  they  have  also  been  found  in  cases  of  nephritis  without  lardaceous 
disease.  Indeed,  the  diagnosis  of  lardaceous  kidney  resolves  itself  into  one  of  guesswork 
in  a  case  in  which  there  has  been  prolonged  suppuration  or  severe  syphilis  to  give  rise  to 
it,  and  in  which  there  may  be  smooth  firm  enlargement  of  the  liver,  moderate  enlargement 
of  tne  spleen,  and  more  or  less  severe  diarrhoea,  to  indicate  corresponding  lardaceous 
change  in  the  other  organs  that  are  generally  affected  at  the  same  time  as  the  kidnevs. 

Chronic  Ascending  Nephritis  arises  from  precisely  the  same  causes  as  acute  ascending 
nephritis  or  surgical  kidney,  and  probably  results  from  recurrent  focal  inflammations 
which  heal,  with  the  result  that,  in  the  course  of  months  or  years,  the  kidneys  are  con- 
\erted  into  a  mass  of  irregular  fibrotic  scars  which  together  produce  the  same  local  and 
general  changes  and  effects  as  are  found  in  cases  of  ordinary  red  granular  contracted  kidney. 
It  is  important  to  bear  in  mind  that  any  cause  of  prolonged  obstruction  to  the  urine 
outflow  may  cause  granular  kidney  with  albuminuria,  without  pus  but  with  easts,  in  a 
pale  abundant  urine  of  low  specific  gravity.  The  diagnosis  will  generally  be  ob\ious 
when  the  obstruction  is  due  to  urethral  stricture  ;  it  is  more  apt  to  be  overlooked  in 
other  cases,  though  if  one  bears  in  mind  the  causes  mentioned  in  the  list  above,  the 
methods  of  diagnosis  will  generally  be  clear.  One  would  only  mention  in  particular  that 
uterine  timiours  or  displacements  are  a  very  common  cause  for  slight  albimiinuria  and  a 
few  renal  tube-casts  in  women  ;  and  that  in  men  of  sixty  and  over  enlargement  of  the 
prostate  causes  a  precisely  similar  condition  long  before  Ihere  is  any  delinite  pyuria. 

Pregnancy  Nephritis  is  sometimes  spoken  of  as  though  it  were  an  altogether  different 


ALBUMINURIA  9 

thing  to  nepluitis  of  the  Brighfs  disease  type  in  general.  I  do  not  subscribe  to  this  view, 
I  hold  that  Bright's  disease  has  many  different  causes  and  many  different  types.  It  may 
be  due  to  scarlet  fever,  in  which  case  it  is  very  possibly  streptococcal  ;  it  may  be  due  to 
pneumonia  or  empyema,  in  which  cases  it  may  be  pneumococcal  ;  it  may  be  due  to 
various  other  micro-organisms  ;  it  occurs  in  some  cases  of  cholera,  and  in  severe  secondary 
syphilis  ;  it  is  frequent  in  malaria,  especially  the  quartan  type  ;  it  may  be  due  to  chemical 
substances  such  as  turpentine,  cantharides,  or  oxalic  acid  ;  it  very  often  seems  to  come 
on  from  no  known  cause  at  all,  though  in  such  cases  there  must  be  a  microbial  or  other 
cause  that  is  not  discovered  :  it  may  be  due  to  pregnancy,  in  which  case  it  is  ascribed  to 
unknown  toxins.  In  all  these  cases  the  t>-pes  of  reaction  on  the  part  of  the  kidney  are 
similar,  and  one  can  only  regard  pregnancy  nephritis  as  a  variety  of  non-suppurative 
ne])liritis  in  general.  Very  likely  it  is  only  a  matter  of  degree  whether  it  is  non-suppurative 
or  merges  into  the  type  in  which  there  is  pyuria  as  well  as  albuminuria — pyelitis  of  preg- 
nancy. Pregnancy  may  cause  a  primary  acute  nephritis,  which  may  recover  either  com- 
pletely, or  but  partially  and  persist  as  chronic  nephritis  :  or  may  seem  to  recover  when  in 
reality  it  is  merely  latent,  or  even  slowly  and  insidiously  progressive  ;  it  may  produce 
what  seems  to  be  a  primary  acute  nephritis  which  is  really  but  an  exacerbation  superposed 
upon  a  chronic  nephritis  that  has  been  unsuspected  ;  and  very  possibly  it  may  produce 
nejihritic  changes  which  are  not  associated  with  definite  symptoms  at  the  time,  but  which 
ultimately  result  in  what  is  spoken  of  as  chronic  interstitial  nephritis.  When,  therefore, 
alliuminuria  with  renal  tube-casts,  but  without  pyuria,  occurs  during  pregnancy,  it  matters 
little  what  name  is  given  to  the  condition,  provided  it  is  realized  that  just  the  same  difli- 
culties  offer  themselves  here  as  in  Bright's  disease  in  general,  in  arriving  at  a  conclusion 
as  to  wlietlier  the  renal  lesion  is  acute,  chronic,  or  acute  on  chronic. 

Various  Forms  of  Bright's  Disease. — Of  all  these,  the  hardest  to  diagnose  with 
certainty  is  pih/iiiri/  acute  iiephrilis  in  the  adult.  The  majority  of  adult  cases  that  are 
labelled  acute  J3right"s  disease  are  really  suffering,  not  from  primary  acute  nephritis,  but 
from  an  acute  exacerbation  upon  the  top  of  already  existent  but  possibly  latent  chronic 
nephritis.  The  dilliculty  is  to  arrive  at  the  diagnosis  between  these  two,  particularly 
since  many  of  the  jxiints  mentioned  in  text -books  as  occurring  in  acute  nephritis  are  really 
due,  not  to  thi'  acute  attack,  but  to  the  subacute  or  chronic  i-enal  lesion  which  has,  until 
then,  been  unsuspected. 

The  best  exam|)l(s  of  |)rimary  acute  tiejiliritis  are  to  be  seen  in  eases  that  are  already 
under  observation  for  some  other  disease,  notably  scarlet  fever  or  lobar  pneumonia.  Some- 
times the  onset  of  the  nephritis  is  indicated  by  general  (cdema,  especially  of  the  eyelids 
and  lace,  ankles,  genital  organs,  and  loins  ;  but  it  cannot  be  insisted  upon  too  sti'ongly 
thai  irdema  is  not  esseiilial.  many  cases  of  acute  nephritis  having  no  o-dema  at  all,  especi- 
ally if  the  patient  is  already  in  bed  when  the  kidney  inllammation  begins,  as  in  scarlatina 
cases.  If  the  urine  were  not  examined  the  renal  lesion  would  often  escape  recognition 
altogether  :  and  there  can  be  no  df)ubl  that  many  cases  of  primary  acute  nciihritis  do 
escape  rccognilion  in  this  way,  coming  under  observation  later  when  they  present  symptoms 
of  chronic  Tvpliritis,  or  an  acute  exacerbation  on  chronic  nephritis. 

The  essential  point  in  the  diagnosis  is  urine  examination.  According  to  the  severity 
of  the  nephritis  there  will  be  more  or  less  diminution  in  the  total  daily  (piantity  :  it  is 
eoinnion  for  less  than  20  oz.  to  be  passed  in  the  t  W(iit\ -lour  hours,  and  often  the  amount 
falls  to  10  oz..  .>  oz..  or  even  to  none  at  all  for  a  wliiU'.  The  spccilic  gravity  is  raised  to 
lO'J.j.  KKiO,  or  even  to  lO:!".,  but  ranl\  to  10  10.  The  naction  is  generally  acid  at  first, 
but  it  soon  beconics  alkaline  on  standing.  The  colour  is  extremely  variable,  according 
as  little  or  much  bloo<l  is  present  :  sometimes  it  is  almost  normal  or  merely  that  of  a  con- 
centrated urine  ;  mori'  often  llieie  is  some  tinging  with  blood,  varying  from  bright  red 
to  brownish,  brown,  brown-black,  or  to  that  peculiar  blackish  tint  which  is  descrilied  as 
smoky.  There  is  a  getieral  cloudiness  of  the  spe<'imen,  and  on  standing  it  deposits  a  heavy 
sediriicnt  which  ofl<ii  has  a  dark  brownish  tint  owing  to  the  phosphates  carrying  the  blood 
pigmenl  with  thcin.  Microscopically,  the  ccntrifugalized  deposit  consists  jjartly  of 
amorphous  debris  due  to  earthy  phosphates,  and  to  the  disintegration  of  cells  anil  tube- 
easls  :  and  one  expects  to  lind  an  abundance  of  red  corpuscles,  renal  epithelial  cells,  \ari- 
able  numbers  of  epithelial,  fatty,  granular,  hvaline.  an<l  blood -casts,  an  excess  of  Iciieocyles, 
an  occasional  cr\stal  of  calcinin  omiImIc  or  uric  acid,  and   irregular  gnmular  iriasscs  which 


10  ALBUMINURIA 

are  not  defluitcly  tutic-casts.  It  is  noteworthy,  however,  that  in  the  very  aeiite  stages 
there  may  be  no  tube-casts,  though  shed  renal  epithelial  cells  are  abundant  :  in  such  a 
case  tube-casts  will  show  themselves  in  a  few  days.  It  is  important  that  each  specimen 
should  be  examined  as  fresh  as  possible,  owing  to  the  tendency  of  casts  and  cells  to  dis- 
integrate on  standing.  In  addition  to  red  corpuscles  there  is  often  much  free  lia^moglobin  ; 
the  tincture  of  guaiacum  test  will  be  positive,  and  the  spectroscope  will  show  the  bands 
of  oxyhaemoglobin  or  of  metha?moglobin.  Coaguhible  proteid  is  generally  present  in 
abundance,  the  proportions  of  globulin  and  albumin  varying  greatly,  but  together  amount- 
ing to  anything  between  2  and  20  parts  per  thousand — often  about  15  parts  per  thousand 
at  first,  rapidly  dropping  to  less  after  tlie  first  few  days  of  treatment,  until  at  the  end  of 
from  a  fortnight  to  a  month  it  may  be  1  part  per  thousand  or  less,  or  even  absent 
altogether.  In  a  few  cases,  however,  tliere  is  very  little  coagulable  proteid  but  an 
abundance  of  albumose,  so  that  the  boiling  test  gives  but  a  faint  cloud,  whilst  the  nitric 
acid  test  yields  a  dense  white  ring,  soluble  on  warming,  to  reappear  on  cooling.  There 
is  generally  an  excess  of  nucleo-proteid  also.  The  urea,  chlorides,  and  phosphates  all 
fall  below  the  normal  totals,  though  their  percentages  may  be  increased  if  the  urine  is 
very  concentrated. 

With  this  condition  of  urine  there  will  be  little  doubt  as  to  the  presence  of  acute 
nephritis  ;  the  only  question  then  is  whether  it  is  primary,  or  an  exacerbation  upon  chronic 
nephritis.  The  former  is  probable  if  it  is  known  that  the  urine  was  free  from  albumin  up 
to  the  time  of  the  attack,  if  the  patient  is  known  to  have  suffered  recently  from  scarlet 
fever,  pneumonia,  diphtheria,  secondary  syphilis,  or  some  other  similar  fever  ;  if  the  heart 
is  of  normal  size  and  its  sounds  natural,  the  blood-pressure  natural,  and  the  retina"  healthy. 
It  may  be  that  the  patient  himself  may  have  been  exposed  to  scarlatinal  infection,  and 
without  having  had  the  rash  may  develop  nephritis  ;  the  association  of  peeling  of  the 
skin,  or  recent  sore  throat  with  enlarged  glands  in  the  neck,  or  otitis  media,  might  suggest 
the  diagnosis  in  these  mild  cases  of  scarlatina,  though  sometimes  acute  nephritis  in  a  child 
may  be  the  sole  evidence  of  the  disease.  The  course  of  the  malady  will  also  assist  the 
diagnosis  ;  the  albuminuria  of  primary  acute  nephritis  may  clear  up  entirely  in  from  a 
fortnight  to  six  weeks,  though  in  unfavourable  cases  it  persists  and  chronic  nephritis 
develops  out  of  the  acute.  If,  on  the  other  hand,  it  is  found  that,  in  a  case  of  ajjparently 
recent  acute  nephritis,  with  general  oedema,  hoematuria  and  the  other  urinary  changes 
described  above,  there  is  cardiac  hypertrophy,  with  a  prolonged  lumpy  first  soimd  at  the 
impulse,  a  ringing  aortic  second  sound,  a  blood-pressure  of  more  than  150  mm.  Hg,  and 
possibly  albuminuric  retinitis,  the  probability  is  that  the  acute  nephritis  is  not  primary, 
but  an  acute  exacerbation  of  an  unsuspected  chronic  nephritis.  There  is  often  a  history 
of  former  scarlet  fever  or  of  syphilis  in  such  cases  ;  the  patients  may  be  of  any  age,  from 
childhood  to  past  middle  life.  If  the  patient  survives,  one  or  other  of  two  conditions 
usually  results  :  either  the  albuminuria,  the  scanty  urine,  and  the  tube-casts  persist,  whilst 
the  patient  remains  waterlogged  until  the  end  comes  in  a  few  weeks  or  months,  or  else 
the  acute  exacerbation  subsides  and  the  clinical  characters  of  chronic  nephritis  remain. 

Some  of  these  cases,  but  by  no  means  all  of  them,  are  exampjles  of  primary  acute 
nephritis,  persisting  and  becoming  chronic.  It  must,  however,  always  be  very  difficult, 
and  indeed  almost  a  matter  of  opinion  in  many  cases,  to  decide  whether  a  patient  is  suffering 
from  a  chronic  nephritis  which  is  the  result  of  a  primary  acute  nephritis  that  has  not 
cleared  up,  or  from  a  chronic  nephritis  which  was  jiresent  but  unrecognized  before  an  acute 
exacerbation  drew  attention  to  it  ;  my  own  view  is  that  many  cases  in  which  young  adults 
seem  to  develop  acute  nephritis  from  no  more  definite  cause  than  exposure  to  damp  or 
cold,  are  really  examples  of  acute  on  chronic,  and  not  of  primary  acute,  Bright's  disease. 
The  albuminuria  in  these  cases  does  not  clear  up,  and  it  is  a  mistake  to  restrict  the  diet 
or  the  daily  occupation  after  the  acute  exacerbation  has  subsided.  In  spite  of  the  per- 
sistence of  albuminuria,  these  patients  do  best  if  they  are  given  iron  and  allowed  to  go 
about  their  ordinary  avocations  ;  they  have  diseased  kidneys,  and  they  will  not  live  many 
years,  but  there  is  no  need  to  adopt  treatment  which  constantly  reminds  them  of  the  fact. 
As  the  acute  exacerbation  subsides,  the  amount  of  urine  rises  rapidly  to  60  or  70  oz.  or 
more  per  diem,  and  remains  increased  even  after  all  oedema  has  passed  away  ;  the  specific 
gravity  falls  to  1012,  1010,  or  1008  ;  the  albumin  persists  to  the  extent  of  anything  between 
O'o  and  8  parts  per  thousand  ;    blood  is  absent,  though  an  occasional  red  corpuscle  may 


'    ALBUMINURIA  U 

be  .seen   iiiKkr  the  microscope  ;    and  there  arc  moderate  numbers  of  hyaUne.    granuhir 
or  even  fatty  casts,  with  an  occasional  renal  cjiithclial  cell. 

It  happens  not  infrequently  that  a  young  patient  sufferino-  from  chronic  iicpliritis 
comes  under  observation  for  shortness  of  breath,  jialpitations,  ana-mia,  or  for  inflammation 
of  one  or  other  of  the  serous  membranes,  without  ever  having  had  any  symptoms  of  acute 
nephritis  at  all.  The  kidneys  that  would  be  found  in  such  cases  differ  from  the  granular 
contracted  kidneys  of  older  people  in  tliat  they  are  pale  instead  of  red.  They  are  pale 
granular  contracted  kidneys,  precisely  similar  to  those  which  may  result  from  a  long 
antecedent  acute  nephritis  that  has  not  entirely  cleared  up.  When  they  develop  without 
any  known  preceding  attack  of  acute  nepliritis  they  have  been  referred  to  as  Rose-Bradford 
kidneys.  It  is  by  no  means  impossible  that  they  are  really  the  result  of  a  preceding  acute 
nephritis  which  escaped  recognition  because  there  was  no  oedema  to  attract  attention  to 
the  need  for  urine  examination.  The  patient  may  be  of  any  age,  though  generally  between 
five  and  thirty-five.  There  may  be  no  sign  of  anytliing  wrong  until  acute  uraemia,  with 
convulsions,  leads  to  rapid  death.  On  the  other  hand,  in  a  typical  case,  in  addition  to 
the  urine  changes  mentioned  above,  one  expects  to  find  some  of  the  following  symptoms 
or  signs  ;  /a  great  increase  in  the  size  of  the  left  ventricle,  as  evidenced  by  displacement 
of  the  impulse  downwards  and  outwards,  even  into  the  sixth  left  intercostal  space  below 
or  outside  the  left  nipple,  with  increase  of  the  precordial  impairment  of  resonance  outwards 
to  the  left  without  corresponding  increase  u])wards  or  to  the  right  ;  a  ringing  second  sound 
in  the  second  right  intercostal  space  close  to  the  sternum,  and  a  prolongation  of  the  first 
sound  at  the  impulse,  or  its  replacement  by  a  localized  blowing  systolic  bruit  ;  more  or 
less  anicmia,  sometimes  very  considerable  and  of  the  chlorotic  type  ;  a  maximum  systolic 
blood-pressure,  of  175  mm.  Hg,  or  more,  sometimes  over  300  mm.  Hg,  even  when  the 
pulse  feels  comi)aratively  soft  to  the  finger  :  albiuninuric  retinitis  ;  a  tendency  to  hemor- 
rhages, especially  to  epistaxis  ;  headache  :  insomnia  ;  brcathlessness  on  exertion  ;  and 
inability  to  work  with  the  usual  energy,  either  mentally  or  physically. 

The  chronic  nepliritis  of  old  people  is  diagnosed  more  often  than  it  exists,  if  one  under- 
stands by  it  tlie  disease  associated  with  small  red  graiudar  contracted  kidneys.  On  the 
other  hand,  the  kidneys  of  most  old  people  exhibit  a  certain  amount  of  interstitial  fibrosis, 
with  occasional  retention  cysts  and  some  granularity  of  the  surface  when  the  capsules 
are  stripped  off.  without  there  being  any  material  diminution  in  tlieir  size.  \Miere  senile 
changes  that  are  almost  normal  end  and  chronic  interstitial  nephritis  begins,  is  difficult  to 
determine.  The  same  applies  to  arteriosclerosis  and  the  renal  changes  associated  with 
this.  Some  regard  arteriosclerosis  and  chronic  interstitial  nephritis  as  essentially  different 
maladies  :  others  regard  the  arterial  as  secondary  to  the  renal  changes  ;  others  hold  thai 
arteriosclerosis  leads  to  a  variety  of  red  granular  kidney  that  is  not  the  same  as  the  red 
granular  contracted  kidney  of  chronic  interstitial  nephritis  :  whilst  others  again  favour 
what  seems  a  likely  view,  namely  that  arteriosclerosis  and  sclerosis  of  the  kidneys  botii 
have  conmion  eaiiscs.  and  that  it  is  more  or  less  an  accident  whether  the  |)aticnt,  on  post- 
mortem cxajiiinal  ion.  presents  more  arterial  or  more  renal  changes,  or  about  tlie  same 
degree  of  both.  During  life  the  differential  diagnosis  between  them  is  sometimes  impos- 
sible. In  either  case  there  will  be  a  hypertro|)hied  left  ventricle,  a  loud  lumjiy  first  sound, 
or  a  blowing  systolic  bruit,  at  the  impulse,  a  markedly  accentuated  aortic  second  sound. 
a  systolic  blood-pressure  somewhere  between  150  and  :520  mm.  Hg.  with  a  tendency  to 
shortness  of  breath  :  giddiness,  especially  on  sudden  change  of  posture  ;  singing  in  the 
cars;  dilliculty  in  concentration  of  mind  ;  and  very  ])ossibly  cardiac  symptoms.  \  aryitig 
from  a  mere  consciousness  of  the  existence  of  the  heart,  to  precortlial  ])ain  of  varying 
severity,  or  even  extreme  heart -failure,  with  (edema  of  the  legs,  ascites,  nutmeg  liver, 
orthopnnea,  and  ])ulmonary  congi'slion.  In  the  latter  case  the  great  difiiculty  will  be  lo 
decide  whether  the  heart  failure  is  due  l<>  |iiiniary  renal  or  arterial,  primary  cardiac,  or  (o 
primary  |)ulni()iiarv  disease,  and  the  only  sure  methods  of  deciding  that  there  is  a  renal 
lesion  are:  tlie  (liseover\-  of  more  than  an  occasional  granular  an<i  h\aliiie  tube-cast  in 
the  in'ine  ;  the  deti'ction  of  albuminuric  retinal  changes  :  and  inslrumeiital  determination 
that  the  blood-pressure  is  nnicli  raised.  Sometimes  inllanunation  of  one  of  the  serous 
membranes  is  the  first  syiiiploni  :  subacute  or  chronic  peritonitis  with  ascites  ;  ])cricar- 
ditis  :  or  pleuiilie  eHiisidii.  On  llic  other  hand,  the  (jaticnt  nuiy  seem  to  have  been  in 
robust  hcMllli  iiiilil  Ihc  nalmc  of  llic  ease  is  suggested  by  a  sudden  apoplectic  seizure  (\uv 


12     .  ALBUMINURIA 

to  cerebral  haMnorrhage.  In  yet  another  group  of  cases  the  mahidy  is  discovered  acci- 
dentally as  the  result  of  examination  for  lile  insurance.  It  is  not  very  uncommon  to  find 
glycosuria  as  well  as  albuminuria,  the  sugar  occurring  in  a  urine  of  normal  specific  gravity 
without  any  associated  acetone  or  diacetie  acid.  The  degree  of  albuminuria  is  very 
variable  ;  when  tliere  are  signs  of  cardiac  failure  there  may  be  oliguria  with  much  albumin 
and  not  a  very  large  munber  of  casts  ;  when  there  is  no  heart  failure  there  is  generally 
polyuria,  the  patient  having  to  rise  several  times  in  the  night,  passing  from  60  to  120  oz. 
of  pale  urine  in  twenty-four  hours,  of  sp.  gr.  1008  to  1012,  often  containing  only  a  trace 
of  albinnin.  and  even  that  not  constantly  ;  there  are  intermediate  cases  in  which  the 
amount  of  albumin  varies  from  0-25  to  4  or  5  parts  per  thousand.  Upon  the  whole  one 
may  say  that,  if  the  increased  albuminuria  due  to  heart  failure  on  the  one  hand,  or  to  a 
super-added  acute  attack  of  nephritis  on  the  other,  can  be  excluded,  the  more  the  disease 
approaches  the  type  of  red  granular  contracted  kidney,  the  more  likely  is  the  albumin 
to  be  small  in  amount  and  intermittent  :  whilst  the  more  the  disease  approaches  in  type 
to  arteriosclerosis  with  renal  changes  on  the  one  hand,  or  to  pale  granular  contracted 
kidneys  on  the  other,  the  greater  will  be  the  amount  of  albumin,  if  any  is  present  at  all. 
riiere  will  be  tube-casts,  chiefly  granular  and  hyaline,  most  numerous  with  pale  granular 
contracted  kidneys,  fewest  with  arteriosclerosis,  and  intermediate  in  numbers  with  red 
granular  contracted  kidneys.  It  need  scarcely  be  added  that  the  absence  of  albuminuria 
does  not  exclude  arteriosclerosis  :  but  we  are  here  dealing  only  with  cases  in  which  albu- 
minuria occurs. 

Cystic  Disease  of  the  Kidneys  is  found  in  three  entirely  different  types  of  patients, 
namely.  (1)  the  new  born,  (2)  the  young,  and  (3)  the  elderly.  In  the  new  born  the  main 
symptom  is  abdominal  distention,  which  may  be  so  extreme  as  to  have  caused  difficulty 
in  delivery  :  the  bilateral  cystic  tumours  can  be  felt,  and  the  diagnosis  in  such  cases 
is  not  dillicult.  Elinor  degrees  escape  detection  at  birth,  and  it  may  be  that  several  years 
elapse  before  the  diagnosis  is  arrived  at  as  the  result  of  finding  bilateral  uneven  renal 
tumours  associated  with  the  passage  of  abundant  pale  urine  of  low  specific  gravity  con- 
taining traces  of  albumin,  a  few  granular  and  hyaline  tube-casts,  and  an  occasional  red 
corpuscle.  Sometimes  a  sudden  and  severe  attack  of  ha-maturia  is  the  first  symptom  in 
the  case.  The  discovery  of  bilateral  irregular  renal  tumours  is  the  clinching  point  in  the 
diagnosis.  In  at  least  one  case  they  were  so  large  as  to  meet  in  the  middle  line,  so  that  a 
loop  of  intestine  that  had  passed  between  and  behind  them  could  not  get  out  again,  and 
the  patient  came  under  observation  for  acute  intestinal  obstruction.  The  third  type  of 
cystic  disease  of  the  kidneys  occurs  in  old  persons,  and  is  but  a  variety  of  chronic  intersti- 
tial nephritis  in  which  the  agglomeration  of  retention  cysts  has  reached  an  extreme  degree  : 
the  enlargement  of  the  kidneys  is  then  much  less  than  it  is  in  young  persons,  where  the 
lesion  is  probably  congenital  ;  the  symptoms  and  urinary  changes  are  precisely  similar 
to  those  already  described  in  cases  of  red  granular  contracted  kidneys. 

(/?)  Albuminuria  ivith  Renal  Tube  Casts  and  ivitfi  Pus. — When  pus  is  present  in  the 
urine  along  with  albumin  and  renal  tube-casts,  the  differential  diagnosis  resolves  itself  into 
that  of  pyuria  that  is  partly  or  wholly  of  renal  origin  (see  Pyuria,  p.  .574).  It  only  remains 
to  add  :  first,  that  it  is  not  sufficient  to  rely  upon  the  naked-eye  characters  of  the  urine, 
or  upon  chemical  tests,  in  excluding  minor  degrees  of  pyuria  ;  microscopical  examination 
of  the  centrifugalized  deposit  is  essential,  especially  in  the  detection  of  acute  pyelitis 
and  pyelonephritis  the  result  of  coli-bacilluria  in  children,  pregnant  women,  and  others 
(p.  09)  ;  secondly,  that  the  amount  of  albumin  actually  due  to  pus  itself  is  small,  so  that 
if  there  is  any  measurable  quantity  of  albumin  present  it  indicates  that  the  kidneys  are 
themselves  affected,  this  being  further  confirmed  when  easts  are  also  found  :  and  thirdly, 
tliat  blood,  like  pus,  is  in  itself  responsible  for  relatively  little  albumin,  so  that  wnen  there 
is  considerable  albuminuria  associated  with  blood,  there  is  strong  ground  for  believing 
that  the  albumin  is  by  no  means  all  due  to  the  blood.  The  presence  of  very  small  quantities 
of  blood  does  not  assist  the  differential  diagnosis  of  the  cause  of  albuminuria  so  much  as 
miglit  be  expected  :  much  blood  indicates  that  the  cause  is  due  to  one  or  other  of  the 
conditions  discussed   under  Hjematiria  (p.  275). 


ALBUMINURIA  13 

II.-    ALBUMINURIA     WITHOUT     TUBE-CASTS. 

Turning  now  to  albuniinmia  without  tube-casts,  one  would  enijjhasize  the  fact  tliat 
more  than  one  microscopical  examination  may  be  required,  for  if  the  urine  is  alkaline, 
or  has  stood  for  any  length  of  time,  casts,  originally  present,  may  have  become  unrecog- 
nizable ;  besides  which,  even  with  definite  nephritis,  there  may  be  very  few  casts  at  one 
time,  many  at  another.  This  applies  particularly  to  the  very  acute  cases  on  the  one  hand 
and  the  very  chronic  on  the  other.  Assuming  that  not  more  than  a  very  occasional  cast 
is  found,  the  chief  conclusion  that  can  generally  be  drawn  is  that  the  albuminuria  is  not 
indicative  of  organic  renal  disease.  The  cases  may  then  be  subdivided  into  :  (1)  Those 
in  luliich  the  urine  presents  some  other  definite  abnormality  besides  albuminuria,  especially 
a)  pyuria.  (6)  ha;maturia.  (e)  haemoglobinuria,  or  (d)  glycosuria  ;  (2)  Those  in  ivhieh, 
■jaerc  the  albumin  removed,  the  urine  tcould  be  normal. 

i .  These  cases  need  not  be  discussed  further  here  :  the  differential  diagnosis  will  be 
found  under  Pyuri.\,  H-ematluia,  H^emoglobinlria,  and  Glycosuria  respectively. 
j  2.  These  are  clinically  of  importance  in  that,  until  the  absence  of  casts  Jias  been 
[letermined,  the  absence  of  organic  renal  changes  cannot  be  concluded.  Even  when  casts 
ire  absent,  a  trace  or  a  small  amount  of  albumin  may  be  the  first  evidence  in  elderlv 
jcrsons  of  enlargement  of  the  prostate,  chronic  interstitial  nephritis,  or  arteriosclerosis  : 
)r  in  younger  persons  of  chronic  ascending  nephritis,  the  result  of  such  things  as  former 
;onorrha-a,  repeated  pregnancies,  uterine  prolapse  or  other  displacement,  chronic  vesical 
atarrh.  or  urethral  stricture.  The  chronic  effects  on  the  kidneys  of  interference  with  the 
irine  outflow  are  apt  to  be  overlooked,  though  if  they  are  borne  in  mind  they  are  generally 
asy  of  diagnosis. 

The  following  arc  a  number  of  other  conditions  which  may  cause  slight  degrees  of 
dbuininuria  without  tube-casts,  but  which  are  obvious,  or  else  diagnosed  by  other  signs 
hat  arc  discussed  elsewhere  :  burns,  scalds,  chronic  alcoholism,  cirrhosis  of  the  liver, 
liabetes  mellitus,  exophthalmic  goitre,  gout,  lead-poisoning,  mumps,  secondary  syphilis, 
norphinism,  mercurialism.  vasomotor  neuroses  such  as  Raynaud's  disease  or  angioneurotic 
edema,  obstruction  to  the  vena  <!ava  inferior  by  thrombosis  or  by  external  tumours,  the 
)rcssure  of  considerable  ascites,  ovarian  cysts  or  solid  tumours,  pernicious  ana-mia. 
lotlgkin's  disease  or  lynipliadcnoma.  lymphosarcoma,  lymphatic  or  splenomcdullary 
euka'inia.  splenic  anaemia,  pcinpliigus,  [jhospliorus  poisoning,  chronic  arsenical  ])oisoning, 
)rcgn:»icy,  severe  ana>mia  the  result  of  syphililic.  malarial,  nialignanl,  tuberculous,  or 
hthisical  cachexia,  ankylostomiasis,  or  infection  with  otlici-  parasites  such  as  Itollirio- 
ephiilus  latus  or  Trichina  spiralis. 

There  remain  three  other  groujis  of  conditions  in  which  albumimiria  and  its  dilTercntial 
liagnosis  are  often  important,  and  these  are:  (1)  Febrile  eonditions  :  (■>)  Heart-failure 
onditions  :    and  (:!)  so-called   ■  I'hi/siologicar  albuminuria  of  adolescence. 

Febrile  Conditions. — In  nearly  every  fever  there  is  some  cloudy  swelling  of  the 
larcnchyma  Tif  various  viscera,  especially  the  kidneys  ;  consetpiently  most  fevers  may 
ometimcs  be  associated  with  albuminuria,  and,  broadly  s[)eaking,  the  higher  the  patient's 
empcrature  the  greater  is  the  liability  to  it.  The  amount  of  albumin  present  is  generally 
lot  great.  We  need  not  enumerate  all  the  various  fevers  in  this  coimcxion.  SulJice  it 
o  say  that  iilbumiiuiria  is  r(lati\ely  conunon  in  scarlatina,  diphtheria,  variola,  erysipelas, 
)yrexial  i)hthisis.  cholera,  dysentery,  Weil's  disea.se.  severe  malaria,  and  yellow  fever  : 
lot  so  common  in  lobar  pneumonia.  bidncho[)neunionia.  tvphoid  fever,  and  empyema  : 
ind  relatively  uncommon  in  other  febrile  conditions,  such  as  acute  rheumatism,  inllucnza, 
neningitis,  measles,  German  measles,  follicular  tonsillitis,  and  .so  on.  The  albiMiiinuria 
nay,  of  course,  be  already  present  in  a  person  who  develops  an  inUrciirrciil  \'r\ii-  :  Ihe 
liagnosis  then  depends  upon  considerations   menlioncd   above. 

If,  on  the  other  hand,  the  albuinimu-ia  is  known  to  have  developed  coincidently  with 
he  febrile  illness,  the  chief  point  to  decide  will  be  whether  it  indicates  actual  nephritis 
)r  not.  .Many  consider  there  is  an  essential  difference  between  ■  febrile  albumimiria  " 
ind  actual  nephritis.  This  may  or  may  not  be  so,  but  it  is  extremely  dillieull  to  be  sure 
if  the  distinction  clinically.  It  may  be  urged  that  to  take  scarlet  lexer  as  an  example  - 
he  albuminuria  of  the  lirst  few  days  is  ■  febrile.'  whilst  that  of  Ihe  second  or  third  week 
s  '  nephritic'     .Vs  a  niiitter  of  fact,  in  not  a  few  cases  in  which  death  has  occurred  in  the 


14  ALBUMINURIA  1 

liist  week  the  '  febrile  "  albuminuria  has  been  associated  with  larr  mottled  acute  nephritic 
kidneys,  even  where  there  has  been  no  oedema,  no  hiematuria,  .id  no  very  large  numbers 
of  renal  tube-casts.  Probably  there  are  all  degrees  of  acute  nephritis,  from  very  slight 
and  transient,  to  very  severe  and  possibly  fatal  ;  and  it  is  a  mistake  to  try  and  make  a 
distinction  in  kind.  The  great  majority  of  cases  of  albimiinuria  during  fever  recover 
completely  ;  some  seem  to  recover  but  come  under  observation  years  later  with  pale 
granular  contracted  kidneys  ;  others  die  during  the  acute  attack.  The  degree  of  albumin- 
uria is  not  a  direct  measure  of  the  renal  changes  unless  the  amount  of  albumin  is  large  ; 
a  small  amount  of  albumin  does  not  necessarily  indicate  trivial  nephritis.  Absence  of 
oedema  is  the  rule.  Microscopical  examination  of  the  centrifugalized  urinary  deposit  is 
essential  :  the  more  the  renal  epithelial  cells,  red  corpuscles.  leucoc>-tes.  and  various  renal 
tube-casts,  the  more  conclusively  can  some  degree  of  actual  nephritis  be  diagnosed. 

When  doubt  lies  between  scarlatina  and  measles  or  German  measles,  or  between 
diphtheria  and  other  forms  of  sore  throat,  the  existence  of  albuminuria  sometimes  assists 
in  arriving  at  the  diagnosis  of  scarlatina  in  the  one  case  or  of  diphtheria  in  the  other. 

In  pneumonia,  albuminuria  has  become  much  less  frequent  since  blistering  wutli 
cantharides  has  gone  out  of  fashion  in  treating  this  disease. 

Heart-failure  Conditions. — The  right  side  of  the  heart  may  fail  owing  to  many 
different  causes,  wliieh  may  be  arranged  under  four  main  headings,  as  follows  :  (ri)  Valvular 
disease  :  {b)  Obstructive  lung  affections  ;  (c)  Myocardial  affections  ;  (rf)  Granular  kidneys 
and  other  liigh  blood-pressure  conditions.  Each  of  these  main  headings  has  many  sub- 
headings (see  Orthopncea,  p.  418).  Any  one  of  them  may  result  in  albuminuria,  though 
the  amount  of  the  latter  is  extremely  variable,  some  cases  of  severe  heart  failure  exhibiting 
no  albiuninuria  at  all,  whilst  others  may  have  as  much  as  10  parts  per  1000,  or  more. 

The  first  step  in  the  differential  diagnosis  is  to  exclude  primary  renal  conditions  by 
negative  microscopical  examination  of  the  centrifugalized  urine  deposit  for  casts,  examin- 
ation of  the  retime,  and  exact  determination  of  the  blood-pressure.  Curiously,  even  with 
feeble  irregular  pulses,  such  as  are  found  in  jjanting  cases  of  mitral  stenosis,  the  blood- 
])ressure  is  considerably  higher  than  normal,  doubtless  owing  to  partial  asphj-xia  ;  so 
that  merely  finding  a  systolic  blood-pressure  of  150  or  160  mm.  Hg  is  no  proof  of  granular 
kidney  or  arteriosclerosis  ;  sometimes,  however,  the  reading  is  as  high  as  200,  250,  300, 
or  even  :J20  mm.  Hg,  and  then  the  diagnosis  of  one  or  other  of  the  latter  is  almost  certain. 
If  renal  and  arteriosclerotic  conditions  can  be  excluded,  the  diagnosis  lies  between 
the  other  three  main  groups.  The  cardiac  bruits,  the  history  of  growing  pains,  chorea, 
or  acute  rheiunatism,  the  youth  of  the  jiatient,  the  family  history  of  heart  disease  or 
rheumatic  fever,  the  association  of  other  rheumatic  affections  such  as  recurrent  tonsillitis 
subcutaneous  nodules,  or  erythema,  will  often  serve  to  point  to  primary  vahular  disease  ; 
in  older  patients,  esiiecially  in  men  between  forty  and  fifty,  there  may  be  aortic  disease 
and  a  history  of  syphilis  and  not  of  acute  rheumatism.  In  severe  heart  failure  in  children 
imder  puberty,  the  result  of  mechanical  dillieulty  with  the  circulation,  an  adherent  peri- 
cardium is  generally  found,  and  clinically,  t!ie  heart  is  large  out  of  jjroportion  to  the  general 
physical  signs. 

When  there  is  a  definite  history  of  recurrent  winter  cough  in  an  elderly  person,  with 
a  hyper- resonant  and  over-expanded  chest,  the  likelihood  of  emphysema  and  hronchilis 
will  at  once  suggest  itself.  Similarly  fibroid  lung,  or  fibroid  hmg  and  bronchiectas^is,  as  a 
cause  of  heart  failure  and  albuminuria,  only  needs  mentioning,  the  diagnosis  generally 
being  obvious  from  tlic  physical  signs,  the  clubbed  fingers,  and  in  the  bronchiectatic  cases, 
the  abundant  intermittent,  and  frequently  foul,  expectoration. 

Myocardial  affections,  such  as  fibroid,  fatty,  or  primary  alcoholic  heart,  are  generally 
diagnosed  by  guessing  at  them  when  other  causes  of  heart  failure  can  be  excluded.  The 
jjatients  are  generally  middle-aged,  shortness  of  breath  on  exertion,  precordial  pain  and 
even  angina  pectoris  occupying  a  prominent  position  amongst  their  cardiac  symptoms  ; 
there  may  or  may  not  be  a  high  blood-pressure,  the  albuminuria  is  not  associated  with 
renal  tube-easts,  there  is  often  no  cardiac  bruit,  or  at  most  a  more  or  less  localized  blowing 
systolic  bruit  at  the  impulse  ;  at  the  same  time  the  heart  is  clearly  enlarged,  and  it  may 
be  beating  rapidly  and  irregularly  ;  there  may  be  a  history  of  syphilis  or  of  chronic 
alcoholism  :  the  jjatient  may  be  ver>-  stout  in  the  fatty,  though  generally  not  so  in  the 
fibroid,  cases.     There  may  be  a  history,  either  of  an  extremely  sedentary  life  upon  the 


ALBUMOSURIA  15 

one  hand,  or  of  over-use  of  the  lieart  by  strenuous  hard  physical  work — as  a  blacksmith, 
an  athlete,  and  so  forth — on  the  other.  Electro-eardiographic  tracings  may  be  required 
in  determining  the  nature  of  the  heart  lesion. 

Needless  to  say,  the  exact  nature  of  the  cardiac  lesion  remains  obscure  or  uncertain 
in  many  of  tliese  cases,  many  a  patient  who  really  has  mitral  stenosis  being  regarded  during 
life  as  suffering  from  chronic  bronchitis  and  emphysema,  and  so  on. 

'  Physiological  '  Albuminuria. — Finally,  we  come  to  the  albuminuria  of  apiiarently 
healthy  males  and  females  lietween  the  ages  of  fifteen  and  thirty.  The  condition  was 
little  known  until  medical  examinations  at  schools,  or  for  life  insurance,  or  for  the 
services  became  common.  It  has  received  a  number  of  names,  of  which  the  following 
are  some  :  "  accidental,'  "  essential,'  "  postural,'  "  cyclic,'  "  orthostatic,'  '  intermittent,' 
'  physiological,'  "  functional,"  •  orthotic,'  albuminuria,  Pavy's  disease,  albuminuria  "  of 
adolescence '  or  "of  puberty.'  It  derives  its  chief  importance  from  the  fact  that 
young  males  who  suffer  from  it  may  be  rejected  for  life  insurance  or  for  the  services,  from 
the  fear  that  they  have  some  form  of  nephritis.  A  similar  condition  occurs  in  females  of 
a  similar  age.  but  it  is  detected  less  often  than  in  males  because  one  has  less  occasion  to 
examine  the  urines  of  healthy  girls  than  is  the  case  with  boys  and  youths.  Collier  and 
others  have  tlirown  much  light  upon  the  nature  of  the  affection  by  their  investigations 
upon  the  urines  of  rowing  men.  It  is  found  that  tlie  urine  passed  just  before  a  boat-race 
being  free  from  albumin,  that  voided  immediately  after  is  generally  loaded  with  it.  A 
few  hours  later  this  albuminuria  is  gone  again.  Now  university  oarsmen  are,  u])on  the 
whole,  long  lived,  hence  this  recurrent  albuminuria  cannot  matter  in  them  ;  and  the  same 
applies  to  the  albuminuria  of  many  adolescents.  A  prominent  feature  of  such  a  case  is 
that  the  urine  first  voided  in  the  morning  is  quite  normal,  wliilst  that  passed  later  in  the 
day  may  contain  anything  from  a  trace  to  five  parts  per  thousand  of  albumin  ;  the  more 
the  youth  has  exerted  himself  physically  by  walking  or  otherwise,  and  the  more  he  has 
exposed  himself  to  cold,  for  instance  during  a  train  journey  to  the  city  on  a  winter's  day, 
or  in  a  cold  ijath.  the  greater  is  the  liaijility  to  this  unimportant  but  possibly  alarming 
albumimiria.  Some  youths  may  pass  albumin  for  days  together  before  an  interval  of 
freedom  from  it  occurs.  Sometimes  they  appear  to  be  in  robust  health,  sometimes  they 
look  a  little  pale,  as  though  they  had  been  overworking  at  an  indoor  occupation  ;  they 
may  be  nervous,  but  often  they  are  not.  A  natural  nocturnal  emission  is  supposed  to 
predispose  to  albuminuria  next  day  ;  so  also  is  a  diet  which  includes  eggs,  especially  raw 
eggs.  The  point  is  that  these  individuals  have  to  be  differentiated  from  sufferers  from 
Hright's  disease.  The  method  of  diagnosis  is  as  follows  :  a  complete  routine  examination 
is  carried  out,  and  no  obvious  affection  of  the  heart  or  other  viscera  is  detected  ;  the  blood- 
pressure  is  normal  :  the  albumin  having  been  discovered,  the  patient  is  directed  to  sui)ply 
a  scries  of  samples,  at  intervals  of  a  few  days,  and  ])referably  passed  inmiediately  after 
rising  in  the  morning.  If  all  samples  contain  albumin  it  will  be  very  didicult  to  exrludc 
organic  disease  ;  if  some  contain  albumin  in  aliundancc,  however,  and  others  none  at  all, 
llie  ])resu»iiptioii  will  be  that  it  is  •  functional  "  :  before  l)eing  finally  satisfied,  however, 
it  is  important  that  a  careful  microscopical  examination  of  the  centrifugalized  dc)iosit 
from  a  specimen  containing  albumin  should  be  made,  no  casts  or  other  abnormal  consti- 
tuents being  found.  The  administration  of  calcium  chloride  or  calcium  lactate  greatly .< 
diminishes  the  lendincy  to  this  form  of  albuminuria.  In  an  adolescent  male  who  has  no 
sym|)toms.  albumimiria  discovered  accidentally,  present  after  exertion  or  after  exposure  to 
cold,  but  absent  alter  rest  in  bed.  and  when  |)resent  not  associated  with  renal  lube- 
casts  or  with  signs  of  arterial,  cardiac,  or  other  disease  that  should  be  delicled  by  physical 
examination,  is  almost  certainly  "  phvsiological."  needing  no  treat mcTit  and  not  judical  i\c 
of  any    lindcrlyiiii;    disease.  Ilrrlurl   Fiiixh 

ALBUMOSURIA  may  be  iliseussed  under  I  wo  main  hca.liugs.  naincly  :  (1)  Onliiiiinj 
.llhiiiniisiiria.  which  is  not  uncommon  but  is  of  little  clinical  importance:  and  fJ)  Hiiicc- 
■  loiits  .llhiimnsiiriti.  which  is  rare  hut   is  clinically  im|)ortant. 

Ordinary  Albumosuria  is  seldom  recognized  because  the  albumose  generally  occurs 
along  with  albumin,  and  is  not  detected  imlil  this  has  been  removed  by  acidulating  with 
accli<-  acid,  boiling  t  iKiroii^lilv.  and  |j||(  ring.  Albumose  mav  be  rceogiii/.cd  in  the  lillrate 
by   the    facl    tliMt    with    llillci--,   nilrir  aciil    lest    it    uives   a    while  cloud    which   disappears  on 


16  ALBUMOSURIA 

warming,  to  reappear  on  cooling  ;  and  its  presence  may  be  confirmed  by  the  violet -red 
colour  ft  gives  with  the  biuret  test,  which  consists  in  adding  excess  of  caustic  soda  to  a 
drop  of  dUute  copper  sulpliate  solution,  adding  this  mixture  in  drops  to  the  urine,  from 
which  all  albumin  has  been  removed,  and  warming.  Another  test  for  albumose  is 
Hofmeister's,  which  consists  in  acidulating  the  urine  with  acetic  acid  and  then  adding 
phosphotungstic  acid  ;  albumoses  give  a  milky  cloud  with  the  latter.  The  deutero- 
albumose  that  gives  these  tests  occurs  in  the  urine  under  a  great  variety  of  circumstances  : 
apparently  the  one  essential  factor  is  cell  destruction  within  the  body.  It  will  suffice  to 
mention  some  of  the  many  diseases  in  which  it  has  been  found  : — 

(a)  '  Febrile '  Albumosuria  :  in  severe  infective  fevers,  such  as  tyijhoid.  scarlet, 
small-pox,  measles,  acute  rheumatism,  lobar  pneumonia. 

(fo)  •  Pyogenic '  Albutnosuriii  :  in  empyema,  phthisis  with  cavitation,  bronchiectasis, 
appendicular  subdiaphragmatic  or  hepatic  abscess,  suppurating  gall-bladder,  pyosalpinx, 
suppurative  periostitis,  arthritis  or  osteomyelitis,  gangrene  of  the  lung,  gangrene  of  the 
leg,  breaking-down  cancer,  acute  peritonitis. 

(c)  •  Hepatogenous  '  Albumosuria  :   in  cancer  of  the  liver,  cirrhosis,  catarrhal  jaundice, 

phosphorus  poisoning,  acute  yellow  atrophy,  infective  cholangitis,  suppurative  jn  lci)hlehitis. 

{(I)  '  Alimentary'  Albumosuria  :   in  cases  of  gastric  or  duodenal   ulcer,  carcinoma  of 

the  colon  or  stomach,  ulcerative  colitis,  tuberculous  ulceration  of   the   bowel,   acute   and 

chronic  dysentery. 

(e)  •  Hcvmatogenous '  Albumosuria  :  in  leuka-mia,  scurvy,  purpuric  conditions,  and 
with  internal  hcematomata,  such  as  pelvic  hsematocele. 

(/)  ■  Albuminuric  '  Albumosuria  :  many  cases  of  acute  nephritis,  syphilitic,  cardiac 
and  other  forms  of  albuminuria,  are  associated  with  albumosuria.  There  is  some  doubt, 
however,  as  to  whether  the  reagents  employed  in  the  qualitative  analysis  do  not  themselves 
convert  some  of  the  albumin  into  albumose. 

(g)  Albumosuria  due  to  unclassified  causes  :  such  as  pregnancy,  especially  if  the  fcetus 
has  died,  though  sometimes  even  without  this. 

The  amount  of  albumose  present  in  any  of  the  above  conditions  is  seldom  large,  and 
diagnostically  it  has  little  if  any  significance  except  when  it  occurs  apart  from  albumin. 
Even  then  its  main  importance  lies  in  the  necessity  of  not  mistaking  it  for  albumin.  This 
error  would  only  arise  with  the  nitric  acid  test,  for  albumose  does  not  form  a  cloud  on 
boiling  with  acetic  acid.  It  is  urged  by  some  that  albimiosuria  in  appendicitis  points  to 
abscess  rather  than  to  simple  inflammation  ;  that  in  a  pleuritic  case  it  points  to  empyema 
rather  than  to  serous  effusion  :  that  in  a  mcningitic  case  it  points  to  the  suppurative  or 
epidemic  cerebrosjjinal  forms  rather  than  the  tuberculous  ;  and  so  on  ;  but  it  is  very 
doubtful  if  the  symptom  can  carry  so  much  weight  as  this.  In  a  given  case  the  presence 
of  ordinary  albumosuria  points  to  a  graver  prognosis  upon  the  whole  than  if  no  albumose 
were  present,  but  it  is  not  particularly  helpful  in  differential  diagnosis. 

Bence-Jones  Albumosuria,  on  the  other  hand,  though  rare,  is  clinically  important. 
The  nature  of  the  jiroteid  present  is  still  undecided  :  it  certainly  is  not  ordinary  albumose. 
Its  most  striking  characteristic  appears  when  the  urine  is  warmed  after  aeidulation  with 
acetic  acid  to  prevent  precipitation  of  phosphates  :  long  before  the  urine  boils  a  dense 
milky  precipitate  appears,  suggesting  at  first  sight  either  phosphates  or  coagulated 
albumin  ;  it  attracts  attention  at  once  from  the  fact  that  on  further  warming  it  begins 
to  clear  up  again,  and  after  boiling  it  almost  or  completely  goes.  It  will  be  reaUzed  that 
the  precipitat'e  cannot  be  albumin  or  phosphates,  for  not  only  would  neither  of  these  clear 
up  at  boiling-point  in  this  way,  but  also  the  aeidulation  of  the  urine  has  been  sufficient 
to  prevent  phosphates  from  coming  down,  whilst  the  temperature  at  which  the  dense 
sticky  precipitate  appears  (about  60°  C.)  is  far  lower  than  that  at  which  albumin  coagulates. 
If  any  albumin  is  present  at  the  same  time  the  clearing  at  boiling-point  will  be  but  partial ; 
the  albumin  should  then  be  removed  by  boiling  and  filtration,  when  nitric  acid  added  to 
the  filtrate  will  gi\'e  a  white  ring  which  redissolves  on  warming,  to  reappear  on  cooling, 
like  that  of  albumose.  This  Bence-Jones  proteid,  when  present,  generally  occurs  in  much 
larger  amounts  than  ordinary  albumose  ever  does,  so  that  it  is  seldom  overlooked  unless 
it  is  mistaken  for  albumin.  It  may  amount  to  anything  between  1  and  20  parts  per 
thousand,  or  more.  It  may  be  present  on  some  days  and  not  on  others.  It  indicates, 
almost  with  certainty,  that  there  is  some  affection  of  the  bone-marrow  ;    it  might  be  due, 


AME\()RHH(EA  17 

for  instance,  to  secondary  deijosits  of  nialignant  disease  in  bones,  or  to  leukieniia  :  but 
in  the  great  majority  of  cases  it  has  occurred  in  connection  witli  multiple  myelomata — 
Tvahler"s  disease  or  myelopathic  albumosuria  of  Bradshaw.  Unless  there  is  other  evidence 
ro  the  contrary,  abundance  of  Bcnce-Jones  i)roteid  in  the  urine  indicates  multiple  tumours 
in%olving  the  bone-marrow,  Herbert  Freiieh 

ALKAPTONURIA. — (.Sec  Urine,  Abxormai.  Coloratiox  of.  p.  74C.) 

ALLOCHEIRIA — Literally  means  '  other  handness.'  It  sometimes  happens  that 
when  a  patient  is  touched  upon,  say,  the  back  of  his  right  foot,  and  is  then  asked  where 
he  has  been  touched,  he  says,  "  Upon  the  back  of  my  left  foot."  This  reference  of  sensa- 
tions to  exactly  corresponding  parts  of  the  limbs  or  body  on  the  wrong  side  is  known  as 
allocheiria.  ]-:xperiments  have  shown  that  complete  allocheiria  results  from  transverse 
hemisection  of  the  spinal  cord.  It  seems  that  sensory  impulses  travel  much  the  more 
readily  up  their  own  side  of  the  cord,  but  can  also  pass  by  the  opposite  side  if  necessary  : 
when  they  arc  compelled  to  do  .so,  the  brain  interprets  them  as  coming  from  that  side  of 
the  body  which  usually  sends  impulses  up  tliis  particular  side  of  the  cord.  AMien  a  patient 
exhibits  allocheiria.  therefore,  it  generally  indicates  that  there  is  a  lesion  affecting  one  side 
of  the  spinal  cord,  or  the  upward  extensions  of  the  tracts  which  convey  sensory  impulses 
from  the  cord  to  the  brain,  more  than  the  other.  It  is  necessarily  a  rare  symptom.  It 
might  result  from  a  stab  or  a  bullet  wound  damaging  the  cord  unilaterally  ;  or  from  a 
gununa  or  neoplasm  of  the  spinal  meninges  ;  it  may  be  functional  ;  rarely  it  may  result 
from  the  cord  becoming  comjjressed  more  on  one  side  than  on  the  other  by  spinal  caries, 
a  new  growth,  callus,  or  a  fracture-dislocation  :  and  occasionally  it  may  be  noticed  when 
there  is  a  cord  disease  which,  though  usually  bilateral,  happens  to  have  advanced  more 
rapidly  on  one  side  than  upon  the  other,  as  in  exceptional  cases  of  disseminated  sclerosis, 
locomotor  ataxy,  or  softening  from  syjjhilitic  endarteritis  and  thrombosis.  Except  in 
functional  eases,  allocheiria  will  seldom  be  the  only,  or  even  the  chief,  feature  in  the  case  : 
paresis,  pain,  or  some  other  symptom  i)resenl  will  afford  greater  assistance  in  the  diagnosis 
than  will  the  allocheiria  itself.  Herbert  FrencI,. 

ALOPECIA.— I  See    Hai.dm-.ss.    p.   70.) 

AMAUROSIS.-  (See  N'isio.n.  Uia-ixrs  ok.  p.  ?.-,«.) 

AlVlBLYOPIA.^(Sec  Vlsion.  Dki-hcts  oi-.  p.  T.>!t.) 

AMENORRHOHA.-  'I'lie  lime  al  which  menstruation  lirsl  appears  is  very  variable 
wilhiii  (crhiiii  Imiits,  being  itilluciieed  largely  by  climatic  and  racial  |)eculiarilies  :  in  this 
■ounlry  alioul  roiirleeu  may  be  taken  as  the  average.  When  the  meiislrual  Mow  has  not 
X'ciime  cslablislicd  it  is  usual  to  speak  of  primary  amenorrluea.  whilst  cessation  of  the 
How  alter  II  has  once  been  regularly  established  is  known  as  secondary  amenorrluva.  From 
the  lahlc  of  the  causes  of  amenorrha-a  below,  it  will  be  seen  that  .some  of  them  must 
f  necessity  give  rise  to  primary  anienorrlKea.  whilst  others  more  coirunonly  produce  the 
icoiulary  variety.  In  investigating  a  ease,  therefore,  it  is  imijortant  to  ascertain  first 
whelher  the  condition  is  primary  or  secondary,  and  next  whether  it  is  real  or  only  apparent. 
The  latter  cotidilion.  known  as  cryptometiorrlKra.  implies  that  the  menstrual  How  takes 
place  but  is  imable  to  escape  exiernallv  because  there  is  some  closure  of  a  pari  ot  Ihe  genital 
an.il.  The  congenital  I'oriTi  of  (  iyploMienorrh<ra  is  the  only  vari(l\  nicl  willi  al  .ill 
ominonly,  accpiircd  closmc  i<\  a  pari  of  Ihe  genital  canal  being  cxeciilingly  rare.  Slenosis 
il  IIk'  \agina  is  not  iinconurron  as  a  result  of  injui-y  and  infection,  but  a  srrrall  sinirs  is 
iisrially  lell  which  srrlliees  lor  tire  escape  of  the  menstrual  llriid.  We  are  led  lo  suspect 
rxploineirorrlroa  when  the  patient  volunteers  the  statement  that  she  has  pelvic  pain, 
headache,  and  jio.ssibly  vomiting,  of  monthly  occurrence,  in  fact  the  usual  rnenslrual 
molimina.  unaccompanied  by  any  visible  How.  .\  physical  cxaminalion  shorrld  be  made 
a(  oiici'  in  such  a  ease,  iirehrdiiig  abdominal  palpation,  inspect  ion  oi  I  lie  \ril\ii.  arrd  a  i-eeto- 
ilxlominal  bimanual  exainirralirrn.  The  coirrnron  form  is  thai  in  uliicli  Ihe  lower-  end 
>f  Ihe  vagina  is  irnperfor-ali'.  Ihe  liynicn  iisrrally  bcirrg  visible  on  llie  outer  side  of  Ihe 
■Cdudiirg   rrrernhrane.      The   eoir.|,lrt,-   ,  xainniiilion    irr    sncli    ;i    case    uill    i-e\eal   a    llnel  iral  ini; 


18 


AMENORRHa^]A 


.swcllinji-  reaching  from  the  \iilva  to  tlio  ])clvic  brim,  above  which  the  uterus  can  oftii 
be  palpated  and  moved  about.  It  is  further  of  considerable  importance  to  make  oni 
wliether  the  uterus  and  Fallopian  tubes  are  distended  with  menstrual  products  alonu-  witi 
llie  distended  vagina,  for  in  the  presence  of  ha-matosalpinges  the  treatment  is  considerablx 
modified.  Abdominal  section  is  required  in  such  a  case  to  avoid  rupture  of  the  tubes  wlici 
tlie  vajiina  collapses  after  incision  of  the  occluding  membrane.  Distention  of  the  vagin; 
(jr  hicmatocolpos  is  complete  in  this  case,  but  may  be  partial  where  the  lower  part  of  tli( 
vagina  is  absent,  and  then  is  likely  to  be  accompanied  by  distention  of  the  uterus 
(ha-matometra)  and  ha-matosalpinx.  Complete  absence  of  the  vagina  can  only  be  inferrei 
from  ]3hysical  examination,  when  the  distended  organ  appears  to  be  only  the  uterus. 
Although  a  secondary  phenomenon,  acquired  cryptomenorrhoea  produces  the  saim 
symptoms  and  requires  the  same  kind  of  investigation  as  the  congenital  ca.ses.  It  niu^ 
not  be  forgotten  that  ae<|uired  closure  of  tlie  vagina  following  the  vaginitis  of  specific  fe\  (  i 
may  t)ccur  in  infancy,  and  will  then,  of  course,  produce  ])rimary  amenorrhoea. 


CAUSES    OF    APPARENT    AMENOHRHCEA. 


Cniigeiiilal  : 

Iiiipeiibrate  vagiiui 
Iniporforatc  hymen 
AljseiK'c  of  the  vagiiui 
Acijuireil  : 

Closure  of  the  vagina  : 
Due  to  specific  fevers 
Due  to  injury 


I'lii/sidlogicdl  : 
IJeforc  puberty 
After  the  menopause 
During  ])reanancy 
During  lactaticm 

I'alliohgiail  : 

(Jenerative  System  : 

Ah.sence  of  essential  organs 
Infantile  uterus 
Small  adult  t\pe  of  uterus 
Deficient  ovarian  activity 
Destruction     of    both 
ovaries  : 
By     double      ovarian 

growths 
I?y  )ielvi<'  iMll;iinniatiiin 
Supcriiuohitiiui      oi'      the 

uterus 
Note. —  Real  atnenorrlicpa 


Ini])erf'oratc  ecr\ix 

Double   uterus   with   retention 

Hivmatocolpos 


Ilaniatometra 
Iheinatosalpinx 


Closure  of  the  cervix  : 
Due  to  injury 
Following  operations 


CAUSES    OF    REAL    AMENOI?RHCE 
Circulatory  System  : 
Chlorosis 
Anfemia 
Leueocvtha'uiia 
II(i(lgkiM"s  disease 
Wastiiii;   iliseases  : 

Ahili^iiant    growths 

Tubercle 

Prolonged  siippiu'ation 

Diabetes 
Late    stages    of    nephritis 
Late  stage  of  some  forms  of 

heart  disease 
Late    stage    of    cirrhosis    of 

the  liver 
Nervous  system  : 
Tnihceilifv 
L'  Cretiiiisni 

\'ari<nis  fdi'ius  of  insanity 

nay  be  (1)  Primary  witli  delayed  onset  ; 
(3)  Secondary. 


Cold   just   before   or   durini 

menstruation 
Suggestion — fear     of     ijreg 

nancy 
Anorexia  nervosa 
Altered  internal  secretions  : 
Myxoedema 
Exophthalmic  goitre 
Addison's  disease 
Acromegaly 
Obesity 

Change  of  habits 
Toxic  : 

After  specific  fevers 
Chronic  poisoning  by  lead 

merctuy,  morijhia,  alcoho 


(2)  I*riinary  and  permanent  ; 


In  considering  tlie  diagnosis  of  the  causes  of  real  amenorrhoea.  the  primary  ani 
secondary  forms  afford  us  an  important  clue  to  the  possible  causation.  Suppose,  fo 
instance,  that  menstruation  has  once  been  established  regularly,  it  is  clear  that  there  canno 
be  any  serious  congenital  anomaly  of  the  generative  system  ;  the  uterus  and  ovaries  mus 
at  least  be  present  and  functional.  We  then  must  make  a  systematic  examination  of  th 
generative,  circulatory,  nervous,  and  ductless  gland  systems,  in  order  to  learn  by  a  proces 
of  exclusion  which  group  of  causes  we  ha\'e  to  deal  with.  If.  however,  the  amcnorrhoei 
is  primary  and  real,  that  is.  the  patient  has  no  molimina,  our  examination  nuist  first  b 
directed  towards  finding  out  whether  the  essential  organs,  namely,  uterus  and  ovarief 
are  present,  and  are  normal  in  size  and  shape  as  far  as  a  bimanual  examination  can  ascertain 
ir  necessary,  an  anaesthetic  may  be  given  for  this  purpose,  for  it  is  often  a  matter  of  c;)n 
siderable  difficulty  to  decide  the  question.  If  the  fact  of  absence  of  the  essential  organ 
can  be  established,  we  are  clearly  justified  in  considering  the  amenorrhoea  to  be  permanent 
and  the  patient  or  her  friends  should  be  told  of  this. 


AMNESIA  19 

Ajjart  from  congenital  anomalies,  it  is  remarkable  how  few  lesions  of  the  generative 
(irjiaiis  there  arc  which  produce  amenorrhoea  ;  only  those  diseases  which  destroy  both 
ovaries  completely  or  render  the  uterus  functionless  can  cause  amenorrhoea,  and  under 
this  heading  we  find  only  double  ovarian  growths,  the  late  stages  of  pelvic  inflammation 
(sali)ingo-o6phoritis),  and  superinvolution  of  the  uterus.  A  tumour  destroying  one  ovary 
as  a  rule  has  no  effect  on  menstruation  at  all.  provided  the  other  is  present  and  I'lmctionally 
perfect.  It  is  possible  for  one  ovary  only  to  be  functional  :  for  instance,  that  on  the  same 
side  as  the  undeveloped  half  of  a  unicornuate  uterus  may  be  quite  atrophic  and  functionless. 
The  presence  of  two  tumours  in  the  abdomen  symmetrically  arranged  with  regard  to  the 
uterus  will  sometimes  permit  of  the  diagnosis  of  double  ovarian  destruction,  but  quite 
CDiiimonly  one  tumour  is  much  larger  than  the  other,  and  the  double  nature  of  the  lesion 
cannot  be  established  initil  the  abdomen  is  opened.  Su])erinvolu_tion  of  the  uterus  is  not 
dillienlt  to  recognize  when  we  remember  that  it  always  follows  pregnancy,  and  the  small 
size  of  the  uterus  can  be  made  out  readily  by  bimanual  examination  and  the  passage  of 
the  uterine  sound.  The  organ  sometimes  measures  only  IJ  inches  by  the  sound.  It  must 
not  be  forgotten  that  even  in  these  cases  the  primary  lesion  may  be  an  ovarian  atrophy, 
but  very  little  is  known  on  this  point.  The  term  ""  deficient  ovarian  activity  "'  is  a  time- 
honoured  one.  and  must  be  taken  to  mean  the  absence  of  the  internal  secretion  of  the 
ovary.  It  is  obvious  that  this  condition  cannot  be  diagnosed  by  any  physical  examination, 
and  its  presence  can  only  be  inferred  when  absolutely  no  other  lesion  of  any  system  can 
be  found  to  aecoimt  for  amenorrhea,  either  primary  or  secondary. 

It  is  impossible  in  the  space  at  our  disposal  to  draw  up  any  detailed  method  by  which 
the  various  diseases  under  the  circulatory,  nervous,  etc..  systems,  can  be  diagnosed  ;  these 
are  discussed  under  the  headings  of  other  symptoms  that  they  produce.  It  is,  however, 
not  out  of  place  to  note  here  that  amenorrhoea  caused  by  general  diseases,  unconnected 
with  the  generative  .system,  depends  upon  :  (1)  Alterations  in  the  blood  itself  ;  (2)  Alter- 
ations in  blood-pressure  :  (.3)  Altered  relation  of  the  nerve  impulses  which  form  part  of 
the  stimulus  for  menstruation  :  (4)  Altered  relations  between  the  internal  secretions  of 
llie  ovary  and  the  thyroid  glands  on  the  one  hand,  opposed  to  the  suprarenal  and  pituitary 
irlands  on  the  other.  Finally,  with  regard  to  ])rcgnaney.  which  is  the  conuiionest  of  all 
causes  of  secondary  amenorrluea,  it  may  be  fornuilated  as  an  axiom  that  an  otherwise 
healthy  woman  who  has  had  perfectly  regular  menstruation  is  probably  pregnant  if  she 
has  a  jjcriod  of  absolute  amenorrhoea.  Nevertheless,  the  presence  of  pregnancy  must 
never  be  assumed  without  a  most  careful  consideration  of  the  history,  combined  with  a 
complete  physical  examination.  The  diagnosis  of  pregnancy  nuist  always  l)c  made  uixm 
a  complex  of  syrTiptoms  rather  than  upon  any  one  :  the  combination  of  amenorrhoa, 
secretion  to  be  s<)tieezed  from  the  breasts,  morning  sickness,  vaginal  discoloration,  and  an 
abdominal  tumour,  can  only  mean  jiregnaney  in  the  vast  majority  of  eases.  The  addition 
of  I'o'tal  ino\cnicn(s  and  the  lietai   heart-sounds  iiiaki-  the  diagnosis  absolute. 

T.  (1.  Stevciit. 

AMNESIA  (Loss  of  Memory).  Memory  is  one  of  the  higlicv  funelions  of  the  brain, 
and  presents  wide  Narialions  in  ifs  degree  of  de\(lopiiient  in  dilferent  indixiduais.  'flic 
physiological  range  being  so  extc'MsJNe.  it  is  almost  impossible  to  say  whether  an  apparently 
poor  memory  is  pathological  or  not.  when  llic  condition  is  of  long  standing  and  stationary. 
.Slight  degrees  of  impairment  of  inciiiory  arc  of  interest  to  the  psychologist,  but  to  the 
majority  of  tneclieal  nun  the  loss  must  be  considerable  or  of  peculiar  character  before  it 
is  of  diagnostic  iniportanee.  In  some  forms  of  excitement  there  may  be  exaltation  of 
memory  (hypernuiesia )  ;  cxciits  are  recalled  and  magnified  in  importance,  wliich  in  normal 
states  would  never  have  icaclicd  the  surliK'C  of  conscious  memory.  In  all  i'ornis  of 
dementia,  on  the  oilier  hand,  memory  becomes  impoverished  (hy])omnesia).  and  may 
eventually  fail  altogether  (amnesia).  Ucferenee  can  l)e  nia<le  to  only  a  lew  states  in  wliich 
the  condition  of  memory  may  be  of  service  in  diagnosis. 

Dnnnilin.  In  all  forms  of  dementia  senile,  general  paralytic,  toxic,  etc.  memory 
is  impaired,  and  it  is  the  rule  to  find  that  recent  c\cnts  are  lost  before  those  belonging  to 
distant   y<ars.      I'',\<n  when  memory  is  obliteratcil  almost  completely',  a  few    isolateil  events 

in    the    past    may    lie    recalled    distinctly    will I     llieir    surroundings,    and     inav    lake    a 

prominent    place    in    the   ])atient"s   personalilv.     These  traits  charaeteri/e  seuilil\.  bid    arc 
also    t<i    !)(■    roiiiiil,    when    IddUcd    l(ir.    in    oilier   dinuiilcd    slates. 


•20  AMXESIA 

Epilepsy. — Amnesia  is  an  important  feature  of  the  epileptic  seizure  ;  in  the  majority 
of  epileptics  no  memory  of  the  convulsion  is  preserved,  although  events  immediately 
preceding  it  may  be  retained  clearly,  as  well  as  those  which  follow  the  return  of  consciousness  : 
in  other  cases  the  amnesia  may  cover  a  period  preceding  the  attack  (retrograde  amnesia),' 
while  in  others,  actions  are  performed  after  the  attacks,  in  an  apparently  conscious  state, 
which  the  patient  is  quite  unable  to  recall  later  on.  To  this  phenomenon  may  be  applied 
the  term  antegrade  amnesia  in  association  with  post-epileptic  automatism.  Epileptic 
amnesia  is  often  important  in  connection  with  medico-legal  questions  and  criminology.  ' 
In  addition  to  temporary  lapses  of  memory,  the  majority  of  epileptics  suffer  from  the 
progressive  hypomnesia  common  to  all  forms  of  dementia.  It  is  one  of  tlie  first  signs  of 
their  intellectual  deterioration,  and  not  the  result  of  the  administration  of  bromides  to 
which  it  is  generally  attributed. 

Trnnma. — Severe  falls  or  blows  on  the  liead  often  cause  complete  amnesia  ;  the  latter 
may  cover  not  only  a  period  of  unconsciousness,  but  also  a  period  preceding  or  following  it, 
or  both.  As  in  cases  of  epilepsy,  the  amnesia  may  be  retrograde,  anterograde,  or  antero- 
retrograde. 

Korsakozv's  Syndrome. — This  condition,  generally  the  result  of  alcoholism,  is  character- 
ized by  hypomnesia,  disorientation,  and  pseudo-reminiscences.  The  patient  loses  memory 
for  recent  events,  has  no  appreciation  of  time  or  place,  talks  freely  and  often  plausibly 
about  events  which  have  never  occurred,  and  yet  may  retain  a  very  natural  attitude  of 
mind  towards  his  surroimdings.  So  natural  may  be  his  manner  of  talking  and  his  behaviour, 
that  the  above-mentioned  mental  deficiencies  nray  escape  notice  unless  the  medical  man 
a[)i)lies  himself  to  their  discovery. 

Toxcemia. — In  many  infective  diseases,  such  as  enteric  fever,  the  return  of  health  may 
reveal  a  state  of  amnesia  covering  a  considerable  part  of  the  patient's  illness,  and  this 
blank,  the  result  of  intoxication  of  the  higher  cerebral  centres,  may  be  permanent. 

Hysteria. — Anmesia  is  probably  quite  complete  in  connection  with  some  forms  of 
hysterical  '  fits.'  The  patient  in  the  interval  between  attacks  has  no  recollection  of  the 
latter,  although  they  are  not  associated  with  loss  of  consciousness.  This  fact  underlies 
the  theory  which  assumes  a  double  consciousness  ;  the  person  in  one  state  of  conscious- 
ness has  m  memory   for  events  which  oeciu'  in  the  other.  E.  Far(jnli(ir  Buzzard. 

ANEMIA  is  a  general  and  inexact  term  which  may  include  one  or  more,  or  even  all, 
of  several  iliflerent  changes  in  the  blood,  but  of  which  the  main  criterion  clinically  is 
diminution  in  the  amount  of  haemoglobin  contained  in  a  given  volume,  usually  but  not 
invariably  associated  with  a  decrease  in  the  number  of  red  cells  per  c.mm.  of  blood.  Changes 
in  the  leucocytes  are  not  essentially  related  to  anaemia,  though  their  behaviour  affords 
means  of  diagnosing  some  forms  of  aniemia  from  others.  Various  terms  have  been  used 
to  denote  different  ways  in  which  the  blood  may  depart  from  the  normal,  and  these  may 
be  defined  shortly,  though  they  are  seldom  imjaortant  in  practice. 

Olisocytlia'itiid  or  hypoeythcemia  both  signify  a  diminution  of  the  number  of  red  cells 
below  the  normal  5.(H)0,()00  per  c.mm.  of  blood  in  a  man,  4,500,000  in  a  woman.  Oligcemia 
means  a  diminished  total  amount  of  blood  in  the  body  ;  hydrceniia,  an  increased  percentage 
of  water  in  the  blood  ;  polyplasmia,  an  increase  in  the  volume  of  the  plasma  of  the  blood 
such  as  occurs  in  chlorosis  ;  oligochromcemia,  a  diminution  in  the  amount  of  haemoglobin 
per  c.nun.  of  blood. 

For  purposes  of  comparison  of  one  case  with  another,  one  speaks  of  the  red  cells  and 
of  the  haemoglobin  as  being  normally  100  per  cent  in  health.  An  anaemia  may  be  such 
that  the  haemoglobin  is  greatly  diminished  without  so  great  a  diminution  in  the  red 
ct)rpuscles  :  it  is  also  possible  for  the  haemoglobin  and  the  red  cells  each  to  be  diminished 
in  e<|ual  proportions  ;  and  thirdly,  it  is  possible  for  both  the  haemoglobin  and  the  red 
corpuscles  to  be  diminished,  but  for  the  hffimoglobin  to  be  relatively  less  so  than  are  the 
red  cells.  The  red  corpuscles  contain  relatively  less  haemoglobin  than  they  ought  to  in  the 
first  variety  of  anaemia,  which  is  probably  the  commonest  of  all  ;  in  the  second  group, 
although  there  is  ana^nia,  each  red  corpuscle  contains  its  full  quantity  of  hirmoglobin  : 
whilst  in  the  third  group,  although  there  is  anaemia,  each  corpuscle  contains  more  haemo- 
globin than  it  normally  should.  .As  a  means  of  expressing  these  facts  shortly,  one  speaks 
of  the  colour  index  :    this   is  the  ratio  of  the   haemoglobin  tf)  the  red  corpuscles.      If  the  red 


AX.EMIA 


21 


corpuscles  and  uemoglobin  are  each  100  per  cent  of  normal,  the  colour  index  is  kip  „,  1 
If  the  ha.moglob,n  were  diminished  to  40  per  cent  of  normal,  whilst  the  red  cells  l^^  onh- 
hmnnshed  to  80  per  cent  of  normal,  the  colot.r  index  would  be  4§.  or  0-5-the  mZhc 
Hipe.  ,n  w  uch    he  mdex  ,s  less  than   1.     If  the   ha-moglobin   and  the  red  cells  we,rbot^^ 

-"or  t  irt.  r"  ""I  ,  "°'""'-  :'"^  "°""*  ''"  '"^'"■"'"  -'*"  -  "-„,al  colour  ndexo 
„  or  1.  If  the  lurmoglobm  were  dimimshed  to  30  per  cent  of  normal,  whilst  the  red 
cells  were  dnnm.shed  to  20  per  cent  of  normal,  the  colour  index  would  be  au  or  i-5- 
that  IS  to  say,  greater  than  1,  a  condition  which  is  spoken  of  as  the  pernidous  type  of 
colour  mdex,  because  it  is  seen  best  in  pernicious  ana?mia.  ^^ 

Pallor  may  or  may  not  indicate 
anapmia.  Many  per.sons  look  almost 
white,  and  yet  their  blood  is  not  in 
an  abnormal  condition.  Pallor  is  nor- 
mal in  night-workers  and  in  those  who 
work  underground.  Even  in  some 
daylight  workers  the  distribution  of 
the  cutaneous  capillaries  seems  to  be 
such  that  the  superficial  skin  has  little, 
if  any,  of  the  normal  colour  of  blood, 
and  yet  the  individuals  arc  not  ana?mic 
in  the  sense  of  having  any  diminution 
of  the  ha'moglobin  or  the  red  cells. 
The  error  of  mistaking  mere  pallor  for 
iina-inia  is  avoided  by  means  of  a  eve,,  mm 
l)lood-count.  which  in  all  cases  should 

inclu.le  estimation  of  the  percentage  of  haemoglobin,  and  of  the  total  number  of  red  cells 
.er  c.mm   •  and   in  most  cases  determination  of  the  number  of  leucocytes  per  c.mm     a 

i:;::;:d^::;^'fihr:,r"' ""'  ^"  ^^^"""^*'°"  °^  ^"^  ^'-^-^-^  «^  ^'-  red'^orpusdesin 

Corpuscles  are  best  counted  hv  nu-Miis  of  tlie  Tlionia-Xciss  or  Tl.nm.,  I  ..;*     i 

Having  proved   that  the  patient    is  suffering  from  real  ana>mia.   that   is  to  say  from 

innution  in  the  percentage  of  ha-moglobin.  and  probably  from  a  diminution  in  the  red 

Is   dso.  the  next  step  in  the  diagnosis  is  to  ,l..ter„,ine  what  is  its  nature.     Attempts  Ire 

nct'-cs  ma,le  to  ht  all  cases  of  ana-mia  into  one  or  other  of  two  main  grou   s      itnJd 

m,,,,,-!,  and   .«ro,,r/«ny   respectively;     but    this   is   noi    reallv   very   helphif  clinical         In 

n||ny  e..es  the  nature  of  the  ana-mia   is  obvious  at  once-^t  may  be  ™  a  v     o  po^^ 

.ar    uu  han,or,l,age  or  other  blood   loss,  or  the  later  stages  of  phthisis,  svphil  s    ca  icer 

IK  arKd  cachexia,  and  so„n.     Sometimes,  however,  even  though  ana.mii  is  n.  Iv    h^ 

.     a  use  which  ,„  some  patients  is  obvious,  it  is  not  obvious  in  (he  pali..,,,  with  whom  one 

.nc  ""„''""'"«•  ""•'  '"">  "-•  ^'-«""-«  '-  to  be  arrived  a,  bv  a  pro<.ess  of  ex.^l  .13 

Lis         r^    '"";'"'    '".™'"""'--    l-'-|.s.    the    diineulties    that   arise    sometimes 

agnosinn    l,,|wee„    lungaling   en.loearditis.    gastric   eareinoina.    and    pernicious   anxmi- 

he  ween  a„:..„.,a  dii.-  to  blood-loss  and  bloo.l-,..ss  due  to  anemia.'  In  arii^a      1; 

'  .    .    .         )  .    un,n.,s  n ,   ,  „.  n„Hrnnn..„r  or  nrgaNvc  WW  pirl.n:  is  probablv  more 

i  n <  7,;  Lr ;'''";:'■'■  '■'":'^"''-"""-  ''-'-■  ""•>•  — --  m  which  tn.:  biood 

;::.;.-;i.tiu";:;:';,;;;:;;;;;;^:;r;;;;;--^ 

"r;,;:::;:"'""-" "'" ' ' ""  '■'' -""■  — -  — -1;,';::::::;;:: 

Blood  Changes  common    to  all    .Severe    Ana-mias.      I,,  mmv  s.x.n    a„.,M,ia   Ih.n    ar.. 


.22  AN.EMIA 

certain  blood  changes  wliich  are  almost  always  to  be  found,  which  are  not  characteristic 
of  any  one  variety  of  anaemia,  but  which,  seeing  that  pernicious  anaemia  in  its  later  stages 
is  |)robably  the  profoundest  of  all  the  ana?mias,  are  perhaps  better  seen  in  it  than  in  any 
other  disease.     These  are  : — 

(a).  A  very  great  diminution  in  the  iiiiiiibcr  of  red  corpuscles,  down  even  to  so  low  a 
figure  as  600,000  per  c.mm. 

(6).  Great  variation  in  the  slnqyes  of  the  red  cells — poikilocytosis  ;  poikilocytes 
(Plate  II.  Fig.  E)  always  retain  a  smooth,  curved  outline,  but  instead  of  being  flat  circular 
discs,  like  normal  corpuscles,  they  may  be  oval  or  pear-  or  hour-glass-shaped,  and  so  on. 
It  is  important  not  to  mistake  crenated  corpuscles  [Plate  II.  Fig.  D),  or  red  cells  that  have 
become  polygonal  by  reason  of  mutual  moulding  when  fixed  in  too  close  apposition  with 
one  another  (Plate  II,  Fig.  C).  for  poikilocytes. 

((•).  Alterations  in  the  sizes  of  the  corpuscles.  In  normal  blood  the  red  cells  are  almost 
all  of  the  same  diameter,  about  7/i  :  in  any  severe  an;emia  they  may  vary  considerably  in 
size,  many  being  much  smaller  than  iwrmnl—niicioeyfes  (Plate  II.  Fig.  li)  :  some  larger 
than  normal — macrocytes  or  megalocytes  (Plate  II,  Fig.  B). 

(d).  The  presence  of  nucleated  red  corpuscles.  Normally  none  are  present  in  the  blood 
even  in  infancy  ;  in  any  severe  anaemia  they  may  appear  in  varying  numbers,  and  according 
to  their  sizes  they  are  termed  microblasls.  normoblasts,  megaloblasts.  or  gigaritoblasts  (Plate  II, 
Fja,  P) the  latter  containing  more  than  one  nucleus,  the  others  only  one.  It  has  some- 
times been  stated  that  the  greater  the  number  of  nucleated  corpuscles  the  less  favourable 
tlie  prognosis,  but  this  is  not  necessarily  the  case,  except  in  so  far  that  it  is  unusual  for 
nucleated  forms  to  appear  until  a  severe  stage  of  the  anaemia  is  reached. 

None  of  the  above  changes,  one  must  repeat,  are  diagnostic  of  any  particular  variety 
of  severe  ana-mia,  though  they  are  perhaps  most  marked  in  the  later  stages  of  pernicious 
aniemia. 

Normal  Varieties  of  White  Corpuscles. — It  often  happens  that  variations  in  the 
relative  proportions  of  the  different  leucocytes  in  the  blood  afford  means  of  differential 
diagnosis.  Before  changes  from  the  normal  can  be  understood,  it  is  necessary  to  say  a 
word  or  two  about  the  normal  varieties  of  white  cells  :  these  number  anything  from  5.000 
to  10,000  ])er  c.mm.,  the  total  changing  considerably  at  different  times  of  the  day.  \V\\en 
lilms  are  made  it  is  found  that  four  easily  distinguishable  varieties  are  to  be  seen.  These 
have  received  different  names  at  the  hands  of  different  observers,  but  they  are  so  distinct 
tliat  names  hardly  matter,  and  they  might  be  termed  quite  well  types  A,  B,  C,  and  D 
respectively.  If.  however,  one  has  to  choose  between  the  different  names  that  have  been 
g.\en  to  them,  the  following  may  jjerhaps  be  selected  as  the  most  frequently  employed  :— 
(\)  Small  lymphocytes  :  (2)  Large- lymphocytes  ;  (3)  Polymorphonuclear  cells  ;  (4)  Coarsely 
granular  ciisinophilc  cdr/iiiscles. 

1.  The  stiKill  IjinipliiHyles  (Plate  II,  Fig.  H)  stain  blue  with  Jenner's  stain,  both  as  to 
nucleus  and  proto|jlasm.  The  nucleus  is  round,  and  the  i)rotoplasm  is  relatively  small  in 
amoimt  and  free  from  granides. 

2.  The  large  lymphocytes,  or  Injaline  corpuscles  (Plate  II.  Fig.  J),  stain  blue,  both  as 
to  nucleus  and  protoplasm.  The  nucleus  is  more  or  less  kidney-shaped,  and  the  proto-, 
plasm  relatively  large  in  amount  and  free  from  granules. 

3.  The  polymorphonuclear  cells  (Plate  II,  Fig.  K)  stain  blue  as  to  the  multilobed, 
nucleus,  red  as  to  the  relatively  abundant  protoplasm,  which  imder  the  high  power  isl 
seen  to  be  speckled  with  very  fine  red  granules. 

4.  The  coarsely  granular  eosinophile  corpuscles  (Plate  II.  Fig.  L)  stain  blue  as  to  thi 
multilobed  nuclei,  red  as  to  the  protoplasm,  the  amount  of  which  is  approximately  tlK 
same  as  in  the  polymorphonuclear  cells,  but  differs  from  the  latter  in  that  it  is  studdet 
with  very  striking  large  eosinophile  granules. 

The  Only  dilliculty  that  arises  in  making  a  differential  leucocyte  count  in  normal  bloof 
is  that  whereas  tlie  small  lymphocytes  usually  become  fixed  in  such  a  way  as  to  covei 
relatively  small  areas,  so  that  the  cells  seem  to  consist  mainly  of  nucleus,  at  other  time: 
tliey  spread  out  flatter  over  larger  areas,  and  then  the  rounded  nucleus  seems  to  bi 
surrounded  by  much  protoplasm  (Plate  II.  Fig.  I).  A  small  lymphocyte  flattened  out  ii 
this  way  is  apt  to  be  called  either  a  large  lymphocyte  by  those  who  do  not  insist  upon  \\v 
reniform  micleus  of  the  latter,  or  a  transitional  lymphocyte  by  others.     There  is  no  deductioi 


PLATE  .II 


RED      XND      WHITE      BLOOD      CORPUSCLES 

As  seen  umler  the    ',th  inrh  .ijl-hiiiiifrsion  lens. 


o 


♦ofJ^ 


^i:K;.^ 


^^Hp     »^' 


IP 


CoiiyriijhI. 


""  V^ 


7.  /^  Ford,  lid. 


A.  Normal  red  corpuwU's;  B.  Mc?,'alocytes  and  microcytfs ;  C.  Ni)rniJil  red  corpuscles  made  aiiiiulnr  by  imperfect 
ILvntlon  ;  D  C'reimted  red  <(H'pUik.*Ie»;  E,  I'oikilocylori  ;  F.  Xucleuled  rod  corpuscles;  {!)  Xormobkisis,  (2)  Megaloblnsts; 
(.1)  <;ii;antobla«l.s;  G.  I'liiictuto  biisophillu  niid  polychromnsia;  H.  Small  lymphocyte;  I.  Imleterminatc  lymphocyte; 
J.  I.Hree  hyaline  lymjilioc-yic;  K,  I'olymorplioniiclcar  corpuscle;  L,  Coarsely  granular  eoaiiiophile  corpuscle;  M, 
Myelocyte;    N.    Kosinophtk-'inyelocytc ;  *0.    Hsiwdphilc  corpuwle, 

SliKX     01'     iu,\r;N(»s(s— 7V.  /air  /t.  '2'J 


AN.^iMJA  23 

of  particular  clinical  value  to  be  obtained  by  distinguishing  these  cells  from  small  lympho- 
cytes :  it  is  better  that  they  should  be  grouped  with  the  small  lymphocytes  for  clinical 
purposes  at  any  rate,  only  undoubted  large  hyaline  cells  with  reniform  nuclei  being 
included  in  the  group  of  large  lymphocytes  or  hyaline  corpuscles. 

The  relative  proportions  of  these  cells  differ  according  as  the   individual  is   a  child 
a    grown-up    person  :     for    an    adult    one    may    say    that,    roughly    speaking,    out    of 
100  leucocytes 

Alioiit   2.")  will  III-  siiiiill   lymphocytes 

S  will  be  lai>;e  hyaline  lymphocytes 

65  will  be  polymorphonuclear  cells,   and 

2  will  be  coarsely  granular  cosinophile  corpuscles 

100 

In  children  the  tendency  is  for  the  small  lymphocytes  to  be  relatively  more  numerous 
in  health,  and  still  more  so  in  any  illness — up  to  40  per  cent  or  even  more — whilst  the  poly- 
morphonuclear cells  are  correspondingly  diminished. 

Some  observers  prefer  to  represent  the  different  varieties  of  white  corpuscles  not  as 
percentages  but  as  total  numbers  per  c.mm.  of  blood. 

Abnormal  Varieties  of  Wliite  Corpuscles. — \Vhereas  the  above  are  the  only  kinds 
of  white  cells  in  healthy  blood,  in  certain  diseases  the  following  abnormal  forms  are  met 
with  :— 

Myelocytes. — These  are  large  cor]niscles  (Plate  II,  Fig.  M),  comparable  in  size  to  the 
polymorphonuclear  cells,  but  differing  from  the  latter  in  having  either  a  perfectly  round, 
an  oval,  or  possibly  a  slightly  kidney-shaped  nucleus,  rather  than  a  multilobed  one.  There 
are  all  gradations  of  them,  and  at  the  two  extremes  it  is  difficult  to  differentiate  some  from 
large  lymphocytes  and  others  from  polymor])honiiclear  cells.  They  arc  to  be  distinguished 
from  the  latter  by  the  roundness  of  the  nucleus,  and  from  large  lymphocytes  bv  the 
granularity  of  the  protoplasm.  The  granules  in  fpiestion  are  sometimes  stained  brightly 
with  eosin — cosinophile  myehrytcs  (Plate  II,  Fig.  iV),  distinguishable  at  once  from  the 
-)rdinary  eosinophile  corpuscles  by  their  nuclei  being  nearly  spherical  :  more  often,  how- 
-'ver.  the  granules  stain  blue,  or  some  colour  between  blue  and  red — ordinary  or  neiitrophile 
'Hyeloeytes.  No  uselul  clinical  information  can,  so  far  as  is  at  present  known,  be  oi)taincd 
)y  laying  stress  upon  these  differences  in  the  staining  reactions  of  different  mycloc-ytes, 
io  that  they  are  usually  coimted  together  simply  as  myelocytes.  There  is  only  one  condition 
n  which  they  are  very  numerous,  and  that  is  spleno-medullary  leukicmia  :  but  the\-  may 
)CCur  in  small  numbers  in  various  other  affections  also,  particul.nly  in  lymphaih  iioiiia, 
Hodgkin's  disease,  i)ernicious  ana'inia,  and  aplastic  ana>mia. 

Iiasoj)liile  Coijiiisctcs  (Plote  II.  Fig.  ()). — These  are  nuich  smaller  Ihan  myelocytes, 
:heir  size  being  comparable  to  thai  of  small  lymphocytes:  they  differ  from  the  latter  in 
hat  the  prolopliism.  instead  of  being  homogeneous,  contains  from  2  or  .'J  to  jicrhaps  20  or 
norc  very  large  gramdes  which  stain  deep  blue  with  Jenncr's  stain.  They  are  unniistakc- 
ible.  No  deliiiite  clinical  deductions  can  be  drawn  from  their  presence  beyond  the  fact  that, 
r  there  are  more  than  1  or  2  per  1,000,  the  blood  is  abnormal.  They  may  be  present  in 
nany  different  varieties  of  anatnia,  but  they  are  not  characteristic  of  any:  they  seldom 
iniount  to  more  than  2  or  :i  per  eciil,  and  oflcn  to  no  more  lliaii  ()•.".  per  ecnl,  even 
n  disease. 

Plinctale  ISiisDjihiliii.  'I'Ikic  mic  ccrlairi  coiKlil  ions,  pailieiilarl,v  pririieioiis  aiiainia  in 
ts  later  stages,  leukaniia,  and  lead  poisoning,  in  which  the  red  cells,  instead  of  staining 
liuforrnly  pink  with  the  eosin  of  .lenner's  stain,  ])resent  large  munhers  of  small  blue  specks 
ir  granules  in  Iheir  protopl.ism  (Plate  II.  Fig.  (1).  a  condition  known  as  pinietate  haso/iliilia. 
[n  a  case  of  doulil.  when  pcriiicioiis  anainia  has  been  cxelude<l  by  there  being  a  low  colour 
ndex,  and  wlicn  leukaniia  is  conl  raindiciilcd  by  llic  fact  llial  there  is  a  normal  leucocyte 
:ount,  the  pnsciice  (it  extensive  piMK'lale  basophilia  is  said  somclimes  to  alfonl  eiin- 
irinati\c  evi.lenec  (if  pjnnibisrri. 

We  iiiiiN    now  pass  on   lo  eiiiisidcr  the  e iiKinei'  \arielies  of  an:eMiia.  (lealilii;   liisl    with 

mjeniias   wilh   p(isili\,.   |,|oo>l    pictures. 


24  AN.EMIA 

(.1).— AN/EMIAS    WITH     POSITIVE     BLOOD     PICTURES. 

Pernicious  Anaemia  is  a  distase  (jf  insidious  onset  in  adults,  the  main  syni|)toins  heino; 
progressive  loss  of  muscle-power  and  increasing  pallor,  with  loss  of  weight,  but  with 
relatively  less  loss  of  body  volmnc.  Various  other  symptoms  may  be  associated  with 
these,  or  no  others  may  be  present.  The  diagnosis  is  seldom  made  until  a  relatively  late 
stage  of  the  malady  has  been  reached,  by  which  time  there  is  a  great  diminution  in  the 
hipmoglobin,  down  ])erhaps  to  30  per  cent  of  normal  or  less,  and  a  still  greater  diminution 
of  the  red  cells,  down  perhaps  to  25  per  cent,  20  per  cent,  or  even  10  per  cent  of  normal  ; 
consequently  the  colour  index  is  high,  and  this  is  the  pathognomonic  sign  of  the  disease. 
Tiiere  is  no  leucocytosis,  but  rather  leucopenia  (p.  3S1)  :  the  differential  leucocyte  count 
shows  a  relative  increase  in  the  small  lymphocytes,  a  corresponding  diminution  in  the  poly- 
niorphonuelear  cells,  normal  numbers  of  eosinophilc  corpuscles  and  large  lymphocytes, 
occasional  bas()i)liili'  corpuscles,  and  one  or  two  myelocytes.  Blood  films  also  show  all  the 
changes  described  above  (p.  22)  as  conmion  to  any  severe  anaemia,  but  with  particularlj- 
large  relative  mniibers  of  megalocytes.  When  these  blood  changes  are  all  present  there 
can  be  no  doubt  about  the  diagnosis,  and  we  need  not  enter  here  into  all  the  other  symptoms 
that  may  be  presented  by  the  patient.  It  is  important  to  remember,  however,  that  there 
is  one  group  of  the  cases  in  which  ner\e  symi)toms  predominate  before  the  anaemia  is 
pionounced.  The  diagnosis  of  ])crnicious  antemia  cannot  be  made  without  a  blood-count, 
anil  it  can  be  made  absolutely  with  one  :  one  word  of  warning  is  required,  and  that  is  that 
the  colour  index  is  not  continuously  high  in  every  ease  of  jjernicious  anaemia,  so  that  perhaps 
several  blood-counts  may  be  required  at  intervals.  It  should  also  be  noted  that  the  power 
of  temporary  recuperation  is  considerable,  and  wlien  the  patient's  condition  improves  the 
Ijlood  may  return  partly  or  wholly  to  normal  ;  during  such  remission  the  colour  index, 
instead  of  remaining  greater  than  1.  becomes  1  or  less  than  1. 

There  are  certain  cases  of  very  severe  ana;mia  which  some  would  include  under  the 
heading  of  pernicious  anaemia,  although  the  colour  index  is  persistently  less  than  1.  It  is 
more  useful,  however,  from  a  clinical  point  of  view  to  leave  these  cases  unlabelled,  or  at 
any  rate  not  to  call  them  pernicious  anaemia,  which  has  so  characteristic  a  tjlood  picture. 
One  variety  has  recently  become  separated  from  the  rest  under  the  title  of  aplastic  (nurmia. 
the  cliief  characters  of  which  are  a  profound,  [jrogressive,  and  ultimately  fatal  anicmia 
for  which  no  cause  can  be  foinid.  which  seems  in  many  respects  to  simulate  pernicious 
an;emia,  but  which  is  persistently  associated  with  a  low  instead  of  a  high  colour  index. 
It  is,  moreover,  imaccompanied  by  a  positive  Prussian  blue  reaction  in  the  liver — Perrs 
test  with  jjotassiimi  ferrocyanide  and  hydrochloric  acid — post  mortem  :  this,  when  positive, 
is  strongly  confirmatory  of  pernicious  anaemia,  for  very  few  other  conditions  give  it,  and 
they  are  rare     sprue,  for  example,  is  one  such,  and  bronzed  diabetes  another. 

Spleno-meduUary  Leukaemia. — In  the  earlier  stages  of  this  disease  there  is  no  antemia 
at  all,  though  later  diminution  both  in  the  ha-moglobin  and  in  the  red  cells  may  be  profound. 
The  essential  ])oint  in  the  diagnosis  is  the  occurrence  of  a  very  great  increase  of  the  total 
number  of  leucocytes,  not  at  all  uncommonly  up  to  such  a  figure  as  200,000,  and  sometimes 
up  to  600.000  or  even  1.000,000  per  c.mm.  There  is  only  one  other  condition  which  can 
l)roduce  so  extreme  an  increase  in  the  total  number  of  leucocytes,  and  that  is  It/mphalic 
Icidiccmia.  The  two  are  immediately  distinguishable  from  one  another  by  the  differential 
leucocyte  count,  the  characteristic  point  about  which,  in  spleno-medullary  leukaemia,  is 
the  large  number  of  myelocytes  present.  These  may  amount  to  £0,  to  even  50  per  cent, 
or  more,  of  all  the  leucocytes  present,  with  the  consequence  that  there  is  a  relative  but 
not  an  absolute  diminution  in  the  other  varieties  of  white  cells.  Occasional  basophile  cells 
are  seen  :  but  whate^•er  may  be  the  proportion  of  these  or  other  leucocytes,  the  main 
jioint  in  the  diagnosis  is  the  large  relative  number  of  myelocytes  in  association  with  an 
enormous  increase  in  the  total  leucocyte  count.  When  an<emia  ultimately  ensues  it  is  of 
the  chlorotic  type  :  that  is  to  say,  tlie  ha?moglobin  falls  before,  and  to  a  greater  extent 
than,  the  red  cells.  The  disease  generally  lasts  from  one  to  three  years  before  ending  fatally, 
and  in  the  later  stages  all  the  blood-changes  cliaract eristic  of  severe  anaemia  may  be  found. 
Clinically,  the  other  main  feature  of  the  complaint  is  the  enormous  enlargement  of  the  spleen, 
which  here  reaches  dimensions  bigger  than  in  any  other  disease,  the  viseus  often  extending  j 
right  across  the  middle  line  to  the  right  iliac  fossa  or  down  into  the  pelvis.     It  is  note- 


■a 


I 


Tart  of  ii  blooU  lilm  from 


of  sovoro  iiornicious  unn-mui,  sliowiiiK  poikilocyle 
ludeatc'ij  reii  cells,  utiij  puiiftiite  busophiliu. 


icytcs,  mogiilOL'ytca, 


INni;\   (II-   IIIAIINDSIS    -Tn  ji,,;-  i>.  H 


AN.EMIA 


25 


wortliy  tliat  in  jiatients  treated  with  the  .i-rays  the  spleen  very  often  becomes  greatly 
reduced  in  size,  and  the  blood  picture  may  return  nearly  to  normal,  though  it  seldom  if 
ever  happens,  even  when  the  number  of  leucocytes  ]3er  e.mni.  has  reached  the  normal, 
that  there  is  an  absence  of  myelocytes  in  the  differential  leucocyte  count.  Notwithstanding 
this  apparent  improvement  in  the  blood  and  in  the  spleen,  the  length  of  time  the  patient 
survives  does  not  seem  to  be  increased.  The  splenic  enlargement  is  not  associated  with 
enlargement  of  the  lymphatic  glands. 

Lymphatic  Leukaemia. — There  is  no  age  at  which  any  form  of  leuktemia  may  not 
occur  :  but  uijon  the  whole  the  spIeno-meduUary  form  affects  adults  rather  than  children, 
whereas  the  lymphatic  affects  children 
rather  than  adults.  Its  course  is  usually 
rapid  and  invariably  fatal,  death  resulting, 
as  a  rule,  within  three  or  four  months 
from  the  first  definite  sym])tonis.  Ana?mia 
is  much  more  rajiid  in  its  development  in 
the  lymphatic  than  in  the  spleno-medull- 
ary  form.  The  first  symptoms  may  be 
either  anaemia,  or  lymphatic  glandular 
enlargement  in  the  neck,  axilhr,  and 
groins,  or  the  occurrence  of  purpura,  epis- 
taxis  or  other  forms  of  luemorrhage,  or  in 
certain  cases  a  complete  change  in  the 
ehihrs  temperament  in  the  direction  par- 
ticularly of  excessive  irritability  of  temper, 
with  loss  of  appetite  and  obvious  and  pro- 
gressive illness.  There  are  cases  in  which 
no  glands  are  enlarged,  the  diagnosis  not 
being  at  all  obvious  without  a  blood-count. 
More  often  there  is  general  enlargement  ol 
he  lymphatic  glands,  visceral  and  peri- 
)heral,  sometimes  a.ssociated  with  similar 
ucreasc  in  the  size  of  other  glands,  par- 
icularly  the  salivary  and  lachrymal — 
'III  ulic/.'s  syndrome — and  the  spleen  is 
I'    il\     always    palpable    and    sometimes 

n-'.  though  seldom  so  big  as  it  is  in  spleiio-incdulJary  Icuka-mia.  Serous  iiillammations 
"  Miinnon.  and  there  is  apt  to  be  pyrexia,  as  in  other  severe  aiuemias.  especially  h) 
|||'  no-inedullary  leuk;emia  {Fia.  4).  Ilodgkin's  disease  (Fig.  247.  p,  ,570),  and  pernicious 
iiriiiiM    iFi'S-   "JKi,   J).   .">(><)).     The  diagnosis  is  afforded  at   once  bv  the  blood-count  in  the 


FiV-   3.— A 
i    laclirvma 
iipliutic  leuka- 


of    chronitT    enlargement    of    the    saliv.iry 
case  of 
tKindlii  lent  hii  llr.  I'nchTid:   Tiuili.r.) 


i,i'>nl\-    of    cas 


There 


a    \iirving  degree   of 


in    llic  leucocytes,  sometimes 


■0  L-liiirt  (niortunt'  anil  evnninj,')  in  a  t 
who  improved  very  inurlicclly  under 


.  hdlar.- lonka-niia 
it  wliile  in  liosiiital. 


•aching  no  higher  than  2<),()(H)  or  .•iO.OOO,  more  ollen  SO.dOO  lo  KHl.oiMt.  and  soiucliiiK  s. 
Ut  more  rarely,  lo  rnueli  higher  figures,  siicli  as  -JOO.OOO.  (idO.OdO.  ,S(M(.(!IH>  or  iven 
500,0(1(1  per  e.iiiTii.  Whalever  the  lolal  leucocytes  coiml.  linwev.r.  Ilie  striking  fealme 
the  I  ii.iriiioiis  rclalixc  increase  in  the  small  lyinphocylcs  in  tin-  ililierenl  iai  leucocyte 
Hint.     Out    ol   every    hundred    leucocytes   it    is   not    uifeommou  to  (itid   thai    <((>.  or  even 


AN.EMIA 


95  or  98  are  lymphocytes  :  so  that  there  is  an  enormous  relative  and  sometimes  absohiU 
reduction  in  the  other  white  corpuscles.  Amongst  them  will  be  found  an  occasional 
mvelocvtc  and  one  or  two  basophile  corpuscles.  The  red  cells  and  the  lia-moglobin 
become  diminished  progressively,  and  the  former  may  exhibit  all  the  other  changes 
described  above  (p.  -22)  as  characteristic  of  any  very  severe  anemia.  Whereas  m  most 
cases  the  colour  index  becomes  less  than  1  as  the  disease  progresses,  in  a  few  mstances, 
especially  some  time  before  the  end,  the  colour  index  has  been  found  to  be  greater  than  1, 
as  it  is  in  pernicious  ana-mia.  There  is  no  likelihood  of  mistaking  one  condition  lor  the 
other  on  account  of  the  changes  in  the  white  cells. 

Some  authorities  describe  two  t\Tes  of  lymphatic  leuksemia  according  as  the  lympho- 
cytes seen  in  the  films  are  of  relatively  large  or  small  size  :  as  has  been  explained  above, 
however  there  is  always  difficulty  in  deciding  whether  differences  in  apparent  size  of  the 
lymphoc'ytes  constitute  differences  in  kiiul.  and  there  is  no  very  great  climeal  purpose 
served  in  drawing  the  distinction  here,  unless  perhaps  that  upon  the  whole  the  larger  the 
lymphocytes  present  the  greater  the  number  of  months  the  patient  is  likely  to  survive. 

The' chief  difficulties  that  arise  in  the  diagnosis  occur  in  two  ways  :  first,  there  are  a 
few  instances  in  which  lymphatic  leuka-mia  has  run  its  course  without  any  actual  increase 
in  the  number  of  leucocytes  per  c.mm.  of  blood,  the  diagnosis  being  afforded  only  by  the 
enormous  relative  increase  in  the  small  lymphocytes;  and  secondly,  children  normally 
have  a  relatively  high  leucocyte  count,  from  which  it  happens  that  lymphatic  leukaenna 
may  sometimes  be  suspected  in  them  when  it  is  not  really  present.  Suppose,  for  instance 
a  eiiild  suffers  from  an  obscure  illness  associated  with  ana-mia  of  the  chlorotic  type  with 
an  increase  in  the  leucocytes  up  to  25,000  per  c.mm.  and  a  relative  increase  of  the  small 
lymphocytes  up  to  55  per  cent,  would  one  be  justified  in  diagnosing  lymphatic  leukaemia  ! 
One  micriit  be  if  there  was  general  enlargement  of  the  lymphatic  glands  and  enlargement  of 
the  spleen  ■  but  otherwise  both  the  leucocytosis  and  the  relative  increase  in  the  lympho- 
cytes mio-ht  be  due  to  some  other  complaint,  and  the  only  means  of  arriving  at  the  diagnosis 
mi<xht  be  by  awaiting  developments.  It  is  not  safe  to  insist  upon  a  diagnosis  of  lymphatic 
leuka-mia  unless  there  is  either  a  very  large  increase  in  the  total  number  of  leucocytes,  or 
a  relative  increase  in  the  small  lymphocytes  up  to  90  per  cent  or  over,  or  both  these  changes 

at  tlie  same  time.  „  ,     ,         •     ■    i 

Mixed  Forms  of  Leukfemia.—.Mt hough  the  majority  of  cases  of  leukaemia  belong 
either  I.,  the  spkno-medullarv  or  the  Ivmphatie  form,  there  are  cases  in  which  the  symptoms 
■ind  the  blood  changes  partake  of  the  characters  of  both.  Either  the  splenic  or  the 
iMuphatic  Glandular  enlargement,  or  both,  may  be  marked  :  there  may  be  no  ana?mia 
iintil  the  disease  has  passed  its  earlier  stages,  when  the  red  cells  and  haemoglobin  pass 
tliron.di  the  chlorotic  type  of  changes  until  they  reach  those  severe  alterations  characteristic 
of  airaiKcmias  in  their  last  stages  ;  the  white  corpuscles  show  more  or  less  increase  m 
their  total  numbers,  and  the  differential  leucocyte  count  shows  not  only  considerable 
numbers  of  myeloc\4es,  such  perhaps  as  20  per  cent  or  more,  but  also  a  great  relative 
increase  in  the'lvmphocytes  up  to,  it  may  be,  60  per  cent  or  over.  The  occurrence  of  these 
cases  of  "  mixed'  leuka-mia  would  seem  to  indicate  that  there  is  really  no  absolute  difference 
in  kind,  but  rather  only  :.  difference  in  type,  between  the  lymphatic  and  the  spleno-meduUary 
forms  already  described. 

Parasitic  Ansemia  associated  with  Eosinophilia.— Many  varieties  of  the  jjarasites 
that  affect  man  produce  hardly  any  blood  changes  at  aU—riichocepl,ali,s  dispnr.  (Xryum 
vermicularis.  Ascaris  Jumhrkoides.  Other  parasites,  however,  produce  very  marked  changes 
in  the  l)lood,  and  one  may  mention  in  particular  Dolhriocephalus  hitiis.  Aiil.ilhstomiim 
d„iHlci„ih:  TrichiiHi  spiralis.  BilliarJa  liwmatohin,  Filaria  smigiiinis  Iiominis.  and  not  a  few 
cases  of  hydatid  disease.  The  ana-mia  which  results  may  be  very  profound,  and  the  blood 
may  exhilait  all  the  changes  described  above  as  common  to  the  severest  anaemias.  Th« 
colour  index  is  usually  low,  but  sometimes  it  is  greater  than  1,  simulating  pernicious  ana-mia 
but  whatever  the  total  leucocj^tes,  the  differential  count  very  commonly  presents  a  con- 
siderable increase  in  the  coarsely  eosinophile  corpuscles,  and  this  Eosinophili.\  (p.  219)  n 
association  with  severe  aiKi-mia.  is  suggestive  of  the  presence  of  some  toxic  parasite.  H 
.Iocs  not  indicate  which  parasite  is  present,  however,  this  being  determined  by  caretu 
examination  of  the  fa-ees,  urine,  and  so  forth  (see  Parasites,  Intestinal,  p.    519). 

Parasitic  Ansemia  associated  with  Parasites  in    the    Blood.—The   four  best   knowi 


I'lirt  of  ;i  Mood  (iirn  from  a  uiso  of  splctio-meduUury  ((Mikuiiiiu.  wliowiiiu  fivo  noiitropliile  mycloi-ytos.  oiio  fo-inophili; 
itiyeliK-ytc,  three  hiisophile  cells,  and  one  ltirmflo;it<'"|  red  veil  in  lulditioii  to  iiurnial  i-orpuscU'-. 


lNIH-;\  i}V   lU\r;NosfH    -To  facr  p.   2t! 


AN. EMI  A 


27 


diseases  in  which  human  beings  have  parasites  in  the  blood  are  :  malaria,  filariasis,  trypano- 
somiasis, and  relapsing  fe\er.  In  all  these  there  may  be  much  destruction  of  red  cells  with 
consequent  aniiniia  of  the  ehlorotic  type.    In  most  cases  the  history,  particularly  of  residence 


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pliipsiMi;  toy 


r>  some  tni|ii(;il  country  where  the   disease   in  fpicstion  is  likely  lo  occiu',  will  suggest  the 
|iagnosis.  and   the  examination  of  Ihc  blood,  cillicr  fresh  or.  in  lilms.  will  be  coiilirmalive. 
Hclfi/tsiiiii  fiTcr  iisi'd   lo  be  prcMilcnl    in  (ircal    Hiilain.  and  it   still  occurs  in  cpiilcmic 
jf>rm  in   times  of   famine   in   association   with    Mnclciiiiniss.      II    is  commoner  iibroail.      It    is 


Its  best  known 
It 


■28  ANtEMIA 

<luc  lo  infection  by  the  spirocliEete  of  Obermeier  (Plate  XXVJII,  Fig  I,  p.  614)  introduced 
into  the  body  by  the  bites  of  bugs.  It  is  a  long  spiral  organism,  40  ^i  long  and  1  fj  broad, 
aetivelv  motile  in  fresh  blood,  but  best  seen  in  films  stained  with  Leishman's  stain.  They 
first  appear  a  day  or  two  before  the  paroxysms  of  fever  {Fig.  5).  and  may  reach  large  num- 
bers. In  the  intervals  they  are  not  to  be  found.  The  course  of  the  disease  usually  suggests 
the  diagnosis,  outbursts  of  pyrexia  associated  witli  extreme  prostration  and  severe  illness, 
lasting  about  a  week  or  rather  less,  alternating  with  intermissions  of  about  the  same 
length.  There  may  be  an  indefinite  number  of  relapses  before  the  patient  either  dies  or 
recovers. 

Filariasis  may  be  latent  for  a  long  time  before  it  produces  symptoms, 
effects  are  elephantiasis  of  the  legs  or  genital  organs,  with  or  without  chyluria. 
occurs  in  many  parts  of  the  tropics,  particularly  in  some  of  the  Pacific  Islands,  such 
as  Figi :  and " in  certain  parts  of  thina.  Tlie  elephantiasis  and  chyluria  are  due  to 
mechanical  obstruction  to  the  pelvic  lymphatics  by  the  mature  worms.  The  blood  exhibits 
more  or  less  ansemia  of  the  clilorotic  type,  with  a  varying  degree  of  eosinophilia,  whilst  at 
certain  times  of  the  day  or  night  the  peripheral  blood  also  contains  the  long  but  narrow 
filarial  embryos  (Plate  XXJIII.  Fig.  F.  p.  fiU).  There  are  probably  different  varieties  of 
the  organism,  but  they  cannot  be  distinguished  easily  by  the  appearance  of  these  embryos 
alone.  Without  laying  stress  upon  generic  differences,  it  is  important  that  in  most  cases 
they  are  to  be  found  in  the  peripheral  blood  only  at  night  (Filaria  barierofti  nocturna);' 
(luring  the  day  they  seem  to  retreat  into  the  deep  vessels  ;  there  are  other  cases,  however, 
in  whTch  embryos,  very  similar  in  appearance,  occur  in  the  peripheral  blood  in  the  daytime 
and  not  at  night  (Filaria  diurna)  ;  whilst  in  Filaria  perstans  tliey  are  present  in  the  blood 
both  day  and  night.  Roughly  speaking,  one  may  say  that  each  embryo  when  stretched  out 
is  200  /(long  and  4  to  5  /i  wide,  and  they  stain  by  Leishman's  method.  They  may  be  found 
in  the  blood  of  patients  who  have  returned  to  England  after  contracting  the  disease  abroad. 

TryiJanosomiasis — the    cause    of   sleeping   siekiiess.     Trypanosomes  of  many  different  I 
kinds  are  known  to  affect  various  animals,  birds  and  fish,  but  the  only  one  which  is  important 
in  man  is  the  Trupaiioxiiiiia  gamhieiise  (Plate  XXI  III,  Fig.  G.  p.  614).     It  is  to  be  found  in  \ 
blood  films  stained  by  I.cislmum's  method  months  or  years  before  it  finds  its  way  into  the  ! 
cerebrospinal  fluid  to  procluie  sliiping  sickness.     It  has  a  large  and  definite  nucleus  about 


j.-i,,,  fi. — Case  of  simple  tertian  malaria,  showing  the  attacks  occurring  every  thk-ij  daj. 
{Clmrt  supplied  by  the  London  School  of  Tropical  Medicine.) 

its  middle,  surrounded  by  protoplasm  whicli  becomes  jjrolonged  into  a  relatively  long  un 
dulating  membrane  terminating  in  a  llagellum.  It  is  an  extra-corpuseiilar  organism  readilj 
distinguishable  when  seen  in  its  mature  stage.  It  occurs  particularly  in  people  who  havei 
been  resident  in  Uganda  or  other  district  in  which  Glossina  palpalis,  the  fly  which  spreads 
tlie  disease,  abounds.  The  diagnosis  is  much  less  easy  when  the  blood  contains  only 
inmiature  forms.  It  is  sometimes  easier  to  find  the  embryos  in  fluid  obtained  by  punctm-ing 
tlie   enlarged   inguinal   or  other  lymi)hatic  glands  often   present   in   these   patients.      It   i> 


PLATE     V 


LYMPHATIC      LEUK/EMIA 


A.     # 


oo 


o      o 


W 


m 


C: 


G 
O 


« 


Oo 


#i 


o 


'■""  of  ^  I' 1   liln,   fnmi   u  .  ,i,p  „(  lv„il.l,:.li,-  Wnk.vmv.K  sliowini;  :.  hir-c  rc:.>c  in    llu.  small  lympliocyte 


IXIIKV    l)F    I.IAi:NC)>is   -7V)   /,„v  ;,.    SS 


AX.TIMIA 


29 


irt-orthy  of  note  tliat  one  variety  of  severe  an;eniia  occurring  in  Assam,  associated  with 
nTexia  and  enlargement  of  the  spleen,  and  formerly  thought  to  be  a  variety  of  malaria,  is 
lue  to  a  variety  of  trypanosomiasis  in  which  only  immature  forms  of  the  parasite  (Leishman- 
Donovan  bodies)  have  been  found  (Plate  XX\  III.  Fig.  H.  ji.  (>14)  :  and  here  not  in  the 
general  blood  stream,  but  in  the  fluid  obtained  by  splenic  puncture.  The  disease  is 
emied  Kula-azar. 

Mdhiiia  is  not  essentially  associated  with  anicmia  ;  but  in  jiatients  who  have  had 
■ecurrent  attacks  blood  destruction  by  the  parasites  leads  to  considerable  reduction  both 
II  the  red  cells  and  in  the  ha;moglobin,  the  colour  index  generally  being  of  the  chlorotic 
ype.  The  changes  in  the  white  corpuscles  are  described  on  p.  ;J61.  Tlie  diagnosis  can 
iften  be  surmised  when  a  patient  who  is,  or  has  been,  resident  in  a  malarial  district  suffers 
rem  ])eriodic  rigors  with  pyrexia.     Theoretically  there  are  two  main  types  of  the  disease, 


Fi(j.  7. — Case  of  quartan  malarial  fpver,  the  attacks  recurring  every  fourdi  day. 
•  (Chart  supptwd  by  llic  London  School  of  Tropical  Mcilicin, .} 

the  terliiin.  in  which  the  paroxysms  come  on  everv  alternalc  das  uilh  complete 
jery  intermediate  day  (Fi«.  (i)  ;  and  the  qunrUin.  in  which  llicr.'are  two-day  int 
|al  the  paroxysms  occur  every  fourth  day  {Fi<>.  7).  What  happens  in  a  malaria 
^•wever,  is  that  alter  a  patient  has  Imcii  infccte.l  by  one  set  of  mos,|uit(.  bite 
tlian  or  ((uarlaii  ague,  he  becomes  infected  subsctitiently  upon  differeni  days 
*>si|iiit<>(s  ujil,  „t|,er  tertian  or  (|iiartan  parasites,  so  that  there  is  a  minglin<. 
•the  cllcls  (>r  different  sets  of  luematozoa.  For  instance,  if  a  patient'' had 
•ifected  by  two  tertian  parasites,  the  one  producing  rigors  upon  .Monday  \\\ 
Jiday,  and  Sunday,  and  Ih,.  other  attacks  u|.on  Tuesdav.  'I'lmrsdav.  Satiin 
-mday,   tins  patient   woulrl  have  a  paroxvsm  everv  day.  the   Ivpe  Ixiii..' tli.n  spo 


■edom 
ds.  so 
strict, 
ilh  a 
other 
etlK'r 
'Come 
sday, 
and 
(.r  as 


,,Q  AX.EMIA 

,,„nMian  {Fis  8).     If  l.o  were  infected  by  two  quartan  parasites,  the  one  produeing  attacks 

uln  Monda;.  Thursday,  and  Sunday,  and  the  other  upon  Tuesday.  Fnday    and  Monday, 

e  oec'n-renee  of  the  paroxysms  beeon,es  less  regular,  for  the  patient  would  haye  a  r.gor 

r^,n  Monday,  another  on  Tuesday,  none  on  Wednesday,  a  rigor  upon  Thursday  and  Friday, 

t  n.Mu.  ouSatunlay.  and  so  on.    Eaeh  infection  by  a  fresh  brood  of  malanal  parasites 

1  ipli.ates  the  elinieal  picture,  until  finally  in  those  who  haye  been  long  in  nialanal  districts 

attacks  of  pyrexia  may  be  quite  irregular  or  even  almost  continuous.     Kach  paroxysm 

as  three  charac  eristic  stages,  any  one  of  which  may  last  from  half  an  hour  to  two  or  three 


(Cliarl  riijtiilial  hij  Ihe  London  School  of   Trop 


hours.'  or  eyen  more.     During  the  first  or  cold  stage,  the  patient  shiyers  w  th  a    e^ere  r.go, 
eels  ;old,  looks  blue  and  pinched,  but  neyertheless  has  a  rise  of  tempera  ure  to  102    K  o 

loV  F.     The  teeth  chatter  and  the  patient  wraps  himself  up  to  try  and  keep  -am       Th, 
s  followed  by  t.,e  ho,  staae.  which  begins  with  flushing  of  the  face,  seyere  headache,  pa  us 
he  back   further  rise  of  the  temperature  to  104=  F.  to  106^  F..  and  a  sensation  of  such  he^ 
at    1  e  patient  throws  off  the  clothes  and  calls  for  cooling  drinks.     This  ends  in  the  thi 


,,„  .,  -,  ■;..  of  malarial  fever  Ulustrating  severe  tertian  attacks  alternating  with  mild  tertian  attack,  due  to 
double  iniection.     (.Chart  supplied  i,j  Ihc  London  School  ol  Tropical  Media,,-.) 

or  srccnting  singc.  during  which  the  skin,  previously  dry,  breaks  out  into  perspiration  so  scv. 
t ha  alKthe  bedclothes  may  be  .vringing  wet.  The  temperature  now  falls,  and  the  pa  . 
more  or'less  exhausted,  sleeps,  and  on  waking  feels  comparatively  well  except  for  a  sens 
Takness  ;  he  may  be  able  to  do  his  ordinary  work  until  the  next  paroxysm  comes  on  O. 
Ta  few  cases  do'^nruch  severer  symptoms  supervene  if  proper  treatment  be  adopted, 
the  absence  of  treatment,  however,  malaria  may  lead  to  hypeinnTcxaa  (10,  F-11-  J 
o  coma  •    or  to  a  condition  of  algidity  and  collapse  ;    any  one  of  which  may  end  in  dea 


The  diagnosis  may  be  confirmed  to  some  extent  bv  findino  that  tlic  inrcxial  outbursts 
inninish  or  cease  altogether  under  the  administration  of  quinine,  but  tlic  only  real  proof 
f  the  nature  of  the  complaint  is  the  discovery  in  tlie  blood  of  the  malarial  parasites 
Plate  XXVIII.  Figs.  A.  B.  C.  D.  and  E.  p.  614).  It  is  important  to  note  that  the 
idnnnistration  of  ,|uinine  renders  it  dillicult  or  impossible  to  (hid  these  in  blood  films   and 


Fir:  10.— Case  o!  m»larml  lever  befoming  complex  from  multinle  malari:il  ii.feL-tion. 
(Chavl  supplird  lij  llie  London  Sc/mol  of   '/'ro/iiml  .Valichie.) 

len  the  behaviour  of  the  leucocytes  (p.  8(il)  mav  bo  verv  heli)hil.  .Vllnnninuria  is 
.mmon.  and  the  urine  generally  contains  urobilin  .luring  aetixc  malaria,  ceasino-  to  do  so 
hen  the  latter  becomes  latent  :  microscopically,  golden  brown  piun.ent  granules\re  often 
be  lound  ui  the  centrifugali/.ed  deposit  :  these  and  the  urobilin  together  may  point  to 
e  diagnosis  when  no  parasites  can  be  loun.l  in  the  hlo.,,1.     For  a  detailed  account  .,f  all 


■...y,  .l".'?;?'^'! \y....'J\  .1 .... 3     1  — » — 1 — r~~] — i — I — 


li 


Fiij.  11.— CImrt  to  illustrnte  irrewilnr  pyrexiii  in  chronic  ni'ilnria. 
(Chart  mijiplied  bij  the  I^mton  .fclmol  of  Tropical  Medicine.) 

•  Stages  and  apju-aranccs  of  various  malarial  parasil.s.  leM-l„M,l<s  „(  |nmi<al  nu-ili.ine 
mid  be  eons.dled.  There  arc  two  uiain  types  lo  l„.  sen  in  lihns  slaind  l.v  l.cish.nans 
.."'':""■  7^-/'"'"  ""■'  ""■  <rrsr,;„-f,.nn.  The  lallcr  arc  p.Mhaps  th..  rarer,  though  ll... 
."  ".MXNol  malaria,  particulai  ly  the  lestivo-auluimial  form  met  with  on  the  West  (oasi 
Alnca.  arc  generally  due  to  it  :  the  cn^eeulie  parasil.s  .annot  !..■  misl.ak.n  lorauvtlm... 
••      J  Me  ..nlmary  t.itian  aii.l  ,,uartan  agu.s  ar.'  due  to  III.'  ring  f.>ri naiasil.s    alii.ir 


32  ANAEMIA 

thouoh  the  two  types  are  distinct  from  one  another,  are  sufheiently  similar  not  to  be 
distinouishable  in  films  except  by  experts.  If  blood  is  examined  at  the  begmnmg  of  the 
ri..or  the  stage  most  commonly  seen  is  that  of  Plalc  XXV III.  Fig.  B.  p.  614.  The  two 
chief  points  of  morphological  distinction  between  tertian  and  riuartan  parasites  are,  fnsi, 
that  the  pi.nnent  granules  are  much  blacker  and  fewer  in  number  with  the  quartan  than 
the  tertian"  and  secondly,  that  in  the  rosette  stage  the  quartan  seg.nents  are  fewer  than 
the  tertian  One  remarkable  feature  about  malaria  is  that  it  may  remam  latent  for  many 
years  and  yet  recur  in  those  who  have  long  since  returned  to  Great  Britam  from  the  tropics. 
What  has  happened  to  the  parasites  in  the  interval  is  not  known,  but  their  re-appearance 
is  brought  about  by  such  conditions  as  general  depression  of  health  from  overwork  or 
worry,  or  as  the  result  of  some  intercurrent  malady. 

(B).— ANEMIAS    WITH    AN    INDETERMINATE    OR    NEGATIVE    BLOOD-PICTURE. 

The  diaonosis  of  the  fact  of  anfcmia  is  made  by  means  of  a  blood-count,  but  in  the 
oreat  maiorit'v  of  cases  the  cause  of  the  anaemia  itself  is  not  indicated  by  the  blood  con.l.tion. 
The  differential  diagnosis  has  to  be  made  on  other  grounds.  One  may  subdivide  6Yo»;j  B 
into  four  sub-groups,  namely.  (1)  Those  cases  in  which  the  ana-mia  is  slight  and  in  itself 
not  a  very  prominent  symptom  ;  e.g.,  in  an  indoor  worker  or  a  convalescent  :  (2)  Those 
cases  in  which  though  the  ansmia  mav  be  severe,  the  routine  examination  of  the  patient 
d'iscovers  some  more  or  less  obvious  and  not  absolutely  uncommon  cause  for  it  ;  e.g., 
chronic  tubal  nephritis  :  (3)  Those  cases  in  which,  though  the  anemia  may  be  severe,  no 
obvious  lesion  c-.m  be  discovered,  but  in  which  there  is  nothing  about  the  case  to  suggest 
that  the  condition  is  a  rare  or  unusual  one  :  e.g..  chlorosis  :  (4)  Those  cases  in  which  the 
■inxmia  may  be  more  or  less  severe,  in  which  there  may  or  may  not  be  obvious  lesions  to 
Leconnt  for  "it,  but  in  which  the  circumstances  of  the  case  suggest  that  the  disease  is  unusual 
or  rare  ;    e.g.,  chloionia.  . 

Cases  in  which  the  Ansemia  is  slight  and  in  itself  not  a  very  promineni 
symptom  —It  is  clear  that  before  any  an-xmia  that  is  not  due  to  acute  blood  loss  Iron 
intern  il  or  external  hemorrhage  reaches  a  severe  stage,  it  must  pass  tlirough  a  phase  ii 
which' it  mav  be  regarded  as  slight  or  mild.  This  group  therefore  really  includes  all  the 
other  crroups  at  some  stage  of  their  development,  and  the  diagnostician  will  often  label  1 1 
case  to'start  with  comparatively  mild  or  unimportant,  when  the  course  of  events  nltunateh 
shows  that  this  was  wrong.  For  instance,  a  case  of  pernicious  ana-mia  may  exhibit  wha 
seems  to  be  unimportant  svmptoms  for  months  or  years  before  the  ana-m.a  reaches  s. 
definite  and  severe  a  stage  as  to  be  diagnosed  correctly.  The  group  now  under  discussioi 
is  meint  to  include  onlv  such  slight  degrees  of  anemia  as  are  themselves  not  important  i 
the  niatter  of  diagnosis  ;  for  instance,  in  people  who  live  too  much  indoors,  in  those  wh. 
•ire  convalescent  from  some  illness,  in  those  who  suffer  from  chronic  indigestion,  constips 
tion  obesitv  some  forms  of  chronic  intoxication  by  microbial  products,  due  to  such  thing 
as  infective  synovitis  or  arthritis,  pyorrhoea  alveolaris  and  oral  sepsis,  uterine  or  ovar.a  , 
disease  the  earlier  stages  of  phthisis,  empyema,  latent  or  deep-seated  caseous  glands  < 
tuberculous  affection  of  joints,  vertebrae  or  peritoneum  in  children,  the  milder  cases  , 
olumbism  and  so  on  :  in  all  these  cases  there  may  be  a  sufficient  degree  of  anaemia  to  attrae 
some  attention,  but  the  diagnosis  will  rest  upon  other  symptoms  and  signs  than  thoS'j 
connected  with  the  blood,  and  in  most  cases  the  anemia  will  not  be  extreme. 

Cases  in  which,  though  the  Anamia  may  be  severe,  a  routine  examination  ( 
the    patient    discovers    some    more   or    less    obvious    and    not    absolutely    uncommo 

*'''"*//«"L!rk«2e.-Some  of  the  most  striking  cases  of  anemia  in  this  group  are  those  i 
which  there  has  been  recurrent  or  severe  loss  of  blood.  When  the  latter  has  been  la 
bv  euistaxis  hemoptysis,  hematemesis,  hematuria,  menorrhagia.  metrorrhagia,  metrostaxi 
nurDura  or  by  the  escape  of  blood  per  rectum,  the  nature  of  the  anemia  will  generally  1 
'.bvious'and  the  differential  diagnosis  will  depend  upon  the  cause  of  the  particular  lienio 
rha^e  in  question  (see  Epist.vxis,  etc.).  One  should  insist  upon  a  complete  blood-count 
■ill  these  cases  however,  in  order  to  exclude  pernicious  anemia,  leukemia,  and  the  otU  , 
conditions  in  which  the  blood-picture  is  positive,  lest  the  bleeding  be  due  to  the  blood  sta 
and  not  the  blood  state  to  the  bleeding.     The  possibility  of  melena  should  also  be  borne 


I'jirl  of  a.  blood  tihn  from  ii  l- we  of  iiiuliui  i,  !?howiriij  three  in;il:iriil  iKinisites  of  tlie  ring   ty\ 


INDKX  <>K  |pi\.;\()sis    -To  face  p.  .".li 


AN.BMIA  33 

mind,  for  without  examination  of  the  faeces  the  extreme  pallor  resulting  from  loss  of  blood 
from  such  a  lesion  as  a  duodenal  ulcer  maj^  not  be  diagnosed  correctly.  Hcemophilia  should 
not  be  forgotten  :  the  way  the  patient  bleeds  excessively  from  slight  scratches  or  cuts  will 
generally  point  to  the  diagnosis,  especially  if  there  is  a  family  history  of  a  similar  condition, 
males  being  affected  more  than  females.  The  blood-i)icture  in  haemophilia  is  entirely 
negative,  the  ana-mia  that  results  from  the  bleeding  being  of  the  chlorotic  type.  It  is 
•sometimes  stated  that  the  result  of  blood-loss  is  to  jjroduce  an  antemia  in  which  the  red 
corpuscles  and  the  hicmoglobin  are  equally  reduced,  so  that  the  colour  index  remains  more 
or  less  normal.  This  may  be  true  of  an  acute  bleeding  such  as  venesection  or  post-partum 
haemorrhage,  but  the  effect  of  recurrent  blood-loss  is  to  produce  the  chlorotic  type  of  ana-mia, 
in  which  the  red  corpuscles  are  less  diminished  than  is  the  hicnioglobin. 

Cachexia. — A  similar  blood  picture,  namely  an  anemia  of  the  chlorotic  type  more  or 
less  severe,  but  without  anything  which  may  be  called  pathognomonic,  either  as  to  the 
red  cells  or  the  leucocj'tes,  is  to  be  found  in  almost  all  forms  of  cachexia,  whether  due  to 
syphilis,  tuberculous  or  malignant  disease,  malaria,  beri-beri  and  other  tropical  illnesses, 
oesophageal  stenosis,  or  starvation.  .\  careful  physical  examination  of  the  patient  and 
enquiry  into  his  symptoms  may  point  to  the  correct  diagnosis  ;  but  it  is  to  be  borne  in 
mind  how  dillieult  it  sometimes  is  to  detect  phthisis,  or  some  cases  of  carcinoma  or  sarcoma, 
even  when  far  advanced.  Sputum  analysis  should  not  be  omitted  ;  rectal  examination 
should  not  be  forgotten  ;  the  a;-rays  may  serve  to  detect  lesions  within  the  thorax,  and 
Wassermann's  serum  reaction  may  be  employed  when  sj-jjliilis  is  suspected.  It  is  remarkable 
how  little  anaemia  may  result  from  some  varieties  of  cancer,  particularly  carcinoma  of  the 
breast  ;  whilst  other  varieties,  especially  carcinoma  of  the  stomach,  produce  progressive 
ana-mia  eom|)arativeIy  early.  It  is  noteworthy  that,  whereas  in  former  times  the  absence 
of  free  hydrochloric  acid  from  the  gastric  juice  at  the  ])roper  interval  after  a  test  meal  was 
regarded  as  good  evidence  in  favour  of  a  carcinoma  ventriculi,  it  has  now  been  established 
firmly  that  the  hydrochloric  acid  may  be  very  deficient  or  entirely  absent  in  a  great  many 
other  conditions  also  ;  it  is  absent  in  almost  all  cases  of  advanced  carcinoma,  whether  of 
the  stomach  or  not  :  and  in  many  chronic  maladies  associated  with  ill-health  all  the 
.secretions  of  the  body  suffer,  and  amongst  them  the  liydrochlorie  acid  of  the  gastric  juice. 
It  follows,  therefore,  that  it  is  only  when  the  diagnosis  has  been  narrowed  down  to  there 
being  some  lesion  of  the  stomach,  that  the  discovery  that  the  hydrochloric  acid  is  very 
deficient  or  absent  affords  evidence  that  the  lesion  is  a  carcinoma. 

Parasitic  affcclions  sometimes  escape  recognition,  even  when  they  have  led  to  siilHcient 
an;emia  to  attract  attention  (see  Parasites,  Intkstin.vi.,  p.  519).  The  two  varieties  most 
a|)t  to  lie  associated  with  ana?mia  arc  Ayihi/lnslnnnini  diindcnalc  and  Rotliriocephaliis  latas. 
liilliarziri  lifotialohiti  may  also  lead  to  severe  anicmia.  but  generally  does  so  on  account 
of  the  II.KM  ATI  HI  A  (p.  -IH-J.)  that  it  produces.  I'.osinophilia  (p.  218.)  may  suggest  a 
parasitic   infection. 

Certain  drufix  are  apl  lo  produce  annniia  ol'  I  he  simple  ciiloi-olic  tyjie  if  llicir  adniiiiisi  ra- 
tion is  continued  over  a  long  period  ;  pai'licuiarly  niciciiij/.  ai\ciiif.  lead  and  srdiciilrdcs. 
.Veute  mereurialism  is  commonly  assoeialed  wilh  stomatitis  and  salivation,  l)ut  in  cliniiiic 
cases,  in  addition  lo  aiia-mia,  there  is  apt  to  l)e  a  motor  ty()e  of  peripheral  neuritis  all'ccting 
the  limbs  and  associated  with  a  remarkable  tremor  (p.  72(>),  ))artieularly  of  the  hands.  The 
diagnosis  is  generally  arrived  at  from  the  fact  that  the  patient  has  been  receiving  mercury 
nicdit'inally,  or  is  employed  in  some  work  in  which  mercury  is  used,  for  instance,  the  making 
of  thermometers  or  mirrors,  or  the  curing  of  rabbit  skins  for  the  manufacture  of  hats. 
Arsenical  paisoiiiii!'  seldom  gives  rise  to  ana-mia  as  its  sole  symi)tom  :  but  it  is  noteworthy 
that  although  liipior  arscnicalis  is  an  admirable  remedy  for  the  relief  of  pernicious  aiia-mia, 
arsenic  it>(ir  is  also  a  cause  of  ana-mia  amongst  those  who  work  in  it.  .\s  a  ruli;.  in  addition 
to  a?i:emia  there  is  iiiarUcd  pigmentation  of  the  skin  (I'late  I'JJ),  and  Addisorrs  disease 
may  be  siimilated.  In  the  latter,  howexcr.  the  pigmentation  occurs  on  the  nuicous 
membranes,  particularly  of  the  lips  and  cheeks,  as  well  as  upon  the  skin,  and  this  - 
though  in  very  exceptional  cases  a  similar  |)igmentation  within  the  mouth  has  been 
obser\-ed  ill  |)eriiicious  ana-mia  (see  Plate  \.\H.  p.  :V2H).  and  perhaiis  after  taking  arsenic 
lor  long  periods — is  ;dways  very  suggestive  of  Addison's  dis(-asc,  and  the  diagnosis  may 
be  eoiifiriiK-d  by  finding  a  slight  di-grec  of  cosinophilia,  a  remarkably  low  blood-pressure, 
down  (-\(-M  to   N(»  mm.  Ilgor  less,  attacks   of   \-omitiiig,  syiK-ope,  ami   n-miirkahli-  asl  lu-nia. 

1)  "  ;5 


34  AN.EMIA 

If  there  is  active  tuberculosis  of  the  suprarenal  capsules,  Calmette's  or  von  Pirquet's 
reactions  with  tuberculin  {Plate  XXXl'II.  p.  770),  may  be  positive,  but  these  two  tests 
are  now  less  relied  on  than  formerly.  In  arsenical  cases  there  may  also  be  evidence  of 
peripheral  neuritis  and  of  hyperkeratosis  of  the  soles  and  palms.  Analysis  of  the  hair 
will  discover  an  abnormally  hiirli  percentage  of  arsenic.  The  chlorotic  type  of  anaemia  in 
lead  poisoning  may  be  extreme,  but  the  diagnosis  will  depend  upon  other  symptoms,  of  which 
any  or  all  of  the  following  may  occur  : — a  blue  line  upon  the  gums  ;  constipation  ;  nausea  ; 
vomiting  ;  epigastric  pains  ;  abdominal  colic  ;  a  tendency  to  repeated  abortion  in  women  ; 
peripheral  neuritis,  particularly  of  the  wrist-drop  type  ;  various  cerebral  symptoms  of  any 
degree,  from  mere  headache  or  insomnia  to  epileptic  convulsions  or  acute  mania,  or  other 
serious  mental  signs  summarised  by  the  term  saturnine  encephalo])atliy  :  impairment  of 
sight  ;  optic  neuritis  :  ophthalmoplegia,  chiefly  affecting  the  sixth  cranial  nerve  :  a 
tendency  to  gout,  albimiinuria  and  granular  kidney,  and  the  secondary  effects  of  the  latter. 
The  absence  of  a  blue  line  on  the  gums  does  not  exclude  lead  poisoning  in  those  whose  teeth 
are  clean  ;  nor  does  its  presence  ])ro\'e  lead  poisoning,  for  most  workers  in  lead  exhibit  a 
blue  line  whether  they  have  other  symptoms  or  not.  In  cases  of  doubt,  it  may  be  necessary 
to  collect  an  abimdance  of  urine,  evajjorate  it,  and  apply  the  ordinary  tests  for  inorganic 
lead.  The  occu])ation  of  the  ]iatient  will  often  suggest  the  diagnosis.  Salicylates  are  said 
to  produce  an;emia  if  their  administration  is  continued  for  a  long  period  ;  but  it  is  also 
possible  that  the  anaemia  may  be  due  to  the  condition  for  which  the  salicylates  are  being 
given,  namely  acute  rheumatism.     The  diagnosis  is  generally  obvious. 

In  addition  to  the  aniemia  that  may  result  from  acute  rheumatism  itself,  there  is  apt 
to  be  pronoimced  an;emia  in  some  forms  of  vahiilar  heart  disease,  particularly  affections 
of  the  aortic  valves,  whether  rheumatic  or  syphilitic.  Mitral  disease,  particularly  mitral 
stenosis,  is  more  likely  to  cause  polycj-thasmia  (p.  533),  unless  there  is  fungating  or  infective 
endocarditis.  The  occurrence  of  a  progressive  anaemia  in  chronic  heart  cases  always  arouses 
suspicion  of  the  latter  ;  most  cases  of  fungating  endocarditis  present  synijjtonis  of  failing 
compensation  which  are  often  very  difficult  to  distinguish  from  those  due  to  the  mechanical 
effects  of  chronic  vahnlar  disease,  so  that  it  is  often  difficult  to  distinguish  a  heart  case 
without  fungating  endocarditis  from  one  in  which  fungating  endocarditis  has  supervened. 
In  addition  to  aniemia  the  following  points  would  be  in  favour  of  the  latter  :  sudden  and 
radical  changes  in  the  character  of  the  heart  bruits,  for  instance  from  musical  to  blowing, 
and  vice  versa  ;  enlargement  of  the  spleen  ;  the  occiuTcnce  of  haemorrhages,  particularly 
subcutaneous  or  retinal  ;  optic  neuritis  :  pyrexia  {Fig.  243,  p.  566),  whatever  its  type, 
provided  it  cannot  be  explained  by  any  intercurrent  affection  such  as  tonsillitis  or  jileurisy 
— though  the  absence  of  pyrexia  does  not  exclude  the  disease  :  rigors,  though  these  are 
often  absent  ;  and  symptoms  of  infarction  or  embolism  in  the  spleen,  kidney,  brain, 
intestine,  retinal  or  peripheral  vessels  resulting  in  convulsions  or  paralysis  ;  cessation  of 
pulse  in  one  or  other  of  the  accessible  arteries  such  as  the  radial,  posterior  tibial  or 
dorsalis  pedis  ;  acute  gangrene  of  some  part  whose  circulation  has  thus  been  cut  off 
suddenly — a  toe,  or  the  tip  of  the  nose  for  example  ;  the  develojiment  of  a  spontaneous 
peripheral  aneurysm  ;  sudden  hsematuria  :  sudden  acute  pain  over  the  spleen,  associated 
jjerhaps  with  a  peritonitic  rub.  It  is  noteworthy  that  there  is  but  little  leucocytosis- 
in  infective  endocarditis.  Cultivations  from  the  blood  obtained  by  aseptic  venesection 
may  serve  to  clinch  the  diagnosis,  and  also  to  indicate  what  seriuii  or  vaccine  treatment 
should  be  employed  ;  though  it  is  remarkable  how  often  blood  cultures  are  negative  in 
these  cases,  even  when  the  blood  is  obtained  during  a  period  of  high  pyrexia.  , 

It  is  in  some  cases  easy,  but  in  others  relatively  difficult,  to  be  sure  of  the  diagnosis 
of  subacute  nephritis.  Anaemia  is  a  prominent  symptom  in  the  chronic  nephritis  of  yoimg 
peojjle,  though  the  reverse  is  generally  the  case  in  the  red  granular  kidney  of  later  life  ;  for 
the  differential  diagnosis,  see  Albuminuria  (p.  9).  The  old  aphorism  of  "■  the  large 
white  person  with  the  large  white  kidney  "  may  sometimes  suggest  the  malady. 

Many  subacute  or  chronic  maladies  associated  with  continued  absorption  of  microbial 
toxins  have  anaemia  as  a  prominent  sj-mptom.  One  may  mention,  for  instance,  chronic  colitis, 
whether  muco-membranous,  '  simple  '  ulcerative,  or  tropical  dysenteric  (see  Diarrhcea, 
]).  17"2)  ;  deep-seated  suppuration  acts  in  the  same  way,  and  one  is  familiar  with  the 
pallor  of  patients  suffering  from  empyema  :  the  development  of  this  aiuemia  after  the 
crisis   of   lobar   pneumonia,   or   in   connection   with   broncho-[3neumonia,  in  children,   not 


AN.ilMIA 


35 


infrequently  suggests  that  an  empyema  lias"  developed  ;  the  diagnosis  may  be  confirmed 
by  the  physical  signs,  but  it  will  be  clinched  by  finding  pus  when  the  chest  is  needled. 
Leucocytosis  or  a  relative  increase  in  the  polymorphonuclear  cells  does  not  help  in 
determining  the  presence  of  empyema  so  much  as  in  other  cases  of  suppuration,  because 
empyema  is  nearly  always  secondary  to  lobar  or  lobular  pneumonia,  and  in  each  of  these 
there  is  also  a  polymorphonuclear  leucocytosis.  Other  examples  of  chronic  sepsis  which 
may  produce  severe  ana-mia  are  chronic  appendicular  abscess  ;  pyosalpinx  ;  hepatic 
abscess  ;  the  breaking  down  of  ovarian  or  uterine  timiours  ;  chronic  endometritis  ; 
pyorrha?a  alveolaris  :  infection  of  sinuses  connected  with  bones  or  joints,  particularly 
unclean  tuberculous  hi])  or  knee  joints  ;  psoas  abscess  ;  suppurative  periostitis  or  osteo- 
myelitis, with  necrosis  of  bone  ;  secondary  coccal  infections  in  phthisis  with  cavitation, 
or  in  bronchiectasis.  Chronic  sepsis  may  produce  Jardaccnus  disease,  which  itself  is  also 
a  cause  of  profound  anaemia,  with  a  peculiar  pale  yellowish  or  transjjarent  appearance  of 
the  skin,  though  its  diagnosis  is  exceedingly  ditlieult  in  any  but  advanced  cases.  It  is 
guessed  at,  as  a  rule,  on  account  of  there  being  a  chronic  purulent  discharge  from  lung, 
joint  or  limb,  or  else  severe  tertiary  syphilis.  There  may  be  enlargement  of  the  liver  and 
spleen,  albuminuria,  and  a  tendency  to  diarrhoea  ;  but  even  when  all  these  symptoms  are 
present,  it  not  infrequently  hap|)ens  that  the  post-mortem  examination  shows  that  there 
was  no  lardaceous  disease  at  all. 

Rheumatoid  arthritis  is  an  indefinite  group  of  joint  diseases  which  differ  essentially  from 
osteo-arthritis  (]).  S48),  in  that  with  the  former  there  are  more  or  less  severe  constitutional 
symptoms,  including  slight  pyrexia,  loss  of  appetite  and  weight,  pigmentation  of  the  skin, 
and  ana-niia.  The  nearest  lymphatic  glands,  e.g.,  the  eijitrochlear  when  the  hands  are 
affected,  are  often  enlarged  and  tender.  The  diagnosis  seldom  depends  upon  the  anicmia, 
however.  Probably  there  are  many  varieties  of  rheinnatoid  arthritis  which  will  some  day 
be  classified  upon  a  bacteriological  basis  into  those  due  to  gonococci,  streptococci,  staphy- 
lococci, ])neumoeocei,  JiaciUus  coli  communis,  Spirochceta  pallida,  and  so  on.  There  are 
two  types  that  are  ])artieularly  prone  to  anaemia,  and  these  are,  first,  the  form  in  which 
there  is  marked  spindle-shaped  enlargement  of  all  the  first  intcrphalangeal  joints  in  adults, 
whatever  otiicr  joints  may  be  affected  at  the  same  time  (p.  IH'I)  :  and  secondly,  a  general 
destructive  affection  of  the  joints  in  children,  associated  with  emaciation,  an;emia,  enlarge- 
ment of  the  spleen  and  of  the  lymphatic  glands,  and  known  as  Still's  disease  {Fig.  l(ii), 
p.  377).     (See  .Joints,  AtTiicxiONS  of,  p.  3;:17.) 


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Cirrhosis  of  the  liver  sooner  or  later  leads  to  ana"mia  of  the  chlorotic  type,  although' in 
the  earlier  stages  the  alcoholic  jiatient  may  have  a  rubicund  complexion  ;  by  the  time 
the  ana-mia  is  pronounced  there  will  almost  certainly  have  been  other  .syni])toms  of  the 
complaint,  particularly  II.kmatkmksis  ([).  'ifi.T),  Jalnuicf.  (p.  :!21-),  or  Ascitks  (p.  i'.i). 
Patients  with  cirrhosis  of  the  liver  often  have  some  evening  pyrexia  {Fig.  I'J),  and  they 
tend  to  undue  pigmentation  of  the  skin. 

Ilil/icrlailalion  is  a  pniininent  cjiuse  of  anu-mia  and  general  ill-health,  especially  in 
women  in  towns.  The  cause  for  prolongation  of  the  period  of  lactation  is  often  an  idea 
that  pregnancy  will  not  recur  whilst  the  last  infant  is  being  suckled.  The  diagnosis  is 
generally  obvious  if  its  j)o.ssibility  is  borne  in  mind. 


36  AN.milA 

Gastric  ulcer,  or  rather  the  symptoms  which  are  often  stated  to  be  those  of  gastric 
ulcer,  is  frequently  associated  with  anaemia  ;  the  latter  in  a  few  cases  is  the  result  of  direct 
loss  of  blood  by  H^matemesis  (p.  268),  or,  in  the  case  of  duodenal  ulcer,  Mel^na  (p.  75). 
A  duodenal  ulcer  may  sometimes  simulate  gastric  ulcer,  but  more  often  it  produces  symptoms 
which  are  apt  to  be  mistaken  for  gall-stones,  the  pain  being  referred  to  a  spot  about  an  inch 
below  the  tip  of  the  ninth  right  rib.  As  a  rule  the  pain  in  cases  of  duodenal  ulcer  bears  a 
definite  relationship  to  food,  being  greatest  when  the  patient  is  beginning  to  be  hungry, 
and  relieved  by  the  taking  of  food.  Gastric  ulcer,  on  the  other  hand,  is  much  more  difficult 
to  diagnose,  for  even  when  the  patients  have  suffered  from  epigastric  pain  coming  on 
inmiediately  after  food,  from  vomiting  whicli  relieves  the  pain,  and  from  one  or  more  attacks 
of  hoematemesis,  it  is  possible  for  the  latter  to  be  due  to  generalized  oozing  froin  the  gastric 
mucosa — '■  gastrostaxis  '" — rather  than  a  definite  measuraljle  ulcer.  AVlien  there  has  been 
no  hiematemesis  the  diagnosis  is  still  more  dilficult,  though  it  is  noteworthy  that  in  nearly 
half  the  cases  in  which  the  presence  of  an  ulcer  has  been  proved  by  operation  there  has  been 
no  history  of  hsematemesis.  It  was  formerly  stated  that  gastric  ulcers  are  common  in  the 
female  sex  between  the  ages  of  fifteen  and  thirty,  especially  in  the  unmarried  and  the 
anaemic  :  notably  amongst  the  servant  class  ;  operative  demonstrations  of  gastric  ulcers, 
however,  seem  to  show  that  they  are  really  commoner  in  later  life,  and  affect  men  as  often 
as  women,  so  that  there  is  a  very  decided  possibility  that  the  gastric  symptoms  of  ana?mic 
women  are  not  in  fact  due  to  idcer.  One  meets  with  patients  who  have  pain  the  moment 
they  take  food,  in  whom  vomiting  after  meals  is  persistent,  in  whom  the  diagnosis  of  gastric 
ulcer  would  certainly  have  been  made  in  former  years,  but  in  whom  that  diagnosis  is  made 
now  only  with  considerable  caution.  It  has  become  increasingly  recognized  that  the 
vomiting  and  the  gastric  signs  arc  often  due  to  the  anaemia  itself,  and  result  from  anaemic 
<lilatation  of  the  heart.  In  diagnosing  between  this  condition  and  that  of  true  gastric 
ulcer,  one  of  the  best  plans  is  to  put  the  patient  to  bed,  and  when  she  has  been  recumbent 
for  twenty-four  or  thirty-six  hours,  to  see  what  is  the  effect  of  giving  her  fidl  diet.  Full 
diet  will  be  borne  quite  well  in  cases  of  severe  anaemia  associated  with  gastric  symptoms 
without  ulcer  so  long  as  the  ]5atient  remains  in  bed  ;  but  if  she  gets  ujj  and  returns  to  work 
before  the  anaemia  is  cured  the  gastric  symptoms  come  on  again  directly.  The  vomiting 
and  the  epigastric  pain  seem  to  be  related  not  so  much  to  food  as  to  work  in  these  cases. 
When  there  is  an  ulcer,  however,  an  attempt  to  adopt  full  meat  and  vegetable  diet  on  the 
second  day  of  resting  in  bed  nearly  always  fails  if  there  have  been  severe  symptoms  up  to 
that  time. 

Conditions  in  which,  though  the  Anaemia  may  be  severe,  no  obvious  Lesion  can 
be  discovered,  whilst  at  the  same  time  there  is  nothing  to  suggest  that  the  case  is 
a  rare  or  unusual  one. 

Chlorosis  is  almost  the  only  malady  which  conies  under  this  heading,  if  one  includes  the 
milder  ansemias  of  girls  and  young  women  as  well  as  the  severe  cases  of  yellow-green  sickness 
to  which  the  term  should  strictly  speaking  be  limited.  The  cases  of  anaemic  vomiting  just 
discussed  might  also  come  under  the  same  heading.  Chlorosis  and  simple  chlorotic  anaemia, 
without  obvious  organic  lesions,  are  affections  of  the  female  sex — absent  before  puberty 
and  common  immediately  after,  seldom  lasting  after  thirty  years  of  age,  and  generally  not 
so  long  ;  cured  as  a  rule  by  marriage  ;  never  fatal  even  when  severe  ;  an  affection  of  all 
classes,  but  mostly  of  indoor  workers  such  as  servant  girls,  and  not  often  affecting  those 
who  are  employed  in  outdoor  jjursuits.  The  diagnosis  is  generally  easy.  The  patients  are 
comparatively  well  covered  though  they  often  eat  very  little.  Emaciation  is  rare  in 
chlorosis,  and  this  is  probably  due  to  the  fact  that  the  blood  is  less  deficient  in  quantit\ 
than  diluted  by  excess  of  water.  The  leucocytes  are  normal  both  in  total  mnnber  and  in 
differential  count.  The  red  corpuscles  are  often  much  less  diminished  than  might  be 
expected  from  the  appearance  of  the  patient,  the  chief  feature  of  the  complaint  being  the 
great  reduction  in  the  haemoglobin,  so  that  the  colour  index  may  fall  to  0'5,  O'i.  or  even 
less.  As  the  condition  improves  the  red  cells  return  to  normal  fairly  quickly,  and  the 
hsemoglobin  rises  steadily  but  less  rapidly.  The  way  in  which  the  patients  react  to  treat- 
ment by  rest  in  bed,  by  the  giving  of  iron,  by  keeping  the  bowels  open,  and  by  living  in  a 
sunny  atmosphere,  is  remarkable,  and  helps  to  clinch  tlie  diagnosis  in  any  case  of  doubt. 
It  has  been  mentioned  above  that  there  are  many  blood  changes  which  are  common  to 
severe  ana?mias  ;    it  should  be  noted  that  even  when  the  haemoglobin  has  fallen  to  30  per 


AN.EMIA 


37 


cent  of  normal  in  a  sc\ere  case  of  chlorosis,  the  changes  in  the  blood-cells  enumerated  on 
page  "^2  seldom  appeal'.  Chlorosis,  more  often  than  any  other  form  of  anaemia,  leads  to 
hicmic  cardiac  bruits,  ])articularly  a  blowing  systolic  bruit  in  the  pulmonary  area  and  a 
briiil  (le  dkible  in  the  neck.  The  patients  are  often  constipated,  are  apt  to  suffer  from 
menstrual  irregularity,  particularly  amenorrhaca.  which  may  last  for  months,  and  a  tendency 
to  oedema  of  the  feet.  The  viscera  are  generally  normal.  Chlorosis,  unlike  many  other 
forms  of  severe  anicinia.  seldom  produces  albuminuria. 

Cases  in  which  the  Anaemia  may  be  more  or  less  severe,  in  which  there  may 
or  may  not  be  obvious  lesions  to  account  for  it,  but  in  which  the  circumstances  of 
the  case  suggest  that  the  disease  is  unusual  or  rare. 

Iliidal.iii'x  ilisainc  is  often  spoken  of  as  though  it  were  an  affection  in  which  the  blood- 
ci^unt  indicates  the  diagnosis.  This  is  not  the  case,  however,  the  blood  changes  being 
merely  negati\e,  though  a  blood-coimt  is  essential  in  order  to  exclude  leuk.tmia  by  finding 
that  there  is  no  leucocytosis.  At  first  there  is  no  anaemia  ;  later  there  is  progressive  anaemia 
of  the  chlorotic  type,  with  finally  all  the  changes  in  the  red  cells  common  to  the  severe 
ana-mias  (p.  22).  There  is  no  leucocytosis,  or  none  of 
moment.  The  differential  leucocyte  count  may  be  normal ; 
more  often,  however,  there  is  .some  relative  increase  in  the 
lymplK)cytcs  with  proportionate  relative  diminution  in 
the  ])olym<)ri)lionuclear  cells,  and  when  a  large  iiumliir  of 
white  corpuscles  are  examined  occasional  myelocytes  and 
one  or  two  ba.sophile  corpu.scles  will  be  detected.  The 
diagnosis  is  made  from  the  enlargement  of  the  Lymphatic 
Gla.vds  (p.  377)  and  of  the  Splken  (p.  63.5). 

Splenic  (itKvniid  is  a  malady  in  which  there  is  con- 
siderable enlargement  of  the  spleen,  progressive  annemia 
of  the  simple  chlorotic  type,  and  no  other  very  obvious 
evidence  as  to  what  is  wrong  with  the  patient.  It  is 
])robablc  that  more  than  one  condition  is  at  present 
labelled  splenic  an-,cmia  :  a  considerable  number  of  the 
cases  turn  out  ultimately  to  be  cirrhosis  of  the  liver 
(p.  fi33),  in  which  ctilargement  of  the  spleen  happens  to 
have  been  the  first  symptom  to  attract  attention,  very 
likely  years  before  the  other  effects  of  cirrhosis  manifested 
themselves.  AVhen  splenic  anaemia  is  the  original  diagnosis 
in  a  case  which  ultimately  proves  to  be  cirrhosis  of  the 
li\(T,  the  condition  is  often  spoken  of  as   linutVs  disease. 

.Iphistir  (iiKVitiid  has  been  mentioned  above  (p.  24), 
and  there  are  a  considerable  mnnber  of  obscure  cases  of 
severe   aiueiiiia    to    which    up    to    the    present     no    delinile 

lalirU  can  Ik  allaclicd.  Some  of  tliesc  sinuiialc  pcrnicioiis  anaiiiia.  hut  al 
the  lallii-  in  liasiiig  a  colciui'  index  peisistciil  ly  liss  lliaii  1.  Due  can  only  i-i 
as  severe  .iTid  even   fatal   un-named  anarnias. 

l'siitdi)-i(uk(rniiii  iiiftinlion  is  a  t'oiulilion  in  wliicli  ciini-mcins  (■nlargcin<nl  < 
takes  plac<-  in  a  young  child  or  infant  {Fifi-  13),  associated  as  a  rule  with  more  or  less  ascites 
and  enlar;;cmciit  of  the  abdomen.  So  great  is  the  splenic  eidargcmcnt  sometimes  that  the 
condition  at  first  suggests  Icukicmia  ;  but  when  a  blond-count  is  made,  although  the  red 
•  •ells  niay  be  very  nuich  diminished  an<l  exhibit  all  the  changes  characleristic  of  severe 
aniemia,  there  is  no  extreme  leucocytosis,  so  that  the  condition  cannot  be  classified  as  a 
leuka-mia,  and  hence  is  termed  "  pseudo-leid<a'mia  itd'anlum  ;  '  it  has  also  been  called  '  i-im 
Jid.sili's  tlisc/ise.'  It  generally  begins  at  an  age  ol'  less  than  two  years.  The  liver  is  enlarged, 
bul  less  so  than  the  spleen.  'J'licre  may  be  severe  haemorrhage  from  the  mucous  membranes, 
anrj  liicrc  js  (irirn  |MricMlic  |iyie\ia.  The  disiaM'  may  l)e  mislaken  for  rickets  or  for  <nn- 
gcnilal  syphili^  :  iriiliiil  some  aulhorilies  lliink  llial  il  is  realiv  due  hi  iiiie  or  oilier  <ii-  liolli 
of  lliese  causes  in  an  exaggerated  degree.  W'liellier  this  is  sii  in-  nol.  the  pi-ognosis  is  lair 
even  when  the  ana-mia  has  reached  a  severe  degree.  'I'he  asiilcs  rna\  disappear,  the  huge 
KpU'cTi  iTiay  become  restored  to  its  normal  (lim<'nsions,  and  llic  palieni  recover  coiTiplelely 
in  llic  course  of  monllis. 


I  dilTer  fn 
■Icr  |.>  lli( 

,ril,rspl. 


38 


AN.^MIA 


Myxcedema  is  a  condition  which  may  be  mistaken  for  simple  anremia,  and  consequently 
it  is  apt  to  be  overlooked,  particularly  at  that  stage  which  merits  the  term  '  hypothyroidism  ' 
rather  than  myxocdema.  It  is  an  affection  of  women  ratlier  tlian  of  men  ;  it  conies  on 
\'ery  slowly,  and  sometimes  it  can  be  diagnosed  only  by  watching  the  beneficial  effects  of 
thyroid   treatment.     There   is   generally   excess  of  gelatinous   subcutaneous  tissue,   which 


Fig.  15. — My-xcedema  :  the  character- 
istic facies,  illustratitiff  tlie  broadeniiis  of 
the  features  ami  the  niahir  flush.  (Com- 
pare Fi'j.  It.) 


gives  the  patient  a  puffy  or  a?(lematous  appearance,  especially  in  the  face  [Fig.  15),  hands 
(Fig.  10),  and  lower  limbs,  so  that  not  a  few  cases  are  mistaken  for  nephritis.  The  urine 
is  copious  and  of  low  specific  gravity,  but  usually  does  not  contain  albumin  :  thovigh  in 
some  cases  there  is  sullicient  albimiiniiria  to  make  the  case  still  more  like  one  of  Brights 
disease.     The  ajiiiarent  a'deiua  docs  not  i)it  on  pressure,  or  pits  far  less  easily  than  it  would 

if  it  were  ordinary  oedema  ;  the 
skin  becomes  thickened,  and  the 
hair  decreases  in  quantity  and 
becomes  brittle.  Physical  move- 
ments are  lethargic,  and  the  in- 
tellect dull,  so  thiit  there  is  slow- 
ness of  action  bt)th  of  body  and 
(if  mind,  symptoms  that  disappear 
in  a  remarkable  way  under  thyroid 
treatment.  In  some  cases  the 
mental  symjjtoms  predominate  to 
such  a  degree  that  some  form  of 
flelusional  insanity  or  dementia 
may  be  diagnosed,  or  even  a 
cerebral  tumour.  The  chlorotic 
type  of  amemia  which  accom- 
|i;inics  myxocdema  may  be  masked 
liy  a  local  flush  over  the  malar 
bones,  not  unlike  that  of  mitral 
stenosis. 

Scurvy  is  a  rare  disease  which 
may  lead  to  the  most  ])rofoimd 
anaemia,  though  it  seldom  does  so 
without  also  producing  extensive  haMnorrhage  into  the  skin,  beneath  the  periosteum  of 
the  tibia-  or  other  bones,  from  mucous  membranes,  and  especially  from  the  spongy  and 
ftrtid  gums.  It  is  not  common  now-a-days,  except  in  a  mild  form  in  children, — scm~vii- 
rickctfs  or  Burloiv's  disease — in  which  tenderness  of  the  bones  associated  with  antemia, 
often  mistaken  for  rickets    is  the  main  sym])tom.     The  tenderness  in  question  is  due  to 


ANURIA  39 

local  sub-periosteal  hiemorrhage,  and  the  vfiCy  in  which  the  complaint  rapidly  gets  better 
under  suitable  treatment  with  fresh  vegetable  diet  helps  in  clinching  the  diagnosis.  Tlie 
severer  forms  of  scurvj'  are  due  to  prolonged  de])rivation  of  fresh  food,  such  as  is  rare  in 
modern  practice,  though  it  used  to  be  common  on  board  ships. 

Chloroma  is  a  very  rare  affection,  related  to  lymphatic  leukaemia  on  the  one  hand  and 
to  lympho-sarcoma  on  the  other.  It  is  associated  with  the  formation  of  multiple  tumours, 
especially  in  connection  with  bones,  and  a  progressive  and  severe  ana?mia  of  indeterminate 
tyi)e.  The  condition  is  fatal,  and  the  diagnosis  is  at  once  suggested  by  the  green  colour  of 
the  nei)])lastic  dcpi'sits.  Ilerberl  French. 

ANjCSTHESIA.  -(See  Sensatiox,  AnNoitMAi.niKs  ok.  \).  fiOt.) 

ANALGESIA. — (See  Sens.vtiox,  ABNomiAi.iTiES  ov,  p.  COl.) 

ANASARCA.     (See  CEdema.  p.  411.) 

ANKLE-CLONUS  is  best  elicited  when,  the  patient  lying  on  his  back,  witli  his  knees 
slightly  Hexed,  the  ob.server  quickly,  but  not  violently,  dorsiflexes  the  foot,  the  liand  being 
api)l)ed  along  its  outer  border  in  such  a  way  as  to  keep  it  well  outwardly  rotated.  The 
result,  when  ankle-clonus  is  present,  is  a  scries  of  rliythmical  jerks  at  tlie  ankle-joint.  a[  the 
rate  of  al)out  7  per  second — fite  contractiniis  coiiliiiiiiHii  "x  /"",2  <"'■'  the  pressure  is  iiiiiiiilaiiiril. 
The  last  proviso  is  inii)ortant.  because  it  often  ha|)pcns  that  a  few  ankle-jerks  are  olHained. 
varying  in  number  from  two  or  three  to  as  many  as  twenty  or  thirty,  but  gradually  tailing 
off  and  ceasing,  although  the  pressure  on  the  sole  is  maintained.  This  is  sometimes  spoken 
of  as  a  ■•  tendency  to  ankle-clonus,""  but  for  clinical  purposes  it  is  not  ankle-clonus  at  all, 
and  indicates  nothing  more  tlian  hypersensitiveness  of  the  nervous  system,  and  not  organic 
<llsease.  .\nklc-clonus.  on  the  other  hand,  denotes  changes  in  the  corresponding  crossed 
pyramidal  tract,  and  it  is  to  be  expected  in  association  with  increased  knee-jerk  and  extensor 
plantar  rellex.  Its  chief  value  lies  in  determining  between  functional  and  organic  exaggera- 
tions of  the  knee-jerk  ;  tlie  latter  may  be  very  brisk  as  the  result  of  pure  nervousness,  but 
if  it  is  associated  with  either  an  extensor  plantar  reflex  or  ankle-clonus,  or  both,  the  exaggera- 
tion is  due  to  organic  disease  of  the  upper  neuron,  liemiplegie  or  paraplegic  as  the  case 
may  be.  Whereas.  Ii<)\ve\er.  the  presence  of  maintained  ankle-clonus  is  conclusive  proof 
of  an  upper  neuron  affection,  the  absence  of  such  eloiuis  does  not  exclude  such  lesion  ; 
ankle-clonus  is  not  met  with  until  there  is  a  relatively  large  amount  of  lateral  column  change  ; 
it  comes  later,  as  a  rule,  than  the  extensor  ])lantar  reflexes.  Herbert  French. 

ANOSMIA.     (See  SMi;t,i.,   AiiNoiniAi.iTJi-.s  oi'.   p.  (ill.) 

ANURIA — :)r  suppression  of  urine  must  lie  <listinguislir(l  tmrn  reletilidii  iif  urine. 
\\\  which  urin<-  is  secrete;!  from  the  kidneys,  but  is  rclaincd  in  I  he  hladdcr  froni  scinie 
lesion  causing  obstruction  to  the  urethra,  such  as  urethral  stricture  or  prostatic  obstruction 
ill  the  male,  or  pressure  or  dra;)  upon  the  iirellira  by  !i  large  pelvic  tumour  or  a  retrovcrted 
gravid  uterus  in  the  female.  Ketention  of  urine  may  also  occur  without  urethral  obstruc- 
tion in  various  forms  of  disease  of  the  spinal  nervous  system  aliccling  the  lumbar  centres. 
In  retention  of  urine  there  is  pain  above  the  jiiibes,  eonstani  and  urgent  desire  to  pass 
urine,  and  the  distended  bladder  forms  a  tense,  oval,  dull  tumour  almve  the  piibes  in  tlie 
middle  line.  In  many  cases  a  previous  history  of  obstruction  (o  I  he  urinary  How  will  be 
oblained.  wliilsl  in  (itlicrs  the  involuntary  dribbling  nf  urine  I'niin  llic  urelhra  from  an 
o\(r-ilislcnilc(l   liluldcr  at   mice  ilislinuiiishcs  the  cusc   IVniii  one  iif  aiiiiiiM. 

CALSKS   or   .vxnuA. 

A.    Oljslniilive  : — 

Caleulus  in   kidney  or  ureter 

\'esical  carcinoma  iiiMplviiig   Ihc   iiicdiic  ciriliees 

I'tcriiie  carciiKinia 

Large  pelvic  or  aliiliuiiinal   I  iiiiKnirs. 
II. — \(iii-i)lislrii(liif  : 

'I'oxic,    lia'ma|(ij;cn(iiis  (ir   asceiiiling. 


40  ANUBIA 

In    renal    disease,    nepliritis.    lardaceous    disease,    tubereulosis,    polycystic    disease, 
suppurative  pyelonephritis 

Reflex,  after  operations  or  trauma,  or   the  sudden  emptying  of  an   over-distended 
bladder. 

In     jjoisoning     from     mercury,    lead,    phosphorus,     oxalic     acid,     cantharides,    or 
turpentine. 

In  severe  collai)sc. 

Hysteria. 
Anuria  may  occur  and  be  complete  without  any  other  symptom,  and  it  is  remarkable 
that  in  the  obstructive  forms,  especially  with  calcidus,  anuria  may  be  complete  for  several 
dajs  without  any  other  symptom — latent  urtemia.  In  the  non-obstructive  forms,  anuria 
may  be  accompanied  from  the  onset  by  the  various  symptoms  of  uraemia,  such  as  vomiting, 
convulsive  muscular  twitchings,  dyspnoea,  and  headache.  In  the  obstructive  form  there 
may  be  total  absence  of  any  urine  secreted,  or  a  small  quantity  may  be  passed  of  low  specific 
gravity,  and  containing  very  little  urea  or  solids.  Albumin  is  absent  unless  there  be  hsema- 
turia  or  cystitis,  when  pus  may  be  present  also.  The  patient  may  com]3lain  of  aching  in  one 
or  both  lumbar  regions,  but,  with  the  exception  that  no  m-ine  is  passed,  seems  to  be  in 
ordinary  hcaltli.  The  appetite  is  good  and  the  mental  state  clear  ;  but  after  a  variable 
period,  from  seven  to  ten  days,  the  patient  becomes  drowsy,  the  tongue  dry,  temperature 
subnormal,  apiietite  deficient,  and  pujjils  small.  There  may  be  muscular  twitching  ;  the 
drowsiness  gradually  becomes  deeper,  without  any  true  uremic  convulsions,  and  death  may 
be  postponed  for  as  long  as  twenty  days  from  the  onset  of  the  anuria.  This  sequence  is  very 
different  from  that  seen  when  anuria  occurs  from  non-obstructive  causes,  when  there  is 
frequently  marked  distin-bance  of  the  nervous  system  :  headache  and  giddiness  are  followed 
rapidly  by  convulsions,  delirium,  and  dyspntra.  with  vomiting  and  small  pupils,  the  patient 
rapidly  becoming  comatose  and  dying  in  a  few  days. 

^.—OBSTRUCTIVE    ANURIA. 

Calculous  Disease  is  the  most  frequent  cause  of  obstructi\e  anuria.  It  may  occur 
at  any  age,  but  is  conunonest  in  men  of  about  forty.  Suppression  of  urine  may  arise  from 
the  impaction  of  a  small  calculus  in  the  ureter  of  a  kidney  which  is  practically  normal,  or 
may  be  due  to  the  total  destruction  of  the  renal  secreting  substance,  which  has  progressed 
gradually  and  without  marked  symptoms.  Between  these  two  extremes  there  may  be 
many  stages,  and  the  two  conditions,  namely,  ureteric  impaction  and  renal  destruction, 
may  exist  at  the  same  time.  Clinically,  it  is  rare  for  calculous  anuria  to  arise  from  simul- 
taneous blockage  of  both  ureters  by  calculi  ;  it  is  less  uncommon  to  find  that  one  kidney 
has  been  destroyed  by  ]>revious  disease,  the  ureter  of  the  remaining  organ  then  becoming 
obstructed  by  a  stone.  Exceptionally,  the  blockage  of  one  ureter  may  cause  reflex  suppres- 
sion of  urine  in  the  other  kidney,  especially  if  the  function  of  the  latter  is  impaired  already 
by  disease  :  but  in  these  cases  the  anuria  is  usually  temporary.  Calculous  anuria  may  occur 
suddenly,  and  in  patients  who  are  apparently  in  good  health,  for  it  is  no  imcommon  thing 
for  a  patient  to  go  on  in  good  health  when  he  jsossesses  only  one  functionally  active  kidney, 
the  other  ha^'ing  been  destroyed  by  slow  disease,  or  being  absent  :  or  there  may  be  a  history 
of  ]}re\ious  linnbar  pain,  ha?maturia,  pyuria,  or  the  passage  of  calculi.  At  the  onset  of 
anuria  there  is  usually  pain  in  the  lumbar  region  along  the  course  of  the  ureter  of  the  side 
most  recently  affected  ;  it  commonly  lasts  a  day  or  so  and  then  subsides,  or  it  may  last 
throughout  the  period  of  anuria.  In  addition,  there  is  frequently  a  constant  desire  to  mic- 
turate, although  no  urine  is  passed,  or  if  the  anuria  is  intermittent,  urine  of  pale  colour  and 
low  specific  gravity,  sometimes  blood-stained,  may  be  passed.  If  the  anuria  remains 
complete,  no  other  symptoms  may  occur  for  several  days,  a  feature  which  is  common  to  the 
obstructive  forms  of  anuria,  but  is  in  marked  contrast  to  the  non-obstructive  variety.  After 
a  period  of  anuria  lasting  from  seven  to  ten  days,  the  patient  becomes  drowsy,  the  tongue 
is  dry,  there  is  disinclination  for  food,  and  the  general  symptoms  of  uraemia  may  come  on  ; 
but  in  many  cases  the  patient  may  die  before  any  symptoms  of  iirremia  occur.  Thus,  it  is 
usual  to  speak  of  a  tolerant  and  a  urcemic  period  in  obstructive  anuria.  The  tolerant  stage 
of  obstructive  anuria  may  be  even  further  prolonged  if  the  fimctional  kidney  be  already 
hydronephrotic  from  previous  intermittent  obstruction,  even  to  twenty  days.     The  sudden 


ANURIA  41 

obstruction  to  the  urinary  flow  in  a  comparatively  normal  kidney  causes  complete  suppres- 
sion, whilst  a  partial  or  intermittent  obstruction  causes  dilatation  of  the  kidney.  It  such  a 
kidnej'  be  the  fimctionating  organ,  and  become  completely  obstructed,  the  dilatation  will 
increase  ;  and  a  lumbar  tumour  may  be  palpable.  If  there  is  pain  on  pressiu'c  over  the 
kidney,  or  aloni;  the  coiu-se  of  the  ureter,  the  diagnosis  is  strengthened,  or  it  may  be  decided 
to  settle  the  diagnosis  by  immediate  operation.  In  some  cases  in  which  one  kidney  has 
been  destroyed  gradually  without  pain,  and  anuria  occurs,  there  may  be  great  dilliculty  in 
determining  which  of  the  two  kidneys  is  the  functional  organ  which  has  recently  become 
obstructed  ;  in  these  cases  it  is  a  good  rule  to  operate  ujion  the  side  on  which  the  pain  has 
occurred  most  recently.  If  the  patient  is  not  too  stout,  palpation  may  detect  a  distinct  area 
of  pain  over  a  calculus  impacted  in  the  course  of  the  ureter  :  or  on  careful  rectal  or  vaginal 
examination  a  calculus  impacted  in  the  vesical  end  of  the  ureter  may  be  felt.  If  the  case  is 
seen  early,  evidence  of  ureteric  calculus  may  be  obtained  by  the  cystoscope,  wlien  the  ureteric 
orifice  of  the  obstructed  side  may  be  seen  to  be  congested  or  ecchymosed ;  or  a  ureteric 
bougie  impermeable  to  the  Rontgen  rays  may  be  passed  into  the  ureter  and  a  skiagram 
obtained,  though  it  is  only  exceptionally  that  this  can  be  carried  out.  Operation  upon  the 
side  of  the  recent  pain  may  be  urged  strongly,  when  the  kidney  can  be  opened  and  drained, 
and  opportunity  taken  to  explore  as  much  of  the  m-eter  as  can  be  felt  by  the  parietal  incision 
and  bj'  catheterization  from  above. 

Anuria  from  Vesical  Carcinoma  implies  that  either  both  ureteric  orifices  are 
involved  in  the  disease,  or  tliat  the  ureteric  orifice  of  the  only  functional  kidney  is  implicated. 
The  condition  is  uncommon  as  a  pine  oljstructive  anuria,  for  in  most  cases  the  kidneys  ai'e 
already  the  seat  of  changes  due  in  part  to  the  back  pressure  and  in  part  to  sepsis,  so  that 
when  anuria  terminates  a  case  of  vesical  carcinoma,  it  is  more  often  due  to  renal  disease 
than  to  ureteric  obstruction.  If  the  bladder  has  remained  uninfected  by  septic  organisms, 
the  gradually  increasing  ureteric  obstruction  may  first  cause  hydronephrosis,  so  that  when 
the  obstruction  becomes  com])lete  the  renal  distention  may  increase  quickly,  and  the  sym- 
ptoms of  ura?mia  be  delayed.  In  cases  arising  from  vesical  carcinoma,  it  is  very  rare  for  the 
anuria  to  occur  before  symptoms  of  vesical  growth  arc  a|)])arent,  such  as  hirniaturia.  pyuria, 
increased  frequency  and  ])ain  on  micturition;  but  in  the  infiltrating  tyj)e  of  carciiionia, 
hicmaturia  and  frequency  of  micturition  may  be  absent  for  a  long  time.  In  all  cases,  careful 
vaginal  or  rectal  examination  will  detect  infiltration  and  thickening  of  the  base  of  the  bladder, 
and  the  growth  can  be  seen  through  the  cystoscope  (Plate  A'l'/,  Fig.  F.  p.  "284). 

Uterine  Carcinoma. — .Anuria  is  fre(|uent  in  the  tenniiial  stage  of  uterine  carcinoma, 
when  tlic  growlli  lias  extended  into  the  cellular  tissues  of  the  l)road  ligament  and  involved 
the  terminal  portions  of  the  ureters,  or  when  the  orifices  of  the  latter  are  implicated  in  the 
direct  infiltration  of  the  growth  into  the  bladder  base.  In  the  majority  of  cases  dying  from 
uterine  cancer  in  the  inoperable  wards  of  the  I-ondon  Cancer  Hospital,  the  kidneys  are 
found  to  be  hydronephrotie.  the  renal  pelvis  dilated,  or  the  renal  .secreting  tissue  sclerosed. 
a])art  from  the  fre(|uent  infeetion  with  septic  micro-organisms.  In  all  cases  the  growth 
has  rcacheil  an  adxanccd  stage,  and  (he  disease  has  been  apparent,  but  it  has  been  recorded 
that  anuria  has  occurred  before  the  paliciil  lias  coinplaiiud  of  any  symptom  pointing  to  the 
uterine  condition.  'I'liese  eases  iniglil  simulate  olhei-  I'onus  i>[  ohslruclive  anuria.  l)ul  the 
diagnosis  woulil  be  apparent   iipoti  \agirial  examination. 

Pelvic  or  Abdominal  Tumours,  such  as  iilerinr  lihroinx  cimal 
ala.  may  cause  anuria  from  direct  pressure  on  I  he  imcIcis.  cs|iccI;iII' 
is  iiupacted  in  the  pcKic  ca\ity.  'I'lie  cause  ol  the  anuiia  will  be  a 
of  the  abdomen  and  of  the  peKic  organs. 

/<.— NON-OBSTRUCTIVE    ANURIA. 

MarUcd  iliiiiiiiiil  icm  in  Ihc  aiiKiuiil  nl  urine  or  ciini|ilclc  anuria  may  occur  williiiMt 
obstrucli\c  Icsiiiii  cil  llir  iirin.ny  a|i|i:MMl  lis.  due  in  many  inslanccs  lo  disease  of  llie  iciial 
secreting  tissues.  In  iniiiiy  (il  llicsc  ciiscs  the  symptoms  dilfer  reinarkalil\'  from  lliose 
seen  in  o))slrueti\c  iiiiiiiia.  in  llial  llic  anuria  is  aci  ompaiiied  by  symptoms  of  uriemia  in  a 
sliorl  time,  and  not  alter  an  inlcr\al  of  days  as  in  the  obslrueli\-e  eases.  Anuria  may  occur 
under  eerlain  loxic  conditions,  as  in  acute  fe\'ers.  or  in  acute  poisoning  by  mercury,  lead, 
phosphorus,  or  I  iirpciil  inc  ;  the  liislorv  and  accom|)anying  syniploms  of  such  cases  arc 
usiiiilly  siiHicienl   lo  |iiiinl   lo  llie  naliirc  of  the  urinary  siq)pression. 


o\  i 

iirian   carciiinm- 

pai 

•1  (it  IIh'  tumour 

■nt 

on  r\aiiiiniiliiin 

42  ANURIA 

Anuria  in  Renal  Disease. — In  acute  nepliritis.  anuria  may  occur  early  or  after  the 
disease  is  well  established,  and  is  usually  accompanied  by  marked  disturbance  of  the  nervous 
system.  The  sudden  onset  of  the  disease  after  exposure  to  cold,  or  in  the  course  of  an  acute 
specific  fever  such  as  scarlet  fever,  enteric,  or  pneimionia,  or  in  hicmatogenous  renal  infec- 
tions, associated  with  pallor,  backache,  pulliness  of  the  face  and  ankles,  and  slight  pjTcxia, 
together  with  the  small  anioimt  of  urine  jiassed  before  the  suppression  becomes  complete, 
are  points  all  suggesting  acute  nephritis.  If  the  urine  has  been  tested  before  the  onset  of 
anuria,  it  is  often  of  reddisli-brown  coloiu-  from  the  presence  of  blood,  and  contains  abundant 
albumin,  together  with  renal,  epithelial,  and  blood  casts.  In  chronic  nephritis,  anuria  may 
iKcur  as  a  late  symptom  in  the  disease,  and  is  occasionally  jjreceded  by  a  period  in  which 
polvuria  is  marked.  Anuria  in  chronic  nephritis  is  accompanied  by  prominent  symptoms 
of  unvmia.  such  as  headache,  giddiness,  convulsions,  stertor,  and  coma,  and  unless  the  flow 
of  urine  is  re-established  quickly,  death  ensues.  The  previous  history  of  the  case,  high 
arterial  tension,  cardiac  hypertrophy,  retinal  changes,  and  signs  of  baek-])ressure,  with  or 
without  ascites  and  anasarca,  will  point  to  the  nature  of  the  anuria.  In  other  diseases  of 
the  kidney,  such  as  lardaccous  cUsease,  suppurative  pyelonephritis,  or  bilateral  tuberculosis, 
anuria  may  be  preceded  by  general  failing  health,  with  loss  of  apiietite.  subnormal  tem- 
(lerature.  a  dry  brown  tongue,  headache,  increasing  pulse-rate,  hiccough,  and  attacks  of 
dyspna-a  :  frequently  there  may  be  polyuria  before  suppression  occurs.  In  these  cases  the 
anuria  is  terminal,  the  condition  of  the  kidneys  having  been  known  |)reviously.  With  the 
occurrence  of  anuria  there  may  be  great  restlessness,  with  muscular  twitching,  loss  of 
sphincteric  control,  convulsions,  and  a  gradual  la])se  into  coma. 

Poli/ci/slic  disease  of  the  kidneys  frequently  terminates  in  anuria  and  ursemia.  but  the 
diagnosis  of  the  disease  has  ])robably  been  arrived  at  ])reviously.  The  symptoms  resemble 
in  a  great  measure  those  of  chronic  nephritis,  with  the  exception  that  ascites  and  a?dema  of 
the  extremities  are  imcommon.  Headache,  flatulence,  and  digestive  troubles,  sickness,  anrl 
general  lassitude  are  symptoms  of  renal  inefHciency,  whilst  arteriosclerosis,  a  bilateral  renal 
tumour,  and  a  low-speeilic-gravity  urine  in  increased  quantity,  would  suggest  ])olycystic 
disease.     ILvmaturia  is  the  lirst  symi)tom  in  not  a  few  of  these  cases. 

Anuria  following  Operations  or  Trauma. — .Anuria  may  occur  in  patients  who  have 
underuone  an  (iperiiticm  and  who  are  the  subjects  of  renal  disease,  or  may  occur  occasionally 
even  when  no  renal  disease  is  jjrescnt.  .\ny  extensive  operation  which  involves  a  good 
deal  of  shock  in  a  patient  with  renal  disease,  or  in  whom  the  kidneys  have  been  subjected 
to  back-pressure,  as  in  uterine  myomata,  may  succumb  to  anuria  unless  apjiropriatc  measures 
are  imdcrtaken  :  even  an  apparently  trivial  operation  on  the  urinary  organs  may  cause  acute 
suppression  of  urine.  This  must  be  difl'erentiated  carefully  fniin  the  retention  of  urine  in 
the  bladder  often  seen  after  operations  such  as  for  ha-morrhoids  or  for  hernia.  Acute 
svippression  of  urine  may  follow  operations  upon  the  lower  urinary  tracts,  such  as  the  passage 
of  instruments,  or  the  performance  of  internal  urethrotomy.  Anuria  is  particularly  liable 
to  occur  when  a  catheter  is  passed  to  relieve  an  over-distended  bladder  in  a  ease  of  prostatic 
enlargement  or  urethral  stricture,  the  kidneys  being  already  distenrled  from  back-pressure 
or  infected  with  septic  processes,  and  it  must  be  laid  down  as  a  golden  rule,  that  if  a  catheter 
is  passed  in  these  cases,  the  urine  must  be  withdrawn  very  gradually.  .Anuria  following 
operations  upon  the  lower  urinary  tract  is  diagnosed  by  the  direct  relationshi])  between  the 
operation  and  the  onset  of  symptoms  :  by  the  rigors,  pyiexia,  and  the  profound  jirostration, 
rapidly  followed  by  convulsive  movements  and  coma. 

.Anuria  may  also  occur  in  the  severe  collapse  following  an  injinv,  in  the  late  stages  of 
cholera  or  i/cllinv  fever,  and  occasionallj-  as  a  manifestation  of  hysteria.  It  may  be  simulated 
by  a  iiuiliiigfrer.  li.  II.  Jocelyn  Swan. 

APHASIA. — (See  Spekch,  .Abnormalitihs  of,   p.  (i\Li.) 

APHONIA. — (See  Speech.  Abnormalities    or.   jj.  (i2S.) 

APPETITE,  ABNORMAL.— .Vppetite  may  be:  (1)  Increased:  (2)  Diminished; 
(3)   I'rrverlcd. 

Increase  of  Appetite  sometimes  occurs  in  cases  of  hyperchlorliydria.  The  general 
condition  is  then  well  maintained,  there  is  usually  pain  or  discomfort  in  the  later  period  of 


ASCITES  43 

digestion,  relieved  (temporarily)  by  the  takinsi;  of  more  food.     A  test  meal  shows  excess  of 
hydrochloric  acid. 

In  (lifihetes.  especially  in  its  earlier  stages,  there  is  often  an  abnormal  craving  for  food  : 
but  in  si)ite  of  large  meals  the  patient  wastes.  Kxamination  of  the  urine  will  establish 
the  diagnosis. 

Itilcslinal  parasilcs  (round-worms  and  tape-worms)  are  believed  to  be  a  cause  of  excessive 
ii])pctite  in  some  cases.  This  is  doubtful  :  but  in  any  ease  the  point  can  always  be  cleared 
up  l)y  giving  an  anthelmintic. 

In  some  cases  of  Injsieria  an  excessive  ap]jetitc  is  ])rescnt  (bulimia).  The  patient  is 
usually  a  young  woman,  and  other  stigmata  of  hysteria  are  present. 

Diminution  of  Appetite  occurs  in  many  forms  of  dyspepsia,  especially  when  associated 
with  a  lessened  gastric  secretion.  Thus  it  is  almost  constantly  present  in  gastritis.  exce])t, 
]3erha]}s.  in  the  acid  form.  If  renal  disease,  advanced  mitral  disease,  or  cirrhosis  of  the 
liver  be  present,  secondary  gastritis  may  be  diagnosed.  If  there  be  a  history  of  the  abuse 
of  alcohol  or  tobacco,  or  of  indiscretions  in  diet,  or  if  there  be  a  marked  defect  of  the  chewing- 
apparatus,  there  is  probably  primary  gastritis.  The  tongue  Avill  probably  be  furred,  and 
a  test  meal  shows  diminished  acidity  and  probably  an  excess  of  mucus,  but  the  examination 
of  the  stomach  is  otherwise  negative.     (See  also  Indigestion,  p.  317.) 

Loss  of  ajjpetite  is  also  an  early  symptom  in  eases  of  gastric  carcinoyna,  and  should 
lead.  cs])ecially  in  elderly  subjects,  to  careful  examination  for  other  signs  of  that  disease. 
There  is  fre(|uently  a  special  distaste  for  meat  in  such  cases.  (See  Indigestion,  p.  31(>.) 
In  children  a  jirofonnd  anorexia  is  sometimes  an  early  symptom  of  tiibercidosis. 

In  hysterical  young  women  complete  disinclination  for  food  {a)wre.ria  nervosa)  is  some- 
times met  with.  The  diagnosis  is  based  upon  the  absence  of  other  causes  of  the  symptom, 
the  presence  of  other  signs  of  hysteria,  and  the  history  of  mental  or  emotional  shock.  The 
loss  of  appetite  in  such  cases  may  amount  to  a  complete  refusal  of  all  food,  and  the  jiatient 
may  emaciate  to  a  dangerous  degree.  Obstinate  constiiiation  is  usually  present  as  well. 
.Mlicfl  to  these  cases  is  the  loss  of  appetite  which  occurs  in  mel;'.ncln)!ic  forms  of  insaiiiti/. 
In  such  a  case  delusions  may  be  present. 

Perverted  Appetite  may  occur  in  the  course  of  prcgiiaiicji.  and  is  of  no  special  signili- 
oanee.  It  is  met  with.  too.  in  nervous,  anaruic  children,  in  whom  it  often  takes  the  form  of 
<lirt-eating  (jiica).  Here.  also,  it  is  not  a  sign  of  any  diagnostic  value.  Perverted  appetite 
is  also  a  common  occurrence  in  insanity  :  but  other  evirlence  of  mental  disturbance  is  always 
present  as  well.  Nnhcrl  lliilihisdii. 

ASCITES,  or  the  aceunuilation  of  serous  fluid  in  the  Dcrittineal  cavity,  is  not  a  disease 
in  ilself.  for  it  may  be  produced  by  a  great  variety  of  conditions.  It  is  easy  to  determine 
its  precise  cause  in  some  cases  :  in  others  it  may  be  almost  impossible  to  say  during  life 
what  is  the  primary  condition.  One  may  discuss  (1)  lis  jihi/sical  signs:  (2)  IIikc  to 
ilislingnisli  it  from  ollnr  coiiilitiiins  ichicli  nun/  sininlatc  it  :  (3)  .1  rlassipril  list  of  its 
ciiKsfs  ;  (4)  The  eliief  points  uiiicli  will  Inlp  in  arriving  al  a  rorrrcl  differrntinl  diagnosis  in 
a  ji/irlicniar  ease. 

1.  PHYSICAL  SIGNS.  Inspection.— The  abdomen  is  distended  uniformly,  the  degree 
varying  with  the  ainouiil  of  lluid.  If  the  <|uantily  is  large,  and  its  accumulation  has 
been  rapid,  the  abdomen  is  more  or  less  globular,  the  urnliili<'al  ngion  being  the  most 
prominent,.  The  skin  is  tense  and  shiny,  and  there  may  be  lineu'  alhieantes.  If  the  (|uantity 
of  ihiid  is  large  but  its  accumulation  has  been  gradual,  bulging  of  the  Hanks  is  more  marked  ; 
the  Iciucr  rihs  may  be  pushed  outwards,  and  the  epigastric  angle  widened.  If  the  (piantity 
of  lluid  is  small,  only  a  slight  bulging  of  the  Hanks  may  be  noticed.  The  a|>pearanee  of  the 
ahdotuen  depends  a  good  dc.il  on  the  position  of  the  |)alient.  If  lying  on  one  side,  the  most 
dependent  part  is  the  most  prominent,  owing  to  the  lluid  gravitating  to  that  side  of  the 
abdomen.  If  the  jiatient  stands  or  sits  upright,  the  hypogastric  and  iliac  regions  will  be 
most  bulged.  The  umbilicus  becomes  stretched  transversely  and  Hush  with  the  surface, 
or  even  protruded  ;  it  retains  its  position  in  the  median  abdominal  line,  and  remains  nearer 
to  the  pubes  than  to  the  ensiform  cartilage.  In  tiH)ereulous  peritonitis  the  skin  in  its 
inunediate  neinlibourliood  may  be  reddened  and  (edematous,  or  there  may  be  a  fa'cal 
lislula  lure.  In  cirrhosis  of  the  li\-er  the  veins  around  the  mnliilieus  are  said  to  be  dilated, 
liul    llir  s(i. .■ailed   ■  eapiil   inc-dusa' "  is  rare.      The  siiperliciid   \(ins  :dl  over  I  lie  iilMlorncn  and 


44  ASCITES 

lower  part  of  the  cliest  may  be  dilated,  the  blood  flowing  in  an  upward  direetion,  this  reversal 
of  the  stream  occurring  mainly  when  the  inferior  vena  cava  is  oljstructed.  either  by  the 
tension  of  the  ascites  or  by  something  related  to  its  cause.  (See  Vkins.  Varicose  Abdom- 
inal, p.  748.)  The  abdominal  respiratory  movements  may  be  absent  or  much  diminished. 
The  cardiac  impulse  may  be  displaced  upwards  and  outwards.  The  legs,  thighs,  and 
scrotum  may  be  cedematous,  and  so  may  the  loins. 

Palpation. — The  abdomen  may  be  anything  between  quite  flaccid  and  very  tense. 
A  fluid  thrill  may  be  obtained  by  placing  the  hand  flat  against  one  iUink  and  gently  flicking 
the  other  with  the  fingers  of  the  other  hand  ;  the  possibility  of  a  thrill  being  transmitted  in 
the  abdominal  wall  should  be  eliminated  by  getting  the  patient  or  an  assistant  to  place  the 
side  of  his  hand  on  the  front  of  the  abdomen,  so  as  to  stop  the  mural  thrill  at  the  point 
of  contact  with  the  abdominal  wall.  If  the  above  precaution  is  taken,  anri  a  thrill  is 
obtainable,  it  denotes  the  presence  of  fluid. 

If  the  liver  or  s|)leen  has  enlarged  it  sinks  backwards,  so  that  between  these  organs 
and  tlic  abdoiiiiniil  wall  a  layer  of  fluid  is  present  ;  if  the  hand  placed  on  the  abdomen,  in 
the  right  or  kit  hypochondriac  region  as  the  case  may  be,  is  suddenly  dejircssed,  this  lluid 
is  displaced,  and  the  surface  of  the  enlarged  organ  can  then  be  felt.  This  phenomenon  of 
■  dipping  '  is  almost  pathognomonic  of  ascites. 

Percussion. — When  the  patient  lies  Hat  on  his  back  the  fluid  gravitates  to  the  posterior 
part  of  the  abdomen,  and  the  air-containing  viscera  float  to  the  anterior  part,  so  that  the 
percussion  note  is  resonant  in  front  and  dull  in  the  flanks.  As  the  fluid  increases  in  quantity, 
the  line  of  dullness  creeps  forward  from  the  flanks  and  upwards  from  the  pubes,  and  keeps 
a  concave  upper  border  ;  in  extreme  cases  the  abdomen  may  be  dull  all  over,  particularly  in 
children. 

One  of  the  most  prominent  jihysical  signs  of  ascites  is  the  efl'ect  jiroduced  on  the  per- 
cussion note  by  a  change  in  the  posture  of  the  patient.  If.  after  examining  him  lying  on 
the  back  and  finding  dullness  in  the  flanks  and  resonance  in  the  front,  he  be  turned  on  one 
side,  the  uppermost  flank  becomes  resonant  and  the  line  of  dullness  on  the  other  side  rises 
nearer  to  the  median  abdominal  line,  owing  to  the  fluid  gravitating  to  the  most  dependent 
part.  If  only  a  very  small  (|uantity  of  fluid  is  present,  the  abdomen  may  be  resonant  all 
over  when  the  patient  lies  on  his  back  ;  but  if  he  is  ))ercussed  in  the  knee-elbow  position, 
the  umbilical  region  may  be  found  to  be  dull. 

In  some  cases,  especially  of  tuberculous  peritonitis,  shortening  of  the  mesentery  is  apt 
to  be  associated  with  the  ascites  ;  the  intestines  cannot  then  rise,  and  the  result  is  didlness 
all  over  the  abdomen,  or  in  very  exceptional  cases  dullness  in  front  with  resonance  in  the 
flanks.  Chronic  peritonitis  may  cause  the  fluid  to  be  loculated,  through  matting  together 
of  the  intestines.  The  abdominal  distention  may  then  not  be  uniform,  and  change  of 
])0sture  may  not  alter  the  character  of  the  ])crcussion  note. 

Mensuration. — Tlie  abdonun  should  be  measured,  fixed  points  being  taken  in  front 
and  behind,  e.g.,  the  umbilicus  in  front  and  the  tip  of  the  third  lumbar  spine  behind.  This 
is  important  in  order  to  watch  the  effect  of  treatment.  The  distance  of  the  umbilicus  from 
the  ensiform  cartilage,  pubes,  and  anterior  superior  iliac  spines  should  also  be  noted,  yin 
ascites,  the  navel  is  nearly  always  nearer  the  pubes  than  the  ensiform  cartilage,  and  -equi- 
distant from  the  two  anterior  superior  iliac  spines  when  the  patient  lies  flat  on  his  back. 

It  is  always  important  to  examine  the  abdomen  carefully  after  paracentesis  ;  the 
cause  of  the  ascites  can  often  be  discovered  in  this  way,  in  the  shape  of  tumours,  or  enlarge- 
ments of  organs,  which  were  previously  obscured  by  the  tenseness  of  the  abdominal  wall. 

2.  DIAGNOSIS. — Ascites  has  to  be  distinguished  from  other  conditions  which  may 
give  rise  to  geiieral  abdominal  distention,  especially  from  : — Tympanites  :  Ovarian  and 
parovarian  ci/fils  :  Gravid  uterus  ivitk  hi/drops  amnii  ;  Distended  bladder  ;  Distention 
associated    7>.illi    obesiti/  :    Plianluni    tumour  ;    Large  abdominal  eysts  and  solid  tumours. 

Tympanites  is  distinguished  from  ascites  by  the  following  signs  : — The  outline  of 
distended  coils  of  intestine  may  be  visible,  and  peristaltic  movements  may  be  noticed. 
There  is  no  fluid  thrill  if  precautions  are  taken  to  prevent  a  thrill  being  transmitted  by  the 
abdominal  wall.     The  abdomen  is  resonant  all  over,  both  in  front  and  in  the  flanks. 

Ovarian  Cyst. — There  may  be  a  history  of  the  enlargement  of  the  abdomen  having 
been  noticed  at  an  early  date  to  be  more  on  one  side  than  the  other,  and  to  ha\e  arisen  from 
the  pelvis.     The  umbilicus  may  be  nearer  to  the  ensiform  cartilage  than  the  pubes,  and 


ASCITES  45 

nearer  to  one  anterior  superior  iliac  spine  than  tlie  otlier.  A  fluid  thrill  may  not  be  obtained 
far  back  in  the  flanks,  but  only  in  front  of  the  mid-axillary  lines.  There  is  usually  dullness 
in  front,  with  resonance  in  the  flanks.  The  outline  of  the  cyst  may  jiossibly  be  noticed 
during  the  respirator^'  movements.  On  measuring  the  abdomen  the  greatest  circumference 
is  usually  below  the  umbilicus  ;  whereas  in  ascites  it  is  generally  at  the  umbilicus.  A 
vaginal  examination  may  reveal  that  the  uterus  is  drawn  upwards  and  that  its  mobility  is 
impaired  :  whereas  in  ascites  it  is  low  down  and  movable.  If  ])aracentesis  has  been  per- 
formed, the  nature  of  the  ovarian  fluid  is  characteristic,  being  usually  thick,  tenacious, 
viscid,  and  of  a  brownish  or  greenish  colour  ;  whereas  ascitic  fluid  is  yellowish,  limpid,  and 
clear.  Much  dilficulty  arises  when  ovarian  cyst  and  ascites  are  both  present,  owing  to 
infection  of  the  jjeritoneum  by  secondary  deposits  from  the  ovary.  Even  without  this, 
however,  it  is  by  no  means  alw.ays  easy  to  distinguish  between  ovarian  cyst  and  ascites 
when  the  abdominal  disteutiiin  lias  become  extreme. 

Gravid  Uterus  with  H.ydrops  Amnii. — In  this  condition  it  may  be  possible  to 
make  out  the  outline  of  the  enlarged  uterus  ;  the  tumour  may  vary  in  consistency  as  the 
uterine  wall  contracts  and  relaxes  ;  on  vaginal  examination  the  cervix  is  soft  and  patulous 
and  the  uterus  enlarged.  There  will  be  other  signs  of  ])regnancy,  the  characteristic  condition 
of  the  breasts,  foetal  movements  and  heart  sounds,  and  the  history  of  amenorrhoea.  There 
will  be  dullness  in  the  front  of  the  abdomen,  resonance  in  the  flanks. 

Distended  Bladder. — This  may  reach  well  above  the  lunbilicus,  most  frequently  in 
women  as  tlic  residt  of  a  retroverted  gravid  uterus,  or  in  men  over  sixty  from  enlarge- 
ment of  the  prostate.  The  most  important  symptoms  are  :  incontinence  of  urine  from 
over-distention  and  overflow,  and  abdominal  distention.  There  is  generally  a  globular 
mass  to  be  palpated  in  the  middle  line  above  the  ]>ubes  and  reaching  up  to  the  umbilicus 
or  higher  :  it  is  dull  to  jiercussion  in  front,  with  resonance  in  the  flanks.  The  passage  of 
a  catheter  should  clear  up  all  doubt. 

General  Obesity  may  cause  much  abdominal  distention.  The  mesentery,  omentum, 
and  abdominal  wall  may  be  so  loaded  with  fat  that  it  is  difficult  to  make  a  satisfactory 
examination,  and  it  may  be  almost  impossililc  to  determine  with  certainty  the  presence  of 
even  a  moderate  amount  of  fluid. 

Phantom  Tumour,  The  abdomen  may  occasionally  be  so  distended  in  women,  espe- 
cially at  the  time  of  the  climacteric,  that  ascites,  ovarian  tumour,  or  j>regnancy  may  be 
sinnilated  when  there  is  merely  a  phantom  timiour.  If  an  ana-sthetic  is  administered  it 
often  disap|)eais,  the  rigid  abdominal  wall  becomes  flaccid,  and  it  can  be  determined 
whether  fluid  in  the  peritoneal  cavity  or  any  abdominal  tumour  is  present  or  not. 

Large  Abdominal  Cysts  may  occasionally  sinndate  ascites,  e.g.,  hy(lrone|ihrosis,  pan- 
creatic cvsl,  and  hydatid  <\sl  :  th(\-  do  not,  however,  cause  unihirm  distrutiou  ot  the 
abdomen  as  a  rule.  They  arc  most  likely  to  be  mislaken  for  simple  chronic  ))eritonitis  in 
which  local  collections  of  fluid  have  arisen  from  matting  together  of  the  intestines.  Hydro- 
nephrosis may  be  distinguished  by  its  position  and  by  the  fact  that  it  may  vary  in  si/.e,  a 
decrease  being  associated  with  an  increase  in  the  amount  f)f  urine  passed.  Pancreatic  cyst 
may  be  dilTerenliated  by  its  jxisition  in  the  U)(per  part  of  the  abdomen  and  by  its  more  or 
less  circular  oulline.  If  paracentesis  abdominis  has  been  peH'ormcd.  the  character  of  the 
llni<l  and  its  rerments  would  ])oint  to  the  nature  of  the  disease. 

'■>.  CAUSES. —  Having  made  uj)  one's  mind  that  the  general  alHldininal  disttiition  is 
due  to  lluiri  in  the  peritoneal  cavit>,  on<-  must  ni  \l  liiircrcnl  iate  Ihe  canse  ol  the  ascites. 
The  following  is  a  classilied  list  : — 

i.  Diseases  of   the   Peritoneum  : 

Xon-snppinali\c   aenle   perilimilis 

■.Simple"  chronic  peritonitis 

Tul)erenlons  peritonitis 

Malignant  ])erjtonilis,  generally  secondary  to  a  priniaiy  growth  elsewhere 

Hydatid  cysts  in  the   peiiloncal  ca\ity. 

ii.  Obstruction   to  the   main   Portal   Vein   by  :  — 
Non-snppnral  i\c  thrombosis 
Ivilargcd   portal   lymphatic  glands  : — 

Maliijnanl  I  'I'uIk  lenluns 

l.ymphadincinialons  |  l.yrriphal  ic    lenka-mic 


ASCITES 

Tumours  of  adjacent  organs,  such  as  : — 

Liver  I  Duodenum 

Pancreas  Colon 

Kidney  Suprarenal  capsule 

Stomach 
Rarities  such  as  aneurysm  of  the  hepatic  artery 

iii.  Diseases   of   the   Liver  : — 

Cirrhosis 

IVrihepatitis,  really  part  of  chronic  simple  j)eritonitis 

Carcinoma  j     Doubtful  causes  if  the  lesions  are  confined  to  the  liver  ;   i.e.. 

Sarcoma  I  it  there  is  ascites,  it  is  probably  not  due  to  the  carcinoma, 

Sypliilis  j  etc..  in  the  liver,  but  to  simultaneous  affection  either  of 

Hydatid  disease      )  tlie  peritoneum  or  of  the  portal  lymphatic  glands 

iv.  Obstruction   of   the   Inferior  Vena   Cava   above   the   Hepatic   Veins  by  : — 
Tliriinil)()sis  Mediastinal  growth 

Clu'onic  niediastinilis 

V.  Chronic  Failure  of  the  right  Heart  ('  backward  pressure  ')  the  result  of : — 
Valvular  disease  : —  Adherent   pericardiimi 


Mitral  stenosis  Clironic  lung  affections,  especially  : 

Mitral  regurgitation  Emphysema 

Aortic  stenosis  or  regurgitation  with  '  Recurrent  bron- 


Generally    as- 
sociated 


secondary  mitral  regurgitation  i^-  chitis 

Rheumatic  or  syphilitic  Fibroid  lung- 

Congenital  pulmonary  stenosis  (rarely)  Chronic  high  blood  pressure  : — 


Red  gramdar  contracted  kidneys 
Pale  granular  contracted  kidneys 
Arteriosclerosis 


Chronic  myocardial  affections  : — 
Fatty  degeneration  I  Fibroid  heart 
Fatty  infiltration       |  Primary  alcoho- 
Fatty  s\iperposition  |       lie  heart 
vi.  Bright's  Disease.     In  Bright's  disease  ascites  may  be  caused  in  at  least  four  different 
ways. — namely,  as  the  result  of  : — 

Part  of  a  general  dropsy  I       Secondary  to  hypertrophy  and  dilatation 

Acute  peritonitis  i  of    the    heart,    followed    by    failure    of 

Clnonic  ])eritonitis  <  compensation 

vii.  Severe  Anaeiqias,  in  wliich  the  ascites  is  usually  the  result  of  acute,  subacute,  or 
chronic  intercurrent  j)eritonitis,  as  in  : — 

Splenomedullary  leukaemia  I  Splenic  ana-mia 

Lymphatic  leukaemia  j  Pernicious  ana-mia 

Hodgkin"s  disease  Aplastic  ana-mia 

Pseudo-leukicmia  infantinii  [  Malaria 

f.  DIFFERENTIAL  DIAGNOSIS. — If  a.scites  is  the  only  fluid  accumulation  present  in 
the  [latient:  il'.  althougli  there  is  also  swelling  and  oedema  of  the  legs,  the  ascites  is  known 
to  have  apjjeared  first  :  or  if  the  ascites  is  out  of  proportion  to  dropsy  elsewhere  :  it  is 
most  probably  due  either  to  some  form  of  peritonitis,  to  portal  obstruction  from  thrombosis 
of  or  pressure  on  the  portal  vein,  or  to  cirrhosis  of  the  liver. 

If  it  is  associated  with  general  anasarca,  that  is  to  say,  with  cedema  of  the  legs,  body, 
and  face,  perhaps  even  of  the  scalp,  and  possibly  with  other  serous  effusions,  the  probable 
cause  is  acute,  or  acute  on  chronic,  Brighfs  disease. 

If  swelling  and  oedema  of  the  legs  were  noticed  first  and  the  ascites  followed,  heart 
failure  from  one  of  the  causes  in  Group  V,  or  obstruction  of  the  inferior  vena  cava  abo\e  the 
hepatic  veins,  would  be  the  most  likely  cause  ;  it  is  important  to  remember,  however,  that 
in  the  slighter  cases,  or  in  those  of  long  standing,  the  patient  is  often  uncertain  which  swelled 
first,  his  legs  or  his  abdomen,  and  his  statements  on  the  point  may  be  misleading. 

If  jaundice  is  associated  with  the  ascites,  it  points  to  some  form  of  portal  obstruction 
as  the  cause,  either  cirrhosis  of  the  liver,  or,  if  the  jaundice  is  intense,  to  some  actual  pressure 
on  the  portal  vein  and  common  bile  ducts,  generally  due  to  malignant  disease. 

If  enlargement  of  the  liver  is  associated  with  the  ascites  this  may  be  due  to  carcinoma, 


ASCITES  47 

sarcoma,  cirrhosis,  perihepatitis,  s\'pliilis  of  tlie  hver,  or  to  nutmeg  change  the  result  of 
backward  pressure  from  ctironic  heart  or  lung  disease. 

If  the  ascites  is  assf)ciated  with  multiple  abdominal  tumours  it   suggests  tulierculous 
or  malignant  ])crit(initis.  or  in  rarer  cases  hydatid  disease. 

i.  Diseases   of    the    Peritoneum. 

Acute  yon-suppurativePgjiiloiiilis  is  an  acute  inflammation  of  the  peritoneum  analogous 
to  acute  ■  simple  "  ])jeuris^^^ith  serous  eflusion.  One  seldom  speaks  of  ascites,  however, 
in  connection  with  ac^te  nifective  peritonitis  such  as  w^^ti  ||j^l  D6  pus  formation  if  laparo- 
tomy were  not  resorted  to  :  and  it  is  dillicult  to  draw  a  decW^l^fte  between  acute  peritonitis 
in  which  the  fluid  should  be  called  ascites,  and  other  conditions  of  acute  generalized 
peritonitis  to  which  the  term  would  not  be  applied.  There  are,  however,  cases  in  which 
acute  serous  effusion  due  to  non-suppurative  peritonitis  occurs  in  acute  and  chronic  Bright"s 
disease:  or  acute  tuberculous  peritonitis  almost  simulating  general  suppurative  peritonitis;  c 
whilst  pneumococcal  and  gonococcal  peritonitis  may  be  acute  in  onset,  and  yet  take  the 
form  of  an  ascitic  effusion,  recovery  occurring  without  the  necessity  for  laparotomy.  It  is 
probably  a  question  of  the  dose  of  the  micro-organism  that  affects  the  ])eritoneum,  and  it  is 
by  no  means  impossible  that,  whereas  the  perforation  of  a  gastric  ulcer,  duodenal  ulcer, 
dysenteric,  typhoid,  or  tuberculous  ulcer  of  the  intestines,  or  leakage  from  a  pyosalpinx,  an 
ai)pendicular  abscess,  stercoral  ulcer  of  the  colon,  or  a  perirectal  or  prostatic  abscess, 
generally  gives  rise  to  acute  general  [jeritonitis  which  would  prove  suppurative  if  it  were 
not  operated  on,  the  same  conditions  may  in  some  eases  lead  to  a  slighter  affection  with 
a  severe  but  non-suppurative  ascitic  effusion  ending  in  s|3ontaneous  recovery.  AVhether 
laparotomy  is  indicated  or  not  in  any  given  instance  must  depend  upon  the  individual 
circumstances  of  tlie  case  ;  but  it  is  much  safer  for  the  jiatient  to  be  operated  upon  for 
acute  non-suppui>tive  peritonitis  of  the  type  of  wliich  we  are  now  speaking  than  for 
general  suppurative  j)eritonitis  to  escape  operation. 

Sini])le  Climm'c  Perildiiilis  is  a  chronic  inflanunation  tliat  is  not  tuberculous  or  malig- 
n;uit.  It  may  follow  siniple  acute  peritonitis,  but  its  two  commonest  causes  arc  :  a  former 
tuberculous  ])critonitis  from  whieli  the  tubercles  have  disajjpeared  ;  and  the  chronic  inllam- 
mation  which  results  from  repeated  paracentesis  abdominis  for  any  other  variety  of  ascites. 
The  latter  is  important  ;  it  sometimes  happens,  in  a  heart  case  for  instance,  that  both  trdema 
of  the  legs  and  ascites  have  been  prominent  symptoms,  paracentesis  abdominis  being  indi- 
cated on  account  of  the  cardiac  distress  ;  the  tapping  of  the  abdomen  may  have  had  to  be 
repeated  scviTal  times,  and  yet  ultimately  the  cardiac  compensation  has  been  restored. 
the  patient's  general  conrlition  Incoming  (juitc  good  and  the  (cdema  of  the  legs  disappearing  : 
yet  in  spite  of  this  general  improvement,  ascites  may  still  persist  and  re(|uire  further  tapping 
at  intervals.  In  such  a  case,  whereas  at  first  the  ascites  was  due  to  backward  pressiu'e 
from  the  failing  heart,  it  ultimately  becomes  due  to  chronic  ])eritonitis.  the  result  of  the 
repeated  tappings.  It  is  Tisually  associated  with  perihepatitis,  which  indeed  is  only  one 
of  the  local  manifestations  of  <'hr(inie  peritonitis.  l^Aen  when  all  inllamination  has  {•cased, 
the  great  thickening  of  the  peritoneum  over  the  diaphragm,  liver,  and  spleen  may  liave 
blocked  up  those  pores  through  which  the  peritoneal  secretions  naturally  drain  away,  .so 
that  the  Ihiid  keeps  on  re-accumulaf  iiig,  and  necessitates  re|)eatcd  tapping,  which  in  some 
cases  has  been  performed  over  three  hundred  times.  The  peritoneum  becomes  thickened 
generally,  aiul  the  intestines  bfamd  down  and  matted  together.  There  may  be  local  or 
general  ahtlominal  distention,  depending  on  whether  loculi  are  formed  or  not  liv  the  adhe- 
sions. On  iK'count  of  the  short ciiiTig  of  the  niesentcry  and  malting  together  of  the  inlesliiies 
there  may  he  dullness  all  over  the  ahdoruen.  so  that  this  form  of  ascites  is  particularly  liable 
to  be  mistaken  for  ovarian  cyst  or  luinour.  .Mbuniinuria  is  fre(|Ucnt  on  account  of  interfer- 
ence with  the  renal  circulation,  and  IIkic  may  even  be  a  few  tube  casts  :  there  may  or  may 
not  be  actual  renal  disease,  but  this  should  not  be  diagnosed  from  the  albuminuria  unless 
there  is  also  high  hlood-prc'ssurc,  retinitis,  or  other  eonllrmalory  sign.  Ahdoniiiial  pain  is 
generally  slight,  and  although  there  may  be  \-omiting  or  coiislipation.  there  is  usually  neither. 
Tiibcrciiloii.s  Pcrilonilis.— This  is  the  most  eonunon  cause  of  ascites  In  eliildrcn.  There 
are  several  varieties,  of  which  the  following  may  be  distinguished  : — 

1.  The  acute  a.scltie  form,  whieli  may  siimilate  acute  general  peritonitis  due  to  perfora- 
tion of  a  viscus  (see  above). 

2.  The  peritoneum  may  be  studded  all  over  with  miliary  tubercles  without  any  caseous- 


48  ASCITES 

masses.  The  ]ihysical  signs  are  those  of  ascites  without  any  abcloniinal  tumour,  and  it  is 
not  diflicult  to  mistake  it  wlien  it  occurs  in  an  adult  for  cirrliosis  of  the  li\er  or  for  malignant 
peritonitis,  especially  that  form  wliich  is  secondary  to  ovarian  tumour.  In  a  child,  the 
occurrence  of  ascites  witliout  u'dema  of  the  legs  at  once  suggests  tuberculous  peritonitis  ; 
in  an  older  person  tuberculous  peritonitis  is  much  less  common. 

3.  The  omentum  may  be  contracted  and  thickened  from  infiltration  with  caseous  or 
fibro-caseoiis  material,  and  a  hard  abdominal  tumour  simulating  an  enlarged  liver  may  be 
felt.  It  may  be  distinguished,  liowever.  by  the  resonant  percussion  note  between  it  and  the 
costal  margin,  and  the  liver  edge  may  be  palpable  above  and  distinct  from  the  omental 
mass  which  simulates  it.  Ascites  in  cases  of  this  kind  is  generally  less  in  amount  than 
in  the  miliary  tuberculous  form. 

■i.  The  intestines  may  be  matted  together  and  the  adhesions  thickened  and  infiltrated 
with  tuberculous  deposits,  so  that  the  peritoneal  cavity  may  be  divided  into  several  loculi 
of  fluid,  tfie  abdominal  distention  being  not  uniform,  and  paracentesis  only  removing  part 
of  the  ascites. 

5.  The  mesentery  may  be  thickened  and  contracted,  and  tlie  intestines  bound  down 
to  the  posterior  parts  of  the  abdominal  cavity,  so  that  if  there  is  ascites  there  will  either  be 
dullness  all  over  the  abdomen,  or  dullness  in  front  with  resonance  in  the  flanks,  suggesting 
ovarian  cyst  rather  than  tubercidous  peritonitis.  After  paracentesis,  a  more  or  less  defined 
irregular  deeply  situated  tumour  may  often  be  felt. 

6.  \Vhen  the  caseation  affects  the  mesenteric  glands  in  particular,  multiple  irregular 
tumours  are  felt,  sometimes  but  not  always  associated  with  ascites. 

7.  Occasionally  local  thickenings  in  the  abdominal  wall  are  to  be  felt  as  the  result  of 
subperitoneal  inflammatory  deposits,  a  condition  which  may  often  be  mistaken  for  rigid 
contraction  of  the  recti  muscles  or  for  disease  of  the  parietcs  rather  than  of  the  peritoneum  ; 
if.  however,  there  is  ascites  at  the  same  time,  tuberculous  peritonitis  would  be  very 
proljable,  particularly  in  a  child. 

It  will  naturally  depend  upon  the  acuteness  of  the  tuberculous  process  whether  there 
will  be  pyrexia  or  not,  and  whether  there  will  be  abdominal  pain  and  tenderness.  In  the 
caseous  varieties,  whether  of  the  glands,  omentum,  mesentery,  or  abdominal  wall,  pain  and 
tenderness  are  the  rule,  and  the  temperature  generally  rises  to  101°  F.  to  104°  V.  each 
evening.  It  is  not  at  all  unconunon  in  such  cases  for  redness  and  oedema  to  develop  roimd 
the  umbilicus,  and  for  a  purulent  discharge  to  occur  from  the  latter,  or  for  a  fiecal  fistula  to 
develop.  The  commonest  cause  for  spontaneous  fsecal  fistula  of  the  umbilicus  is  tuberculous 
]jeritonitis.  When  the  active  tuberculous  process  has  become  quiescent  there  may  still 
be  ascites,  though  the  temiierature  is  subnormal.  AVhen  paracentesis  is  performed,  it  is 
advisable  to  inject  some  of  the  fluid  into  a  guinea-pig,  to  see  if  the  latter  develops  general 
tuberculosis.  The  nature  of  the  case  may  sometimes  be  suggested  by  the  presence  of  tuber- 
culous lesions  elsewhere  in  the  patient's  body  ;  for  instance,  in  the  spine,  kidney,  a  joint 
such  as  the  hip  or  knee,  glands  in  the  neck,  or  lupus,  though  very  often  tuberculous  peritonitis 
is  the  only  objective  lesion. 

Ascilic  Fluids. — It  lias  liocn  stated  tliat  chemical  analyses  of  ascitic  lluid  often  afford  material 
assistance  in  arri\  ini;  at  a  diaL;iii'--is  oT  its  eau>e  :  lait  in  |ji'actice  only  the  broadest  conclusions  can 
be  drawn.  The  liiulni  I  lie  sihiiIh-  ijiasily,  llir  laii^er  the  jicrcentage  of  albumin,  and  the  greater 
the  tendency  to  spuMlaiu  mis  c  cpai;iilali"ii.  tin-  nimi-  dilinitely  can  one  conclude  that  the  condition 
is  an  inflammatory  exudate  — e.g.,  specilic  gravity  l,0'j."i.  luiiity  ])aits  per  thousand  of  albumin, 
with  a  spontaneous  coagulation.  The  lower  the  spn  illc  i;iavity,  the  smaller  the  percentage  of 
albumin  and  the  more  definite  the  absence  of  spontaiu oiis  ((laiiulatioii  tlic  more  likely  is  the  condi- 
tion to  be  a  non-innamniatory  transudate — e.g.,  speeilic  gravity  1,005,  five  parts  per  thousand  of 
albumin,  and  no  coagulaf inn.  There  are,  however,  many  intermediate  cases  in  which  chemical 
investigation  of  tlie  lliiid  leaves  one  in  doubt  as  to  wliether  the  condition  is  inflammatory  or  not. 

It  lias  also  been  stated  that  diflenntial  analyses  of  the  proteids  are  lieljjful,  notably  as  to 
wliether  there  is  more  globulin  or  more  alliiiiuiii  lucsent  :    but  it  is  doubtful  whetlier  this  really  is  so. 

iMiei'oscopical  examinations  are  ninre  \ahialjle  than  chemical  ;  the  centrifugalized  deposit 
sliould  be  examined  under  the  lii;;li  pci«(r  ;  it  may  exliibit  many  leucoc\^es  in  intlaminatory  con- 
ditions, polymorphonuclear  cells  inrdoiniiiating  in  acute  conditions,  small  lymphocytes  in  siiljaiiite 
or  chronic  affections  such  as  tulierciildus  ]ieritonitis  ;  peritoneal  cells  in  cases  of  inllanuiiation  ; 
and  ncra'.idnally  the  diagnosis  is  elinelicd  by  finding  actual  fragments  of  new  growtli  or  hydatid 
liouUli  Is  ( /■(!'.  IS).  'I'lic  (li  |M)sits  may  also  be  stained  for  bacteria,  and  sometimes  tubeicle  bacilli, 
strc]itci(iH  I  1,  sl:i|.h\  l.jcdcci,  ^diincncci,  or  pneumoeocci  may  he  found.  When  investigating  ascitic 
fluid  liacUiiulciijiealiy,  lui\ve\er,  it  is  jjrobalily  better  to  resort  to  cultural  or  inoculation  methods 
than  to  rely  solely  ujion  liliiis  prepared  from  the  deposit. 


ASCITES 


49 


Cancerous  Peritonitis  usually  occurs  in  patients  over  forty,  and  the  growth  is  practically 
always  secontiary.  Primary  carcinoma  of  the  peritoneum  is  very  rare,  and  it  is  usually 
colloid  aufl  not  associated  with  ascites.  In  secondary  cases  the  omentum  may  be  thickened 
and  infiltrated,  the  umbilicus  fixed,  the  urachus  palpably  infiltrated,  and  nodules  and  masses 
may  develo))  all  over  the  peritoneiun.  Rapid  emaciation  and  cachexia  are  the  rule.  .\ 
large  quantity  of  fluid  may  be  present,  and  if  it  is  blood-stained  at  the  first  tapijing  tjiis 
is  very  suggestive  of  malignant  disease. 
.Ascites  may  be  the  first  and  only  evidence 
of  growth,  and  it  may  be  mistaken  for  that 
of  tuberculous  peritonitis  or  cirrhosis  of  the 
liver,  especially  when  the  abdominal  disten- 
tion is  so  marked  that  no  nodules  can  be 
felt.  Evidence  of  a  primary  growi^h  should 
always  be  looked  for  with  care,  especially 
in  connection  with  the  stomach,  pancreas, 
colon,  rectum,  or  ovaries.  Rectal  examina- 
tion should  never  be  omitted,  and  if  need 
be  the  sigmoidoscope  may  be  used.  It 
should  not  be  forgotten  that  usefid  indica- 
tion of  intra-abdominal  malignant  disease 
is  sometimes  afforded  by  enlargement  of 
the  left  supra-cla\icular  lymphatic  glands 
by  secondary  deposits  {Fig.  17). 

There  is  one  variety  of  secondary 
malignant  peritonitis  which  merits  special 
mention — namely,  that  which  may  result 
from  a  proliferating  papillomatous  ovarian 
cyst.  The  malignancy  of  the  latter  is 
sometimes  relative,  so  that  although  there 
may  be  thousands  of  ])a))illoma  deposits  on 
the  peritoneum,  causing  ascites  that  may 
need  tapping  scores  of  times  at  short  in- 
tervals, there  may  be  no  other  secondary 
deijosits  aiiyv>lurc.  The  diagnosis  may  be 
made  as  I  lie  nsult  ol  careful  vaginal  examination, 
nanl  ])apillomata  in  the  ascitic  fluid,  or  ])erliaps  I 
■  simple  '  peritonitis  until  the  abdomen  is  opened. 

Ili/iliitiil  ( 'lists  in  the  peritoneal  cavity  may  Ix-  primarx,  hut  more  often  they  are 
seeondarx  lo  lix.iatid  disease  of  the  liver.  The  malady  is  rare  in  this  country,  though 
comiuoTK  T  ill  Australasia  and  elsewhere.  The  patient  is  generally  an  adult  and  th<'  diagnosis 
is  often  obvious,  though  sometimes  it  may  be  very  obscure.  There 
may  be  a  large  globular  tumour  in  the  lixer.  rarely  giving  the 
typical  hydatid  thrill  :  lliere  ma\  he  I^osinoimtu.i.v  (p.  219).  and 
an  investigation  ol  I  he  lilooil  scniiii  in  special  laboratories  may 
show  the  specilie  hydatid  scniiii  reaclioii.  In  some  eases  in  whieii 
there  are  hydatid  cysts  associated  with  ascites  it  is  possible  to 
make  the  diagnosis  by  rectal  examination  ;  one  has  felt  globular 
bodies  about  tlie  size  of  grapes  in  front  of  the  anterior  rectal  wall, 
and  when  these  have  been  pressed  upon  to  investigate  them  more 
fully,  they  have  slipped  away  frotn  imder  one's  linger  through 
being  pushed  up  into  the  ascitic  fluid  ;  after  waiting  a  moment  the 
back  into  Douglas's  pouch.     .Similar  mobility  of  spherical  masses 


Fiff.  17.— Knlarsremeiit  of  the  left  supraclavicular  glands 
ill  a  ca.se  of  abdominal  malignant  disease  (carcinoma  of  the 
si!,'inoid  colon). 


ir  bv  findin 


fragments  of  the  iiialig- 
l)e   regarded   as   ehrciiiic 


I'iij.  IS.— Eel 


1 


(P^ 


linger   has  icil   thin 
in   the  asej|l<'   fluid   iii:iy  ix 
diagnosis  depends  U|ioii   I  he 
centesis  or  by   la|)aidlomy. 
of  liooklcis  dors  nol    rxellldc 
ease   nol    |ndduciiii;    hooklrls 
Cliilloiis  .i.scilis  is  nol    ill 


noted 


where      lor  iristan<-e.   in  an  iliac  fossa.      The  ultimate 

ileleelion  of   hooklels  (/•'/i,'.   IS)  in  I  he   lliiid   obtained   l)y   paia- 

II    is  iiii|iorhiiil    to   hear  In   iiiiiid.   h 

hxdalid  (lisr;isc,  llie  cysts  sometimes 


ilscir 


specilie  iiialaily.  tor  lln 


we\-er. 

that 

the  absence 

icing  si 

erile 

.  and  in  llial 

ire  Ihaii 

one 

eonililion  in 
1- 

50 


ASCITES 


which  the  ascitic  fluid  may  ajjjjear  hke  milk.  Tliis  may  result  from  obstruction  to  the 
main  abdominal  lymphatics,  particularly  the  receptaculum  chyli  and  thoracic  duct  ;  or 
from  their  rupture  after  injury  to  tlie  abdomen  ;  more  often  the  condition  is  associated  in 
this  coimtry,  in  some  way  which  is  not  fully  understood,  with  the  ]5eritonitis  of  chronic 
T}ri«lil'.s-  Discaxc,  or  of  leiihceniia.  The  best  known  tropical  cause  for  chylous  ascites  is 
Filfirid  saiigiiiiiis  hotninis  with  cle])hantiasis.  In  rare  cases  the  secondary  deposits  of 
nuilioiiant  disease  may  be  such  as  to  obstruct  the  thoracic  duct,  and  so  produce'  the 
chylous  condition  of  the  ascitic  fluid.     Chyluria  may  or  may  not  occur  at  the  same  time. 

There  are  two  types  of  chylous  ascites,  one  in  which  actual  chyle  accumulates  in 
the  peritoneal  cavity  as  the  result  of  direct  leakage  from  the  thoracic  duct  or  receptaculum — 
true  chylous  ascites  ;  the  other  in  which  the  condition  is  in  the  main  one  of  ascites,  but  the 
fluid  becomes  milky-looking  from  little-understood  chemical  changes  taking  place  in  it, 
particularly  in  the  proteids.  This  is  termed  chyliform  ascites,  or  pseudochylous  ascites. 
There  is  much  more  real  fat  in  the  former  condition  than  in  the  latter  :  but  chyliform  ascites 
is  commoner  than  true  chylous  ascites.  The  diagnosis  between  the  two  is  afforded  by 
chemical  and  microscopical  analyses  of  the  fluid  obtained  by  tapping,  the  chief  points  of 
distinction  being  as  follows  : — 


Chylous  Ascites. 

1 .  The  fluid  tends  to  accumulate  very 
rapidly,  and  in  consei|Ucnec  larjic  vohuucs  arc 
rcinoved  at  ])araccntesis. 

2.  (icneraily  ycUowish-wliite  in  colour  and 
less  perfectly  emulsified. 

3.  IJegree  of  o])alescenoe  nifnc  or  less  con- 
stant at  successive  tappings. 

4.  Possesses  an  odour  corresponding  to  the 
odour  of  the  food  ingested. 

a.  Microscopically  the  fluid  contains  fine  tat 
"lobules,  but  vcrv  few  celhdar  elements. 


6.  General 
n  standin". 


distinct    creaniv    layer 


7.   S])erilic  i;ravity  i;inirally  exceeds  1012. 
S.   Drpivssiim  i.t  irc-i/.in;;  piiint  about  0-51°  C. 
and  approximating  that   l<pr  eliyle. 

9.  Total  solids  vary  considerably,  hut  usually 
exceed  4  per  cent. 

10.  The  total  protein  content  f;onerally  ex- 
ceeds 3  grams  ])er  cent,  and  of  this  the  strum- 
albumin  is  the  largest  fraction,  gloliulin  occurring 
only   in   traces. 

11.  JIueinoid  sidjstanees  absent. 

12.  The  fat  content  is  generally  hiyh,  vaiyiny 
liom  0-4  to  4  per  cent.  The  fat  corresponds 
in  all  its  ])roperties  to  the  fat  contained  in  food. 

I.'!.  Of  the  lipius  cliolestcrol  is  invariably 
f(iiui(l.  and  lecithin  only  ociurs  in  traces. 

14.  Xo  cvideiue  of  the  presence  of  a  lipin- 
ulohulin   eondiinatiim. 


15.  The  salts  and  the  organic  substances 
present  api>roximate  to  the  values  found  for 
ehvle  obtained  from  the  thoracic  duct. 


Cliijtiform  Ascites. 

1.  Collects  more  slowly,  the  volume  of  the 
fluid  varying  with  the  exciting  pathological 
condition. 

2.  In  colour  a  pine  milky-white  solution  in 
the  form  of  an  almost  perfect  enudsion. 

3.  The  opalescence  generally  increases  or 
diminishes  at  successive  tappings. 

4.  Odourless. 

5.  Microscopically  the  qiumtity  of  free  fat 
is  variable  ;  often  numerous  Hue,  highly  refrac- 
tile  granules  are  present,  and  these  do  not  give 
the  reactions  for  fat.  Cellular  elements  may 
be  numerous  and  often  contain  fat  ;  sometimes 
very  scanty. 

().  \  cream  may  or  may  not  form,  but  does 
not  affect  the  o])aIeseenee  ;  a  sediment  fre- 
quently settles  out. 

v.  Specific  gravity  less  than  1012. 

8.  Dei)ression  of  freezing  point  ranges  from 
0'36°  to  0'61°,  and  thus  corresponds  to  the 
tifiures   for  blood  scrum. 

)l.  Tcital  solids  rarely  exceed  2  per  cent. 

10.  The  ])rotein  constituents  vary  between 
1  and  3  grams  per  cent,  and  of  these  the 
serum-globulin  occurs  in  ap|)reeiable  quantities. 

11.  .Mueiiioid   substances   present. 

12.  The  fat  content  is  generally  low,  and  it 
may  be  present  in  traces  only  :  in  its  melting  and 
chemical  composition  it  jjrovcs  to  be  patho- 
logical  fat. 

13.  The  most  characteristic  lipin  is  lecithin, 
though  cholesterol  is  occasionally  present. 

14.  The  lecithin  is  mainly  combined  with  the 
iilobiilin,  and  when  present  is  the  cause  of  the 
opalescence  of  the  fluid.  Such  fluids  resist 
putrefaction. 

!.■).  The  salts  and  organic  materials  correspond 
closely  to  those  of  lymph  and  serous  fluids. 


ii.  Obstruction  to  the  Main  Portal  Vein. — This  is  most  commonly  due  to  enlargcmctii 
I J  llic  jKirtiil  lyniphiilic  Shiiiils  by  secondary  deposits  of  malignant  disease  ;  it  is  common  for 
the  main  bile-ducts  to  be  ob.structed  at  the  same  time,  so  that  an  increasing  depth  of  jaundice 
accompanies  the  ascites.  When  there  are  masses  of  secondarv'  growth  in  the  liver  associated 
with  jaiuidicc,  or  ascites,  or  both,  it  is  seldom  that  the  hepatic  masses  are  themselves  respon- 


ASCITES  51 

sible  for  tlie  syniptonis,  these  being  more  often  due  to  tlie  associated  deposits  in  the  i)ort:il 
lymphatic  glands.  The  diagnosis  is  made  on  discovering  a  primary  growth,  more  often  a 
carcinoma  tlian  a  sarcoma.  It  is  much  rarer  for  tlie  lympliatic  glandular  enlargement  to  be 
lymphadenomatous.  tuberculous,  or  due  to  lymphatic  leukaemia.  If  ascites  were  a  promi- 
nent symptom  in  any  of  these  conditions,  it  would  be  regarded  as  consequent  on  affection 
of  the  peritoneum  rather  than  on  obstruction  to  the  portal  vein,  unless  there  were  deepen- 
ing jaundice  at  the  same  time.  In  the  latter  ease  malignant  disease  would  be  simulated. 
General  enlargement  of  the  lymphatic  glands  in  tlie  axilla",  groins,  and  neck,  with  or  without 
evidence  of  enlargement  of  those  in  the  thorax  or  abdomen,  together  with  enlargement  of 
the  spleen,  would  suggest  either  lymphadenoma  or  lymj)hatic  leuk;emia  ;  the  absence  of 
positive  blood  changes  would  render  the  former  more  likely,  for  in  lymphatic  leukEemia  there 
is  more  or  less  considerable  leucocj-tosis  with  a  great  relative  increase  in  the  small  lympho- 
cytes up  to  90  per  cent  or  more  (p.  25).  Only  in  very  rare  cases  do  tuberculous  portal 
glands  cause  ascites,  and  when  they  do  the  diagnosis  must  be  one  of  guess-work  only,  unless 
in  association  with  definite  tuberculous  jieritonitis  there  were  jaundice  suggesting  obstruction 
to  the  common  bile-duct  and  to  the  portal  vein  at  the  same  time. 

Thrombosis  of  the  porlti!  rein  may  be  su])purative.  in  which  case  there  is  no  ascites,  but 
a  pjTexial  condition  with  rigors  and  possibly  jaundice,  diagnosed  as  a  rule  only  when  there 
has  been  sonic  delinite  inflammatory  focus  in  the  portal  area,  such  as  appendicitis,  which 
miglit  lead  to  infection  of  the  portal  vein.  Primary  thrombosis  of  the  portal  vein  is  rare, 
and  its  diagnosis  can  seldom  be  more  than  guessed  at.  It  leads  to  marked  ascites,  possibly 
with  simultaneous  increase  in  any  tendency  there  may  be  to  piles,  and  without  evidence  of 
tuberculous  or  malignant  disease  of  the  ijcritoncuni  or  cirrhosis  of  the  liver.  It  is  by  a 
process  of  exclusion  that  the  diagnosis  of  portal  vein  thrombosis  might  be  arrived  at. 
especially  if  the  ascitic  fluid  withdrawn  by  paracentesis,  when  examined  chemically,  were 
found  to  contain  a  relatively  very  high  proportion  of  coagulable  jsroteids  without  any  par- 
ticular tendency  to  spontaneous  coagirlation.  and  without  those  polymorphonuclear  cells 
or  lymphocytes  that  would  be  found  if  the  high  i)ercentage  of  proteid  were  due  to  the 
ascites  being  iiiHaiumatory. 

'riinioiiis  (if  iitljdci'rit  orgaii.s  seldom  obstruct  the  portal  vein  enough  to  cause  ascites 
willioul  presenting  other  symptoms  which  suggest  the  diagnosis.  Sometimes,  however, 
unless  the  tumour  can  be  felt,  great  dilliculty  may  be  experienced  in  determining  the  nature 
ol  the  ease,  t  arcinoma  of  the  pancreas  may  be  accompanied  by  glycosiu'ia  and  the  passage 
of  fatly  stools,  io/etlier  with  deepening  jauTidice,  progressive  enlargement  of  the  gall-l)ladder, 
and  a  positive  ('a\i.\iii)(;!-.'s  I' \n(  lii-.ATic  Hi'.ac  IION  (p,  100).  On  account  of  the  relation  of 
the  tumour  to  the  aorta,  marked  transmitted  pulsation  may  be  felt  in  it,  and  by  inflating 
the  stomach  it  may  be  demonstrated  tliat  the  tumour  lies  posterior  to  the  latter.  Kenal 
tumours  may  be  dilliciilt  to  distinguish  from  enlargement  of  the  liver  when  they  are  big  ; 
but  they  are  generally  a.ssoeiated  with  Albtminuiua  (p.  1).  II.KMArrniA  (p.  "275),  or 
l'^  I  ui.v  (p.  57 1).  Carcinoma  of  the  stomach,  duodemun.  colon,  or  suprarenal  capsule 
would  be  suggested  by  tlie  ])osition  of  the  mass,  or  by  the  gastric  or  inteslinal  symptoms  ; 
if  there  were  ascites  aeeomjjanving  them,  it  would  generally  be  due  not  to  the  primary 
tumour,  b\it  to  secondary  deposits  cither  in  the  peritoneum  or  in  the  portal  lymphatic  glands, 
.Inriirysm  of  the  liepiilic  iirliri/  is  a  pathological  curiosity,  though  in  recorded  cases  it 
has  produced  ascites  and  jaundice.  The  conunonest  cause  of  aneurysm  of  the  hepatic  artery 
is  fungatiiiir  endocarditis  with  embolism. 

iii.  Diseases  of  the  Liver,  Cirrhosin  of  llif  l.ivrr.  Wlicn  asciirs  is  ihic  lo  ihis  the 
<lia.:nosis  is  sometimes  easy  oTi  accoiinl  of  the  liisl(]ry  of  chniiiie  aiciiholism,  and  possibly 
of  ioriner  luematemcsis,  mclaria  (ir  jaijiKlicc.  Tlicie  ma\  also  he  acne  rosacea  and 
lelangicetases  on  the  cheeks,  or  ex  en  a  hot  lle-iiose.  a  furred  and  tremulous  tongue,  a 
history  of  morning  sickness,  cramps  in  I  he  legs  at  nighl,  nausea,  loss  of  appetite'  especially 
lor  breakfast,  epistaxis,  perhaps  the  presence  of  distended  veins  roimd  the  umbilicus, 
liicmorrlioids,  enlargement  of  the  M\(r.  the  surface  of  which  is  hard  and  rough  and  the  edge 
irniiular  anil  perhaps  beaded,  enlargemenl  of  the  spleen,  icteric  tinge  of  the  eonjuiicl  i\  a\ 
and  a  peculiarly  sallow,  slightly  pigmented  laeies,  which  is  almost  eliaraelerislie  in  the  later 
.stages  of  the  malady.  (  irrhosis  is  a  slowly  progressive  disease  sometimes  extending  over 
twenty  years  or  mure,  producing  a  large,  smooth,  unilobular  cirrhotic  liver  with  jaundi<'c 
and  a  l(  ihUiicv    to   liMinalcmesis  in   its  earlier  sialics  ;    but    later  a   small   li\<r  In   which,   in 


52  ASCITES 

addition  to  the  unilobular  fibrous  tissue,  there  has  developed  a  much  coarser  multilobular 
meshwork  which,  by  progressive  contraetion.  has  led  to  the  previously  large,  smooth  organ 
becoming  smaller,  rougher,  and  harder,  initil  it  may  sometimes  be  so  small  as  to  be  no  longer 
palpable.  Only  in  the  very  last  stage  does  it  produce  ascites.  People  have  been  known  to 
be  total  abstainers  for  as  long  as  eighteen  years  or  more  after  the  first  symptoms  of  cirrhosis 
have  developed,  and  yet  to  die  with  a  granular,  contracted.  "  hob-nail  "  liver  and  ascites. 

Perihepatitis. — A  case  of  cirrhosis  of  the  liver  seldom  survives  long  after  it  has  first 
become  necessary  to  tap  the  abdomen,  and  when  paracentesis  abdominis  has  to  be  performed 
more  than  once  or  twice  in  a  case  supposed  to  be  cirrhosis,  this  points  to  the  diagnosis  being 
wrong,  the  case  being  one,  not  of  cirrhosis,  but  of  perihepatitis.  This  is  not  always  so,  how- 
ever, for  it  happens  sometimes  that  even  when  the  ascites  was  originally  due  to  cirrhosis, 
the  repeated  tapping  produces  perihepatitis,  the  greatly  thickened  capsule  of  the  liver 
being  the  result  of  multiple  tappings  for  what  was  at  first  cirrhotic  ascites.  It  is  exceedingly 
difficult  to  be  certain  of  the  diagnosis  of  simple  perihe])atitis  ;  the  condition  is  really  only  part 
of  a  chronic  jjeritonitis.  The  capsule  of  the  liver  becomes  much  thickened,  and  it  contracts 
and  distorts  the  organ,  and  rounds  the  edge,  or  else  turns  it  \\\>  or  under,  in  a  way  which  is 
characteristic.  It  is  only  if  this  eurlcd-under  or  turned-up  edge  can  be  detected  that  the 
diagnosis  of  perihepatitis  can  be  made  with  certainty.  Syphilis  is  possibly  the  cause  of  the 
malady  in  some  cases. 

Ascites  associated  with  carcinoma  or  sarcoma  of  the  liver  is  usually  accomjianied  by 
intense  jaimdice.  and  there  is  always  doubt  as  to  whether  these  symptoms  are  not  due 
rather  to  coincident  affection  of  the  portal  lymphatic  glands  than  to  the  deposits  in  the  liver 
itself.  The  latter  becomes  much  enlarged,  \  ery  hard,  the  edge  often  coming  well  below  the 
uml)ilicus.  Probably  the  largest  livers  that  occur  are  due  to  secondaiy  carcinoma  or  sar- 
coma. They  may  reach  a  weight  of  22  lb.  or  more.  Besides  being  very  hard,  the  liver  may 
be  tender,  and  umbilicated  nodules  may  be  felt  on  its  surface.  Primary  growth  of  the  liver 
is  exceedingly  rare,  and  though  it  leads  to  progressive  and  deejjening  jaimdice,  it  does  not 
often  produce  ascites.  Secondary  growth  is  so  much  more  common,  that  it  is  important  to 
look  for  the  primary  growth  elsewhere  with  great  care  before  primary  growth  in  the  liver  is 
diagnosed.  Retinal  and  rectal  examination  should  not  be  omitted  ;  and  Cammidge's  pan- 
creatic reaction  (p.  100)  should  be  tested,  in  case  the  primary  growth  be  in  the  pancreas. 

Syphilis  may  produce  local  peritonitis  over  a  gimima  ;  it  may  also  lead  to  general 
chronic  peritonitis  and  thus  to  ascites.  The  diagnosis  is  made  upon  the  history,  upon  the 
signs  of  syphilis  elsewhere,  and  upon  Wassermann's  serum  reaction. 

Hydatid  disease  of  the  lix'cr  seldom  of  itself  causes  ascites,  though  it  may  be  associated 
with  coincident  affection  of  the  peritoneum  with  ascites  (p.  49). 

We  may  now  pass  on  to  consider  those  cases  in  whicli.  if  the  history  is  correct,  there  has 
been  swelling  of  the  legs  l)ef'ore.  or  at  any  rate  not  later  than,  swelling  of  the  abdomen  :  and 
if  one  Icillows  the  classilication  as  given  on  pages   f.")  and  +(i.  one  CDnies  next  to  : — 

iv.  Obstruction  of  the  Inferior  Vena  Cava  above  the  Hepatic  Veins. — This  is  rare, 
and  will  seldom  be  diagnosed  imless  there  is  either  (1)  clear  evidence  of  extension  of  throm- 
bosis to  the  inferior  vena  cava  from  a  previous  thrombus  in  one  leg,  associated  with  exten- 
sion of  oedema  up  the  back,  followed  by  albuminuria  and  perhaps  ha-maturia  when  the 
renal  veins  are  involved,  and  then  by  ascites,  together  with  varicose  distentif)n  of  the 
abdominal  veins  and  re\ersal  of  the  blood-stream  in  them  •  or  (2)  a  history  or  the  physical 
signs  of  chronic  mediaslinitis.  which  generally  results  from  recurrent  attacks  of  pleurisy 
and  pericarditis,  esijeeially  rheumatic,  or  of  iiitratiioracic  neiv  groicth.  which  is  distinguished 
from  chronic  mediastinitis  by  the  shorter  history  and  by  the  .r-ray  appearances.  {Fig.  42, 
p.  105.)     (See  Veins.  Varicose  TnoR.\cic,  p.  750;  and  Veins.  Varicose  Abdominal,  p.  748.) 

V.  Chronic  Failure  of  the  Right  Side  of  the  Heart  (Backward  Pressure). — Ascites 
as  the  result  of  backward  pressure  in  chronic  heart  and  lung  disease  is  nearly  always  preceded 
by  swelling  and  (edema  of  the  legs.  Careful  examination  ol'  the  heart  and  lungs,  a  history 
of  acute  rheumatism,  or  of  recurrent  winter  cough,  or  an  abundant  and  oftensi\e  periodic 
expectoration,  may  suggest  valvular  disease  of  the  heart,  chronic  bronchitis  and  emphysema, 
or  fibroid  lung  with  or  without  bronchiectasis,  to  account  for  the  ascites.  Nutmeg  liver 
also  results  in  these  cases,  the  enlargement  varying  with  the  degree  of  heart  failure,  the 
surface  of  the  organ  being  smooth,   sometimes  pulsating  synchronously  with   the  heart. 


ASCITES  53 

tender,  with  a  well-defined  edge  which  may  reach  below  the  level  of  the  innbilicus  in  the 
right  nipple  line.  The  urine  is  apt  to  contain  albumin,  and  when  the  heart  failure  has 
reached  an  advanced  degree  it  may  be  exceedingly  difficult  to  say  whether  it  is  due  to  primary 
valvular  disease,  primary  lung  disease,  jirimary  kidney  disease,  primary  arterial  disease, 
oi  to  primary  affection  of  the  muscle  of  the  heart.  The  importance  of  casts  in  the  urine 
in  the  differential  diagnosis  has  been  referred  to  under  Albiminuria  (p.  6),  where  the 
significance  of  the  blood-pressure,  of  retinal  changes,  and  so  forth,  are  also  discussed. 

The  valvular  heart  lesion  most  ajit  to  be  mis-diagnosed  in  connection  with  ascites  is 
mili/il  stenosis  ;  for  by  the  time  the  heart  failure  has  reached  a  sufficient  degree  to  cause 
ascites,  characteristic  bruits,  especially  the  presystolic,  become  no  longer  audible  in  many 
cases.  The  heart  beats  very  rapidly  and  irregularly,  no  bruits  may  be  audible  at  all.  Mitral 
stenosis  may  still  be  suggested  by  the  characteristic  appearance  of  the  face,  with  its  yellowisli 
|)Mlior  of  the  forehead,  and  around  the  nose  and  mouth,  with  bright  or  dark  red  coloration 
of  the  lips  and  over  the  malar  bones  and  upper  portions  of  the  cheeks  ;  or  by  the  history  of 
acute  rheumatism  or  chorea,  though  absence  of  such  a  history  by  no  means  excludes  valvular 
heart  disease.  It  may,  however,  be  im]M)ssible  to  say  whether  there  is  mitral  stenosis  or 
not  mitil  the  patient  has  been  kept  in  bed,  given  digitalis,  and  watched  for  a  week  or  more, 
until  there  is  some  degree  of  recovery  of  the  cardiac  compensation  ;  by  whieli  time  the 
characteristic  bruits  of  mitral  stenosis  very  often  return  with  the  increasing  force  of  the 
lieart"s  beat. 

Some  of  tlie  luirdest  ol  luart-laiiure  cases  to  diagnose  with  certainty  are  those  due  to 
cliioiiic  iijjvctioiis  of  the  iiijpciiiiUnm  or  to  adhiicnt  pericaidiiiiti.  In  each  case  the  diagnosis 
is  arrived  at  mainly  by  a  process  of  exclusion.  Chronic  myocardial  degeneration  seldom 
occurs  in  young  people,  or  at  any  rate  it  is  much  commoner  in  middle  life  and  later.  The 
symptoms  are  those  which  are  connnon  in  all  varieties  of  chronic  heart  failure  (p.  418),  what- 
e\er  the  cause  of  the  latter.  There  may  or  may  not  be  the  systolic  bruit  of  mitral  regurgita- 
tion, or  a7i  aortic  systolic  bruit  due  to  atheroma  of  the  aortic  valves,  but  upon  the  whole 
the  physical  signs  do  not  suggest  vahular  disiase  :  the  urinary  ihanges  and  the  absence  of 
casts  do  not  suggest  nephritis  or  granular  kidney  :  the  blood-pressure  may  not  suggest 
arteriosclerosis  :  the  lung  signs  do  not  suggest  bronchitis  and  emphysema,  or  fibroid  lung  : 
so  that  some  myocardial  affection  is  all  that  is  left  to  diagnose.  If  there  is  a  history  of  tlie 
drinking  of  much  alcohol,  particularly  beer.  iiriiiKiiii  (ilcniiiilir  heart  may  be  susiiected,  though 
this  is  less  eonuuon  in  Kuglaud  than  in  (iermany.  Fall//  superpiisition  would  he  suggested 
if  there  was  general  ot)esity  with  shortness  of  breath  on  orditiarv  exertion  ;  whilst  overload- 
ing of  the  surlaee  of  the  heart  seldom  occurs  without  some  />(//)/  iiililtriilioii  at  the  same  time. 
Fatlij  (leoeiiernlioii  is  more  likely  after  a  long  febrile  illness,  or  chronic  (joisoning  by  phos- 
phorus, arsenic,  or  lead,  or  by  the  hy])olhctical  toxins  of  severe  anu-mias,  such  as  pernicious 
or  aplastic  ana-mia.  Fibroid  lie/irl  is  very  dillieidt  to  distinguish  from  fatty  heart,  but  it  is 
the  more  likely  in  a  syphilitic  patient,  particularly  if  tlic  palieiil  is  not  obese  and  if  there 
Is  syphilitic  aortic  reyuruilatioii  or  angina  pectoris. 

-lilliereiil  perirardiinii  is  not  in  itself  an  explicit  term,  for  tin  re  are  three  dill'ereiit  <(indi- 
lions  which  come  under  the  one  heading  :  there  luiiy  be  (1)  .\dhesions  between  the  parietal 
ami  visceral  layers  of  the  perieardimn  ;  (2)  Adhesions  between  the  iiarietal  |)erieardium 
and  tlie  structures  around  it,  particularly  the  i)leura',  diaphragm,  and  chest  wall  ;  or  (3) 
.Vdhesions  bolli  of  the  parietal  to  the  visceral  layer  of  |)ericardiiun  and  of  the  parietal  layer 
to  the  structures  outside  it  really  a  form  of  chronic  niediastinitis.  It  is  clear  that  the 
physical  signs  will  difler  aeeonliui;  to  which  of  these  three  things  has  hap|)eMed.  That 
whic'li  ought  to  be  implied  strictly  1>\  llie  term  adherent  pericardium  is  adhesion  of  the 
|)arlctal  to  the  \ise(  lal  layer,  without  aii\  oIIkt  aclhcsioiis  whatever,  and  of  this  condition 
there  are  no  positive  physical  signs  at  all.  \u\r  need  lliei<'  be  any  symptoms.  The  diagnosis 
is  generally  made  by  "iiess-work.  the  palieiil  being  known  to  ha\c  had  pericarditis,  or  being 
suspected  of  having  had  it  because  of  having  sulfered  from  aeule  rlieunialism  willi  severe 
complications,  and  the  heart  now  being  round  iinieli  larger  than  it  ought  to  he  in  proportion 
li'  the  apparent  valvular  disease  as  indiealeil  li\  I  lie  bruits.  It  is  common,  however,  for  the 
parietal  and  visceral  layers  of  |)ericardiuMi  lo  he  universally  adherent  without  the  hear! 
being  big.  iiiul  without  there  being  any  ill  erieets  at  all.  the  condition  being  met  with  posl- 
niorteni  in  patients  who  die  of  something  cpiite  dilTcrent.  It  is  otdy  when  the  parietal  layer 
has  become  .•KlhcrenI   lo  the  xisecral  la\cr  when  the  heart   was  alreads'  dilated  at   the  lime  nf 


54  ASCITES 

the  |)eiiciirditis  that  symptoms  subsefjuently  accrue,  the  result  riither  of  the  inability  of  the 
already  big  heart  to  maintain  siillicient  hypertrophy  than  of  any  intrinsic  interference 
with  its  action  by  the  adJierent  pericardium  itself.  It  quite  often  hap])ens.  indeed,  that 
when  there  has  been  rheumatic  myocardial  affection  without  ])cricarditis.  the  big  heart  that 
results  is  out  of  all  proportion  to  the  valvular  disease,  and  yet  in  the  post-mortem  room  no 
abnormality  of  the  pericardiinn  is  found. 

The  following  points  in  connection  with  heart  disease  in  children  are  as  true  as  most 
aphorisms  :  mitral  stenosis  is  almost  unknown  before  puberty,  whatever  the  bruits  that 
suggest  it  ;  heart  disease  never  proves  fatal  before  puberty  unless  as  the  result  either  of  the 
severity  of  the  acute  inflammation  of  valves,  muscle,  or  pericardium,  or  else  from  adherent 
pericardium.  Fatal  mechanical  failure  of  the  heart  before  jjuberty  in  a  patient  who  presents 
no  symptoms  of  rheumatic  reinfection  points  to  adherent  pericardiimi. 

Adhesions  between  the  parietal  pericardium  and  the  structures  outside  it,  without  any 
adhesion  between  the  parietal  and  visceral  layers  within  the  pericardium,  are  exceedingly 
common,  generally  resulting  from  former  ])leurisy.  The  former  inflammation  must  have 
extended  outside  both  the  pericardium  and  the  pleune.  so  that  it  was  really  a  mediastinitis  ; 
but  clinically  the  condition  is  seldom  spoken  of  as  mediastinitis.  because  it  is  of  very  little 
importance,  and  in  itself  produces  no  symptoms  ;  the  physical  sign  which  might  suggest  it 
is  deficiency  in  the  movement  of  the  position  of  the  cardiac  impulse  to  the  left  or  to  the  right 
as  the  patient  rolls  from  one  side  to  the  other. 

The  third  variety  of  adherent  pericardium,  namely  that  in  which  there  are  adhesions 
between  the  parietal  and  visceral  layers  and  between  the  jiarietal  layer  and  the  chest  wall, 
pleurse,  and  other  structures  outside  it,  is  really  a  combined  condition  of  adherent  pericar- 
dium and  mediastinal  adhesions  which,  when  an  extreme  degree  is  reached,  becomes  what 
is  known  as  chronic  mediastinitis.  Here  again,  it  is  possible  for  neither  symptoms  nor 
physical  signs  to  present  themselves,  the  condition  being  found  unexpectedly  in  the  post- 
mortem room.  It  is  this  condition  which  is  generally  diagnosed  under  the  name  of  adherent 
pericardimn.  There  will  be  a  history  of  former  pericarditis,  pleurisy,  or  both,  probably 
rheumatic.  The  heart  will  be  large  out  of  all  proportion  to  any  valvular  disease  that  is 
present,  without  there  being  other  ob\ious  cause  for  its  hypertrophy  and  dilatation,  such  as 
nephritis,  arteriosclerosis,  hard  work,  alcoholism,  fatty  or  fibroid  heart,  or  chronic  lung 
disease.  If  the  ])arietal  |)ericar(liiuu  is  adherent  both  to  the  pleura"  and  to  the  diaphragm — 
particularly  the  latter — there  will  very  likely  be  retraction  of  the  lower  left  ribs  posteriorly, 
synchronous  with  the  heart-beat  ;  it  is  this  physical  sign — systolic  retraction  of  the  lower 
left  ribs — which  is  generally  regarded  as  pathognomonic  of  adherent  pericardium  ;  it  is 
really  evidence,  of  course,  of  adhesions  outside  rather  than  within  the  pericardimn.  The 
sign  needs  to  be  looked  for  with  some  care  ;  the  observer  watching  the  posterior  profile 
of  the  left  chest  from  the  patienfs  left  side,  small  movements  obviously  due  to  cardiac  and 
not  7-esi)iratory  action  are  to  be  seen  in  the  ninth  or  tenth  intercostal  space  in  the  line  of 
the  angle  of  the  scapula,  or  just  outside  this  :  irregularity  in  the  heart's  action  often  render- 
ing these  visible  only  now  and  then — perhaps  only  when  a  strong  heart-beat  happens  to 
coincide  with  the  most  favourable  phase  of  respiration.  The  sign,  however,  is  far  from 
uncommon.  Another  physical  sign  which  is  regarded  by  some  as  indicative  of  general 
pericardial  adhesions,  is  an  ingoing  imi)ulsc  in  the  third  or  fourth  intercostal  .space  half-way 
between  the  left  nipple  and  the  left  liordcr  of  the  sternum,  synchronous  with  an  outgoing 
impulse  nearer  the  apex,  giving  an  oscillating  or  see-saw  appearance  to  the  precordial 
region — some  of  the  intercostal  spaces  moving  inwards  at  the  same  time  as  others  move 
out  with  the  heart-beat.  As  a  matter  of  fact,  the  probable  explanation  of  the  ingoing 
mo\ement  nearer  the  stern.mi  when  the  part  of  the  heart  which  is  nearer  the  apex  causes 
the  ordinary  outgoing  impulse,  is  the  visible  withdrawal  of  the  hypertropliied  right  ventricle 
as  it  contracts.  This  see-saw  appearance  in  the  precordial  region  is  indicative  therefore 
of  great  hypertrophy  of  the  right  ventricle  ;  it  does  not  indicate  what  is  the  cause  of  this 
hypei-trophy,  though  amongst  its  causes  would  be  adherent  pericardium.  A  similar 
appearance  is  often  seen  in  cases  of  extreme  mitral  stenosis  of  long  standing,  even  when 
there  is  no  adherent  ])ericardium. 

Bright's  Disease  may  produce  ascites  in  more  ways  than  one  :  the  effusion  may  for 
instance.  sim])ly  be  part  of  a  general  anasarca,  the  accumulation  of  the  ascitic  fluid  in  the 
peritoneal  cavity  corresponding  precisely  with  its  accunmlatiou  in  the  sTibcutaneous  tissues  ; 


ATAXY  55 

or  the  Bright's  disease  may  lead  to  aeute  or  chronic  peritonitis  of  the  types  described  above  ; 
or.  especially  in  chronic  cases  associated  with  pale  or  red  granular  contracted  kidneys,  there 
may  be  failure  of  the  dilated  and  hypertrophied  heart,  with  ascites,  which  may  be  very 
difficult  to  distinguish  from  that  of  primary  heart  disease  ;  especially  as  the  greater  part  of 
the  associated  albuminuria  is  now  the  result  of  the  heart  failure  rather  than  of  the  renal 
sclerosis  :  and  easts  may  seem  unduly  few  in  proportion  to  the  albinnin.  If  the  blood- 
pressure  is  \ery  high  the  diagnosis  is  more  likely  to  be  arteriosclerosis  or  granular  kidney 
than  primary  heart-failure,  though,  curiously  enough,  the  blood-pressure  is  generally  above 
normal  in  heart-failure  from  any  cause,  even  when  the  pulse  is  as  irregular  and  feeble  as  it 
often  is  in  the  late  stages  of  mitral  stenosis.  This  terminal  rise  of  blood-pressure  in  heart 
cases  pr(ibal)ly  results  from  the  ]5artial  asphyxia. 

Severe  Aneemias  often  cause  ascites,  but  they  do  not  give  rise  to  much  difficulty  in 
diagnosis,  because  the  sub-acute  or  chronic  peritonitis  which  is  the  cause  of  the  ascitic 
exudate  in  these  eases  arises,  as  a  rule,  comparatively  late  in  the  disease,  after  the  diagnosis 
has  been  made  on  other  grounds,  by  blood-counts  and  otherwise.  (See  An.emia.  p.  20  : 
.Spr.KEX.  Enlargement  of,  p.  028  :  Lv.mph,\tic  Gland  Enlargement,  p.  376.)  One  need 
not  do  more  here  than  refer  to  the  huge  enlargement  of  the  spleen  without  lymphatic  glan- 
dular enlargement,  and  the  great  leucocytosis  with  a  large  jjortion  of  myelocytes,  in  spleiio- 
midiitlari)  leukcemia  :  the  considerable  leucocytosis.  the  enlargement  of  the  lymphatic 
glands  and  probably  of  the  spleen,  and  the  great  relative  increase  of  the  small  lymphoc_\-tes, 
in  lymphalic  leukcemia  ;  the  enlargement  of  the  lymphatic  glands  and  of  the  spleen,  and  the 
absence  of  any  positive  blood  changes,  beyond  ana>mia  of  the  chlorotic  type  without  leuco- 
cytosis. in  Ilorlskin'fi  disease  :  the  enlargement  of  the  spleen,  the  absence  of  lymphatic 
glandular  enlargement,  and  the  occurrence  of  a  progressive  and  ultimately  severe  an:rmia. 
of  the  simple  chlorotic  type  without  leucocytosis,  but  with  an  occasional  myelocyte  and 
basophilc  corpuscle,  in  splenic  ana'inia  (which  often,  as  the  course  of  the  disease  goes  on. 
turns  out  to  be  cirrhosis  of  the  liver)  ;  the  profound  anaemia  and  the  high  colour-index 
without  leucocytosis.  in  pernieious  anmmia  ;  the  severe  aniemia  suggestive  of  j)ernieious 
aniemia.  but  with  a  persistently  low  colour-index,  in  aplastic  anwmia  ;  and  the  s])lcnic 
enlargement  with  profound  chlorotic  ana-mia  without  leucocytosis,  in  pseudo-lciika'mia 
irfaiilum.  Ilerh'il   French. 

ATAXY  is  tlic  term  used  to  describe  voluntary  movements  which  are  imperfectly 
controlled  or  co-(>nlinate<l.  It  is  displayed  in  its  simplest  form  by  infants  under  the  age 
of  one  year.  In  palliologieal  slates,  it  is  often  a  sym|)tom  of  great  diagnostic  importance; 
but  before  its  value  as  a  localizing  sign  of  disease  can  be  utilized,  it  is  necessary  to 
ai)preciate  broadly  the  physiological  mechanism  by  which  co-ordination  is  brought  about, 
and  the  possible  situations  where  a  lesion  is  able  to  disturb  the  smooth  working  of  that 
mechanism.  For  the  proper  co-ordination  of  xdlunlary  m()\<iiient.  impulses  from  the 
muscles,  tendons,  joints,  and  skin  of  the  part  which  is  moved  nnisl  naeli  the  brain.  These 
impulses  are  of  two  kinds  : 

1.  .Sensory  alTerciil  impulses  wliicli  ;iic  ciinicl  l(.  tin'  nnhniiii  li\  wii\  of  tlic  p(ii|ilii'i:il  iiiTses, 
llic  |)Ost(-ri()r  eohunns  of  the  coM,  the  lilkt,  :inrl  liii;illy  IVotu  the  l):is:il  ■iViu;;!!:!  [«  tin-  imlex  iu  the 

neiyhbourhoDil  ot'  the  luotov  ;u<a.     'I'licse  iriipiilscs  crnss  Ir rie  side  nf  Ijic  IiihIv  tn  llic  opposite 

lieniispheie,    the  erossiu;;   taUiiiL;   place   In    the   medulla. 

2.  Non-.^eiis(>ry  allerenl  iiupulses,  so-cmHciI  t)ee:iusc  llicy  ucxcr  reacli  (■(lusciiiusiiess,  pa.ss 
from  tlie  pciiplicnil  sinietincs  coiicerued  in  niovenicul.  hv  wav  of  the  pciiplieial  nerves  and  the 
iiseendiiiL'  ccrilu'lhir  lra<-ts  of  the  eoid.  to  the  ccrchilliifii,  and  I'liincipMlly  to  the  eerelellar  lolic  (if 
the  same  si<lc  ot'the  hody.  In  some  manner  which  is  not  i)erleetiy  uiidcislood,  liut  in  whicli  preser- 
vation of  muscular  tone  is  probably  concerned,  the  co-<)perati( I   the  (  rKliclhun   is  rcipiiicd  if 

movements  initiated  in  the  motor  area  of  the  eerebrinn  are  to  be  ear  ii(  il  out  in  :i  co-nKliiMilc  rMannii . 

Not  oidy  n)usl  these  two  sets  ol'  impulses  reach  the  brain,  but  the  parts  of  the  brain, 
cerebral  and  cerebellar,  whieli  lorm  their  destiiudion.  nmst  also  be  intact  if  volmUary 
movement   is  to  be  carried  out   with  accuracy  and  co-ordinal  ion. 

From  the  clinical  point  of  \  iew  it  is  necessary  lo  ascertain  in  the  liisl  phice  ululher  a 
patient  is  ataxic,  and  in  the  second  whether  the  ataxy  can  be  allriliuted  to  tin-  loss  ol  the 
sensory  or  non-sensory  alhrcnl  impulses.  In  some  cases  the  alaxy  is  obvious  :  in  others 
it  can  be  <Ieteeted  oid\-  by  the  <ar(lul  applicaliou  ol  (crtain  tests.  I'or  instance,  a  patient 
may    walk    into    a    well  liiibled    room    with    perfect    case    anil    without    anything    rciu.irkablc 


56  ATAXY 

in  liis  unit,  Ijiit  if  he  is  asked  to  walk  along  a  line,  placing  one  foot  exactly  in  front  of  another, 
he  may  at  onee  display  his  lack  of  co-ordination.  Such  ataxy  is  just  as  important  from  a 
diagnostic  standpoint  as  the  imperfect  attempts  of  an  advanced  tabetic  patient  to  walk 
even  when  supported  by  companions  on  either  side.  It  is  the  quality  and  not  the  quantity 
of  a  defect  which  gives  the  needed  information. 

The  eo-ordin^tion  of  movements  performed  by  the  up]>er  extremities  must  also  be 
investigated  with  the  same  care.  The  jjatient  may  handle  his  stick  in  (piite  a  natural 
manner,  but  if  asked  to  unbotton  and  button  his  coat,  to  touch  the  ti])  of  his  nose  with  the 
tip  of  his  linger,  to  write,  etc..  he  may  fail  to  convince  the  observer  that  his  control  of  fine 
movements  is  up  to  the  normal  standard. 

Having  ascertained  the  existence  of  ataxy,  the  next  ste))  is  to  decide  whether  it  is 
dependent  on  the  loss  of  sensory  or  non-sensory  afferent  imiiulses,  or  on  the  imperfect 
function  of  the  cerebrum  or  cerebellum.  If  the  ataxy  is  due  to  loss  of  sensorj'  impulses, 
it  will  lie  increased  by  the  loss  of  visual  impulses  brought  about  by  closing  the  eyes.  It 
will  also  be  ])ossible  to  demonstrate  the  loss  of  sensorj'  impulses  by  asking  the  jiatient  to 
describe  the  position  of  a  liml^  with  his  eyes  closed  after  it  has  been  moved  by  the  observer. 
When  these  two  tests  are  i30siti\c.  it  may  safely  be  assumed  that  the  lesion  affects  the  first 
set  of  impulses  or  their  cerebral  destination. 

If.  on  the  other  hand,  the  ataxy  is  uninfluenced  by  closing  the  eyes  and  the  patient 
is  perfectly  accurate  in  describing  the  position  of  his  limbs,  it  is  probable  that  the  cerebellar 
tracts  are  at  fault,  or  the  cerebellum  itself. 

For  further  localization  of  the  lesion  in  any  i)articular  case  it  will  be  necessary  to  take 
into  account   concomitant  phenomena. 

Interference  with  the  passage  of  im|)ulses  necessary  for  proper  co-ordination  may  be 
l)rovokc<l  by  lesions  in  (1)  The  /ifiijiliciiil  nerves  :  (2)  The  spinal  cord  :  (3)  The  brain-stem  ; 
(4)  77/c  cerebrum  :  and  (.5)  Tlie  cerebellum.  Let  us  now  consider  the  effect  of  lesions  in  these 
different  regions,  iuid  the  diagnostic  evidence  as  to  their  localization  afforded  by  ataxy. 

1.  Peripheral  Nerves. — A  severe  lesion  of  a  peripheral  nerve  must  lead  to  ataxy  of 
movements  performed  by  the  muscles  to  which  it  is  distributed  ;  severe  lesion  will  also 
paralyze  the  muscles,  however,  and  thus  prevent  any  ataxy  being  demonstrated.  Less 
severe  lesions,  such  as  occur  in  slight  cases  of  perijjheral  neuritis,  allow  of  some  volimtary 
movement,  so  that  ataxy  becomes  demonstrable.  Thus  a  case  of  periijheral  neuritis  of 
alcoholic  or  diphtheritic  origin  may  show  impaired  strength,  together  with  ataxy  in  all 
four  limbs.  The  diagnosis  of  a  peripheral  nerve  affection  in  such  a  case  will  depend  on 
the  following  points:  In  the  first  place,  the  .symptoms  will  be  found  to  be  symmetrical, 
and  in  the  affected  limbs  the  impairment  of  strength  will  be  most  marked  in  the  extensors 
of  the  wrists  and  ankles.  Sjicuiuily.  slight  ana'sthesia  to  cotton-wool  may  be  detected 
over  the  glove  and  stocking  areas.  ^Vith  regard  to  pain  (p.  (i06),  there  may  be  blunted 
cutaneous  sensibility  to  the  prick  of  a  pin  over  the  same  area,  but  almost  constantly,  deep 
pressure  on  the  affected  muscles  will  establish  the  fact  that  these  tissues  are  abnormally 
sensitive.  This  is  a  most  imjiortant  point  in  diagnosis,  because  it  strikes  an  essential 
distinction  between  cases  of  ataxic  peripheral  neuritis,  sometimes  described  as  pseudo- 
tabes, and  cases  of  true  siiinal  tabes,  in  which  it  is  an  almost  invariable  rule  to  find 
diminution  or  loss  of  painful  sensibility  on  squeezing  the  muscles.  In  the  third  place,  the 
tendon  reflexes  will  be  markedly  diminished  or  completely  absent,  while  the  plantar  reflexes 
will  probably  be  unobtainable.  Finally,  the  use  of  electrical  currents  upon  the  muscles 
« ill  show  that  the  response  to  faradie  ciu'rents  is  materially  lessened  or  abolished,  and  that 
the  contraction  excited  by  the  make  and  break  of  the  galvanic  ciu'rent  may  be  of  the  slow, 
worm-like  type  so  characteristic  of  the  reaction  of  degeneration  (p.  .58i). 

The  ataxy  of  peripheral  neuritis  has  in  itself  no  reliable  characteristic  to  distinguish 
it  from  ataxy  due  to  spinal  disease.  That  it  is  due  to  a  lesion  of  the  jjcripheral  nerves  is 
concluded  not  from  the  nature  of  the  ataxy,  but  from  the  presence  of  other  syniptom>. 
also  referable  to  interference  with  the  functions  of  the  nerves.  The  gait  is  imsteady.  and 
the  patient  keeps  his  legs  apart  in  order  to  lessen  the  tendency  to  lose  his  balance.  The 
clumsiness  of  the  upper  extremities  may  be  demonstrated  by  his  inability  to  bring  the 
first  finger  of  one  hand  accurately  into  ajiposition  with  that  of  the  other,  or  to  touch  the 
tij)  of  his  nose  with  either.  Both  the  imsteadiness  of  gait  and  the  awkwardness  of  the 
fingers  are  exaggerated  if  he  attemj)ts  to  walk,  or  Qurry  out  movements  with  his  hands 


ATAXY  57 

when  his  eyes  are  closed.  A  tendency  to  high-steppage  will  be  noticeable  in  walking  if. 
in  addition  to  the  ataxy,  there  is  well-marked  paresis  of  the  dorsiflexors  of  the  ankles.  In 
such  a  case  the  jiatient  is  obliged  to  lift  the  feet  to  an  nnvisiud  height  in  order  to  clear  the 
ground . 

•2.  Spinal  Cord. — The  ataxy  due  to  disease  of  the  s])inal  cord  is  seen  best  in  tabes 
iliiisfilis.  in  which  malady  degeneration  of  the  (josterior  colunm  ascending  tracts  occurs 
early,  and  in  wliicli.  consequently,  the  patient  does  not  receive  the  normal  impulses  from 
the  muscles,  tendons,  and  joints  so  necessary  for  the  preservation  of  his  sense  of  position 
and  movement.  Contrary  to  popular  ideas,  gross  ataxy  is  met  with  only  in  a  small  pro- 
portion of  the  cases  of  this  disease,  and  it  is  often  necessary  to  apply  delicate  tests  to 
demonstrate  its  presence.  The  patient's  gait  may  not  be  remarkable  in  good  daylight, 
but  he  may  complain  of  its  uncertainty  in  the  dark,  or  he  may  be  obviously  ataxic  with  his 
eyes  closed.  Another  patient  may  have  noticed  nothing  amiss  with  his  walking  in  the 
ordinary  way,  but  if  he  is  asked  to  follow  a  line  on  the  floor,  placing  one  foot  exactly  in 
front  of  the  other,  his  impaired  jiower  of  balance  will  become  apparent,  especially  if  he  is 
directed  to  accomplish  this  test  with  his  head  raised  and  his  eyes  fixed  on  something  in 
front  of  him  instead  of  ujjon  his  feet. 

In  cases  of  moderate  ataxy  the  gait  and  stance  of  the  patient  are  remarkable  for  the 
wide  base  he  assumes,  and  his  tendency  to  guide  his  feet  by  means  of  his  vision.  Romberg's 
sign  can  be  obtained  easily.  This  sign  is  not  diagnostic  of  tabes,  as  is  so  often  assumed, 
but  is  merely  used  for  the  purpose  of  ascertaining  whether  the  removal  of  visual  impulses 
will  convert  a  condition  of  stability  into  one  of  instability.  Many  if  asked  to  describe 
Uomberg's  sign,  reply,  "  You  direct  the  patient  to  put  his  feet  together  and  close  his  eyes  ; 
if  he  sways  or  falls,  the  sign  is  present."  This  is  obviously  incorrect,  because  the  patient 
may  sway  even  before  his  eyes  are  closed.  In  order  to  test  a  patient  for  this  sign,  he  nuist 
be  directed  to  stand  with  his  feet  as  near  together  as  he  is  able  to  do  with  steadiness,  and, 
having  established  his  stability  in  that  position  with  open  eyes,  he  must  be  told  to  close 
the  latter.  If  he  sways  or  tends  to  fall,  it  is  clear  that  he  had  been  depending  on  his  visual 
impulses,  and  that,  without  their  aid,  the  im])idscs  derived  from  his  legs  and  trunk  were 
insullicient  for  the  jjreservation  of  his  equilibrium.  We  have  in  this  test,  therefore,  a 
valuable  method  of  ascertaining  whether  the  function  of  the  posterior  columns  is  being 
carried  out  normally. 

'i'o  judge  from  the  descrij)tions  given  in  some  text -books,  the  typical  gait  of  tabes  is 
one  in  which  the  legs  arc  thrown  into  the  air  and  the  Icct  brought  to  the  ground  with  a 
more  or  less  noisy  stamp.  As  a  matter  of  fact,  this  type  of  gait  is  seen  only  in  a  small 
proportion  of  cases,  and  is  rarely  observed  cxcc))!  when  the  |)alient  is  depending  for  sujiprjrt 
either  on  :i  couple  of  sticks  or  on  one  or  two  attendants.  In  other  wiirds.  he  has  become 
so  ataxic  that  he  cannot  walk  unsupported,  and,  being  suj)porteil.  he  no  longer  attempts 
to  control  the  exuberance  of  his  leg  movements  by  means  of  his  sight. 

Tabetic  ataxia  in  its  moderate  and  extreme  degrees  can  be  dcnKinstr.ded  when  the 
patient  is  at  rest  in  bed.  by  asking  him  to  carry  out  accurate  movements  with  his  hands 
and  feet  with  and  without  the  aid  of  his  vision.  In  slighter  degrees  the  fact  that  the  ataxia 
is  de|)endent  on  interference  with  his  sense  of  position  and  movement  may  be  proved  by 
asking  him  to  describe  the  position  of  a  linger  or  toe  which  the  observer  moves  in  dilierent 
directions,^  .Sometimes  it  is  as  well  in  testing  this  sense  in  one  limb  to  ask  the  patient  ti) 
place  the  corresponding  limb  in  llic  s;nii<'  positinn.  when  the  error  will  be  made  more  obvious. 

The  diagnosis  of  tabes  eaiiiml  be  in:ide  Iroin  I  lie  character  of  the  ataxy  alone,  since  in 
nllicv  diseases,  such  as  Krie<lrci<'li's  ataxy,  disseniinaled  sclerosis,  or  cdMibincd  degenerMtion 
lit  the  cord,  there  is  or  may  be  sclerosis  of  tlie  ])oslcriov  columns  resulling  in  similar 
inco-ordination.  It  is  iinportanl,  Iherelore.  to  rciiicinber  thai  in  tabes  llie  poslerior  roots 
are  allcelcii  :iko.  and  IIimI  IIk  re  is  vei'\-  ollin  sonic  iiilci  rncncc  willi  olhcr  alliiciil  impulses, 
especially  lliosc  which  coiiNcy  sensations  of  pain  IroTO  the  iniiscjcs  and  skin,  and  those 
which  are  conc<rncd  with  the  deep  rellcxcs  and  the  iiiaintcnancc  of  muscular  lone.  Thus, 
in  this  disease  one  of  the  earliesi  symptoms  is  relative  analgesia  to  pin-piicks  and  to  deep 
pressure  on  tin  muscles  in  the  lower  extremities  ;  at  the  same  lime  it  must  not  be  I'orgollcn 
that   the  tabetic  phenomena  may  be  limited  to  the  upper  extremities  (cervical  tabes). 

In  Frinlri  irh's  iiln.)//.  ilissrinhiiilfil  .scli  ri}\is.  and  olhcr  spinal  disease,  as  well  as  in  some 
cases  of  lalics,   llic  alaxx'  due   to   llic   lesion   ol    Ihc   posterior  colninns   may   be  coinplicaled 


58  ATAXY 

and  intensified  by  the  faet  that  there  is  also  interferenee  in  tlie  patli  of  tlie  non-sensory 
afferent  impulses,  which  pass  from  the  extremities  to  the  cerebellum  via  the  ascending 
cerebellar  tracts  in  the  spinal  cord.  If  this  form  of  ataxy  is  present,  the  help  which  the 
patient  derives  from  vision  for  the  purpose  of  controlling  his  inco-ordinate  movements  is 
largely  discounted,  and  he  may  be  as  ataxic  with  open  as  with  closed  eyes. 

In  some  lesions,  sucli  as  those  resulting  from  syringomyelia  or  nav  groivths,  only  one 
side  of  the  cord  may  be  affected,  and  a  Brown-Sequard  form  of  paralysis  be  exhibited  (p.  497). 
II  tlie  paralysis  is  not  complete,  some  ataxy  may  be  observed  in  the  paretic  limb. 

3.  The  Brain-stem. — Lesions  of  the  medulla,  pons,  or  crura  may  produce  ataxy  if 
they  interfere  with  tlie  passage  of  either  sensory  afferent  impulses  to  the  cerebrum  or  non- 
sensory  afferent  impulses  to  the  cerebellum.  The  cerebellar  imjjulses  can  be  interfered 
with  only  at  the  medullary  level  ;  that  is  to  say,  before  they  have  passed  into  the  cerebelhini 
via  the  inferior  peduncle.  A  good  example  of  hemiataxia  of  this  origin  is  afforded  by  any 
case  of  thrombosis  of  one  posterior  inferior  cerebellar  artery.  This  uncommon  condition 
affects  the  structures  on  one  side  of  the  medulla,  and  is  characterized  by  hemiataxia  of  the 
homolateral  limbs,  together  with  loss  of  sensibility  to  pain.  heat,  and  cold,  on  the  contra- 
lateral side.  The  ataxy  is  of  the  cerebellar  type  ;  that  is  to  say.  it  is  not  associated  with 
loss  of  sense  of  position  and  movement  in  the  affected  limbs,  and  is  little  influenced  by 
closure  of  the  eyes.  Above  the  medulla,  lesions  which  are  capable  of  producing  ataxy  by 
interfering  with  the  sensory  impulses  from  the  muscles,  joints,  and  tendons,  usually  cause 
paralysis  of  the  same  parts,  so  that  the  co-ordination  is  more  latent  than  real,  and  therefore 
of  little  diagnostic  importance. 

4.  The  Cerebrum. — From  the  basal  ganglia  to  the  cortex,  the  path  of  the  afferent 
ini])alses  necessary  for  co-ordinate  movements  lies  near  to  that  of  the  efferent  impulses 
from  the  motor  area,  and  it  is  only  rarely  that  lesions  affect  the  sensory  fibres  and  leave 
the  motor  intact.  Every  now  and  then,  however,  a  patient  complaining  of  loss  of  use  of  the 
limbs  on  one  side,  is  found  on  examination  to  be  suffering  from  imjjaired  sense  of  position 
and  movement  in  those  limbs  rather  than  from  paralysis.  His  co-ordination  may  be  fairh' 
good  so  long  as  he  can  utilize  his  vision,  but  with  closed  eyes  he  has  no  notion  of  the  position 
of  his  arm  or  leg,  and  no  knowledge  of  the  nature  of  objects  placed  in  his  hand  (astereognosis). 
This  may  even  be  the  case  when  other  sensory  stimidi,  such  as  those  of  touch,  pain,  and 
heat,  are  appreciated  perfectly.  A  similar  condition  may  be  observed  during  recovery- 
from  a  slight  hemiplegic  "  stroke,'  the  patient  displaying  a  degree  of  clumsiness  and 
awkwardness  with  his  fingers  quite  out  of  proportion  to  his  loss  of  vohmtary  power.  A 
process  of  re-education  for  finer  movements,  similar  to  the  education  of  early  life,  is  necessary 
before  he  is  able  to  overcome  this  form  of  ataxy. 

Ataxic  movements  are  not  imcommon  in  the  subjects  of  infantile  hemiplegia.  The 
hand  on  the  affected  side  may  be  permanently  clumsy  and  incapable  of  carrying  out  the 
delicate  manipulations  necessary  for  \vriting,  sewing,  etc.  In  other  cases  all  voluntary 
efforts  are  interfered  with  by  the  constant  presence  of  involuntary  movements  of  an 
athetotic,  choreiform,  or  trenuilous  character,  sufficient  to  prevent  their  attaining  any 
dexterity. 

Whatever  the  nature  of  the  lesion,  cerebral  ataxy  is  generally  characterized  by  its 
hemiplegic  distribution,  and  by  its  increase  when  the  eyes  are  closed  ;  generally  the  loss 
of  im]julses  suliser\ing  the  sense  of  position  and  movement,  and  often  of  other  sensory 
impulses,  can  l)r  demonstrated  by  suitable  tests. 

5.  The  Cerebellum. — Cerebellar  ataxy  may  be  unilateral,  as  in  some  cases  of  tumour 
of  one  lateral  lobe,  or  bilateral,  as  in  the  acute  cerebellar  ataxia  of  children  due  to  encephalitis. 
In  vmilateral  cases  the  ataxy  is  most  marked  on  the  same  side  as  the  lesion,  and  is  associated 
with  hypotonia  and  some  paresis  of  the  affected  limbs.  On  the  other  hand,  it  is  important 
lo  note  that  the  reflexes  on  the  affected  side  are  normal,  that  the  ataxy  is  not  accompanied 
by  any  loss  of  sense  of  position  and  movement,  and  that  closure  of  the  eyes  does  not 
materially  increase  the  patient's  disal)ility.  The  ataxy  often  differs  from  that  due  to 
disease  of  the  posterior  spinal  colimin  in  that  it  is  complicated  by  vertigo.  This  may  take 
the  form  of  a  sensation  of  rotation  on  the  part  of  the  patient,  or  of  rotation  of  surrounding 
objects,  sometimes  of  both.  The  vertigo  and  the  ataxy  are  generally  nuich  less  noticeable 
in  the  recvnnbent  position.  The  cerebellar  gait  resembles  that  of  a  drunken  man  :  the 
l)atient  reels  from  side  to  side,  with  a  general  tendency  to  deviate  or  fall  to  the  side  of  tlie 


atkdi'hy.  -.muscular 


59 


lesion  if  only  one  lobe  is  affected.  He  is  unable  to  balance  himself  properly  on  tlie  homo- 
lateral foot,  and  his  manual  dexterity  is  iniijaired,  so  that  he  may  be  unable  to  iced  or 
clothe  himself.  The  ataxia  is  not  always  limited  to  the  trunk  and  limbs,  but  may  affect 
the  tongue,  lips,  palate,  and  vocal  cords,  so  that  their  movements  may  be  controlled 
imjierfeetly,  and  a  characteristic  "  cerebellar  articulation  "  attracts  attention.  Finally,  a 
lesion  of  the  cerebellum  sufficient  to  cause  ataxy  nearly  always  causes  nystagmus  also, 
which,  in  disease  of  one  lobe,  is  more  marked  during  deviation  of  the  eyes  to  that  side. 

(i.  Hysterical  Ataxy. — Ataxy  is  sometimes  hysterical,  and  may  then  be  the  only 
disorder  of  function  exhibited  by  the  patient,  or  may  be  associated  with  hysterical  hemi- 
plegia, paraplegia,  hemiana-sthesia,  etc.  The  diagnosis  depends  partly  upon  the  absence 
of  signs  of  organic  disease,  partly  on  the  presence  of  other  hysterical  stigmata,  and  partly 
on  its  character.  For  example,  we  may  cite  the  case  of  a  boy  who,  when  lying  in  bed,  was 
able  to  feed  himself  and  to  carry  out  all  movements  of  his  upper  and  lower  limbs  with 
perfect  accuracy,  but  who,  when  placed  on  his  feet  and  told  to  walk,  displayed  the  wildest 
inco-ordination  and  loss  of  equilibrium.  It  was  noticeable,  however,  that  he  always  reached 
some  chair  or  bed  on  which  to  collapse  finally,  even  when  jilaced  in  the  middle  of  the  room 
at  sonic  (listance  from  any  support.  It  would,  of  course,  be  unjustifiable  to  apply  this 
last  test  before  the  observer  was  satisfied  from  careful  examination  that  there  were  no 
signs  of  organic  disease.  E.  Fai(j>iliar  liiizuird. 


ATHETOSIS.  -(See  Contkactidn-s, 


Kil.) 


ATROPHY,  MUSCLLAR.- Muscular  atrophy  is  often  merely  part  of  a  gcncnil 
<caslhig  of  llic  ii-holc  lioilif,  flue  either  tt)  chronic  lesions  such  as  carcinoma,  sarcoma,  tuber- 
culosis. syiJhilis,  malaria,  ulcerative  colitis,  marasmus,  starvation,  hepatic  abscess,  cirrhosis 
of  the  liver,  diabetes,  anorexia  nervosa,  or  to  acuter  maladies,  such  as  diarrhoea  and  vomit- 
ing, ptomaine  ])oisoning,  typhoid  fever,  dysentery,  cholera,  and  so  forth.  The  history, 
and  the  other  symptoms  in  the  case,  will 
usually  serve  to  indicate  these.  If  any  doubt 
remains  as  to  whether  the  atrophy  is  neuro- 
trophic or  not.  the  electrical  reactions  will 
be  tested  :  there  will  be  no  reaction  of 
degeneration  (H.D.)  when  the  atro])hy  is 
merely  part  of  a  general  wasting,  whereas  if 
— as  might  be  the  case  in  a  diabetic  jjaticnt. 
for  instance — there  is  peripheral  neuritis  in 
addition,  this  will  be  indicated  by  a  partial 
or   coini)letc    H.I).     (Sec    Hi; action    oi-   1)i'.- 

GK.NKRATION,    p.    ')X2.) 

In  the  next  i)lacc,  I  he  atrophy  may  be 
tlu'  result  of  ilisiisc.  Organic  disease  of  the 
nervous  system  may  or  may  not  be  present 
at  the  same  time  :  the  patient  may  be  bed- 
ridden IroTii  locomotor  ataxy,  for  example, 
or  from  guicral  paral\sis  of  the  insane  :  and 
the  muscles  ol  the  limbs  may  coiis(((Uentl\ 
become  so  thin  that  peripheral  neuritis  or 
degeneration  of  the  anterior  cornual  cell-, 
may  be  siinulaled,  and  a  determination  ol 
the  absence  of  H.I),  may  be  the  only  means 
of  excluding  these.  II  is  important  to  re- 
member that  in  the  /jiiiiifiii/  iiiiisciildr  di/s- 
Irophif.i,  whether  of  the  pseudo-hypertrophic, 
the  juvenile,  the  infantile,  the  facio-scapulo- 
humeral  or  I,ari<loii/y  -  Dcjerinc  or  other 
types,  there  is  no  reaction  of  degcneral  ion, 
the   electrical    responses   and    the   supcrli(i;il   and   deep  reflexes  remaining   normal  in  type, 

llioiiyli  liny  (llniiiilsli  in  (i<'j,rrce  ,is  llic  an nl   of  muscle  grows  less  and   less,   until   finally 

""I"'    i""    no    iriiiscle    to    respond   al    all.     'I'lie  primary  nniscular  dystrophics   (j).   5i:i)  are 


60 


ATROPHY,     MUSCULAR 


com])aratively  easy  to  diagnose,  however,  on  account  of  their  insidious  onset  in  cliildren, 
tlieir  slow  but  progressive  downhill  com'se,  their  occurrence  in  different  members  of  the 
same  family,  the  absence  of  sensory  disorder,  and  the  absence  of  R.D.  They  are  distin- 
guished from  the  iiifiiiilUc  paralysis  which  results  from  acute  anterior  poliomyelitis  (Fig.  19) 
by  the  latter  having  a  sudden  onset,  R.D.  at  its  height,  whilst  the  resultant  wasting  does 
not  advance  progressi\ely,  but  after  recovering  to  a  certain  degree,  tends  to  remain 
stationary. 

Pcri])heral  neuritis  is  distinguished  from  |)riniarv  muscular  dystrophy  by  the  history 
and  course,  and  by  the  presence  of  R.D.  at  some  period  of  the  malady.  Two  other  affections 
that  may  be  confused  with  a  primary  museular  dystro]>hy.  ])articularly  as  they  also  are 


Fiij.  L'li.— Tuorh-    iMTi-n 

■;,1    tvp.-'  ot   nouro-nniscn 

ilystrophy— early  ;  tlir  |.;ii 

iriit  1-  thf  voiitiger  iM-otl 

of  the  girl  in  -/■'"/.    '1. 

\'iti    ilir   iilantar-flexion 

the    bin    toes    an-l    Hir    , 

t,.i'i>iii_-   of   the    feet;   t 

calves  are  not  yci    \\;i-!iil 

le  boj-   ill   Fi:j. 

ajvnuced  stage 

led  to  the  calves, 


hereditary,  begin  insidiously  at  an  early  age.  and  slowly  advance — arc  Fii('(liricli\-:  atd.ry, 
and  Tootli's  peroneal  ti/ite  (if  jiroiire^siie  niiisiiihir  ahophi/.  l^acli  of  these  may  cause  talipes, 
moreover,  and  therefore  shnulate  infantili  |KiiMlysis.  i  \((  |il  that  in  the  latter  the  talipes  is  ■ 
generally  one-sided,  whereas  in  the  other  two  it  is  bilateral.  In  Friedreich's  ataxy  (see 
!>.  51".i)  there  is  no  real  wasting,  but  rather  a  lack  of  development.  Tooth's  peroneal  type 
of  )irogressive  muscular  atrophy  is  apt  to  come  on  after  some  febrile  malady  such  as  measles 
or  whooping-cough,  the  lirst  thing  noted  being  inability  to  dorsiflex  the  big  toe,  which 
hangs  down  in  a  way  that  is  the  exact  converse  of  its  erect  position  in  Friedreich's  ataxy 
(Fig.  20)  ;  the  paresis  takes  months  or  years  to  spread  to  the  rest  of  the  legs,  and  finally 
to  the  hands  (Fig.  21 ),  the  slowness  of  the  ]5rogress  and  the  absence  of  sensory  symptoms 
showing  that  it  is  not  peripheral  neuritis,  whilst  the  R.D.  in  the  affected  muscles  excludes 


ATROPHY,     MUSCULAR  61 

ii  primary  muscular  (lystr()])liy.  The  lesion  is  in  the  anterior  eorniial  cells  and  starts  in 
the  lumbar  enlaruement.  The  knee-jerks  are  retained  until  the  ()uadrice])s  of  the  thigh 
is  involved. 

Local  muscular  atro])hy  may  be  due  to  tliscasc  of  the  pnrls  hciwatli.  as  in  the  case  of 
the  pectoralis  major,  the  supraspinatiis,  the  deltoid,  the  infraspinatus,  and  other  shoulder 
muscles  when  the  imderlying  luni;  is  the  site  of  active  phthisis.  Similar  local  atrophy 
results  very  ([uickly  from  acute  and  subacute  affections  of  joints,  es])eeially  in  the  muscles 
whose  origin  is  above  the  affected  joint.  The  gluteal  atrophy  associated  with  tuberculous 
hip-joint  is  well  known  :  similarly,  knee-joint  disease  leads  to  thigh  atroi)hy,  elbow  disease 
to  atrophy  of  the  muscles  of  the  upper  arm,  and  so  on.  The  same  applies  to  the  effects 
of  fractures,  new  growths,  sprains,  and  splints  ;  the  atrophy  is  sometimes  so  rapid  that 
some  think  it  cannot  be  due  sinijjly  to  disuse,  but  must  have  a  neuro])athie  factor  also. 
The  affected  muscles  present  no  R.D.,  however.  One  jjarticular  form  of  paralysis 
associated  with  the  use  of  splints  merits  special  mention,  namely.  Volckmann"s  paralysis 
of  (he  forearm.     (See  PAnAi.vsis  op  the  Uppf.k  Extremity,  p.  .508.) 

Hemiatrophy  of  the  face  or  trunk  is  generally  congenital,  and  the  diagnosis  is  not 
diHieult  (see  p.  4<)4). 

If  it  can  be  decided  deflnitely  that  there  is  some  nervous  cause  for  muscular  atrophy, 
the  best  proof  of  which  is  the  detection  of  partial  or  complete  R.D..  the  diagnosis  lies 
between  one  or  other  of  the  following  conditions  : — 

1.  Causes   in   the  Spinal   Cord. — 

Progressive  muscular  atrophy  A  few  cases  of  transverse  I  Tooth's  peroneal  ty|)e  of  )iro- 
Aniyotropliie    hitcnil    sclerosis    i         myelitis  gressive  muscular   atro|)hy 

Syriiigomvclia  |    Acute  anterior  ])olioniycIitis 

•_'.  Causes   In   the  Peripheral   Nerves. 

TaiiKMirs  of  the  CMiula  ('(iniua        New  growth  (iummata,  etc.,   involving  the 

Pelvic  tumours   involving  the        Accessory    cervical     rlh.     (((■.,  cranial  or  other  nerves 

huiibo-sacral  plexus                            pressing     on     the     Inachial  Injury    to    pcripluial    nerves, 

Sciatica                                                     pk-xus  I        ineiuding  the  eUccts  of  callus 

Aneurysm  after  fractures 

Peripheral  neuritis,  of  which  the  following  are  some  of  the  causes  : — 

Certain      inorganic     chemical  Certain  severe  ana-mias  :  Mcii-hiri 

substances,   notably  Pernicious  anaTnia  Sy|ihilis 

I-ead                                      "  Splcno-nieilMllary    leuUa'Uiia  Typlioid    lever 

.Arsenic  I.\  rn|ihatic  Icuk'aiiiia  Inllucnza 

Mercury  Ilnd^kin's  disease  Oral   sepsis 

Splenic  auicinia  Certain  eoiistitntional  diseases 

Certain  or;!anie  chcMiical  conj-  Certain      niicroliial      ay     allied  sonictiines     attributed     l.i 

pounds,    notably  liixins  endogenous  poisons  : 

Alcohol  I)i|ihthcria  Gout 

Ktlier  Leprosy  I         Diabetes   mellitus 

Carbon   bisnlpliide  Malaria  !    Pregnancy 

Nai'ldlia                                             I  Chronic  pya-niia  Other   eauses    as    yet    undeter- 

I  Infective  endocarditis  niincil. 

In  arriving  at  a  diagnosis  in  a  particular  case,  it  is  important  not  to  use  the  term 
'  lutuitis  ■  luitil  all  the  other  possible  Icsiiuis  have  been  excluded.  Tooth's  peroneal  lyi)C 
ol  progressive  muscular  atrophy  and  acute  anterior  ])oliom\  clil  is  have  already  been 
iliseusscd.  The  Udler  is  sometimes  regarded  as  essentially  a  disease  of  early  life,  but  it  is 
important  to  renu^mber  that  it  is  by  no  means  impossible  for  it  lo  affect  an  adult,  in  whom 
the  symptoms  and  results  may  be  precisely  similar  to  what  they  wotdd  l)c  in  a  child. 

I'rdfiirnsivc  muscular  (ilid/ihi/  is  a  disease  of  adults.  It  shows  no  particular  tendency  to 
occur  in  several  members  of  the  same  family.  It  begins  insidiously,  and  advances  slowly 
for  months  and  years,  affecting  lirst  the  small  nuiscles  of  the  bauds,  causing  alrophv  with 
H.I),  iiijlhe  interossei  and  in  the  muscles  of  the  Ibcnar  and  h\pothciiar  cmineuees  :  the 
p<'i-Mliar  deformilv  .|es(  libcd  as  •  main-ciinriHe  '  results  (p.  to:)).  In  I  lic'  course  of  months 
Ibc  paresis  spreads  from  the  bands  to  the  forearm,  and  lalcr  to  llic  upiicr  arm.  Disease 
of  the  pcripluTal  nerves,  such  as  the  ulnar,  is  cxcludc<l  by  the  fact  that  the  paralyzed 
umseles  are  not  all  supplied  from  the  same  nerve  trunk  -tlu-  thenar  nmscles  supplied  li\ 
the  median  lieiiii;  alleetcd  cipi.ally  with  the  bypo-tlu'iiar  supplied  by  Ibc  ulnar.  All  Ibe 
muscles  bcldw  the  wiisl   are  iuvoKcd  more  or    less  togclbir.  Ibcn   all    Ibe    nuiscles    below  the 


62  ATROPHY.     MUSCULAR 

clliow,  and  so  on;  this  paralysis  of  associated  groups  of  muscles  as  distinct  from  muscles 
NU|)])lied  by  the  same  nerve,  at  once  suggests  a  progressive  degeneration  of  the  anterior 
ciirnual  cells  of  the  cervical  enlargement  of  the  cord.  Disease  of  the  brachial  plexus 
^v()uld  be  excluded  first  by  the  fact  that  the  lesion  is  bilateral  and  symmetrical,  and 
secondly  by  the  absence  of  pain  or  other  sensory  disturbance.  The  ])atholog>'  of  the  disease 
is  analogous  to  the  nuclear  cell-degeneration  in  the  medulla  oblongata  that  leads  to  bulbar 
(labio-glosso-pharyngo-laryngeal)  paralysis  :  and  indeed,  progressi\e  muscular  atrojihy 
may  either  follow  or  be  followed  by  bulbar  paralysis. 

If.  at  the  same  time  that  there  are  the  signs  of  progressive  muscular  atrophy  in  the 
hands,  there  is  also  spastic  paresis  of  the  legs,  with  no  wasting,  but  increased  knee-jerks, 
ankle  clonus,  and  extensor  plantar  reflexes,  the  onset  having  been  quite  gradual,  without 
sensory  disorder,  and  without  bladder  or  rectal  trouble  unless  the  disease  has  reached  quite 
a  late  stage,  the  condition  is  amyotrophic  lateral  sclerosis. 

It  is  important  that  the  character  of  the  onset  and  the  absence  of  sensory  symptoms 
be  insisted  on,  in  order  to  exclude  syringomyelia  and  anomalous  cases  of  transverse  myelitis. 
Si/ringomyelia  is  rare,  but  it  has  one  very  characteristic  feature,  namely,  the  preservation 
of  ordinary  cutaneous  sensibility  with  the  loss  of  power  of  distinguishing  heat  from  cold, 
or  pain  from  touch,  in  some  part  of  the  limbs  or  trunk.  There  need  be  no  other  symptom 
than  this  dissociation  of  sensations,  or  skin  lesions  in  the  jiartesthetic  parts  may  be  a 
prominent  feature — Morvan's  disease  ;  if  the  enlargement  in  and  around  the  central  canal 
of  the  cord  displaces  and  destroys  the  anterior  cornual  cells  in  the  lower  part  of  the  cervical 
enlargement,  progressive  muscular  atrophy  is  simulated  :  if  at  the  same  time  the  bulging 
of  the  central  canal  and  the  changes  around  it  cause  compression  of  the  crossed  pyramidal 
tracts,  there  will  be  all  the  motor  symptoms  and  signs  of  amyotrophic  lateral  sclerosis,  the 
diagnosis  being  only  possible  when  the  sensory  symptoms  are  typical. 

It  is  generally  stated  that  transivrse  myelitis  causes  spastic  paraplegia  without  muscular 
wasting  or  R.D.  This  is  in  the  main  true,  because  the  few  anterior  cornual  cells  destroyed 
by  the  transverse  softening  of  the  cord  in  the  commonest  site,  namely,  the  dorsal  region, 
correspond  to  an  iMtcrciistal  or  abdominal  segment,  the  wasting  of  which  is  difficult  to 
detect.  If,  howcxci.  tin-  Iransverse  myelitis  occurs  so  high  up  as  to  involve  the  lower  part 
of  the  cervical  eiilargnmnt — to  involve  the  cord  yet  higher  up  is  incompatible  with  lite, 
because  both  the  intercostals  and  the  phrenic  nerves  would  be  paralysed — a  certain  niunber 
of  the  anterior  cornual  cells  sending  motor  nerves  to  the  hands  and  arms  would  be  destroyed, 
the  result  being  a  main-en-griffe  like  that  of  progressive  muscular  atrophy  :  and  the 
simultaneous  interference  with  tlie  crossed  pyramidal  tracts  would  produce  a  picture 
identical  at  first  sight  with  amyotrophic  lateral  sclerosis.  Not  only,  however,  would  there 
very  likely  be  impairment  of  all  forms  of  sensation  as  well  as  paresis,  in  a  case  of  transverse 
myelitis,  but  instead  of  the  onset  being  gradual  and  the  progress  a  steady  advance  downhill, 
as  in  progressive  muscular  atrophy  or  amyotrophic  lateral  sclerosis,  the  onset  would  have 
been  comparatively  rapid,  followed  by  a  cessation  or  even  by  an  improvement  if  the  jjatient 
lived.  Similarly,  if  transverse  myelitis  occurs  so  low  down  as  to  involve  the  lumbar  enlarge- 
ment of  the  cord,  it  would  cause,  not  spastic  paraplegia  with  increased  knee-jerk,  ankle 
clonus,  extensor  plantar  reflex,  no  wasting  and  no  R.D,  :  but  absence  of  knee-jerk,  no 
ankle  clonus,  no  extensor  plantar  reflex,  marked  muscular  atrophy  of  the  legs,  with  R.D., 
]jaraesthesia,  bladder  and  rectal  trouble.  The  involvement  of  the  sphincters  in  such  a 
case  would  be  of  considerable  aid  in  excluding  peri])heral  neuritis  ;  whilst  Tooth's  peroneal 
type  of  prog^essi^'e  muscular  atrophy  and  acute  anterior  poliomyelitis  would  be  excluded 
not  only  by  the  para;sthesia,  but  also  by  the  history  of  the  mode  of  onset  and  the  course 
of  the  maladv. 

A  timiour  involving  the  caiida  equina  is  rare,  but  it  is  not  altogether  diflicult  to  diagnose. 
It  may  be  more  diflicult  to  determine  the  nature  of  the  mass — gunmia,  glioma,  primary 
sarcoma,  secondary  sarcoma  or  carcinoma — than  its  site.  The  onset  of  symptoms  is 
generally  gradual,  and  one  leg  is  aflected  either  earlier  than,  or  more  than,  the  other. 
Weakness  in  the  leg,  together  with  severe  pains  both  in  it  and  in  the  lower  part  of  the 
lumbar  region  of  the  spinal  column,  will  be  followed  by  muscular  atrophy  and  R.D. 
Sciatica  may  at  first  suggest  itself,  until  it  is  found  that  neither  the  pains  nor  the  paresis 
correspond  to  one  single  nerve  ;  and  when  the  disease  progresses  and  the  other  leg  is 
affected,  anaesthesia  supervenes  upon  the  paralysis.     The  site  of  the  pain  over  the  region  of 


ATROPHV.     .ML'SCULAR  63 

tlic  Cauda  cfiuina  i^  an  iin|jiirtant  jjoint  in  tlu-  diagnosis,  whilst  rectal  and  ]jossibly  \aginal 
examinations  arc  essential  for  the  exclusion  of  a  pelvic  mass — snch  as  carcinoma  of  the 
rectnm,  uterus,  or  ovary,  a  flbromyoma,  a  cyst,  a  sarcomatous,  gummatous,  tuberculous, 
or  inflammatory  mass,  or  e\en  a  displacement  of  the  womb — which,  by  interfering  with 
the  nerves  at  the  back  of  the  pelvis  might  produce  very  similar  symptoms.  Sacro- 
iliac joint  disease  can  generally  be  excluded  by  the  fact  that  the  pains  arc  not  definitely 
referred  to  the  joint,  whilst  any  wasting  that  might  be  associated  with  disease  of  that 
joint  would  not  be  accompanied  by  R.D. 

Srialicii  (p.  438)  does  not  always  give  rise  to  wasting  of  the  corresponding  muscles  : 
but  sometimes  it  does,  and  occasionally  it  nuiy  do  so  bilaterally,  with  R.D.  The  localiza- 
tion of  the  pain,  tenderness,  and  atrophy  to  the  parts  supplied  by  the  great  sciatic  nerve, 
without  affection  of  other  nerves  and  muscles  in  the  leg  or  calf,  would  point  to  sciatica, 
especially  if  the  lesion  was  unilateral,  and  if  the  patient,  though  imable  to  flex  his  thigh 
to  a  right  angle  with  his  abdomen  at  the  same  time  that  lie  keeps  his  knee  extended,  can 
extend  his  leg  backwards  at  the  hi])-joint  in  a  way  that  would  be  impossible  if  he  had  a 
psoas  abscess  ;  and  if  he  is  able  to  bear  firm  backward  pressure  on  the  knee  when  the  leg 
of  the -affected  side  is  flexed  and  outwardly  rotated  in  such  a  way  that  the  foot  lies  across 
the  opposite  knee — a  test  which  will  exclude  hip-joint  disease. 

When  the  lesion  is  a  thoracic  (nieiiri/.im  or  neoplasm,  or  :.n  accessory  cenical  rib  pressing 
on  or  involvinti  the  brac)iial  plexus,  the  wasting  is  almost  certain  to  affect  one  arm  only, 
or  one  arm  mudi  more  than  the  other,  and  the  diagnosis  will  be  made  by  j)hysical  cxamina- 
tioM  of  the  thorax,  assisted  by  the  .r-rays. 

The  only  cranial  nerve  paralyses  that  are  likely  to  be  associated  with  marked  atrophy 
of  muscles,  are  those  of  the  seventh  with  facial  atrophy  (]>.  tOU).  and  of  the  twellth  with 
atrophy  of  the  tongue. 

Injaries  io  periplicral  nerves,  or  inclusion  of  the  latter  in  callus,  will  generally  be 
diagnosed  by  the  history,  and  by  the  fact  that  in  distribution  the  nuiseular  atrophy  and 
H.l).  eorres])ond  accurately  with  one  or  more  of  the  peripheral  nerves  that  may  have  been 
di\ided  or  otherwise  injured. 

If  all  the  conditions  described  above  can  be  excluded,  it  is  probable  that  the  cause 
of  the  nuiseular  atrophy  is  some  variety  of  peripheral  neuritis.  To  merit  this  diagnosis, 
the  affected  muscles  shoukl  be  multiple  and  .symmetrical  :  partial  or  com|)lete  R.D.  should 
be  obtained  :  there  nuiy  or  may  not  be  sensory  changes  ;  the  reflexes,  both  superficial  and 
deep,  are  for  a  short  time  exaggerated,  and  then  become  deficient  or  <lisai)pcar  altogether 
for  the  time  being.  Wasting  may  be  extreme,  but  the  tendency  is  for  slow  recovery  to 
ensue,  improvement  beginning  to  set  in  some  three  or  four  months  after  the  neuritis  ceases. 
.Sometimes  the  nature  of  the  case  is  obvious,  but  it  is  often  easier  to  diagnose  peripheral 
neuritis  than  to  discover  its  exact  cause.  The  different  conditions  that  may  i)roduee  it 
are  cnutncrateil  above.  In  diagnosing  between  them  the  history  is  very  iniporlant.  Kor 
instan<(',  if  the  patient  has  never  been  abroad  leprosy  and  hcri-tieri  are  unlikely,  whereas  if 
he  has  been  abroad  amongst  lci)ers,  and  if  he  has  areas  of  ana'sthesia  without  nuieh 
paresis,  with  or  without  the  characteristic  nodules  and  bosses  of  subcutaneous  infiltration 
{Fin.  l^IJ.  p.  lot),  followed  by  ulceration  and  necrosis,  the  diagnosis  of  leprosy  will  at 
once  suggest  itself.  The  chief  dilliculties  will  perhaps  be  to  exclude  syringomyelia  on  the 
one  hand  and  tertiary  syphilis  on  the  other.  The  good  clfeets  of  treatment  by  iiotassium 
iodide  and  mercury  may  assist  in  deteeting  syphilis,  and  \Vasseruiann"s  reaction  may  be 
positive  :  in  syringomyelia  there  is  little  or  no  loss  of  eulaucous  sensibility  like  there  is  in 
leprosy,  though  there  is  loss  of  power  to  distinguisli  lii.il  licmi  viM.  and  pain  fniiii  touch. 
The  ultimate  lest  of  leprosy  would  be  to  excise  a  small  poitinii  nl  tlu  allrcted  tissue  and 
to  examine  it   for  the  acid-fast  leprosy  bacilli. 

Iliii-hcri  is  sometimes  seen  in  this  country,  geiurally  in  patients  wlm  liaxc  come  into 
lort  in  a  ship  from  the  Kast  :  several  of  the  crew  have  generally  been  aflVctcd  at  the  same 
time,  some  nuiy  have  <lied  :  the  peripluTal  luurilis  and  muscular  wasting  will  often  be 
associated  with  (edema,  and  there  is  often  a  history  that  the  dietary  has  consisted  of 
"Iceorlieated  rice. 

I'he  presence  or  absence  of  gly<MisMria  will  scrxe  to  diagnose  or  cNelude  ilialictic 
neiirilis.  |.i,ss  of  knee-jerk  in  dialietis  Miellitus  is  cdMiparal  i\  ily  eoinnion,  but  e\lensi\e 
peri|)li(  lal    ncmitis    is    i Ii    rarer.       It     is    Mssdcialed    with    jiain    and    par.istliisia    as  well 


64  ATROPHY.     MUSCULAR 

as  paresis  and  nniscular  atiopliy,  and  it  affects  the  limbs,  especially  the  legs,  rather  than 
the  trunk. 

Gout  as  a  cause  of  peripheral  neuritis  is  always  open  to  doubt,  for  often  the  nein-itis 
of  a  gouty  subject  is  really  due  to  the  indulgences  that  brought  on  the  gout.  Difliculty 
may  also  arise  in  attributing  a  neuritis  to  pregnancy  even  when  the  patient  is.  or  has  been 
recently,  jjregnant. 

In  the  case  of  blood  diseases  it  is  important  to  bear  in  mind  that  these  are  usually  treated 
with  arsenic,  so  that  the  peripheral  neuritis  may  be  due  to  the  treatment  rather  than  the 
disease.  This  will  be  rendered  the  more  probable  if  there  are  or  have  been  other  symptoms 
of  subacute  or  chronic  arsenical  poisoning,  such  as  coryza,  nausea,  \omiting,  abdominal 
colic,  diarrhoea,  headache,  pigmentation  of  the  skin  not  unlike  that  of  Addison's  disease, 
hyperkeratosis  of  the  palms  and  soles,  or  herpetiform  eruptions,  AVith  arsenical  neuritis  the 
limbs  are  involved  most,  particularly  the  legs,  and  there  are  pains  and  paraesthesia  as  well 
as  jjaresis.  The  blood  diseases  may  themsehcs  cause  peripheral  neuritis,  however,  just  as 
severe  anfemias,  such  as  pernicious  ana-mia,  may  cause  degeneration  in  other  parts  of  the 
nervous  system  also,  notably  in  the  long  tracts  in  the  spinal  cord,  with  consequent  sensory, 
ataxic,  or  paretic  symi^toms.  varying  with  the  ])arts  involved.  If  the  jjeripheral  neuritis 
occurs  early  in  the  blood  disease,  the  latter  may  not  come  to  mind  as  a  possibility. 
A  blood-count  is  essential  (p.  *24).  OligocythaMuia  with  high  colour  index,  no  leuco- 
cytosis,  a  relative  lymphocytosis,  and  the  presence  in  blood  iilms  of  a  preponderance  of 
megalocytes.  are  changes  characteristic  of  pernicious  ancemia,  in  addition  to  which  the 
primrose-yellow  skin  may  be  typical.  Great  increase  in  the  total  number  of  leucocytes  up 
to  anything  from  .50,000  to  1.000,000  per  c. mm.  would  suggest  Icucocytlia'niia  :  if  this  were 
the  spleno-medullary  form,  myeK)cytes  would  probably  be  30  per  cent  or  more  of  all  the 
white  cells  seen  in  films,  whilst  in  tlie  lymphatic  form  the  lymphocytes  would  similarly 
amount  to  90  per  cent  ;  in  both  forms,  jjarticularly  the  siileno-medullary,  the  spleen  and 
liver  would  be  big,  whilst  in  the  lymphatic  tyjie  there  would  ])robably  be  general  enlarge- 
ment of  the  lymphatic  glands. 

Ilodgkin's  disease  or  lympliadcnoma  suggests  itself  when  the  s])leen  and  many  of  the 
lymphatic  glands  are  enlarged,  without  any  characteristic  blood  changes — at  most  a  simple 
auicmia  without  leucocytosis,  with  relative  lymphocj'tosis,  and  an  occasional  myelocyte, 
basophile  corpuscle,  and  nucleated  red  cell  in  films.  Splenic  ancemia  is  a  doubtful  entity, 
the  name  being  applied  when  there  is  simple  anitmia  with  apparently  idiopathic  enlarge- 
ment of  the  spleen.  Many  such  patients  ultimately  turn  out  to  have  cirrhosis  of  the  liver 
— Banti's  disease.     Peripheral  neuritis  in  sucJi  a  case  may  well  be  alcoholic. 

Malaria  will  be  diagnosed  by  the  history,  and  by  the  discovery  of  the  hirmatozoa  in 
the  blood  (p.  29).  The  difficulty  may  be  to  exclude  alcohol  as  a  cause  for  the  neuritis  in 
a  jiatient  who  has  also  suffered  from  severe  malaria. 

Infective  endocarditis  is  sometimes  so  chronic  and  insidious  that  it  escapes  detection. 
Pt)ints  to  lay  stress  on  are  simimarised  on  p.  34. 

It  may  not  be  easy  to  convince  onselt  that  some  other  cause  of  chronic  pycrniia,  whether 
uterine,  pelvic,  pulmonary,  oral,  or  otherwise,  is  the  cause  of  peripheral  neuritis  in  a  given 
case.     The  same  applies  to  sypliHis,  especially  if  the  patient  is  also  addicted  to  alcohol. 

Influenza  is  not  to  be  diagnosed  as  the  cause  vmtil  every  other  jiossible  exjjlanation  has 
l)een  exhausted  ;  it  is  too  easy  to  attribute  things  to  influenza.  Peripheral  neuritis  from 
typhoid  fever  generally  arises  as  a  direct  sequel  of  a  typical  attack  confirmed  by  Widal's  test, 
so  that  the  diagnosis  is  not  difficult  as  a  rule.  It  has  the  same  type,  sensory  and  motor,  as 
arsenical  neuritis. 

Diphtheria  is  one  of  the  most  important  of  all  the  causes,  and  if  the  diphtheria  itself 
has  been  slight,  it  may  have  been  overlooked  entirely,  especially  as  the  neuritis  develojij. 
two  or  three  weeks  or  longer  after  the  sore  throat.  It  is  important,  tlierefore.  to  lose  no 
time  in  taking  cultivations  from  the  throat  in  all  doubtful  cases  of  peripheral  neuritis  :  it 
may  still  be  possible  to  find  the  causal  organisms  in  swabbings.  The  nature  of  the  case 
may  be  suggested  at  once,  however,  if  there  has  been  a  nasal  alteration  in  the  voice  (p.  58SI), 
or  if  there  is  an  inaliility  to  swallow  liquids  owing  to  their  regurgitation  through  the  nose — 
e\idence  of  jiaralysis  of  the  palate  that  is  almost  characteristic  of  diphtheria  ;  the  pu))il 
reflexes  are  also  apt  to  be  affected,  and  the  patient  may  be  thought  to  ha\-e  an  error  ol 
refraction    because    pjiresis    of    the    ciliary    muscle    renders    acconunodation    difiicult    oi 


PLATE     VII. 

PIGMENTATION       DUE      TO      ARSENIC 


'4  K 


ATROPHY,     MUSCULAR  65 

impossible  for  the  time  beinn;.  The  symptoms  may  stop  at  the  ])alate  and  eye  ;  but  in 
bad  cases — perhaps  as  the  result  of  a  toxin  different  from  that  wliieh  directly  affects  the 
palate — paralysis  and  extreme  atrophy  of  the  limbs,  without  much  sensory  disorder,  follow. 
The  vagus  nerves  may  be  involved,  causing  tachycardia,  and  perhaps  death  ;  equally 
serious  may  be  the  involvement  of  the  phrenic  nerves,  with  weakness  or  paralysis  of  the 
diaphragm. 

In  regard  to  the  vmious  cliemicnl  substances  that  may  produce  peripheral  neuritis, 
iiKjuiries  into  tlie  patient's  occupation  may  assist  the  diagnosis.  Workers  amongst  india- 
ruliber  come  in  contact  with  carbon  bisulphide  fumes,  this  comjioimd  being  used  to  dissolve 
the  rubber.  Xtiplilliii  is  used  extensively  in  some  trades.  The  use  of  a  chemical  may  not 
always  be  obvious  until  careful  inquiries  are  made — for  instance,  one  may  not  at  first  see 
what  a  person  who  ]]re])ares  rabbit  skins  for  conversion  into  hats  has  to  do  with  mercury, 
until  it  is  learned  that  mercurials  are  used  to  preserve  the  pelts.  Mercurial  neuritis  is 
characterized  by  a  remarkable  tremor  of  the  hands  and  arms,  in  addition  to  the  muscular 
atrophy  in  the  amis  and  legs  ;  there  are  not  many  sensory  symptoms  as  a  rule.  Lead 
neuritis  is  easily  diagnosed  when  it  causes  the  characteristic  wrist-drop,  though  a  similar 


piiniivsis  111  I  lie  liand  may  be  due  to  other  forms  of  peripheral  neuritis  such  as  diplitheritic 
IFifi.  22).  or  to  the  result  of  compression  of  the  musculo-spiral  nerve  by  callus  or 
(Tutch-hcad.  or  by  sleeping  with  both  arms  across  the  arms  of  a  chair — '  Saturday  night 
palsy"  :  in  fihirnbic  wrist -drop  all  the  muscles  supplied  by  llic  musculo-spiral  nerve  beyond 
llic  triceps  bcconic  paralyzed,  except  the  supinator  longus  and  the  cxiciisor  ossis  iiictacarpi 
pollicis,  aiKJ  IIk  re  is  no  sensory  disorder  :  the  escape  of  the  supinator  longus  dislinguishcs 
wrist -drop  due  to  plutnbism  from  that  due  to  compression  of  the  nuisculospiral  nerve  ;  the 
diagnosis  is  confirmed  by  finding  a  blue  line  upon  the  gums  and  the  other  signs  of  lead 
pf)is<)iiing  described  on  p.  :( I-.  'I'he  dillicully  arises  in  less  typical  cases  in  which  the  lead 
causes  generalized  peripheral  neuritis  in  both  legs  and  arms,  ])erha[)s  without  any  other 
syniploins.  without  even  a  blue  line  upon  the  gums  if  the  teeth  are  kept  clean.  'I'he  source 
<)r  the  lead  may  be  very  far  from  (ib\ious  it  may  be  some  obscure  thing,  such  as  a  hair- 
wash,  or  (he  result  of  water  contaminati<in  due  to  electrolysis  in  water-pipes,  the  result  of 
leakage  in  an  electric  main.  In  ease  of  doubt  it  may  even  be  worth  while  to  analyze  the 
faices  or  cvajxirate  down  a  large  bulk  of  urine  and  apply  the  lunmonium  suliihide  test  for 
lead  to  the  residue  :  a  drop  or  two  of  Ihc  latter,  allovved  to  fall  into  a  tall  glass  full  of 
amnioniiini  suiplude,  will  cause  a  white  trail  l<>  develop  in  the  fluid  as  tlii'  drop  descends. 
Arseniciil  nvurilis  has  been  mentioned  above  (p.  Gl)  ;    it  may  arise  in  patients  who  are 


66  ATROPHY,     .^lUSCULAK 

taking  arsenic  in  medicinal  doses,  for  instance  for  chorea  or  peniicions  ana'mia,  or  the 
j)oison  may  be  taken  unawares,  as  in  the  Manchester  e]3idemic.  in  which  fatal  results  foUowerl 
contamination  of  beer  with  ai-senic.  It  has  even  been  held  that  alcohol  itself  is  no  cause  ot 
peripheral  neuritis,  and  that  those  patients  who  have  developed  it  as  the  result  of  lonjj- 
continiicd  drinkini;  to  excess — possibly  without  a  single  actual  intoxication  in  the  popular 
sense — owe  the  nerve  trouble  and  generalized  muscular  atrophy,  not  to  the  chemical  sub- 
stance C„H,.0,  but  to  other  bodies  associated  with  it.  Clinically,  however,  it  is  sufficient 
if  the  diagnosis  of  the  cause  of  periplieral  neuritis  can  be  narrowed  down  to  alcohol  in  some 
form  or  other,  and  for  this  to  be  possible  an  accurate  history  is  essential.  The  greatest 
difliculty  arises  in  the  ease  of  secret  drinkers,  especially  women  who  may  ajjpear  to  be  above 
suspicion.  The  neuritis  is  ushered  in  with  pains  and  cramps  in  the  limbs,  followed  by 
wasting  which  may  reach  an  extreme  degree  :  the  trinik  and  limbs  sometimes  look  like 
those  of  a  i)erson  who  has  been  starved  to  death  :  if  arsenic  is  suspected,  a  portion  of  hair 
should  be  sent  for  cliemieal  analysis  ;  the  hair  of  a  ])erson  taking  arsenic  stores  the  latter 
in  proportions  sufficient  to  allow  of  its  detection. 

It  only  remains  to  add  that  there  will  alwa\s  be  some  cases  in  \\hich  the  cause  of  the 
peripheral  nem-itis  fails  to  be  found.  Herbert  French. 

ATROPHY,  OPTIC— (See  ()pnTn.\i.MOscopic  Appearances.  Notes  on.  p.  416.) 

ATROPHY,  TESTICULAR.— When  one  testis  is  smaller  than  the  other,  it  is  first 
necessarv  to  determine  which  is  the  abnormal  one  :  for  when  one  is  slightly  enlarged,  it  may 
be  regarded  erroneously  as  normal  and  the  other  as  too  small.  Some  inequality  may  be 
jjliysiological.  as  is  the  case  with  paired  organs  generally.  Physiological  atrophy  of  the 
testes  is  apt  to  occur  in  advanced  life  ;  it  may  begin  as  early  as  fifty,  though  many  old 
men  have  testicles  of  normal  size. 

A  testis  in  an  abnormal  position,  in  the  inguii\al  canal  f>r  elsewhere,  is  subject  not  only 
to  such  causes  of  atrophy  as  may  affect  one  normally  situated,  but  ma>-  also  be  inhibited  in 
growth  from  compression  by  surrounding  parts. 

The  causes  of  atrophy  of  a  normally  situated  testis  may  be  grouped  imder  three  main 
headings,  as  follows  : — 

1.  Interference  with  the  Blood  Supply: — 


Compression  of  the  spermatic  cord,  as  by  an 

inguinal  hernia,   a  spermatocele,   or  an  ill- 

tittina    truss. 
C(iiii|ir(ssiiiTi   of  the  testicle  by  affections  of 

tlir   liniica   vaginalis,  such  as  hvdrocele  or 

hainaldcrle. 


Venous  stasis,  tlie  resuh  of  varicocele. 

.\s  a  sequel  of  operation  in  the  region  of  the 
spermatic  coril,  such  as  those  for  the  cine 
of  varicocele,  spermatocele,  or  hernia. 

Elephantiasis. 


2.  Atrophy,  after  Orcliitis  or  Epididymitis,  due  to  such  causes  as — 

(ionorrlicea  I         Mumps  I  Gout 

Tubercle  .Y-rays  Syphilis 

Injury  |         Typhoid   fever  |  Influenza  (?) 

3.  Neurotrophic  Causes,  especially  after  injury  to  the  brain  or  spine. 

It  has  been  stated  that  the  atrophy  may  residt  from  iodide  of  potassiimi  :  this  is 
dillicnlt  to  prove,  for  it  seldom  hapjjcns  that  this  drug  is  given  unless  there  is  already  some 
oilier  possible  cause,  particularly  sy]ihilis  or  orchitis. 

In  the  differential  diagnosis  between  the  al)o\c  causes  the  history  is  in  most  instances 
\cry  important. 

The  cause  in  any  of  the  cases  in  Group  1  will  generally  be  ob\'ious.  It  is  only  necessary 
to  bear  in  mind  that  an  operation  for  varicocele,  for  instance,  may  have  been  performed 
successfully,  and  the  patient  may  thereafter  contract  an  orchitis  followed  l)y  tcsticidai 
atrophy  for  which  the  operation  may  be  blamed  unjustly. 

As  regards  Group  2.  it  is  very  doubtful  whether  influenza  ever  really  ])rodueed  either 
orchitis  or  testicular  atrophy.  There  may  be  a  definite  history  of  gonorrhoea,  followed  b\ 
orchitis,  which  preceded  the  atrophy,  and  then  diagnosis  is  easy.  It  is  to  be  remembered 
however,  that  by  no  means  every  orchitis  is  gonococcal.  If  miunps,  typhoid  fever,  goul 
and  injury  are  borne  in  mind,  these  causes  of  orchitis  and  testicular  atrophy  will  1" 
recognized  more  often  than  they  are.     JMiunps  is  particularly  apt  to  be  overlooked  :   orchitii 


AURA  67 

may  be  the  sole  e\'idence  of  this  complaint.  If  the  patient  is  seen  when  the  orcliitis 
is  active,  bacteriological  examination  of  any  urethral  discharge  is  essential  to  the  dia- 
gnosis, which  depends  on  whether  gonococei  are  detected  or  not.  If  gonorrlura  can  be 
excluded,  then  the  diagnosis  of  the  nature  of  the  orchitis  is  arrived  at  by  considering 
the  evidence  as  to  gout,  mumps,  and  so  on. 

It  is  sometimes  stated  that  orchitis  may  result  from  strain,  atrophy  resulting  in  due 
course.  There  are  a  few  cases  in  which,  apparently  as  the  result  of  great  bodily  exertion, 
es])ecially  the  lifting  of  heavy  loads,  inflammation  of  the  testicle  follows  :  but  it  is  difficult 
to  say  that  in  these  cases  the  strain  alone  produced  the  symptoms  ;  there  is  the  possibility 
that  there  may  have  been  residual  gonorrhcca  in  the  jjrostate  or  jjosterior  urethra,  the 
action  of  the  strain  being  merely  to  light  u))  the  latent  inflammation.  It  is  possible  that 
sometimes  the  latent  infection  is  not  gonococcal,  but  due  to  other  organisms,  such  as  staphy- 
lococci or  streptococci,  whilst  recent  observers  record  the  bacillus  coli  comnumis  as  the 
causal  organism  in  some  cases  of  "  spontaneous  '  orchitis. 

There  remain  a  number  of  cases,  however,  in  which  there  is  no  clear  history  of  orchitis, 
the  latter  having  been  relatively  slight.  Testicular  atropliy  will  then  seem  to  have  arisen 
idiopathically,  and  it  is  important  to  remember  how  often  it  is  the  result  of  former  injury, 
such  as  a  kick  at  football,  a  blow  from  a  cricket  ball,  contusion  from  falling  astraddle  on  a 
fence  or  bicycle,  and  so  on.  The  injury  may  date  back  to  boyhood,  many  years  before 
testicular  atrophy  is  noticed,  and  it  will  often  be  difficult  to  ))rove  that  the  latter  was  really 
due  to  the  former.  r.1 

A])art  from  obvious  tuberculous  epididymo-orchitis.  transient  enlargement  of  a  testis 
is  to  be  observed,  if  looked  for,  in  tuberculous  subjects  ;  whether  this  can  be  regarded  as  a 
dcMnite  tuberculous  orchitis  or  not.  it  sometimes  results  in  atrophy. 

Tlie  j'-rays  are  a  possible  cause  of  testicular  atrophy,  and  all  users  of  .r-rays  should  be 
careful  to  have  a  suitable  lead  shield.  That  sterility  can  result  from  repeated  applications 
of  these  rays  is  well  known. 

.\s  regards  (Jroup  8.  the  history  as  a  rule  gives  the  diagnosis.  Remarkable  instances 
have  been  recorded  in  which,  within  a  few  months  of  injury  to  the  brain  or  spinal  cord, 
particularly  after  injury  to  the  hmibar  vertebrje,  or  the  occipital  region  of  the  skull,  the 
glandular  elements  of  the  testicle  have  disappeared.  A  case  of  Kocher"s  exemplifies 
this:  A  man.  age  41.  the  lather  of  four  children,  fell  on  his  head  from  a  considerable 
height.  .\t  lirst  he  did  not  ajipear  to  be  greatly  damaged,  but  ])resently  twitchings 
occurred,  and  the  patient  became  unable  to  work.  From  this  time  on  Iiis  sexual  powers 
diminished  greatly,  and  his  beard  and  iiubic  hair  fell  out.  Eighteen  niontlis  later  this  hair 
was  gone  compklcl\ .  and  about  five  years  after  the  accident  the  left  testicle  was  tbc  size 
of  a  hazel  nul.  the  right  the  size  of  a  bean.  llnhirt   J'rnirli. 

AURA  is  the  term  applied  to  the  inunediate  prelude  of  an  cpiUplic  seizure.  It  is 
recognized  in  some  form  or  another  in  about  ;i()  or  40  per  cent  of  epilcplics,  and  with  rare 
exceptions  always  takes  the  same  shape  with  every  attack  in  each  indixidual.  An  aura 
may  be  motor,  .sensory,  ])sychical,  visceral,  or  related  to  some  special  sense.  A  motor  aiua 
may  he  rcpresenled  by  an  involuntary  movement  of  a  limb  or  a  part  of  a  limb  ;  in  othei' 
cases  it  talTcs  the  form  of  a  general  movement  such  as  rumiing.  .\  si'iisori/  aura  is  conmion. 
and  is  described  as  a  pain,  a  numbness,  or  a  tingling  in  some  part  of  the  patient's  body.  .\ 
psj/rliical  iuna  is  often  expressed  as  a  vague  apprehension,  or  an  indescribable  feeling,  or  a 
sense  of  unreality.  .\  Tisreral  aura  is  fre<|uent.  usually  as  an  •epigastric  sensation"  or 
queer  feeling  starting  in  the  region  of  the  stomach  and  rising  to  the  throat,  or  less  often  as 
a  pcremjjtory  desire  to  go  to  stool.  An  aura  of  special  sense  may  be  olf/KiDii/.  -riKiiiil. 
iKidiloi-i/.  m  fiii.ilnloij/  :  a  pleasant  or  unpleasant  (iridui-  m  flavour  may  be  pincJNcil  b\  llie 
patient,  or  some  alleralion  in  vision  may  warn  liini  u\'  llu'  onset  of  a  sci/mc.  or  he  may 
hear  voices  or  some  parlieular  kind  of  soimil. 

The  aura   of  epilepsy   is.   in   relation   to  diagnosis,   imporlani    fr al    Icasl    I  wo   points 

of  view.  Ill  llic  lirsl  place,  it  olleli  affords  a  clue  to  the  parliiular  hiealily  in  llie  brain 
froie  whicli  tlic  '  III  '  or  •  sloiin  '  originates  and  spreads.  This  ma\  not  he  ol  iiiiieli 
value  in  the  case  of  idiopathic  epilepsy,  because  there  is  no  method  at  present  known  lo 
us  by  which  the  seal  of  the  disease  can  be  treated  successfully.  In  tlu' ease  of  .buksonian 
epilepsy,  on  the  other  hand,  the  knowledge  of  the  locality  in  which  a  (il   is  generated  some- 


6K  AURA 

times,  although  unfortunately  not  often,  allows  of  benefit  being  obtained  from  surgical 
assistance.  For  instance,  an  aura  may  be  the  first  symptom  of  the  presence  of  an  intra- 
cranial groivth.  A  tumour  of  the  uncinate  region  of  the  temporo-sphenoidal  lobe  may  be 
revealed  by  the  presence  of  signs  of  increased  intracranial  pressure  and  the  repeated 
occurrence  of  an  olfactory  aura,  followed  by  a  vague,  dreamy  state  of  consciousness.  A 
lesion  of  one  occipital  lobe  may  be  suspected  from  the  occurrence  of  epileptiform  fits 
immediately  preceded  by  an  ain-a  in  which  there  is  loss  of  sight  in  the  opposite  visual  field. 
An  aura  of  pain  starting  in  the  left  foot,  spreading  up  tlie  left  side  of  the  body,  and 
terminating  in  a  generalized  convulsion,  suggests  a  lesion  in  the  post-RoIandic  region  of  the 
right  parietal  lobe.  Such  instances  of  the  importance  of  an  aura  as  a  localizing  sign  in 
diagnosis  might  easily  be  multiplied,  but  a  general  knowledge  of  the  functional  anatomy  of 
Ihe  brain  will  suffice  to  supply  other  examples  of  a  similar  kind  to  the  reader's  mind. 

In  the  second  place,  the  importance  of  recognizing  a  subjective  sensation  as  an  aura, 
and  so  recognizing  the  existence  of  epilepsy  in  its  simplest  and  sometimes  earliest  form, 
can  hardly  be  over-estimated  from  the  point  of  view  of  treatment.  VMien  a  patient  describes 
himself  as  being  liable  to  subjective  sensations  occurring  at  intervals,  and  for  which  he 
cannot  account,  careful  inquiry  should  be  made  as  to  their  nature.  The  chief  characteristics 
of  an  aura  are:  (1)  Its  spontaneous  development  without  cause,  generally  during  good 
health  :  (2)  The  suddenness  of  its  onset  ;  and  (3)  The  identity  of  each  sensation  with  the 
last.  It  should  be  understood  clearly  that  an  aura  may  occur  alone,  or  may  be  followed 
by  momentary  loss  of  consciousness  (petit  mal),  or  by  loss  of  consciousness  with  convulsions 
(grand  mal).  In  some  cases  an  aura  may  be  repeated  with  frequency  for  many  months 
before  a  typical  epileptic  seizure  supervenes,  and  if  recognized  as  such  during  this  stage, 
it  is  reasonable  to  expect  that  treatment  will  have  more  chance  of  success  than  at  a  later 
period,  when  the  "  habit "  of  convulsions  has  been  established  firmly. 

Finally,  it  should  be  emphasized  that  in  cases  of  epilepsy  the  recurrence  of  an  aura, 
even  without  further  manifestations  of  the  disease,  is  evidence  that  the  morbid  tendency  is 
not  controlled  completely,  and  that  discontinuance  of  treatment  will  lead  to  the  reappearance 
of  more  serious  attacks.  E.  Fanjubar  Buzzard. 

BABINSKI'S  SIGN — consists  in  a  modification  of  the  plantar  reflex.  In  testing  the 
latter  the  j)atient  should  be  lying  upon  his  back,  with  his  legs  very  slightly  flexed  and  each 
foot  everted  so  that  its  outer  border  lies  comfortably  in  contact  with  the  bed  or  couch  : 
the  sole  should  be  warm  and  dry  ;  the  ankle  should  be  gently  but  firmly  grasped  by  one  of 
the  observer's  hands,  to  prevent  the  undue  dorsiflexion  of  the  whole  foot  which  often  makes 
it  difficult  to  decide  which  way  the  toes  themselves  move,  wliilst  the  outer  side  of  the  sole  is 
firmly  and  steadily  stroked  from  the  heel  forwards  with  some  such  instrument  as  the  butt 
end  of  a  pencil.  In  healthy  adults  the  big  toe  and  the  other  toes  will  become  plantar-flexed  : 
when  the  great  toe  becomes  dorsiflexed  instead,  it  presents  tlic  extensor  plantar  reflex,  or 
Babinski's  sign,  ^^liichever  way  the  other  toes  move,  it  is  with  the  direction  of  movement 
of  the  big  toe  alone  that  Babinski's  sign  is  concerned.  It  is  noteworthy  that  if  Babinski's 
sign  is  present,  the  fact  is  usually  ascertained  with  ease  ;  when  there  is  any  doubt  as  to 
which  way  the  great  toe  moves,  the  plantar  reflex  is  seldom  really  extensor. 

The  great  value  of  the  sign  is  in  distinguishing  between  functional  and  organic  affections 
of  the  nervous  system.  If  the  patient  is  a  fully  conscious  adult  with  paresis  of  one 
or  both  legs,  the  existence  of  an  extensor  plantar  reflex  is  proof  that  the  lesion  is  organic. 
The  converse  is  not  true  ;  for  with  locomotor  ataxy,  and  with  lower  neuron  affections 
such  as  infantile  paralysis.  Tooth's  peroneal  tjpe  of  progressive  muscular  atropliy.  perijiheral 
neuritis,  Landry's  acute  ascending  paralysis,  and  primary  nniscular  dystropliics,  the  plantnr 
reflex  is  flexor  if  it  is  obtainable  at  all. 

Babinski's  sign  is  seen  best  when  there  is  a  lesion  in  the  crossed  jiyramidal  tract.  Thus 
it  is  present  in  cases  in  which  tumour,  abscess,  hsemorrhage,  thrombosis,  or  embolism  have 
caused  hemiparesis  or  hemiplegia  by  affecting  either  the  pyramidal  cells  themselves  in 
the  motor  cortex  or  the  pyramidal  fibres  in  the  internal  capsule  ;  in  cases  of  cerebellar 
tumour,  owing  to  the  fact  that  this,  by  compressing  the  medulla,  nearly  always  causes 
lateral  sclerosis  of  the  cord  as  well  ;  and  in  cases  of  disseminated  sclerosis,  transverse  myelitis, 
either  primary  or  due  to  compression,  ataxic  paraplegia,  Friedreich's  ataxy,  amyotrophic 
lateral  sclerosis,  primary  lateral  sclerosis,  some  cases  of  syringomyelia,  and  in  those  cases 


BACTEKIURIA  69 

of  irregular  sclerosis  of  tlie  cord  that  may  be  associated  with  sc\erc  ohgocytha?mias  such  as 
pernicious  anjeniia.  Tlie  differential  diagnosis  of  these  conditions  wilf  be  found  under 
Hejiiplegia  (p.  £02)  and  Paraplegia  (p.  310)  and  elsewhere.  Babinski's  sign  is  not  found 
in  those  cases  of  hysteria  that  sometimes  sinnilate  one  or  other  of  the  above  conditions  ; 
provided  always  that  the  ])atient  is  a  conscious  adult.  This  proviso  is  important,  because 
the  plantar  reflex  may  be  extensor  without  there  being  any  decided  changes  in  the  cord 
or  brain  in  infants  and  (luite  young  children  :  also  in  a  considerable  proportion  of  older 
children  suffering  from  chorea  :  and  also  sometimes  in  adults  during  deep  sleep,  or  under 
conditions  of  nnnatural  unconsciousness  such  as  that  due  to  a  general  ana;sthetic,  or  acute 
alcoholic  intoxication,  or  such  affections  as  epilepsy,  uraemia,  concussion,  saturnine  encephalo- 
pathy, and  in  some  other  forms  of  coma.  These  exceptions,  however,  scarcely  detract 
from  the  great  value  the  sign  has  as  a  means  of  distinguishing  between  organic  and  functional 
paralysis  of  the  legs  of  the  upper  neuron  type.  "  "  "  Herbert    French. 

BACILLURIA.— (See  Bacteriuria.  uifra.) 

BACTEHIURIA  (see  Plate  XXVIII.  p.  Ol-i)  is  a  comjjreliensive  term  employed  to 
indicate  that  the  urine  when  freshly  voided  contains  micro-organisms.  Bacilluria  is  a  term 
of  similar  imjiort,  but  is  restricted  to  those  cases  in  which  rod-shaped  bacteria  are  present. 
The  \:iginal  segment  of  tlu^  female  urethra  and  the  anterior  portion  of  the  male  urethra  are 
n<)rniall>-  inhabited  by  certain  non-])athogcnic  bacteria  (chiefly  cocci,  such  as  Streptococcus 
brevis.  StapliijIoioccK.s  ulhiis.  also  varieties  of  Bacillus  xerosis,  etc.),  which  are,  of  course, 
present  in  urine  obtained  under  ordinary  conditions,  and  so  constitute  what  may  be  termed 
physiological  bacteriuria.  Bacteriuria  as  a  pathological  condition  tlue  to  some  lesion  of 
the  urinary  system  posterior  to  the  urethra  can  only  be  recognized  with  certainty  by  the 
examination  in  the  laboratory  of  a  catheter  specimen  of  the  urine  collected  with  the  most 
scrujiulous  attention  to  asepsis  :  for,  on  the  one  hand,  a  perfectly  clear  acid  urine  may  be 
hea\ily  loaded  with  bacteria,  and.  on  the  othei-.  a  mine  may  owe  its  turbidity  cither  to 
purely  physico-chemical  causes,  or  to  the  growth  in  it  of  bacteria  which  have  gained  access 
after  its  exit  from  the  urethra.  Moreover,  although  the  identity  of  the  infecting  organism 
may  be  suspected  from  general  clinical  considerations,  cultivation  exijcriments  are  essential 
in  order  to  settle  the  matter  beyond  doubt. 

Bacteriuria  may  be  jxrsistent  and  may  indicate  either  general  or  local  infection.  It  is 
a  rare  symptom  of  general  infection,  save  one  of  such  intensity  that  an  acute  ne])hritis, 
as.soeiated  with  a  definite  luematuria.  has  supervened.  I'sually  its  appearance  indicates 
a  local  infection  of  the  urinarj-  tract  :  it  then  occurs  with  greatest  frequency  in  young 
children  and  ])regnant  women,  when  the  micro-organism  concerned  is  usually  B.  cofi,  and 
the  site  of  the  infection  the  pelvis  of  the  right  kidney.  It  is,  however,  met  with  at  all  ages 
and  in  both  sexes,  and  many  djlfercnt  bacteria  have  been  recorded  as  the  causative  faetoi's, 
and  whilst  the  itilccliun  is  commonly  due  to  some  partieulav  micro-organism,  the  possibility 
of  multiple  infection  nuist  not  be  forgotten —the  most  usual  being  a  double  inlVction  due 
to  H.  roll  communis  and  Streptococcus  pijoneiies  lotigus. 

When  Intermittent,  bacteriuria  may  indicate  a  general  inleclion.  or  a  local  inreetion 
of  some  area  <iistant  from  the  minary  tract,  as,  for  exanii)le,  a  tonsillitis  or  a  dental  abscess, 
anil  often  in  an  obscure  ease  of  pyrexia  a  bacteriological  examination  of  the  urine  will  well 
repay  the  trouble  involve.l.  Intermittent  bactcrim-i,i.  parti<iilariy  of  the  staphylococcic 
type,  is  often  associated  with  Isidncy  ealcnius,  and  il  is  aKd  rwit  uuconmion  in  Cases  of 
rheiimatoiil  arthritis. 

Haelerinria  may  he  a  s_\  iiiolorri  in  : 

-I.  General  Infections,  with  oi-  witliout  associalid  nr|i|]ritis.  due  to: 

Slnploeoeeus  py»«cnc>,  loii^r„s        Sl:i|.li ylneoeciis    pyojrcncs    ail-        15.  coli 


einnoet 


ininunis 


H.   (iMial vpliosus 
M.  typluiMis  I    .Micincocens  niclilerisis 


/'?  Local   Infections : 

»e|ihritis,  pyelonephritis.  ,„■  ureteritis  due   to: — 
"•^"''  .  H.    |.neinn.mi;r    (Kriedliin.ler's       Sla|.l,yl.i 


H.  luherciildsis 
M 


liacillus) 
Strcplocdceiis  py(i;;cMcs  Iciml'Ms        Pn. 


70  BACTERIURIA 

Cystitis  due  to  : — 
B.  coll  I    B.  typhosus  I    Staphylococcus    pyogenes    au- 

B.  tuberculosis  i    Streptococcus  ])yoaeues  loufjus    |        reus 

Prostatitis  due  to  : — 
B.  coll  I    Staphylococcus    ijvogcucs    au-       Streptococcus  pyogenes  longns 

tJonococcus  I        reus 

Urethritis  due  to  : — 
Conococcus  <    Pneiunococcus  j   Micrococcus  catarrlialis 

Sta|)hylococcus  aureus  or  albus    '    Streptococcus  pyogenes  longus    , 

In  tlie  above  table  the  various  micro-organisms  are,  speaking  generally,  arranged  in 
the  order  of  their  frequency. 

Finally,  a  slight  and  transitory  bacteriurla  due  to  B.  coli  commioiis,  and  one  usually 
passing  off  without  any  treatment,  can  frequently  be  observed  following  operative  measures 
upon  the  rectum  or  anus,  or  the  organs  of  generation. 

In  general  infections  the  urine  is  either  normal  in  appearance,  or  by  reason  of  its  admix- 
ture with  blood  may  present  any  tint  from  "  .smoky  '  to  bright  red.  The  reaction  is  usually 
acid;  often  a  degree  of  acidity  is  recorded  which  if  present  in  an  artificial  culture  medium 
would  inhibit  the  growth  of  the  infecting  micro-organism.  Albumin  is  present,  varying  in 
amount  from  a  trace  to  7,  8,  or  more  parts  per  thousand,  and  microscopical  examination 
of  the  centrifiigalized  deposit  shows  blood-cells,  renal  tube-casts,  and  renal  epithelium,  in 
addition  to  the  infecting  bacterium.  The  clinical  sym|)tonis  ])resented  by  the  patient  are 
those  of  the  general  systemic  infection. 

In  local  infections  of  the  genito-urinary  tract  where  infection  is  due  to  one  species  of 
micro-organism  only,  the  urine  jjresents  a  somewhat  similar  appearance  ;  blood,  liowever, 
may  be  entirely  absent,  while  pus  when  measured  by  the  centrifuge  may  vary  in  volume 
from  a  trace  to  10  or  20  per  cent  of  the  total  bulk  of  urine.  In  the  early  .stages  of  a  local 
infection,  however,  microscopical  examination  of  the  deposit  may  merely  show  the  presence 
of  leucocytes  slightly  in  excess  of  normal,  so  that  without  the  use  of  the  microscope  the  fact 
of  pyuria  may  easily  be  missed  altogclher. 

Occasionally,  and  particularly  in  adult  cases,  it  may  be  noted  that  the  urine  passed 
during  the  day  is  neutral  or  faintly  alkaline — the  change  in  reaction  then  being  due  to 
|)hysioIogical  causes.  In  those  cases  where  the  urine  is  strongly  alkaline  the  alkalinity  is 
due  to  annnonia  resulting  from  the  decomposition  of  urea,  not  by  the  jiathogenic  infecting 
organism  but  by  non-pathogenic  saprophytes  which  have  gained  access  to  the  urine,  either 
after  it  has  been  voided  or  whilst  still  intra  vesicam.  In  the  latter  instance  the  contamina- 
tion may  have  taken  place  as  a  residt  of  careless  instrumentation,  or  (as  in  the  female)  by 
continuity  of  surface,  but  it  also  fretjuently  occurs  owing  to  the  passage  of  micro-organisms 
through  the  inflamed  bladder  wall  from  the  lumen  of  the  adjacent  large  intestine. 

The  clinical  symptoms  associated  with  bacteriuria  due  to  local  infection  vary  enor- 
mously with  different  patients.  Frecjuency  of  micturition,  scalding,  didl  aching  pains  in 
one  or  both  loins,  with  tenderness  on  deep  jjressure  over  the  kidney  or  meters,  pains  in  the 
perineum  and  hypogastriiun  (according  to  the  situation  of  the  jirimary  infection),  severe 
rigors,  pyrexia  {Fig.  193,  p,  456),  anorexia,  nausea,  and  vomiting  are  amongst  those 
commonly  observed.  It  is  important  to  remember  its  relatively  common  occurrence  in 
children,  in  whom  there  may  be  hardly  any  symptoms  at  all,  or  perhaps  general  delicacy 
or  ill-health,  or  gastro-intestinal  disturbance,  without  any  special  urinary  symptoms 
attracting  notice.  The  urine  generally  contains  only  a  trace  of  albumin,  and  no  obvious 
]}us  ;  the  diagnosis  then  depends  upon  bacteriological  investigation  of  a  catheter  specimen, 
the  need  for  which  will  be  suggested  by  the  discovery  of  a  decided  excess  of  leucocytes  in 
the  centrifugalized  deposit  from  the  specimen  first  collected  during  the  routine  examination 
of  the  patient.  .Inn.  Ejire. 

BALDNESS. — Alopecia,   or   baldness,   may  vary   in   degree   from   slight   thinning  to: 
complete  loss  of  the  hair.     There  are  three  main  varieties  of  simple  baldness  or  alopecia 
namely:   (1)  CoiigciiHal.  (2)  Senile,  a.nd  (3)  Premature. 

Congenital  Alopecia  is  seldom  complete,  and  the  hair  may  be  laiuigo-like.  In  tin 
latter  case  the  diagnosis  is  certain,  as  it  also  is  when  the  baldness  is  accom])anied  1)\ 
developmental  defects  in  the  skin  or  its  appendages.     Wlien  there  is  comjilete  absence  o 


BLACK    SPECKS    BEFORE    THE    EYES  71 

the  hair,  not  only  of  the  head  but  also  of  the  eyelids,  faee.  trunk,  armpits,  and  jiubie  regions, 
tlie  diagnosis  is  obvious. 

Senile  Alopecia  needs  no  description. 

Premature  Alopecia  may  be  (a)  idiopathic  or  (b)  symptomatic.  The  former,  much  less 
fre<|uent  than  tlie  latter,  and  due  to  no  recognizable  cause  except  heredity,  usually  begins 
between  the  ages  of  twenty  and  thirty-five  ;  in  many  cases  at  the  vertex,  like  senile  baldness, 
but  often  at  the  teni])le,  when  it  extends  backwards  elliptically.  Symptomatic  premature 
baldness  may  be  either  temporary  or  permanent,  gradual  or  rapid,  and  is  dependent  upon  a 
great  variety  of  local  or  constitutional  causes,  including  seborrhcea  of  the  scalp,  psoriasis, 
chronic  eczema,  erysipelas.  ritigiLonn.favus.  lupus,  erythematosus,  syphilis;  it  is  also  a  sequela 
oi  fevers  or  other  acute  systemic  diseases,  and  sometimes  of  a  severe  shock  to  the  nervous 
system  such  as  inay  result  from  a  sudden  and  imexpected  bereavement  or  the  like.  When 
it  occurs  as  a  sequel  to  fevers,  in  sjT)hilis,  ringworm  (except  after  severe  kerion),  erysi]3elas, 
and  ec/.ema,  the  loss  of  hair  is  usually  but  tenijiorary  :  in  seborrhcea,  favus,  lupus  erythema- 
tosus, morplitta,  and  folliculitis  decalvaiis,  it  is  generally  ])ermanent  :  it  is  always  so  when 
the  hair-follicles  have  been  destroyed. 

The  most  important  form  of  symptomatic  balilness  is  that  which  is  associated  with 
seborrliiea.  whether  of  the  oily  or  of  the  dry  kind.  Seborrluric  alnprcia  lias  the  same 
distribution  as  idiopathic  baldness.  Another  form  of  symptomatic  baldness  is  the  condition 
known  as  alopecia  areata,  in  which  the  hair  falls  out  in  more  or  less  circular  smooth  white 
patches,  generally  of  irregular  distribution.  I'sually  the  patches  continue  to  spread  for  a 
time,  and  may  run  into  others,  denuded  areas  of  irregular  outline  thus  lieing  formed,  with 
a  surface  white  and  smooth  as  a  billiard  ball.  The  hairs  at  the  edges  of  the  patches  are 
looser  than  the  others,  and  among  them  may  be  seen  short  stinnps  that  have  atrophied 
dose  to  the  root,  so  that  they  resemble  a  note  of  exclamation  (!).  In  rare  cases  the  hair 
falls  out  not  in  patches  but  more  generally  and  very  rapidly  ;  and  sooii  the  whole  scalp 
may  be  bared,  and  even  the  hair  of  the  whole  body  may  be  lost,  and  with  it  the  nails  of 
the  lingers  anrl  toes.  The  affection  with  which  alopecia  areata  is  most  easily  confoimded 
is  riui'icorui  of  llic  trichophytic  variety  :  the  differential  diagnosis  between  the  two  alTections 
will  be  found  under  hi  xc.ors  .\i'i-i;CTiONS  OF  nil;  Skin  (|j.  24fi).  Alopecia  areata  may 
also  be  confused  with  another  form  of  symptomatic  bahlness,  namely,  alopecia  cicatrisata, 
the  pseudo-pelaite  of  Hroeq,  in  which  depressed  islands  of  baldness,  round  or  of  irregiilar 
shape,  occur  on  the  scalp,  the  |)atches  usually  spreading  and  coalescing  into  large,  smooth, 
shiny  areas  :  these  are  cicatricial  :  there  is  destruction  of  the  follicles  so  that  the  hair  is 
never  restored  ;  there  are  normal-looking  hairs  on  the  bald  areas,  and  the  notc-of-exclama- 
tion  stumps  of  alopecia  areata  are  absent.  The  bald  jiatchcs  sometimes  met  with  in 
secondary  sy/jtiilis  may  be  dislingiiishcd  from  those  of  alo]>ecia  areata  by  the  co-existence 
of  oilier  syphilitic  symptoms,  by  the  positive  Wasscrmann's  serum  reaction,  iind  by  the 
effects  of  s])ecific  treatment.  The  bald  areas  of  lupus  erythematosus  arc  in  greater  or  less 
degree  cicatricial,  there  is  destruction  of  the  follicles,  and  a  border  which  is  slightly  or 
distinctly  inllanied.  luillirulilis  deadvinis  is  cii  atricial  also,  and  at  the  edge  of  the  bare 
patches  a  small  rc<l  p^ipiilc  (ii-  p:ilc-|i  oC  cin  (lii-iiia  can  he  seen  siirniiiiuling  each  follicle. 

Maliiitm    .Monis. 

BEARFNG-DOWN    PAIN.      (Sec  I'mn.   Hi.aiun.^-im.w  n.   p.    |-_'(1.) 

BLACK   SPECKS  BEFORE   THE   EYES  arc  of  two  ty|)cs  :  (1)  Moving:.  CJ)  Fired. 

Moving  Bhick  Specks  :iic  |ii:i(lii;illy  alwnys  due  to  mused-  I'olitantes.  The  aiiiicous 
and  \il  noils  liiiiniiiirs  an  mil  aiisoiiilcly  homogeneous  :  in  both  there  are  minute  particles 
in  most  persons,  and  llicsc  throw  sliadiMVs  upon  the  retina  which  arc  referred  by  the  patient 
lo  points  in  the  visual  held  outside  him.  They  seem  to  be  in  I'ronI  of  his  eyes,  interfering 
with  what  he  wishes  li>  look  ;il  :  \(l  wlicii  he  tries  lo  liiciilr  tlniii  (IcHnilciv  !iy  looking 
directly  at  llicui,  llic\  iininciihilclv  llnal  aw;i\-.  as  il  were,  IVoiii  liis  diiccl  livid  iif  \ision 
to  a  peripheral  part,  lie  can  never  locus  llicm.  aiidvcl  he  nia\  lieconscioiis  of  seeing  them 
all  the  time.  Only  lew  ))ersons  in  p<rlcct  health  are  troubled  in  this  way.  for  although 
the  niiisea-  Mililanles  may  be  present  all  the  lime,  the  mind  neglects  them  and  fails  Lo 
notice  them.  When  the  eye  is  liicil  by  close  work,  however,  or  the  patient  is  suffering 
from  brain-fag.  worry,  insomiiia.  Iiilioiisness  or  other  similar  condition.  Ihey  may  attract 
his  notice   very   much   and    make   liiiii    I'liir   llial    he   is  d<-\  clo|iing  some  serious   lesion   such 


72 


BLACK    SPECKS    BEFORE    THE    EYES 


as  a  cataract.  JNIicroscopists  often  find  them  a  great  nuisance.  After  a  rest  or  a  holiday 
they  will  cease  to  obtrude  themsehes  upon  the  patienfs  notice,  but  he  will  notice  them 
again  when  he  gets  overworked  or  rim  down.  In  a  similar  way  muscoe  volitantes  may  be 
troublesome  in  those  who  are  suffering  ill  health  due  to  almost  any  organic  cause,  especially 
if  it  is  associated  with  AnvTsmia  (p.  20).  The  way  in  which  the  specks  float  away  when  an 
attempt  is  made  to  focus  them  is  characteristic. 

Fixed  Black  Specks. — When,  on  the  other  hand,  the  patient  notices  a  black  spot  nr 
spots  in  liis  field  of  vision,  always  present  and  always  in  exactly  the  same  relationship 
to  tlie  jjoint  upon  wliich  he  is  focussing  his  eye — not  floating  away  into  different  parts  of 
the  held  of  vision  like  niusca?  volitantes — a  careful  examination  of  the  eye  with  the  ophthal- 
moscope, assisted  perhaps  by  the  perimeter  to  map  out  the  abnormal  blind  spot  with 
accuracy,  will  generally  reveal  some  organic  lesion  in  the  eye  to  aecoimt  for  them.  An 
opacity  in  the  cornea  from  old  keralilis,  or  syneehise  from  adhesions  due  to  old  iritis,  or 
a  cataract,  may  be  seen,  or  tiny  white  patches  at  the  macula  indicative  of  incipient  albuiniti- 
uric  retinitis  of  grave  omen  :  or  a  small  detachment  of  the  retina  ;  or  a  melanotic  sarcoma 
of  the  eyeball ;  or  early  optic  neuritis  ;  or  a  thrombosed  retinal  vein  :  or  an  embolizcd  branch 
(if  a  retinal  artery  ;  or  a  hcemorrhage  into  the  vitreous  ;  or  a  scotoma  from  localized  optic 
atrophy,  such  as  is  met  with  sometimes  in  cases  of  disseminated  sclerosis.  Special  ophthal- 
mic experience  will  be  needed  to  diagnose  between  these  different  conditions,  althougii 
the  ophthalmoscopic  a|)pearances  (p.  41.5)  of  some  of  them  are  pathognomonic. 

Herbert  French. 

BLEEDING  GUMS. — -^  spongy,  bleeding  condition  of  the  gums,  attaining  such  a 
degree  that  the  teeth  become  covered  by  the  exuberant  blood-oozing  tissues,  was  a 
prominent  feature  of  scurvy,  a  serious  and  often  fatal  disease  which  used  to  be  common 
on  sailing  ships  when  fresh  food  was  necessarily  absent  from  the  diet  for  weeks  or  even 
months  at  a  time.  It  is  now  rare  in  its  full  development,  but  is  still  foimd  in  a  mild  form 
amongst  children — infantile  scurvy,  or  Barlow's  disease — as  the  result  of  long-continued 
feeding  with  tinned  milk  without  fresh  food.  Its  chief  features  are  anscmia  and  tenderness 
of  the  long  bones  due  to  ha-morrhagcs  under  the  periosteum  ;  in  severer  cases,  besides 
sponginess  and  bleeding  of  the  gum  with  more  or  less  general  stomatitis,  there  maj-  be 
purpura  and  other  ha>morihages.  The  diagnosis  is  suggested  by  the  diet  history,  and 
confirmed  by  the  benefit  that  follows  the  addition  of  fresh  milk  and.  in  older  children, 
fresh  vegetables.  A  similar  condition  may  arise  in  adults  whose  circumstances  compel  them 
to  live  on  tinned  foods.  There  are,  however,  many  other  causes  of  bleeding  of  the  gums 
besides  scurvy.  The  differential  diagnosis  is  generally  easy,  but  sometimes  very  dilTicult. 
The  first  point  to  determine  is  whether  the  gum  condition  is  due  to  local  changes  only,  or 
whether  it  is  part  of  a  more  general  condition. 

(.1).  Bleeding  Gums  due  to  General  Conditions  or  preceded  by  Lesions  else- 
where than  in  the  Mouth  : — 


Scurvy 

Splciionicdiillary  leuk.'emia 
Lympliatic  IciiUu'iniu 
Hodykiii'N    disease 
Perniciiius  aiianiia 
Aplastic  auiemia 
Splenic  ana-mia 
Harnophilia 

(B).  Bleeding  Gums  due 

Injury,  e.g.,  by  toutli  bnisli 

Dental  caries 

Tartar 

Pyorrhoea  alveolaris 

Alveolar  abscess 

Pa])illonia 

Epulis 

Myeloid  saroonia 


Purpiua  (see  Pl'rpi'R.\,  p.  o.32) 

Syphilis 

Mercurialism 

Iodide  poisoning 

Phosphorus  poisoning 

Arsenic  poisoning 

Lead  poisoning 

to  purely  Local  Conditions  :- 

Epithelioma 
Actinomycosis 

Acute  or  chronic  stomatitis 
not  obviously  due  to  any  of 
the  causes  already  men- 
tioned, e.g.  : 

Aphthous  stomatitis 
T_'leerativc  stomatitis 


Febrile  or  asthenic  states 
accompanied  by  sordes,  e.g., 
pneumonia,  ty]ilioiil  fever, 
the  later  stages  ol'  nialiyiuiiit 
cachexia,  general  paralysis, 
acute  yellow  atrophy  ol'  tlie 
liver,  and  so  forth 

Dyspepsia 


Gannrenous         stomatitis 

(cancrum    oris,     phage- 

da;na  oris,   noma  oris) 

Tuberculous   gingivitis 

Erythema  bullosxim,  dermatitis 

herpetiformis,       |)empliia;us, 

affecting  the  mouth  as  well 

as  the  epidermis 


A.  Bleeding  Gums  due  to  General  Conditions. — iMan\-  of  the  above  conditions  arc 
discussed  under  other  and  more  prominent  symptoms,  so  that  here  we  need  refer  to  them 
but  briefly  (see  Spleen,  Enl.\rgement  of,  p.  628;  An^mi.\,  p.  20  ;  Purpura,  p.  552;  etc.). 


BLEEDING    GUMS  73 

A  blood-eount  is  required  to  diagnose  or  exclude  letikwmia  or  pernicious  ancemia.  Tlie 
family  history  may  suggest  hcemophilia.  Splenic  anwmia,  Ilodgkin's  disease,  and  aplastic 
anamia  attract  attention  more  on  account  of  the  enlargement  of  the  sjjleen  (p.  628), 
or  of  the  lymphatic  glands  (p.  376)^  or  of  the  ana?mia  (p.  20),  than  because  of  spongy 
gums.     Purpura  (p.  552)  is  itself  a  symptom  and  not  a  disease. 

Syphilis,  particularly  in  its  secondary  stage,  may  produce  stomatitis,  pharyngitis, 
lar>-ngitis,  and  gingivitis,  with  bleeding,  even  when  no  mercurial  treatment  has  been 
adopted  ;  the  secondarj'  roseola  may  still  be  present,  or  the  history  may  be  obvious. 
Dilliculty  arises  mainly  in  women  and  children,  and  when  the  chancre  has  been  extragenital 
(Fig.  23).  ^Vasse^nlann■s  serinn 
test  may  be  tried,  or  the  Spiro-  f 
clmta  pallida  (Plate  XXVIII, 
Fig.  J.  p.  (il4)  looked  for  in  scrap- 
ings from  the  mucous  lesions. 

Mercury    is     very    liable    to 
cause  profuse  salivation  and  acute       ^^^^B  ^^^Wmi^^'  ? 

stomatitis,    with    distressing    and  ^      ^      .  _ 

painful    swelling    of    lips,    gums, 
tongue,    and   cheeks  :    swallowing 

may  become  impossible,  the  glairy  ^,V,.  ^S.-PrUnary  syplulitic  soie  on  ti.e  lower  li|.. 

saliva  hangs   in   strings  from  the 

protruding  tongue  and  bulging  lips,  the  mucosa  bleeds  on  the  slightest  touch,  and  tlie 
patient  is  the  picture  of  abject  misery.  Some  persons  are  far  more  intolerant  of  mercury 
than  others,  but  its  worst  effects  have  occurred  when  the  remedy  has  been  employed  when 
the  teeth  arc  carious,  or  the  mouth  unclean,  and  when  there  is  albuminuria  (syi)hilitic 
nephritis).  The  diagnosis  depends  upon  a  knowledge  of  the  drugs  that  are  being  given 
or.  in  occupation  cases,  of  the  chemicals  that  the  patient  has  been  working  with. 

Iodides  may  cause  profuse  coryza,  due  to  conjuncti\al,  nasal,  and  oral  catarrh,  but 
the  amount  of  bleeding  that  accompanies  it  is  slight.  The  nature  of  the  drugs  being  taken 
will  suggest  the  diagnosis,  or  if  there  is  doubt  as  to  the  drugs,  the  urine  may  be  tested  for 
iodides. 

Phosphorus  used  to  produce  very  severe  stomatitis,  going  on  to  necrosis  of  the  jaw — 
•  pliossy  jaw  ■ — not  infre<|uently  ending  in  death  as  the  result  of  fatty  degeneration  of 
the  li^■er  antl  heart  :  this  is  unconnnon  since  restrictions  have  been  laid  upon  the  use  of 
crude  yellow  ])ho.sphorus  in  the  manufacture  of  matches.  The  oecu])ation  generally  serves 
to  suggest  the  diagnosis.  fc^Kp  t*' 

Arsciiir  and  lead  are  both  rare  causes  oT  hlii-ding  gums  ;  (ic(  iipalioii.  or  medical 
l)r(seriptioii,  or  habits  as  regards  drinking,  may  suggest  the  diagnosis,  and  there  may  be 
other  signs  of  the  |)oisoning,  particularly  |)igmentation  of  the  skin,  vomiting,  diarrhd'a, 
hyperkeratosis  of  the  soles  and  palms,  and  generalized  i)erii)heral  neuritis  in  the  ease  of 
arsenic' ;  and  the  symptoms  given  elsewhere  (p.  :;  t)  in  the  case  of  lead.  Arsenic  may  be 
found  in  excess  in  the  hair,  or  lead  may  be  detected  in  the  faces  or  in  llu-  lesidue  from  a 
bulk  of  urine. 

Febrile' nnd  asthenic  states  only  cause  sordes  and  bleeding  gmns  when  the  i)atienl  has 
already  been  ill  some  while,  or  wlu'ii  the  nursing  has  been  remiss  ;  the  diagnosis  will  depend 
on  syniptoins  other  than  those  comiected  with  the  gums. 

H.  Bleeding  Gums  due  to  Local  Conditions.  Wlmi  eai(  has  been  laktii  lo  exclude 
Ijeiieral  causes  of  bleeding  of  (he  giuns,  (liHei'enl  iai  ion  between  the  ^■arioUs  local  causes  is 
nf)t  diiri<ull.  Some  patients  are  alarmed  l)\  tlie  sym|)lorn.  when  its  cause  is  nothing  more 
than  the  use  of  a  nr:v  litolh-hrusli  whose  bristles  have  slightly  lacerated  gums  tliat  are 
accustomed  lo  an  older  and  softer  brush.  The  history  will  indicate  other  liirms  ol  local 
injury     ini  ill-lilling  loolh-plate,  pcrhajis.      Ihemoptysis  may  be  simulated. 

Dental  caries  may  be  obvious,  or  it  may  be  hidden  away  I)et\veen  arljacent  teeth  and 
yet  be  irritating  the  gum  enough  to  cause  it  to  bleed  with  undue  readiness  when  the  teeth 
are  brushed.  Tartar  is  obvious  on  inspection.  I'yorrhira  ahealaris.  also  known  as 
suppurative  ginaivitis  or  liigg's  disease,  is  the  n'suK  of  septic  iid'cetion  exieniling  down  into 
the  sockets,  loosening  the  teelh.  causing  Ihc  guni  Ttiari;ins  lo  recede  bv  erosion,  and  leading 
to  a   pinuleiil    liiseliarMe    Iniiii    lielween    llie   ^niins   :iihI    Die   teelh.      'I'liis  <'oM(lilion    mav   be 


BLEEDING    (iUMS 


present  even  when  the  external  aspeet  of  the  teeth  seems  perfect  ;  a  very  fine  probe  may 
.sometimes  be  jjassed  painlessly  down  into  the  tooth-socket  between  adjacent  teeth  where 
the  suppurative  process  has  been  progressing  unsuspected,  and  out  of  the  reach  of  the 
tooth-brush.  The  gums  bleed  on  the  slightest  touch  in  severe  eases,  the  breath  is  foul,  and 
the  constant  swallowing  of  pyogenic  organisms  and  their  products  leads  to  dyspepsia, 
ana"mia,  chronic  ill  health,  listlessness,  functional  nerve  disorders,  and  sometimes  more 
acute  sym]itoms  of  general  pyaemia,  especially  multiple  infective  synovitis  and  arthritis. 
Neurasthenia  and  depression  ultimately  ensue  in  many  cases,  and  sometimes  very  severe 
and  even  fatal  ancemia  or  purpura. 

The  diagnosis  of  alveolar  abscess  is  generally  obvious,  though  infection  of  a  benign  or 
malignant  neic  groivlh  may  simulate  it  for  a  time.  Microscope  examination  of  the  excised 
tumour  is  the  only  certain  way  of  diagnosing  the  nature  of  an  odontoma,  papilloma,  simple 
epulis,  myeloid  sarcomatous  epulis,  or  epithelioma  of  the  gum. 

Actinomijcosis  is  rare  in  man  :  but  the  jaw,  gum,  or  cheek  are  parts  least  imcommonly 
affected.  The  chronic  nature  of  that  which  partakes  of  the  characters  partly  of  a  neoplasm 
and  partly  of  an  abscess,  in  a  person  who  has  had  occasion  to  put  straws,  cotton,  or  other 
vegetable  products  into  his  mouth,  may  suggest  the  diagnosis,  which  will  be  confirmed  by 
the  iinding  of  the  ray  fungi  in  the  purulent  discharge,  or  in  sections  from  parts  excised. 

Minute  grey  or  yellowish  specks  in  the  pus  are 
said  to  be  characteristic,  but  they  are  not  always 
seen,  and  it  is  by  microscopical  examination  that 
the  diagnosis  is  made  with  certainty  (see  Plate 
XXl'III.  Fig.  S.  p,  014). 

Stomatitis  in  its  various  degrees  may  have  a 
general  cause,  such  as  mercurialism  (see  above)  : 
or  it  may  be  due  to  purely  local  infection  with 
micro-organisms.  It  might  perhaps  be  classifitd 
bacteriologically — the  variety  spoken  of  as  thrush 
being  due  to  the  oidiam  albicans,  for  instance, 
t'linically,  however,  it  is  more  often  classified  by 
its  degree — into  acute  catarrhal,  ulcerative,  and 
gangrenous.  All  these  affect  the  mucosa  of 
cheeks,  lips,  tongue,  and  palate,  in  addition  to 
the  gums,  and  any  of  the  inflamed  parts  bleed 
readily.  The  first  degree  is  characterized  by  red- 
ness, swelling,  tenderness,  and  pain,  with  inability 
to  move  the  tongue  about  in  order  to  eat  and 
swallow,  swelling  and  jirotrusion  of  the  lips,  foul- 
ness of  the  breath,  and  very  often  salivation. 
There  may  or  may  not  be  localized  greyish  or 
white  aphthous  patches  ;  these  are  commoner  in 
children.  When  ulcers  occur,  these  are  generally 
nuiltiple  and  shallow,  very  painful,  with  more  or  less  glazing  of  the  ulcerated  surface, 
and  acute  hy])cr!iemia  of  the  margins.  The  gangrenous  form  is  better  known  as  caiicrnm 
oris  (Fig.  24),  fortunately  rare,  though  sometimes  seen  in  ill-eared-for  children  who  have 
contracted  measles  or  some  other  acute  (Iil)ilil:iting  fever.  The  cheek  is  affected  first,  a 
dusky-red  or  black  spot  appearing  within  and  without,  spreading  rapidly  and  leading  to 
sloughing  and  perforation  of  the  cheek,  gangrene  of  the  gums  and  jaw,  falling  out  of  the 
teeth,  a  very  foul  nauseating  odour  of  the  breath,  and  death  from  utter  exhaustion.  The 
diagnosis  is  generally  olivious. 

Tnbcrcalinis  gingivitis  is  rare,  but  when  it  does  occur  it  is  very  severe.  The  natm'c 
of  the  bleeding  gums  will  be  suggested  by  the  co-existence  of  phthisis,  and  tubercle  bacilli 
may  aboimd  in  smears  from  the  gum. 

Erythema  bullosum.  dermatitis  herpetiformis,  and  pemphigus — particularly  the  first — may 
affect  mucous  membranes  as  well  as  the  skin,  especially  the  mouth,  colon,  and  vagina. 
The  result  as  regards  the  mouth  is  very  distressing  ;  the  crusts  and  resultant  inflammation 
of  lips,  gums,  tongue,  cheeks,  palate,  fauces,  and  jiharynx,  may  make  it  impossible  for  food 
to  be  taken  orally,  and  the  ])atient  loses  weight  rapidly  and  Ijeeonies  very  ill.     The  nuieous 


Fhj.  --M.— Cai 


BLOOD    PER     ANUM  75 

membrane  everywhere  bleeds  on  the  shghtest  touch,  and  the  condition  is  pitiable.  There 
is  generally  pjTcxia.  The  diagnosis  is.  as  a  rule,  easy,  for  the  mucous  membranes  are 
seldom  attacked  unless  the  skin  is  affected  also  (see  Bullae,  p.  86  and  Ecsinopiiilia, 
p.  -18).  Herbert  French. 

BLEEDING  NOSE.  -(.See  Epistaxis,  p.  220.) 

BLEEDING,  UTERINE. — (See  Menorrhagia,  [).  385  ;  Metrorrii.vgia,  p.  380  ;  and 
Metrostaxis.  ]).  392.) 

BLINDNESS.— (See  Vision,  Defects  of,  p.  7.57.) 

BLISTERS.— (See  Bri.i,.T;,  p.  96.) 

BLOOD,  COUGHING   UP  OF.— (See  H  emoptysis,  p.  28.5.) 

BLOOD   IN   THE   URINE. -(See  Hematuria,  p.  275.) 

BLOOD  PER  ANUM. — Blood  may  be  passed  i)cr  anum  whenever  bleeding  takes 
place  from  any  part  of  the  alimentary  canal.  If  it  comes  from  a  point  high  up,  as  from 
the  stomach  or  duodenum,  it  is  usually  altered  in  appearance,  so  that  black,  tarry  stools 
arc  passed  (mchena)  :  if  it  comes  from  the  colon  or  from  the  lower  end  of  the  ileum,  it' is 
passed  as  red  blood,  easily  recognizable  as  such.  If  the  (|uantity  is  xcry  large  it  may  be 
bright  red  even  in  the  case  of  lesions  high-up  :  the  colour  ikpcnds  on  the  rapidity  of  jmssage 
through  the  Ixiwel  and  the  eonseijuent  extent  to  which  the  digestive  juices  have  acted 
upon  it. 

Bccognilion  of  the  actual  presence  of  blood,  pure  or  mixed  with  the  motions,  is  not 
(iltcii  dillicull,  except  when  the  (piantity  is  small.  The  typical  tarry  stools  of  hiemorrhage 
high  up  in  the  alimentary  tract  arc  unlike  anything  else.  The  black  colour  is  much  more 
pronounced  than  the  pigmentation  of  the  stools  caused  by  iron  or  bismuth  sulphide,  which 
produce  rather  a  slaty  or  dirty  greyish-black  tint  :  while  the  viscid  consistency  of  the 
ha-niorrhagie  stool  is  also  characteristic.  Administration  of  charcoal  by  the  mouth  may 
produce  deep  black  stools,  and  eating  bilberries  is  also  said  to  do  so.  In  case  of  doubt, 
the  chcmiea!  aiwl  spcctniscopieal  tests  for  l)lood  may  be  applied  :  for  which  purpose  it  is 
best  to  aeiduiiili-  tlic  faces  strongly  with  acetic  acid  and  to  extract  the  acid  mixture  with 
ether  :  a  clear  solution  of  blood-pigment  is  thus  obtained,  suitable  for  the  spectroscope 
or  for  the  guaiacum  test.  In  some  cases  blood  corpuscles  may  be  recognizable  imder  the 
iiiicroseope  if  a  portion  of  the  fa-ces  is  rubbed  up  with  physiological  saline  solution,  (irains 
ol  charcoal  will  be  distinguishable  under  the  microscope  if  this  substance  has  been  taken. 

Tlic  conditions  associated  willi  the  passage  o!  blood  pvv  anum  may  be  divided  con- 
veniently for  diagnostic  purpose  into  :  (1)  'I'Iidhv  in  n'liich  lrir«c  <iii<inlitiex  of  nllerc/l  hUuid 
are  ptisseil  (true  niehena)  :  (2)  I'hosr  in  ■u'liich  liir<ir  ijniinlitir.s  of  red  or  inidllcrcil  blood  (ire 
voided;  (3)  'Dntse  in  icliicli  sniidl  amoniils  <if  such  hlooil  ore  seen  ;  and  ( t)  Coses  of  so-v(dled 
oieiill  liifniorrlnitie,  only  recognizable  by  chemical  or  <>tli(r  special  tests.  The  conditions 
eliissed  under  hcailings  (2)  and  (3)  necessarily  overlap,  inasniiich  as  the  exact  ciuantity  of 
lilcHiil  (lis<1iMigiil  is  \(ry  \ariMl)le:  the  lormcr  comprise,  roughly  speaking,  alieeliims  of 
the  liciwcl  ;    llir  Nillci-,  lesions  iilioul   the  icctutii  and  anus. 

Large  quantities  of  altered  blood  mny  escape  in  cases  of  ulceration  ol'  the  slomaeli 
or  duodenum.  It  is  usually  mixed  with  acid  gastric  juice,  and  thus  blackened.  .Such  cases 
are  g<'nerally  associated  with  |)ain  after  meals,  vomiting,  lia'inatemcsis,  and  increased  acidity 
of  the  gastri<'  juice.  Tenderness  will  be  elicited  on  pressure  over  the  epigastrium,  most 
often  at  a  point  rather  to  llu'  right  of  the  middle  line  and  about  four  inches  below  the 
xiphisternal  jimetioii  in  the  pyloric  region.  Distinction  between  lesions  of  the  stomach 
:iii(l  1)1'  the  duodenum  is  dillieult  ;  l)ul  in  gastric  ulceration  the  pain  usually  arises  within 
:ni  Ininr  after  meals,  and  is  relieved  by  vomiting  :  in  duodenal  ulcer,  it  often  reaches  its 
a( me  iilxiul  Ihiic  or  lour  hours  after  a  meal,  aixl  II  may  .it  lirsl  be  relieved  by  taking  food 
(•  huiiMcr  pMJii).  Ill  gastric  ulcer,  the  greater  part  of  llic  blood  which  escapes  is  likel> 
lo  l)c  Miinilccl  :  ill  diiodeiial.  most  of  it  to  be  passed  per  aiiiim.  Duodenal  uleeration  is 
iniisl  eoiiimoii  in  men.  'I'lii'  symptoms  of  gastric  ulcer  are  much  more  <-oiiiiiioii  in  women  : 
but  it  has  been  shown  that   in  many  such  instances  no  actual  ulcer  can  be  found,  the  blood 


76  BLOOD     TEK     ANUM 

escaping  apparently  by  a  process  of  oozing  through  the  mucous  membrane — a  condition 
referred  to  as  gastrostaxis.  Evidence  obtained  fi'om  post-mortem  findings  shows  the  two 
sexes  to  be  about  equally  liable  to  this  affection. 

Large  quantities  of  unaltered  or  but  slightly  altered  blood  may  be  passed  in  cases  of 
ulceration  of  tlie  small  intestine,  as  in  enteric  fever,  tuberculosis,  or  the  peculiar  lesions 
associated  with  chronic  interstitial  n('i)liritis.  The  jihenomena  of  enteric  fever  need  not 
be  detailed  at  length — initial  luadaclic,  cpistaxis,  and  fever  ;  fullness  of  the  abdomen  and 
possibly  diarrhoja,  rose  spots,  enhngenunt  of  the  spleen,  mental  dullness  or  deliriuni  : 
leucopenia,  and  Widal's  agglutinative  reaction  in  the  blood.  Tuberculous  ulceration  of 
the  intestine  seldom,  if  ever,  occurs  apart  from  tuberculosis  of  the  lungs,  and  it  is  a  rare 
cause  of  profuse  intestinal  hsemorrhage.  It  is  associated  with  pain  and  tenderness  in  the 
abdomen,  and  with  emaciation  and  signs  of  pulmonary  disease.  Tubercle  bacilli  may  be 
foimd  on  examination  of  the  faeces. 

Chronic  Brigltt's  disease  may  be  associated  with  ha?morrhage  from  the  bowel  as  from 
other  parts  of  the  body.  The  absence  of  other  causes,  such  as  ulceration  :  the  existence  of 
liigh  blood-pressure  and  enlargement  of  the  left  ventricle,  the  cardiac  impulse  being  dis- 
placed outwards  and  downwards  ;  and  the  constant  or  occasional  appearance  of  albumin 
and  renal  tube  casts  in  the  lu-ine,  with  weakness,  antemia,  and  perhaps  epistaxis,  will  point 
to  this  cause. 

Bleeding  into  the  pancreas  and  eniljolism  or  thrombosis  of  one  of  the  mesenteric  vessels 
may  both  lead  to  moderate  haemorrhage  from  the  bowel.  In  both  alike  there  will  be 
symptoms  of  sudden  abdominal  pain  and  constipation  with  collapse,  closely  resembling 
the  phenomena  of  intestinal  obstruction.  A  certain  diagnosis  can  hardly  be  made  without 
laparotomy.  Patients  who  sidfer  from  pancreatic  apoplexy  are  usually  fat.  Blocking 
of  a  mesenteric  vessel  by  embolism  is  most  likely  to  occur  in  sufferers  from  some  form  of 
cardiac  disease,  especially  malignant  or  ulcerative  endocarditis  (p.  34). 

In  the  peculiar  condition  known  as  HenocKs  purpura  (p.  .556)  there  occur  attacks  of 
colic,  constipation  and  vomiting,  with  passage  of  blood  per  anuni.  The  symptoms  may 
closely  simulate  intestinal  obstruction  or  intussusception,  and  may  be  indistinguishable  from 
mesenteric  embolism.  A  diagnosis  may  sometimes  be  made  when  other  phenomena  of 
bleeding  are  present,  such  as  hsematemesis,  haematuria,  petechia:  in  the  skin,  or  cpistaxis. 
or  by  concomitant  affections  of  joints  (hEemorrhagic  arthritis)  :  the  patient  is  generally 
yoimg  ;   a  history  of  previous  attacks  may  also  be  obtained. 

A  good  deal  of  blood  may  be  passed  per  anum  in  some  cases  of  general  lia'morrhagic 
conditions,  such  as  profound  anaemia,  leuka?mia,  and  purpura  ha;morrhagica.  The  general 
appearance  of  the  patient,  and  examination  of  the  blood  (p.  24)  w-ill  suffice  to  distinguish 
the  two  former  ;  and  in  the  last  there  will  j)robably  be  visible  haemorrhages  in  the  skin 
and  bleeding  from  other  mucous  surfaces. 

The  possibility  of  the  rupture  of  an  aneurysm  into  the  stomach  or  bowel  may  be  men- 
tioned for  the  sake  of  completeness  ;  a  diagnosis  can  only  be  made  by  recognition  of  the 
]>ulsating  aneurysmal  swelling,  and  the  condition  will  probably  be  rapidly  fatal. 

In  infants,  considerable  quantities  of  blood  may  be  passed  per  anum  owing  to  septic 
infection  of  the  umbilical  cord,  the  ha>morrhage  arising  either  from  an  actual  ulcer  of  the 
stomach  or  duodenum,  or  from  a  purpuric  condition  caused  by  bacterial  toxaemia  ;  in  a 
few  such  cases  running  a  rapidly  fatal  course  the  passage  of  dark  or  bright  blood  per  rectum 
in  increasing  quantities  is  almost  the  only  symptom,  and  the  cause  of  the  bleeding  is  not 
clear  even  when  searched  for  at  autojisy  ;  the  fatal  symptom  may  develop  within  a  day 
or  two  of  birth  (Mcla-na  neonatorum). 

Haemorrhage  of  moderate  degree  is  usually  associated  with  disease  of  the  large 
intestine,  though  occasionally  profuse  bleeding  may  occur  in  such  affections.  The  blood 
is  bright  in  colour  and  generally  mixed  with  mucus.  In  tropical  dysentery  there  is  severe 
tenesmus  and  great  frequency  of  deficcation,  only  blood-stained  mucus  in  small  quantities 
being  passed  wlien  the  disease  is  well  established.  In  ulcerative  colitis,  which  appears  to 
be  a  bacillary  dysentery  of  temperate  climates,  there  are  the  same  diarrhoea,  frequency 
of  defaccation,  and  wasting  as  characterize  the  tropical  malady,  but  tenesmus  is  less  marked 
and  the  stools  are  usually  more  faecal.  Some  cases  of  idcerative  colitis  closely  simulate 
enteric  fever  ;  they  may  be  distinguished  by  the  absence  of  Widal's  reaction,  and  by  recog- 
nition of  the  idcers  in  the  lower  part  of  the  large  bowel  by  means  of  the  sigmoidoscope. 


oc 


BLOOD    PER     ANUM  77 

Examination  of  the  stools  in  cases  of  tropical  dysentery  may  reveal  the  presence  of 
the  AmKha  histolytica  (Fig.  25).  This  large  organism  measures  some  30  to  40  /,  in  diameter 
and  is  distinguished  from  the  harmless  Amoeba  coli  by  its  well-developed  clear  outer  layer 
of  ectoplasm,  by  its  small  and  eccentrically  placed  nucleus,  and  by  the  presence  of  inoested 
blood-corpuscles  within  its  substance.  "  "^ 

In  the  search  for  amceba;  a  flake  of  mucus  should  be  spread  out  as  thinly  as  possible 
on  a  slide,  and  if  the  organisms  are  very  scanty,  the  addition  of  a  drop  of  1  per  cent  watery 
methylene  blue  is  of  assistance,  as  it  stains  the  pus  and  epithelial  cells  at  once,  whilst  for 
a  time  the  amoebiB  resist  taking  up  the  stain  and  also  retain  their  activity  :  they'thus  stand 
out  clearly  amid  their  blue  surroundings  as  light  refraetile  motile  bodies.  In  such  a  pre- 
paration examined  directly  after  it  is  made,  it  is  possible  to  detect  them  with  a  very  low 
power,  such  as  a  Zeiss  A  or  a  half-inch  lens,  a  higher  power  being  turned  on  to  verify  the 
find.  ^Vith  some  practice  they  may  also  be  seen  in  unstained  mucus  with  the  low  power 
as  small  glistening  particles,  the  condenser  being  fully  lowered  for  this  method  of  examina- 
tion, and  any  likely  object  being  scrutinized  further  by  a  i  inch  lens.  Full  doses  of 
ipecacuanha  or  emetine  should  not  be  given  before  the  stools  are  examined  microscopically 
or  a  negative  result  is  likely  to  be  obtained  in  amoebic  cases,  just  as  in  malaria  after  quinine 
has   been   taken.     The   stools  should 

always     be     examined     as     fresh     as  ^ 

possible,  preferably  within  an  hour 
of  being  passed.  In  cool  climates  the 
specimen  may  be  kept  at  blood-heat 
for  a  short  time  and  the  slide  warmed. 
The  organisms  •-hould  always  be  seen 
in  active  motion  before  a  positive 
diagnosis  is  made,  for  there  arc  often 
large  mucoid  cells  present,  especially 
in  bacillary  dysentery,  which  may 
easily  be  mistaken  by  the  inexperi- 
enced for  inactive  ama?ba;. 

In  bacillary  dysenterj'  the  patho- 
genic organisms  belong  to  a  group  of 
closely  allied  bacteria  classed  under 
the  title  B.  di/senterice.  They  are 
short,  rod  -  shaped  bacteria,  with 
rounded  ends,  somewhat  resembling 
II.  inpliii.'iiis,  but  uon-iiKitile.  These 
haeilll  grow  on  ordinary  laboratory 
media,  do  not  coagulate  milk,  and  do 
not  form  indol.  They  are  not  stained  by  (iram": 
ulcerative  colitis  is  undetermined,  but  organisms 
isolated  by  some  observer.s. 

Malignant  dincasc  of  the  intrslinr  may  ylvc  rise  t 
typical  case'of  cancer  of  the  large  bowel,  an  cldcrlv  person  has  sullered  from  ..radually 
increasing  weakness,  wasting,  and  constipation.  .Utacks  of  colicky  i«iin  may  supervene, 
and  some  enlargement  of  the  abdomen  may  be  noticed.  Blood  mav  be  present  in  the 
motions  from  time  to  time,  hut  is  not  often  a  marked  feature.  Examination  of  the 
abdomen  may  reveal  \ermicular  movements  of  the  hvpertrophied  bowel,  which  tend  to 
pass  m  a  d,H,„|,.  ,lin<li.,ii  along  the  course  of  the  colon,  an.l  to  cease  at  a  particular  point. 
Here  a  .lehmte  tumour  may  be  palpable  ;  but  as  the  llexures  of  the  colon  are  lavouritc 
seats  for  neoplasms,  it  often  happens  that  the  growth  is  situated  deepiv  in  the  pelvis  or 
beneath  the  lower  ribs,  and  cannot  be  felt.  There  is  little  or  no  IcN-er  unUss  there  arc 
extensive  secondary  deposits,  especially  in  I  he  li\,r,  which  mav  become  greatly  enlarged. 
Acute  inteslmal  obstruction  may  finally  occur.  The  diagnosis  is  often  assisted  either  bv 
the  sigmoidoscope'  or  by  the  use  of  ,r-rays  alter  a  bismuth  meal  (p.  ]•_'.-,). 

As  contrasted  with  the  above,  non-malianaiil  iilnmlion  of  tlir  niloii  is  likcK  |,,  i,avc 
a  more  marked  ons.l.  with  pain.  Irc,,uencv  ..I  .Idacaliou,  an.l  loose  n.oli.ms  Th.-  stools 
often  eonlain  eonsi,|,.n,l,|,.  ,,uarililirs  ol   blood  mixed  will,  mucus.      The  bo.ly   U-mperalure 


Fig.  25.— foo    Ama-ba  histolytica  faftcr  Jilrgciis);    f6)  Atimba  coli. 
/"v?  V       "  '  (b')^Amaba  mli,  encysted  (after  ClwaaraiKli  and  linrbusallo;. 


(N)  Nucleus ;     (N')  Kuck-i  alter  div 
pintvr.) 


melhod.      The 
reseml)linij    li. 


.  (C)  Wood  corpi 

exact    bacteriology   of 
ili/snilrii(e    liave    been 

>r  hu'inorrhage.      In  a 


78  BLOOD    PER     ANUM 

is  raised,  often  to  a  high  degree  (103°  F.)'  pa'"  is  "^ore  constant,  and  tenderness  may  be 
elicited  all  along  the  course  of  the  large  intestine.  Often  the  ulceration  extends  into  the 
sigmoid  flexure  of  the  colon,  and  may  be  visible  on  examination  with  the  sigmoidoscope. 
In  ititussusceplion,  blood  and  mucus  are  passed  without  ftecal  matter  accompanying 
them.  The  condition  is  commonest  in  infants  and  young  children.  There  are  usually 
symptoms  of  severe  illness,  with  screaming,  drawing  up  of  the  legs,  frequent  pulse,  and 
some  collapse  ;  rarely  the  condition  may  be  encountered  with  but  few  grave  signs.  A 
rectal  examination  is  essential,  as  in  many  cases  the  intussusceptum  may  be  felt  with  the 
finger  ;  a  careful  palpation  of  the  abdomen  will  usually  reveal  an  elongated  tumour,  which 
may  sometimes  be  felt  to  harden  and  relax  again  with  the  peristalsis  of  the  gut. 

In  infants,  simple  colitis  may  give  rise  to  the  appearance  of  blood  and  mucus  in  the 
motions,  but  there  is  generally  some  fa?cal  material  passed  at  the  same  time,  which  is  not 
the  case  in  intussusception  after  the  contents  of  the  colon  below  the  intussusception  have 
been  evacuated.  In  simple  colitis  the  motions  are  frequent  and  loose,  and  they  may  contain 
nuicus.  In  milder  cases  they  may  be  green  and  slimy,  but  in  the  more  severe  they  are 
brownish  and  verv  offenst\'e,  iind  in  the  worst  cases  consist  of  little  more  than  a  dirty  serous 
discharge.  The  child's  temperature  will  probably  be  raised  ;  the  pulse  is  frequent,  and 
there  nfay  be  vomiting.  A  collapsed  condition  may  occur  at  a  late  period  of  this  malady— 
rarely,  in  acute  choleraic  cases,  it  may  ensue  within  the  first  twenty-four  hours.  In  intussus- 
ception, on  the  other  hand,  collapse  usually  occurs  quickly  :  and  there  is  absolute  con- 
stipation, with  iiassage  only  of  a  small  amount  of  blood-stained  mucus.  The  only  cases 
which  can  give  rise  to  a  dilliculty  of  diagnosis  are  the  rare  instances  in  which  intussusception 
is  ]5resent  without  severe  symptoms  ;  and  here  rectal  and  abdominal  examination  will 
probably  reveal  the  true  condition  of  affairs.  By  means  of  rectal  examination  in  an  infant 
a  considerable  area  of  the  abdomen  can  be  investigated,  especially  if  an  anaesthetic  be 
administered.  In  all  cases  of  doubt  in  intestinal  affections  accompanied  by  bleeding  this 
procedure  is  urgently  demanded. 

The  intense  diarrhea  accompanying  arsenical  poiso/tiitg  may  be  accompanied  by  the 
passage  of  traces  of  blood  and  mucus.  The  condition  will  be  distinguished  by  its  rapid 
onsetrsome  half-hour,  or  so  after  a  meal,  by  the  epigastric  pain,  tenderness,  and  vomiting, 
followed  by  collapse,  jvith  rapid  irregular  pulse,  and  clammy  skin.  A  chemical  examination 
of  the  vomited  matters  should  be  made  in  suspected  cases,  by  Keinsch's  or  Marsh's  test. 

Traces  of  blood  smeared  over  the  motions  are  suggestive  of  piles,  which  may  be  seen 
on  inspecticni  if  external,  and  felt  by  the  examining  finger  if  internal  to  the  sphincter. 
Occasionally  a  sharp  attack  of  bleeding  may  occur  from  this  cause  if  a  varix  be  ruptured. 
The  condition  is  usually  accompanied  by  a  sense  of  fullness,  weight,  and  even  pain  in  the 
rectum,  and  the  patient  may  be  conscious  of  "  something  coming  down  "  and  having  to 
be  replaced  after  defa?cation. 

Some  amount  of  blood  may  arise  from  an  anal  fistula,  which  may  also  lead  to  a  dis- 
cluirge  of  mucus  and  of  pus.  Inspection  and  digital  examination  will  discover  this 
affection,  the  external  opening  of  the  fistula  being  close  to  the  margin  of  the  anus,  the 
internal  often  just  above  the  border  of  the  sphincter. 

Cancer  of  the  rectum  does  not  usually  give  rise  to  much  haemorrhage,  but  traces  of  blood   j 
may  be  passed  from  time  to  time,  and  sometimes  a  sanious  discharge  occurs.     The  main   i 
syniptoms  are  usually  wasting  and  cachexia  ;   gradually  increasing  difficulty  in  defalcation  : 
and  rarely,  aheratioii  in  the  size  and  shape  of  the  fa?cal  masses,  which  may  be  thin  or  ribbon- 
like.    Sometimes  alternating  periods  of  diarrhoea  and  constipation  occur  :    or  there  may  ^ 
be  morning  diarrhoea,  the  matter  passed  being  thin  fluid.     Pain  in  the  sacral  region  generally  ] 
occurs  at  some  period  of  the  disease,  and  it  may  radiate  down  the  thighs.      The  growth  may 
l)e  seen  by  means  of  the  speculum  or  sigmoidoscope,  and  also  felt  by  the  examining  finger. 
Reeiul  poljjpi  are  common  in  ihildren,  and  may  rarely  be  encountered  in  adults.     They 
give  rise  to  frequent  bleeding,  which  may  occasionally  be  considerable  in  amount.     The 
patient  may  be  conscious  of  something  present  in  the  rectum  giving  rise  to  a  sensation 
of  fullness  and  frequent  desire  to  defalcate.     Digital  examination  will  reveal  the  existence 
of  a  pedunculated  tumour,  or  rarely  of  multiple  tumours.     Occasionally  a  polypus  may 
protrude  at  the  anus  after  defa-cation.  and  nnist  be  <listinguished  from  prolapse  of  mucous 
membrane  by  examination  with  the  finger. 

Another  condition  affecting  the  rectum  which  may  be  signalizetl  by  free  bleeding  is 


BLOOD     PER     ANUM 


79 


Fig.  26.— Ova  of  BiUmrzla  Imiilaliihi 
tr  a  terminal  -spine — the  common  form ;  t 
■eseiiting  a  lateral  spine.    (Uuilt  poirtr.) 


that  of  papilloma  or  villous  tumour.  The  symptoms  will  closely  resemble  those  of  rectal 
polypi,  but  the  blood  is  likely  to  appear  in  large  quantities.  Digital  examination  may 
discover  a  soft,  velvety  patcli  on  the  rectal  wall,  and  the  examining  finger  will  be  with- 
drawn covered  with  blood.  The  growth  may  be  seen  by  means  of  a  specidum  as  a  soft, 
vascular  ma.ss,  bleeding  on  the  slightest  touch.  The  condition  is  miconniion.  It  is  likely 
to  occur  at  an  earlier  age  than  cancer,  but  the  latter  is  not  unknown  in  persons  under  20 
years  of  age. 

Simple  prolapse  of  Hie  anal  mucosa  will  lead 
to  slight  ha-morrhage.  The  condition  is  often 
seen  in  children,  and  may  be  recognized  on  in- 
spection of  the  anus,  when  a  red  globular  swell- 
ing of  everted  mucous  membrane  is  visible. 
Adults  will  be  conscious  of  having  to  push  the 
part  back  after  passing  a  motion.  Such  prolapse 
often  acconi])anies  piles. 

i'lccralioii  of  the  reetum.  of  venereal  origin, 
occurs  chiefly  in  women.  Bleeding  is  not  usually 
a  very  marketl  feature,  but  attacks  of  haemor- 
rhage may  take  place.  The  condition  is  recogniz- 
able by  digital  examination,  and  by  inspection 
through  a  rectal  speculum  or  the  sigmoidoscope. 

Tlie  ulceration  usually  extends  right  down  to  the  anus,  whereas  there  is  nearly  always  an 
intiival  of  normal  mucosa  between  the  anus  and  an  ulcerating  cancer  of  the  rectum. 

'J'lie  |)arasite  called  liilhartia  Jurmatobia  may  occur  in  the  rectum,  though  less 
fr((|uently  here  than  in  the  bladder.  Its  presence  gives  rise  to  the  passage  of  mucus 
and  blood  per  anuni.  There  may  be  discomfort  in  the  rectum  and  frequency  of  defaeca- 
tion.      Infection   is  contracted  abroad,  especially  in  Kgy})t — a  fact  which  may  lead  to  a 

suspicion  of  the  presence  of  the  affection  in  patients 
who  have  resided  out  of  I'^ngland.  Diagnosis  can 
only  be  made  by  finding  the  ova  of  the  parasite  in 
the  fa'ces.  Their  well-known  shape — oval  with  a 
pointed  spike  at  one  end,  or  rarely  at  the  side  {Fig- 
2(i) — renders  them  unmistakaljle  objects  under  the 
niieroseope. 

In  eliildicn  I  lie  |ircs(iiee  of  I  liicad-worms  (Oj'J/- 
uris  vcrmicuhirin)  in  the  rccliiin  Mia_\-  lead  to  tlie 
liiscliarge  iil  small  ainoimls  ol  mucus  coloured  by  a 
liacc  ol  bliiiid.  'I'lir  wiirnis  will  be  seen  readily  on 
inspection  of  the  child's  motiims.  They  are  white, 
about  the  thickness  of  coarse  lliicMd.  and  \  to  j  in. 
in  length. 

In  some  cases  the  actual  cause  of  even  much 
blooil  being  passed  per  anum  remains  luidiagnosable, 
and  (iccasioii  Hl\  llic  cause  seems  to  be  'vicarious 
nil  list  lual  inn,'  nol  u  il  listanding  the  doubts  held  by 
mari\-  as  Id  llie  i)(issil)ility  n[  the  latter.  The  follow- 
ing is  a  very  suggest ive  case  from  the  ))ractiee  of 
Dr.  Keuell  AtUins.m  :  "A  girl,  age  i:U,  very  tall  (or 
her  age,  menstruated  regidarly  for  more  than  a  year. 
T  was  sent  Cor  because  she  was  jiassing  blood  per 
aiuun  :  that  was  on  A|)ril  !».  The  blood  was  (piite 
l)riglil  and  In  ((iiisidciMlilc  (|u:uilil\  ;  I  here  was  no  oilier  syni|il(>m  except  a  little  nausea 
and  voniitiiig  of  fiolhy  mueiis.  She  complained  of  pain,  mostly  over  the  pubes  on  each 
evacuation,  but  none  at  other  times.  No  abdoinimd  tenderness  or  distention.  No  tem- 
perature. Nothing  to  be  r<-!t  per  rec'tum.  On  .Vpril  1  !■  she  passed  a  large  dark,  semi- 
digestc><l  clot.  About  the  'Jlth  she  ought  to  have  menstruated  and  <lid  not.  The  blood 
continued  to  be  passed  until  the  "iSth.  Just  a  trace  on  the  'iittli.  None  since.  She  has 
remained  well,  mcnshuiilinn  has  recurred  regulailv,  and    llicn'   has   been   no  repetition  of 


Fifj.  27. — AukiilnsUtmujit  dttotlemilr.  A. 
wllh  liooks;  B.'i'nil;  c.  Kntire  worm. 
liiticrr). 

(l-'rom  Mnliml  hai>nralory  Methods. 
Dr.  Horhert  l''i 


lle.1,1 
(h.w 


BLOOD    PER     ANUM 


^j 


'1 


^-^ 


•S^ 


Fig.  2S.—dnkijlos[u)iu(m  duodcnalc.  Ova  at  different 
stages.  Near  the  centre  is  an  ovum  of  Trichocephalus  dispar 
(x  50).  (By  permission,  from  Dr.  Haldane  and  Dr.  Boycott's 
paper  in  The  Journal  of  Hygiene,  Vol.  iii.) 


^h 


w 


f.K 


Fig.  29. — .Inh-i/lostoiiiiim  fhuuhiifilf.  Two-cell  stage  of 
deveioping  o\Tani  (x  200).  (By  permission,  from  Dr.  Haldane 
and  Dr.  Boycott's  paper  in  The  Journal  of  Hygietle,  Vol.  iii.) 


SPECTRAL    .VESOKPTION    BA2;DS. 


I 

II      1^ 

■ 

M     ^H 

Fi,    U  — I.i  luced  lj-.i-iiL,.L'l(.l.iri. 

1 

ir    -^m 

I 

T    :^^m 

W       ^^^I^^^^H 

I'l'i.  :;l.— Acid  haimatin. 

1          ■■^■■i 

Fig.  ;^5. — Hethiemoglobin. 

1 

■    ^^B 

BLOOD-PRESSURE,     ABNORMAL  81 

the  passage  of  blood  per  rectum,  and  she  seems  to  be  a  normal  girl.  What  was  the 
cause  of  the  bleeding,  and  wliere  did  it  come  from  ?  ^^'as  it  an  instance  of  vicarious 
menstruation  ?  "" 

Occult  haemorrhage  is  the  term  applied  to  the  presence  of  minute  traces  of  blood 
in  the  motions,  revealed  only  by  chemical  or  spectroscopical  examination.  It  may  occur 
in  any  lesion  of  the  alimentary  canal  in  which  there  is  breach  of  surface,  as  in  ulcer,  cancer, 
or  .severe  inflammation.  Such  hicmorrhage  will  also  be  present  constantly  in  cases  of 
infection  with  the  parasitic  worm  Ankijlostomum  duodenale  (Fig.  27).  This  condition, 
which  is  met  witli  in  persons  who  have  resided  in  certain  parts  of  the  tropics  such  as  India, 
or  who  have  worked  in  mines  or  tunnels  in  which  the  soil  has  been  contaminated  by  fellow- 
workers  suffering  fiom  the  disease,  leads  to  profound  ansemia  ;  and  tlie  ova  of  the  worms 
may  be  found  in  the  fieces  by  microscopical  examination  (Figs.  28  and  29).  The  tests  for 
occult  bleeding  may  be  applied  in  cases  of  difficulty  when  there  is  reason  to  suspect  ulcera- 
tion or  cancer.  No  meat  or  meat-extracts  must  be  administered  for  a  day  or  two  before 
the  test  is  made,  lest  the  haemoglobin  present  in  them  sliould  vitiate  the  results.  The 
existence  of  any  bleeding  from  the  gums  must  also  be  excluded.  One  of  the  simplest 
methods  of  detecting  occult  hicmorrhage  is  to  rub  up  some  of  the  faeces  with  water,  acidify 
with  strong  acetic  acid,  and  then  shake  out  with  about  I  volume  of  ether  ;  the  latter 
extracts  the  hffimatin,  and  the  characteristic  bands  may  be  detected  in  the  ethereal  extract 
by  means  of  the  spectroscope  (see  Figs.  33  and  34).  w.  Cecil  Bosanquet. 

BLOOD,   VOMITING  OF.— (See  H.«matemesis.  p.  26.-,.) 

BLOOD-PRESSURE,  ABNORMAL. — Blood-pressure  cannot  be  gauged  accurately 
with  the  finger  :  when  instruments  of  jjrecision  are  used  to  verify  opinions  expressed  as 
the  result  of  merely  feeling  the  pulse,  it  is  astounding  how  erroneous  digital  impressions  of 
pulse-tension  and  Ijlood-pressure  are.  It  is  most  important  not  to  diagnose  an  abnormality 
of  blood-pressure  until  the  latter  has  been  measured  instrumentally.  There  are  four  main 
kinds  of  blood-pressure,  namely,  maximum  systemic  arterial  ;  minimum  arterial  ;  mean 
arterial  :  and  venous.  Instruments  have  been  devised  for  measuring  all  these,  but  clinic- 
ally the  only  really  important  variety  is  the  maximum  systemic  arterial  lilood-pressure. 
This  may  be  either  iiljiiormalli/  /oic  or  filjiioi/iiiilli/  liigli.  but  no  stress  should  he  put  upon  any 
but  considerable  departures  from  the  normal.  Healthy  individuals  who  have  not  been 
kept  in  bed  have  an  average  pressure  in  early  adult  life  of  120  to  130  nnu.  Ilg.  Children 
have  less  than  this,  though  at  this  early  age  it  seldom  hai)pens  that  anything  is  to  be  learned 
by  measiu-ing  the  blood-pressure.  .As  years  advance,  the  blood-pressure  tends  normally  to 
rise,  so  that  at  fitly  or  si\ty  a  reading  of  1.50  or  100  nun,  Ilg,  or  thereabouts,  which  in  a 
younijer  person  would  indicate  disease,  would  be  normal. 

Abnormally  high  blood-pressure  may  reach  figures  such  as  320  mm.  Ilg,  and  any- 
thing from  170  mm.  Ilg  upwards  is  essentially  abnormal,  whatever  the  age  of  the  patient. 
It  nearly  alwa>s  indicates  rigi<lity  of  the  vessels  as  the  result  of  arteriosclerosis,  and  it  is 
very  olten  assoeialcd  with  renal  <legeiiernlion,  which,  as  time  goes  on,  ultimately  becomes 
red  granular  contracted  kidney.  Curiously  enough,  and  contrary  to  what  might  be  expected, 
the  maxinunn  syslolie  blood-pressure  is  higher  than  normal  in  eases  of  luarl  luilure  such  as 
result  from  inilnil  stenosis,  even  when  the  i)ulse  is  so  irregular  and  fe(l)lc  that  i(  can  only  be 
felt  with  certain  beats,  and  when  one  would  have  thought  that  there  nmst  be  a  fall  in  the 
hlood-pressure  :  the  cause  for  the  rise  in  such  eases  is  prol)al)ly  the  piirtial  aspliy.ria  acting 
upon  the  \Msoinolor  eeiitrt'  :  similarly,  a  rise  of  l)loo<l-pi(ssure.  e\cn  lo  220  mm.  Ilg  or 
more,  may  accoiiipaMV  Hie  aspljyxial  attacks  of  I{ayri;iiid"s  syndrome.  Cases  of  meltiiiehnliii 
have  al)norm;i||y  high  blood-pressures  :  when  the  melancholia  improves,  the  pressure  falls, 
and  may  return  to  normal  when  the  patient  recovers  from  the  mental  symptoms.  The 
chief  importance  of  high  blootl-pressure  is  in  diagnosing  arterial  or  renal  degeneration, 
with  eonseijuenl  tenderie\-  to  iiiio/ile.ri/  or  to  elironie  lienri  failure.  It  should  be  remembered 
Ihal  any  patient  who  is  kept  in  bed  lends  to  have  a  diminution  in  the  blood-pressure,  and 
this  applies  lo  iirlciio-selerolie  pal  ients  as  well  as  others:  a  person  may  have  a  blood- 
pressure  of  2.,0  mm.  Ilg  or  more  when  up  and  about,  and  yel  when  lie  is  kept  in  bed  the 
pressure  may  fall  lo  1  ."lO  mm.  Ilg.  to  rise  again  wlien  he  relurns  to  aelive  life.  Prolonga- 
tion of  the    lirsl    soiiikI    al    llir    impulse    or    a    ringing   aceent  iial  ion    of    Ihc    aoilie    second 


82  BLOOD-PRESSURE.     ABNORMAL 

sound,  may  ser\e   to   indicate  tliat  tliere   is  a   high  blood-pressure  wlien  no   instrument 
is  at  liaud  to  verify  tlie  fact. 

Abnormally  low  blood-pressure  of  moderate  degree  may  be  observed  in  many  different 
circumstances  associated  with  asthenia  ;  it  is  apt  to  accompany  Graves's  disease  :  and  exces- 
sive smoking  of  cigarettes  ;  but  in  itself  a  low  maximum  systemic  blood-pressure  is  seldom 
of  diagnostic  significance  excepting  in  Addison's  disease.  In  a  case  in  which  the  degree  of 
pigmentation  of  the  skin  or  of  mucous  membranes  may  leave  doubt  as  to  wliether  .'Vddison's 
disease  is  the  diagnosis  or  not,  a  blood-pressure  so  low  as  80  mm.  Hg  would  be  confirmative 
of  the  diagnosis,  although  tliere  are  cases  of  Addison's  disease  in  which  the  blood-pressure 
may  be  no  lower  than  110  mm.  Hg.  Herbert  French. 

BLUE   SCLEROTICS. — (Sec  FRACTrnE.  Spontaneous,   p.  2J.2.) 

BLUE-BRAIN.— (See  Dead  Fingers,  p.  162.) 

BOILS.-    (Sec  Pi-sTrLES.  p.  557.) 

BONE,  SWELLING  ON  A.— (See  Swelling  on  a  Bone,  p.  (i(i7.) 

BONES,  SPONTANEOUS  FRACTURE  OF.— (See  Fractlre.  Spontaneous,  p.  242.) 

BORBORYGMI  are  gurgling  noises  in  the  abdomen  produced  by  peristaltic  move- 
ments of  the  bowel  acting  upon  the  mixed  gaseous  and  fluid  contents.  With  the  stetho- 
scope applied  to  the  abdomen  they  may  be  heard  in  all  normal  persons,  varying  in  intensity 
at  different  jjhases  of  digestion.  When  a  meal  has  been  taken  after  a  period  of  fasting, 
the  passage  of  the  intestinal  contents  through  the  ileoca;cal  valve  may  be  heard  distinctly 
with  the  stethoscope  placed  over  tlie  rigtit  iliac  fossa  some  six  hours  or  less  after  the  meal  ; 
but  it  is  seldom  possible  to  decide  what  precise  portion  of  the  bowel  is  responsible  for  the 
]iroduction  of  borborjgmi  heard  elsewhere. 

Normally,  these  sounds  should  not  be  audible  either  to  the  ])atient  or  to  other  persons  : 
but  occasionally  even  in  health  they  may  be  heard  quite  loudly.  In  some  individuals 
indeed,  especially  in  women,  the  sounds  become  annoyingly  obtrusive,  and  they  may  even 
acquire  a  pathological  degree.  They  may  be  very  loud  when  a  person  is  beginning  to  get 
over-hungry.  It  may  be  very  difficult,  however,  to  decide  exactly  as  to  their  cause  :  some- 
times the  patient  seems  to  be  otherwise  perfectly  healthy.  More  often  there  is  evidence  ol' 
functional  nerve  disorder  or  hysteria,  so  that  the  borborygmi  may  be  due  to  functional 
errors  in  the  intestinal  peristalsis  or  in  the  secretions  within  the  bowel.  They  may  be 
associated  with  Flatulence  (p.  240),  though  by  no  means  necessarily  so.  Observation 
of  the  patient  may  detect  air-swallowing  ;  intestinal  putrefaction  is  indicated  by  excess  of 
indican  in  the  urine,  or  by  a  high  ratio  of  organic  to  inorganic  urinary  sulphates  ;  fermenta- 
tion of  carbohydrate  is  suggested  when  there  is  no  evidence  of  air-swallowing,  when  urine 
analyses  do  not  confirm  any  suspicion  of  proteid  putrefaction,  and  when  the  borborygmi 
are  increased  by  carbohydrate  foods. 

IJorborygmi  are  apt  to  be  increased  in  asphyxial  conditions,  and  may  be  very  marked 
in  cases  of  heart  failure  with  cyanosis. 

The  absence  of  borborygmi  may  sometimes  be  important,  for  one  of  the  first  effects  of 
peritonitis  is  to  inhibit  peristalsis  ;  without  peristalsis  borborygmi  cannot  be  produced, 
and  therefore,  if  ]3eritonitis  is  suspected,  the  presence  of  well-marked  borborygmi  on  auscul- 
tation of  the  abdomen  is  an  argument  against  there  being  general  peritonitis,  whilst  com- 
plete silence  of  the  abdomen  is  in  favour  of  this  diagnosis.  Herbert  French. 

BRADYCARDIA,  or  undue  slowness  of  the  pulse-rate,  is  compatible  with  health, 
some  iTidividuals  having  a  normal  pulse-rate  of  50,  whilst  in  a  few  it  does  not  exceed  40  or 
even  30  per  minute.  Occasionally  bradycardia  of  this  kind  is  foimd  in  more  than  one 
member  of  the  family.  It  is  important  to  auscultate  the  heart  to  exclude  the  possibility 
of  the  rate  of  the  pulse  as  felt  at  the  wrist  not  being  the  same  as  the  rate  of  the  heart-beat  ; 
often,  jjartieularly  with  mitral  stenosis,  by  no  means  every  pulse  wave  becomes  palpable 
at  the  wrist,  and  the  rate  may  then  seem  to  be  slow  when  perhaps  in  reality  it  is  twice  the  j 
apparent  rate. 


BRADYCARDIA  83 

Absolute  slowness  of  the  pulse-beat,  as  distinct  from  its  relative  slowness  in  proportion 
to  the  pyrexia,  is  best  seen  in  the  symptom-complex  termed  Stokes-Adams'  disease,  the 
phenomena  of  which  are  syncopal  attacks  associated  with  epileptiform  convulsions,  coma, 
stertor,  and  cyanosis,  the  rate  of  the  heart-beat  being  found  to  have  dropped  to  a  half  or 
even  to  less  than  half  of  that  which  is  natural.  These  symptoms  are  due  to  difliculty  in 
the  transmission  of  the  contraction-stimulus  from  the  auricle  to  the  ventricle  alono-  the 

Time   marl,  -     [  I '      I  '  1 — 
jiigs  in  i,  and     [_ _  _-_zrr- 


Fi'j.' iT.—ElKtro-cardiosami  sLowiiif.'  complete  licart-block.  The  aurit-vihir  waves  (  p)  recur 
at  ci|Ual  intervals,  but  bear  no  relationship  to  the  ventricular  waves.  lAt  X  the  auricular  and 
tlie  ventricular  waves'are  simultaneous. 

auriculo-vcntricular  bundle  of  His.  The  inhibitory  factor  is  not  the  same  in  all  cases,  but* 
is  often  associated  with  arteriosclerosis  and  dejjenerative  changes  in  the  bundle  of  His, 
together  with  myocardial  degeneration  and  atheroma  of  the  coronary  arteries  ;  or  to  .syphilis 
of  the  bundle  of  His  or  to  destruction  of  that  bundle  by  a  gumma^  sarcoma,  or  carcinoma. 
The  diagnosis  is  apt  to  be  that  of  epilepsy  until  the  fact  has  been  established  that  the  pulse- 
rate  falls  during  an  attack  to  about  half  the  normal  ;  but  when  this  observation  has  been 
made,  the  difference  between  Stokes-Adams'  disease  and  ordinary  epilepsy  is  clear.     The 


had 
Left 
left  l<-B 


-nnielimcs  cvhibit,..!  panial  I t-lilock  as  al.ovc,  ami  soiuii  iiiii-s  corMplcCc,  as  in  I'l.j.  W. . 

I''"" '"ii  arc  those  of  '  heart-block'  the  diagnosis   of  which    in  its  lesser   degrees  caniiol 

be  made  without  careful  instrumental  records  i.C  the  venous  and  .■irlerial  pulses  and  of  the 
cardiac  movcmculs,  made  either  l)y  means  d  I  he  pdlygniph.  or  l>etter  still  the  electro- 
cardiograph. (■onsid(ral)Ic  slowing  of  the  pulsc-nilc  has  also  been  noted  in  souie  cases  of 
iirwinia.  even  without  licarl -bloc^k  ;  both  in  the  chronic  type  of  the  alTection  and  during 
uneniic  coma.      IJnidyeardia  is  by  no  means  constant  in  iira'mia  however. 

Increased    inlnit  raiiial    pvcssiuc    sometimes    causes    bradvcardia    in    certain    cases    of 


K-t 


BRADYCARDIA 


cerebral  heemorrJiage.  tumour  or  abscess,  and  in  the  early  stages  of  tuberculous  meningitis  : 
in  other  forms  of  meningitis,  and  in  the  later  stages  of  tubercnlous  meningitis  the  initial 
bradycardia  changes  to  tachycardia.  If  in  a  given  case  there  is  otitis  media  or  some 
other  local  infective  focus  which  might  produce  a  cerebral  abscess,  pyrexia  with  a  pulse- 
rate  of  50,  55,  or  60  is  an  argument  in  favour  of  intracranial  abscess  ;  the  other  complications 
of  otitis  media,  especially  lateral  sinus  thrombosis,  mastoid  abscess,  or  suppurative 
meningitis,  jiroduce  a  rapid  pulse-rate  instead  of  a  slow  one  ;  the  reverse  is  not  true,  for  it 
is  not  possible  to  exclude  cerebral  abscess  merely  on  the  ground  that  there  is  no  bradycardia. 
Cerebral  tumour  can  generally  be  distinguished  from  cerebral  abscess  by  the  greater  length 
of  the  history,  the  more  pronounced  optic  neuritis,  or  the  absence  of  predisposing  cause  to 
cerebral  abscess,  such  as  otitis  media  or  bronchiectasis  ;  whilst  cerebral  haemorrhage  is  more 
rapid  in  its  onset,  is  less  likely  to  have  marked  optic  neuritis,  and  if  there  is  pyrexia  it  is 
apt  to  be  extreme,  reaching  the  level  of  hj'perpyrexia  ;  generally  the  patient  is  an  elderly 
man  who  has  cither  high  blood-pressure,  albuminuria,  or  other  evidence  of  degenerated 
arteries  or  granular  kidneys. 

In  myxcedema  the  pulse-rate  is  seldom  fast,  and  it  may  be  abnormally  slow. 

Certain  drugs  are  apt  to  slow  the  heart  markedly  when  they  have  been  administered 
in  full  doses  over  a  long  period,  the  three  most  important  being  digitalis,  strophanthus,  and 
sodium  salicylaic  :  the  diagnosis  depends  on  knowledge  of  the  medicine  the  patient  is  taking. 

Jaundice  is  generally  stated  to  cause  marked  slowing  of  the  pulse-rate  :  it  is  true  that 
artificial  introduction  of  bile  salts  and  pigments  into  the  circulation  in  animals  slows  the 
heart,  but  clinically  in  man  it  is  rare  to  find  jaundice  and  absolute  bradycardia  associated. 

Herbert  Frenclt. 

BRADYPN(EA,  or  imdue  slowness  of  breathing,  is  not  a  very  common  symptom, 
hut  it  may  be  met  with  in  marked  degree  imder  various  conditions,  of  which  the  following 
are  the  chief  : — 


1.  As  an  Effect  of  certain  Drugs  or  Poisons  : — ■ 

Clil<irol(iriii  Chloral  Suli)lional 

Opium 


•plua 
iIkiI 


Chloral 

Chloral  hvilrate  Triona! 

Butyl  eliloial   liydrate  Tctroual 

Veronal  Jlediiial 


Cerebral  Compression  resulting  from  : — 

Depressed  fracture  of  the  i      Pontine    ha'niorrhage 

skull  Cerebral   tumour 

Meningeal  hoemorrhage  Cerebral  abscess 

Ccreliral  ha'moirhaiie  ]      Cerebellar  tMniour 


Aconite 
Antimonv. 


Cerebellar  abscess 
Osteoma   of  tlie   cranium 
Gumma  of  the  meninges. 


3.  Shock  or  Collapse  from  : — 

Severe   injury 

.Sudden  onset  of  acute  illness 

4.  Caseous    Bronchial    Glands. 

5.  Functional  Conditions  : — 

Hysteria  [    Ki)ilepsy 

6.  Ursemia. 


Operations 

E.xeessiveloss  of  Ihiid  IVom  eliolcraic  diarrhcra. 


I    Catalepsy 


I    Trance. 


7.  Diabetes  Mellitus  with  impending  Coma  ('  Air-hunger '). 

Although  l)radypn(ea  may  result  liciiii  any  of  the  above  causes,  it  is  not  constant  in 
most  of  them,  and  in  the  majority  it  is  an  incident  which,  even  if  present,  is  not  of 
diagnostic  importance.  This  applies  particularly  to  the  conditions  mentioned  in  Groups 
(1)  and  (2),  in  many  of  which  the  jjatient  is  likely  to  be  at  least  stuporous,  and  perhaps 
completely  comatose  (see  Coma,  p.  117).  The  cerebral  lesions  will  be  indicated  by  assoc; 
ated  headache,  vertigo  and  vomiting,  and  confirnied  by  the  discovery  of  optic  neuritii 
(Plate  XIX,  Figs.  K.  L.  p.  416). 

Now  and  then,  in  the  case  of  a  child  suffering  from  tuberculous  meningitis,  one  comes 
across  a  curious  type  of  slow  breathing,  in  which  two  or  perhaps  three  short  respirations 
occur  in  quick  succession,  followed  by  so  long  a  pause  that  the  patient  may  appear  to  be 
dead.  This  type,  known  as  Biofs  breathing,  does  not  resemble  Cheyne  Stokes"  breathing 
(p.  107)  clinically  at  all,  but  it  is  probably  related  to  it  pathologically.     It  occurs  in  those 


JS 

if 


BRADYPNCEA  85 

who  arc  ap])roac'hino  death,  but  may  be  present  for  a  day  or  more  before  dcatli  actually 
occurs. 

If  the  bradypna?a  is  due  to  a  poison,  the  circumstances  of  the  case  may  suggest  this, 
and  it  may  be  confirmed  by  chemical  analysis  of  the  gastric  contents  or  of  the  contents 
of  adjacent  bottles  ;  though  there  may  be  the  same  difficulties  of  deciding  whether  the 
patient  is  "  drunk  or  dying,"  as  are  discussed  on  p.  118.  One  important  point  is  not  to 
conclude  forthwith  that  the  presence  of  sugar  in  the  urine  indicates  diabetic  bradypnoea 
and  coma,  for  mmibers  of  patients  suffering  from  deep  alcoholism  have  sugar  in  their  urine 
for  the  time  being  ;  generally,  however,  without  acetone  (p.  3)  and  in  a  low  specific 
gravity  urine. 

In  cases  of  shod:  or  coUapsc  the  existence  of  bradypncra  will  be  overshadowed  by  the 
other  symptoms  in  the  case,  and  it  is  not  in  itself  important. 

The  slow  breathing  that  results  sometimes  from  caseous  broncliial  glands  differs  from 
most  of  the  above  in  that  it  affects  patients,  generally  children,  who  are  not  acutely  ill  ; 
though  delicate,  they  may  even  be  going  to  school,  and  yet  their  respiration  rate  may  be 
as  slow  as  12  or  even  10  to  the  minute  for  weeks  or  months.  There  is  generally  tachy- 
cardia at  the  same  time.  Many  sucli  children  shake  oft  their  delicacy  in  the  course  of 
a  year  or  two,  for  the  majority  of  cases  with  caseous  bronchial  glands  get  well  without 
being  diagnosed  ;  but  the  relationship  between  this  bradypncea  and  affection  of  the  glands 
has  been  established  repeatedly  in  patients  dying  from  accident  or  other  causes.  During 
life  the  diagnosis  may  be  established  by  finding  the  shadow  of  the  caseous  glands  in  the 
thorax  with  the  .r-rays  (Fig.  01,  p.  l-t9). 

Little  need  be  said  about  the  functional  conditions  in  which  bradypnoea  may  occur. 
Old  people  tend  to  breathe  iruich  more  slowly  than  young  unless  there  is  shortness  of  breath 
from  emphysema,  bronchitis,  or  myocardial  affection.  Epileptics  breathe  normally 
between  their  attacks  ;  but  during  a  seizure  they  cease  breathing  altogether  for  the  first 
twenty  seconds  or  so — the  tonic  stage — and  then  their  respirations  start  slowly  and 
stertf)rously  ;  the  bradv'pnoea  may  then  cease  suddenly,  or  it  may  persist  in  minor  degree 
during  the  period  of  post-epileptic  stupor.  Ilysleria  may  produce  almost  any  symptom  ; 
brady])nnea  is  possible  though  tachypnoea  is  more  common  ;  the  diagnosis  depends  upon 
other  features  of  the  case  (p,  465).  Cntalcpsi/  and  trance  are  both  mental  conditions, 
diagnosed  by  watching  the  case  or  by  the  history  ;  in  catalepsy  the  movements  of  respira- 
tion may  be  very  slow,  but  they  are  obvious  :  in  trance,  on  the  other  hand,  the  breathing 
movements  may  be  apparently  absent  altogether  for  days  or  weeks,  the  patient  lying 
motionless  like  one  dead.  The  chief  dilfieulty  is  to  exclude  actual  death  ;  the  thermometer 
helps  nnieh  —  the  body  docs  not  become  cold  :  the  lieart  sounds  may  be  just  audible  even 
though  the  pulse  (antiot  be  felt  :  and  the  fact  that  some  respiration  is  taking  jilace  may 
be  reiogni/.ed  by  holding  a  bright  mirror  close  to  the  nostrils  and  mouth,  when  a  slight 
dimming  from  condensation  of  expired  air  will  be  seen.  In  very  exceptional  cases,  how- 
ever, death  is  simulated  so  closely  that  the  patient  lias  been  upon  the  point  of  being 
buried  before  the  mistake  has  been  discovered. 

L'ra'niia  may  be  associated  with  breathing  that  is  either  ripid.  or  normal,  or  slow  ; 
the  latter  is  cxcc[)tional  ;  but  in  sonic  eases  of  unemie  coma  bradypncea  is  pronounced. 
Cerebral  ci)Tnpr(ssif)n  by  a  hiemorrhage.  abscess,  or  tumour  may  be  sinuilalcd,  and  a 
knowledge  that  the  urine  contains  albumin  and  tube  easts,  au<l  that  the  blood-pressiu'c  is 
high,  will  not  always  decide  between  them.  Ueeurrent  convulsive  seizures  would  ijoint 
to  ura-niia  to  some  extent,  but  they  may  also  occ.ir  from  gross  brain  lesions,  and  optic 
neuritis  may  also  be  common  to  both.  To  clinch  the  diagnosis  of  ura-mia  it  may  be 
necessary  to  lest   blond  or  cerebrospinal  flui<l  to  see  if  it  contains  excess  of  urea. 

Dialjclcs  niellitiis  is  lial)le  to  cause  the  most  characteristic  bradypncea  of  all — the 
'air-hunger"  of  diabclic  coma.  This  is  not  a  dyspncca,  as  the  name  niight  suggest,  but 
a  condition  of  extremely  deep  slow  breathing  with  a  tnaximum  respiratory  excursion  both 
in  the  intake  and  in  the  output  of  air.  The  "  hunger  '  for  air  is  one  of  getting  the 
niaxituum  of  air  in  and  out  with  each  deep  slow  breath,  rather  than  one  of  getting  in  as 
many  breaths  as  possible  in  a  given  time.  The  patient  becomes  increasingly  drowsy,  and 
generally  complMius  of  pjiins  in  the  upper  half  of  the  ahdouien.  'I'lie  breathing  rale  bigins 
to  fall  from  f,S  to  1(1,  to  If.  anil  progressively  .lown  lo  perhaps  only  li  lo  llie  minulc. 
There  is  a  long  pause  between  each  brealli.  and   llicn  inspiration  slarls  and.  willioul   any 


86  BRADYPNCEA 

Ininv,  the  stupcrosc  jjatient  ijoes  on  drawing  aiv  deeper  and  deeper  into  his  chest  until 
lie  cannot  expand  it  to  take  in  any  more  ;  the  head  is  often  thrown  slowly  back  during 
the  process,  the  mouth  slowly  opens  wider  and  wider  as  the  head  goes  back  ;  then  there 
is  a  pause  at  the  height  of  inspiration  before  an  equally  deep,  slow,  solemn  expiration 
follows,  and  the  head  comes  forward  and  the  mouth  closes  partially  until  the  next  slow 
deep  inspiration  is  in  progress.  The  patient  seldom  lives  much  longer  than  forty-eight 
hours  after  this  onset  of  air-hunger  and  diabetic  coma,  but  the  air-hunger  is  sometimes 
seen  in  cases  not  yet  comatose.  It  may  then  pass  off  for  a  time,  but  it  is  always  a  sign  of 
grave  danger,  and  it  is  the  most  characteristic  of  all  the  forms  of  bradypnoea. 

Herbert  FrencJi. 

BREAST,  DISCHARGE  FROM.— (See  Dischakgk  from  tiik  Nipple,  p.  181.) 

BREAST,   PAIN    IN. -(See  Pain  ix  the  Breast,  p.  429.) 

BREAST,   SWELLING  OF  THE.— (See  Swelling,  Mammary,  p.  085.) 

BREATH,  FOULNESS  OF  THE. — This  is  due  to  one  or  other  of  four  main  groups 
of  conditions,  namely,  septic  and  putrefactive  changes  within  the  mouth  or  nose  ;  septic 
or  putrefactive  changes  within  the  lungs  ;  smoking  or  the  ingestion  of  substances,  such  as 
garlic  or  onions,  whose  products  are  excreted  by  the  lungs  or  saliva  ;  and  severe  toxic 
conditions,  espeeiallj'  those  affecting  the  alimentary  canal  or  peritoneum. 

\Mien  the  foulness  of  the  breath  is  not  habitual,  but  occurs  as  the  result  of  recent  illness, 
there  will  be  symptoms  of  the  latter  which  point  to  the  diagnosis  quite  apart  from  the  con- 
dition of  the  breath,  and  one  need  merely  indicate  as  possible  causes  such  things  as  typhoid 
fever,  general  peritonitis,  post -puerperal  sepsis,  intestinal  obstruction,  and  a  host  of  other 
conditions  of  this  kind  in  which,  even  though  the  mouth  be  clean,  there  may  be  foulness  of 
the  breath,  such  tendency  being  greatly  exaggerated  if  sordes  have  been  allowed  to  collect. 
Foulness  of  the  breath  due  to  the  ingestion  of  foodstuffs  such  as  onions  or  garlic  is 
familiar  enough  ;  there  are  certain  drugs,  for  instance  gnaiacol  or  paraldehyde,  which  may 
produce  a  similar  symptom  without  the  patient's  friends  realizing  why  the  breath  should 
be  so  tainted. 

Foulness  of  the  breath  due  to  lung  conditions  will  nearly  always  be  indicated  either 
by  the  abundant  and  putrid  sputum,  or  by  the  abnormal  physical  signs,  in  the  thorax. 
The  condition  may  be  due  to  pMhisis  with  secondary  infection  of  the  cavities  by  pyogenic 
organisms,  fa;lid  bronchitis,  bronchiectasis,  gangrene  of  the  lungs,  empyema  or  other  abscess 
which  has  ruptured  into  the  lung.  The  cases  which  give  rise  to  most  difficulty  in  differential 
diagnosis  are  those  in  which  an  empyema  has  been  situated  deeply,  for  instance  between 
the  lower  lobe  and  the  diaphragm,  or  between  two  lobes,  without  reaching  the  surface  ; 
there  may  be  absolutely  no  abnormal  physical  signs,  and  the  diagnosis  has  to  be  made  from 
the  symptoms  and  history.  The  patient  has  generally  had  some  obscure  febrile  illness,, 
possibly  with  cough,  but  without  much  expectoration,  until  one  day,  after  a  particularly 
severe  bout  of  coughing,  a  large  quantity  of  pus — perhaps  a  teacupful  or  more — has  been 
brought  up  suddenly,  since  when,  at  intervals  of  hours  and  days,  there  has  been  similar 
expectoration  of  quantities  of  putrid  pus.  Deep-seated  empyema  without  abnormal  physical 
signs  most  resembles  bronchiectasis  or  bronchiolectasis,  but  is  distinguished  by  the  sudden  , 
way  in  which  the  first  large  quantity  of  purulent  expectoration  came  on.  In  both  cases 
there  may  be  clubbing  of  the  fingers,  the  sputum  contains  pus  corpuscles  and  pyogenic  and 
non-pyogenic  micro-organisms  other  than  tubercle  bacilli,  but  no  elastic  fibres  indicative 
of  lung  destruction. 

Gangrene  of  the  lung  produces  an  unmistakable  stench  of  the  worst  kind  ;  the  detection 
of  elastic  fibres  in  the  sputum,  after  boiling  with  caustic  soda  to  destroy  other  tissue 
elements,  clinches  the  diagnosis. 

Phthisis  with  cavitation  may  produce  foulness  of  the  sputum,  but  hardly  ever  the  stench 
of  gangrene,  unless  gangrene  has  supervened.  It  is  distinguished  from  bronchiectasis  and 
from  hidden  empyema  by  discovering  tubercle  bacilli  in  the  sputum.  The  chief  difficult 
arises  when  the  tuberculous  part  of  the  malady  has  ceased,  the  cavities  formerly  excavatu 
by  the  tuberculous  process  having  been  usurped  by  secondary  pyogenic  organisms. 


BREATH.     SHORTNESS     OF  87 

Foul  breath  is  due  in  the  great  majority  of  cases  to  local  decomposition  in  the  mouth, 
often  diagnosablc  on  simple  inspection  in  the  form  of  tartar,  septic  gums,  carious  teeth  with 
decomijosing  food  ])articles  in  them,  pijorrluea  alvcolaris,  or  stomatitis  (p.  542)  ;  or  it  may 
he  that  the  nose  or  tliroat  are  at  fault  rather  than  the  mouth,  as  the  result  of  necrosis  of  the 
7iasal  bones,  purulent  hypertrophic  or  atrophic  rhinitis,  ozocna,  septic  tonsillitis  or  other  varieties 
of  Sore  Throat  (p.  613)  ;  very  vile  foulness  of  the  breath  occurs  with  Vincent's  angina 
(p.  614),  and  with  scpianious-celled  carcinoma  of  the  mouth  or  tongue  :  in  children  the 
possibility  of  some  foreign  body  having  got  impacted  in  the  throat,  nose,  or  nasopharynx 
should  not  be  forgotten. 

It  is  only  when  all  such  local  conditions  have  been  excluded,  and  when  there  is  no  acute 
illness  nor  any  lesion  of  the  lungs,  that  one  can  attribute  foulness  of  the  breath  to  constipation 
or  to  dyspepsia.  It  is  sometimes  very  difficult  to  find  out  why  the  patient's  breath  is  not 
sweet,  and  indeed  there  are  some  persons  in  whom  all  the  functions  of  the  body  seem  to  be 
normal,  and  the  mouth  clean,  and  yet  the  breatli  is  foul.  If  there  are  any  symptoms  of 
gastro-intestinal  disorder,  especially  flatulence  or  constipation,  one  is  inclined  to  attribute 
the  condition  of  the  breatli  to  the  stomach  or  the  bowels  ;  but  when  there  are  no  symptoms 
of  error  in  these,  it  is  more  than  likely  that  the  trouble  is  due  to  some  local  condition  not 
discovered  on  ordinary  insiiection,  particularly  putrefaction  of  food  particles  which  may 
become  impacted  between  the  teeth  even  in  persons  who  use  both  tooth-brush  and  mouth- 
wash daily.  Herbert   Frtiicli. 

BREATH,  SHORTNESS  OF.— This  is  a  very  common  complaint  which  should  be 
differentiated  c.Trcfully  lioin  dilliiulty  of  breathing,  the  hitter  term  being  reserved  entirely 
for  cases  of  obstruction  in  the  main  air-passage,  the  larynx,  and  trachea — diphtheria, 
growths,  and,  very  much  more  rarely,  pressure  from  without  being  the  main  causes.  Short- 
ness of  breath  is,  in  the  patient's  mind,  a  conscious  quickening  of  the  resjjiratory  movements 
to  supply  a  conscious  need  of  air.     The  following  are  chief  causes  : — 

Increased  Need  for  Oxygen. — Fevers  and  other  septic  processes  inducing  excessive 
oxygen  requirements.     Exercise  in  health — temporary  shortness  of  breath. 

Diminished  Supply  of  Oxygen. — (1)  Blood  conditions  in  which  the  red  corpuscles 
cannot  carry  a  sufficient  charge,  or  do  not  yield  up  their  supply  with  sufficient  ease  ; 
(2)  Cardiac  conditions  of  inefficiency  of  circulation  ;  (3)  Pulmonary  conditions  of  diminished 
surface  of  contact,  or  ease  in  contact,  of  air  and  blood  in  alveoli  ;  (4)  .A.tmosphcric  con- 
ditions of  diminished  j)artial  oxygen  pressure  in  the  alveoli  of  the  lung  ;  (.5)  Deformities 
of  the  ehesl  nicclianically  ])reventing  tlie  expansion  of  the  lung.  The  diagnosis  of  these 
condilions  is  not  (Hllicidl  when  once  attention  is  drawn  to  the  possibility  of  their  occurrence, 
but  we  must  advert  briclly  to  each  of  them  to  indicate  the  guides  to  the  cause  in  a  case 
not  at  once  obvious. 

Fevers  and  Septic  Conditions. — The  tliermometer  and  the  obvious  illness  of  the 
patient  will  gcncially  iiuliciilc  these  :  nor  indeed  is  shortness  of  breath  a  common  complaint 
in  such  patients,  their  minds  being  filled  with  other  ideas. 

Exercise  in  Health. — Here  it  is  necessary  to  be  sure  of  the  health  ;  it  may  or  may 
not  be  that  the  person  is  merely  out  of  condition,  and  undertakes  exercise  which  only  a 
trained  athlete  can  perform  i)ropcrly.  The  only  way  to  avoid  mistakes  is  to  ask.  Docs 
the  shortness  of  breath  soon  disappear  ?  and  then  to  make  a  careful  examination  of  the 
patient   to  sec  if  imy  of  the  midcrmciitioiied  eawses  are  at   work  :     - 

1.  Blood  Conditions.  These  iiicludr  :  (i)  Siiiiplc  loss  of  lilood  :  (ii)  Antcrnia  simplex  : 
(iii)  .Aiiatnia,  severe,  pernicious  or  Icukaniie  ;  (iv)  Polyeylhutiiia  ;  (\)  .Somi'  pathological 
constituent,  as  in  diabetes,  ura-mia,  (iravcs's  disease,  etc. 

The  actual  laboratory  diagnosis  of  the  blood  condition  is  simple  enough  if  we  decide 
to  have  it  examined.  The  jioints  that  may  lead  us  to  have  this  done  would  naturally  eonie 
in  the  following  order.  \  history  of  loss  of  blood  is  pretty  sure  to  be  voluutceicd  -piles, 
excessive  menstruation,  obvious  trauma,  loss  at  parturition,  etc.  ;  suspicion  is  very  likely 
to  be  aroused  by  the  colour  of  the  patient's  face,  especially  when  eouple<l  with  a  primary 
complaint  of  shortness  of  l)reath.  Didlicles  and  nnemia  are  likely  to  show  other  signs,  and 
the  urine  will  give  the  clue  to  the  diagnosis.  Never  omit  to  have  the  blood  examined  it 
the  <-ause  of  a  shortness  of  breath  is  not  apparent  on  simple  physical  examination  ;  indeed, 
line   iiiiisl   go   larllicr.   and   say   if  some  <!isily   iliaguosablc  eoiwlition   is   not    present  :     I'or   il 


88  BREATH.     SHORTNESS    OF 

must  be  remembered  that  blood  conditions  are  the  very  ones  to  be  tlie  exciting  cause  of 
cardiac  inefficiency,  wliicli  by  itself  is  often  liard  to  diagnose  it  there  be  no  obvious  bruit 
or  irregularity  in  rhythm. 

2.  Cardiac  Conditions. — Inefficiency  in  circulation.  These  include  :  (i)  Valvular 
disease  (acute  and  chronic)  :  (ii)  Muscular  weakness  (fatty,  fibrosis,  etc.)  ;  (iii)  Nerve 
conditions  (arrhythmia  ?)  ;    (iv)  Pericarditis  and  pericardial  effusion. 

i.  Valvular  Disease. — If  a  bruit  be  present,  it  may  fairly  be  assumed  that  the  heart  is  a 
factor  in  causing  shortness  of  breath,  but  unless  some  other  tell-tale  sign  be  present  it  must 
not  be  assimied  that  it  is  the  only  factor,  for  it  is  very  common  to  find  patients  with  bruits 
who  will  not  confess  to  shortness  of  breath. 

ii.  Muscular  Weakness. — We  cannot  under  the  jjresent  heading  give  all  the  points  in 
connection  with  "  morbus  cordis  sine  murmure "  ;  it  must,  however,  be  stated  that  a 
diminution  in  the  muscular  energy  of  the  heart  is  a  most  important  contributory  factor  in 
producing  shortness  of  breath  in  all  ]jathological  conditions  of  the  blood,  including  renal 
affections  and  diabetes,  in  convalescence  from  acute  disease,  and  in  acute  pericardial 
affections  ;  it  is,  perhaps,  the  commonest  cause  of  all  of  shortness  of  breath.  Want  of 
tone  in  the  soimds,  likeness  of  the  first  to  the  second  sound,  and  irregularities  in  rhythm, 
are  the  jjrincipal  points  to  look  for.  The  lu'ine  should  be  examined  with  care,  both  for 
albumin  and  tube-casts  ;  the  ophthalmoscope  should  be  used  in  the  detection  of  albuminuric 
retinitis  ;  and  it  is  often  wise  to  measure  the  systemic  blood-pressure  to  find  out  whether 
it  is  greatly  above  the  normal  or  not.  In  tliis  connection  fat  wants  special  mention  ;  fatty 
degeneration  of  heart  muscle,  and  overloading  of  the  heart  with  interstitial  fat  will  both 
cause  shortness  of  breath,  and  it  is  practically  impossible  to  differentiate  the  two  with 
certainty  during  life.  In  very  stout  individuals  the  latter  is  of  course  to  be  suspected,  but 
the  former  cannot  be  excluded  ;  in  fact,  when  such  a  patient  complains  of  shortness  of 
breath,  his  case  requires  the  greatest  acumen  to  decide  the  cause  and  then  the  treatment. 
The  previous  general  health  affords  the  strongest  clue,  coupled  with  the  history  of  the  onset 
of  the  shortness  of  breath.  In  a  stout  subject,  as  indeed  in  all  other  patients  in  whom  I 
am  trying  to  judge  the  question,  "  Am  I  dealing  with  a  case  of  cardiac  insufficiency  without 
a  bruit  ?  "  I  adopt  the  following  simple  plan.  I  listen  with  the  stethoscope  to  the  heart, 
counting  the  pulse  frecjuency  and  noting  the  sounds  while  the  patient  is  sitting  in  a  chair 
in  the  course  of  conversation,  and  again  do  the  same  while  he  is  standing.  I  then  make 
the  patient  hurry  in  his  niovemcnts.  run  upstairs,  or  several  times  across  mj'  consulting 
room,  and  again  repeat  my  observations  on  frequency,  rhythm,  and  sounds  ;  I  then  get 
him  to  lie  down  on  a  sofa  whilst  I  make  anotlier  examination  on  the  same  points.  It  is 
thus  possible  in  three  or  four  minutes  to  get  most  valuable  information  as  to  the  response 
of  the  heart  to  increased  work,  as  well  as  to  relief  from  work,  and  to  draw  jjretty  accurate 
conclusions  as  to  its  muscular  efficiency,  which  after  all  is  the  chief  point  to  be  considered. 
I  roughly  assume  that  there  is  an  average  difference  in  Iiealth  of  about  five  beats  per 
minute  between  sitting  and  standing,  that  effort  should  increase  this  difference  to  somewhere 
about  fifteen  to  twenty  beats  a  minute,  and  then  in  about  three  minutes  a  reasonably  healthy 
heart  should  resume  its  resting  frequency  from  such  mild  exertion  as  mentioned  abo\e. 
If  exertion  removes  a  '  resting  '  irregularity  in  rhythm,  I  assume  the  heart  is  muscularlj' 
in  a  reasonable  state  of  health. 

iii.  Nerve  Conditions. — I_,ocal  pressure  on  the  nerves  may  cause  cardiac  arrhythmia 
and  breathlessness,  but  these  will  have  other  signs  and  symptoms  easily  discoverable  ; 
general  nervousness  and  neurasthenia  are  often  characterized  by  shortness  of  breath  on 
exertion  or  excitement,  there  being  frequency  of  the  beat  without  any  arrhythmia. 

iv.  Pericardial  Diseases. — A  differential  diagnosis  between  these  and  a  hypertroph>' 
or  dilatation  of  the  ventricles  may  be  demanded  for  other  reasons,  but  qua  shortness  of 
breath,  there  is  no  didiculty  in  determining  that  either  cardiac  or  pericardial  trouble  is  tlu- 
cause. 

3.  Pulmonary  Conditions. — These,  again,  will  be  fairly  obvious  on  proper  examination, 
including,  as  they  do.  every  disease  of  the  lung  ;  but  we  would  specially  draw  attention  to 
the  possible  presence  of  a  quiet  pleural  effusion,  which  not  very  infrequently  is  so  insidious 
as  to  give  rise  to  no  complaint  but  that  of  shortness  of  breath.  Again,  in  the  early  days 
of  phthisis,  it  may  be  that  a  cough  and  shortness  of  breath  are  nearly  all  that  is  complained 
of.     Bronchitis,     advanced    tubercle,    broncho])neumonia.     lobar    pneumonia,     and    acute 


BRUITS,     CARDIAC  89 

])leiiri.sy,  are  all  easily  recognizable  causes  of  shortness  of  breath.  The  only  intrinsic 
affection  of  the  lungs  not  at  once  easily  discoverable  is  emphysema  without  its  usually 
accompanying  bronchitis  ;  the  shape  of  the  chest,  the  defieiency  of  \esicular  sounds,  the 
increased  resonance  to  percussion  will  generally  give  a  clue. 

4.  Atmospheric  Conditions  need  no  diagnosis  ;  partial  asphyxia  by  bad  air,  high 
mountains,  and  caisson  work,  are  the  three  chief  alterations  in  gaseous  surroundings.  All 
are  obvious. 

5.  Deformities  of  Cliest  are  again  obvious  :  Pott's  cur\-ature  is  the  chief  one.  They 
derive  their  ini])()rtance  from  the  fact  that  commonly  one  lung  is  Iiors  de  combat  almost  to 
start  with,  and  hence  a  very  slight  affection  of  the  other  may  cause  great  difliculty  in 
breathing.  Fred  J.  Smith. 

BREATHING,   CHEYNE-STOKES.— (See  Cukvnk-Stokes  Rhspiuation.  p.  107.) 

BREATHING,  SLOW.     (See  Bkauvpncea,  p.  84.) 

BRITTLE  BONES.— (See  Fiiacture,  Spontaneol s,  p.  242.1 

BRUITS,    CARDIAC. 

I.— SYSTOLIC    BRUITS. 

(A).  Systolic  Bruits  in  the  Mitral  Area. — When  a  definite  systolic  bruit  is  audible 
over  the  niitnd  ana  whicli  ((irrcspoiuls  to  that  portion  of  the  chest  w-all  lying  immediately 
over  the  cardiac  apex,  its  cause  is  sometimes  obvious.  If,  for  example,  a  person  who  has 
I)reviously  had  an  attack  of  rheumatic  fever  presents  a  bruit  with  its  point  of  maximum 
intensity  over  the  cardiac  apex,  conducted  outwards  into  the  left  axilla,  there  being  lost, 
and  heard  again  near  the  inferior  angle  of  the  left  scapula,  then  such  a  bruit  is  almost 
certainly  due  to  organic  disease  of  the  mitral  valve  causing  regurgitation  through  it.  This 
is  confirmed  by  finding  that  the  heart  is  enlarged,  the  area  of  cardiac  dullness  increased, 
and  the  apex  beat  (lis])liiced  downwards  and  to  the  left.  Such  enlargement  points  to  the 
cardiac  condition  not  lieing  of  recent  origin  ;  bulging  of  the  pra»cordia,  often  seen  in  children, « 
is  additional  evidence  in  the  same  direction. 

In  some  cases,  however,  the  diagnosis  is  not  so  obvious,  and  for  a  definite  conclusion 
to  be  arrived  at  it  is  necessary  to  consider  all  the  following  conditions  whieli  may  i)ro(luce 
a  systolic  bruit  in  the  mitral  area  : — 

(1).  Mitral  regurgitation,  due  to  chronic  organic  disease  of  the  mitral  vahe. 

(2).  Acute  endocarditis  :    (d)  Sinij)le  :    (,h)  Ulcerative  or  malignant. 

(;j).  -Mitral  regurgitation  where  there  is  no  disease  of  the  mitral  valve,  but  ililatation 
of  the  left  ventricle  as  the  result  of  («)  Disease  of  the  aortic  vahe  :  (}>)  Disease  of  the 
niyocardiiun,  such  as  myocarditis.  ])arcneliymatous  degeneration.  I'atty  heart,  fibroid  heart  ; 
(r)  Disease  external  to  the  heart,  causing  hypertrophy  and  dilatation  of  the  lell  ventricle 
such  as  arterial  sclerosis  and  interstitial  nephritis  ;  (d)  Adherent  pericardium,  which  is 
lre(|ucnt!y  associated  with  organic  disease  of  the  valves. 

(  !•).   Funclional   bruits. 

(.■>).  Cardiii-respiralory  bruits. 

{()).  Congenital  malfortnalioii  ol   llie  licart. 

(7).  Aneurysm  of  the  heart. 

(N).  Acute  ijcrlcarditis. 

I.  The  rollowiiig  points  are  in  laNour  ol  llic  liiiiit  being  due  to  arfiii'iiii'  ilisciisr  iif  llic 
inilnil  j'fdvr  of  long  standing  :  (ii)  iMiIargerneiil  of  the  lieart,  shown  by  displacement  of 
the  apex  bi'at  and  increase  iti  the  area  of  cardiac  dullness.  In  mitral  regurgitation  the 
enlargement  is  due  to  hypertrophy  and  dilatation  of  the  li^l't  ventricle,  the  differential 
'diagnosis  ol'  the  other  causes  of  which  will  be  found  on  p.  2()(i  :  (h)  \  history  of  ])ast 
rheumalie  lexer  or  of  chorea  ;  (c)  The  age  of  the  patient  :  in  children  and  young  adults 
mitral  regurgitation  is  far  more  likely  to  l»-  the  result  of  a  previous  endocarditis  than  of 
dilatalidii  (if  the  mitral  oriliee  without  valvular  disease  ;  (rl)  The  absence  of  pyrexia  lulps 
in  exeludiiig  a  recent  endocarditis,  though  in  children  sulTering  from  rlieuuiatie  endocarditis 
the  temperature  is  often  normal  while  they  are  being  treated  with  .salicylates.  In  cases  of 
recent  endocarditis  there  may  be  no  physical  signs  of  any  great  eidargcment  of  the  left 
ventricle,  and  usually  the  apex  beat   is  I'oiuid  close  to  its  iKuiiial  position. 


00  BRUITS.     CARDIAC 

2.  Acute  endocarditis  is  nearly  always  associated  with  some  other  affection  ;  for 
example,  there  may  be,  or  have  been,  acute  rheumatism  or  chorea,  or  pneumonia  or  some 
other  infectious  process,  such  as  scarlet  fever,  erysipelas,  septicaemia,  or  puerperal  fever. 
The  heart  is  not  found  to  be  enlarged,  or  only  to  a  slight  extent,  provided  that  the  condition 
is  not  one  of  an  acute  endocarditis  affecting  old  sclerotic  valves  ;  the  bruit  is  soft  and 
blowing — never  musical  in  simple  eases — and  it  is  localized  to  the  impulse  instead  of  being 
transmitted  into  the  axilla.  In  malignant  endocarditis  the  constitutional  disturbances  may 
be  severe  ;    the  points  in  the  diagnosis  will  be  foimd  on  p.  Si. 

3.  The  points  in  favour  of  mitral  regurgitation  due  to  dilatation  of  the  left  ventriele  are  : 
((/)  The  age  of  the  patient  :  myocardial  degenerations,  except  those  occurring  in  infectious 
processes,  are  not  likely  to  be  present  before  middle  life  ;  (h)  The  presence  of  arterial 
sclerosis  and  chronic  interstitial  nephritis,  as  determined  by  increased  blood-pressure, 
accentuation  of  the  aortic  second  sound,  thickening  of  the  radial  arteries,  retinitis,  and 
polyuria  with  a  trace  of  albumin  ;  (e)  The  existence  of  non-rheumatic  aortic  obstruction 
or  regurgitation  with  hypertrophy  and  dilatation  of  the  left  ventricle  ;  (d)  Shortness  of 
breath  and  cardiac  distress  upon  exertion,  without  any  obvious  cardiac  lesion  ;  if  these 
be  associated  with  a:dema  of  the  legs,  engorgement  of  the  lungs,  and  enlargement  of  the 
liver  without  a  very  high  blood-pressure  and  without  obvious  primary  lung  trouble  sueli 
as  fibrosis  or  emphysema,  dilatation  of  the  mitral  orifice  as  the  result  of  myocardial 
degeneration  is  probable.  If  this  is  the  result  of  fatty  infiltration,  the  cardiac  condition  is 
often  part  of  general  obesity. 

Regurgitation  through  the  mitral  valve  may  be  caused  by  a  dilatation  of  the  left 
ventricle  dependent  upon  an  adherent  pericardium.  The  following  signs  of  adherent  peri- 
cardium must  be  looked  for  :  (a)  Systolic  retraction,  which  is  best  determined  by  inspection 
of  the  chest  wall  from  the  side,  and  is  due  to  an  indrawing  of  the  intercostal  spaces  during 
the  ventricular  systole.  \Vlien  this  is  situated  near  the  apex  beat  it  is  due  to  an  adherent 
pericardium  :  it  may  also  be  noticed  over  the  lower  sternal  region,  or  at  the  ensiform 
cartilage,  or  over  a  lower  left  rib  behind  the  posterior  axillary  line.  Systolic  retraction 
is  not  always  due  to  an  adherent  pericardium,  for  in  thin  persons  and  in  children  a  systolic 
indrawing  of  the  third  and  fourth  left  intercostal  spaces  close  to  the  sternum  is  often  seen, 
and  is  produced  by  the  normal  recession  of  the  base  of  the  heart  during  each  ventricular 
systole.  Systolic  retraction  due  to  adherent  pericardium  is  often  followed  by  (b)  The 
diastolic  shock,  palpable  and  due  to  the  sudden  relaxation  of  the  ventricular  wall ;  (c)  Eiastolic 
collapse  of  the  veins  of  the  neck,  or  Friedreich's  sign,  which  is  produced  during  the  ventricular 
diastole  ;  it  is  found  chiefly  in  this  condition,  but  does  not  always  occur,  and  is  sometimes 
seen  without  pericardial  adJiesion  being  present ;  (d)  The  pidsus  paradoxus,  the  cardiac  beats 
becoming  more  feeble  at  the  end  of  inspiration,  so  that  during  each  inspiration  the  pulse- 
beat  becomes  very  weak,  or  is  lost. 

4.  A  systolic  bruit  at  the  cardiac  apex  may  be  functional  in  origin,  in  which  case  it  is 
localized  to  the  mitral  area,  being  conducted  only  for  a  short  distance  into  the  axilla,  and 
not  heard  posteriorly.  The  condition  is  associated  with  anemia  and  other  debilitating 
conditions.  Other  functional  bruits  are  nearly  always  associated  with  it,  especially  one  in 
the  pulmonary  area,  and  also  a  bruit  de  diable  in  the  neck. 

5.  A  cardio-respiratory  Ijruit  is  frequently  heard  at  the  cardiac  apex,  and  is  sometimes 
mistaken  for  one  caused  by  niitral  regurgitation.  The  bruit  varies  with  the  movements 
of  respiration,  the  more  usual  sounds  heard  being  bruits  corresponding  with  the  ventricular 
systoles  of  two  or  three  heart -beats  during  inspiration.  Such  murmurs  should  not  be 
ignored,  as  they  may  be  due  frequently  to  pleuritic  friction.  To  distinguish  them  from  cardiac 
bruits  is  usually  easy,  and  the  chief  diagnostic  points  are  :  (a)  Cardio-respiratory  bruits 
vary  in  intensity  with  the  movements  of  respiration,  being  louder  during  inspiration. 
[b)  When  present  at  the  apex  they  are  abolished  when  the  breath  is  held  in  deep  inspiration 
(<■)  They  vary  in  intensity  and  character  with  alterations  in  the  posture  of  the  patient. 
((/)  The  bruits  sound  nearer  to  the  ear  than  cardiac  bruits,  (f)  Each  bruit  commences 
suddenly  and  ends  abruptly.  (/)  They  are  not  conducted  in  the  recognized  direction  ol 
valvidar  murmurs. 

6.  A  congenital  systolic  bruit,  when  heard  in  the  mitral  area,  is  always  part  of  a  loud 
bruit  with  its  point  of  maxinumi  intensity  nearer  the  base  of  the  heart.  'Wlien  such  ." 
nuumur  is  heard  in  children,  with  little  or  no  displacement  of  the  apex  beat,  and  the  are; 


BRUITS.     CARDIAC  91 

of  cardiac  dullness  is  increased  to  the  right  of  the  sternum,  the  condition  is  always  congenital. 
The  lesion  will  generally  be  either  patent  septum  ventriculorimi,  pulmonary  stenosis,  or 
patent  ductus  arteriosus  (p.  156).  Mitral  regurgitation  due  to  a  congenital  defect  practically 
ne^er  occurs. 

7.  An  fineiiri/sm  at  the  cardiac  apex  is  rare,  and  is  scarcely  possible  to  diagnose,  so  that 
it  need  not  be  taken  into  account  when  considering  the  differential  diagnosis  of  apical  bruit. 

8.  When  acute  pericarditis  is  present,  a  systolic  bruit  which  is  part  of  a  '  to-and-fro  ' 
friction  murmur  may  be  heard  in  the  mitral  area.  Such  a  murmur  changes  its  character 
with  the  pressure  of  the  stethoscope  and  with  the  different  phases  of  respiration  :  and  it  is 
not  conducted  into  the  axilla.     Other  signs  of  pericarditis  are  usually  present  (p.  213). 

(B).  Systolic  Bruits  over  the  Pulmonary  Area,  i.e.,  over  the  second  left  intercostal 
space  close  to  the  sternum,  may  be  caused  by  the  following  conditions  : — 

(1).  Congenital  cardiac  malfurniaiions,  especially  pulmonary  stenosis  and  patent  ductus 
arteriosus. 

(2).   Fiinrtiuna!  lirait. 

(3).  Cardio-respiratorij  Ijriiil. 

{i).  Acquired  pulmonary  stenosis,  which  is  a  very  rare  lesion. 

To  distinguish  between  an  organic  and  congenital  defect  and  a  functional  condition  is 
usually  quite  easy.  Pulmonary  stenosis  is  nearly  always  congenital,  and  is  therefore  found 
for  the  most  part  in  children  ;  and  its  presence  is  confirmed  by  other  signs  of  congenital 
heart  disease,  such  as  little  or  no  displacement  of  the  apex  beat  with  considerable  enlarge- 
ment of  the  right  side  of  the  heart,  together  with  cyanosis  of  varying  degree,  and  clubbing 
of  the  fingers  (p.  Ill)  and  toes.  With  a.  patent  ductus  arteriosus  the  bruit  is  often  similar 
although  cyanosis  and  clubbing  of  the  fingers  and  toes  are  usually  absent  ;  instead  of  the 
murmur  being  definitely  either  systolic  or  diastolic  in  time,  a  long  rumbling  bruit,  com- 
mencing during  systole  and  passing  on  into  the  diastole  of  the  ventricles,  is  heard.  Such 
a  bruit  is  considered  to  be  pathognomonic  of  this  congenital  defect,  as  it  is  impossible  for 
a  bruit  extcnfling  from  systole  into  diastole  to  be  produced  within  the  heart.  WTien  a 
patent  fluctus  arteriosus  is  present,  .r-ray  examination  of  the  heart  sometimes  shows  a 
shadow  bulging  to  the  left  between  the  arch  of  the  aorta  and  the  left  ventricle.  It 
appears  like  a  "cap'  above  the  ventricle,  due  to  dilatation  of  the  pulmonary  artery. 
A'-ray  examination  will  help  in  the  diagnosis  of  most  forms  of  congenital  heart  disease, 
because  it  shows  definitely  the  enlargement  of  the  right  heart  with  little  alteration  in  the 
position  of  the  left  border. 

Other  congenital  maH'ormations,  such  as  a  patent  interventricular  septum .  may  produce 
a  systolic  bruit  in  the  pulmonary  area,  though  the  maximum  intensity  of  the  abnormal 
.sound  is  lower  down  on  the  left  of  the  steriunn  ;  in  many  cases,  however,  the  differential 
diagnosis  of  the  ventricular  congenital  malformation  is  impossible. 

2.  The  functional  pulmonary  bruit  is  common  in  chlorosis  and  other  ana'inic  and 
debilitated  conditions,  and  in  exophthalmic  goitre  ;  it  is  also  frequent  in  school-children 
a't.  5  1. 5.  The  bruit  alters  with  tlie  position  of  the  ))atient.  being  louder  in  the  recumbent 
than  in  the  erect  pcjslurc,  whereas  in  congenital  dcfeets  the  ijosition  of  the  i)atient  lias 
verj'  little  inlluenee  ujjon  the  loudness.  The  presence  of  a  bruit  dc  dialilr  in  the  neck  conlirnis 
the  diagnosis  of  the  functional  origin  of  the  bruit,  and  there  is  generally  no  such  increase 
of  cardiac  dullness  to  the  right  of  the  stermmi  as  occurs  in  congenital  malformation  and 
acquired  i)ulnionary  stenosis.  A  systolic  thrill  may  be  present  in  the  pulmonary  area  botli 
in  organic  and  functional  conditions,  but  is  more  conunou  in  the  former  and  therefore  in 
favour  of  ])uInionary  stenosis. 

.\  systolic  bruit  is  frc(|ucntly  heard  over  the  ujipcr  portion  of  the  manubrium  in  young 
children  in  the  sitting  posture,  when  the  head  is  so  raised  that  the  eyes  arc  looking  directly 
up  at  the  ceiling.  It  disapj)ears  when  the  chin  is  lowered.  It  is  usually  of  no  importance, 
although  it  may  be  a  sign  of  enlarged  lympliatic  glands  at  the  bifurcation  of  the  trachea. 

3.  ('ardio-rispiralorif  bruits  are  sonu'tinies  heard  at  the  base  of  the  heart,  and  more 
often  on  the  left  side  of  the  slerninn.  Tliey  vary  with  the  niovcmenls  of  respiration  and 
also  with  changes  in  the  posture  of  the  patient,  but  not  in  so  dellnile  manner  as  do  the 
canlio-respiralory  bruits  which  arc  heard  in  the  mitral  area. 

t.  Pulmonary  sloiosis  may  be  an  acipiired  lesion,  although  very  rarely  :  if  in  a  ycpiing 
adult    such  a  liruit   as  lias   just   been  described   is  present,  and   if  tlicrc   is  a  |)asl    hislory  of 


9-2  BRUITS.     CARDIAC 

iliciimatio  fever,  together  with  lesions  of  the  other  valves,  espeeially  the  mitral,  then  it 
may  be  fairly  presumed  that  the  bruit  is  due  to  an  accjuired  pulmonary  stenosis.  The 
history  helps  greatly  in  the  diagnosis,  for  if  the  lesion  were  congenital  there  would  be 
symptoms  of  its  presence  dating  back  to  infancy. 

Systolic  bruits  due  to  other  valvular  lesions  may  also  be  heard  over  the  pulmonary 
area,  but  they  have  their  point  of  maximum  intensity  over  other  portions  of  the  pra"eordia, 
and  are  only  heard  over  the  ])ulmonary  area  on  account  of  their  loudness  and  extent. 
Tliese  bruits  are  not  likely  to  be  mistaken  for  tliose  that  have  just  been  described. 

(C).  Systolic  Bruits  over  tlie  Aortic  Area. — When  a  systolic  bruit  is  heard  with  its 
point  of  maximum  intensity  in  the  aortic  area,  which  corresponds  to  that  portion  of  the  chest 
wall  overlying  the  second  right  costal  cartilage,  and  is  conducted  upwards  into  the  vessels 
of  the  neck,  it  arises  either  at  the  aortic  valve  or  in  the  ascending  portion  of  the  aorta.  The 
chief  point  in  the  diagnosis  between  these  two  conditions  is  the  character  of  the  aortic  second 
sound.  If  the  bruit  be  due  to  changes  in  the  valves  causing  obstruction,  then  the  second 
sound  will  be  altered  in  character,  being  muffled  and  sometimes  inaudible,  as  the  rigidity  of 
the  aortic  cusjjs  prevents  them  closing  suddenly  in  the  normal  manner.  The  presence  of 
an  aortic  diastolic  bruit  would  make  quite  clear  the  valvular  origin  of  the  systolic  bruit. 
When  the  bruit  is  due  to  changes  in  the  aorta,  in  consequence  of  atheroma,  dilatation,  or 
aneiuysm,  and  not  to  aortic  obstruction,  then  the  second  sound  is  usually  clear.  The 
presence  of  a  pulsating  tumour,  pulsation  in  the  second  right  intercostal  space  without  a 
timiour,  or  dullness  in  this  region,  would  suggest  an  aneurysm  and  so  confirm  the  diagnosis 
of  the  bruit  arising  in  the  aorta.  A  systolic  bruit  over  the  aortic  area  is  of  frequent 
occurrence  ;  but  for  the  purpose  of  diagnosis  it  must  be  remembered  that  such  a  bruit  is 
rarely  due  to  stenosis,  and  more  frequently  results  from  a  progressive  sclerosis  of  the  aortic 
valve  without  real  stenosis,  or  from  changes  in  the  aorta.  Before  aortic  stenosis  is  diagnosed 
there  should  be  a  loud  systolic  bruit  in  the  second  right  intercostal  space,  together  with  a 
systolic  thrill,  and  evidence  of  hypertrophy  of  the  left  ventricle.  If  the  bruit  is  due  to 
acute  eixlocarclitis,  with  vegetations  on  the  semilunar  valves,  then  the  left  ventricle  is  not 
enlarged  to  such  an  extent  as  in  aortic  obstruction,  or  in  atheroma  of  the  aorta.  Afunctional 
III- ait  confined  to  the  aortic  area  is  very  rare,  but  may  be  distinguished  by  there  being  no 
enlargement  of  the  left  ventricle,  and  by  the  presence  of  other  functional  bruits,  especially 
a  bruit  (le  (liable.  If  marked  amcmia  exists,  either  from  some  primary  blood-disease  or 
secondary  to  a  cachectic  condition,  due  to  malignant  disease,  tuberculosis,  malaria,  a  large 
haemorrhage,  etc.,  then  the  diagnosis  of  a  functional  bruit  is  confirmed. 

In  rare  cases  a  very  loud  systolic  bruit  in  the  aortic  area  is  due  to  a  saccular  aortic 
aneurysm  opening  into  the  pulmonary  artery  or  into  the  superior  vena  cava  ;  in  either  case 
there  will  generally  be  a  history  of  acute  dyspnoea  developing  suddenly,  together  with 
cyanosis  ;  and  when  the  superior  vena  cava  is  opened  into  in  this  way  there  is  generally 
acute  oedema  of  the  face,  neck,  and  arms  also  (Fig.  99,  p.  208).  A'-ray  examination  may 
assist  the  diagnosis  materially  in  either  case. 

(D).  Systolic  Bruits  over  the  Tricuspid  Area. — A  bruit  heard  best  over  the  tricuspid 
area,  which  corrcsjionds  to  that  ])art  of  the  chest  wall  overlying  the  lower  portion  of  the 
sternum,  is  of  diagnostic  importance  in  that  it  indicates  tricuspid  regurgitation,  which  is 
nearly  always  due  to  dilatation  of  the  right  ventricle.  That  the  bruit  is  due  to  tricuspid 
regurgitation  is  confirmed  by  finding  the  cardiac  dullness  extending  to  the  right  of  the 
sternum,  fullness  and  pulsation  in  the  veins  of  the  neck,  and  evidence  of  failing  cardiac 
compensation,  as  shown  by  oedema  of  the  legs,  and  enlargement  and  pulsation  of  the  liver. 
Many  bruits,  systolic  in  rhythm  and  produced  at  the  tricuspid  valves,  are  best  audible  in 
the  neighbourhood  of  the  cardiac  impulse,  l)ut  they  are  not  conducted  outwards  into  the 
left  axilla  like  bruits  ]jroduced  at  the  mitral  valve.  On  the  other  hand,  when  a  mitral 
systolic  bruit  is  loud  enough,  it  may  be  audible  in  the  tricuspid  area,  but  there  would  not 
be  the  signs  of  passive  congestion  unless  there  was  general  failure  of  compensation.  It 
should  be  borne  in  mind,  of  course,  that  tricuspid  regurgitation  often  occiu's  without  pro- 
ducing any  bruit  at  all,  so  that  absence  of  sytolic  bruit  does  not  exclude  tricuspid  leakage. 

II.— DIASTOLIC   BRUITS. 

A  diastolic  bruit  heard  over  the  precordia  is  always  due  to  organic  disease  of  the  heart. 
If  it  be  piesent  over  the  aortic  area,  that  is,  over  the  second  right  costal  cartilage  close  to 


BRUITS,     CARDIAC  93 

the  sternum,  and  conducted  downwards  along  the  left  border  of  the  sternum,  and  sometimes 
outwards  towards  the  cardiac  impulse,  then  the  bruit  is  due  to  aortic  regurgitation. 
Sometimes  its  point  of  maximum  intensity  is  in  the  aortic  area,  sometimes  to  the  left  of 
the  sternum  in  the  third  intercostal  space.  Examination  of  the  pulse  confirms  the  diagnosis, 
for  the  ■  water-hammer  '  pulse  is  found  only  with  aortic  regurgitation.  Capillary  pulsation 
is  also  present  ;  it  is  demonstrated  by  placing  a  glass  slide  on  the  everted  lower  lip,  or  by 
pressing  the  finger  nail  so  that  the  proximal  half  of  it  remains  pink  and  the  other  is 
blanched,  or  by  stroking  the  forehead  firmly  with  the  finger  and  watching  tlie  alternate 
blanching  and  reddening  of  the  resultant  streak.  Capillary  pulsation  may  also  be  found 
in  cases  of  marked  anaemia,  and  in  the  normal  person  in  a  Turkish  bath.  A  double 
murmur  is  frequently  heard  over  the  larger  arteries  in  aortic  regurgitation,  particularly 
over  the  femoral  artery,  where  it  is  spoken  of  as  Duroziez's  sigyt.  The  first  murmur  is 
produced  when  the  vessel  is  distended  with  blood,  and  the  second  when  the  blood-pressure 
suddenly   falls  on  account  of  the  regurgitation. 

As  the  diastolic  bruit  of  aortic  regurgitation  is  frequently  associated  with  a  systolic 
one,  the  result  of  aortic  obstruction,  a  '  to-and-fro  '  murmur  is  produced  which  may  some- 
times be  mistaken  for  pericardial  friction  sound.  In  pericardial  friction  the  systolic  and 
diastolic  sounds  do  not  commence  accurately  with  the  first  and  second  soinids  of  the  heart, 
arc  not  conducted  in  the  recognized  direction  of  an  endocardial  bruit,  and  are  altered  in 
intensity  by  the  pressure  of  the  stethoscope.  Having  decided  that  the  bruit  is  due  to 
aortic  regurgitation,  it  must  be  remembered  that  such  a  lesion  may  be  the  result  of  : — 

1 .  A  progressive  sclerosis  of  the  aortic  vahes,  being  part  of  a  general  arterial  degenera- 
tion, or  due  to  a  localized  sj'philitic  lesion. 

2.  Endocarditis,  either  rheimiatic  or  malignant. 

;{.  Rupture  iij  (I  segment,  due  to  either  excessive  strain  on  an  already  diseased  valve, 
or  to  malignant  endocarditis. 

!■.  Dilatation  of  the  aortic  ring,  secondary  to  dilatation  or  aneui'vsm  of  the  ascending 
portion  of  the  arch  of  the  aorta. 

5.  Congenita!  nialforniiition. 

The  age  oi  the  patient  helps  greatly  in  the  differential  diagnosis  :  if  the  lesion  be  found 
in  a  child  or  young  adult,  the  condition  is  almost  invariably  the  result  of  endocarditis  ; 
if,  on  the  other  hand,  aortic  regurgitation  occius  in  middle  life,  it  is  nearly  always  due  to 
sclerosis  of  the  aortic  valve,  especially  sy])hihtie,  and  the  diagnosis  is  confirmed  by  finding 
a  positive  Wassermann  reaction,  or  degenerative  changes  in  other  arteries,  chronic  renal 
di.sease,  and  considerable  hypertrophy  of  the  left  ventricle.  If  the  regurgitation  be  due  to 
dilatation  of  the  aortic  ring.  It  can  only  be  diagnosed  when  the  existence  of  dilatation  or 
aneurysm  of  the  aMciidiiig  ]>orlion  of  the  arch  of  the  aorta,  is  indicated  by  dulliuss  in  the 
second  right  intercostal  space  close  to  the  sternum,  by  i)uIsation  or  a  ])ulsating  tumour 
in  this  area,  or  by  an  ,r-ray  examination.  Sometimes  the  aneurysm  may  be  situated  just 
above  the  sinuses  of  Valsalva,  and,  while  producing  aortic  regurgitation  by  causing  dilata- 
tion of  the  aortic  ring,  may  give  no  other  ))hysical  sign  of  its  presence.  It  may  be  very 
small,  and  yet  may  cause  sudden  death  by  rupture  into  the  pericardial  sac. 

A  diastolic  bruit  heard  only  down  the  left  border  of  the  sternum  is  practically  always 
due  to  aortic  regurgitation,  but  on  some  occasions  it  may  be  i)r<)duced  by  pulnionari/ 
regurgitation  as  the  result  of  endocarditis,  dilatation  of  the  pulmonary  ring,  or  a  con- 
genital defect.  I'lilmonary  regurgitation  is  most  often  secondary  to  mitral  stenosis,  due 
to  dilatation  of  the  pulmonary  orifice  as  the  result  of  increased  pressure  in  the  pulmonary 
circulation.  The  other  two  forms  are  very  rare,  and  dilliciilt  to  distinguish  I'idm  aortic 
regurgilalion  unless  there  is  evidence  of  enlargement  of  the  right  ventricle  and  iml  nl  llie 
lelt,  and  then-  is  no  "  water  hammer  "  pulse  as  in  aortic  regurgitation. 

Diastolic  hniils  aodililc  al  the  <unliac  impulse  are  flue  either  to  endocarditis  of  the 
mitral  vaKc.  to  milral  stenosis,  or  to  aortic  regurgitation.  An  aortic  diastolic  bruit  is 
often  eoiidiicled  as  far  as  the  cardiac  apex  iind  replaces  the  second  sound  here  ;  sometimes 
the  iliMslolic  bruit  which  is  hcar<l  in  the  aortic  area  is  lost  on  being  traced  down  the  lell 
border  ol'  the  sternum,  to  reappear  at  the  ajiex.  'i'hc  diastolic  bruits  of  mitral  stenosis  can 
be  distinguished  by  their  appearance  later  in  the  diastolic  period,  and  the  most  common 
i.s  presystolic  a  crescendo  murmur  ending  in  a  loud  slapping  liist  sound.  .\n  aortic 
regurgitant    bruit    is  gencrallv   blowing  in  cliaraelcr,  whereas   llic  bruil   ot   inilral   siciiosis  is 


9t 


BRUITS,     CARDIAC 


often  rumbling.  Early  diastolic,  mid-diastolic,  and  late  diastolic  bruits,  occur  also  in 
mitral  stenosis,  but  none  of  these  should  be  mistaken  for  the  bruit  of  aortic  regurgitation, 
as  the  latter  condition  would  be  associated  with  hjpertrophy  and  dDatation  of  the  left 
Ncntricle,  the  apex  beat  being  displaced  outwards  and  downwards,  even  to  the  sixth  inter- 
costal space,  and  would  be  confirmed  by  the  characteristic  "  water-hammer  '  pulse.  In 
mitral  stenosis  without  mitral  regurgitation  there  is  very  little  displacement  of  the  apex 
Ijeat,  because  the  left  \cntricle  is  not  enlarged.  The  bruit  of  mitral  stenosis  is  often 
associated  with  a  presystolic  thrill,  whereas  that  of  aortic  regurgitation  is  not. 

In  order  to  imderstand  the  various  bruits  which  occur  in  mitral  stenosis,  the  manner 
in  which  they  are  ])roduced  must  be  discussed.  They  are  caused  by  the  blood  being  forced 
tlirough  the  stenosed  mitral  valves.  The  two  forces  which  produce  this  are  the  contraction 
of  the  walls  of  the  left  auricle  and  of  the  right  ventricle.  The  suction  action  of  the  left 
\entricle  during  its  diastole  is  probably  not  sufficient  in  itself  to  cause  the  bruit,  but  simply 
helps  in  the  work  of  the  left  auricle  and  right  ventricle.  The  presystolic  bruit  of  mitral 
stenosis  occurs  during  the  end  of  the  ventricular  diastole,  and  corresponds  to  the  systole 


n    n    „iin 


D 


n 


D 


Mid-iUastolic  bn 


D 


al  steuosis  fSiinyer's  Physical  .?/yn^). 


of  the  left  auricle.  A  mid-diastolic  bruit  sometimes  occurs  in  mitral  stenosis.  This  may 
be  the  only  bruit  present,  but  there  may  be  a  presystolic  bruit  as  well,  resulting  in  two 
distinct  bruits  during  the  ventricular  diastole.  These  two  bruits  may  be  fused  into  one 
when  the  contractions  of  the  right  ventricle  and  left  auricle  are  vigorous.  The  mid-diastolic 
bruit  is  probably  due  to  the  previous  contraction  of  the  right  ^•entricle  increasing  the  blood 
pressure  in  the  lungs  and  left  auricle,  and  so  forcing  tiie  blood  through  the  stenosed  mitral 
^'rtlve.  It  varies  slightly  in  its  situation  in  the  ventricular  diastole  in  different  cases,  but 
whether  early  or  late  it  is  always  separate  fi'om  the  previous  second  sound  instead  of 
replacing  the  latter  in  the  way  an  aortic  regurgitant  murmur  does.  Wlien  the  force  of  the 
contractions  of  the  left  auricle  begins  to  fail,  or  when  there  is  aiiriciiifir  fibriUaiion.  as  shown  by 
total  irregularity  of  the  heart  or  by  an  electro-cardiogram  {Fig.  196,  p.  486).  the  presystolic 
bruit  often  disappears.  In  mitral  stenosis  there  may  therefore  be  a  presystolic  bruit,  or  a 
mid-diastolic  bruit,  or  mid-diastolic  and  presystolic  bruits,  or  a  bruit  which  occupies  almost 


BRUITS.     t'ARDIAC 


95 


tlie  whole  of  the  ventiie.ilar  diastole.  With  all  these  bruits  the  first  sound  at  the  apex  is 
usually  slapping  or  thumping  in  character.  This  alteration  in  the  first  sound  may  be 
present  without  any  of  the  above-mentioned  bruits,  and  is  in  itself  very  characteristic  of 
mitral  stenosis.  In  some  cases  the  second  sound  is  redu])licated  at  the  cardiac  apex,  while 
in  others— and  this  in  the  majority  of  the  cases—it  is  inaudible.  The  pulmonary  second 
.sound  is  accentuated  or  reduplicated.  The  bruit  may  be  accompanied  by  a  mitral  systolic 
bruit,  as  regurgitation  often  occurs  through  the  stenosed  orifice. 

A  presystolic  bruit  in  the  mitral  area  is  usually  due  to  mitral  stenosis,  but  it  also  occurs 
without  any  mitral  stenosis  in  some  cases  of  aortic  regur^Uaion  or  of  dilatation  of  the  left 
ventricle,  when  the  bruit  is  spoken  of  as  Flinfs  murmur.  To  distinguish  between  the  latter 
and  the  simUar  bruit  of  actual  mitral  stenosis  may  be  dilhcult  :  in  an  uncomplicated  case 
of  mitral  stenosis  the  apex  beat  is  normal  in  position,  but  when  Flint's  murmur  is  present 
the  apex  beat  is  displaced  to  the  left  on  account  of  the  enlargement  of  the  left  ventricle. 
The  presence  of  aortic  disease  also  points  in  the  direction  of  the  bruit  being  Flinfs  murmur. 
This  bruit  is  often  considered  to  be  caused  by  the  vibration  of  the  anterior  curtain  of  the 
mitral  valve  as  it  lies  between  the  regurgitating  blood-stream  through  the  aortic  orifice 
and  that  flowing  into  the  ventricle  from  the  left  auricle.  If  this  were  the  true  explanation. 
Flmt's  murmur  should  f)ccur  early  in  diastole  instead  of  being  presvstolic.  Another  view 
IS  that  the  blood  regurgitating  through  the  aortic  orifice  lifts  the  anterior  curtain  of  the 
mitral  valve,  and  so  obstructs  the  mitral  orifice  at  the  end  of  the  ventricular  diastole. 
Neither  of  these  explanations  seems  to  be  sufficient  to  account  for  the  murmur.  In  a 
normal  heart  the  ratio  of  the  diameter  of  the  mitral  opening  to  that  of  the  left  ventricle  is 
about  1  to  -2  :  in  mitral  stenosis,  on  account  of  the  contracted  orifice,  the  ratio  may  be,  say, 
i  to  2,  the  size  of  the  left  ventricle  remaining  the  same,  and  a  presvstolic  bruit  occurs,  iii 
aortic  regurgitation,  although  the  diameter  of  the  mitral  orifice  remains  the  same,  yet  the 
diameter  of  the  left  ventricle  is  greatly  increased  on  account  of  its  dilatation.  The  ratio 
between  the  diameter  of  the  mitral  opening  to  that  of  the  left  ventricle  might  be.  say,  1  to  4. 
or  exactly  the  sjime  ratio  as  occurs  in  mitral  stenosis— a  relative  mitral  stenosis  when  the 
size  of  the  mitral  opening  is  compared  with  that  of  the  left  ventricle.  The  one  condition  is 
merely  on  a  larger  scale  than  the  other  {Fig.  40)  :  and  as  the  altered  ratio  of  these  two 
diameters  produces  in  mitral  stenosis  a  presystolic  bruit,  it  is  probable  that  the  same  ratio, 
although  the  factors  are  on  a  larger  .scale,  produces  in  aortic  regurgitation  a  Flinfs  murmur 
—which  IS  also  presystolic  in  time.  A  presystolic  bruit  is  sometimes  present  without  any 
aortic  reguigilalioii.  and  williout  mitral  stenosis,  but  always  with  an  enlarged  left  ventricle  ; 
and  this  seems  to  point  to  llic  regurgitation  of  (he  bloo.l  Ihrough  the  aortic  valves  not 
taking  any  direct  part  in  tlie  production  of  the  bruit.  The  followina  diagrammatic  draw- 
ings of  Ihe  h,.arl  are  eonMr„e|ed  to  show  the  prob-.l,!,.  i,„„l,.  ,,f  production  of  Flinfs 
murmur  : — 


Xormnl  heart. 

Kiitio     of     rliametcr    o( 

mitral  vai\'es  and  dili- 

"ii'terot  left  ventricle, 

alioiit  1  to  'i. 


Mitral  stenosis. 


II).      IJiat-riim  to  e,v|iluici  the  origin  of  I'liiitH 


Dilated   lert  ventricle. 
Hat  io 'about  1  to  •!  ;  i.e.  tlie  same 
proportion  as  in    mitral  stenosb. 
I'nsystolic  bniit  (I'linfs). 
ur  (.Sawyer's  rittmfat  si-nts\. 


but 


l)iasloli( 

it     is    pos 


liniit.N 
iblc    Co 


are   heard  only  vcr>'  occasionally  over  other  areas  of  I  lie  i.rcconi 
a    pnsyslolic   bruit    to  occur   in   llic   Irieiispid    region   as   the   icsiilt 


96  BRUITS,    CARDIAC 

tricuspid  stenosis  ;    such  a  bruit  is  rarely  ])resent  witluiut  valvular  disease  of  the  left  side 
of  the  heart  also. 

A  functional  bruit  is  never  diastolic  in  rhythm  ;  but  it  is  important  to  distinguish 
the  niid-diastolic  bruit  of  acute  endocarditis  from  the  similar  bruit  of  fibrotic  stenosis. 
Diu'ing  endocarditis  there  is  some  thickening  of  the  valve-flaps  from  inflammatory  oedema, 
and  this  leads  to  bruits  not  unlike  those  of  fibrous  stenosis.  The  diagnosis  depends  u]3on 
(1)  The  development  of  the  bruit  under  observation  :  if  in  a  case  of  acute  rehuniatism  a 
mid-diastolic  bruit  is  noticed  to  develop  rapidly,  it  cannot  be  due  to  fibrosis,  and  must  result 
from  acute  inflanmiation  of  the  valve  :  (2)  The  course  of  the  bruit  :  if  it  is  due  to  fibrosis 
it  will  persist,  if  to  endocarditis  it  will  change  with  time,  becoming  less  definite  if  the 
endocarditis  resolves,  more  definite  if  the  inflammation  goes  on  to  scarring  and  stenosis  : 
(3)  The  age  of  the  patient  :  mitral  stenosis  does  not  occur  commonly  before  puberty,  so 
that  it  is  most  risky  to  interpret  a  diastolic  apical  bruit  in  a  child  as  being  due  to  mitral 
stenosis.  J.  E.  II.  Snwijer. 

BULLy£. — A  bulla  is  literally  a  water-bubble  :  it  is  synonymous  with  bleb  or  Ijlister  ; 
it  differs  from  a  vesicle  only  in  its  size,  which  may  be  from  half  an  inch  in  diameter  to  that 
of  a  tangerine  orange  or  more.  Almost  any  vesicular  skin  disease  may  be  of  bullous  degree 
occasionally  ;  there  are  certain  diseases  in  which  bidla-  are  characteristic  ;  and  there  are 
yet  other  affections  in  wliich.  although  bulUe  are  not  always  present,  they  may  occur 
sometimes  in  a  marked  degree.  The  following  are  the  chief  conditions  under  whicli  bulla; 
are,  or  may  be,  a  prominent  featiu'c  of  the  case  : — 

A.  Conditions  in  which  Bullae  .vre  usual  : — 

Pemphigus  I  Herpes  gestationis  I  Pempliigus  neonatorum 

Erythema  biillosuni  j  lirythema  iris  Cheiropompholyx 

Dermatitis  herpetiformis  |  P^pidermolysis  bullosa       | 

Local  application  of  vesicants,  sucli  as  cantharides,  arnica,  rhus  toxicodendron,  croton 
oil,  nitric  acid,  scaldmg  water,  hot  solids,  or  extreme  cold,  for  instance  after  freezing 
with  carbon  dioxide  snow. 

Local  friction  by  splints  after  fractin-es  ;   or  by  boots,  oars,  tools,  etc. 

li.  Conditions  in  which  Typical  Bull.e  >l\y  occur,  though  they  are  not  usual  : 


Erysipelas 

Impetigo  contagiosa 
lodism 
Bromidism 


Glanders 
Syphilis 
Syringomyelia 
Gangrene 


Frostbite 

Raynaud's  disease 
Scurvv' 


Extreme  oedema  from  Brighfs  disease  or  heart  failure 

Workers  amongst  turpentine,  chrysarobin,  varnish,  aniline  dyes,  and  other  chemicals  ; 
tar  products,  resin,  volatile  oils  ;  satin-wooil,  primula  obconica,  and  some  other 
plant  products. 

Poisoning  by  large  doses  of  certain  hypnotic  drugs,  notably  veronal  and  acetanilido. 
especially  towards  the  end  of  a  fatal  case. 

The  diagnosis  is  sometimes  obvious  ;  for  instance,  herpes  gestationis — also  known  as 
hydroa  gestationis,  erythema  gestationis,  and  dermatitis  pruriginosa  polymorpha  recurrens 
graviditatis — is  probable  when  a  bullous  erujjtion  develops  in  a  pregnant  woman  ;  and  the 
diagnosis  is  certain  if  there  is  a  history  of  former  pregnancies  each  associated  with  a  similar 
eruption,  with  complete  freedom  from  the  complaint  between  the  pregnancies.  The  eruption 
itself  is  precisely  similar  to  that  of  dermatitis  herpetiformis,  described  below,  and  there  is 
generally  eosinophilia  (p.  99).  In  most  cases  the  trouble  begins  in  the  later  months  of 
pregnancy,  but  tends  to  develop  earlier  in  each  successi\e  ])riguancy  :  and  whereas  in  most 
cases  it  suljsides  rapidly  when  the  child  is  born,  in  a  few  instances  it  may  last  into  the  |)iR'r- 
perium,  or  even  develop  only  during  that  period.  The  most  troublesome  part  of  the  com- 
plaint is  the  itching  and  irritation,  that  often  amount  to  actual  pain.  A  person  subject  tci 
pempliigus  or  erythema  buUosum  might  develop  an  attack  during  pregnancy  ;  but  herpes 
gestationis  is  excluded  if  recurrence  takes  place  apart  from  pregnancy,  whilst  the  occurrence 
of  the  bullous  eruption  solely  in  association  with  pregnancy  makes  the  diagnosis  obvious. 

Bnlhe  in  an  infant  generally  receive  the  term  pempliigus  neoiKitnnnn,  but  the  eruption 


BULL.??:  97 

is  not  related  to  ordinary  pemphigus,  so  it  is  a  pity  the  word  pemphigus  is  employed  at  all. 
There  are  two  distinet  varieties,  namely  :  (1)  That  in  whieli  the  bullae  are  chiefly  on  the 
hands  and  feet,  one  of  the  manifestations  of  a  severe  and  generally  fatal  type  of  congenital 
syphilis,  in  which  the  eruption  appears  almost  immediately  after  birth  instead  of  after  an 
interval  of  days  or  weeks,  as  in  other  cases  ;  and  (2)  That  in  which  there  is  an  infection  of 
the  skin  of  the  nature  of  impetigo — generally  staphylococcal,  but  in  some  cases  due  to  less 
usual  organisms  such  as  the  liaciUus  pyoajaneus — producing  bulte  instead  of  the  more 
usual  pustules  ;  the  latter  is  an  affection  of  poverty-stricken  districts,  occurring  in  more 
or  less  epidemic  form,  sometimes  closely  related  to  the  practice  of  a  particular  midwife, 
and  fortunately  rare  now-a-days. 

Clieimpunipholi/.r  may  generally  be  recognized  at  once.  It  is  a  dysidrosis,  and  the 
sweat-glands  (jf  the  palms  and  soles  are  most  affected,  though  those  of  the  forehead,  chest, 
and  back,  may  sometimes  be  affected  too.  As  a  rule  the  sweat  retained  in  the  glands 
produces  subcutaneous  vesicles  that  are  barely  larger  than  sago  grains  ;  as  the  superficial 
epidermis  becomes  worn  off,  the  little  sweat-cysts  reach  the  surface,  a  process  assisted  by 
the  scratching  that  usually  results  from  the  accompanying  irritation.  After  each  cyst 
bursts  there  is  destiuamation  which  may  simulate  that  of  scarlatina.  The  malady  occurs 
in  summer  weather,  or  in  tropical  climates,  especially  in  those  who  perspire  freely. 

Blisters  produced  by  vesicants  are  diagnosed  readily  when  it  is  known  that  any  applica- 
tion is  being  used.  Dilliculty  arises  mainly  in  two  classes  of  persons,  namely,  (1)  In  those 
who  live  in  houses  ujion  which  the  lihiis  toxicndei}dron  is  grown  as  a  Virginia  creeper,  the 
nature  of  the  case  being  discovered  usually  from  the  fact  that  the  patient  is  always  affected 
when  at  home,  and  never  when  away  :  and  (2;  In  hysterical  patients,  or  in  malingerers, 
who  produce  the  skin  eruption  surreptitiously.  If  the  latter  is  suspected,  it  is  generally 
possible  to  place  the  patient  imder  conditions  which  preclude  self-application,  when  the 
disappearance  of  lesions  confirms  the  diagnosis  ;  or  the  actual  vesicant  employed  may  be 
discovered,  liquor  epispasticus  for  instance,  or  some  other  preparation  of  cantharides  ; 
croton  oil  ;  cajjsicum  ;  carbolic  acid  ;  mylabris  ;  iodine  ;  or  one  of  the  strong  mineral  acids, 
especially  nitric  acid. 

The  relationship  of  occupation  to  a  bullous  dermatosis  may  become  obvious  from  the 
way  the  skin  trouble  recurs  whenever  any  particular  work  is  resinned  ;  the  list  above 
indicates  the  kind  of  occui)ations  that  are  liable  to  produce  it;  nearly  all  these  ]in>duce 
l)ull;e  far  more  seldom  tlian  they  do  a  vesicular  dermatitis. 

Kxtremely  (cilcniatous  tissues  are  easily  blistered,  and  on  this  account  one  must  be 
chary  of  diagnosing  anything  l)ul  simple  l)lislers  when  bulla-  develop  upon  o-dcmat(ius  legs 
or  other  parts  in  assoeialion,  for  instance,  with  liii<iltt's  disviisc,  or  in  chronic  licuii  cases  with 
failing  eomjiensation.  The  same  api)lies  to  the  blebs  arising  on  the  skin  oi  fractured  limbs, 
and  also  in  the  region  of  a  local  gaiigretie  ;  or  necrosis  of  the  soft  parts  due  to  such  causes 
an  frost-bile,  or  Hai/tiaiiil's  disease,  or  scurvy.  The  diagnosis  in  these  <'ases  will  nearly  always 
be  clear  enough,  and  so  will  it  be  in  eases  of  simple  blisters  due  to  friction. 

Having  thus  excluded  the  more  obvious  cases,  there  remain  :  pem])higus,  erythema 
bullosimi.  dermatitis  lurpeliformis,  erythema  iris,  epidermolysis  bullosa,  er\sipelas,  impetigo 
contagiosa,  iodism,  bromism,  glanders,  syphilis,  and  syringomyelia.  Of  these,  acquired 
typliilis  is  sD  seldom  bullous  that  it  would  not  be  diagnosed  unless  there  was  strong  collateral 
evidence  of  the  nature  of  the  coiTiplaint.  Syriiiiiomyelia  is  rare  also,  and  bulhe  occur  in  but 
a  small  proporlion  ol  the  eases  ;  should  they  do  so  they  would  attract,  attention  from  being 
eonlined  Id  a  local  ana.  Ilie  lingers  and  hands  lor  instance,  leaving  the  rest  (if  Ihc  peison 
free.  The  diagnosis  would  be  conlirmed  by  linding  cutaneous  sensibilily  natural,  Ihough 
I  lie  patient  cannot  distinguish  |)ain  from  touch,  or  heat  from  cold,  in  the  airectcd  (larts. 
Tlic  cutaneous  alTcctions  of  i-yringomyelia  are  known  as  .Morvan"s  disease.  The  lesions 
arise  because  the  skin  is  ins<nsili\ c  lo  Ihings  lliat  arc  painlul  iir  ImiI  enough  lo  pniduee 
sores  and  blisters. 

The  palicnfs  oceupalion  may  suggesi  llie  malady  in  a  <asc  of  \>\i\\in\s  liliniilers  :  a  horse 
Willi  uliicli  Ihc  palicnl  had  lo  do  mighl  be  known  lo  be  aMecled  wilh  Ihe  eoniplainl.  The 
sUiii  ciiiplion  is  sometimes  ipiile  a  lale  nianircslalion  of  a  |)rolonged  and  obscure  febrile 
illness  when  Ihe  glanders  inleelion  has  started  internally,  for  instance  in  the  lungs.  The 
Hneilliis  inidlci  may  be  found  in  direcl  smears  tnini  the  contents  of  Ihc  bnllii',  or  in  cultures 
from   Ihi'in.      Ha<'tcriol(.gical  methods  alloid   Ihc  linal  criterion  of  ylandcrs. 

1)  r 


98  BULL^ 

Both  bromides  and  iodides  may  ]3rodiice  various  types  of  skin  eruptions.  Tlie  commonest 
is  simple  acne  ;  but  there  may  l)e  a  patchy  erythema  with  cutaneous  infiltration  or  nodular 
swelling  studded  with  yellow  points  from  which  thick  puriform  fluid  can  be  expressed  ;  or  a 
conHiient  furuncular  lesion  ;  or  a  true  bullous  erujition  or  hydroa.  The  latter  is  decidedly 
rare,  but  its  occurrence  should  be  borne  in  mind,  and  enquiry  made  as  to  aiiy  drujjs  thai 
the  patient  may  be  takinn  ;  in  the  case  ol  iodides  the  urine  uives  a  bhiish-urcen  colour  with 
the  guaiacum  test,  tliough  no  blood  is  present,  and  if  there  is  still  doubt  a  quantity  of 
mine  may  be  evaporated  down,  and  either  bromine  or  iodine  detected  by  ordinary  chemical 
tests.  Bromide  and  iodide  eruptions  have  been  recorded  in  infants  at  the  breast  when  the 
mother  has  been  taking  the  drug  without  herself  presenting  any  cutaneous  symptoms. 

Bullous  impcligo  conlngiosa  is  a  variety  of  impetigo.  Fluid  accunnilates  in  the  infected 
spots  so  (piickly  that  at  first  it  does  not  appear  to  be  purulent,  but  rather  to  take  the  form 
of  big  vesicles  or  bulhc.  These  often  become  pustular,  and  as  they  dry  up  the  crusts  over 
them  have  a  eharact eristic  yellow  honey-like  appearance.  The  condition  can  be  diagnosed. 
as  a  rule,  from  tlie  fact  that  other  parts  of  the  body  present  the  tj^sical  lesions  of  ordinary 
imjjetigo  ;  there  may  be  other  patients  affected  in  the  same  house  or  school,  and  the  condi- 
tion is  as  readily  curable  by  antiseptic  measures  as  is  impetigo.  There  is  a  very  rare  and 
extremely  grave  disease  described  as  impetigo  herpetiformis  in  pregnant  women  ;  but  this 
seems  to  be  an  aggravated  form  of  dermatitis  herpetiformis  or  herpes  gestationis  become 
piuiilent  and  contagious.     It  is  found  in  Austria,  but  not,  apparently,  in  England. 

Erysipelas  is  a  familiar  cause  of  bulla>,  and  when  blebs  are  present  upon  the  typical 
tender,  slightly  raised,  and  well  demarcated  red  skin  at  the  height  of  the  affection,  in  associa- 
tion with  the  constitutional  symptoms  and  pjTexia,  there  can  seldom  be  diilicidty  in  the 
diagnosis.  It  is  when  the  erysipelas  is  subsiding  or  has  subsided,  whilst  the  bulla?,  or  the 
remains  of  them,  are  still  obvious,  that  difficulty  might  arise.  Streptococci  may  be  detected 
bacteriologically . 

If  all  the  above  conditions  can  be  excluded,  and  the  ])atient  is  suffering  from  a  disease 
of  which  bulte  with  more  or  less  erythema  are  the  chief  manifestation,  tlien  the  diagnosis 
has  been  naiTOwed  down  to  one  or  other  of  the  following  :  pemphigus,  erythema  bullosum, 
dermatitis  herpetiformis,  erythema  iris.  aTid  epidermolysis  bullosa  :  there  is  evidence  to 
show  that  these  are  closely  related  in  some  respects,  the  different  names  applying  to  affec- 
tions that  differ  more  in  type  than  kind.  If  the  patient  develops  bulla-  on  various  parts  of 
the  trunk  and  limbs  without  any  erythema,  or  at  any  rate  without  any  erythema  imtil  the 
bulla'  have  been  present  a  longer  or  shorter  time,  the  condition  is  described  as  pempliigns. 
If  the  bulla>  develop,  not  on  normal-looking  skin,  but  upon  places  v.here  there  has  already 
been  cr>thema,  associated  with  more  or  less  itching,  or  even  pain,  before  the  buIUe  develo]), 
and  if  the  whole  eruption  consists  of  this  combined  condition  of  erythema  and  large  bulla-, 
the  name  used  to  designate  it  is  enjtliema  lidlosiim.  If  the  bulhc  tend  to  dry  up  at  their 
central  parts  and  then  to  be  followed  by  a  secondary  ring  of  vesicles  or  blebs  aroimd  the 
original  one,  these  secondary  vesicles  being  followed  in  turn  by  others  upon  a  yet  larger 
ring  outside  them,  the  condition  is  referred  to  as  herpes  iris  or  as  erythenia  iris,  according 
as  there  is  little  or  much  erythema  before  the  first  vesicles  or  bulla?  a])])ear.  ^Vhen  the 
bullae  are  apt  to  develop  on  any  part  of  the  body  from  a  degree  of  rubbing  or  scratching 
whicli  in  the  ordinary  individual  would  be  quite  unlikely  to  produce  blisters,  this  imdue 
tendency  to  blister  formation  from  what  ought  to  be  inade(iuate  causes  is  spoken  of  as 
epidermolysis  bullosa,  a  condition  which  may  persist  throughout  life  without  necessarily 
leading  to  any  other  untowai'd  symptoms  ;  it  is  probably  related  to  factitious  urticaria. 
Dermatitis  herpetiformis  is  a  polymorphous  eruption,  of  which  bulhc  form  but  a  part  ;  the 
trouble  begins  with  itching  of  the  skin,  and  more  or  less  general  disturbance,  part  of  which 
arises  from  the  loss  of  sleep  entailed  by  the  irritation.  In  various  parts  of  the  body  or  limbs 
erythematous  and  urticarial  patches  supervene,  some  of  which  subside  without  furthei' 
development,  whilst  ujion  others  clusters  of  vesicles  soon  appear.  Many  of  the  clusters 
contain  twenty  or  thirty  vesicles  upon  a  single  inflamed  base  ;  some,  fewer  vesicles  of  larger 
size  ;  others  develop  into  typical  blebs  varying  in  aiea  from  that  of  a  sixpence  to  that  of  a 
half-crown.  No  region  of  the  body  is  exeinj)t.  The  characters  of  the  lesion  are  precisely 
similar  to  those  found  in  pregnant  women  sufiering  from  herpes  gestationis,  but  there 
nuist  be  a  difference  in  causation,  for  the  latter,  though  it  occurs  with  every  successive  preg- 
nancy in  the  same  woman,  remains  in  complete  abeyance  between  the  pregnancies,  whilst 


CACHEXIA  99 

dermatitis  herpetiformis — Diihring's  disease  or  hydroa — may  occur  in  either  sex  and  at 
almost  any  age,  tlioiigh  it  is  less  common  in  cliildren  than  in  adults.  It  is  probably  due 
to  the  action  of  some  poison  circulating  in  the  blood,  derived  perhaps  from  the  food  in 
some  cases  ;  it  is  possible  for  two  persons  to  be  taken  ill  after  partaking  of  the  same 
food,  one  with  acute  gastro-intestinal  symptoms,  such  as  diarrha-a  and  vomiting  ;  the 
other  with  acute  pem])higus  ;  it  looks,  therefore,  as  if  pemphigus  and  its  allies  may  be 
related  to  the  acute  urticaria  that  is  so  familiar  in  certain  cases  of  shell-fish  poisoning. 

.\ny  one  of  the  bullous  dermatoses  may  be  either  acute,  subacute,  or  chronic  ;  in  any 
of  these  degrees  there  may  be  practically  no  constitutional  disturbance  on  the  one  hand,  or 
the  patient  may  be  so  ill  with  pyrexia  and  anorexia  as  to  require  to  stay  in  bed  ;  not  a  few 
such,  cases  prove  fatal.  In  all  the  bullous  dermatoses  the  eru])tion  may  be  restricted  to 
the  cutaneous  surface  ;  but  the  bulte  may  also  occur  upon  mucous  membranes,  especially 
of  the  mouth,  palate,  a»sophagus,  nose,  colon,  rectum,  and  vagina.  Even  when  temporary 
recovery  has  taken  place  there  is  a  tendency  for  subsequent  attacks  to  occur.  There  is 
also  a  tendency  to  ha-matoporphyrinuria  during  the  exacerbations. 

Finally,  it  may  be  emphasized  that  although  it  is  often  stated  as  a  general  rule  that 
many  skin  diseases  may  be  associated  with  eosino])hilia,  as  a  matter  of  fact  few  skin  diseases 
other  than  the  bullous  dermatoses  produce  any  marked  degree  of  eosinophilia,  so  that  a 
flifferential  leucocyte  count  may  afford  valuable  diagnostic  evidence.  The  absence  of 
eosinophilia  by  no  means  excludes  pemphigus  or  erythema  bullosum  or  any  other  bullous 
dermatosis,  but  the  presence  of  eosinophilia  in  a  doubtful  case  increases  the  probability  of 
the  condition  being  one  of  these  :  it  is  noteworthy  that  whereas  eosinophile  cells  may 
abound  in  the  contents  of  the  natural  bulla',  those  which  occur  in  a  blister  produced  artifi- 
cially in  the  same  case  present  no  such  eosinophilia.  Ucrberl  French. 

BUZZING  IN  THE  EARS.~(See  Tinnitus,  p.  7'->2.) 

CACHEXIA  literally  means  "  a  bad  habit,'  and  is  an  ill-defined  term  used  to  include 
almost  any  depraved  condition  of  the  body  in  which  nutrition  everywhere  is  defective.  It 
is  generally  applied  to  patients  who  exhibit  at  the  same  time  progressive  loss  of  weight,  and 
change  of  complexion  iu  the  direction  of  sallowness  or  actual  an;cmia.  (See  Wkioht,  Loss 
OF,  p.  7(iH  :  and  .An.kmia,  p.  20.)  The  word  is  generally  prefixed  by  a  qualifying  adjective, 
such  as  cancerous,  syphilitic,  maUirial.  tuberculous  cachexia,  the  diagnosis  being  indicated  by 
other  symptoms  or  by  the  history.  Other  varieties  of  cachexia  that  may  be  given  special 
mention,  and  which,  if  they  are  borne  in  mind,  are  not  as  a  rule  difficult  of  diagnosis,  are 
C.  splcniiii.  including  blood  diseases  such  as  leucocythcmia.  in  which  with  progressive  loss  of 
weight  and  amemia  there  is  enlargement  of  the  Si-i.i:kn  (p.  (i2H)  ;  C.  ulcrinn.  from  chronic 
non-fatal  lesions  of  the  uterus  or  other  jjclvic  organs,  notably  loienrrlioa,  clininic  endo- 
metritis, or  fibroid  tumours  ;  and  often  accom])aiiicd  by  brown  disfiguring  |)igmciilation 
(chloasma  uterinum),  especially  on  llic  rorchead  and  round  the  eyes  ;  C.  pfiriisilicd.  due  to 
infection  by  the  n)ore  serious  irilcsl  iiial  or  other  i)arasitcs,  especially  Aukyloslouiuin  duo- 
ilruiilv.  Ilothriorcjihiilus  lulus.  Hilhiiriiu  iKrinulohia.  and  Trichino  spiralis  :  (.'.  rhliiri)licii.  a 
synonym  for  chlorosis  :  ('.  mcrruriulis.  attributed  to  the  cllecls  of  mercury,  though  perhaps 
reails  due  to  the  syphilis  for  which  the  mercury  has  been  given;  ('.  croplilluihiiicii.  sonie- 
tiriics  associated  with  (Jraves's  disease  ;  C.  palustris,  or  marsh  cachexia,  iluc  cillicr  to  actual 
malaria  or  to  constant  living  in  unhealthy,  damp  surroundings  ;  C.  alkaliuu.  1  he  hail  health 
caused  by  taking  large  (luantities  of  alkalies  for  a  long  jjcriod,  and  evidenc<il  by  pallor, 
breathlessness,  emaciation,  and  anu^mia  ;  ('.  a<piosa,  also  calle<l  pica,  and  (.'.  africuna.  a 
term  given  to  an  aiKcmic  condition  leading  to  serous  effusion,  and  often  accompanied  by 
l)erversion  of  appetite,  seen  in  hot  climales  and  especially  among  negroes  :  it  has  recei\ed 
many  names,  such  as  white  tongue,  stomach  disease  of  negroes,  negro  cachexy,  intratropical 
ana'inia,  dirt-eating  disease  ;  doubtless  many  different  disorders  ha\e  been  included  under 
this  name,  including  the  results  of  malaria  or  of  intestinal  worms  :  ('.  rcualis.  which  results 
from  piolongcd  albuminuria,  espceiali\-  in  subacute  tubal  nephritis;  ('.  scorbutica,  a  con- 
dition formerly  descrilied  as  a-.sociated  with  rickets,  though  more  likely  related  to  the 
inlaiilile  scurxy  ol  Harlow,  nutrition  being  impaired,  the  head  and  upper  pjut  of  the  body 
p(  rspirini;  pniliisrly  during  slee|),  ana'inlii  developing,  and  the  ])atient  l)e;ng  intolerant  of 
bcil-clolhcs  iiwiii;;  l(i  tenderness  or  actual  palnfulness  of  the  bones  from  subperiosteal  ha'inor- 
rhag(•^  ;   there  may  or  may  not  be  bleeding  <,'ums  ;   C.  saluruiua,  from  ehiiinie  lead  poisoning. 

Herbert  French. 


100  CA:MMir)(iES    PANCREATIC    REACTION 

CAMMIDGE'S  PANCREATIC  REACTION.— The  improved  pancreatic  reaction 
depends  upon  tlie  laet  tliat  wlien  tlie  mine  of  a  patient  suffering  from  pancreatic  inflamma- 
tion is  liydrolysed  by  boiling  with  dilute  H  C'l,  a  substance  having  the  reactions  of  a  pentose 
is  set  free,  and  may  be  recognized  by  conversion  into  its  osazone  crystals  by  treatment 
with  phenylhydrazine,  a  golden  yellow  floccident  deposit  of  flexible  hairlike  crystals  forms, 
arranged  in  microscopic  sheaves,  readily  soluble  in  dilute  sulphuric  acid.  The  appearance 
and  solubility  of  the  crystals  are  very  characteristic,  but  as  glycuronic  acid,  which  is  set 
free  to  a  greater  or  less  extent  in  all  urines  during  the  hydrolytic  ])rocess,  also  forms  a  crystal- 
line compound  with  phenylhydrazine,  it  is  removed  by  treating  the  still  acid  urine  witli 
tribasic  lead  acetate,  after  the  excess  of  hydrochloric  acid  has  been  neutralized  with  lead 
carbonate.  The  lead  that  goes  into  solution  has  also  to  be  removed  by  converting  it  into 
an  insoluble  sul])hide  or  sulphate  before  the  phenylhydrazine  lest  is  applied. 

The  resuhs  of  cHnical  experience  and  many  animal  cxixriments  have  demonstrated 
that  a  positive  "pancreatic'  reaction  is  strong  presumpti\e  evidence  of  a  disturbance  of 
fiuiction  and  of  active  degenerative  changes  in  the  pancreas.  In  most  cases  these  are 
consequent  on  inflammation,  either  acute  or  chronic,  but  in  a  few  instances  a  positive 
reaction  seems  to  rise  from  abnormal  physiological  activity.  The  latter  may,  however,  be 
neglected  for  all  practical  purposes,  for  it  is  not  associated  with  symptoms  suggestive  of 
pancreatic  disease. 

It  has  been  pointed  out  repeatedly  that  the  pancreatic  reaction  is  not  pathognomonic 
of  pancreatitis,  and  the  writer  must  again  insist  that  the  residts  of  the  test  must  be  con- 
sidered in  conjunction  with  the  clinical  symptoms  and  the  evidence  to  be  obtained  by  a 
complete  analysis  of  the  urine  and  faeces.  By  doing  so  one  can  not  only  obtain  confirmation 
of  the  indications  given  by  tins  s])ecial  method  of  examination,  but  also  infer  the  probable 
cause  of  the  changes  in  the  |)ancreas.  which  is  a  most  important  point,  for  pancreatitis  is 
rarely,  or  never,  a  primary  disorder,  but  is  usually  secondaiy  to  an  ascending  catarrh  from 
the  duodenum,  gall-stones  in  the  common  bile-duct  or  in  the  ampulla  of  Vater,  invasion  of 
I  he  pancreas  by  a  duodenal  or  gastric  ulcer,  malignant  disease  either  primary  in  the  pancreas 
or  secondary  to  some  other  organ,  back-pressure  from  disease  of  the  heart  or  lungs,  arterio- 
sclerosis, alcoholism  and  cirrhosis  of  the  liver,  syphilis,  tubercle,  influenza,  tyjshoid  fe\er. 
nuunps,  etc.,  etc.  In  many  of  these  the  clinical  signs  and  symptoms  alone  are  sufficient  to 
indicate  the  cause  of  the  pancreatitis,  but  in  others  they  are  so  indefinite  or  obscure  that  it 
is  only  by  considering  the  results  of  a  complete  quantitative  and  qualitative  analysis  of  the 
urine,  and  fa;ces  also,  that  a  correct  diagnosis  can  be  arrived  at. 

A  single  negative  pancreatic  reaction  does  not  exclude  chronic  pancreatitis,  or  rather 
the  results  of  inlliimmation  of  the  pancreas,  for  the  reaction  is  only  given  when  there  are 
active  degen(  valivc  changes  in  the  gland  at  the  time  when  the  urine  is  being  excreted. 
Cirrhosis  of  tlie  i)ancreas  due  to  j)ast  iuHammation  does  not,  therefore,  cause  a  reaction  after 
the  inflanuiiiition  has  subsided.  Cancer  of  the  pancreas  too  is  associated  with  a  positive 
reaction  in  only  about  25  per  cent  of  cases,  the  presence  of  the  growth  being  apparently 
unattended  by  any  inflannnatory  changes  in  the  pancreas  in  the  remaining  75  per  cent. 

As  the  ordinary  method  of  carrying  out  the  test  is  interfered  with  by  the  presence 
of  sugar  in  the  urine,  a  modification,  in  which  a  hydrochloric  acid  solution  of  the  j)recipi- 
tated  lead  salt  from  the  basic  lead  acetate  solution  is  submitted  to  steam  distillation,  has. 
been  devised  (Cammidge,  Glycosuria  and  Allied  Conditions,  p.  274).  The  quantity  of  fur- 
furaldehyde  formed  is  determined  by  treating  the  distillate  with  sodiiun  nitrite  and  then 
titrating  with  iodine  solution.  This  method,  which  can  also  be  used  for  sugar-free  lu'ines, 
gives  <|uantitative  residts  by  whicli  one  case  can  be  com|iarcd  with  another,  and  the  course 
of  any  one  be  followed  accurately.  Numerous  ex])crimciits  luive  shown  that  the  "  iodine 
coellicient  '  of  normal  urines  is  nil,  and  that  even  when  simple  digestive  and  hepatic  disturb- 
ances are  present  it  rarely  exceeds  10  to  1-5  per  cent.  When  there  is  inllammation  of  the 
pancreas  the  iodine  coellicient  rises  to  ten,  twenty,  or  more  per  cent,  with  a  total  for  tlu' 
twenty-four  hours  urine  of  lOO.  200.  or  over.  As  one  would  expect  from  the  (|iialitati%e 
test,  many  cases  of  cancer  of  the  ])aiicrcas  give  a  negative  iodine  coellicient.  Init  in  some 
25  per  cent  similar  readings  to  those  obtained  in  cases  of  pancreatitis  are  obtained. 

Other  points  to  be  noticed  in  examining  the  urine  from  suspected  cases  of  pancreatic 
disease  are  : — 

1.  The  presence   of  calcium  oxalate   crystals   (see   Oxalubia,  p.  42:5)   in   the   centri- 


CAMMIDGES    PAXCKEATR'     REACTION  101 

fugalized  deposit  ;   these  are  met  with  in  63  per  cent  of  cases  of  chronic  pancreatitis,  or 
73  jjer  cent  if  jaundiced  cases  are  excluded. 

2.  A  pathological  excess  of  urobilin  (see  Plate  A'A'A'il',  Fig.  VI.  p.  748)  ;  this  is  a  very 
constant  indication  of  cholangitis,  and  a  particularly  useful  sign  of  gall-stones  in  the 
common  bile-duct,  whether  acconi|)anied  by  jaundice  or  not. 

3.  A  well-marked  indican  reaction  :  pointing  to  a  catarrhal  coudition  of  the  intestinal 
mucous  membrane,  with  abnormal  putrefactive  changes  in  the  contents  of  the  intestine, 
and  possibly  a  duodenal  or  gastric  ulcer. 

4.  Bile  pigment  in  the  urine  :  showing  that  there  is  some  obstruction  to  the  free  flow 
of  bile  into  the  intestine,  due  to  impacted  gall-stones,  gripping  of  the  common  bile-duct  by 
the  inflamed  head  of  the  pancreas  which  surrounds  the  duct  in  62  per  cent  of  cases, 
malignant  disease  of  the  head  of  the  pancreas,  or  a  growth  in  the  common  bile-duct. 

For  the  purposes  of  a  further  differential  diagnosis,  the  results  of  a  qualitative  and 
<iuantitative  analysis  of  the  fa?ces  are  most  important.  In  carrying  out  the  analysis  the 
points  to  be  noticed  particularly  are  : — 

1 .  The  presence  or  absence  of  stercobilin  :  in  gall-stone  obstruction,  traces  at  least  are 
nearly  always  met  with,  whereas  in  malignant  disease  of  the  head  of  the  pancreas  total 
blocking  of  the  duct  is  the  rule,  although  the  soft  growths  occurring  primarily  in  the 
coninion  duet  usually  allow  some  bile  to  (ilter  through  so  that  traces  of  stercobilin  are  met 
witli  in  the  f.Tccs. 

2.  The  percentage  of  unabsorbed  fat  :  in  cancer  of  the  pancreas  this  is  always  very  higli, 
70  to  80  per  cent  ;  it  is  usually  somewhat  less  in  growths  of  the  common  duct,  averaging 
60  to  70  per  cent,  and  varies  from  a  subnormal  percentage  in  early  catarrh  of  the  pancreas  to 
as  much  as  50  or,  rarely,  even  80  per  cent  in  advanced  chronic  pancreatitis. 

3.  More  important  still,  however,  is  the  relation  of  the  ■  unsaponiflcd  '  to  the  '  saponi- 
fied fals,'  for  whereas  the  former  are  in  excess  in  diseases  that  interfere  with  the  digestive 
functions  of  the  i)ancreas,  such  as  cancer  of  the  gland  and  advanced  chronic  |iancreatitis, 
the  latter  i)redominate  in  obstruction  of  the  connnon  duct  by  gall-stones,  without  pan- 
creatitis, and  in  malignant  growths  not  involving  the  pancreas.  It  must  be  borne  in  mind, 
however,  that,  owing  to  the  abnormal  activity  of  fat-splitting  bacteria  in  the  lower  bowel, 
such  as  is  met  with  in  some  cases  of  intestinal  catarrh,  an  excess  of  sai)onilied  fat  may  be 
found  in  cases  of  chronic  pancreatitis  where  the  disease  is  due  to  an  infection  sjjreading 
from  the  duodenum  along  the  pancreatic  ducts.  A  similar  excess  is  often  met  with  in  early 
catarrhal  pancreatitis,  owing  probably  to  an  increased  flow  of  ijanercatie  Juice  analogous  to 
the  salivation  met  with  in  ])arotitis. 

4.  .Microscoi)ieal  examination  of  the  faeces  for  fat  globules,  fatty  acid  crystals,  undi- 
gestcfl  muscle  fibres,  and  coimcctive  tissue,  should  not  be  omitted  :  a  large  excess  of  fat 
globules  and  free  fatty  acid  crystals,  with  numerous  isolated  undigested  muscle  fibres, 
pointing  to  cancer  of  the  pancreas  or  advanced  cirrliosis  of  the  gland,  whereas  nnisele 
associated  with  comieetive  tissue  points  to  defective  gastric  digestion. 

.">.  .\n  acid  reaction  of  the  fresh  stool  is  in  favour  of  a  diagnosis  of  pancreatic  disease  ; 
in  simple  gall-stone  obstruction,  the  fii-ces  are  usually  alkaline. 

6.  Occujt  blood,  when  constantly  present  in  the  faeces  (see  j).  81).  is  suggestive  of 
malignant  disease  or.  more  rarely,  advanced  pancreatitis,  in  which  it  is  now  well  known 
that  there  is  a  Imrnorrhagic  tendency  ;  while  the  discovery  of  blood  intermittently  points  to 
a  gastric  or  duodenal  ulcer,  which  may  be  invading  tlic  pancreas  and  setting  up  paiicrcalitis. 

15y  carefully  considering  all  the  facts  thus  obtained,  and  inter|)reling  lliem  in  the  light 
of  the  clinical  signs  and  symptoms,  it  is  possible,  not  only  to  diagnose  correctly  the  existence 
of  disease  of  the  pancreas,  but  also  to  arrive  at  a  satisfactory  conclusion  as  to  its  probable 
cause.  .MTection  of  the  pancreas  is  much  conunoner  than  is  generally  supposed,  and  many 
trying  cases  of  chronic  indigestion,  recurring  or  pc  isisleril  jiumdice.  and  ohscun-  afl'eetions 
of  the  upper  abdomen  would  be  explained,  and  satisfactorily  treated,  if  investigated  as 
above.  I  nclia-noscd.  and  coiiscciuiril  l\  iiiihcalcd,  |)ancrcatitis  is  probablv  the  most 
conunon  ,  ausc  ol  ilialMlcs  II  Ibis  w,  ic  iiimv  wi<lrlv  recognized  much  might'  be  done  to 
stay  the  lurlhri-  JTicnasc  of  that  disease.  ,.    .,    r,/mw/</.'c. 

CARDIAC    BRUITS. -(See   Huiirs,   (Ain.rA.'.   p.  8<t.) 

CARDIAC  IMPULSE  DISPLACED.     (See  IIkvmt  Imci  i.m;.  I)ps,.|.s,r,n.  p.  -J!!?.) 


102  CHARCOT-LEVDEX    CRYSTALS 

CARDIAC   THRILLS.— (See  Tiimixs,  Phecoudiai,,  p.  720.) 
CASTS  IN   THE   URINE.— (See  Albuminuria,  p.  G.) 
CEPHALALGIA.     (Sec   IIi-.adachf..  p.  293.) 

CHARCOT-LEYDEN  CRYSTALS  were  at  one  time  .sujiposed  to  consist  of  sperniin. 
but  now  there  is  considerable  doul)t  as  to  their  exact  chemical  nature.  Their  chief  import- 
ance from  a  clinical  point  of  view  is  that  they  are  more  common  in  certain  conditions  than 
in  others.  They  may  be  found  either  in  the  sputum,  the  blood,  or  in  the  stools.  They  need 
the  higli  jjower  for  their  detection.  Each  resembles  an  elongated  diamond  witli  clear-cut 
edges,  without  colour,  but  with  a  slightly  yellow  appearance  when  seen  obliquely.  They 
stain  with  eosin,  and  are  soluble  in  hot  water,  in  mineral  acids,  and  in  alkalies,  so  that  for 
their  detection  a  fresh  specimen  is  required. 

In  the  sputum,  they  are  commoner  in  ustlnna  than  under  any  other  circumstances — 
true  spasmodic  asthma,  such  as  also  gives  rise  to  Curschm.\nn's  Spiral.s  (p.  153),  and  eosino- 
jihile  corpuscles  in  the  s])utum.  In  determining  whether  a  given  ease  is  one  of  paroxysmal 
dyspnoea,  cough,  or  bronchitis  on  the  one  hand,  or  true  asthma  complicated  by  bronchitis 
upon  the  other,  numbers  of  Charcot-Leyden  crystals  in  a  fresh  specimen  of  sputimi  are 
evidence  in  favour  of  the  latter.  Small  numbers  of  the  crystals  may  be  found  in  broncJiitis 
and  in  association  with  bronchiectii.iis.  Init  in  true  astlinia  their  numbers  may  be  quite  large. 

The  occurrence  of  Charcot-Leyden  crystals  in  the  blood  is  of  little  diagnostic  value. 
They  are  seldom  found  in  fresh  blood  :  but  when  the  latter  has  stood  for  some  time  in  bulk 
they  develop,  particularly  in  leukwniid.  Some  have  tried  to  draw  important  clinical  deduc- 
tions from  the  development  of  these  crystals  in  blood,  but  it  is  doubtful  whether  they  really 
have  any  significance  of  value. 

In  the  stools.  Charcot-Leyden  crystals  have  been  found  in  a  great  variety  of  diseases, 
but  whether  or  not  clinical  deductions  can  be  drawn  from  their  presence  is  doubtful.  It 
is  stated  that,  when  they  abound,  the  patient  is  probably  suffering  from  an  animal  parasite  : 
but  it  affords  no  indication  of  the  nature  of  the  parasite  present.  Their  occurrence  .should 
lead  one  to  examine  the  faeces  for  parasites  or  their  ova  with  even  greater  care  than  usual. 

Herbert  French. 

CHEST,  BLOODY  EFFUSION  IN.— When,  on  needling  a  pleural  cavity  containing 
fluid,  tliis  fluid  is  l()un<l  to  be  obviously  blood-stained,  the  fact  is  suggestive  of  one  of  three 
things  :  either  the  pleurisy  has  been  exceedingly  acute  :  or  the  chest  lias  already  been 
ta|>ped  not  long  jireviously,  so  that  there  has  been  h;emorrliage  into  the  residual  fluid  ; 
or  there  is  malignant  disease  of  the  pleura. 

The  history  of  the  ease  may  at  once  indicate  whether  the  inflammation  is  very  acute 
or  not  :  the  symptoms  would  have  been  of  short  duration,  with  much  ))yrexia,  whilst  the 
fluid  itseir  would  be  of  high  speeiflc  gravity,  would  contain  a  large  amount  of  albumin, 
would  probably  coagulate  spontaneously,  and  microscopically  would  exhibit  numerous 
I3olynior|jlionuclear  cells  and  lymphocytes,  and  abundant  red  corpuscles,  but  no  jjartieles 
of  growth   in  the  centrifugalized   deposit. 

If  lilood  is  found  in  pleuritic  fluid  at  a  second  tapjiing.  when  it  was  not  present  at  the 
lirst,  the  fact  is  by  itself  of  little  value  in  differential  diagnosis,  for  the  bleeding  has  prob- 
ably been  caused  by  the  act  of  ])araeentesis. 

M'hen  there  is  a  new  growth,  and  the  effusion  contains  obvious  blood  at  a  first  tapping, 
it  is  likely  that  the  symptoms  will  lia\e  been  of  gradual  onset,  without  marked  pyrexia  ; 
the  diagnosis  is  sometimes  cleared  up  by  finding  fragments  of  new  growth  in  the  centri- 
fugalized deposit.  It  is  of  course  by  no  means  every  case  of  malignant  disease  affecting 
the  pleur.T  that  produces  a  blood-stained  effusion  ;  but  when  the  effusion  is  blood-stained  at 
a  first  tapping,  in  a  case  that  has  not  run  a  very  acute  course,  one  should  be  very  .susjiicious 
of  new  growth.  In  not  a  few  such  cases  there  have  also  been  com]3aratively  large  luinibers 
of  coarsely  granular  eosinophile  corpuscles  in  the  effusion.  It  is  often  impossible  to  be  sure 
of  the  diagnosis  until  tiie  progress  of  the  case  has  been  watched,  sometimes  for  weeks  :  |)leural 
eflusion,  like  that  of  a  sini))le  case,  may  be  the  only  sign  for  a  long  time,  but  sooner  or  later 
one  will  expect  to  find  evidence  of  obstruction  to  a  bronchus  or  to  the  superior  vena  ca\a  as 
the  growth  spreads  in  the  mediastiiiuni,  and  occasionally  the  peculiarity  of  the  shadows 
seen  with  the  .r-rays  point  to  the  nature  of  the  case  {Fig.  42,  p,  10.5,)  Ilerlierl  French. 


CHEST.     PUS    IN 


CHEST,  DEFORMITY   OF.— (See  Deformity  of  the  Chest,  p.  166.) 
CHEST,  PAIN  IN.— (.See  Pain  in  the  Chest,  p.    UM.) 

CHEST,  PUS  IN. — When,  on  needling  the  chest,  pus  wells  up  into  the  exploring  sj-ringe, 
it  is  )}i(ih;ible  tluit  the  jiatient  has  an  empyema.  Other  lesions  may  simulate  empyema, 
howevei'.  and  e\  en  when  empyema  is  actually  present  it  is  important  not  to  let  the  diagnosis 
rest  at  that  :  but  rather  to  regard  it  as  a  symptom  and  try  to  diagnose  its  cause.  It  by  no 
means  follows,  of  course,  that  when  the  exploring  syringe  fails  to  detect  pus,  an  empyema 
is  not  present,  for  sometimes  it  is  situated  either  between  the  lower  lobe  and  the  dia- 
phragm, in  front  of  the  lung  or  between  the  lobes,  or  in  some  other  position  in  which  it 
is  dillicult  to  Iiit  it  off  with  the  needle.  When  pus  is  found  but  the  amount  is  only  quite 
small,  there  may  be  doubt  as  to  whether  it  came  from  an  empyema  outside  the  lung,  from  a 
bronchus,  or  an  (ihsees.s  cfwilij  in  Ihe  lung  siihstanee.  The  nature  of  the  case  may  remain 
undecided  until  a  subsetiuent  puncture,  or  a  resection  of  a  rib,  conclusively  discovers  intra- 
pleural pus.  Even  when  pus  wells  up  in  the  exploring  syringe,  it  is  possible  to  mistake  for 
empyema  a  collection  of  pus  which  is  below  the  diaphragm.  A  subdiaphragmatic  abscess 
and  an  abscess  xvilhin  llie  liver  are  the  two  conditions  most  liable  to  simulate  empyema  in 
this  way.  If.  however,  the  history,  the  symjitonis.  and  the  iiliysical  signs  do  not  serve  to 
distinguish  between  these  dilferent 
conditions,  it  will  still  be  clearly 
necessary  to  evacuate  the  ])us. 
and  the  surgeon's  finger  inserted 
through  the  wound  will  be  able 
to  feel  whether  the  dia])hragm  is 
above  or  below  the  collection. 
Even  then  there  is  one  possible 
source  of  error,  namely,  when  there 
is  ])us  both  above  and  below  the 
diaphragm.  A  subdiaphragmntic 
abscess,  secondary  perhaps  to 
appendicitis  upon  the  right  side. 
or  to  a  leaking  gastric  ulcei-  U|)(>n 
the  left,  may  ha\e  infccttd  the 
pleura  through  th<'  diaphragm, 
causing  first  a  serous  and  then  a 
purulent  effusion,  separated  Iroin 
that  below  the  diaphragm  merely 
by  the  thickness  of  tliat  muscle. 
It  may  be  very  dillicult  indeed  to 
be  sure  of  this  condition,  inch  :it 
rilily  cleared  up  until,  when  our 
abnormal  pljysieal  signs  persist,  and  a  sei 
plinigni  as  the  case  may  be.  is  found  at  a  sul 
eonsidcrablc  assisliuicc  sometimes  in  showin 
1)1-  bcldw   il. 

11.  howiNcr.  Ihe  physical  signs,  symptoms,  and  the  result  of  needling,  all  pn>\c  con- 
clusively llial  the  eliesi  contains  Mil  empyema,  it  is  still  necessary  to  deci<le  as  far  as  possible 
the  iialiin-  ol'  Ihi-  lallrr.  Its  (iiiiiinoiiest  cause  is  pneumococcal  infection,  nearly  always 
precede<l  by  lobar  pncimioiiia  in  ailiilts.  in  children  sometimes  by  bronchopnetimonia,  but 
not  iril're(pieritl\  arising  iiisiilidiisly.  It  is  probable  that  many  of  Ihe  so-called  latent 
enipyeniala  of  cliildicn  have  really  been  ipicceded  by  imdiagnoscd  broiieliopiieumonia. 
l)iHieiilt\-  oUcii  arises  from  the  fact  lliat  the  iinioiinl  ol'  pus  prrseiil  is  not  Lircal.  so  tlial 
coiniircsses  the  lung  siiHicienllv  tn  iiiiihr  llic  :il\i(ili  iiirliss,  llir  hmiicliial  liilics 
ill  p.-ileiit.  and  there  is  no  complete  iliillness  al  Hie  base  or  wliercNcr  Hie  empyema 
and  over  the  alfeeted  area  lliire  may  be  broneluMl  bi 
r  the  alisenee  ol'  lireatli-somi(ls  and  of  voice-sound' 
in  adults.      It  llieic  is  doiilil   as  to  the  nature  of  the 


J-,.j:jl.~'-k,: 


l.i.thi 


IIh 


pus 


peration,  the  nature  of  the  case  not  being 
intaining  cavities  has  been  evacuated,  the 
collection  of  pus,  above  or  below  the  dia- 
■(pienl  exploration.  The  .c-rays  may  be  of 
whether    the   diaphragm    is   above    the  |)us 


thoiiMl, 
still  nil 
■  nay  Ik 
instead 
einpyei 


ilhiiiL 


iiipy. 


and  erai 
usually  a 
iia  MS  jiiii 


inpanies 
I  bv  the 


104  CHEST,     PUS    IN 

liistory,  bacteriological  examination  of  the  pus  will  often  inciieate  its  origin.  The  com- 
monest organisms  to  be  found  are  ])neiunoc()cei.  streptococci,  and  staphylococci,  though 
Bacillus  coll  communis,  tyishoid  bacilli,  and  the  Bnciltus  pi/oci/oiieus  also  occur,  and  e\eu 
other  organisms  may  be  i)rescnt  in  some  instances.  The  mode  of  infection  is  generally 
either  via  the  hnig,  or  from  beneath  the  dia])hragm  ;  and  careful  intjuiry  into  the  history 
and  symptoms  will  generally  indicate  which  of  these  two  paths  has  been  the  more  likely. 
When  infection  from  any  j)eritoneal  condition  such  as  appendicitis,  leaking  gastric  or  duo- 
denal ulcer,  infected  gall-bladder,  or  sub-diaphragmatic,  perinephric,  or  hepatic  abscess, 
can  be  excluded,  when  there  has  been  no  injury  to  the  chest  with  broken  rib,  or  a  wound 
communicating  with  the  exterior,  and  when  there  is  nothing  to  indicate  whether  the  infec- 
tion has  succeeded  janeumonia  or  is  itself  pneumococcal,  suspicion  will  arise  that  the  patient 
has  been  suffering  from  phthisis,  whicli  has  caused  a  pleinisy  which  was  at  first  non -purulent, 
but  which  became  converted  into  an  empyema  as  the  result  of  secondary  infection  with 
pyogenic  organisms,  especially  if  there  is  a  tuberculous  family  history,  or  if  the  patient  has 
himself  been  weakly  for  some  time.  The  sputum  should  be  examined  with  ]3articular  care, 
and  K-ray  examination  is  often  Iieljiful  ;  for  even  when  the  compression  of  the  lung  by 
empyema  has  led  to  marked  opacity  at  the  base,  it  may  still  be  possible  to  make  out  that 
apical  mottling  which  is  almost  pathognomonic  of  phthisis  (Fig.  41). 

Rarer  causes  of  empyema  than  those  mentioned  above  will  generally  have  been 
accompanied  by  other  symptoms,  or  by  a  history  which  suggests  the  nature  of  the 
individual  case.  Herbert  French. 

CHEST,  SEROUS  EFFUSION  IN.— When  exploratory  needling  of  the  chest  dis- 
covers clear  serous  lluid  in  the  pleural  ca\ity.  it  is  important  to  regard  the  fact  merely  as  a 
symptom,  for  there  are  many  different  causes  to  which  it  may  be  due,  and.  whenever  possible, 
one  should  decide  what  is  the  actual  cause  in  each  particular  case.  In  the  iirst  place,  the 
effusion  may  be  either  inflammatory  or  merely  a  transudate  ;  the  pleuritic  must  be  distin- 
guished from  the  pleurnl  effusion,  t'linical  points  indicating  that  the  effusion  is  inllani- 
matory  rather  than  passi\e  would  be  :  its  being  unilateral,  not  bilateral  and  symmetrical  : 
and  the  non-existence  of  the  more  common  causes  for  passive  effusion,  ]5articularly  chronic 
heart  failure  or  nejihritis  with  general  anasarca^  Physical,  chemical,  and  microscopical 
analyses  of  the  fluid  may  also  serve  to  indicate  whether  the  effusion  was  active  or  passive 
(see  Ascites,  \>.  48).  There  arc  cases,  of  course,  in  which  there  may  be  doubt,  but  it  is 
generally  easy  to  determine  whether  the  efliision  is  due  to  pleurisy  or  not.  Pleural  effusions 
not  due  to  pleurisy  occur  late,  and  the  diagnosis  will  have  been  made  already  from  the 
existence  of  prominent  symptoms  earlier  in  the  disease,  for  instance.  Ai.bu.minuria  (p.  4), 
Orthopncea  (]>.  41S).  (Kdi.ma  (j).  411).  and  so  forth. 

Pleuritic  effusion,  on  tlie  other  hand,  may  be  the  Iirst  and  most  prominent  symptom 
ill  the  case,  and  it  is  not  always  easy  to  determine  its  cause.  It  should  be  an  invariable 
rule  to  have  the  effusion  examined  microscopically,  both  for  cells  and  for  micro-organisms, 
and  sometimes  to  have  guinea-pigs  injected  with  it  in  order  to  see  whether  in  six  weeks' 
time  the  inoculated  animals  have  developed  general  tuberculosis.  The  commonest  cause 
for  apparently  idiopathic  ])leuritic  effusion  is  latent  or  undiagnosed  tuberculosis  of  the  lung  : 
there  may  be  no  sputum  :  ,>-ray  shadows  may  be  indctirniinate  ;  there  may  be  no  abnormal 
apical  phy.sical  signs  ;  there  may  be  too  few  bacilli  for  them  to  be  detected  on  direct  examin- 
ation of  the  deposit,  even  when  it  has  been  most  carefully  centrifugalized,  and  yet  inocu- 
lated guinea-pigs  may  develop  typical  tuberculosis  and  thus  indicate  the  nature  of  the 
(ileiuisv. 

hitrutliDracic  new  groivth.  wlutlur  of  the  niediastimnn.  lung,  or  (ileura,  is  fortunately 
uncommon  ;  but  whenTt  occurs,  the  symptoms  and  physical  signs  to  which  it  gives  rise 
are  often  very  difficult  to  interpret.  The  growth  may  obstruct  a  bronchus  and  give  all  the 
physical  signs  of  fibroid  lung,  with  or  without  bronchiectasis  ;  it  may  cause  a  big  mass, 
bodily  displacing  the  hmgs  and  heart  :  it  may  cause  multiple  nodules  which,  unless  they 
obstruct  the  superior  ^•ena  ca^'a  and  produce  obvious  varicose  veins  on  the  chest  wall  may 
give  rise  to  no  very  definite  signs  or  sym])toms  at  all  :  or,  what  is  not  at  all  infrequent,  the 
growth  may  lead  to  jjleuritic  effusion  which  may  at  first  seem  to  be  simple,  or  even  be  taken 
to  be  tuberculous,  growth  not  being  suspected  until  the  rapid  reciuTcnce  of  the  effusion, 
repeated  tappings,  and  rai)id  downhill  course  of  the  disease  ultimately  suggest  its  nature. 


CHEST.     SEROUS     EFFUSION     IX 


105 


Microscopical  examination  of  the  ccntrifugalized  deposit  of  the  pleuritic  fluid  sometimes 
leads  to  the  detection  of  particles  of  new  growth  which  clinch  the  diagnosis,  whilst  if  the 
fluid  in  a  case  which  is  not  absolutely  acute  is  blood-stained  at  a  first  tapping,  this  by  itself 
is  highly  suggestive  of  neojilasm  (p.  102).  The  a;-rays  often  assist  materially  in  making 
the  diagnosis  (Fia.  42). 

.Iriilr  rliciniifitisni  is  a  common  cause  of  pleurisy  with  effusion,  particularly  between  the 
ages  of  fi\e  and  twenty-.  It  may  occur  when  there  have  already  been  joint-]5ains,  or  other 
symptoms  of  acute  rheumatism,  such  as  chorea,  recurrent  tonsillitis,  pericarditis,  endo- 
carditis followed  by  valvidar  disease,  skin  affections  such  as  erythema  multiforme,  erythema 
nodosum,  peliosis  rheumatica,  or  subcutaneous  nodides.  In  such  cases  the  diagnosis  is  not 
diflicult  ;  it  is  less  easy  when  the  pleuritic  eflusion  is  itself  the  main  symptom.  The  youth 
of  the  patient,  the  absence  of  anaemia  or  of  ])revious  ill-health,  the  absence  of  abnormal 
apical  lung  signs,  of  a  family  history  of  ])hthisis.  the  presence  of  a  cardiac  bruit,  tlie  occur- 
rence of  heart  disease,  acute  rheumatism,  or  chorea  in  other  members  of  the  same  family, 
the  rapid  onset  of  the  disease,  and  the  almost  equally  rapid  resolution  of  the  eflusion.  are 
points  in  fa\our  of  acute  rheu- 
matism rather  than  tuberculosis. 
^Vhen  in  doubt,  the  ncgatixe  results 
of  guinea  -  pig  inoculation  would 
point  in  the  same  direction,  and 
von  Pirquet's  skin  reaction  would 
be  negative.  There  are.  however, 
many  cases  of  pleuritic  effusion  in 
young  |)eo])le.  in  wlioiii  it  is  inqjos- 
siblc  to  allocate  llic  cause  cither  to 
rheumatism  or  plilliisis.  and  such 
cases  arc  sometimes  s|)ok{ii  of  as 
'simple";  doubtless  most  of  these 
are  either  tuberculous  or  rheumatic, 
many  ultimately  jiroving  to  he  the 
former. 

Pneumococcal     lesions     ol     I  lie 
lung    generally     ])roducc     pleurisy  : 
lohnr      piiiiiDiiiiiiii       indeed,      ncxcr 
occiu-s    uillHJUl    il.    |Iiiiml;Ii    IiiidkIki- 
ptiriiniiiiiiii.   even    when    il    is   pncu- 
tiKieoccal.     often    <l(ies.      It     is     also 
possibU'   for  pncuniococeal   |)leurilic 
effusion    to    occur    without    definite 
lobar    pneumonia    or   bi'onchopneu- 
inonia  preceding  il      primary  pneu- 
mococcal  pleurisy.   I  he  diagnosis  bcin 
fluid.      It    is    dillieult    to    say    whcic 
pneumococcal    enqiyenia     bc'giiis.     W,. 
case  often   exhibiling   clear    lluid    at 
pus   Inter   still. 

lirifilil's  iliscdsv  niii\  <'ausc  eillicr  a  passive  eriMsioii  rriini  liciul  Iniliirc  ill  elirdiiic  eases, 
or  simple  aceiMnulalion  ol'  tederna  lluid  in  the  pleural  cavities  without  heart  lailuic  in  cases 
in  which  the  general  iiilema  ol  Urighls  disease  is  extreme  :  or  actual  pleurisy  with  serous 
effusion,  probahly  the  result  of  intircurrent  inhclion  by  some  organism,  corresponding 
with  the  peritonitis  with  .Ascrrios  (p.  4:5)  and  the  |)ericarditis  that  may  also  occur  in  these 
cases.  'I"he  diagnosis  will  be  indicated  by  the  .Ai.nr.MiMHiA  (p.  4).  Jissociatcd  with  renal 
tube-casts  :  and  if  there  is  bilateral  effusion  without  universal  (cdcma.  but  with  signs  of 
heart  laihuc  in  the  I'orm  ol  orthopiKca.  <c(lema  of  the  legs,  and  |)erhaps  ascites,  the  cliiision 
is  |)assjve  :  it  hclongs  to  the  second  <'ategory  if  there  is  universal  (i<lema  ;  whilst  ii  (he 
effusion  is  inllanunalory  it  will  probably  be  unilateral,  or  else  more  miukerl  in  one  side  of  Ihc 
chest  (hitii  in  the  other.  In  a  few  cases  .-ui  extensi\i-  pleuritic  ellusion  in  a  middle-ageil  or 
eldi-rly  person  is  the  llrsi   indiealion  lli:il    llieii'  is  ini\  lliing  reiiiil  Hie  in.ilhr,  I  he  diagnosis  of 


Kis;lit 


Left 


Fig.  42.— Skiii^ram  slio«-iii2  sarcoma  of  the  right  hmf: 
seeonUary  to  sarcoma  of  a  kidney.  Tlie  patient  was  a  child,  xuicd 
n  years"  GG.  .Ma.sscs  of  new  uro'wth.  H.  He.-irt.  TIic  lower  mark 
G  point«  in  the  rlirection  of  the  lower  ma-ss  ol  growtli.  but  the  lino 
h:us  not  been  prolonged  so  far  iis  to  the  shadow  of  the  growth 

(Hkiiujmm  hij  Dr.  C.    Thnrsliin  r!nl/„ii,l.) 


X  coiiliriiHil    liy   Hie 
piieiiiMoeoeeal     sen 


■oNcry  ol'  piieiuiKieneei  in  llic 
enusion  stops,  howe\er.  and 
o  merging  into  one  another,  and  the  same 
cNploralioii.    eloudv  lluid   a    few  davs  later,  and 


106  CHEST,     SEROUS     EFFUSION    IN 

red  oramiliir  contracted  kidney  being  confirmed  by  the  urinary  changes,  big  heart,  ringing 
aortic  second  sound,  high  blood-pressure,  or  by  albuminuric  retinitis. 

Any  of  the  severe  blood  diseases,  particularly  Hodgkin's  disease,  lympliadenoma,  leu- 
kinnia,  splenic  anceniia.  j)seiido-leuk(emin  infantum,  and  to  a  less  extent  pernicious  ancemia, 
may  give  rise  to  inflammation  of  any  of  the  serous  membranes,  and  thus  lead  to  ascites, 
pericarditis,  or  pleurisy  with  effusion.  The  latter  is  seldom  an  early  sym])tom  in  such  cases, 
however,  and  the  diagnosis  will  generally  be  known  already  from  the  presence  of  ])ronounced 
An.«;mia  (j).  20),  enlargement  of  the  Ly.aiphatic  Gl.vnds  (p.  376),  or  enlargement  of  the 
.Spleen  (p.  628),  with  or  without  pathognomonic  blood-changes  already  discussed  under 
these  various  headings. 

Pleuritic  effusion  may  sometimes  be  secondary  to  infection  of  the  pleurce  from  inflam- 
nialori/  changes  beloiv  the  diaphragm  ;  thus  appendicitis  may  lead  to  micro-organisms  tracking 
up  behind  the  ascending  colon  to  reach  the  diaphragm,  there  perhaps  producing  a  small 
subdiaphragmatic  abscess,  or  a  local  inflammation  which,  stopping  short  of  pus  formation, 
ultimately  subsides.  The  bacteria  in  contact  witli  the  lower  surface  of  the  diaphragm  can 
pass  through  the  latter  arid  infect  the  pleura  without  there  being  any  actual  perforation  of 
the  dia|)hragm  ;  it  is  noteworthy  that  passage  of  micro-organisms  in  the  reverse  direction 
is  so  rare  as  almost  to  be  negligible  ;  acute  peritonitis  often  [jroduces  acute  pleurisy,  but 
the  latter,  or  even  empyema,  seldom  produces  peritonitis.  Any  inflammatory  mischief 
below  the  diaphragm  may  lead  to  dry  pleurisy,  jjleuritic  effusion,  or  empyema.  One  need 
not  enumerate  all  such  causes,  but  they  should  be  borne  in  mind  as  possibilities.  There 
may  have  been  acute  general  peritonitis,  or  a  more  local  inllaniiiiatinn  of  the  peritoneum 
tracking  in  the  manner  already  described  in  connection  with  ap])<ndicitis.  This  is  possible 
when  there  is  leaking  from  a  gastric  or  duodenal  ulcer  ;  local  infection  from  the  gall-bladder  ; 
pyosalpinx  :  ])elvic  peritonitis  due  to  whatever  cause  :  perinephric  inflammation  secondary 
to  renal  calculus  or  injury,  acute  ascending  nephritis,  tuberculosis  of  the  kidney  ;  hepatic 
abscess  or  otlur  inllanunatory  changes  in  or  about  the  liver,  such  as  infective  cholangitis, 
suppurative  pylephlcljitis,  or  the  softening  and  breaking  down  of  new  growth,  gumma,  or 
hydatid  cyst.  When  the  possibility  of  a  pleuritic  effusion  being  secondary  to  an  abdominal 
lesion  of  some  kind  is  borne  in  mind,  the  diagnosis  of  the  case  is  generally  indicated,  at 
least  approximately,  by  the  preceding  history  and  symptoms.  It  the  fluid  obtained  smells 
as  though  it  were  infected  with  Bacillus  coli  communis,  this  would  be  an  additional  argument 
in  favour  of  some  subdiaiihragmatic  cause. 

InfarrliDii  of  the  lung,  wliitlur  thrombotic  or  embolic,  is  apt  to  cause  dry  pleurisy  :  but 
if  the  infarct  has  been  extensive,  or  is  due  to  embolism  from  some  septic  source  such  as  a 
lateral  sinus  or  jugular  vein  thrombosis  in  connection  with  otitis  media,  or  other  similar 
lesions  causing  venous  clotting,  the  inflammation  of  the  pleura  tends  to  go  further  and 
produce  an  effusion  which,  at  first  serous,  may  later  become  pundent.  The  diagnosis  is 
sometimes  oijvious  ;  but  when  after  an  operation,  perhaps  for  excision  of  an  inflamed 
appendix,  the  patient  a  few  days  later  develojis  pleurisy  with  effusion,  it  may  not  occur  to 
one  that  a  possible  explanation  of  the  trouble  is  that  more  than  one  systemic  vein  in  the 
region  of  the  right  iliac  fossa  has  become  inflamed  and  thrombosed,  and  that  portions  of 
the  clot  have  been  detached  and  carried  to  the  lung,  where  multiple  infected  emboli  ha^•e 
led  to  pleurisy  and  serous  effusion,  without  going  so  far  as  to  produce  either  abscess  in  the 
lungs  or  empyen>a.  .Should  h;pmoptysis  occur  in  such  cases,  as  it  sometinics  does,  phthisis 
may  be  feared  ;  but  it  will  be  excluded  l)y  tlic  al)scncc  of  tubercle  bacilli  on  repeated 
examination  of  the  sputum. 

Occasionally  the  fluid  obtained  on  needling  the  chest  is  distinctly  chi/lous,  in  which 
case  the  first  suspicion  to  be  aroused  is  that  there  has  been  some  interference  with  the 
thoracic  duct,  either  by  injuri/  or  by  an  intrathoracic  neiL'  groictli.  Sometimes,  howevei-. 
this  rare  symptom  is  flue  to  remoter  causes,  such  as  chronic  nephritis  or  Icuka'uiia,  just  ;i-- 
tliese  may  occasionally  i)ro(luce  chylous  ascites  (see  p.  50)  ;  in  a  few  instances  a  chylous 
effusion  into  tlie  chest  has  cUarcd  up  alter  tapping,  and  no  ascertainable  cause  for  it  found. 

Multiple  serositis  or  polyorrhomenitis  is  a  term  used  to  express  any  condition  in 
which  there  is  recurrent  inllammation  and  serous  effusion  into  more  than  one  serous  mem- 
brane. It  generally  affects  the  ijeritoneum.  pericardium,  and  both  pleiu'a?  either  sinudtan- 
eously  or  successively.  It  is  not  a  disease  in  itself,  so  that  the  differential  diagnosis  of  the 
cause  of  the  combined  effusions  has  to  be  made  upon  the  same  lines  as  that  described  for 


CHEYXE-STOKES    RESPIRATION  107 

each  separately.  There  are  cases  in  which,  even  when  the  patient  dies,  the  precise  nature 
of  the  multiple  serous  inflammations  and  effusions  is  obscure  ;  it  is  very  possible  that  the 
original  microbial  cause  has  disappeared,  leaving  behind  it  so  much  fibrotic  thickening  of 
the  membranes  that  even  the  normal  secretions  arc  unable  to  drain  away  as  fast  as  they 
should.  The  result  is  that  recurrent  tapping  at  comparatively  short  intervals  becomes 
necessary,  and  the  patient  ultimately  dies  of  exhaustion,  nothing  being  found  post  mortem 
except  fibrous  thickening  of  the  peritoneum,  pericardium,  and  pleurfc.  with  more  or  less 
extensive  perihepatitis,  perisplenitis,  adherent  pericardiimi,  and  chronic  mediastinitis. 
The  general  opinion  is  that  the  primary  cause  in  these  cases  has  been  either  acute  rheuma- 
tism or  tuberculosis.  Sometimes  secondary  malignant  disease  affects  more  than  one  of 
the  serous  membranes  at  the  same  time,  and  produces  a  clinical  picture  which  at  first 
simulates  chronic  simple  polyorrhomenitis  :  there  are  generally  symptoms  due  to  the 
primary  growth  :  but  occasionally,  especially  in  connection  with  diffuse  carcinoma  of 
the  stomach — "  indiarubber-bottle  '  stomach — the  primary  growth  causes  no  symptoms, 
and  the  nature  of  the  multiple  serous  effusions  may  be  obscure  unless  particles  of  new 
growth  can  be  detected  in  the  ccntrifugalized  deposit,  or  secondary  masses  can  be 
found  in  the  liver  or  lymphatic  glands.  The  left  supraclavicular  glands  should  be 
examined  carefully  (Fi^.  17,  p.  49).  Sometimes  the  diagnosis  is  not  arrived  at  until  a 
post-mortem  examination  is  made. 

Bcsirlcs  chronic  tuberculous,  rheumatic,  and  malignant  polyorrhomenitis,  a  similar 
condition  may  be  <luc  to  Bright's  disease  or  any  of  the  severe  ana-mias  ;  the  differential 
diagnosis  of  the  serous  effusions  to  which  these  may  give  rise  has  been  discussed  above. 
Careful  examination  of  the  blood  and  urine,  together  with  estimation  of  the  blood-pressure, 
examination  of  the  optic  discs,  and  routine  physical  examination  of  the  various  body 
systems,  are  essential  before  the  correct  diagnosis  can  be  arrived  at.  Herbert  French. 

CHEST,   VARICOSE  VEINS  ON.— (See  Veins,  Varicosk  Tuoracic,  p.  7.-,0.) 

CHEYNE-STOKES  RESPIRATION,  or  periodic  breathing,  consists  in  the  occurrence 

of  a  siiiis  (jf  ins|iiraliiiiis.  bigiimiiig  with  a  hardly  perceptible  movement  increasing  to  a 
inaxlinuiu.  and  tlicu  ilccliniiig  in  force  and  length  until  tliey  cease  in  a  period  of  iipncca  of 
some  seconds'  duration,  during  wliich  the  patient  may  a])pear  to  be  dead,  but  at  tlie  end  of 
which  a  low  inspiration,  followed  by  one  more  decided,  anil  then  others  of  Increasing  depth, 
mark  the  begimiing  of  a  new  ascending  series  of  inspirations,  which  in  their  turn,  when 
the  maxinuuri  has  been  reached,  become  progressively  smaller  again,  to  end  in  another 


__^iifc4^- 


period  of  aprioa  :  :in(l  so  on  willi  more  or  less  periodicity  (A'/i'.  Hi).  Tin-  ilnralicjii  of  each 
I)c-rio(l  Niirics  from  li;df  a  iiiiimic  In  two  miuulcs  or  c\cn  more,  'i'here  is  a  peculiar  variety 
of  periodic  breathing  in  which,  instead  of  a  waxing  and  waning  se((uciu'e.  only  I  wo  or  perhaps 
three  rapid  deep  breaths  arc  Tnadc  at  a  time,  with  long  periods  of  apiiiia  l)el\veen  them — 
a  variety  of  periodic  breathing  which  is  sometimes  spoken  of  as  Hiofs. 

Periodic  breathing  may  occur  during  sleep  in  the  very  young  and  in  the  very  old  wilhoid 
tlu're  being  an\  aclnal  disease.  In  other  persons  Cheyne-StoUes  breathing  is  generally  a 
late  phi^norni  n<iri,  lia\  irig  been  preceded  by  oilier  symptoms.  ))articularly  urainic  or  cardiac  ; 
in  a  few  eases  ol  |>l■ogr(■^si\  <■  solleiiing  in  the  medulla  oblongata  secondary  lo  arterial 
degeneration.  (  lieyne-Slokes  respiralion  ma\-  li<'  the  salient  symptom  in  the  ease,  liroadly 
speaking,  one  may  elassily  llie  chief  causes  of  pirioilic  brcalhing  as  follows  : 

1.  Arterial,  especially  with    Degenerative    Changes  in  the  Medulla  Oblongata: — 

Ai'lirin-sclcidsis.   with  iir  williniil    <;raniilar   kiiincy. 
SrniN'   ill  ;;(M(i:itiiiri. 


108  CHEYNE-STOKES    RESPIRATION 

2.  Uraemic,  in  cases  of  : — 
Acute  ne[)liritis  I    Tuberculous  kidney  I    Cystic   kidneys 

Clironic  ncpliritis  Ascendinj;  nepliritis,  acute  or       Carcinoma  oif  the   kidney 

Calculous  <lise;ise  ol' the  kidney  |        chronic  |    Sarcoma  of  the  kidney. 


3.  Chronic  Heart  Failure : — 

Secondary   to   valvular    lieart   disease 
Secondary  to  myocardial  degeneration,  especi- 
ally fatty  or  fibroid  heart 


Secondary  to  cluduic  obstruction  in  the  lungs, 
especially  from  emphysema  and  bronchitis, 
or  I'lbroid  luni> 

Associated  with  very  high  systemic  blood- 
pressure. 


4.  Narcotic  Poisoning,  especially  from 

Morjihia  '  Chloral  !  Veronal 

Opium  Hulyl   chloral  hydrate  j  Sidi)honal 

5.  Macroscopic  Lesions  of  the  Brain  or  its  Coverings  : — 


Meningitis,  tuberculous,  su]ipurati\  e,  ])osterior 

basal,   cerebrospinal 
Ilydrocejihalus 
Tumour  of  the  brain,   especially  of  the  jjons 

or   medulla 


Ha?morrhaf>e 

Softening  of  the  lirain  secondary  to  : 
Chronic  arterial  degeneration 
Syphilis  Caisson  disease 

Embolism  General  paralysis 


6.  Acute  Specific  Fevers,  such  as  : — 

Pneumonia  I  Diphtheria  ]  Alalaria 

Cholera  j  Typhoid  fever  j  Infective    endocarditis 

The  diflerential  diagnosis  of  these  various  conditions  will  be  indicated  by  symptoms 
and  signs  other  than  the  Cheyne-Stokes  rcs|)iration.  for  the  latter  will  have  occurred  late 
in  the  great  majority  of  the  cases.  The  urine  will  be  examined,  the  blood-pressure  measured, 
the  physical  signs  of  the  heart  noted,  the  retina  examined  lor  retinitis,  optic  neuritis,  or  for 
choroidal  tubercles,  and  careful  in(|uiries  will  be  made  into  the  history.  Where  narcotic 
jioisoning  may  be  suspected,  the  gastric  contents  may  be  recovered  and  analyzed,  bottles 
foimd  imder  suspicious  cirevmistances  may  be  examined  in  the  same  way,  or  evidence  of 
iiypodermic  injections  sought  for  on  the  patient's  body  or  limbs.  When  Cheyne-Stokes 
respiration  occurs  as  the  main  symptom  in  the  case,  the  great  probability  is  that  there  are 
degenerative  changes  in  the  medulla  oblongata,  nearly  always  secondary  to  arterial  degener- 
ation, either  senile,  syphilitic,  or  sclerotic.  When  there  have  been  obvious  symptoms  of 
some  other  kind  before  Cheyne-Stokes  respiration  develops,  the  latter  is  far  more  important 
from  the  prognostic  than  from  the  diagnostic  standpoint.  It  is  a  sign  of  evil  omen,  though 
in  a  few  cases  it  has  persisted  for  inaiiy  months  before  the  end  came,  and  in  a  few  it  has 
<lisappcared  entirely  for  the  time  being,  even  after  it  had  been  well  marked  for  days  or  weeks. 

Herbert   French. 

CHILLS.     (.See  Ricohs,  p   594.) 

CHORDEE. — A  condition  in  which,  during  erection,  the  penis,  instead  of  remaining 
straight,  becomes  curved  like  a  banana,  either  downwards  or  to  one  side.  It  is  nearly 
always  due  to  gonorrhcca,  though  in  rare  cases  it  has  residted  from  injury  without  gonor- 
rhoea. The  differential  diagnosis  will  depend  upon  the  history  and  the  existence  or  other- 
wise of  a  urethral  discharge  containing  gonococei.  The  condition  itself  is  probably  due  to 
inflammatory  effusion  into  one  corpus  cavernosum,  or  the  corpus  spongiosum,  as  the  case 
may  be  ;  or,  in  the  absence  of  inflanuiiatioii,  to  blood  extravasation  from  a  burst  vessel. 
Fracture  of  the  penis  has  occurred  during  resisted  coitus,  the  diagnosis  dejiending  on  the 
history  and  the  break  that  is  palpable  in  the  penis  during  erection.  Herbert  Freiieli. 

CHYLURIA. — The  passage  of  milky-looking  urine,  due  to  the  admixture  with  it  of 
cmulsilicd  fat,  is  known  as  chyluria.  It  is  not  likely  to  be  mistaken  for  phosphatmia. 
even  when  the  latter,  especially  after  the  largest  meal  of  the  day,  causes  the  urine  to  be 
almost  like  thin  milk  from  the  spontaneous  deposition  of  the  excess  of  phos])hates  whilst 
the  urine  is  still  in  the  bladder.  The  opacity  in  the  latter  case  disappears  on  the  addition 
of  a  drop  or  two  of  acetic  acid,  whilst  the  fat  droi)lcts  of  chyluria  do  not  clear  up  with  acids, 
are  obvious  under  the  microscope,  and  may  bi'  lironght  out  still  more  clearly  by  the  use 
of  special  fat  stains,  such  as  osniic  acid,  sudan  III.  or  salfrauin.  ^Vs  a  ride  the  urine  coagu- 
lates on  standing,  and  subsei|ucntly  liciuefies  again,  when  it  throws  up  a  fatty  sciun  and 


t'LAW-HAXD 


109 


deposits  ii  seflimcnt.  Tlic  fat  is  most  plentiful  after  meals  whicli  contain  fat:  tlie  degree 
of  chyhiria  consequently  varies  considerably  in  the  same  patient,  and  may  sometimes  be 
almost  absent. 

The  commonest  cause  for  the  symptom  is  infection  by  Filariu  sanguinis  liomiiiis  in 
the  tropics,  adults  being  affected  more  often  than  children,  and  females  more  often  than 
males.  There  may  or  may  not  be  elepltnntinsi.i  at  the  same  time  :  the  diagnosis  may  be 
suggested  by  eosinophilia  and  confirmed  bv  the  discovery  of  tlie  embrvos  in  the  blood 
(Plate  XXVIII,  Fig.  F,  p.  614). 

C'hyluria  may  also  occur,  however,  in  those  who  have  never  been  abroad,  and  it  is 
sometimes  associated  in  some  way  that  is  not  yet  fully  understood  with  sub-acute  nephritis  ; 
there  may  be  chylous  ascites  (p.  .50)  at  the  same  time.  Tlie  diagnosis  depends  upon  the 
history,  the  general  crdema,  the  anemia,  cardiac  hy])ertrophy,  and  upon  the  discovery  of 
an  abundance  of  albumin  with  renal  epithelial  cells  and  tube-casts  in  the  centrifugalizcd 
urinary  deposit,  as  well  as  fat  droplets  in  the  su])ernatant  fluid. 

Sometimes  chyhiria  develops  (juite  ajiart  from  any 
renal  lesion,  either  spontaneously  or  as  the  result  of 
abdominal  injury  ;  and  it  has  generally  been  found  in 
these  rare  cases  that  there  has  been  either  rupture  of 
the  receptaculum  chyli,  or  else  a  blockage  in  the 
thoracic  duct.  The  latter  sometimes  results  in  cases  of 
malignant  disease,  especially  carcinoma  of  some  intra- 
abdominal organ  with  secondary  deposits  in  the  glands 
in  the  posterior  mediastinum.  The  development  of 
chyhiria  in  such  cases  would  be  a  late  symptom,  and 
the  diagnosis  would  probably  have  been  made  already- 
on  account  of  other  symptoms,  especially  the  discovery 
of  a  primary  tumour.  It  is  important  not  to  forget 
rectal  and  vaginal  examination,  lest  the  growth  should 
be  pelvic.  IlcrhnI  Frnirh. 

CLAW-FOOT  (Pied-en-griffe)  {Fig.  -14).  is  mueli 
less  coiniiHiri  lli.iii  t  i,  \\\ -ii  am>.  but  it  may  arisi'  IVoin 
similar  <auses.  The  iiihinal  i)(i|)liteal  nerve,  which 
supplies  the  intcrossei  and  hiinbricals  of  I  he  fool  Ihroiiali 
its  externa!  plantar  branch,  is  homologous  to  the  ulnar 
nerve  in  the  upper  extremity.  Its  buried  ((iimsc  in  [\iv 
leg  does  not,  however,  expose  it  to  the  same  ehauccs  of 
injury  as  the  more  superlicial  ulnar  nerve,  and  eoiise- 
MMintly  claw-foot  is  not  often  the  result  of  trauma. 
Disease  or  injury  of  the  first  and  second  sacral  segments 
of  spinal  roots  may  produce  the  characteristic  deformity 
of  the  toes,  in  which  case  there  would  probably  be  dis- 
turbances of  sensibility  in  tlie  corresponding  cutaneous 
areas.  In  aT-ute  poliomyelitis  affc<'tiiig  those  segments, 
history  of  onset,   as  in   llie  case  of  claw-liaii.l  of  siniif 


/•'W.    n.--Clau-lV,ot. 


I  lie    dia,! 
iriyiii. 


iiosis    (I 


■|,.n,N 
n,i„h,n 


on    llic 
lUa-.aril. 


CLAW-HAND  (Main-en-grirrc)  is  IIk-  n-.uw  used  to  describe  a  hand  el.ara.cteri/cd 
l>y  a  claw-like  position  of  the  lingers  {Fig.  I.-,),  'i'he  lingers  are  extended  at  the  mclacarpo- 
]plialaTigcal  joints  and  Hexed  at  both  iMici-phalaiigeal  joints.  This  iiosilion  is  the  result 
lof  the  over-:ulion  of  the  extensor  coinnuuns  digitorum  and  llexores  digitorum  when  un- 
jopposed  by  the  normal  antagonism  of  the  inlerossei  and  luiMbrieales.  It  is  not  symptomatic 
j'>r  any  particular  <lisease.  but  results  from  any  nuirbid  condition  which  produces  atrojiliic 
jjiaralysis  of  the  intrinsic  hand  muscles  so  long  as  the  long  extensors  of  the  lingers  remain 
Snfaet.  I'rogressiir  mimciilar  alrojiliii,  ulnar  jiarali/sis,  sf/ringonii/cliu,  (rrvical parhi/nirningilis 
(iculc  jiolioini/rlilis.  pemncal  alroiili//.  and  supeinumerarij  ribs  arc  among  the  conditions 
winch  may  give  rise  to  claw-hand  to  a  lesser  or  greater  degree.  In  any  particular  case 
he  diagnosis  of  the  underlying  eondilion  depends  on  the  nsull  of  fiirtiicr  investigation. 

In  progressive  muscular  alrajih!/.  uiisling  ,,[  llii'  iiil  ririsic  ImikI  nuisclcs  is  often  an  early 


110  CLAW-HAND 

symptom  (p.  61),  and  a  claw-hand  may  develop  before  the  long  extensor  muscles  of  the 
fingers  have  become  involved  in  the  disease.  All  four  fingers  are  usually  affected  to  an 
a]>proximately  equal  extent,  and  there  is  often  marked  wasting  of  the  thenar  and  hypothenar 
eminences.  When  the  abductor  pollicis  is  also  involved,  the  thumb  tends  to  come  into 
line  with  the  fingers  and  gives  an  appearance  to  the  hand  resembling  that  of  the  ape  (ape's 
hantl).  The  flexors  of  the  wrist  often  become  involved  before  the  extensors,  with  the 
result  that  the  wrist  is  hyperextended,  and  a  '  |)reaclier".s  hand  '  results.  The  absence 
of  pain  and  of  all  sensory  disturbance,  the  gradual  onset,  and  the  general  exaggeration 
of  the  deep  reflexes,  serve  to  distinguish  this  condition  from  some  of  the  other  causes  of 
claw-liand. 

In  iihifir  paralj/sis  the  claw-position  i.s  more  marked  in  the  ring  and  little  fingers  than 
in  the  middle  and  first  fingers,  owing  to  the  fact  that  the  two  outer  lumbricals  are  supplied 
by  the  median  nerve.  The  adductor  pollicis  is  the  only  thenar  muscle  to  .suffer,  but  the 
hypothenar  eminence  is  wasted.  If  the  injury  to  the  nerve  is  above  the  point  where  it 
gives  off  the  branch  to  the  flexor  carpi  ulnaris,  the  latter  muscle  will  also  be  paralyzed, 
and  flexion  of  the  wrist  will  be  carried  out  with  a  leaning  towards  the  radial  side.  In  ulnar 
paralysis  the  palsy  is  limited  to  the  muscles  supplied  by  the  ulnar  nerve,  and  there  is 
usually  some  sensory  loss  in  the  area  of  skin  innervated  by  the  latter. 

The  claw-hand  of  si/ringo- 
myelia  (Fig.  45)  resembles  that  of 
]3rogressive  muscular  atrophy  in 
general  appearance,  and  may  show 
the  modifications  to  which  the 
term  "  ape's  hand  '  and  "  preacher's 
hand  '  have  been  applied.  The 
muscular  atrophy  is  not  limited 
to  the  distribution  of  a  single 
nerve,  but  involves  the  muscula- 
ture innervated  by  the  eighth 
cervical  and  first  dorsal  spinal 
segments, — the  segments,  in  fact, 
in  which  the  gliosis  frequently 
Fi,,.  ij  -tiriiigomyeik-  ci.iw  i,;ir.,i.  begins.     The  diagnosis  depends  on 

the  presence  of  dissociative  anaes- 
thesia, trophic  and  vasomotor  disturbances  such  as  whitlows,  glossy  skin  (peau  lisse), 
main  succulente,  and  is  often  corroborated  by  the  occurrence  of  oculo-pupillary  pheno- 
mena, nystagmus,  scoliosis,  and  evidence  of  spastic  paralysis  in  the  leg  of  the  same  side. 
Cervicnl  pnrlii/inrningitis  only  leads  to  a  claw-hand  when  it  interferes  with  the  function 
of  the  eighth  cervical  and  first  dorsal  anterior  roots,  and  leaves  uninjured  the  sixth  and 
seventh  cervical  roots.  The  condition  is  generally  bilateral  with  some  asymmetry,  and  it 
is  usually  associated  with  pain  and  ill-defined  disturbances  of  sensibility  in  the  two  arms. 
An  acute  poliomyelitis  affecting  the  eighth  cervical  and  first  dorsal  segments,  and 
lea\ing  intact  the  sixth  and  seventh  cervical  segments,  is  uncommon.  The  history  of 
acute  onset,  with  constitutional  symptoms  such  as  headache,  fever,  vomiting,  and  convul- 
sions, affords  a  clue  to  the  diagnosis.  The  absence  of  sensory  loss,  and  the  possible  presence 
of  atrojihic  palsies  in  other  parts  of  the  body,  form  additional  data  in  these  cases. 

In  peroneal  atrophy  the  diagnosis  depends  on  the  symmetry  of  the  afi-ection  and  the 
preceding  or  concomitant  atrophy  of  the  leg  muscles,  generally  beginning  in  those  supplied 
by  the  peroneal  nerve  (see  Figs.  20  and  21,  p.  60). 

Supernumerarji  eervieal  ribs  may  lead  to  the  ijroduction  of  a  claw-hand  when  they 
cause  neuritic  changes  in  the  trunk  formed  by  the  eighth  cervical  and  first  dorsal  eon- 
trilnitions  to  the  brachial  plexus.  The  muscular  atrophy  is  preceded  by  pain  in  the 
arm  and  neck,  and  sometimes  by  vasomotor  changes  and  diminution  "of  the  radial 
pulse.  Analgesia  in  the  distribution  of  the  eighth  cervical  and  first  dorsal-root  areas 
may  also  be  detected,  but  the  diagnosis  mav  depend  mainly  on  the  skia^raphic  discovery 
of  the  rudimentary  ribs  (,,.  443).  '  E.°Far,p,l,ar  Buzzard. 

CLONUS,  ANKLE.— (See  Ankle-clonus,  j).  39.) 


CLUB-FOOT 


111 


CLUBBED  FINGERS,  or  bulbous  cularuemcnt  of  the  soft  parts  of  tlic  terminal 
])lialani;es,  with  o\ei-cui\in<;-  of  the  nails  both  transversely  and  longitudinally,  are  seen 
eharaeteristieally  in  mor))us  ca^ruleus.  and  also  in  association  with  fibroid  lung.  They 
are  distinguished  readily  from  enlargement  (hie  to  bony  changes,  such  as  those  of  acromegaly 
and  pulmonary  osteoarthropathy. 

Minor  degrees  may  occur  with  almost  any  disease  that  leads  to  persistent  congestion 
of  terminal  ]jarts,  such  as  mitral  stenosis,  mitral  regurgitation,  emphysema,  chronic 
bronchitis,  pleurisy  with  effusion,  empyema,  chronic  phthisis,  some  form.s  of  aortic  or 
subclavian  aneurysm,  asthma,  pericarditis,  adherent  pericardium,  mediastinitis,  or 
mediastinal  neoplasm.  In  such  cases,  however,  the  clubbing  has  to  be  looked  for — it  does 
not  thrust  itself  (ipon  one"s  notice  ;  it  may  also  pass  away  again  -when  the  cause  is  removed, 
for  instance,  when  an  empyema  is 
cured  by  operation. 

Obvious  and  extreme  finger-club- 
bing has  only  two  main  cavises — 
congenital  heart  disease  with  cyanosis 
(Fig.  46).  especially  pulmonary  stenosis 
with  or  without  a  perforated  interven- 
tricular septum  :  and  fibroid  lung, 
especially  if  associated  with  bronchi- 
ectasis. The  distinction  between  these 
two  will  generally  be  obvious.  The 
former  dates  from  infancy  and  is 
associated  with  extreme  cyanosis  and 
a  loud  pulmonary  systolic  bruit  an<l 
thrill  ;  the  latter  develoi>s  later  in 
life,  is  seldom  associated  with  such 
extreme  cyanosis  cxcejjt  when  the 
patient  is  in  extremis,  and  is  accom- 
panied l)y  displacement  of  the  heart 
and  other  signs  of  fibrosis  of  the  lung. 

Difficulty  may  arise  in  those  rarer 
cases   of  congenital    h;'art    disease    in  "  .xtrcinc  rv:iii"M>. 

which  there  is  no  bruit — for  instance 

when  the  heart  gives  off  a  single  large  vessel,  tlie  place  of  the  pulmonary  arteries  being 
taken  by  intercostal  vessels — but  even  here  the  fact  that  the  lividity  is  out  of  jHoportion 
to  the  dyspncra,  and  the  history  that  the  cyanosis  and  the  finger-clubbing  date  from 
soon  after  birth,  afford  immediate  clues  to  the  diagnosis.  Congenital  heart  disease  with- 
out cyanosis— patent  duetvis  arteriosus,  for  instance — does  not  give  rise  to  clubbed  fingers. 
In  lung  eases  the  diagnosis  is  either  obvious  from  the  i)hysical  signs  :  or  else,  if  the 
abnormal  physical  signs  are  so  slight  as  by  themselves  to  suggest  little  more  than  bron- 
chitis, the  existence  of  marked  clubbing  of  the  lingers  is  iini)orlant  evidence  that  the 
lung  trouble  is  more  extensive  than  this,  and  that  there  is  really  nuich  fibrosis,  and  prob- 
ably bronchiectasis,  too  deep-seated  to  permit  of  the  usual  physical  signs  being  detected 
at  the  surface  of  the  chest.  \  moderate  degree  of  clulibing  of  the  fingers  is  sonielimcs 
observed  in  cases  of  cirrhosis  of  the  liver.  i)arl  icularly  in  that  l>pc  which  begins  as  splenic 
anicmia — Hanli's  disease  (see'  p.  .'IT).  This  su:;g<>sls  thai  Hie  changes  in  the  linger  lips 
have  a  chemical  as  well  as  a  mccliaiiicMJ  factor  in  llicir  causation.  Iliihcil  l-'irnch. 


CLUB-FOOT,  or  TALIPES.  Any  dclbrmily  of  the  fool  not  limited  to  the  toes 
(■(iTinnoiils  yocs  uiiilcr  Ihi-  narnc  of  club-foot,  or  talipes.  .The  diagnosis  of  the  differenl 
Iciiiiis  of  lali|Hs  is  cxliciiiily  dillrciilt.  owini.'  lo  (lie  tninibcr  <if  causes  ;uul  the  coinplicaled 
nalin-e  of  the  ilcformil  iis.  11  ina\  In-  well.  Ilicn  lorr.  In  il.line  liriclly  llic  chief  variclics 
of  simple  dcl'ormily. 

1.  Talipes  Equinus.  In  lliis  coiKlilinn  Ihc  line  pari  of  llir  fool  caiinol  lie  raised 
lo  the  normal  dcgrei'.  Any  lieallliv  adiill  is  able,  willi  I  lie  knee  sliaiiilil,  lo  ilorsill.'X  Hie 
aiikli'  lo  such  an  extciil  Ihal  llii-  ball  of  llie  -iral  loc  is  I  wo  or  Ihrce  iiicliis  liiglicr  lliaii  Ihe 
proriiiiuiice   of  the    heel.      'I'lic   (l(i;nr   of  dorsillexion    is   e\cn    "Tialcr   in    iiifaiils,    bill    uilh 


112  CLUB-FOOT 

advancing  years  the  movement  beeomes  limited,  so  that  old  people  may  hardly  be  able 
to  dorsiflex  the  foot  beyond  the  right  angle. 

2.  Talipes  Calcaneus. — In  this  condition  the  heel  is  depressed  and  tlie  fore  part  of 
the  foot  elevated.  Kxtension  of  the  ankle  is  limited,  so  that  the  fore  part  of  the  foot  may 
not  touch  the  ground  in  walking. 

:!.  Talipes  Valgus. — The  foot  is  everted  and  abducted  at  the  ankle-joint,  so  that  the 
inner  malleolus  is  too  prominent. 

4.  Talipes  Varus. — The  foot  is  inverted  and  adducted  at  the  ankle-joint,  so  that  the 
outer  malleolus  is  too  ])rominent.  In  this  condition,  however,  there  is  more  serious 
deforniity  at  the  medio-tarsul  joint,  at  which  the  fore  part  of  the  foot  is  adducted  and 
inverted. 

5.  Talipes  Cavus. — The  arch  of  the  foot  is  too  high  or  hollow.  This  may  be  due  to 
depression  of  the  fore  part  of  the  foot,  of  the  heel,  or  of  both. 

Club-feet  may  be  divided  into  (I)  The  Congenital,  (II)  The  Acquired. 

I.  CONGENITAL  TALIPES. 

Congenital  talipes  is  usually  quite  easy  to  diagnose,  because  of  the  history  of  the 
liresence  and  the  nature  of  the  deformity  at  birth.     There  are  two  chief  varieties  of  it  : 

(1)  Equino-varus  ;    (2)  Calcaneo-valgus. 

Sometimes  the  history  is  lacking  or  misleading,  and  the  shape  of  the  feet  has  been 
so  altered  by  treatment  or  neglect  that  it  is  very  dilficult  to  distinguish  the  condition  from 
paralytic  talipes,  especially  that  due  to  paralysis  of  the  lower  neuron.  In  making  the 
distinction  it  is  important  to  remember  that  the  shortening  is  usually  very  much  less  in 
congenital  cases,  and  that  wasting  of  the  muscles,  apart  from  tight  splinting,  is  also  much 
less.  Trophic  idcers,  and  cold  and  blue  feet,  which  are  common  in  cases  of  paralysis,  do 
not  occur  in  congenital  talipes.  Moreover,  the  toes  are  not  hyper-extended  at  the  meta- 
tarso-phalangeal  joints,  a  condition  commonly  present  in  jiaralytic  talipes.  The  reaction 
of  degeneration  is  not  present  in  congenital  cases,  thus  distinguishing  it  from  talipes  due 
to  comparatively  recent  paralysis  of  the  lower  neiu'on.  The  reflexes  are  not  exaggerated, 
thus  distinguishing  it  from  talipes  due  to  paralysis  of  the  upper  neuron.  In  congenital 
equino-\arus  the  small  conical  heel  is  not  only  raised  but  also  turned  inwards  in  a  character- 
istic way,  and  it  is  generally  separated  from  the  inner  aspect  of  the  foot  by  a  deep  furrow. 
There  is  also  a  curious  flattening  on  the  outer  side  of  the  foot,  just  in  front  of  the  external 
malleolus,  where  the  skin  is  dimpled  and  loose.  There  is  also  a  furrow  on  the  inner  side 
of  the  foot  opposite  the  medio-tarsal  joint.  The  varus  is  always  worse  than  the  ecpiinus, 
whereas  in  paralytic  cases  the  equinus  is  usually  worse  than  the  varus.  With  care  the 
overstretched  weak  muscles  can  be  shown  to  be  capable  of  voluntary  contraction. 

II.  ACQUIRED  TALIPES. 

This  condition  may  be  sid)divided  as  follows  :  (1)  The  paralytic,  due  to  :  (a)  Disease 
of  the  upper  neuron  ;    (b)  Disease  of  the  lower  neuron  ;    (c)  Primary  muscular  disease  ; 

(2)  Postural,  e.g.,  talipes  valgus  ;  (3)  Due  to  fibrosis  of  muscle,  with  retraction  :  (-1)  Due 
to  bone  disease  :  (5)  Due  to  joint  disease  ;  (6)  Due  to  contracting  scars  ;  (7)  Due  to 
hysteria. 

1.  The  Paralytic. — (a)  In  talipes  due  to  destruction  of  the  iqrper  neuron  the  reflexes 
are  exaggerated  and  the  plantar  reflex  is  extensor  ;  whereas  in  talipes  due  to  disease  of 
the  lower  neuron  the  reflexes  are  unchanged,  diminished,  or  lost.  Reaction  of  degeneration 
may  be  present  with  lesions  of  the  lower  neuron,  and  absent  with  lesions  of  the  upper. 
Coldness  and  blueness  of  the  feet  are  only  common  in  lesions  of  the  lower  neuron,  and  the 
same  is  true  of  trophic  ulcers.  The  shortening  and  wasting  are  generally  nnich  greater 
in  lesions  of  the  lower  neuron,  and  the  distribution  of  the  paralysis  is  much  more  irregular 
than  in  those  of  the  upper.  When  the  disease  of  the  upper  neuron  is  in  the  brain,  it  is 
usual  for  the  arm  as  well  as  the  leg  to  be  paralyzed  {infantile  hemiplegia),  or  both  feet  may 
be  involved  synmietrically  {congenital  spastic  paraplegia).  Occasionally  there  may  be  a 
cerebral  monoplegia.  In  any  case  the  deformity  due  to  disease  of  the  upper  neuron  is 
almost  characteristic,  and  is  mostly  ecjuinus,  usually  with  a  little  valgus,  but  occasionally 
with  slight  varus  ;    whereas  when  the  lower  neuron  is  affected    the  deformity  is  nearly 


CLUB-FOOT  113 

always  equino-varus  or  talipes  vali;us.  In  distinguishing  various  destructive  lesions  of 
the  upper  neuron,  the  history  and  tlie  natvire  of  the  deformity  may  help.  In  hemiplegia  or 
monoplegia  there  may  he  a  Iiistory  of  difficult  labour,  with  delivery  by  forceps,  indicating 
injury  to  the  cerebral  cortex,  or  meningeal  haemorrhage  with  secondary  fibrosis  of  the 
motor  area.  Tlie  deformity  may  not  be  obvious  for  a  year  or  more  after  birth,  and  it  is 
usually  noticed  first  when  the  child  begins  to  walk.  In  other  cases  it  may  be  due  to 
thmnibosis  of  the  cerebral  veins  following  measles  or  influenza,  or  to  rupture  of  some  of  the 
cortical  veins  during  whooping-cough  or  violent  fits  of  passion.  Congenital  spastic  para- 
plegia is  distinguished  by  its  symmetry,  and  by  the  amount  of  spasm  as  shown  by  the 
unexpected  degree  of  flexion  of  the  ankles  that  can  be  produced  by  firmly  pressing  upwards 
the  fore-parts  of  the  feet.  Moreover,  there  is  usually  some  mental  incapacity,  and  often 
the  history  of  nervous  disease  in  the  family.  When  the  lesion  is  in  the  spinal  cord,  there 
may  be  a  history  of  spinal  injury  or  evidence  of  spinal  caries,  or  of  growth  causing  a  spastic 
paraplegia.  In  amyotrophic  lateral  sclerosis  there  are  signs  of  paralysis  and  wasting  of 
the  upper  limbs.  Friedreich's  disease,  or  hereditar//  ataxi)  is  an  occasional  cause  of  talipes 
equinus  or  equino-varus.  It  can  be  recognized  by  the  inco-onlination,  the  nystagnius, 
the  slurring  of  speech,  the  age  of  onset,  which  is  usually  about  six  to  nine  years,  the  absence 
of  knee-jerk,  and  the  Ivillux  erectus. 

(h).  Lesions  of  the  loicer  nearon  may  be  in  the  cord  (infantile  ))aralysis),  or  in  the  eauda 
equina  (spina  bifida),  in  the  lumbo-.sacral  cord  or  sacral  plexus  (e.g.,  carcinoma  of  the 
rectum),  or  in  the  periplieral  nerves  (peripheral  neuritis  injured  sciatic  nerve,  or  Tooth's 
neuro-muscular  paralysis).  Infantile  paralysis  results  from  acute  anterior  poliomyelitis 
and  is  distinguished  by  its  irregular  distribution,  reaction  of  degeneration,  and  its  vaso- 
motor and  trophic  lesions.  It  is  frequently  possible  to  show  that  the  patient  is  unable  to 
use  certain  nniscle.s  or  groups  of  muscles,  especially  the  anterior  tibial  and  peroneal  group. 
II  is  unusual  for  the  paralysis  to  be  limited  to  the  leg  ;  the  thigh  is  often  affected  to  some 
extent,  and  often  tiie  oi)posite  leg.  It  is  important  to  examine  for  spina  bifida  ;  talipes 
due  to  this  is  not  ueecssarily  symmetrical  ;  one  foot  may  be  involved  more  than  another, 
and  the  deformity  is  often  progressive.  I  have  seen  several  cases  of  talipes  calcaneo-valgus 
associated  with  it.  and  also  pure  cavus,  and  one  very  bad  ease  of  e(juino-varus  of  one  foot. 
and  equino-valgus  of  the  other.  The  foot  may  drop  in  peripheral  iienrilis  due  to  diphtheria, 
lead  poisoning,  or  alcoholism.  In  each  of  these  conditions  there  is  other  evidence  of  the 
disease.  In  many  cases  of  growth  in  the  pelvis  the  foot  may  drop  owing  to  invasion  of  the 
sacral  plexus  by  the  growth,  which  may  be  either  sarcoma  of  the  pelvis  or  carcinoma  of 
the  rectum.  Wounds  of  the  thigh,  or  the  jiressure  of  tight  splints  in  the  treatment  of 
fracture,  or  the  forcible  extension  of  a  contracted  knee,  may  lead  to  paralysis  of  the  sciati<' 
nerve,  es|)ecially  of  its  external  poiiliteal  branch.  This  may  lead  to  talipes  e(iuino-varus. 
A  similar  deformity  may  follow  injury  of  the  lumbar  s])ine  with  secondary  hienuito-rhachis, 
or  growth  anywhere  in  the  course  of  the  sciatic  nerve.  I  ha\c  known  it  follow  the  use  of  a 
Ilodgen  extension  apparatus.  Tooth's  nciiro-miisniUtr  ii(ir(d//sis  (Figs.  20  and  21,  p.  <>(!) 
causes  paresis  of  the  anterior  tibial  and  peroneal  nuiseles,  with  talipes  c<|uino-varus  and 
marked  cavus,  and  deformity  of  the  toes.  It  may  be  distinguished  from  infantile  paralysis 
Ijy  the  synunctrical  affection  of  both  feet,  by  the  wasting  of  the  thenar  eminences,  and  the 
hi.story  of  similar  deformity  in  the  family,  and  from  the  primary  nmscular  dystrophies 
by  the  occurrence  of  reaction  of  degeneration. 

(r).  /'riniarif  Miisriilar  Disease.  -  In  primary  muscular  paralysis  (see  .VruoiMiv,  Mrs- 
(11. All,  p.  ,")!»)  talipes  may  be  developed  late  in  the  disease  ;  but  as  a  rule  the  patients  do 
iiol  li\c  long  enough  for  the  deroriiiily  to  become  a  striking  feature.  The  family  history 
assists  the  diagnosis,  and  in  the  pseudo-hypertrophie  form  there  is  the  charaeterlslie  way 
in  which  the  patient  raises  himself  from  the  supine  position  by  rolling  into  the  prone  position 
.111(1  then  lifting  himself  on  his  toes  and  hands,  and  working  his  hands  up  the  fronts  of  the 
lliiyhs. 

2.  Postural. — .\c(|uircd  talifies  \algus  may  be  due  either  to  jjosture  or  to  paralysis 
ol  I  he  tibiales  muscles.  When  a  patient  attempts  to  adduet  and  invert  the  fore-part  of 
Hie  fool,  the  tendons  of  these  muscles  can  be  seen  to  stand  out  when  they  are  not  jjaraly/.ed. 
The  foot  may  be  forced  into  a  cramped  i)osition  by  tight  boots,  and  a  form  of  talipes 
cavus  may  thus  develop,  with  marked  deformity  of  the  toes,  which  are  hyper-cxtended  at 
mctatarso-phalangeal    joints    and    flexed    at    the    others.     This    condition    nuist    not    be 

I)  8 


114  CLUI3-FOOT 

founded  with  a  similar  one  due  to  paralysis  of  the  small  muscles  of  the  foot,  especially 
the  intcrossci  and  lumhricales. 

3.  Fibrosis  and  Contracture  of  the  Muscles  of  the  Calf. — Very  rarely  the  calf  muscles 
may  contract  as  a  result  of  an  isehainia  analogous  to  that  occurring  in  the  fore-arm,  and 
leading  to  contracture  of  the  wrist  and  fingers  (Volkmann's  contracture.  Eig.  58,  p.  141). 
The  same  condition  may  develop  as  a  result  of  cellulitis  of  the  calf  muscles,  often 
associated  with  comiioimd  fracture  of  the  leg.  or  with  acute  necrosis  of  the  tibia.  In  all 
these  conditions  it  is  iinjiortant  to  prevent  the  development  of  talipes  equinus. 

4.  Bone  Disease. — Injury  or  inflammation  of  the  tibia  near  the  epiphysial  lines  in 
youtli  may  lead  either  to  arrest  or  over-growth  of  the  affected  bone.  This  is  not  uncommonly 
a  cause  of  tali])es,  which  can  be  recognized  if  care  be  taken  to  make  comparative  measure- 
ments and  ,i-ray  examinations  of  the  bones. 

5.  Joint  Disease. — In  fractures  into  the  ankle  joint,  such  as  Pott's  and  Dupuytren's 
fractures,  a  very  bad  form  of  talipes  equino-valgus  may  form  unless  care  be  taken  to 
correct  the  deformity  and  to  keep  the  ankle  moving.  Talipes  equinus  may  arise  as  a  result 
of  the  maltreatment  of  sprains  or  arthritis  of  the  ankle,  either  septic  or  tuberculous,  unless 
care  be  taken  to  keep  the  joint  dorsi-flexed  during  treatment. 

6.  Contracting  Scars. — Occasionally  tali])es  equinus  follows  severe  burns  or  lacera- 
tions of  tlie  skin  of  the  leg  or  foot.  The  diagnosis  is  usually  obvious  from  the  scars. 
There  may  be  some  wasting  of  the  muscles  from  want  of  growth  of  the  limb   from  disuse. 

7.  Hysteria. — Hysterical  club-foot  may  be  susjjected  from  the  associated  symptoms 
and  confirmed  by  the  absence  of  any  change  in  the  electrical  reactions,  by  the  variation 
of  the  deformity,  and  the  disproportionate  amount  of  spasm,  whicli  passes  off  during  slcej) 
and  inider  an  anaesthetic. 

Finally,  it  is  to  be  remembered  that  if  a  normal  muscle  is  left  in  one  position  over  a 
long  period  with  its  points  of  origin  and  insertion  unduly  approximated,  it  may  presently 
be  found  to  be  impossible  to  lengthen  it  out  ))roperly  again  ;  it  is  in  this  way  that  contrac- 
tures of  muscles  are  apt  to  occur  during  the  course  of  long  febrile  illnes.ses — enterica  for 
instance — when  the  patient  may  remain  curled  up  in  bed  for  weeks.  If  the  limbs  are 
jiassively  extended  and  flexed  each  day.  no  contracture  results,  but  it  sometimes  happens 
that  the  neglect  of  this  precaution  is  followed  by  persistent  contracture  of  what  had  hitherto 
been  normal  muscles,  and  one  of  the  likely  results  of  this  is  club-foot.  1{.  p.  Hozclaiiils. 

COITUS,   PAINFUL.— (See  Dysparkuxia,   j).   193.) 

COLIC. — This  is  a  word  often  used  very  loosely  for  any  severe  abdominal  pain, 
especially  of  a  kind  which  tends  to  wax  and  wane  in  intensity.  Such  pain  may  be  associ- 
ated with  disease  in  almost  any  one  of  the  abdominal  viscera,  and  the  word  colic  is  applied 
(|uite  commonly  to  the  pain  caused  by  the  passage  of  a  calculus  down  the  bile-duct  (biliary 
<olic)  or  the  ureter  (renal  colic).  The  name  '  mucous  colic  '  is  also  used  by  some  writers 
for  the  disease  usually  known  as  muco-membranous  colitis.  It  is  better,  however,  to 
restrict  tlie  term  colic,  used  without  a  qualifying  adjective,  to  pain  caused  by  contraction 
of  the  intestine,  of  a  cramp-like  nature,  caused  by  local  irritation  or  by  general  poisoning, 
in  the  absence  of  any  organic  disease  of  the  bowel.  Diagnosis  therefore  mainly  consists 
(1)  /;(  c.vcluding  such  organic  affections  ;  and  (2)  In  ascertaining,  so  far  as  possible,  the  cause 
of  the  local  spasm. 

In  order  to  exclude  organic  disease  a  careful  examination  of  the  whole  abdomen 
is  needed,  as  well  as  observation  of  the  general  condition  of  the  sufferer.  It  must  be 
remembered  that  in  simple  colic  there  may  be  vomiting,  sweating,  and  some  degree  of 
collapse  owing  to  the  severity  of  the  pain.  The  patient's  temperature  is  not,  however, 
usually  raised  ;  the  abdominal  walls  move  freely  on  respiration  :  and  there  is  little  or  no 
local  tenderness,  pressure  being  often  a  relief  to  the  pain,  so  that  the  sufferer  tends  to  press 
his  abdomen  against  a  pillow  or  other  support.  Though  the  face  exliibits  an  expression 
of  jjain,  there  is  not  the  pinched,  anxious  facies  so  characteristic  of  grave  abdominal 
troubles  ;  and  the  patient  is  likely  to  throw  himself  about  instead  of  lying  still  as  in  such 
conditions  as  peritonitis  or  intestinal  obstruction.  The  pulse  is  not  often  markedly 
affected  ;  it  may  even  be  unduly  slow,  but  in  nervous  subjects  the  anxiety  and  pain 
may  cause  some  rise  in  its  frequency. 


COLIC  115 

The  different  affections  which  may  give  rise  to  abdominal  pain  liable  to  be  called 
colic  by  patients  are  :  Acute  intestinal  obstruction,  intussusception,  appendicitis,  and 
possibly  even  perforative  peritonitis  :  colitis  and  ulcerative  diseases  of  the  colon  ; 
malignant  disease  of  the  intestine  ;  pancreatic  disorders,  acute  and  chronic  ;  gastric  pain, 
especially  that  encountered  in  cases  of  pyloric  obstruction  ;  intestinal  neuralgia,  and 
referred  pains  in  spinal  caries  and  in  cases  of  pressure  by  tiuiiours  or  aneurysms  :  gastric 
and  intestinal  crises  in  locomotor  ataxy  ;  chronic  plumbism  (p.  34) ;  and  renal  and 
liijiary  colic. 

Taking  the  diagnostic  features  separately  : — ■ 

Rise  of  temperature  above  100'  F.  will  indicate  the  existence  of  some  inflammatory 
affection,  such  as  appendicitis.  The  |)ossibility  of  thoracic  disease,  such  as  pneumonia 
or  diaphragmatic  pleurisy,  causing  abdominal  jxiin,  must  be  borne  in  mind  ;  but  such  pain 
is  not  really  colicky  in  character.     (See  Pain,  Abdominal,  p.  -12-1..) 

Vomiting  that  is  repeated  and  severe  does  not  occur  in  simple  colic.  It  suggests  the 
existence  of  intestinal  obstruction,  if  the  temperature  of  the  patient  is  normal  or  subnormal, 
or  of  some  form  of  jieritonitis  if  there  be  fever.  In  the  former  condition  a  faecal  odour 
may  be  noted  in  the  vomit  ;  in  general  peritonitis  the  vomiting  may  be  characteristic, 
large  quantities  of  fluid  being  brought  up  with  little  effort  :  but  these  signs  occur  late  in  the 
course  of  these  conditions  (see  Vomiting,  p.  703).  The  colicky  pains  associated  with  gastric 
dilatation  due  to  pyloric  obstruction  arc  likely  to  end  with  the  expulsion  of  a  large  quantity 
of  foul  fermenting  material.  The  dilatation  of  the  stomach  may  be  ascertained  by  noting 
the  existence  of  splashing  in  the  organ  when  the  fingers  are  "  dipped  '  sharply  in  the  epi- 
gastric region  :  by  eliciting  an  increased  area  of  tympanitic  resonance  :  by  observing  the 
peristaltic  movements  of  the  hypertrophied  walls  of  the  stomach,  as  seen  by  inspection 
of  the  abdomen  ;  by  discovery  in  the  vomit  of  food  taken  some  days  previously,  as  well 
as  of  organisms  of  fermentation  (toruhc  and  sarcinae.  Fig.  121,  p.  2-tl),  the  vomited  matter 
being  generally  foul  and  frothy  ;  and  by  examimitiou  with  the  .c-rays  after  exhibition 
of  a  bismuth  meal   (Fig,   128.  p.  268). 

Tenderness  and  rigidity  of  the  abdominal  wall  are  usually  absent  in  colic.  When 
conjoined,  they  point  to  affection  of  the  ])eritoneum  ;  tenderness  alone  indicates  disease 
of  .some  viscus,  as  in  colitis,  when  it  is  found  along  the  course  of  the  colon,  in  intestinal 
or  gastric  ulceration,  and  so  forth. 

Slight  fullness  of  the  abdomen  may  exist  in  cases  of  colic,  but  it  is  usually  incon- 
spicuous :  more  often  the  abdominal  walls  are  retracted.  Considerable  distention  indicates 
some  organic  trouble,  such  as  cirrhosis  of  the  liver,  intestinal  obstruction,  or  perit<iiiilis. 
.V  contracted  portion  of  bowel  may  sometimes  be  felt.  This  nuist  be  distinguished 
from  an  actual  tumour  or  inflammatory  mass,  and  fr<mi  the  elongated  swelling  felt  in 
intussusception.  The  si)asmodically  contracted  gut  of  colic  is  of  small  diameter,  and  may 
be  felt  to  relax  as  the  j)ain  subsides  and  to  harden  again  with  a  fresh  exacerbation. 

(oiislipalion  is  the  rule  in  i)aticnts  suffering  from  colic,  and  if  a  motion  is  passed  it 
is  small  and  hard.  The  ajjpearance  of  diarrlnea  will  i)oint  to  some  affection  of  the  bowel, 
.such  as  colitis.  In  mucous  colitis,  which  is  associated  with  sc\cre  i)ain.  hard  scybala  may 
be  passed*along  with  casts  of  the  intestine  (/''(,;;.  172.  p.:{'.»8)  or  large  shreds  of  mucus:  these 
may-  take  the  ioirn  of  rolls  resembling  .segments  of  tape-worm,  but  can  easily  be  lloaled 
out  if  |)laee(l  in  water  (see  below).  The  api)earance  of  any  blood  pii'  aiiuin  will  show  that 
.something  more  than  mere  colic  is  present  (see  Hi.ooi)  ri;it  .Xni'M.  p.  7.')). 

.MlacUs  of  severe  abdominal  pain  occur  in  gouty  and  arterioselerolie  subjccls.  accom- 
anied  by  giddiness,  nausea,  and  sonutimcs  vomiting  ('  angina  abdominalis  ")  :  there 
may  be  slight  jaundice^.  I^xamination  of  the  pulse  will  reveal  increased  tension  and 
possibly  disease  of  the  arterial  wall,  and  the  tronble  yields  rapidly  to  nitroglycerine  tablets 
and   io<liil(s. 

I'ain  associaird  uilli  -v  rii(i\alilc  Uiiliicv  (Dicirs  rc/xc.v)  might  be  discrilicd  by  llie  siincicr 
as  colic.  .Such  attacks  arc  chaiacleri/.ed  b\  sudden  pain,  nausea,  laintncss  ajiil  ((illapse  ; 
there  may  be  blood  in  the  urine  (see  I  I.i:\i  \  ri m  \,  p.  280).  In  some  instances  the  kidney 
is  cnlargcil  as  well  as  movable,  owing  lo  dcNcloping  hydronephrosis. 

InlrsliiKil  iiciirrilgia  may  be  dillicult  lo  distinguish  from  colic,  as  both  are  alike 
b]M<lional  disorders  without  organic  disease.  Neuralgia  is  likely  to  occur  in  an  ana'tnic, 
ill-nouiished  person  of  ncurolle  type;    it   arises  without   oh\ious  exciting  cause,  anil  may 


116  COLIC 

TccuT  at  the  same  time  of  the  day  with  some  regularity.  The  pain  has  not  the  cramp- 
hke  character  of  colic,  but  is  aching,  boring,  or  darting.  It  is  a  very  rare  disorder,  and 
can  only  be  recognized  by  exclusion  of  all  organic  disease  and  of  the  intestinal  spasm 
associated  with  colic. 

The  gastric  or  intestinal  crises  of  locomotor  ataxy  may  be  indistinguishable  from  colic, 
except  by  recognition  of  the  other  symptoms  of  the  disease — absence  of  knee-jerks,  ataxy, 
Argyll  Robertson  pupils,  lightning  pains  and  girdle-sensation.  Examination  of  the  blood 
and  cerebrospinal  fluid  may  reveal  the  presence  of  the  Wassermann  reaction  and  excess 
of  lymphocytes  may  be  found  microscopically  in  the  latter  fluid. 

In  children,  who  are  specially  liable  to  suffer  from  attacks  of  colicky  pain  due  to 
indiscretions  in  diet,  it  is  important  to  bear  in  mind  the  possibility  of  appendicitis,  on  the 
one  hand,  as  a  cause  of  abdominal  pain,  and  on  the  other  of  Pott's  disease,  which  may  give 
rise  to  pain  referred  to  the  front  of  the  abdomen.  Examination  of  the  spine  in  these  latter 
cases  may  reveal  the  existence  of  rigidity  and  tenderness,  perhaps  some  prominence  of 
one  or  more  vertebral  spines,  and  examination  witli  the  .r-rays  may  give  positive  evidence 
of  caries  of  the  bodies  of  the  vertebrae. 

Appendicular  Colic. — This  term  is  sometimes  applied  to  attacks  of  pain  in  the  right 
iliac  fossa.  Their  association  with  disease  of  the  appendix  is  doubtful.  Appendicitis 
may  ensue  subseipiently.  but  it  is  as  likely  that  the  original  attacks  may  have  been  due 
to  colitis  (typhlitis),  which  afterwards  spread  to  the  appendix,  as  that  this  organ  was  at 
fault  throughout.  Unless  the  signs  of  appendicitis  are  present  (p.  454),  the  condition 
cannot  be  recognized  with  certainty.  In  all  cases  of  doubt  as  to  the  cause  of  colicky  pains, 
an  examination  per  rectum  is  advisable  ;  it  may  reveal  the  jjresence  of  inflammation  in 
the  appendicular  region,  or  of  an  intussusception,  in  quite  unsuspected  cases. 

The  term  mucous  colic  is  sometimes  used  as  a  synonym  for  nnicous  colitis.  The 
disease  is  characterized  by  obstinate  constipation  and  by  attacks  of  abdominal  pain, 
during  or  after  which  shreds  and  rolls  of  mucus,  or  even  casts  of  large  portions  of  the 
bowel  {Fig.  172,  ]).  398).  are  evacuated  along  with  scybalous  masses.  The  casts  float  out 
in  water  and  are  often  spoken  of  as  "  skins  '  by  patients  who  suffer  from  this  malady. 
Microstiipieally  they  consist  of  mucus  with  few  leucocytes  or  epithelial  cells. 

Biliary  Colic. — The  passage  of  a  calculus  down  the  bile-ducts  gives  rise  to  severe  and 
even  agonizing  pain  in  the  right  hypochondrium.  It  is  of  a  colicky  character,  but  it  is 
apt  to  be  more  intense  than  that  of  simple  colic.  It  may  be  accompanied  by  vomiting, 
sweating,  and  collapse.  Shivering  is  frequent,  and  if  present  is  suggestive  of  this  trouble. 
The  pain  is  likely  to  pass  round  into  the  right  side  and  to  the  angle  of  the  right  scapula  ; 
it  may  even  be  referred  to  the  tip  of  the  right  shoulder.  If  the  calculus  lodge  in  the  common 
bile-duct,  jaundice  will  result.  Its  depth  will  vary  with  the  degree  of  obstruction,  and 
while  the  colic  lasts  it  is  not  likely  to  be  very  intense.  Palpable  enlargement  of  the  gall- 
bladder is  quite  exceptional  in  cases  of  gall-stones.  Actual  proof  of  the  cause  of  the  colic 
may  sometimes  be  obtained  by  finding  a  stone  in  the  heces,  by  passing  them  through  a 
coarse  sieve  under  a  current  of  water.  Attacks  of  gall-stone  colic  are  liable  to  recur,  and 
a  history  of  previous  illness  of  the  same  kind  may  aid  in  the  diagnosis.  \Vomen  are  rather 
more  subject  to  gall-stones  than  men,  and  fat  subjects  suffer  more  than  thin.  The  malady 
is  most  often  encountered  in  middle  life.  In  some  instances  examination  with  the  .r-rays 
may  afford  confirmatory  evidence  of  the  existence  of  calculi  in  the  gall-bladder  ;  but 
failure  of  such  confirmation  does  not  exclude  their  presence,  as  their  substance  is  not  very 
opatpie  to  these  radiations. 

Pancreatic  Colic,  due  to  passage  of  a  calculus  along  one  of  the  ducts  of  the  wland 
may  occur,  but  can  scarcely  be  diagnosed.  It  is  characterized  by  severe,  deeply 
seated  pain  in  the  epigastrium,  sometimes  extending  to  the  back  and  loins.  Exactly 
similar  attacks  of  pain  occur  in  chronic  pancreatitis,  and  may  be  accompanied  by 
shivering,  or  actual  rigors.  Intense  jaundice  may  also  be  seen  in  this  malady,  and  an 
enlarged  gall-bladder  can  usually  be  felt.  The  condition  can  only  be  recognized  when 
there  are  presmj^ther  signs  of  pancreatic  disease — wasting,  pigmentation  of  the  skin, 
and  the  passage  of  bulky,  offensive  stools,  containing  large  quantities  of  fat.  Chemical 
examination  may  show  that  much  of  this  fat  is  neutral  (unaltered)  fat,  with  less  than 
the  usual  proportion  of  fatty  acids  (p.  101).  Microscopical  examination  may  reveal 
the  presence  of  unaltered  meat-fibres  in  the  motions.      The   urine  may  contain    sugar. 


COMA  117 

and  Cammidge's  Tkst  (p.  100)  may  be  applied  to  it,  though  the  trustworthiness  of  this 
reaction  is  not  yet  established. 

Renal  Colic. — The  distinguishing  features  of  the  passage  of  a  cnlciilus  down  the  ureter 
are  similar  to  those  of  biliary  colic,  but  the  pain  starts  in  one  loin  and  radiates  downwards 
to  the  tliigh  and  to  the  testicle  in  the  male,  to  the  labium  majus  in  the  female.  The  urine 
may  contain  blood,  and  also  epithelium,  from  the  pelvis  of  the  kidney  and  from  the  ureter. 
Frequency  of  micturition  is  often  marked,  but  the  ((uantity  of  urine  may  be  small  ;  it 
may  even  be  suppressed  temporarily.  If  the  calculus  become  impacted  in  the  ureter  a 
swelling  may  subsequently  appear  in  the  loin,  due  to  the  formation  of  a  hydronephrosis. 
The  pain  may  cease  suddenly  when  the  stone  passes  into  the  bladder.  The  ,7'-rays  are  of 
considerable  value  in  detecting  the  concretion  {Fia.  192,  j).  45.5).  provided  the  bowels  be 
empty  so  that  shadows  due  to  scybala  can  be  avoided. 

The  pain  due  to  the  presence  of  a  calculus  in  the  kidney  can  hardly  be  mistaken  for 
colic,  but  occasionally  the  symptoms  of  this  condition  may  precede  an  attack  of  renal 
colic.  A  history,  therefore,  of  pain  in  the  loin,  frequency  of  micturition,  and  the  appearance 
of  blood  in  the  urine,  may  help  in  the  diagnosis  of  the  latter  condition.  Tuberculous 
disease  of  the  kidney,  jn  which  the  symptoms  may  be  very  similar,  though  apt  to  be  accom- 
panied by  more  wasting  and  by  evening  pyrexia,  may  give  rise  to  colicky  attacks  if  blood- 
clots  or  caseous  masses  lodge  in  the  ureter.  Pus  and  tubercle  bacilli  may  be  found  iu 
the  urine.     DictTs  crises  have  been  referred  to  above. 

The  principal  causes  of  Intestinal  Colic  are  indigestible  fixid.  (dcoltolic  excess,  and  lc<i<l- 
poisoning.  This  last  should  be  eliminated  first.  It  is  characterized  by  symjjtoms  described 
on  p.  3-i.  There  will  usually  be  a  history  of  some  occupation  involving  contact  with  lead — 
painting,  glazing.  ty|)e-setting.  or  manufacture  of  some  compound  of  lead  :  but  the  possi- 
bility of  poisoning  by  drinking-water  or  by  beer  which  has  stood  in  contact  with  leaden 
|)ipes  nnist  be  remembered — the  latter  especially  in  potmen.  The  chief  signs  of  alcoholism 
are  given  on  p.  7'2(i.  In  cases  due  to  indigestible  food,  a  history  of  the  consumption  of 
Iried  fish,  shell-fish,  jjork.  raw  fruit,  or  other  suspicious  matter  may  Ije  obtained.  The 
pain  is  more  likely  to  move  along  the  course  of  the  colon  than  to  remain  fixed  in  the  centre 
of  the  abdomen  or  at  some  special  point,  as  it  usually  does  in  lead  colic.  In  infants,  colic 
may  be  caused  by  hard  curds  of  milk,  and  be  indicated  by  drawing  up  of  the  legs  and 
screaming.  In  older  children,  unripe  apples,  plum-stones,  and  similar  delicacies  are  often 
the  source  of  the  trouble,  and  fruit-stones  may  be  discovered  subsequently  in  the  motions. 

ir.  Cecil  liosdiiijuet. 

COLOUR  BLINDNESS.— (See  Vision,  Dei-ects  of.  p.  7()2.) 

COMA  is  a  state  of  unnatural,  heavy,  deep  and  prolonged  sleep,  often  accompanied 
by  slou  stertorous  or  irregular  brciithing,  and  frequently  ending  in  death.  It  may  be 
due  to  a  large  number  of  different  causes,  which  may  be  elassihcd  into  two  main  groups, 
namely  :  (A)  Cases  iu  which  coma  is  not  a  prominent  symptom  ciirly  in  the  malady,  but 
only  in  a  late  stage,  when  the  nature  of  the  disease  has  alreaily  been  suggested  by  otiier 
symptoms  :  .-hkI  {!{)  Cases  iu  which  coma  comes  on  carl\-  and  m;iy  l)c  tin-  most  prdrniiicnt 
featUH'   ol    the   ciise. 

(hi)up  A   includes — 

1.  Certain  Severe  Fevers  in  which  coma  may  occur  as  a  tcrniirial  plieuomciioii  : 
Tv|,hiis    lever                                       i         .Measles  UlacUwater   lever 
Tviihoiil    lexer                                      i         Scarlet    lever                                            MaliL'iiaiit    malaria 

<  liiilera  I  Ulieiuiiatie   lever  liifeeli\e  endoearditis. 

Dysiiiteiy  Yellow    fever  l)i|ilillieria. 

2.  Acute  Inflammatory  Lesions  of  the  Brain  or  the  Cerebral  Meninges  : 

.\eiili-  <iiee|ilialilis  Taliereiiliiiis  iiKiiiimitis  Kpidemie  cerebrospinal  ineniti- 

.Suppiiialive   Mieiiirii;ilis  Posterior    hasal    meiiiiiuilis  gitis,  or  spotted  lever 

:{.  Certain  Less  Acute  Lesions  of  the  Central  Nervous  System  : 

Cerebral    tmiinur  I'ost-i  |>ile|ilie  slale  Disseminated  sclerosis 

Cerebral   abscess  Ceiieral  paralysis  ol  I  Ik    insane  Syphilis  of  the  brain 

I'.  Diseases  in  which  General  Metabolism  is  probably  at  Fault : 

Craniia  t  lioheniia  liavnand's  disease 

l)ial)etes  Addiscjns  disease  .Mvxcrdenia 


118  COMA 

Group  B  includes  tlie  following  conditions — 

1.  The  Results  of  Head  Injury: 

Com|iression     l>y     nuniii^fal  C'oiifussion  '    Fracture    of   the    base    of   the 

liu'morrhage  lJc])rcs.sc(l  fracture  skull. 

2.  Vascular  Lesions  of  the  Brain  : 

Embolism  I    Thrombosis  :     («)   arterial,    {h)  the  superior  longitudinal. 

Haemorrhage  '        of  a  venous  sinus    such    as 

3.  The  Acute  Effects  of  Drugs,  particularly  : 

Alcohol                                                 i    Carbon   monoxide  Trional 

Opium                                                  i    Absinthe  I    Tetronal 

Jlorphia                                                   Chloral  hydrate  I    Bromides 

Carbolic  acid                                     i    Veronal  Chloroform    and    other    ana-s- 

Oxalic  acid                                         I    .Sulphonal  thetics. 

4.  The  Chronic  Effects  of  Chemicals,  cs])cciallypluiiibisui :  (Saturnine  encephalopathy). 
.5.  The  Effects  of  Extremes  of  Temperature  :     Heat  stroke      |      Excessive  cold. 

6.  Excessive  Loss  of  Blood   from  : 

Ruptured  tubal  gestation  ILcMiateniesis  Intestinal  bleeding 

Post-partum   ha-nicirrhagc  i    Duodenal   bleeding  |    Ruptured  aneurysm. 

I-henioptysis  i 

7.  Stokes-Adams'   Disease.*^ 

8.  Sudden    Nervous   Shock. 

9.  Hysterical   Trance. 

Although  it  is  generally  possible  to  make  a  broad  distinction  between  the  two  groups 
cnunieiated  above,  it  is  necessary  perhaps  to  point  out  that  some  conditions  which  usually 
give  rise  to  other  symptoms  before  they  produce  coma,  sometimes  pass  mirecognized  until 
coma  supervenes.  This  applies,  for  example,  to  certain  cases  of  diabetes  mellitus,  ursemia, 
suppurative  meningitis,  or  cerebral  abscess  or  tumour  ;  whilst,  conversely,  some  conditions 
which  usually  exhibit  coma  early,  may  not  do  so  imtil  after  there  have  been  other  sym- 
ptoms to  indicate  the  nature  of  the  case.  It  is  not  necessary  to  enter  into  the  difierential 
diagnosis  of  those  conditions  in  which  other  prominent  symptoms  have  preceded  coma. 

When  coma  is  either  the  first  or  the  most  prominent  symptom  in  the  case,  it  is 
important  to  arrive  as  near  the  correct  diagnosis  as  may  be  at  the  earliest  possible  moment, 
the  case  being  relegated  to  one  or  other  of  the  following  four  classes,  which  differ  from  one 
another  radically  as  regards  treatment  : — 

1.  Cases  in  which  immediate  trephining  is  required,  e.g.,  for  meningeal  hsemorrhage. 

2.  Cases  in  which  active  treatment  by  lavage  of  the  stomach  or  by  the  administration 
of  antidotes  is  required,  as  in  opiiun  or  other  poisoning. 

3.  Cases  in  which  active  medicinal  or  jihysical  treatment  is  rc(|nircd  :  for  instance, 
diabetic  coma  requiring  the  administration  of  alkalies,  or  urtemia  rc(iuiring  venesection. 

•i.  Cases  in  which  absolute  rest  is  indicated,  especially  in  cerebral  ha-morrhage. 

When  investigating  a  case,  notice  first  whether  there  is  any  evidence  of  unilateral 
paralysis  :  the  pii]jils  may  be  markedly  unequal,  one  cheek  may  be  more  puffed  out  on 
expiration  then  the  other,  one  arm  or  leg  may  fall  more  limply  than  the  other  ;  there  may 
be  differences  between  the  two  knee-jerks  or  the  two  plantar  reflexes  ;  there  may  be 
conjugate  deviation  of  the  eyes.  If  there  is  distinct  evidence  of  imilateral  paresis  or 
paralysis,  there  is  almost  certainly  a  cranial  or  intracranial  lesion — ha-morrhage,  embolism, 
fracture,  tumour,  abscess,  thrombosis  or  meningitis.  Next,  examine  the  head  with  particu- 
lar care  to  see  if  there  are  any  signs  of  injury  ;  the  presence  of  a  scalp  woimd  or  even  of  a 
fracture  does  not  of  course  prove  that  this  is  the  primary  cause  of  the  coma,  for  the  (laticnt 
may  have  become  unconscious,  from  a  cerebral  ha>morrhage  for  example,  and  in  falling 
may  have  struck  his  head,  in  which  case  the  injury  is  due  to  the  coma,  and  not  the  coma 
to  the  injury.  Some  of  the  greatest  difficulties  in  diagnosis  ari,se  on  this  account,  particularly 
when  the  patient  has  previously  taken  sufficient  alcohol  for  his  breath  to  smell  of  it,  and 
to  suggest  that  he  is  drunk.  Careful  observation  for  several  hours  may  be  required  before 
the  diagnosis  can  be  settled,  and  even  then  errors  are  sometimes  unavoidable.  A  clear 
history  is  generally  lacking,  but  if  available  it  often  assists  materially  in  deciding  the  nature 
of  the  case.     The  cars  and  nose  shoidd  be  examined  with  care  to  sec  whether  cerebrospinal 


COMA  119 

fluid  or  blood  is  coming  from  either,  as  an  indication  that  there  is  a  fracture  at  the  base  of 
the  skull  ;  blood  coming  forward  into  the  subconjunctival  tissue  may  afford  similar 
evidence. 

Cerebral  hcEmorrhage  is  much  more  common  in  an  elderly  than  in  a  young  person, 
whilst  the  reverse  is  true  of  embolism.  The  latter  may  occur  instantaneously,  wliilst 
ha;morrhage  produces  coma  rather  more  gradually  ;  and  thrombosis,  syphilitic  or  other- 
wise, often  leads  to  hemiplegia  so  gradually  that  no  coma  occurs.  The  presence  of  albu- 
minuria with  easts,  with  a  high  blood-pressure  as  measured  instrumentally  ;  the  history, 
in  an  elderly  man,  of  a  previous  seizure  of  a  similar  kind  with  definite  hemi|)k'gia, 
especially  if  there  is  also  an  enlarged  heart  with  a  lumpy  first  sound  at  the  impulse,  or 
perhaps  a  local  systolic  bruit  there,  with  a  ringing  aortic  second  sound,  would  all  indi- 
cate cerebral  ha-morrhage,  associated  with  defective  arteries  and  perhaps  with  granular 
kidney.  .Mbimiinurie  retinitis  should  be  looked  for.  Strong  evidence  in  favour  of 
cerebral  embolinm  would  be  afforded  by  a  previous  history  of  acute  rheumatism  aiid  tlie 
existence  of  a  ])resystolic  or  other  bruit  indicative  of  organic  heart  disease,  especially  if 
there  are  signs  fp.  34)  suggesting  that  fungating  endocarditis  has  supervened. 

Supposing  there  is  no  evidence  of  a  unilateral  paralysis,  it  does  not  immediately 
follow  that  none  of  the  above  conditions  are  present  ;  one  form  of  cerebral  haemorrhage 
in  particular  that  may  cause  no  unilateral  paralysis  is  pontine  hcemorrhage  ;  this  might  be 
suggested  at  once  by  the  very  small,  almost  ])in-point  pupils,  though  similar  i)in-p(iint 
pupils  may  be  due  to  opium  poisoning.  The  thernionuter  affords  a  means  of  (liiignosis 
between  these,  for  opium  poisoning  leads  to  a  subnormal  temperature,  whilst  lueniorrhage 
into  the  pons  Varolii  causes  the  temperature  to  rise  even  to  the  point  of  hyperpyrexia. 
The  diagnosis  of  other  varieties  of  coma  due  to  poisoning  can  seldom  be  arrived  at  accu- 
rately unless  the  circumstances  of  the  ease  either  allow  of  an  analysis  of  the  gastric  contents, 
or  else  jjoint  to  the  |)atient  having  taken  an  over-dose  of  one  of  the  drugs  mentioned  in 
the  above  list,  either  accidentally  or  with  suicidal  intent.  The  bottle  may  be  found  near 
the  |)atieiit. 

Coma  due  to  jioisouing  by  carbon  monoride  is  sometimes  obvious  from  the  patient's 
bright  cherry-red  eoloin'  ;  it  is  impossible  to  convert  the  carboxyhiemoglobin  in  his  blood 
into  rcdueerl  luemoglobin  by  the  ordinary  anunonium  sulphide  method  :  and  there  is 
generally  direct  e\  idence  of  the  mode  of  |)ois()ning,  such  as  the  fact  that  the  |)atient  is 
found  in  a  room  with  the  windows  slnit  and  the  gas  turned  on,  or  has  been  subjected  to 
the  fumes  of  slow  combustion  from  a  stove,  brazier,  limekiln,  or  some  other  fire  which 
has  been  burning  with  an  insuHieient  supply  of  oxygen. 

Saturnine  enceplnilopnthi/  is  very  variable  in  its  symptoms  ;  it  may  take  the  form  of 
epileptiform  convulsions  ;  more  or  less  dementia  ;  continued  coma  ;  acute  mania  ; 
in<leed.  its  tiniltirormity  is  one  of  its  chief  features.  The  occupation  of  the  patient  may 
point  to  I  he  diagnosis  I'orthwitli,  or  there  may  be  a  blue  line  upon  the  gums  or  other  signs 
of  lead  poisoning  (p.  ;M.).  Not  iiifre(|uenlly,  however,  the  nature  of  the  case  gives  rise 
to  much  perplexily  before  the  diagnosis  is  ultimately  made.  One  method  of  arriving  at 
the  latter  is  to  collect  an  abundance  of  urine,  evaporate  it  to  dryness,  and  apply  the  tests 
for  lead  to  the  residue  :  or  to  test  for  lead  in  the  lieees.  The  ease  is  apt  to  be  mistaken  for 
either  cerebral  liainorrhage.  cerebral  tumour,  or  getu-ral  paralysis  of  the  insane.  Optic 
neuritis  may  he  due  (lireelly  to  phmibism.  and  tliis  makes  the  dilfercntial  diagnosis  still 
more  dillleult,  unless  there  is  clear  collateral  e\idenee  of  lead  poisoning. 

Mfl.rifdema  is  geniTally  diagnosed  rniin  the  facics  (j).  38)  and  general  stale  of  the 
subcutaneous  tissues,  or  from  the  results  of  thyroid  treatment  :  occasionally,  hdwevcr, 
one  meets  with  a  case  in  which  the  mentiil  symptoms  so  hir  outweigh  the  others  that  the 
nature  of  the  malad\-  is  apt  to  escape  attention  altogether.  An  attiiek  of  coma  is  rarely 
the  first  sign,  tlioiigh  it  may  be  :  more  oltcn  there  is  a  longish  history  of  progressive  nu'ntal 
slowness,  somclimes  with  delusions,  anil  ollen  associated  with  attacks  of  irascible  cNcitalion 
idlernaling  willi  Ills  of  (iepression  :  or  with  bonis  of  mental  lethargy  stopping  short,  as 
a  ri:lc.  (it  mcIiiiiI  comim. 

(lima  liiir  lilliii'  In  liait  sirii/.r  iir  In  i\|iiisinr  In  r.rccssii'e  cold  is  generali\'  iiuliciilril 
by  the  ciillulcral  e\  iiiiiiee,  especially  as  regards  the  lemperature  of  the  palienfs  surrouiiil- 
iiigs,  or  his  liasiii;;  been  exposed  lo  very  sirong  sun's  riiys  wlien  at  work.  The  chief 
dillieiilly  will  be  to  make  certain  that  there  is  not  any  \asciilar  lesion  of  the  brain.     When 


120  COMA 

there  is  doubt,  the  course  of  the  case  may  indicate  its  nature,  heat-stroke  generally  recover- 
ing rapidly,  or  ending  fatally  with  hyperpyrexia  :  but  sometimes,  even  in  a  fatal  case,  the 
diagnosis  may  remain  in  doubt  imtil  a  post-mortem  examination  has  been  made. 

Acute  encephalitis  is  a  disease  of  children  rather  than  of  adults  ;  its  general  symptoms 
are  those  of  acute  meningitis  ;  the  patient  becomes  unconscious  more  rapidly,  however, 
than  is  usual  with  the  latter,  and  yet.  notwithstanding  the  apparent  severity  of  the  illness, 
recovery  may  occur,  either  within  a  few  days  or  a  week  or  two.  The  diagnosis  rests  upon 
the  course  and  recovery,  for  in  the  earlier  stages  it  will  nearly  always  have  been  regarded  as 
acute  meningitis.  The  same  aj)])lies  to  acute  thrombosis  of  the  superior  longitudinal  sinus. 
the  diagnosis  between  which  and  acute  encephalitis  or  meningitis  is  generally  one  of  opinion 
only,  unless  operative  measures  are  resorted  to,  or  a  post-mortem  examination  made.  Optic 
neuritis,'  as  well  as  headache,  vomiting,  and  general  convulsions,  may  occur  in  all  three. 

General  paralysis  of  the  insane  does  not  as  a  rule  give  rise  to  coma  and  epileptiform 
convulsions  imtil  the  nature  of  the  case  has  been  indicated  already  by  the  mental  and 
physical  changes — particularly  the  ideas  of  grandeur,  the  loss  of  highest  cerebral  control 
in  one  way  or  another,  the  changes  in  disposition,  and  the  inability  to  perform  the  finer 
movements  required  for  writing,  dancing,  playing  the  piano  or  violin,  painting,  and  so 
forth,  in  which  the  patient  may  at  some  time  previously  have  been  an  adept.  Occasion- 
ally, however,  notwithstanding  some  alterations  in  the  mental  character,  the  diagnosis  of 
general  paralysis  may  not  have  entered  one's  mind  in  a  given  case  until  a  sudden  syncopal 
seizure,  with  or  without  convulsions,  attracts  particular  notice  to  it.  It  is  not  impossible 
that  such  a  case  may  even  then  be  mistaken  for  one  of  severe  cerebral  luemorrhage,  and 
it  may  be  treated  as  such  imtil  it  is  found  that  the  coma,  severe  though  it  may  have  been, 
passes  off  rapidly  in  a  way  that  would  not  have  been  the  case  had  it  been  a  haemorrhage 
of  corresponding  severity.  The  recurrence  of  these  attacks  will  make  the  diagnosis  certain, 
even  if  it  remains  in  doubt  for  a  time,  and  examination  of  the  cerebrospinal  fluid  for 
excess  of  small  lymphocytes  or  for  Wassermann's  serum  reaction  will  serve  to  clinch  the 
diagnosis  in  most  cases. 

Severe  hcemorrhage  other  than  cerebral  as  a  cause  for  coma  is  usually  indicated  at 
once  by  the  sudden  extreme  blanching,  not  only  of  the  patient's  cheeks,  but  also  of  his 
lips  and  mucous  membranes.  The  pulse-rate  rises  to  100,  120,  or  even  150.  according 
to  the  amount  of  blood  that  has  been  lost  :  if  there  has  been  external  evidence  of  the 
haemorrhage,  the  differential  diagnosis  will  be  arrived  at  as  discussed  under  such  headings 
as  HyEmatemesis,  H.i;.moptysis,  MErRORRH.\GiA,  etc.  If  the  bleeding  has  been  internal 
in  a  healthy  person,  the  commonest  cause  is  duodenal  ulcer  in  a  man,  pelvic  ha^matoeele 
or  rujitured  tubal  gestation  in  a  woman  ;  similar  blanching  in  cases  of  typhoid  fever  would 
])oint  to  intestinal  bleeding.  The  coma  in  such  cases  comes  on  suddenly,  but  it  does  not 
long  remain  profoimd.  It  is  often  preceded  by  amaurosis,  and  may  be  accompanied  by 
epileptiform  convulsions,  so  that  acute  uraemia  may  be  simulated. 

When  an  aortic  aneurysm  ruptures  either  into  a  bronchus,  the  oesophagus,  trachea, 
stomach,  or  bowel,  the  amount  of  blood-loss  seldom  leads  to  coma,  but  rather  to  sudden 
death  ;  sometimes,  however,  when  the  bleeding  is  into  some  closed  space  such  as  the 
mediastinum  or  retroperitoneal  tissue,  the  blood-escape  is  checked  to  some  extent,  and 
acute  blanching  with  coma  precedes  further  bleeding  and  death.  Rupture  of  an  aortic 
aneurysm  into  the  pericardium  causes  sudden  death  before  the  amount  of  blood  lost  has 
been  sufficient  to  jjroduce  marked  blanching. 

The  phenomena  of  Stokes-Adams'  disease  are  described  on  p.  83. 

Hysterical  or  functional  trance  is  an  affection  of  young  women,  and  it  is  not  very 
common  ;  the  diagnosis  is  arrived  at  by  a  process  of  exclusion,  and  until  the  case  has  been 
watched  for  some  time  its  nature  may  not  be  obvious  unless  there  have  been  other  hysterical 
symptoms  previously  (p.  465).  It  is  a  dangerous  diagnosis  to  make  imtil  every  other 
possible  cause  for  coma  has  been  considered  and  satisfactorily  excluded,  for  it  is  not 
difficult  to  jump  to  the  conclusion  that  coma  in  a  girl  or  young  woman,  really  arising 
perhaps  from  a  cerebral  tumour  or  abscess,  is  due  to  a  neurosis.  It  is  most  important 
to  examine  the  ojjtie  discs  with  great  care,  lest  there  should  be  o])tie  nem-itis.  the  latter 
never  being  functional.  Herbert  French. 

CONJUNCTIVITIS. — (.See  Kye,  Acite  Inflammation  of,  p.  231.) 


CONSTIPATION  121 

CONSTIPATION. 

I.     CHRONIC     CONSTIPATION. 

The  indigestible  residue  of  a  meal  normally  reaches  the  descending  colon  in  less 
than  sixteen  hours,  and  in  defa-cation  all  the  contents  of  the  large  intestine  beyond  the 
splenic  flexure  are  evacuated.  Some  of  the  residue  of  a  meal  taken  eight  hours  after 
defa-cation  should  be  excreted  at  the  next  defalcation  in  individuals  whose  bowels  are 
opened  every  twenty-four  hours.  If.  however,  the  bowels  are  only  opened  on  alternate 
mornings — a  condition  which  is  not  necessarily  pathological — forty  hours  instead  of  sixteen 
would  elapse  before  some  of  the  residue  of  the  meal  would  be  excreted.  Constipation  may 
therefore  be  defined  as  a  condition  in  xchich  none  of  the  residne  of  a  meal,  taken  eight  hours 
after  defwcation.  is  exereted  uithin  forli/  linnrs.  Constij)ation  thus  defined  can  be  recognized 
by  giving  three  charcoal  lozenges  with  food  eight  hours  after  defaecation  ;  if  a  blackened 
stool  is  not  passed  within  the  next  forty  hours  the  patient  is  constipated.  The  abnormal 
action  of  the  bowels  in  constipation  may  manifest  itself  in  three  different  ways  : — 

1 .  DeJiEcation  may  occur  with  insufficient  frequency.  A  daily  action  of  the  bowels  is 
merely  a  matter  of  convenience,  and  many  people  in  perfect  health  only  defsecate  once  in 
two  cr  three  days.  .As  a  rule,  however,  an  individual  may  be  regarded  as  constipated  if  his 
bowels  are  not  (>i)ened  at  least  once  in  forty-eight  hours. 

2.  7V/r  stools  may  be  insufficient  in  quantity  and  a  certain  amount  of  fceces  is  retained. 
although  the  bowels  may  be  opened  once  daily  or  more  often.  This  condition  (cumulative 
constipation)  can  be  differentiated  readily  by  the  charcoal  test  from  that  in  which  the 
bowels  are  properly  emptied  but  the  fa-ces  are  very  small  in  ((uantlty  owing  to  the  diet  or 
to  the  imusually  active  absorptive  power  of  the  intestines. 

3.  The  Imicels  may  Ije  opened  daily,  yet  the  fcrces  are  hard  anil  dry.  oiving  to  prolonged 
retention  before  e.rcretion  :  the  deficient  ((uantity  of  water  in  the  stools  also  renders  them 
less  bulky  than  normal.  The  stools  may  be  similar  in  character  when  an  excessive 
quantity  of  fluid  is  lost  by  other  channels,  as  in  diabetes.  By  means  of  the  charcoal 
test  it   is  easy  to  determine  whether  constii)ation  is  also  present. 

After  ciiiislipalioti  has  been  diagnosed,  it  is  necessary  to  determine  its  cause.  The 
first  essential  is  to  distinguish  between  two  great  classes  of  constipation  :  that  in  which 
the  passage  through  the  intestiness  is  (lelayed  whilst  defa-cation  is  normal — Intestinal 
Constipation  :  and  thai  in  which  there  is  no  delay  in  the  arrival  of  f;eces  in  the  pelvic  colon, 
but  their  liiuil  excretion  is  not  performed  adequately — I'clvi-rrclal  Constipation  or  Dyschezia. 

.I.^DIA(;.\()SIS  HKTWKKN  IXTKSTIX.M,  ( OXSTII'ATIOX  AXI)  1)YSCIIKZL\. 

.\  rectal  examination  shouiii  be  macic  in  llic  incirtiing.  aftrr  an  attempt  has  been  made 
to  open  the  bowels  without  the  assistance  ol  mcilicitie.  enemala.  or  suppositories.  If  more 
than  a  very  small  i|uaiitily  of  fa'ces  is  found  in  the  rectum,  dyschezia  may  be  diagnosed. 
If  the  rectum  is  almost  or  cpiite  empty,  tlie  constipation  must  be  due  to  delay  in  the  passage 
through  the  intestines,  except  in  uncommon  cases  of  dyschezia  in  which  there  is  inability 
to  pass  fa-ces  from  the  pelvic  colon  into  the  rectum.  The  latter  condition  can  be  recognized 
on  rectal  examination,  if  the  pelvic  colon  is  felt  through  the  front  wall  of  the  rectum  to  be 
lilled  with  solid  fa'ces  :  the  prt-scncc  of  fa'ces  in  the  pelvic  colon  can  also  be  jiroved  by 
signioidoseopie  examination  made  .it  once,  without  preparation  of  the  ])atient  by  washing 
out  his  bowils. 

.\t  the  same  time  Ihc  alidnnieu  shdiild  be  palpaUd.  If  s(  yh.-ila  are  felt  in  any  part 
of  till-  eiilon.  iiilislinal  coiistipal  ion  iriusi  he  presciil.  This  is.  hiiwcxer.  not  necessarily 
till-  case  it  r:r<(s  arc  tell  in  Ihc  iliac  or  pil\  ic  (miIhii.  as  the  rectum  ill  dyschezia  may  be  so 
full  of  I'li-ccs  that  reli'iilidU  oeciiis  seciniilarily  in  the  p<i\  ic  eohui  ;ind  rectum:  such  a 
eiiiidilioM  would  be  rcengni/.ed  by  the  rectal  c-Naminatioii. 

When  a  palii'iit  h-cK  IIkiI  tlicre  is  somclhiiig  in  his  rectum  which  he  eaimcil  e\pel  al  all. 
or  Ihal  aller  delacal  imi  Ihc  iilicr  is  iiienmplcte.  d>scliezia  is  jirobablv  present.  The 
aliseiicc  iif  this  symploin  dues  mil  c\elii(le  the  possibility  of  dyschezia  as  the  rectum  is 
often  so  insensitive  in  such  cases  Ihal  no  sensation  is  experienced.  e\-cn  when  it  is  tilled 
tiglitly  with  faeces.  The  frcijucnt  passage  of  very  small  pieces  of  hard  fa'ces  (fragmentary 
constipation),  or  the  oei'urrciicc  of  psi  udo-diarrlioM      in  which  small  iliiid  stools,  sometimes 


122  CONSTIPATION 

containing  hard  fragments  ot  feces,  are  passed,  although  the  charcoal  test  shows  the 
presence  ot  constipation— are  both  symptoms  suggestive  ot  dyschezia. 

Some  indication,  which  is  not,  however,  absolutely  reliable,  can  be  obtained  from 
the  results  of  previous  treatment.  Patients  who  have  found  that  diet  and  mild  aperients 
readily  give  them  relief  are  probably  suffering  from  intestinal  constipation.  Those  who 
have  obtained  better  results  with  enemata,  and  particularly  with  suppositories,  probably 
have  dyschezia.  Dyschezia  is  of  course  also  present  in  those  patients  who  have  to  dig 
out  the  fa-ces  from  the  rectum  with  their  fingers. 

Examination  with  the  a;-rays  is  the  only  method  by  which  the  two  classes  of  const iini- 
tion  can  be  separated  with  absolute  certainty,  and  by  which  the  predominant  conditi.m 
can  be  discovered  in  cases  in  which  both  are  jjresent  together.  Two  ounces  of  barium 
sulphate  mixed  with  porridge  or  bread  and  milk  are  taken  at  breakfast,  and  at  intervals 


Fig.  47.— Habitual  Constipation.  Ti 
after  bismuth  breakfast.  No  bLsnii 
beyond  the  first  two  inches  of  the  i 
Subsequent  examinations  showed  that 
occurred  along  the  whole  of  the  larje 


Fig.  4S. — Dyschezia.  Twenty-four  hours  after  bi 
nnitli  breakfast.  -\U  the  bismiitli  has  collected  in  tl 
tlilateil  colon  and  rectum,  except  traces  which  remain 
the  transveree  colon.  In  spite  of  this  the  patient  felt  i 
de.-iire  to  deficcate. 


during  the  next  two  or  three  days  observations  are  made  of  the  shadow  produced  on  the 
fluorescent  screen.  The  colon  should  be  emptied  as  completely  as  possible  by  aperients 
and  enemata  for  two  or  three  days,  but  no  medicine  should  be  given  the  day  before  the 
examination,  on  the  morning  of  which  an  enema  must  be  used  if  the  bowels  have  not  acted 
naturally.  During  the  period  of  observation  no  aperients  or  enemata  should  be  given, 
and  the  patient  should  be  allowed  to  continue  his  usual  occupation  and  to  take  his  ordinary 
diet.  In  intestinal  constipation,  delay  is  ob.served  in  the  passage  through  some  part  or 
all  of  the  colon,  and  occasionally  the  small  intestine  :  in  dyschezia  there  is  no  delay  in  the 
intestines,  but  the  act  ot  defalcation  does  not  empty  the  pelvic  colon  and  rectum  com- 
pletely (Figs.  47,  48). 

B.     DIAGNOSIS  OF  THE  CAUSE  OF  INTESTINAL  CONSTIP.VTION. 


Intestinal  constipation  may  be  due  to  (1)  T//c  motor  activily  of  the  intestines  being 
(Icftcient  ;  or  (2)  The  force  required  to  carry  the  fceces  to  the  pelvic  colon  being  excessive. 
In  the  first  group  of  cases  aperients  are  generally  much  more  effective  than  in 
the  second  ;  in  the  latter  there  may  be  a  history  that  purgatives  are  producing 
less  effect  than  formerly,  or  that  they  now  completely  fail  to  act,  but  that  enemata 
still  give  a  more  or  less  satisfactory  result.  The  increased  activity  of  the  intestines 
in  their  attempt  to  respond  to  the  excessive  demands  in  the  second  class  often  leads 
to   colic. 


CONSTIPATION 


123 


1.  Dkfk'ient  Motor  Activity  may  be  (hie  to: — 

{a).  Weakness  of  the  Intestinal  Musculature. — When  constipation  has  existed  from 
infancy,  especially  if  it  is  present  in  several  members  of  the  family,  it  is  hkely  to  be  due  to 
congenital  hypoplasia  of  the  intestinal  musculature.  Constipation  develo])ini;  gradually 
as  old  age  approaches  is  generally  due  in  part  to  senile  intestinal  hypoplasia.  When 
constipation  occurs  in  ehlorotie  girls,  in  cachectic  conditions,  in  rickets,  and  in  fevers, 
it  may  generally  be  assumed  to  be  due  to  weakness  of  the  intestinal  musculature  secondary 
to  these  conditions. 

When  tlie  abdomen  is  constantly  distended  and  tympanitic,  and  the  patient  eomphiins 
of  attacks  of  colic,  which  are  relieved  by  the  passage  of  flatus,  it  may  be  assumed  that  the 
constipation  is  due.  in  part  at  least,  to  the  incapacitating  effect  of  distention  on  the  intestinal 
musculature.  The  Fl.vtulexce  (p.  240)  may  be  primary,  or  it  may  be  secondary  to  the 
constipation,  in  which  ease  some  other  cause  of  the  condition  must  be  looked  for. 


\ . 

/^ 

!" 

/  /  (  iT^ 

«;:;;ig^ 

^1 

1 
\--- 

AC      IIV)^ 

^=-^^y^ 

-W 

I" 

mf: 

3 

T 

R 

H^ 

nu[iiiiei>,  til  tlii^  uiiU  tile  jollowiiit;  liitures,  reprt^eiit  tint 
houni  lifter  a  bi.'itnutli  IireukfjLst  at  vvliich  the  (lifFereiit  parts 
of  the  colon  are  reached,  c  CaM-uin:  AC.  Asceiidiiiij  colon; 
HF.  Hepatic  flexure;  SF,  Splenic  rlexnrc  ;  DC.  Iireceii.lint- 
i-i.li.ii  ;  ic.  lliiu'  colon;  PC,  I'elvic  colon;  R.  liecluni 
U.   I  nihilicus :    p,  l'elvi..<. 


J-'iij.  ^t'K — I'ost-dysenteric  atony  and  pare-is  of  the  colon. 
Compare  the  lumen  of  the  colon  and  the  slow  passive  of 
fieccs  through  it  with  Fig.   49. 


The  consti|)ali(in  of  Inl  |m(i|iIc  is  due  In  |i;iil  Id  Ihe  iiunicuiicy  of  llic  iiitcsl  iii:il 
musculature  rcsulliiig  fr<iiii  hilly  iiilill  r';il  imi. 

In  some  of  these  conditions  atoii\  nl  llic  ciiUiii  can  be  recognized  with  the  .i-rays  by 
its  :ibnorm!'illy  large  lumen.  In  addition  to  llic  sluw  passage  of  heees  {Figs.  4i)  and  ;)0). 

(/').  Deficient  Reflex  Activity  of  the  Intestines. 

Iiisiilliciciit  Sliiiiiildlioii  (if  Iiifcslhiiil  Miirniu  Ills.  Careful  eni|uiry  slidiild  be  m;icle  iulo 
the  palieiil's  ilici  ;iiid  linbils.  as  many  <:tses  are  due  to  too  little  food  biiiig  liikeii.  or  to 
the  food  eonttiining  too  lillle  meelitinleal  or  chemical  peristaltic  stimulants,  and  some  are 
due  to  ilelieieul  exercise.  Other  ("ises  result  from  a  "greedy  colon."  the  absorption  of 
food  being  nniisn;illy  coinplilc.  In  sjiilr  iil'  cnungli  Imid  of  ;i  suHicifntly  stimulating 
character  bi-ni'.'  I;ikcn.  :ind  In  spllr  nl  llic  lacl  lliiil  llic-  ;ilid(initii  is  nlr;icted  and  no 
aeeumuhilion  of  faeces  ciin  he  lill  in  litlicr  the  eiildii  cir  tlic  rcctuin.  yet  a  very  delieicnt 
<|Uantity  nf  fa-ces  is  exerilcd.  This  is  the  type  df  c;ise  in  which  beiulit  results  from  the 
use  dl'  iigar-agar  or  jietroleum.  In  eonstipiition  due  to  ;iii  unMiihihle  diet  or  Id  a  greedy 
(iildii  the  stools  are  generally  small,  dark,  and  di\.  :incl  siiiclj  less  slriiiigl\  lh:in  normal. 
In  Msophagcal  or  pyloric  obstruction  eonstipatidii  is  ;ihv;iys  priscnl  owing  In  Hie  sniiill 
•  luantity  of  food-residue  which  rciichcs  the  colon.  The  other  symptoms  generally  prevenl 
a  mistake  in  ditignosis  being  made:  but  oeeasiontdly  in  pyloric  obstruction  the  palienl 
eonililiiins    df    iidtliing    but    vome    slight     indigcstiiin    nr    weakness    in   itdditiim  to  the  eon- 


124 


CONSTIPATION 


stijjation.  The  passage  of  a  stomach-tube  twelve  hours  after  a  large  meal,  when  the 
stomach  should  be  completely  empty,  and  an  a;-ray  examination,  will  clear  up  the  diagnosis 
in  doubtful  cases. 

Deficient  Sensibility  of  the  Intestinal  Mucous  Membrane. — This  is  the  probable  cause  of 
the  constipation  when  there  is  a  history  of  excessive  tea-drinking  or  of  the  long-continued 
use  of  large  doses  of  aperients  ;  it  is  also  partly  responsible  for  the  constipation  associated 
with  catarrhal  colitis — in  which  excess  of  mucus  is  passed  with  the  stools — whether 
this  is  primary  or  a  result  of  constipation  due  in  the  first  instance  to  some  other  cause. 

Depression  of  the  Nervous  System. — In  neurasthenic,  hypochondriac,  and  insane  patients, 
the  condition  of  the  nervous  system  is  the  chief  cause  of  the  constipation  which  is  almost 
invariably  present  :    but  an  improper  diet  is  generally  an  additional  factor. 

((').  Inhibition  of  the  Motor  Activity  of  the  Intestines. — This  group  of  cases  can 
often  be  recognized  by  the  fact  that  sedatives,  such  as  opiinn  and  belladonna,  give  relief, 
whilst  purgatives  are  required  in  unusually  large  doses,  and  produce  an  unusual  amount  of 
colic  unless  given  with  a  sedative.  The  ,r-rays  show  that  the  small  intestine  as  well  as  the 
colon  is  traversed  slowly  ;  this  is  unusual  in  other  forms  of  consti])ation  (Fig.  ,51 ).  Inhibition 
may  be  direct,  central,  or  reflex. 


Fig.  51 — Constipation  due  to  lead  poisoning.  The  passage 
lirougli  the  small  intestine  as  well  as  the  colon  is  slow,  owing 
u  tlie  inhibitory  action  of  the  splanchnic  nerves. 


Direct  Inhibition  in  Lead  Poisoning. — The  diagnosis  is  suggested  by  the  occupation  of 
the  patient,  a  blue  line  on  his  gums  or  other  symptoms  of  plumbism  (p.  34). 

Central  Inhibition. — A  history  of  a  recent  shock  or  worry  is  obtained. 

Reflex  Inhibition. — Constipation  is  a  frequent  symptom  of  painful  diseases  of  abdominal 
and  pelvic  viscera,  other  than  the  intestines  themselves.  It  can  then  be  cured  only  by 
treating  the  primary  condition,  so  that  it  is  essential  to  ascertain  the  cause  of  the  pain. 
Constipation  is  particidarly  liable  to  result  from  disease  of  the  ^•crnliform  appendix,  female 
genital  organs,  stomach,  duodenum,  and  gall-bladder. 

((/).  Irregular  Spasmodic  Contraction  of  the  Intestine :  Spastic  Constipation : 
Enterospasm. — AV'lien  constipation  is  associated  with  pain.  es])(cially  if  the  pain  conus 
in  attacks  during  which  the  difliculty  witli  the  ijowcls  is  increased,  the  possil)ility  that  It 
is  due  to  spasm  of  the  colon  must  be  considered.  The  pain  is  situated  in  the  course  of  the 
large  intestine,  most  frequently  in  the  iliac  and  pelvic  colon,  but  occasionally  in  other  parts. 
The  affected  parts  of  the  colon  can  generally  be  felt  as  a  contracted,  tender  cord,  in  which 
scybala  may  be  detected  and  the  narrow  lumen  can  be  recognized  with  the  a-rays  {Fig.  52). 
\Vlien  the  pain  is  in  the  right  iliac  fossa  ap])endicitis  may  be  simulated  :  the  long  duration 
of  the  attacks  without  any  pyrexia,  the  occasional  history  of  similar  pain  on  the  ojjposite 
side,  and  the  contracted  condition  of  the  ascending  colon  and  sometimes  of  the  ca>cum 
(though  in  other  cases  the  caecum  may  be  distended  and  tympanitic),  are  distinctive  features 
of  spastic  constipation.     When  the  pain  is  in  the  left  side,  a  tumoiu-  of  the  descending  or 


CONSTIPATION 


1-25 


iliac  colon  may  be  suspected  :  the  long  history,  the  absence  of  visible  or  palpable  peristalsis 
and  of  distention  above  the  contracted  part,  and  the  absence  of  occult  blood  from  the 
stools,  are  ])oints  which  distinguish  spastic  constipation  from  cancer  of  the  colon.  In  cases 
of  spastic  constipation  the  stools  should  always  be  examined  for  mucus,  as  the  spasm, 
especially  when  it  occurs  in  neurotic  women,  is  often  only  a  symptom  of  muco-membranous 
colitis,  shreds  or  membranes  of  coagulated  mucus  being  passed  by  the  patient  (p.  398). 


2.  Constipation  due  to  Excessive  Force  required  to  carry  the  F.bces  to  the 
Pelvic  Colon  may  be  due  to  : 

(a).  Obstruction  by  Faeces. — Dr>%  hard  fa-ces,  which  require  abnormally  strong 
peristalsis  to  carry  them  to  the  pelvic  colon,  result  from  :  (i)  Insufficient  consumption  of 
water — a  common  cause  of  constipation  in  women  :  (ii)  Excessive  loss  of  water  by  other 
channels — one  cause  of  the  constipation  of  diabetics,  and  of  individuals  who  perspire  freely 
and  arc  only  constipated  in  hot  weather. 

(h).  Narrowing    of    the    Intestinal    Lumen. 

Organic  SIrictiire. — Unless  this  is  due  to  a  palpable  tumour  it  may  be  very  dilliciilt 
to  distinguish  from  consti- 
pation due  to  less  serious 
causes.  More  or  less  colic 
is  generally  present,  and 
its  situation  often  gives  a 
clue  to  the  localization  of 
the  obstruction.  .Vn  .r-ray 
examination,  when  tlie 
barium  is  given  by  mouth, 
rarely  gives  any  lul])  in  tin- 
early  stages  of  the  disease, 
although  occasionally  the 
actual  narrowing  of  the 
intestine  is  observed  and 
stasis  occurs  in  the  proxi- 
mal portion  of  the  bowel 
{F  i  'J.  ;>;5).  M  u  eh  m  o  re 
valuable  information  can 
be  gained  by  the  adminis- 
tration of  a  barium  enema. 
Six  ounces  of  barium  sul- 
phate arc  suspended  in  a, 
|)iiU  and  a  half  of  water  to 
which  has  been  added  an 
ounce  and  a  half  of  acacia 
mucilage  and  an  ounce  of 
mctliylateir  spirits.  The  lluid  is  run 
of  one  foot.      In  normal   individuals 


Fuj.  O:;.     .SkiiifeTiUil  to  show 
last  ii  or  4  inches  of  the  traiwv 
stricture  of  thit;  exuct  portion  of  tl, 
riiLture  of  tlie  condition  wn,s  finite  unsuspected 
employed :    gastric  trouble,  possibly  an  ulcer, 


ul  bi^uiuUi  by  a  malignant  stricture  of  tlic 

colon.     At  the  subsequent  operation  a  very  lianl 

rcrae  colon  was  found  and  e.Kcised.    Tlic 

til  bismuth  and  the  jr-rays  wcro 

tliouf,dit   probable  previously. 

colon  twentv-seven  hours 

slaii  Holland.) 


lowly  into  the  bowel  from  a  funnel  at  a  pressure 
rne  of  It  reaches  tlie  ea'cuin  almost  imnicdiately. 
hut  even  in  the  early  stages  of  organic  obstruction  tlie  passage  is  more  or  less  obsl  niclcd 
at  the  seat  of  the  stricture,  owing  apparently  to  a  superadded  spasm. 

Xoii-mdli/imiiil  .slrirtiirrs  of  the  colon  are  rare.  If  tlicic  is  a  history  of  tuberculous  or 
dysenteric  uleeralioii.  the  possibility  of  obslruelioii  due  to  eicalri/alion  shouki  be  eon- 
sidircd.  tlioiigh  this  is  a  very  unusual  oeeurrenee.  Hyperplastic  tuberculous  infiltration 
of  the  iiiteslinc.  <spccially  of  the  cacum.  causes  obslruelion,  but  the  tumour  present  is 
•  lillieull  to  disliMLiuish  from  cancer.  Obstruction  to  the  iliac  or  pelvic  colon  may  follow 
till'  piiicniilis  wliicii  rcsiills  from  the  formation  of  diverticula  in  old  ])cople  who  have  long 
siiirereil  Ikiim  corisliiial  ion.  This  condition  may  also  be  indistinguishable  from  a  growth. 
i)ul  the  possibility  should  lie  borne  in  mind  in  the  case  of  elderly  patients  with  a  tiunour 
in  the  iliac  or  pel\  ie  colon,  where  there  is  a  long  history  of  constipation  :  the  sigmoidoscope 
may  help  in  the  diagnosis.  If  a  \(sico-colic  listula  develops  in  association  with  elironie 
constipation,  it  should  be  remembered  that  |)ericolitis  due  to  ulceration  of  ilixerlieula  is. 
a  more  frccpient  cause  of  this  condition  than  cancer. 


126 


C'OxXSTIl'ATlON 


'■'^■'■m 


Organic  stricture  of  the  colon  is  most  commonly  due  to  cancer.  The  possibility  of 
cancer  should  always  be  considered  when  an  individual  above  the  age  of  forty,  whose  bowels 
have  been  regular  previously,  develops  constipation  of  increasing  severity  without  change 
of  diet  or  habits,  or  when  a  patient,  who  is  habitually  constipated  becomes  more  so  without 
obvious  reason.  The  constipation  is  at  first  intermittent  and  may  alternate  with  diarrha-a  ; 
drugs  become  steadily  less  effective,  and  enemata,  which  at  first  give  greater  relief  than 
drugs,  also  lose  their  effect  slowly.  A  tumour  is  often  not  palpable,  but  an  examination 
under  an  auccsthetic  reveals  the  presence  of  one  in  many  doubtful  cases,  especially  in  fat 
individuals.  The  tumour  may  vary  in  size,  and  even  disappear  after  the  bowels  have 
been  opened  well,  because  a  mass  of  heces  may  become  impficted  above  a  cancerous  stricture 
which  is  itself  impalpable.  Hence,  although  the  presence  of  a  tumour  is  an  important  aid 
in  diagnosis,  its  absence  or  disappearance  docs  not  exclude  the  possibility  of  cancer  ;  only 
when  its  disa])pearance  under  treatment  is  accompanied  by  complete  and  lasting  cure  of 

all  symptoms  can  cancer  be  excluded.  The 
tumour  is  hard,  and  cannot  be  altered  in 
shape  by  pressure,  as  is  the  case  with  fa?cal 
Umiours.  Slight  attacks  of  colic  occur  fre- 
(|uently,  but  they  are  not  often  severe  until 
I  he  obstruction  is  almost  complete  ;  the  colic 
may  bo  accompanied  by  visible  and  palpable 
piristaKis  and  spasmodic  contractions  of  the 
intestine.  The  latter  is  a  most  important 
sign,  as  it  never  occurs  in  colic  associated  with 
lead-poisoning  or  colitis,  and  very  rarely  with 
obstruction  due  to  fa?cal  impaction.  Progres- 
sive loss  of  weight  and  strength,  anorexia, 
and  ana-mia  are  late  .symptoms,  and  it  is  im- 
portant to  make  a  correct  diagnosis  before 
they  have  appeared.  The  obvious  presence 
111'  blood  in  the  faeces  is  an  important  symptom, 
but  it  is  often  absent.  Much  more  frequently 
I  races  are  found  which  are  only  recognizable 
l)y  chemical  tests  (p.  81).  In  the  absence  of 
liicmorrhoids  and  of  lucmorrhage  from  the 
mouth,  throat,  or  nose,  the  presence  of 
'  occult '  blood  in  the  fseces  is  strong  evidence 
that  ulceration  is  present  in  the  stomach  or 
intestines  ;  when  symptoms  pointing  to  gastric 
or  duodenal  ulcer  and  gastric  carcinoma  are 
absent,  and  constipation  is  present,  a  suspicion 
of  cancer  of  the  intestine  receives  important 
confirmation.  In  doubtful  cases  a  sigmoido- 
scopic  examination  should  be  made,  as  cancer 
is  much  more  common  in  the  rectimi  and 
])elvic  colon — which  alone  can  l)e  investigated  by  this  method — than  in  any  other  part 
of  the  intestine. 

A  kink  of  the  colon  is  a  very  unusual  cause  of  constipation.  It  is  sometimes  partly 
res]5onsible  for  the  constipation  which  is  almost  always  present  in  visceroptosis  {Fig.  56), 
and  it  should  be  suspected  when  an  attack  of  localized  iieritonitis.  due  particularly  to 
disease  of  the  female  genital  organs,  appendicitis,  or  Uakage  Irom  a  gastric  or  duodenal 
ulcer,  is  followed  by  constipation.  An  a-ray  examination  should,  liowtver.  always  be 
made  before  advising  surgical  treatment,  as,  in  the  vast  majority  of  cases,  even  if  adliesions 
are  jiresent  they  have  nothing  to  do  with  the  obstruction.  The  a?-rays  show  whether  the 
delay  takes  place  in  the  neighbourhood  of  the  supposed  adhesions,  and  the  presence  or 
absence  of  adhesions  can  also  be  ascertained  by  seeing  how  movable  tlie  colon  is,  and 
whether  the  two  limbs  of  the  various  flexures  can  be  separated  from  each  other. 

^Vhatever  may  be  the  primary  cause  of  Hirschsprung's  disease  (wrongly  called  "  con- 
genital idiopathic  dilatation  of  the  colon  "),  it  is  probable  that  a  kink  is  produced  after 


Fhj.  :.  1.  -Tlie  same  case  ns  Fig.  JS.  Skiattraii i  i.lt.T 
tlir*  ailriiiiiistration  of  a  bismuth  enema  seven  days 
after  Insiimth  had  been  given  by  the  moutli.  Arrest 
of  the  bismuth  by  the  obstructive  carcinoma  at  the 
end  of  the  transverse  colon.  TC.  Food  still  in  tlie 
dilated  transverse  colon  seven  days  after  it  had  been 
<,'iven    by    mouth,     s,    Splenic    flexure :     Comiilete 


the  (iihitation  has  reached  a  certain  (iegree  by  the  ovcrlian<>in})'  of  the  dilated  part  of  the 

colon  over  the  undilated  section  {Fig.  55).     There  is  always  a  history  of  constipation  dating 

from  the  first  few  months  of  Mfe.  although  sometimes  the  bowels  may  be  opened  daily  but 

insuflicicntly.     Soon  after  birth  the  abdomen  becomes 

irreatlv  enlarged,  the  siz.e  varying  from  time  to  time. 

The  outline  of  the  distended  colon  can  be  seen,  and 

peri.stalsis    is   often    visible.      The    abdomen    finally 

becomes  enormous  ;   it  is  then  tense  and  tympanitic. 

Attacks  of  obstruction  are  liable  to  occur,  and  death 

takes    place    most   frequently   between   the   ages    of 

three  and  eight. 

When  a  large  abdominal  tumour  is  present,  con- 
stipation may  be  due  to  its  pressure  on  the  colon. 

Clironic  intussusception  may  cause  symptoms 
similar  to  those  produced  by  a  stricture  :  attacks 
of  colic  accoin])anied  by  visible  peristalsis  occur 
with  increasing  fref|uency  and  severity,  and  they 
are  often  brought  on  by  food  or  aperients.  An 
intvissusccption  should  be  suspected  under  the.se 
circumstances  when  a  sausage-shaped  tumour  is 
l)alpable,  es])eeially  if  blood  and  mucus  are  pas.sed 
at  fre<|uent  intervals.  In  one-third  of  the  cases 
the  a|)ex  of  the  intussusception  can  be  felt  on 
rcctMl   cxaniinalion. 


Hu-^chslJi 


Dl  Pisr       AC     Vm 

cnditit,  colon      TC     ii 

<olon      DC    DeM 

pnihtu  tolon      IC    Hi 

PC    I  oop  of  pch  1 

L  colon     R    Rettiim 

it  pehi  rectal  ]ui 

ictiOM      Tin    .lotted  hr 

sent  the  co*ital  m 

argm^ 

C— DIA(;X()SI.S    OK    TIIK    t  Al  SK    OF    I)VS(  IIKZIA. 

l)>sche/.ia  is  due  to  a  want  of  proper  proportion  between  the  jjower  of  expelling  the 
fares   from    the   pchic   colon   and    rectum,  and   the    force   re(|uiretl   to  do  this  completely. 
It    may    lliereforc    be  due    to   (1)   hi<jjicicnt   Dejaration  ;     or   (2)  An   Obstacle   to    KJJicicnt 
l)cj'((i(ilion. 

1.   l.NF.Ki-KiKNT  Def.ecation  may  be  due  to: — 
(a).  Weakness  of  the  Voluntary  Muscles  of  Defaeca- 
tion,      Tliis  should  l)e  suspected  when  coiisliiialidii  dales 
V.  from    prcgnanev.    or    is    associated    with    ascites,    large 

abdominal  tumours,  or  obesity.  It  is  often  easy  to 
ascertain  the  condition  of  the  abilominal  nuisclcs  by 
simple  palpation  in  the  horizontal  position  :  the  dis- 
eov<-ry  of  a  movable  kidney  or  a  dropped  liver  would 
also  suggest  that  the  abdominal  muscles  are  weak. 
The  patient  should  next  be  told  to  raise  her  head  from 
tlie  couch  :  the  recti  iiuisclcs  contract  and  their  strength 
can  lie  asccrlaiucd,  aiwl  ;iny  separaliciii  between  them 
rccoyiii/.cd.  I''irially.  I  lie  |i:itirril  sliould  be  examined 
standing  up  :  bulging  of  the  abdomen  below  the  um- 
liilicus  {Fig.  5(i)  shows  that  visccropto.sis  is  ])rcscnt  and 
that  the  abdominal  muscles  are  weak.  Tlie  patient 
(irieii  complains  of  abdominal  discond'ort,  which  is  re- 
lieved by  lying  down  or  by  pressing  the  lower  part  of 
I  lie  abdomen  upwarils.  In  all  cases  in  which  a  woman, 
whose  bowels  ha\c  previously  been  regular,  becomes 
constipated  after  the  birth  of  a  child,  the  condition  of 
the  jielvic  lloor  should  be  investigated,  as  well  as  that  of 
the  abdominal  wall.  The  anus  is  iiornially  slightly  re- 
Iracteil  :  the  retraction  is  iiiereaseil  and  the  anus  moves 
slightly  forward  when  the  levator  aiii  iiiiisclcs  are  con- 
cled  by  making  the  iiioveinenl  wliieli  is  reipiired  ulieii  it  is  attempted  to  restrain  a 
iiriieiieiiig   dcfa'calion.      11    thev     are    weak,    the    retraelion    in    the    condition    of   rest    is 


:roittosi.-i. 


128  CONSTIPATION 

absent  or  diminished,  and  on  contracting  tlie  levator  ani  muscles,  the  retraction  and 
forward  movements  are  slight  or  absent.  On  straining,  the  whole  perineum  projects 
much  further  than  it  should  do,  and  in  severe  cases  the  uterus  may  be  more  or  less 
prolapsed  :  in  such  cases  no  further  evidence  is  required  to  show  that  the  dyschezia  is 
partly  due  to  weakness  of  the  levator  ani  muscles. 

When  constipation  is  present  in  asthmatic  or  very  emphysematous  people,  it  is  partly 
due  to  the  fact  that  the  great  rise  in  intra-abdominal  pressure  required  in  deficcation 
cannot  be  produced  by  contracting  the  diaijhragm.  as  the  latter  is  already  almost  as  low 
as  it  can  go. 

(b).  Habitual  Disregard  of  the  Call  to  Defaecation. — When  dyschezia  is  not 
associated  with  weakness  of  the  muscles  of  the  abdominal  wall  or  pelvic  floor,  the  history 
will  generally  show  that  it  has  resulted  from  habitual  disregard  of  the  call  to  defaecation — 
a  very  common  cause  in  girls,  and  a  not  uncommon  one  in  schoolboys  and  business  men, 
who  allow  themselves  too  little  time  between  getting  up  and  beginning  the  day's  work. 
The  call  is  also  often  neglected  if  for  any  reason  defsecation  is  painful. 

(f).  Unfavourable  Posture  during  Defaecation. — Enquiry  should  be  made  as  to  the 
height  of  the  seat  in  the  water-closet,  as  when  this  is  too  high  it  is  impossible  to  assume  the 
proper  crouching  position,  and  defalcation  may  consequently  be  inefficient.  Weakness  of 
the  voluntary  muscles  of  defalcation,  habitual  disregard  of  the  call,  and  the  assumption 
of  an  unsuitable  position  during  the  act,  all  lead  to  the  same  results — the  loss  of  the  defalca- 
tion reflex,  and  atony  and  paresis  of  the  musculature  of  the  pelvic  colon  and  rectum.  The 
loss  of  the  defaecation  reflex  is  shown  by  the  fact  that  the  jjatient  never  experiences  a  desire 
to  defaecate,  even  when  examination  shows  that  the  rectum  is  full  of  fa'ces.  The  atony 
of  the  rectum  is  shown  by  its  abnormally  large  size  and  the  very  slight  resistance  offered 
when  the  finger  presses  upon  its  walls  ;  the  atony  of  the  pelvic  colon  is  shown  by  the 
abnormally  large  .shadow  it  forms  when  examined  with  the  ,i-rays  (Fig.  48,  p.  122).  The 
paresis  of  the  pelvic  colon  and  rectum  is  shown  by  the  patient's  inability  to  dehecate  by  an 
effort  of  will,  when  the  rectum  is  full  of  fa'ces. 

(d).  Primary  Weakness  of  the  Defaecation  Reflex. — This  is  sometimes  the  cause  of 
constipation  in  infants  :  it  is  probably  the  case  when  defalcation  occurs  on  exaggerating 
the  natural  stimulus  by  the  mechanical  effect  of  the  introduction  of  a  finger  into  the  rectum, 
or  by  the  combined  mechanical  and  chemical  effect  of  the  introduction  of  a  piece  of  soap. 

(e).  Organic  Nervous  Diseases. — When  constipation  occurs  in  the  course  of  organic 
nervous  diseases,  such  as  lubes  dorNdlis.  nn/clilis,  or  »ieiiingitis,  it  is  due  to  disturbance  in 
the  defffication  centre  in  the  lumbo-sacral  cord  or  the  tracts  connecting  it  with  the  brain. 
When  constipation  and  difficulty  in  micturition  appear  simultaneously,  the  possibility  of 
some  organic  nervous  disease  should  be  considered,  even  if  no  other  symptoms  are  present. 

(/■).  Hysteria. — When  dyschezia  occurs  in  nervous  individuals  it  is  often  due  to  the 
patient  having  suggested  to  himself  that  he  cannot  open  his  bowels  at  all,  or  unless  he  takes 
a  purgative  or  an  enema.  The  diagnosis  can  be  confirmed  by  the  result  of  treatment  : 
if  such  a  patient  can  be  persuaded  after  a  thorough  examination  that  there  is  really  no 
reason  whatever  why  he  shotdd  not  obtain  a  daily  action  of  the  bowels  without  artificial 
aid,  he  will  have  no  difficulty  in  curing  himself  at  once. 

2.  Obstaci.es  to  Efficient  Def.ecatign  may  be  due  to  : — 

(a).  Hard  and  Bulky  Fseces. — When  the  faeces  are  abnormally  hard  as  a  result  of 
intestinal  constijiation  or  t>f  the  excessive  loss  of  fluid  from  diarrhoea,  hemorrhage,  or  other 
cause,  the  force  required  to  expel  them  may  be  so  great,  especially  if  they  are  bulky,  that 
dyschezia  results.  This  condition  can  be  recognized  easily  by  a  rectal  examination,  which 
shows  that  ficces  of  abnormal  hardness  are  impacted  in  the  rectum. 

(b).  Spasm  of  the  Sphincter  Ani. — When  defa-cation  is  painful  it  is  rendered  difficult 
as  well  by  reflex  spasm  of  the  sijhincter  ani.  The  anal  canal  and  rectum  should  be  examined 
after  the  introduction  of  a  cocaine  suppository,  or  if  necessary  under  a  general  anaesthetic, 
so  that  any  local  cause  of  the  pain,  such  as  an  anal  ulcer  or  inflamed  hicmorrhoids,  may 
be  discovered.  In  the  absence  of  these,  the  genito-urinary  organs  should  be  examined 
thoroughly  for  reflex  causes  of  spasm. 

(c).  Organic   Stricture   of   the    Rectum   and   Anus. — In  every  case  of  constipation  a  T 
digital  examination  of  the  rectum  shoidd  be  made,  and  in  cases  of  doubtful  origin  the  rectum 
and  pelvic  colon  should  be  examined  with  a  proctoscope  and  sigmoidoscope.     Congenital 


CONSTIPATION  129 

narrozvness  of  the  anal  canal  is  recognized  easily  :  it  is  rare,  but  may  give  rise  to  no  symptom 
until  several  years  after  the  child  is  born.  Fibrous  stricture  of  the  rectum  is  an  occasional 
cause  of  dyschezia,  especially  in  women  ;  it  results  from  inflaminatory  infiltration  of  the 
submucous  tissue  secondary  to  infection  of  an  abrasion  of  the  mucous  membrane.  The 
condition  is  generally  painful,  and  often  associated  with  active  inflammation  and  ulceration  ; 
it  can  be  distinguished  readily  from  malignant  stricture  by  means  of  the  proctoscope. 
('(i)icer  of  the  rectum  or  pelvic  colon  is  a  conunon  cause  of  dyschezia  :  when  constipation 
develops  after  the  age  of  forty  without  any  obvious  cause,  especially  if  it  is  accompanied 
by  a  sense  of  fullness  in  the  rectum  and  of  incomplete  relief  after  defaecation,  by  loss  of 
weight  and  strength,  or  by  discharge  of  mucus  and  blood,  the  possibility  of  cancer  of  the 
rectum  should  always  be  considered,  and  a  thorough  examination  made  by  the  flnger  and 
proctoscope  or  sigmoidoscope. 

{(I).  Pressure  on  the  Rectum  from  Without. — Pressure  on  the  pelvic  colon  and 
rectum  by  ti  gravid  uterus  always  ]iroduccs  sonic  dyschezia.  Apart  from  this  the  possibility 
of  a  pelvic  tumour,  such  as  distended  tubes,  cancer,  or  fibroid  of  the  uterus,  and  ovarian 
tumours,  should  be  remembered  in  dyschezia  occurring  in  women,  especially  if  there  is  any 
pelvic  pain.  A  retroverted  but  otherwise  normal  uterus  cannot  be  regarded  as  a  sulHcicnt 
explanation  of  dyschezia. 

(e).  Invagination. — When  a  constijjated  patient,  whose  general  health  is  so  good  that 
cancer  seems  improbable,  complains  that  after  deliccation  he  feels  as  if  something  were 
still  [)rcscnt  in  the  rectum,  especially  if  mucus  and  occasionally  a  little  blood  are  passed, 
the  dyschezia  may  be  due  to  obstruction  caused  by  the  invagination  of  the  mucous  membrane 
of  the  up[)er  part  of  the  rectum  into  the  lower  part.  The  condition  is  generally  a.ssociated 
with  lumbar  pain.  The  invaginated  mucous  membrane  can  be  felt  on  digital  examination, 
especially  when  the  [laticnt  strains. 

II.  ACUTE     CONSTIPATION. 

.\cutc  const  ipalidii  may  be  (A)  Due  to  acute  iiitestiiial  ol>structioii  :  or  (H)  .1  sifuiptom 
of  (a)  some  general  disease,  or  (li)  some  other  acute  alxlaunnid  disease. 

.1.— ACITE    INTESTINAL    OISSTKICTION. 

1.  Tiic  foilowiug  points  help  in  the  distinction  between  acute  intestinal  obslruclion 
and  severe  cases  of  a(  iilc  constipation  of  other  origin  :  (i).  I'isible  and  palpable  peristalsis 
or  stiffening  of  the  iiilcslirus  is  never  present  except  in  obstruction,  (ii).  Vomititig  is  never 
f:rciilcnl,  except  occasionally  at  a  very  late  stage,  ill  iion-ol>structi\e  cases,  (iii).  In  other 
conditions  llic  coastijiidi(ni  is  incomplete  : 

(a).   I'Matus.  and  cs'cn  a  small  <|uantily  of  l;cces,  may  be  i«isscd  spontaneously, 

(b).  A  purgative  may  give  a  result  ;  it  is,  however,  very  unwise  to  administer  purgatives 
ill  such  cases,  but  frei|iiciitly  the  patients  have  already  tried  them  on  their  own  responsibility. 

((■).  ,\  rectal  examination  should  always  be  made.  In  organic  intestinal  obstruction 
tlic  rectum  is  empty  :  if  it  contains  fa'ces  there  may  be  obstruction  due  to  fa-ces,  but  it  is 
exceedingly  rare  for  this  to  prorliicc  symptoms  at  all  comparable  in  severity  with  Ihosc 
due  to  acute  obstruclioli.  Willi  this  exception,  I  lie  prcMiici-  otaiiN  (|iiaiility  ol  laces  uould 
show  that   there  was  no  intestinal  obslruclion. 

(d).  In  doubtful  <'ascs  two  eneiiiala  should  be  yixni.  willi  an  inlrrxal  oi  an  iioiir  : 
llii-  lirst  gcneriUly  brings  away  a  certain  aiiiounl  ol  l^icis.  cmii  M  ohsl  riiclioii  is  coinplele  : 
the  second  only  rcsulls  in  the  passage  of  laces  or  Mains  if  llierc  is  no  coinplele  olislriiction. 
or  if  Hie  obslruclion  is  liigli  in  llie  small  ililcsliiie.  If  there  is  eomplcle  olislriielion  the 
second  enema  is  eillier  retained  or  escapes  unallcrcd  and  with  abnormally  small  force. 

2.  Heioic  considering  any  oilier  possibility,  all  the  hernial  apertures  should  be 
exaiiiiiicd.  even  in  the  absence  of  local  pain,  as  a  slranguhded  hernia  gives  all  the  signs  ol 
aeulc  inlc^l  iiiiil   rjhsl  riiel  \i,\\. 

■■',.  'I'lir  I'olicjwirii:  |ioiiils  should  he  considcicd  ill  del  i  riiiinilig  llic  cause  u\  Hie  aciile 
ililesljiial  obslnielioii  : 

(i).   .\gc.      Inlcslinal   obslniclicjii    in    Hie   ncH-lMirn    is   ■a\ si    invariably  due   lo  a   coii- 

geiiilal  malformation:  as  this  isginnally  in  Hie  icclnni  (p.  .">H(i)  Hie  latter  should  bccxaniincd 

u  9 


-J30  CONSTIPATION 

first  and  onlv  after  it  has  been  found  to  be  normal  should  the  possibility  of  congenital 
obstruction  in  the  duodenum  or  ileum  be  considered.  In  infants  the  conmion  cause  of 
intestinal  obstruction  is  intussusception  ;  at  a  somewhat  older  age  obstruction  may  arise 
in  connection  with  a  Meckel's  diverticulum  ;  but  in  children  and  young  adults  the  most 
common  cause  is  obstruction  by  bands  or  adhesions  resulting  from  local  peritonitis,  due  to 
appendicitis,  tuberculous  peritonitis,  or  caseous  mesenteric  glands.  Acute  obstruction 
occurrincT  in  an  infant  or  child  under  ten  years  of  age,  in  whom  there  is  a  history  of  con- 
stipation and  abdominal  distention  dating  from  soon  after  birth,  is  most  probably  due  to 
Hirschspruno-s  disease  (p.  12C).  After  the  age  of  forty  the  possibility  of  cancer  of  the  colon 
should  always  be  remembered,  and  in  fat  patients,  especially  women,  obstruction  by 
gall-stones.  "  In  patients  over  sixty  acquired  diverticula  of  the  colon  are  likely  to  give  rise 
to  symptoms  and  signs  which  are  generally  mistaken  for  cancer. 

(ii)  History.— A  previous  attack  of  appendicitis,  or  a  history  of  tuberculous  peritonitis, 
or  of  inflammatory  pelvic  disease  in  females,  suggests  the  possibility  of  obstruction  by 
bands  or  adhesions  ;  the  same  diagnosis  should  be  considered  if  the  patient  has  some  ^^-eeks 
or  months  before  had  a  strangulated  hernia  reduced.  A  history  of  biliary  colic  or  of  the 
less  striking  symptoms  which  may  result  from  cholelithiasis  indicates  that  obstruction  may 
be  due  to  impaction  of  a  gall-stone.  When  acute  obstruction  follows  a  period  of  increasing 
constipation  in  middle-aged  patients,  cancer  is  probably  present. 

(iii)    Slate  of  tlir  /i-nic/.s.— The  passage  of  blood  and  mucus  without  any  ficces  is  very 
suggestive  of  an  intussusception.     In  older  patients  it  may  be  due  to  cancer.     The  passage 
ofVtools  during  the  early  stages,  in  spite  of  other  evidence  of  obstruction,  indicates  that 
the  latter  is  situated  in  the  small  intestine, 
(iv).  Abdominal  Examiiiatioti. — 

(a)  Disle»tion.^Gna\  distention  generally  means  that  the  obstruction  is  m  the  colon  : 
it  it  is  present  very  soon  after  the  onset  of  symptoms,  it  is  probably  due  to  cancer  or  volvulus  : 
if  it  has  been  present  to  a  less  extent  for  some  time  before  the  onset  of  acute  symptonis. 
a  growth  is  likely  ;  but  if  it  has  developed  very  acutely,  a  volvulus  is  more  probable.  In 
infants  and  small  children  great  distention  suggests  Hirschsprung's  disease  (p.  126),  if  the 
abdomen  is  tympanitic  ;  if  it  is  partially  dull,  and  if  free  fluid  or  irregular  masses  are 
present,  tuberculous  peritonitis  is  the  probable  diagnosis.  Well-marked  distention  in  both 
flanks  suggests  origin  in  the  pelvic  colon  or  rectum  ;  if  in  the  right  flank  only,  m  the 
hepatic  flexure  or  transverse  colon  ;  if  the  flanks  are  comparatively  undistended  and  the 
central  part  of  the  abdomen  is  most  affected,  the  obstruction  is  likely  to  be  in  the  ileum  or 
the  caecum  ;  distention  is  slight  when  the  obstruction  is  in  the  duodenum  or  jejunum. 

(b).  Visible  Peristalsis  and  Stiffening  of  the  Intestine.— The  position  and  direction  ol 
visible  peristalsis  and  the  position  of  stiffening  coils  of  intestine  may  show  the  localization 
of  the  obstruction.  When  a  series  of  more  or  less  parallel  contracting  coils  is  visible  in  the 
central  part  of  the  abdomen,  the  obstruction  is  in  the  small  intestine  ;  if  it  appears  to 
culminate  in  the  right  iliac  fossa,  this  is  likely  to  be  the  seat  of  disease.  Stiffening  of  a 
length  of  intestine,  which  can  be  seen  to  rise  up  and  felt  to  harden,  most  often  occurs  in 
the" colon,  and  especially  when  there  is  a  growth  near  its  lower  end.  The  most  marked 
peristalsis  and  stiffening  occur  when  acute  obstruction  is  a  sequel  of  chronic  obstruction  ; 
they  may  be  completely  absent  in  very  acute  primary  cases. 

"  (c).  Tumour.— The  diagnosis  of  intussusception  can  be  made  with  certainty  only  when 
the  characteristic  sausage-shaped  tumour  situated  somewhere  In  the  course  of  the  colon  is 
felt.  In  acute  obstruction  due  to  cancer  the  tumour  is  often  not  palpable,  as  it  is  generally 
hidden  by  the  dilated  intestine  ;  but  large  tumours  are  felt  sometimes,  especially  when 
present  in  the  right  or  left  iliac  fossa  :  the  former  are  generally  due  to  cancer  of  the  csecum, 
the  latter  to  cancer  of  the  iliac  colon  and  inflammatory  thickening  round  acquired  diverticula 
—a  condition  which  may  closely  simulate  cancer.     Gall-stones  can  hardly  ever  be  felt. 

(v).  Rectal  Examination. — A  growth  of  the  rectum  can  be  recognized  easily,  and  some- 
times a  growth  of  the  pelvic  colon  can  be  felt  through  the  front  wall  of  the  rectum.  In 
infants,  the  end  of  an  intussusception  may  be  felt  in  the  lumen  of  the  rectum,  and 
more  frequently  the  tumour  can  be  felt  on  bimanual  examination.  Obstruction  due  to 
pelvic  adhesions  can  often  be  recognized  by  the  presence  of  tender  masses  and  the  fixity 
of  some  of  the  pelvic  viscera.  The  presence  of  more  than  traces  of  faces  in  the  rectum 
in  cases  of  undoubted  obstruction  indicates  that  its  situation  is  probably  high  u])  in  the 


CONTRACTIONS  131 

small  intestine.  A  very  ballooned  rectum  suggests  obstruction  high  up  in  the  rectum  or 
in  the  pelvic  colon,  but  this  is  not  an  invariable  rule. 

(vi).  Pain. — When  the  jiain  is  localized,  or  moves  in  a  delinite  direction  to  reach  its 
greatest  severity  at  a  certain  j)()int,  the  latter  is  likely  to  be  near  the  seat  of  the  obstruction. 
When  the  pain  is  situated  in  the  middle  line,  the  obstruction  is  probably  in  the  small 
intestine  if  it  is  above  the  umbilicus,  and  in  the  colon  if  below. 

(vii).  Vomiting. — The  more  frequent  the  vomiting  and  the  earlier  the  onset  of  f;eculent 
vomiting,  the  higher  in  the  intestine  is  the  obstruction  likely  to  be.  It  is  most  severe  in 
small  intestine  obstruction  due  to  bands  or  internal  hernia  :  its  onset  is  later  and  its  occur- 
rence less  frequent  and  sometimes  only  after  food  in  cases  of  growth  and  volvulus. 

(viii).  Borborygmi  are  sometimes  most  marked  over  the  seat  of  the  obstruction. 

(ix).  Shock  and  Collapse  are  more  marked  the  higher  the  obstruction.  They  are  also 
much  greater  when  obstruction  is  accompanied  Ijy  strangulation  owing  to  bands  or  hernia 
than  when  strangulation  is  absent,  as  with  gall-stones  and  cancer. 

B.  SYMPTOM.VTIC. 

In  Acute  General  Diseases. — Constipation  beginning  acutely  is  a  frequent  symptom 
of  a  large  variety  of  acute  infective  and  other  diseases.  It  is  never  so  severe  that  it  cannot 
be  overcome  by  purgatives  or  enemata,  and  the  other  symptoms  are  so  much  more  striking 
in  the  majority  of  cases  that  the  presence  of  consti|)ation  has  Httle  iiilluence  in  forming  a 
diagnosis. 

In  Acute  Abdominal  Conditions. — Constipation  is  a  prominent  symptom  in  most  acute 
abdominal  conditions.  Other  symptoms  are  often  so  well  marked  that  the  question  of 
intestinal  obstruction  hardly  arises.  Thus,  the  diagnosis  can  generally  be  made  by  the 
early  tenderness  and  rigidity,  its  localization,  and  the  early  pyrexia  in  acute  peritonitis  due 
to  a|)pendicitis  or  the  perforation  of  an  ulcer  ;  the  characteristic  situation  and  radiation  of 
the  pain  in  renal  and  biliary  colic,  and  the  frequent  hfematuria  in  the  former  and  jaundice 
in  the  latter  :  the  presence  of  a  timiour  when  an  ovarian  cyst  is  twisted  ;  the  meliena  and 
occasional  hu-matemesis.  and  the  presence  of  a  primary  disease  in  the  heart  or  abdomen 
in  7ne.ienteiir  cinholisni  and  tlironihosis  respectively.  Some  cases  of  acute  pancreatitis  are 
clinically  almost  indistinguishable  from  intestinal  obstruction,  but  flatus  is  generally  |)assed  : 
there  may  also  be  a  history  of  biliary  colic,  and  the  patient  is  generally  fat,  middle-aged, 
and  alcoholic.  The  diagnosis  is  seldom  made  with  certainty  until  the  typical  fat-necrosis 
is  seen  on  opening  the  abdomen.  In  lead  colic  (he  constipation  is  not  absolute,  and  the 
occupation  of  the  patient  and  the  blue  line  on  Ihe  gums  (p.  34)  suggest  the  correct 
diagnosis.  Arthur  /•'.   Hertz. 

CONTRACTIONS,  Athetotic,  Choreiform,  Fibrillar,  Spasmodic,  and  Tetanic^ 

ar(  all  to  be  delined  for  present  purposes  as  involuntary  and  i)ainless  contractions  occurring 
in  the  voluntiirv  nmseles.  I'Yom  Conth.xctitiik.s  (p.  ];J8)  they  may  be  distinguished  by  their 
short  duration,  longer  or  shorter  intervals  in  which  the  affected  muscles  are  relaxed  occurring 
between  t^he  separate  contractions.  From  cramps  they  differ  by  being  painless,  or  com- 
paratively so,  and  also  by  their  sh(jrt  duration.  IJut  in  many  cases  it  is  impossible  and 
also  unceessary  to  draw  any  hard-and-fast  line  showing  where,  for  example,  tetanic 
contractions  cease  and  tetanic  cramps  begin.  In  all  eases  Ihe  occurrence  of  the  contractions 
mentioned  mIxinc  immn  he  taken  to  indicali-  soriii-  iliseasr  of  Ihe  nervous  system,  usually 
organic  hut  suriicl  inics  tunclional. 

ATHETOTIC     CONTRACTIONS,     ATHETOSIS,     OR     MOBILE     SPASM. 

.\thetosis  is  a  I'oru)  of  in\-oluntary  movement  alTceting  the  lingers,  hands,  and 
wrists  most  often  :  less  often  the  toes  and  feel,  anil  in  rare  insl.anees  Ihe  lace.  It  is 
usnallx-  unilateral,  but  in  exceptional  eases  bilateral — Ihe  •double  athetosis"  of  l''reneli 
nciiriilogisls.  The  movements  arc  sjjontancous  and  inecssiint,  and  may  even  continue 
while  the  pal  ieiil  is  asleep  ;  in  other  instances  they  tend  to  cease,  but  are  started  anew  <>i' 
exaggerated  when  voluntary  movement  is  attempted.  In  the  hand,  the  moveinenis  eonsisi 
of  a  succession  of  slow  and  serpentine  llexions,  extensions,  hyperextensions,  and  lateral 
motions,   all   eotnbincil    In  cause   Ihe   tinixers   and    llinnih   lo  cxeenle   Ihe   ninst    curious  and 


132 


CONTKAfTIOXS 


complex  cliitchinii-  or  spreading  movements  (Fig.  57).  The  wrist  is  held  more  or  less  flexed  : 
the  fingers  may  move  about  together,  or  wander  each  individually.  Analogous  movements 
are  observed  when  athetosis  occin-s  in  the  lower  extremity,  or  the  mouth  and  face.  N*) 
great  regularity  characterizes  the  motions  of  athetosis  ;  as  a  rule  they  are  steady  rather 
than  violent  ;  a  large  amount  of  voluntary  control  over  the  affected  parts  is  retained. 
Mobile  spasm  is  due  to  varying  degrees  of  central  irritation  of  muscles  that  are  incom- 
pletely paralyzed  and  somewhat  spastic. 

Primary,  idiopathic,  or  primitive  athetosis  is  a  rare  disease  of  childhood  or  of  adult  life, 
in  which  bilateral  athetotic  contractions  first  make  their  appearance  in  a  previously  healthy 
person,  either  for  no  particular  reason,  or  after  a  chill  or  a  nervous  shock.  It  may  be 
associated  with  epilepsy  or  insanity.  This  form  appears  not  to  be  connected  with  any 
gross  changes  in  the  nervous  system,  thus  diflering  from  all  other  conditions  in  which 
athetosis  is  seen. 

Athetosis  is  conmion  in  the  various  sj>aslic  paraplegias  of  in{a)its  and  children,  whicii 
may  be  either  congenital  or  aciiuired  :  in  Congenital  cerebral  diplegia,  also  known  as 
Little\s  disease  wlien  the  legs  are  affected  chiclly.  the  ncr\<ius  structures  suffer  from  an 
inherited  taint    (alcoholism,    syphilis,    insanity),   and   either    fail    to   dexclop   properly,   or 

degenerate  early  in  life.  The  onset  of  Little's 
disease  is  gradual,  and  usually  early,  but  it  may 
be  delayed  until  the  child  is  as  much  as  six  or 
eight  years  old.  Tlie  patient  is  backward  or 
mentally  deficient,  probably  unable  to  walk,  and 
alllicled  with  bilateral  spastic  paralysis.  This 
may  affect  the  legs,  the  legs  and  arms,  or  even 
the  whole  body,  and  may  be  more  marked  and 
more  spastic  on  one  side  of  the  body  than  on 
the  other  ;  speech  is  defective,  optic  atrophy 
conunon,  and  the  gait  is  clumsy  and  stiff,  "  cross- 
legged  ■  or  '  scissor.'  Involuntary  movements 
occur  in  the  affected  members,  and  are  athetotic 
or  choreiform  ;  tremor  or  intention-tremor  is  also 
not  infrequent.  Although  it  may  not  appear  for 
some  years  after  birth,  this  is  really  a  congenital 
disorder,  and  it  is  to  be  distinguished,  for  reasons 
connected  with  its  pathological  anatomy  and 
etiology,  from  certain  other  forms  of  spastic 
paralysis  in  infants  and  children  that  may  closel>- 
resemble  it  clinically.  These  are  the  acquired 
cerebral  paralyses  of  itifanls.  the  spastic  infantile 
hemiplegias,  monoplegias,  diplegias,  triplegias,  paraplegias,  that  result  from  more  or  less 
localized  cerebral  inflammations  or  lucmorrhage  occurring  at  birth  or  in  infancy.  Poren- 
cephaly, or  the  occiu-rence  of  lacunae  in  the  tissues  of  the  cortex  or  brain,  may  be  found 
in  cither  the  congenital  or  the  acquired  cerebral  paralyses  ;  it  is  really  a  post-mortem- 
room  term,  and  re(|uires  no  special  consideration  here. 

Acquired  spastic  paraplegias  fall  into  two  categories,  according  to  their  etiology  : — 

1.  Jiirth  palsies  :   due  to  meningeal  or  cortical  ha?niorrhage  caused  by  ])rolonged  labour 

or  the  use  of  instruments.     Many  of  these  infants  Iuiac  been  born  prematurely. 

2.  Ac(pmed  jmlsies  :   due  to — 

Encephalitis  after  an  acute  specific  fever,  or  infective  in  origin. 

Polio-encephalitis,  the  cerebral  analogue  of  acute  poliomyelitis  in  the  anterior 
cornua  of  the  cord. 

Cerebral  embolism. 

Cerebral  or  meningeal  ha-morrhage  or  thrombosis. 
The  birth  palsies  are  due  to  injuries  received  in  the  process  of  birth,  and  the  rupture 
of  meningeal  or  cerebral  blood-vessels,  with  the  escape  of  blood  ;  they  develo])  at  once, 
and  the  history  of  the  case  should  make  diagnosis  easy.  The  diagnosis  of  the  exact  cause 
of  an  aciiuired  s/iaslic  paralysis  in  an  infant  or  child  may  be  less  easy.  The  jjaralysis  due 
to  encephalitis  generally  appears  during  the  first  two  or  three  vears  of  life,  but  ma\-  come 


Fiff. 


CONTRACTIONS  133 

on  at  almost  any  age.  Cerebral  tlironibosis  in  children  is  said  to  happen  oftenest  at  about 
the  age  of  six.  Cerebral  embolism  is  likely  to  be  seen  in  infants  or  children  with  acquired 
Ijeart-disease.  the  embolus  being  derived  from  vegetations  on  the  mitral  or  aortic  valves, 
or  from  tluombi  tluit  have  formed  in  backwaters  of  the  (lilate<l  left  auricle  or  ventricle. 
These  infantile  hemiplegias  or  diplegias  are  of  sudden  onset,  and  are  characteristically 
spastic.  Athetotic  movements,  with  or  without  choreiform  contractions,  trophic  lesions, 
and  tremors,  are  common  in  the  affected  limbs  :  the  children  often  grow  up  to  exhibit 
mental  defect,  imperfect  speech,  or  epilepsy.  As  a  rule,  the  face  is  less  involved  than  the 
arm  or  leg,  and  the  athetotic  movements,  confined  to  the  affected  parts,  may  not  begin 
initil  years  after  the  occurrence  of  the  original  cerebral  lesion. 

Post-hemiplegir  athetosis,  which  cannot  be  marked  off  sharply  from  post-heniiplegic 
chorea  (see  p.  134).  is  an  uncommon  sequela  of  hemiplegia  in  the  adult  ;  but  common — 
being  seen  in  about  a  third  of  the  cases — in  the  congenital  and  acquired  hemiplegias  just 
considered.  In  the  adult  it  occurs  oftenest  when  the  lesion  is  situated  near  the  posterior 
l)art  of  tlie  internal  ca])sule  or  the  0])tie  thalamus.  These  athetotic  movements  of  the 
extremities  liave  been  described  already  :  in  the  adult,  they  may  be  combined  with 
choreiform  contractions  involving  the  whole  arm  and  shoulder,  and  the  face.  The 
diagnosis  should  not  be  difficult,  as  the  history  of  a  stroke  will  be  obtained  and  the  physical 
signs  of  a  hemiplegia  will  be  present. 

CHOREIFORM    CONTRACTIONS. 

These  arc  similar  to  the  contractions  seen  in  chorea.  They  are  involuntary  and  inco- 
oidinated  movements.  )nirposive  in  character,  but  aimless  and  ineffective  in  performance. 
'I'hey  arc  jerky,  rajiid.  and  highly  irregular;  grou]is  of  muscles  are  put  into  action  successively, 
as  if  the  original  intention  were  given  up.  or  changed,  as  soon  as  the  complex  movement 
began.  They  may  affect  one  side  of  the  body  only,  or  both.  When  mild,  they  amoimt  to 
no  more  than  excessive  fidgetiness,  involving  perhaps  only  the  hands  and  arms,  or  the 
hands,  arms,  and  face,  in  wriggling  and  grimacing.  When  severe,  they  give  the  patient 
no  rest  :  he  is  tossed  about.  ])erhaps  with  the  idmost  violence,  by  combined  but  irregular 
contractions,  in  which  any  of  the  voluntary  muscles  may  partiei|)ate.  t'horeilorni  con- 
tractions bear  no  resemblance  to  tremors,  whether  coarse  or  line.  From  iiiteiition-tremorx 
they  arc  distinguished  by  the  facts  that  they  continue  when  the  patient  is  at  rest,  that 
they  are  purposive,  and  resemble  ordinary  voluntary  movements  misapplied.  From 
ataxia  they  arc  distinguished  by  occurring  at  rest  as  well  as  on  attempted  movement  :  the 
muscular  cfintractions  of  ataxia  are  merely  inco-ordinatcd.  apparently  ill-designed  and 
clumsily  executed,  types  of  normal  mo\ements. 

ClinrcirorMi  cnril  i'mcI  inns  ai'c'  seen   111  I  he  Idllduing  cciiKliliDiis  :  — 

(  Ikiicu    iiiiiKii-,    or'     St.    \'itus"s     (lance:     I      I'r'c-lieiiiiplegie     chorea:        )iost-lienii|)l('<iie 
chronic  or  limit  iiigton's  chorea  ;  chorea     j  chorea  :  spastic  paralyses  of  iiilanls  ;  coill 

major,  or   iiaiiilcmic  chorea:  hysteria.     '  ciil  sclerosis:    eliorea  eleetrlea  (llciioi'li). 

Chorea,  clioren  niiiinr.  iiciilc  chunii.  or  .S7.  I' Una's  ddtiee.  is  an  acute  disease  of  childhood 
or  adolcsf'cnce.  conmioner  in  girls  llian  boys,  and  closely  comiccted  with  a  history  of 
rheumatism,  and  with  rhciunatic  endocarditis.  Like  rheinnatisni.  it  is  often  a  family 
disease  :  not  infrequently  one  finds  that  one  or  two  children  in  a  large  rheumatic  family 
have  had  rheumatic  fever  or  rheumatism,  anolher  chorea,  and  iiiiotlier  both  rhcimwitie 
fever  an<l  chorea.  It  is  commonly  and  erroneously  held  that  scNcre  rriglit  may  by  itself 
be  the  ciiiise  of  an  attack  of  chorea.  It  may  also  occur  in  adults  in  connection  with  preg- 
naiiry.  u  lien  it  is  soiiiel  inns  of  a  severe  Ixpe.  :inil  may  run  on  iiilo  ins;inily.  The  movc- 
riierils  iiia\  he  eonlineil  to  one  side  of  the  body  heliiieliorea  or  may  alTecl  holh  sides; 
llic  niiiseles  iire  in  general  weak,  speech  may  be  int<rfere(l  with,  respiration  is  often  jerky, 
and  the  patient  is  often  unduly  irritable  anrl  emotional.  I'^xccpt  in  the  severest  eases  the 
iiiovcmenis  cease  during  sleep  :  the  disease  tends  to  recovery  in  the  course  of  perhaps  two 
or  iliKc  nioiillis.  .Mild  cases  in  which  the  face  is  most  affected  may  present  a  certain  resem- 
blance to  I  he  more  chronic  and  (|uitc  uncomiccted  disorder  known  as  habit-spasm,  lialiil- 
iliiin-a.  or  ((iiivalsiju-  tic  (see  Si'.\s.Moi)K'  C'onthactions,  p.  i:il>).  A  laeial  ti<'  is  controlled 
for  a  lime  by  strong  efforls  of  the  will,  whereas  the  facial  movciiienls  of  chorea  will  usually 
lie    Irienased    liv    the    eoneeiit  rat  ion    of    tin-    allinii ii    llii  in  :     llie    l'aei;il    nioxcnieiits 


134  CONTRACTIONS 

of  chorea  are  irregular,  representing  a  succession  of  various  purposive  but  uncompleted 
actions,  while  the  facial  tic  consists  in  tlie  repetition  of  a  single  definite  and  purposive 
movement,  originally  designed,  no  doubt,  to  give  relief  to  some  local  irritation. 

Chro?iic,  degenerative,  or  Huntington^ s  ehorea.  is  a  rare  hereditary  disease  coming  on  at 
the  age  of  thirty  or  forty,  associated  with  slow  and  difficult  speech  and  with  insanity.  The 
involuntary  movements  are  slower  and  more  ataxic  than  those  of  acute  chorea,  and  can 
often  be  suppressed  for  a  time  by  exercise  of  the  will.  They  affect  the  extremities  and  face, 
are  coiiliniious.  cease  (hiring  sleep,  and  are  accentuated  by  excitement,  so  that  at  first  sight 
acute  chiirea  may  l)e  imitated  fairly  closely.  The  diagnosis  between  this  chronic  chorea 
and  an  acute  chorea  tliat  had  become  chronic,  as  sometimes  happens,  would  turn  on  the 
family  history,  mental  symptoms,  age  at  onset,  and  the  course  of  the  disease.  Chronic 
chorea  is  incurable,  and  may  take  twenty  years  or  more  to  run  its  course  :  mental  failure 
occurs  early,  and  is  progressive  :   and  a  family  history  of  chronic  chorea  can  be  obtained. 

Chorea  major,  or  pandemic  chorea,  is  an  epidemic  hysterical  manifestation  occurring  in 
the  more  emotional  races  of  Europe  imder  the  influence  of  religious  excitement.  Chorei- 
form movements  are  among  the  less  conspicuous  of  its  motor  phenomena  ;  it  is  unknown 
in  the  more  phlegmatic  northern  races. 

In  hysteria  the  motor  plienomena  are  notoriously  i)rotean.  Should  a  hysterical  patient 
have  had  chorea  herself,  or  should  she  have  had  the  opportunity  of  observing  it  in  others, 
she  may  reproduce  its  characteristic  movements  with  great  accuracy.  The  diagnosis  may 
be  very  difficult  for  a  time,  particularly  if  the  patient's  previous  history  be  not  known,  and 
hysteria  not  suspected.  Her  temperament  will  probably  lead  her  to  develop  other  signs 
or  symptoms  that  suggest  the  true  diagnosis  ;  such  as  tremors,  paralyses,  contractures, 
hemi-anaesthesia,  anaesthesia  of  the  stocking  and  glove  distribution,  exaggeration  of  the 
deep  reflexes,  or  attacks  of  hysterics.  Remission  of  the  choreiform  movements  and  of  the 
local  symptoms  generally  may  occur  wlien  the  hysterical  patient  thinks  she  is  no  longer 
imder  observation,  or  when  her  attention  is  diverted  elsewhere.  The  hysterical  patient 
simulating  chorea  or  hemichorea  is  likely  to  overdo  the  part. 

Choreiform  movements  may  occur  in  connection  with  hemiplegia  in  two  forms.  Pre- 
liemiplegie  chorea  has  been  recorded  in  a  few  cases,  twitchings  or  even  choreiform  move- 
ments beginning  in  the  limbs  of  one  side  of  the  body  shortly  before  the  onset  of  an  apoplectic 
stroke.  Post-hetniplegic  chorea  is  commoner,  and  more  often  seen  in  children  than  in  adults. 
After  a  hemijjlegia  more  or  less  muscular  spasm  and  movements  of  one  kind  or  another  are 
habitually  seen  on  the  affected  side  of  the  body.  In  many  patients  these  movements  take 
the  form  of  tremors,  fine  or  coarse  ;  in  others  they  are  athetotic  :  in  others  again  they  are 
ataxic,  occurring  only  when  voluntary  movements  are  attempted  :  and  in  yet  others  they 
are  choreiform.  Wliich  of  these  forms  of  muscular  contraction  is  likely  to  occur  in  any 
given  case  it  is  impossible  to  say  ;  they  are  all  due  to  combinations  of  cerebral  irritation, 
muscular  spasm,  and  muscular  paralysis,  mixed  together  in  varying  proportions. 

The  clioreiform  movements  occurring  in  the  spastic  paraplegias  of  infants  and  children. 
conditions  that  have  been  more  vaguely  described  as  cortical  scleroses  on  the  strength  of 
their  post-mortem  aj>pearances,  are  to  be  regarded  as  variants  of  the  athetotic  contractions 
already  considered  above.  Henoch's  chorea  electrica  is  considered  below  :  it  is  the  muscles 
of  the  neck  and  shoulder  that  are  chiefly  involved  in  this  rare  disorfler. 

FIBRILLAR     CONTRACTIONS. 

Fibrillar  contracti(ms  of  the  nuiscles.  or  fascicular  muscular  twitchings,  are  small 
spontaneous  movements  visible  on  the  surfaces  of  muscles,  rhythmical  or  irregular,  involving 
not  the  whole  muscle,  but  only  single  muscular  bundles  in  it.  They  may  be  confined  to  a 
few  of  the  bundles,  or  may  occur  irregularly  in  any  of  the  bundles  composing  a  muscle. 
They  are  almost  always  too  feeble  to  produce  visible  movements  at  the  joints  ;  they  are 
increased  in  fatigue,  and  when  the  muscle  is  mechanically  stimulated.  Similar,  but  coarser, 
twitchings  may  be  seen  in  normal  muscles  when  tliey  are  over-fatigued,  or  on  exposure  to 
cold.  The  finest  fibrillar  contractions  are  said  to  occur  only  in  cases  of  organic  disease  in 
the  central  nervous  system.  They  are  seen  most  freely  in  muscles  that  are  degenerating 
or  undergoing  atrophy,  or  are  shortly  about  to  atrophy,  as  the  result  of  disease  in  the  lower 
motor  neuron  ;    they  cease  to  appear  when  the  muscle  is  much  wasted.     The\-  are  most 


CONTRACTIONS  135 

evident  in  the  extremities  and  tongue,  and  no  doubt  are  due  to  irritation  of  motor  nerve- 
cells  in  the  cord  or  bulb  that  are  hyper-excitable  because  they  are  degenei'ating. 

From  a  diagnostic  point  of  view,  fibrillar  contractions  are  important  because  for 
practical  purposes  they  do  not  occur  in  the  mi/opathies  or  primary  muscular  di/strophies 
that  are  due  to  lesions  in  the  muscles  themselves  and  not  in  the  spinal  cord.  In  only  a  few 
recorded  cases  have  these  fibrillations  been  seen  in  cases  of  myopathy  where  lesion  of  the 
central  nervous  system  could  be  excluded.  Neurologists  and  myologists  have  devoted 
much  attention  to  primitive  myopathy,  with  the  result  that  it  has  become  burdened  with  a 
highly  elaborate  classification  and  nomenclature.  Thus  the  condition  generally  has  been 
described  as  primary  progressive  myopathy,  progressive  muscular  dystrophy  (Erb),  idio- 
jiathic  muscular  atrophy  and  hypertrophy,  jjrimitive  progressive  myopathy,  muscular 
dystrophy.  myo|)athy. 

Special  forms  of  it  have  been  raised  to  the  dignity  of  '  types."  the  chief  of  which  are 
the — 

Simple  atrophic  (Erb)           I         Facio-scapulo-hiinieral  .Mixed  and  transitional 

Pseudo-hypertrophic               |             (Landouzy  and  Dcjcrinc)  (Leydcn     and     Mocbius  : 

.Juvenile  (Erb)                           I         Distal  (Gowers)  Zininicrlin). 
Myotonia  atrophica 

Distinctions  Ijctwccn  these  various  forms  must  be  sought  in  special  manuals.  Tlieir 
iniportanoe  for  present  purjjoses  consists  in  this — that  fibrillary  contractions  may  occur  as 
a  rare  exception  in  most  of  them. 

Contrariwise,  librillar  contractions  are  observed  habitually  in  the  course  of  the  pro- 
gressive muscular  atrophies  of  neuropathic  origin,  variously  known  imder  such  names  as — 
chronic  anterior  poliomyelitis,  amyotrophic  lateral  sclerosis  (Charcot),  progressive  bulbar 
paralysis,  progressive  muscular  atrophy,  toxic  degeneration  of  the  lower  motor  neuron. 
Werdnig-Hoffmann  progressive  muscular  atro])hy  of  infants,  according  to  their  special 
characters.  In  all  of  these,  the  lower  motor  neurons  are  [jrimarily  at  fault,  exhibiling  slow 
or  rapid  degeneration  ;  in  many  cases  the  up])cr  motor  neurons  are  also  alfected,  either 
simultaneously,  or  before  or  after  the  lower.  As  a  rule,  no  cause  for  the  degeneration  can 
be  discovered  ;  but  many — perhaps  a  half — of  the  patients  have  previously  had  acute 
poliomyelitis.  Occurring  in  infants  or  children,  this  neuropathic  muscular  atrophy  is 
generally  of  the  Wcrdnig-IIolfmann  type,  affecting  the  legs  first,  and  spreading  upwards 
to  the  body  and  arms  ;  the  hands  and  feet  are  affected  late,  and  the  deep  rellexes  vanish. 
The  condition  may  at  flr.st  sight  resemble  rickets,  but  in  rickets  there  is  no  real  muscular 
atrophy,  the  deep  reflexes  arc  retained,  and  fibrillar  contractions  do  not  occur.  It  may  be 
indistinguishable  from  one  of  the  primary  myoi)athies  considered  above  ;  but  the  occur- 
rence of  fibrillar  contractions  would  make  the  diagnosis  of  neuropathic  muscular  atrophy 
the  more  probable. 

In  a/lulls  I  lie  disease  may  conform  to  one  of  several  types,  according  to  the  distributicin 
ol  the  atrophy.  In  some  instances  the  lower  motor  neurons  of  the  hand,  arm,  and  neck 
are  attacked,  when  the  Claw-hand  (p.  109)  may  result  ;  in  others,  the  lower  extremities 
may  first  show  the  degeneration.  Charcot's  amyotrophic  lateral  sclerosis  is  characterized 
by  spasticity  of  the  legs  C(imbirii(l  with  atrophy  of  the  muscles  of  the  hands  and  arms.  In 
making  the  iliagnosis  of  ii(uni|)atliie  muscular  atrophy  it  must  be  remembered  that  the 
onset  is  gradual,  that  librillar  contractions  are  present,  that  the  atrophy  proceeds  pari 
passu  with  the  loss  of  power,  and  that  sensation  and  the  sphincters  are  not  involved.  The 
electrical  changes  in  the  muscles  are  of  assistance,  too,  the  partial  Ukvction  oi'  I)kc;i;ni;ua- 
TION  (p.  ,582)  being  exiilbited  ;  the  nerves  react  iiorniMJjy  In  iMiailiMii.  and  to  galvanism  so 
long  as  there  iirc  muscle  fibres  left  to  respond  In  llir  si  iinulal  imi.  \\liilc  liii-  nuiseles  read 
sluggishly,  and  .\.C.C.  is  often  greater  than  K.(  .(  . 

liiilliar  paraljisis  is  due  to  lesions  of  the  medulla  oblongata,  and  the  nerves  mainly 
alTeetcd  arc  the  motor  part  of  the  lil'lh.  the  seventh  (facial),  the  ele\(iilh  (spinal  accessory) 
and  tweirth  (hypoglossal).  In  oilier  eases  (ipiil  lialnioplegia  is  observed  as  well.  It  is  only 
111  the  chronic  cases  of  biiibai-  paralysis  thai  librillar  eontraelions  are  seen,  and  they  are 
particularly  w<ll  shown  in  I  lie  Inngiie.  which  lias  been  ileseiibcd  as  looking  "like  a  bag  hall 
full  of  worms."  The  main  syinplonis  will  be  dillieiilty  in  art  iiiilation.  |)honation.  mastica- 
tion, and,  most  of  all,  in  swallowing. 


CONTRACTIONS 


SPASMODIC    CONTRACTIONS. 


In  general  parlance,  the  epithet  '  spasmodic  "  implies  suddenness  and  short  duration. 
These  characteristics  are  not  implied  by  the  word  as  it  is  used  clinically.  Hence  it  is  neces- 
sary to  distinguish  between  spasmodic  contractions  or  muscular  sjiasms  of  three  kinds, 
according  as  they  are  : — (1)  Short  and  single — the  muscular  twitch  ;  (2)  Short  and  repeated — 
doniis  or  clonic  spasms  :  (3)  Tetanie — commonly  and  imj)roperly  known  as  tonic  spasms  : 
these  ;irc  lona-sustaincd. 

Single  Spasmodic  Contractions  of  a  muscle  or  group  of  muscles,  over  in  a  fraction  of 
a  second,  may  occm-  in  normal  persons  who  are  suffering  from  great  fatigue,  overwork,  or 
nervous  exhaustion.  For  no  apparent  reason,  and  frequently  just  as  the  person  is  going 
off  to  sleep,  a  sudden  violent  twitch  in  one  or  more  of  the  limbs  occurs,  and  wakes  him  up. 
In  other  cases  these  sudden  starts  may  occur  when  the  patient  is  resting  by  day.  In  ahnor- 
matii/  neri'oiis  or  e.rcitaltle  patients  such  sudden  spasms  are  seen  more  frequently,  and  often 
result  from  some  sudden  and  imexpected  sensory  impression — a  sound,  sight,  or  touch. 
The  diagnosis  of  such  spasms  in  nervous  or  jumpy  patients  should  not  be  difficult,  the 
affection  being  very  chronic,  and  no  doubt  familiar  to  the  patient  and  the  patient's  entour- 
age. Coming  on  suddenly,  this  juiiipiness  may  be  a  minor  sign  of  various  nervous  disorders, 
such  as  hysteria,  acute  chorea,  delirium  tremens,  general  paralysis,  or  Graves's  disease. 

Single  twitches  of  muscles  or  of  groups  of  muscles  form  the  outstanding,  feature  of  the 
simpler  forms  of  a  series  of  affections  known  as  liabit  spasms  or  spasmodic  tics.  A  habit 
spasm  consists  in  the  involuntary  repetition  of  some  ordinary  co-ordinated  purposive  act. 
In  many  instances  the  tic  was  at  first  a  natiu'al  reflex  act.  designed  to  allay  some  transient 
irritation.  Thus  a  blinking  tic  may  have  been  initiated  by  the  pain  caused  by  a  foreign 
body  in  the  eye,  or  conjunctivitis  ;  a  sniffing  tic  by  some  temporary  itching  about  the  nares, 
or  it  may  be  associated  with  the  presence  of  adenoid  growths  in  the  nasopharynx  ;  a  shoulder- 
shrugging  tic  by  some  irritation  of  the  neck  due  to  a  tight  or  rough  collar.  By  voluntary 
re|)etition  such  an  act  ultimately  becomes  automatic,  when  it  is  spoken  of  as  a  habit  spasm 
or  tic.  These  motor  tics  exist  in  great  variety,  oftenest  affecting  the  face,  less  often  the 
jaws,  neck,  or  limbs  ;  they  are  so  common  as  to  escape  conunent  in  their  minor  manifesta- 
tions— mannerisms  and  stereotyped  acts — being  set  down  merely  to  •  individuality.' 
Most  tics  can  be  controlled  by  mental  effort  with  some  distress,  are  increased  by  emotion, 
cease  during  sleep,  and  are  cm-able  only  with  great  difficulty  when  well  established.  In  all 
cases  the  patient  is  supposed  to  exhibit  a  certain  psychical  weakness. 

Blore  violent  and  shock-like  muscular  s]5asnis  are  seen  in  the  rare  condition  known  as 
myoclonus  or  paramyoclonus  multiplex.  Myoclonic  movements  are  particularly  sudden 
and  violent,  occurring  bilaterally,  or  first  on  one  side  of  the  body  and  then  on  the  other  ; 
they  are  painless,  but  may  give  rise  to  much  inconvenience  by  their  violence.  They  are 
increased  by  emotion  and  cease  during  sleep.  They  may  be  single,  but  more  often  are 
clonic,  repeated  perhaps  fifty  or  a  hundred  times  in  a  minute.  In  paramyoclonus  multiplex 
there  are  no  mental,  sensory,  or  siihincter  changes,  and  this  rare  disease  is  described  as 
both  familial  and  hereditary.  In  hi/stcria.  myoclonus  is  seen  exceptionally,  accompanied 
by  other  hysterical  manifestations.  In  certain  rare  forms  of  epilepsy,  the  so-called  myoclonic 
epilepsy,  these  paroxysmal  asynchronous  bilateral  lightning-like  movements  have  been 
recorded  ;  the  diagnosis  will  be  easy  here,  as  the  patient  exhibits  the  jjhenomena  of  major 
epilepsy — loss  of  consciousness,  relaxation  of  the  sphincters,  etc. — in  addition  to  the  sudden 
and  forcible  myoclonic  movements.  In  certain  cases  of  minor  epilepsy,  oi-  j)etit  mal,  the 
affection  may  take  the  form  of  spasmodic  twitches  of  the  muscles  of  a  limb,  or  of  the  face, 
associated  with  a  brief  absent-mindedness  or  a  few  seconds  of  loss  of  consciousness  without 
loss  of  automatic  control  over  the  body  generally. 

Clonic  Spasmodic  Contractions,  clonic  spasms,  or  clonus,  are  in  reality  interrupted 
tetanic  contraetions.  consisting  in  the  rhythmical  and  more  or  less  rapid  repetitions  of  the 
single  brief  imiseular  spasm  or  twitch.  .\  typical  clonus  of  muscles  in  the  arms  or  legs  may 
often  be  produced  in  health  by  the  adoption  and  maintenance  of  some  strained  position. 
Thus  ankle-clonus  is  soon  produced  if  a  normal  person  sits  in  a  chair  and  strains  the  heels  up 
while  the  toes  are  held  pressing  on  the  floor.  Such  clonus  is  physiological,  being  due  to 
heightening  of  the  muscle  tone  or  normal  state  of  tonic  muscular  contraction  by  the  applica- 
tion of  mechanical  tension  to  the  calf  nniscles. 


CONTRACTIONS  137 

Pathologically,  clonic  spasms  are  seen  typically  in  tlie  second  or  clonic  stage  of  niiijor 
tjjiltpsfj.  where  they  succeed  the  initial  tetanic  (or  tonic)  stage.  Here  they  are  universal 
and  bilateral  as  a  rule,  although  one  side  of  the  body  may  be  involved  more  than  the  other, 
or  the  arms  more  than  the  legs.  Consciousness  is  lost,  and  the  sphincters  are  often  relaxed. 
Mild  and  limited  clonic  .spasms  of  a  few  muscular  groups,  without  loss  of  consciousness 
and  lasting  for  only  a  few  seconds,  may  be  seen  in  patients  with  major  epilepsy,  and  are 
often  described  by  them  as  "  warnings.'  Such  attacks  are  identical  with  those  of  minor 
cpilc|)sy.  In  certain  epileptic  patients  they  seem  to  be  to  some  extent  under  control,  so 
that  their  threatened  onset  can  be  prevented  if  the  jjatient  can  sit  or  lie  down,  for  example, 
or  can  press  on  or  constrict  the  limb  in  which  the  spasms  are  about  to  appear.  The  diagnosis 
of  lii/slero-epilepsi/  is  sometimes  made  in  these  patients  ;  but  the  term  is  not  a  good  one,  and 
is  often  misleading.  Very  similar  convulsive  seizures  may  be  met  with  in  patients  with 
clironic  nephritis  (urcemic  convulsions)  and  in  pregnant  women  (echimpsia).  The  clonic 
stage  of  epilepsy  may  be  imitated  unconsciously  by  patients  with  hysteria,  or  frankly 
mimicked  by  the  malingerer.  In  hysteria  the  onset  of  the  fit  is  gradual,  not  sudden  ;  con- 
sciousness is  impaired,  not  lost  ;  the  pupil  reacts  to  light,  and  is  not  immobile  as  in  epilepsy  ; 
.screaming  and  purposive  movements  occur  throughout,  and  the  fit  is  often  protracted  : 
the  sphincters  are  not  relaxed,  and  the  tongue  is  not  bitten.  The  malingerer  is  red  and 
heated  by  the  effort  of  i)roducing  the  clonic  sjjasms,  his  consciousness  is  fully  preserved, 
and  he  reacts  to  painful  stinuili  that  leave  the  epileptic  unmoved.  Both  the  liystirical 
patient  and  the  malingerer  show  quivering  of  the  eyelids,  and  are  likely  to  resist  atteui|)ts 
to  open  the  eyes. 

In  Jacksonian  epilepsy,  clonic  convulsions  occur  without  loss  of  consciousness  :  they 
are  usually  unilateral,  starting  in  some  given  muscle  and  spreading  thence  until  both  limbs 
or  half  the  body  are  convulsed.  Transient  paresis  from  exhaustion  may  be  noted  after- 
wards in  the  affected  muscles.  In  severe  or  long-established  cases  the  whole  body  may  l)e 
convulsed,  or  a  tetanic  stage  may  occur  after  the  clonus  ;  in  these  instances  consciousness 
may  be  lost.  Jacksonian  or  focal  epilepsy  may  result  from  any  form  of  local  irritation  of 
the  motor  cortex — trauma,  ha-morrhage,  new  growth,  the  effects  of  syphilis,  chronic  inflam- 
niation.      It  leads  in  the  long  run  to  paresis  and  atrophy  of  the  affected  muscles. 

As  the  names  im])ly.  the  very  rare  conditions  known  as  tnyiirloiiiis  and  piiratiiyiirloniis 
iiiiiltiple.v  cxiiibil  typical  clonic  contractions.  The  elomis  occurs  in  single  nuiscles  or  nuiscle- 
groups,  such  as  the  biceps  and  su]>inator  lougus,  the  (piadriceps  femoris  and  scmitcudi- 
nosus  ;  rarely  in  the  face  :  from  50  to  150  contractions  a  minute  may  occiu'.  Henoch's 
chorea  cicclrica  is  the  same  as  myoclonus.  It  is  said  that  animals  from  which  the  jiara- 
thyroid  glands  have  been  removed  may  exhibit  identical  sjiasms.  For  the  diagnosis  of 
myoelomis,  sec  above.  Clonic  spasms  of  the  neck-nniseles,  particularly  the  sternomastoids, 
are  common  in  tiirlirollis  or  wry-neck. 

Tetanic  Contractions,  tetanic  or  the  so-called  Ionic  spasms.  Physiologists  and  clini- 
cians holli  niaUc  use  of  the  two  terms  "  tetanic  '  and  Ionic"  hnl  uid'ortunatcly  employ 
llicni  in  (lilfcicnl  senses.  Physiological  "  tetaiuis  "  is  the  appMicnIly  steady  state  of 
nuiscnlar  conl  lacl  ion  exhibited  by  the  voluntary  muscle  al  work,  niainltiincd  by  I  lie  fusion 
of  separate'  nuisenlar  twitches  or  spasms  due  to  a  rapid  succession  of  nervous  stinndi.  It 
may  be  seen   in  a  single  muscle  or  in   many   logellui-.     Clinically,  however,  ■tetanus"  or 

■  tetanic  eonliaclions  '  have  come  to  be  associated  with  pain,  besides  being  of  some  dura- 
tion, and  llic  lerms  arc  used  only  when  a  large  number  of  muiscIcs  are  involved  sinudta- 
neously  :  Iclarius  of  a  single  nuiscle  is  referred  to  clinically  as  a  iriDti/)  (p.  i:$!)  and  150).  To 
llie  physiologist,  the  normal  resting  muscle  is  already  in  a  slate  of  "  Ionic  conlraelion,"  and 
exhibits  •  tonus."  This  nniscle-tone  is  mainlained  partly  by  local  or  peripheral  stimula- 
tion (mechanical  tension,  the  venosity  of  the  blood,  drugs  such  as  digitalis  or  veratria),  and 
partly  by  nervous  impulses  that  reach  the  nmseles  more  or  less  continuously  from  the 
motor  nciudus  of  the  central  ner\ous  system.  This  eenhal  elcnienl  of  muscular  tonus  is 
ri-:dl\  of  i(lle\  origin  and  due  lo  poslnre.  the  inaini  enaric<'  ol  llic  ciccl  altilndi-  :  (he  inolor 
iiii|iuUrs  (Icsccnding  in  answer  lo  ascending  inipnlsis  rcccixcd  by  I  lie  ccnl  ral  iiei\diis  syslein 
tidin  Ihe  nniscles  and  joints  eoneeined.      linl    llie  elinician   applies   llie  terms  ■  tonus"  and 

■  loriii'  conl  lacI  ions  '  lo  Ihe  se\cre  and  pathological  nuiscular  eon  I  I'liclions  seen,  for  ex;unple, 
in  (lie  liisl  slagc  of  niajoi'  epilepsy,  which  arc  pliysiologieally  and  seieni  ili(all\-  speaking 
Ichiuie.   iiol    loriir.      'I'his  clinical    misuse  of   Ihe   uord    ■Ionic"    is   wcll-eslablislied    and    time- 


138  CONTRACTIONS 

honoured,  but  only  serves  to  promote  confusion.  The  terms  "  tonic  spasm  '  and  '  tonic 
contraction  '  should  be  reserved  for  states  of  muscle-tone  that  are  raised  only  within  physio- 
logical limits,  and  are  not  pathological.  The  contractions  or  spasms  that  the  clinician  calls 
'  tonic  '  are  almost  always  pathological,  and  in  the  interests  of  uniformity  should  be 
described  as  "  tetanic,'  not  "  tonic'  Exaggerated  states  of  physiological  tone  and  the 
milder  degrees  of  pathologically  heightened  muscular  tonicity  are  described  clinically  as 
spastic  states  or  spasticity,  falling  short  of  tetanus  in  degree,  and  differing  from  both  tetanus 
and  cramp  by  being  painless.  They  are  detailed  under  tlie  heading  Contractures  (p.  139). 
Tyjiical  tetanic  (or  tonic)  spasms  are  seen  in  teUiiiiis.  Here  the  patient  has  become 
infected  by  Bacillus  fetani  (Plate  XX]'III.  Fig.  T.  ]).614),  through  some  known  or  unknown 
wound.  He  first  notices  stiffness  of  the  neck  and  jaws  ;  soon,  increasing  tetanic  spasm  of  the 
muscles  of  mastication  brings  on  trismus  or  lockjaw.  Spasm  of  the  facial  muscles  next 
brings  on  the  painful  grin  known  as  the  risus  sardoniciis.  and  presently  paroxysmal  tetanic 
spasms  of  great  violence  occur  in  practically  all  the  voluntary  muscles,  although  in  mild 
cases  in  children  the  spasm  may  proceed  no  further  than  the  muscles  of  the  face.  If  the 
spasms  are  strongest  in  the  extensors  of  the  back,  the  body  is  arched  backwards  till,  perhaps, 
the  heels  touch  the  head  (opisthotonus).  If  the  flexors  contract  most  powerfully,  the  body 
is  bent  forwards  (emprosthotonus) ;  in  some  cases  the  body  remains  straight  and  stiff  (ortho- 
tonus) when  the  flexors  and  extensors  are  balanced.  These  acutely  painful  paroxysms 
last  for  perhaps  a  few  seconds,  and  recur  at  varying  intervals  on  any  kind  of  stimulation  ; 
they  may  cause  death  by  asphyxia  or  heart-failure.  In  the  intervals  between  them,  a 
milder  but  still  painful  tetanic  (the  so-called  tonic)  contraction  of  the  muscles  is  maintained  : 
or,  in  milder  cases,  nothing  more  than  an  exaggerated  physiological  muscle-tone.  In  mild 
or  chronic  cases  of  tetanus,  the  signs  and  symptoms  will  be  far  less  severe  than  those 
described  above  ;  but  trismus  and  painful  muscular  contractions  will  still  occur.  In  some 
chronic  cases,  the  chief  sign  may  be  a  recurring  but  transient  risus  sardonicus,  perhaps  with 
some  stiffness  of  the  neck  ;  not  a  few  of  these  patients  have  been  treated  for  hahit-spasrn  or 
Itj/sterical  grimacing  for  a  time,  until  the  suspicion  of  tetanus  arose,  or  spread  of  the  tetanic 
spasms  to  the  trunk-muscles  made  the  diagnosis  more  obvious.  The  diagnosis  of  tetanus 
may  have  to  be  made  in  other  instances  from  impacted  wisdom  tooth  :  or  from  tnuseiilar 
rheumatism,  which  may  cause  stiff-neck  but  is  hardly  likely  to  set  up  trismus  ;  or  from 
spinal  mrningilis,  in  which  there  is  fever,  while  the  tetanic  spasms  occur  on  exertion,  and 
do  not  ]irimarily  affect  the  muscles  of  the  jaws,  and  great  pain  is  felt  on  moving  the  head 
and  neck. 

In  .'itrt/chnine  poisoning  trismus  is  absent  or  occurs  very  late,  the  extremities  are 
first  and  most  markedly  affected,  the  nuiscles  are  tiuite  relaxed  between  the  paroxysms, 
and  the  symiitoms  develop  rapidly — within  an  hour  or  two  of  the  administration  of  the 
drug.  In  tetaiiji  {]>.  2)  the  distribution  and  diu-ation  of  the  tetanic  contractions  should 
suffice  to  prevent  any  confusion  with  tetanus.  In  hydrophobia  there  should  be  a  history 
of  a  bite  by  some  animal,  most  often  a  dog  ;  mental  symptoms  are  prominent,  and  the 
spasms  affect  the  muscles  of  respiration  and  deglutition  most,  while  trismus  is  absent. 
In  hysteria  a  patient  may  exhibit  trismus,  tetanic  spasms,  and  opisthotonus  ;  but  no  true 
picture  of  tetanus  will  be  presented,  and  other  evidences  of  hysteria  will  be  found  on 
examining  the  patient,  or  will  develop  if  the  case  be  kept  under  observation. 

A.  J.  Je.i-Bhike. 

TCONTRACTURES — are  lasting  bodily  deformities  resulting  from  a  great  variety  of 

causes.     For  clinical  ])urposes  they  may  be  divided  roughly  into  two  classes,  according  as 
they  are  (1)  Aclivc.  or  (2)  Passive.     The  division  is  not  sharp,  as  active  contractures  when 
long  established  tend  to  become  passive. 
1,  Active    Contractures:    resulting: — 

(a).  Fro7n  lesions  of  the  upper  motor  luiiruii  : 
Cortical    lesions  Transverse  lesions  of  the  cord        Spastic  ataxia 

Hemiplegia  j    .Subacute  combined  degenera-    ;    Spastic  parajjlegia 

Friedreich's  ataxia  '        tion  1    Haematomvelia 

Myelitis  |    Lateral  sclerosis  j 

(ft).  From  lesio7is  of  the  lower  motor  neuron  : 
Acute  poliomyelitis  ]    Progressive  muscular  atrophy    I    Injury  of  nerves 

Chronic  polioiuyelitis  Neuritis 


CONTRACTURES  139 

(f).  From  disuse  : 

Hysteria  |    Torticollis 

2.  Passive   Contractures  :    seen  in  : — 

Late   stajics  of  the   active  eontractures 

Local    organic    diseases    of   the    bones,    joints,   muscles,   fasciae,   skin. 

Active  or  Spastic  Contractures. — In  these,  certain  groups  of  muscles  are  thrown  into 
a  state  of  permanent  contraction,  or  else  the  balance  of  power  between  antagonistic  sets 
of  muscles  is  upset.  In  either  case  bodily  deformity  (flexion,  extension,  curvature)  results  : 
but  the  deformity  can  be  redressed  temporarily  cither  by  steadily  maintained  mechanical 
traction,  or  by  the  forcible  electrical  stimulation  of  the  weaker  set  of  the  antagonistic 
muscles  involved.  In  passive  contractures,  on  the  other  hand,  no  amoimt  of  electrical  or 
other  stimulation  avails  to  correct  the  deformity,  nor  can  the  application  of  force  without 
rupture  of  the  tissues. 

Active  contractures  must  be  distinguished  from  certain  other  forms  of  muscular 
contractions,  particularly  cramps  and  tetanic  (or  so-called  tonic)  contractions  or  spasms 
of  the  voluntary  muscles.  Cramps  may  resemble  contractures  by  their  relatively  long 
duration — thus  tliose  of  tetany  have  been  known  to  persist  for  days  and  even  weeks  ;  but 
pain  is  a  coiistant  feature  of  cramp,  whereas  it  has  no  connection  at  all  with  contractures 
per  se.  Telanic  contraetions  of  muscles  (see  Contractions,  p.  131) — commonly  called  ionic 
by  the  misuse  of  a  word  that  already  has  a  definite  and  different  physiological  meaning 
(p.  187) — resemble  cramps  by  being  painful,  and  differ  froiu  them  only  by  being  more 
generalized.  The  normal  resting  muscle  is,  physiologically  speaking,  in  a  constant  state 
of  lonie  contraction,  and  exhibits  a  certain  reHex  tone  or  tonus  (muscle-tone)  due  to  the 
combined  action  of  two  factors,  one  local  and  one  nervous.  Any  muscular  spasm,  rigidity, 
or  spasticity  set  up  by  increase  of  this  normal  tone  within  physiological  limits,  may  properly 
be  referred  to  as  a  condition  of  tonic  contraction.  But  when  a  spasticity  is  pathological, 
as  are  all  the  "  tonic  contractions  "  of  the  clinician,  it  should  no  longer  be  referred  to  as  a 
state  of  tonic  contraction,  especially  as  it  corresponds  satisfactorily  with  the  physiological 
■  tetanic  contraction  "  or  "  tetanus.'  .V  ty])ical  pathological  spasticity  or  active  contrac- 
ture is  seen  in  Sherrington's  "  decerebrate  rigidity,'  the  extensor  spasm  observed  in  the 
limbs  of  the  cat  or  rabbit  after  removal  of  the  cerebral  hemispheres  and  basal  ganglia.  This 
rigidity  lasts  for  several  days,  and  is  due  to  the  removal  of  the  inhibitory  impulses  normally 
reaching  the  cord  from  the  cortex  and  thalanuis.  A  similar  rigidity,  though,  of  course, 
with  a  (lilleriiit  distribution,  is  seen  in  such  disorders  as  hemi|)legia,  cortical  losses,  lateral 
sclerosis.  Kriedn  ichs  ataxia,  subacute  combined  degeneration,  and  transverse  lesions  of  the 
c<ird. 

The  active  contractures  lollowing  licmiiilegiii  or  cortical  lesions  in  the  motor  area  are 
confined  to  the  affected  side  of  the  body,  and  should  not  be  <lillicult  to  diagnose.  Then- 
are  three  varieties  of  rigidity  after  hemiplegia,  but  only  the  last  of  these  is  usually  described 
as  a  conlraelure  :  (1)  Initial  rigidity,  present  at  the  onset  and  lasting  only  for  a  few  hours  ; 
{'2)  l'',arly  rigidity,  beginiiing  within  a  lew  days  of  the  stroke  and  lasting  for  a  week  or  a  few 
weeks,  posnibly  due  to  tin-  irritation  of  blood-clot  at  the  site  of  the  cerebral  lesion  :  (!!)  Late 
rigidity  or  contracture,  first  appearing  several  weeks  or  months  after  the  .stroke,  and  due 
to  the  fact  that  while  all  the  muscles  of  the  affected  limbs  are  spastic,  certain  groups  of  them 
arc  stronger  than  their  antagonists.  Thus  the  thumb  is  flexed  and  pressed  into  the  palm, 
the  fingers  clenched,  the  wrist  and  elbow  flexed,  the  forciirm  pronatcd,  and  the  arm  adducted. 
The  thigh  is  a<ldu<led.  the  knee  extended,  and  the  heel  drawn  up,  the  fool  inverted,  and 
a  charaelerislic  spastic  gait  results.  The  deep  reflexes  arc  increased  on  the  liemiplegic  side, 
where,  loo,  ankle-clomis  and  Itablnski's  extensor  reflex  can  be  oblaincd.  The  lapse  of 
years  conxcrts  these  a(li\c  eontractures  into  passive  in  conse(|Ucncc  of  the  stnictural 
changes  that   take  |il.iee  in  the  muscles,  f'ascia>,  and  joints. 

(dntraelures  are  highly  characteristic'  of  con<ienilal  and  act/nireil  cerebral  iliple<iias  or 
liiiiiijilegias  line  to  cortical  lesions,  cortical  sclerosis,  or  poreiicephalus  (see  CoN'ritAcrioNS. 
A  rui'.roTic,  p.  l;tl).  The  patients  show  bilateral  spastic  paralysis;  one  side  is  sometimes 
affected  more  severely  than  t\u:  other.  If  the  legs  only  arc  affected  the  condition  is  known 
as  Tyittlc's  disease,  ami  the  gait  is  •  cross-Ieggecl  '  or  *  scissor,'  the  feel  being  pointed  and 
iiiverli-d.  aiul  the  thighs  addiieteil.      Kvpliosis  is  often  seen,  anil   the  arms,  it  iii\dl\i(l.  arc 


140  CONTRACTURES 

lield  in  the  position  of  a  hemiplegic  arm  (see  above).  In  the  acquired  cases  the  spastic 
paresis  is  oftener  unilateral  than  bilateral  ;  the  nutrition  of  the  affected  limb  suffers  con- 
spicuously, and  its  growth  is  retarded  and  incomplete. 

In  Friedreich's  disease,  a  familial  disorder  beginning  usually  between  the  ages  of  se\en 
and  seventeen,  and  seen  oftenest  in  males,  characterized  by  ataxia,  intention-tremor, 
nystagmus,  and  hesitating  or  syllabic  speech,  active  contracture  sets  up  scoliosis  or  scolio- 
kyphosis, pes  varus  or  equinovarus,  and  '  main  bote  " — an  analogous  deformity  of  the 
hand  with  hyperextension  of  the  terminal  ])lialanges.  These  contractures  are  partly  due 
to  muscular  atrophy,  partly  (in  the  case  of  the  foot )  to  over  use  of  certain  muscles  in  attempts 
at  equilibration  ;  the  heel  is  drawn  up,  the  dorsum  of  the  foot  arched,  the  sole  hollowed 
out.  the  toes  flexed  at  the  interphalangeal  joints  and  hyperextended  at  the  metatarso- 
l)halangeal  ;    prominent  hypertrophy  of  the  extensor  longus  hallucis  has  been  found. 

In  suhdcitte  combined  degenerfilioii.  in  which  may  be  included  lateral  sclerosis  if  the 
degeneration  mainly  affects  the  upper  motor  neurons,  there  will  be  contractures.  The 
earliest  symptoms  are  connected  with  sensation  ;  but  the  patient,  usually  an  ansemic  adult 
inthe  .second  half  of  life,  presently  develops  spasticity  in  his  legs.  The  limbs  tend  to  draw 
u|)  as  he  lies  in  bed,  from  flexor  spasm  ;  the  gait  becomes  spastic,  and  walking  is  soon 
impossible — the  condition  becoming  one  of  spastic  paraplegia.  The  deep  reflexes  are 
increased,  and  Babinski's  sign  is  present  ;  segmental  areas  of  anaesthesia  can  be  made  out, 
and  control  over  the  spliincters  is  weakened.  After  some  months,  this  spastic  stage  gives 
place  to  flaccidity.  control  over  the  sphincters  is  lost,  and  the  patient  rapidly  runs  down  hill. 
In  eases  of  transverse  myelitis  or  transverse  lesions  of  the  cord,  and  in  certain  cases  of  hcemato- 
ini/clia  of  insidious  onset,  in  which  the  haemorrhage  perhaps  takes  place  into  an  already 
dilated  central  canal,  spasticity  with  increased  deep  reflexes,  loss  of  sensation,  and  loss  of 
ejjntrol  over  the  sphincters  is  the  rule.  The  diagnosis  is  facilitated  by  the  fact  that  no 
symptoms  occur  in  parts  of  the  body  innervated  from  above  the  cord  lesion  ;  at  the  level 
of  the'  lesion  there  is  evidence  of  nerve-irritation  (girdle  pain,  hypera-sthesia).  In  these 
cases  the  flexors  of  the  leg  overpower  the  extensors  ;  the  limbs  draw  themselves  up  again, 
sooner  or  later,  as  often  as  they  are  extended  for  the  patient. 

So  far.  the  active  contractures  considered  have  all  been  due  to  lesions  of  the  U|)per 
motor  neuron.  A  second  class  contains  those  resulting  from  lesions  of  the  lower  motor 
neuron  and  the  subsequent  muscular  atrophy.  These  contractures  arise  either  from  the 
unbalanced  action  of  the  muscles  that  normally  antagonize  those  that  have  atrophied,  or 
from  late  shrinkage  of  the  paralyzed  muscles  themselves;  and  a  spinal  curvature  may 
come  on  from  the  adoption  of  some  posture  that  facilitates  locomotion  or  the  occupations 
of  life  when  the  spinal  nuiscles  are  intact.  Acute  and  chronic  poliomyelitis,  neuritis,  and 
lesions  of  the  ner^•(^s  liave  to  be  discussed  in  this  connection.  Acute  ])olionii/elitis.  or  infantile 
paralysis,  begins  suddenly  with  malaise,  pains,  and  an  acute  febrile  attack  ;  the  flaccid 
paralysis  appears  early,  and  contractures  begin  to  show  themselves  within  a  few  months, 
as  a  rule.  The  limbs  are  most  involved,  isolated  muscles  or  groups  of  muscles  being 
paralyzed  ;  and  it  should  be  noted  that  the  jjaralysis  is  distributed  in  accordance  with  the 
nuclear  grouping  of  the  muscles  in  the  anterior  cornual  regions  of  the  cord.  Sensation  is 
affected  only  in  the  rarest  instances.  If  many  muscles  in  a  limb  are  paralyzed,  its  growth  is 
nuich  impaired.  Contractures  are  common  in  chronic  poliomijelitis  and  the  various  forms  of 
progressive  m.uscular  atrophy  of  neuropathic  origin  (see  Contraction.s,  Fibrillar,  p.  134).  the 
hands  and  feet  being  mainly  involved,  with  the  production  of  various  forms  of  club-foot  and 
claw-hand.  All  the  muscles  are  involved  together,  and  there  is  no  selection  of  certain 
groujis  for  paralysis  as  is  the  case  in  acute  poliomyelitis.  In  addition,  fibrillar  contractions 
can  be  seen  in  the  degenerating  muscles,  provided  that  they  are  not  covered  too  thickly 
with  subcutaneous  tissue.  The  onset  is  insidious,  and  the  disease  occurs  most  often  in 
middle  age  ;  the  commonest  type  is  that  in  which  the  hands  are  first  and  most  involved, 
but  in  other  cases  the  legs,  and  in  others  the  upper  arm  and  shoulder,  first  give  evidence 
of  the  disease.  Contractures  are  seen  occasionally  in  alcoholic  neuritis  of  the  motor  type, 
and  more  frequently  in  arseniccd  neuritis,  talipes  equinovarus  or  flexor  contracture  of  the 
wrist,  with  excessive  muscular  hyperaesthesia,  being  noted  ;  such  deformities  are  rare  in 
other  forms  of  neuritis,  such  as  those  due  to  lead,  diabetes,  influenza,  diphtheria,  etc. 
Secondary  contracture  of  the  muscles  on  the  affected  side  in  Bell's  facial  paralysis  may 
occur,  and  gives  rise  to  the  impression  that  the  soimd  side  of  the  face  is  paralyzed  while  the 


COXTRAt'TL'RES 


141 


face  is  at  rest,  lor  the  face  as  a  whole  is  jjulU'd  o\er  to  tlie  affected  side  {Fig.  198,  p.  492): 
on  vohmtary  movement,  however,  the  healthy  side  will  be  found  to  move  normally,  while 
the  jjaralyzed  side  remains  comparatively  still.  Contractures  usually  follow  severe  injury 
of  nerves.  luiless  satisfactory  healing  of  the  wound  and  regeneration  of  the  nerve-trunk.s 
take  ])lace. 

.Ictirc  CDiilritrtiires  from  disuse  may  occur  in  otherwise  healthy  subjects  who  for  any 
reason  may  have  been  kept  too  long-  in  one  position.  Patients  who  have  lain  on  their  backs 
in  bed  lor  long  periods  may  have  a  temporary  tali))es  e(piinus  when  they  get  up — an  active 
contracture  due  to  the  weight  of  the  bedclothes  resting  on  the  toes  and  keeping  the  feet 
extended.  Fractured  or  injured  limbs  that  have  been  splinted  and  kept  too  long  in  one 
position,  often  exhibit  active  contractures  when  the 
splints  are  removed  (e.g.,  Volkmann's  ischa-mic  contrac- 
ture of  the  forearm.  Fig.  38).  In  some  cases  the  con- 
tracture is  due  to  fixation  of  the  muscles,  tendons,  or 
muscle-sheaths  by  inflammatory  products  that  have 
become  organized,  in  others  to  adhesions  or  bony  de- 
posits that  have  formed  themselves  in  or  about  the 
joints,  while  in  others  mere  disuse,  without  inflamniatory 
changes,  may  \mdcrlic  these  contractures  :  all  of  these 
would  be  avdideil  by  the  timely  use  of  massage  and 
movement. 

Paralyses  occur  in  perhaps  25  per  cent  of  all 
patients  with  lifisleriii.  in  two  main  types  :  the  laiei- 
flaccid,  the  commoner  spastic,  and  often  marked  enough 
to  |)roduce  active  contracture.  In  hysterical  contracture 
the  affected  muscles  are  not  wasted  exce])t  in  severe 
cases  of  long  duration  :  the  deep  reflexes  are  increase<l  : 
ankle-clonus  may  be  ])resent  ;  but  Babinski's  sign  is 
jjrobably  lu-vcr  observed.  The  limbs  are  most  affected 
(hemi.  mono-,  or  para|)lcgia),  less  often  the  muscles  of 
the  face,  eyelids,  lips,  or  t(mgue.  Certain  attilu<les  are 
highly  characteristic  of  hysterical  spastic  paralyses  : 
the  elbows,  wrists,  and  lingers  are  ke])t  Hexed,  the  arms 
are  adducted  :  llic  hip  muiI  knee  are  extended,  and  the 
foot  is  held  in  a  |i(isilion  of  talipes  C(|uinovarus  :  ptosis 
may  be  seen,  from  spasm  of  the  orbieidaris  ;  torticollis 
from  contracture  of  the  sicrnomastoid.  In  the  less  seven' 
eases  the  stillness  ami  paresis  are  neilher  complele  nor 
marked  enoMi:li  Im-  I  lie  condition  to  be  relVrred  to  as  a 
contracture.  In  all  irislaiu-cs  the  deformity  produced  is 
tlie  result  of  :irli\c  rrniscular  spasm,  aiul  in  severe  cases 
it  camuit    be  ov  rrcoinc    b\    cNereisc   of   I  he    p.ilicni's  will. 


gahani/aliAu.  or  by  ll 
'I'he    colli  raclur 
abolislie.l   only  by  d 
guisliiiig    hyslerieal 


ten     I 


ml 


pplicalioii  of  mechani 
rsisis  during  sleep 
isllicsia  a  cliarMcIc 
rhiies      from     lliosc 


ll  force, 
and  is 
disliii- 

dile      lo 


establish  permaiieiil  passive  < 
contrMcliire  is  the  palieiil's  ii- 
tion  ,,r  llie  deformily  exiiiiiih 
the  liircps.  the  triceps  can  Ik 
is  made  lo  Ilex  llic  :iriii   liirlhi 


inths.  or   e\en    years  :    and  in 
[•lianges  about   the  joints  may 


<)r<;aiiie   disease      Hyslerieal    coiil  i:i<'l  iiies    oflcn    lasl     Tor    i 
cases   of   long    slandiiig   muscular   atrophy   and  slruclura 

finlracture  from  disuse.  Highly  characteristic  of  hysterical 
•  of  antagonislic  muscles  lo  pievc'iit  passive  or  active  correc- 
I.  If.  for  example,  the  arm  is  semillexed  by  contracture  of 
Icll  lo  eoiilrael  and  resist  the  movemeiil  when  IIk'  allempt 
r.  A  siiiiil:ir  eoni  nicl  :oii  of  Mic  I  lieeps  can  lie  IVIl  cir  seen  if 
the  palieni  is  asked  lo  bend  llie  jniiil  lieisclf  :  uilli  llic  rcsiill  lli.il  llii'  joiiil  leniains  un- 
moved, alllioiigli  all  signs  of  great  cllorl  lo  bcnil  llic  arm  may  be  displayed.  I'aiii  and 
tendciness  in  the  conlractcd  muscles  are  usual  :  and  oilier  h\slerical  sligmala  such  as 
hcmiameslliesia.  pariesi  licsia.  claviis  or  globus  liyslcricns,  and  llic  hyslerieal  lempcrauicnl 
l,'<ncrall\,    will    iiol    be   wanliiii;.      Spcci.il    loriiis  of  liysliiic.il   coiilraclurc   iiia>-  give   rise    lo 


142 


CONTRACTURES 


-Dupuytren's  Contracture. 


great  trouble  in  diagnosis  by  imitating  definite  conditions  or  diseases.  Tlius  a  painful 
'  hysterical  hip  "  or  •  hysterical  knee  '  may  pass  on  from  surgeon  to  surgeon,  imtil  one  is 
found  to  operate  upon  the  normal  joint  for  tuberculous  arthritis  ;  hysterical  spasm  of 
some  of  the  abdominal  muscles  may  lead  to  the  diagnosis  of  jjregnancy  or  new  growth — 
pseudo-cyesis   or   phantom   tumour  ;     hysterical  contracture   of  muscles  in   the  neck  or 

shoulder  may  be  diagnosed  as 
new  Lirowth.  the  palpable  tumour 
\  anishing  only  when  the  patient 
has  been  ansesthetized  and  is  on 
the  operating  -  table  awaiting 
incision. 

TiirticiilUs.  or  wryneck,  in 
adults,  may  be  regarded  as  a 
functional  disease,  and  is  a  form 
of  tic.  characterized  in  its  later 
stages  by  contracture  of  the 
affected  muscles  of  the  neck. 
The  muscles  chiefly  affected  are 
those  supplied  by  the  spinal 
accessory    nerve.  Its    clonic 

variety  is  easy  to  diagnose  ;  but 
wliere  the  spasms  are  tetanic  (or 
tonic)  rather  than  clonic,  the 
diagnosis  must  be  made  from 
such  conditions  as  cervical 
caries,  rheumatic  myositis,  or 
deep  inflammation  in  the  glands 
of  the  neck.  Congenital  torticollis  dates  from  birth,  usually  affects  the  right  sterno- 
mastoid  muscle,  and  is  often  associated  with  facial  asymmetry — when  it  is  perhaps  due 
to  congenital  defect  of  the  centres  in  the  bulb.  The  face  is  smaller  on  the  side  of  the 
affected  sternomastoid.  Congenital  torticollis  is  distinguished  from  the  form  of  wryneck 
produced  in  infants  by  rupture  of  the  sternomastoid  muscle  at  birth  during  delivery,  by 
the  fact  that  in  the  latter  a  callus  is  to  be  felt  at  the  site  of  tlie  rupture. 

Passive  Contractures  are  those 
due  to  affections  of  the  bones,  joints 
or  soft  tissues,  that  mechanically 
obstruct  correction  of  the  deformities 
they  produce.  They  also  result  from 
long  continuance  of  the  active  contrac- 
tures considered  above,  by  a  gradual 
process  of  transition.  The  contracted 
limbs  can  only  be  straightened  by 
surgical  measures,  or  by  manipulations 
severe  enough  to  rupture  the  ob- 
structions. 

Passive  contractures  may  result 
from  the  most  varied  local  organic 
diseases  of  the  affected  parts. 
Dupuytren's  Contracture  of  the  jjalmar 
fascia,  leading  to  deformity  of  the 
little  and  ring  fingers  {Fig.  59)  is  so 
characteristic  that  it  can  seldom  be 
mistaken.     It    is    prone   to    occur    in 

gouty  subjects  and  in  those  who  use  the  palms  of  their  hands  most,  as  in  the  case  of 
coachmen  and  those  who  use  spades,  etc.  In  diseases  of  the  joints,  such  as  rheimiatisni, 
rheumatoid  arthritis,  spondylitis  deformans,  tuberculosis,  gonorrhoea,  etc.,  the  patient 
may  lie  in  bed  or  go  about  for  weeks  or  months  in  some  bent  or  contorted  position  that 
involves  the  minimum  of  discomfort  ;   ankylosis  of  the  affected  joints  often  results  from 


-c^ 


^.— Cicatricial  contrac 
Rutherford  Morisou'c 


are  after  a  burn. 
Jiilroductvm  to  Surffenj.) 


CONVULSIONS  143 

the  growth  of  adhesions,  eechondroses,  or  exostoses  in  and  about  the  edges  of  the  joints, 
that  permanently  hniit  their  range  of  movement.  Corresponding  shortening  will  take  place 
in  the  muscles  that  are  relaxed,  and  a  passive  contracture  results.  The  growth  of  a  tumour 
in  or  about  a  joint  may  produce  identical  results.  Traumatic  or  inflanunatory  lesions  about 
the  muscles  or  their  tendons  may  establish  inflammatory  products  locally  that  permanently 
limit  the  movements  of  these  structures.  Large  superficial  scars  due  to  extensive  burns 
or  losses  of  skin  and  the  superficial  tissues,  being,  composed  mainly  of  fibrous  tissue,  may 
contract,  and  so  bring  about  marked  contractures  (see  Fig.  60). 

Spondi/litis  defnrinaiis.  a  chronic  malady  of  the  spinal  colunm  (p.  (i48)  often  results  in 
contractures  and  partial  ossification  of  the  ligaments  and  muscles  of  the  back  ;  and  extreme 
deformity  may  arise  from  myositis  ossificans,  a  rare  but  easily,  diagnosed  affection  in  which 
the  muscles  all  over  the  body  gradually  become  rigid  from  calcification  :  the  patient  has 
generally  been  normal  up  to  adult  life,  and  then  becomes  the  subject  of  acute  attacks  of 
pain  in  various  muscles,  accomiianied  by  local  myositic  .swelling  and  some  pyrexia  :  after 
the  local  inflammation  subsides,  calcium  salts  are  deposited  in  the  site  that  has  been  inflamed 
and  the  affected  muscle  becomes  stiff  and  hard.  Weeks  or  months  may  elapse  between 
successive  attacks  of  tljiis  kind,  but  the  number  of  calcified  muscles  slowly  mounts  up. 
until  in  extreme  instances  the  jjatient  is  rigid  almost  from  head  to  foot — the  •  ossified  man.' 

The  diagnosis  of  the  cause  of  a  passive  contracture  will  obviously  de])end  upon  the 
results  of  the  physical  examination  of  the  affected  part,  and  upon  the  success  with  which 
a  true  history  of  the  onset  and  course  of  the  case  can  be  elicited.  A.  J.  Jex-Blalic. 

CONVULSIONS,  or  CONVULSIVE  SEIZURES,  are  paroxysms  of  involuntary 
muscular  contractions.  They  may  be  divided  into  two  classes,  according  as  they  are  local 
or  general  :  local  convulsions  lia\e  been  considered  under  the  heading  Conth.vctions. 
SpASJroDic  (p.  VMi).  and  the  following  account  deals  mainly  with  general  convulsions.  The 
general  convulsions  without  loss  of  consciou^HCss  that  constitute  RiGOifh  are  described  under 
that  heading  (p.  .594)  ;  with  this  exception,  general  convulsions  are  almost  always  accom- 
panied by  loss  of  consciousness,  excepting  in  some  few  cases  of  partial  epilepsy  and  of 
hysteria. 

In  most  cases  of  convulsions,  both  sides  of  the  body — face,  neck,  arms,  trunk,  and  legs — 
are  convulsed  equally.  But  it  sometimes  happens  that  though  their  cause  is  apparently 
general,  the  movements  are  unilateral,  or  much  more  marked  on  one  side  of  the  body  than 
the  other  ;  for  present  purposes  such  convulsions  may  still  be  termed  general.  I'sually 
convulsions  arc  clonic,  less  often  tetanic  or  t<mic. 

■  Fits  '  may  be  defined  roughly  as  any  sudden  jjuroxysms  or  seizures  occurring  in  the 
course  of  any  disease.  In  eomnKin  usage,  lutwever.  a  "  fit  "  is  a  convulsive  fit.  or  fit  of 
convulsions,  and  if  umiualilied,  the  term  usually  means  an  epileptic  fit,  but  not  always. 

Certain  clinical  features  are  common  to  aJuHisI  all  conxulsive  seizures  in  which 
consciousness  is  lost.  If  the  onset  is  sud<len.  as  it  usualh  is,  I  he  patient  is  apt  to  fall  dow?i 
and  injure  himself  miless  already  recumbent.  If  the  nniseles  of  the  mouth  and  jaws  are 
involved  and  saliva  is  secreted  freely,  the  mouth  foams  ;  if  the  tongue  or  cheeks  are  bitten, 
the  foam  bci'omes  stained  with  blood.  Clenching  of  the  jaws  will  niaki-  the  breathing 
laboured  stertorous,  and  inclTectual.  If  the  nuiscles  of  respiration  arc  greatly  affected, 
cyanosis,  with  congestion  of  the  face,  neck,  and  exposed  parts,  will  be  observed.  The 
convulsive  movcmenis  ar<'  typically  clonic,  limited  in  range.  ])urposeless,  and  accon\i)anie(l 
by  more  or  less  rigidity.  If  the  rigidity  is  marked,  the  amplitude  of  the  movements  will 
be  reduced  correspondingly,  so  that  the  condition  may  even  become  one  of  sliffiu-ss  and 
tetanic  (<ir  so-called  Ionic)  spasm.  It  is  eliaractcrisi  ic  of  epilepsy  that  the  lil  sliouM  consist 
of  a  brief  tetanic  stage  followed  by  a  longer  stage  ofc-lonus  ;  but  convulsive  attacks  of  e\ei\ 
sort  may  occur  in  epilepsy,  and  cither  the  tetanic  or  the  clonic  stage  nuiy  be  ab.sent  or  so 
brief  as  to  pass  unnoticed.  Control  over  the  organic  reflexes  of  micturition  and  defa-cation 
is  often  lost,  the  bladder  and  rectum  being  emptied  involuntarily.  -\s  a  rule  the  reflexes 
cannot  be  oblaiiied  while  the  convulsions  last,  and  are  lost  or  diminished  for  some  hours 
after  they  are  over,  or  arc  uuc<|ual  on  the  two  sides  of  the  body.  When  the  lit  is  over  and 
the  patients  have  recovered  consciousness,  they  often  complain  of  headache  and  lassitude, 
showing  diminished  scnsibilily  to  all  impressions,  menial  hebetude,  and  great  sleepiness. 
Less  orien.  Ilic  palieni  becomes  exeileil  or  lenilicd  allci-  a  lil,   or  cNcii  maniacMl.  ami  he  may 


114 


CONVULSIONS 


also  exhibit  autoiiuitism  lor  lioiirs  or  even  days  ;  in  none  of  these  conditions  will  he  be 
responsible  for  his  actions.  The  duration  of  general  convulsions  is  commonly  to  be  measured 
in  seconds  or  minutes  ;  but  in  severe  cases  they  may  go  on  for  hours  if  untreated,  and  in  the 
status  epilepticus  may  last  for  days  with  only  brief  intermissions.  Prolonged  convulsions 
due  to  any  cause  may  raise  the  temperature  several  degrees  ;  when  they  are  iniilateral, 
the  temperature  is  raised  more  on  the  affected  side  tlian  on  the  other.  Albuminuria  after 
a  fit  is  very  common,  and  may  last  for  a  day  or  two  ;  it  is  by  no  means  necessarily  evidence 
that  the  fit  was  uriemic. 

The  morbid  conditions  in  which  local  or  partial  convulsions,  and  in  rarer  instances  general 
convulsions  also,  occur  without  loss  of  consciousness,  have  been  considered  under  Contrac- 
tions, Spasmodic  (p.  136),  but  for  the  sake  of  clearness  may  be  recapitulated  : — 


Fat  iguc 

Nc'ivous  cxliaustion 

Hiibit  spasm 

Spasmodic  tic 

Myoclonus 


Hysteria 

Jacksonian  e])ilei)sy 
Chorea  electrica   (Henncli) 
Tetany 


Tetanus 
Hydrophobia 
Strychnine  poisoning 
Malingering. 


The  convulsions  commonly  accompanied  by  loss  of  consciousness  will  be  considered 
here  under  the  following  heads  : — 

1.  General   Convulsions   of   Infants   and    Children,  seen  in  : — 

.Mriiiiiiiitis  Idiocy 


Hereditaiy  sypliilis 
Congenital    heart    disease 
Ccrci)ral  paralysis 
Onset    <il'  acute    fevers 


Drug  poisoning 
Enlarged    thymus 


Rickets 

Epilepsy,  minor  and  major. 


2.  General   Convulsions   of   Adolescents   and   Adults,   seen   in  : — 

Intracranial  growth 
General   paralysis 
Chronic  alcoholism 
Cerebral  syphilis 
Hysteria 


Ejiilepsy,  minor  and  nuijor. 
Jacksonian  epile])sy 
E])ileptiforni     convulsions — 

Uremia 

Pregnancy 

Seyeiv  heart  disease 


.Vspliyxia 

Stokcs-.Xdams"    disease 
Saturnine  encephalopathy 
Cerebral    lesions  : — 
."Vpoijlexy 


Meningitis 


3.  Unilateral   Convulsions,    seen  in 


Ai>oplcxy 

Intracranial  growth 


Meningitis 
Epilepsy,  majc 


and  minor 


Malingering. 


.Jacksonian  epilepsy 
Disseminated  sclerosis. 


General  Convulsions  of  Infants  and  Children. — Among  the  commonest  of  all  con- 
\  ulsive  seizures  are  those  occurring  in  children  of  tender  age,  known  as  infantile  convulsions. 
The  sexes  are  affected  equally  ;  about  a  third  of  the  cases  take  place  during  the  first  year 
of  life,  two-thirds  during  the  first  two  years  ;  and  they  are  rare,  apart  from  epilepsy,  after 
the  age  of  five  or  six.  They  arc  of  more  serious  import  in  infants  under  six  months  than  in 
older  children,  and  also  in  anaemic  and  weakly  infants.  In  hcrcdildri/  .ti/jihilis  convulsions 
often  prove  fatal  during  the  first  week  of  life.  For  the  rest,  in  about  half  the  patients  rickets 
is  the  predisposing  cause  :  in  many  of  the  others  some  local  irritation,  such  as  inflammation 
of  the  gimis  in  dentition,  diseases  of  the  nose  or  ears,  the  presence  of  irritating  food  or  tt'orw.v 
in  the  intestine,  renal  or  vesical  calculus,  or  phimosis,  can  be  found  :  while  convulsions  at 
(he  onset  of  acute  infectious  diseases,  such  as  scarlet  fever,  |>neunionia,  measles,  whooping- 
cough,  or  during  their  cour.se.  and  in  nephritis,  are  not  infreiiuent.  Overdosing  with  drugs 
— strychnine,  atropine,  santonin,  morphia — or  with  alcohol,  may  bring  on  convulsions. 
FViglit  and  over-strung  emotions  are  included  among  the  causes  of  infantile  convulsions  ; 
how  far  inheritance,  the  neurotic  or  neiu'opathic  taint,  is  responsible  for  them  is  uncertain. 
They  occur  in  children  with  enlargement  of  the  thymus  gland,  the  so-called  status  lymphaticus. 
and  in  these  not  infrequently  a  fit  has  a  fatal  issue.  Finally,  it  must  be  remembered  that 
in  any  child  there  may  be  early  evidence  of  epilepsy,  or  of  organic  disease  of  the  brain.  Their 
diagnosis  demands  a  very  careful  examination  of  the  child,  and  also  of  its  diet  and  the 
hygiene  of  its  daily  life.  They  may  be  due  to  congenital  heart  disease,  when  there  will  be 
enlargement  of  the  heart,  a  cardiac  murinur  or  murmurs,  and  some  degree  of  cyanosis.  In 
children  with  organic  disease  of  the  brain  (poreucephalus.  congenital  or  actpiired  cerebral 
paralf/sis.  sjxislic  paraplegia,  etc.)  there  will  be  paralysis,  spasm,  and  muscidar  atrophy,  and 
l)ri>l)ably  mental  defect.  If  the  convulsions  are  due  to  the  onset  of  some  acute  infectious 
disorder,  they  will  come  on  suddenly  in  a  child  previously  well,  and  will  be  accom|ianied  by 


CONVULSIONS  145 

high  fever  and  followed  by  the  characteristic  rash.  Similar  convulsions  and  fever  may 
occur  in  mciihigitis.  usually  towards  the  end  of  the  diseas^;  Tliey  are  not  rare  in  ivhooping- 
coiigh,  particularly  in  rachitic  infants,  being  precipitated  by  the  asphyxia  resulting  from 
the  whooping,  and  not  rarely  causing  death.  The  diagnosis  of  fits  due  to  drugs  or  alcohol, 
taken  either  by  the  child,  or  by  the  mother  if  the  child  is  being  suckled,  will  dei)en(i  upon 
obtaining  an  adequate  history  of  the  ease.  In  what  way  eiiliirgcniciil  of  the  llii/iiiiin  brings 
about  convulsions  is  not  known  ;  the  condition  is  fortunately  rare,  and  is  hardly  ever 
diagnosed  during  life.  The  ftts  occurring  in  hi/ilrorrphaliis  and  the  various  degrees  of  mental 
defect  need  only  be  mentioned. 

It  is  to  rickets  that  one  nuist  look  for  the  explanation  of  most  convulsions  occurring 
between  the  ages  of  three  months  and  four  or  five  years.  The  nervous  system  is  unstable 
in  all  young  children,  the  power  of  cerebral  inhibition  not  being  acquired  for  several  years. 
In  rickets  this  instability  is  much  increased,  and  finds  expression  in  irritability,  tits  of 
screaming,  restlessness,  inability  to  sleep  well  at  night,  and  in  the  more  serious  troubles  of 
tetany,  laryngismus  stridulus,  and  convulsions.  Any  child  with  fits  should  be  scrutinized 
for  evidence  of  rickets — exaggerated  curvatures  in  the  long  bones,  the  rickety  rosary,  a 
Harrison's  sulcus  on  the  sides  of  the  chest,  the  large  and  bulging  rickety  head,  thinness  of 
tlie  hair  on  the  Irack  of  the  head  (due  to  head-rolling),  a  tumid  and  Uaecid  abdomen,  lateness 
in  the  closure  of  the  anterior  fontanelle,  and  general  muscular  debility.  Enquiry  should  be 
made  for  other  symptoms  common  in  rickets  that  will  come  under  the  observation  of  the 
mother  or  nurse — tenderness  of  the  bones  and  skull  on  handling  and  washing,  head-rolling 
due  to  tenderness  of  the  skull,  nnich  sweating  about  the  head  in  sleep,  broken  slumber, 
proneness  to  gastro-intestinal  upsets,  eonsti])ation  and  mucous  stools  or  constipation 
alternating  with  diarrhoa.  unusual  liability  to  coryza  and  bronchitis  (or  "  catching  cold  "). 
The  feeding  and  hygiene  of  the  child  must  be  gone  into  :  in  low  life,  rickets  is  mainly  due  to 
deficiency  of  fat  and  protein  in  the  diet,  with  excess  of  carbohydrate  food,  whereas  in  high 
life  the  diet  is  more  likely  to  err  by  lack  of  freshness  due  to  too  careful  sterilization  or  to  the 
use  of  patent  foods  ;  rickety  children  all  suffer  from  want  of  enough  exposure  to  fresh  air 
and  sunshine.  Hut  if  rickets  is  the  main  predisposing  cause  of  infantile  convulsions,  it  must 
be  remembered  that  they  arc  actually  Ijrouglit  on  by  some  secondary  exciting  cause,  such 
as  a  gastro-intestinal  disturbance  with  diarrhaa  or  vomiting,  or  reflex  irritation  of  any  sort. 
Whether  dentition  is  in  itself  enough  to  account  for  convulsions  is  extremely  doubtful, 
although  that  "  teething-fits  '  do  occur  is  one  of  the  things  that  every  woman  knows. 

KpilejiS!/  is  one  of  the  last  causes  of  infantile  convulsions  that  should  be  thought  of, 
cxeepl  when  the  fits  occur  for  the  first  time  in  tolerably  healthy  children  more  than  three 
or  four  years  old.  .\  bad  family  history  of  fits  or  of  insanity  would  make  ci)ilcpsy  more 
probable  ;  so  would  the  occurrence  of  an  aiini  before  the  fit,  and  the  division  of  the  fit  into 
a  Ionic  and  a  clonic  stage,  with  biting  of  the  tongue  or  checks.  The  repetition  of  fits  for 
which  there  is  no  local  or  general  cause,  such  as  those  described  above,  would  be  in  favour  of 
<|iilepsy,  particularly  if  the  sc(|ueiice  extended  over  a  long  period  of  time.  But  one  fit 
undoubtedly  facilitates  the  occurrence  of  another  soon  afterwards,  so  that  the  recurrence 
of  convulsions  for  a  few  ihi\s  or  weeks  in  a  rickety  child  is  not  enough  to  justify  the 
diagnosis ^)r  epilipsy. 

General  Convulsions  of  Adolescents  and  Adults. — Th<'  convulsions  of  eiiilepsi/, 
iri<lu(liiig  bolli  Ihc  iiKijor  and  Die  minor  forms,  are  very  variable  In  extent  and  <luralion. 
In  the  minor  degrees,  ov  petit  nial.  there  is  usually  brief  tonic  or  tetanic  spasm,  with  loss  of 
eonseiousness,  but  without  clonus  or  convulsions.  In  severer  eases  this  is  known  as  tetainiid 
cjiilrpsi/,  a  tetanic  spasm  convulsing  the  patient  lor  some  seconds,  or  <'ven  for  a  minute  oi- 
two.  with  great  risk  of  dealh  by  asphyxia.  In  partiid  epilepsij  the  con\iilsions  arc  conlined 
to  part  of  the  body — the  face,  perhaps,  or  the  arms  and  face.  Midway  belween  minor  and 
major  epilepsy  (iowers  places  "  epilepsia  media,  in  which  there  is  nniscular  spasm  of  tonic 
character,  withont  the  clonic  spasm  which  follows  when  the  tonic  spasm  is  more  severe." 
In  major  epilepsij  the  typical  jjieliirc  is  as  follows  :  after  experiencing  an  aiua  or  warning  of 
sonic  sort  lor  a  lew  seconds,  the  |)alienl  is  seized  with  a  general  lelanic  spasm,  cries  out,  and 
falls  to  the  ground,  this  tetanic  or  tonic  stagi'  lasting  for  from  fi\c  to  thirty  seconds.  This 
tlicn  gives  place  to  the  clonic  stage,  or  convulsions,  with  foaming  at  the  mouth,  and  clonic 
jiictilations  that  are  often  mic(|ual  on  the  two  sides  of  the  body,  .\flcr  a  few  miimtes  the 
<lc>iHis  dies  away  and  the  patient  is  left  eoiiialosc  or  stupelied,  with  a  headache  that  is  slept 


146  CONVULSION'S 

off  in  the  course  of  the  next  few  hours.  Consciousness  is  always  lost  in  true  epilepsy  ;  the 
extent  and  duration  of  the  convulsions,  however,  are  highly  variable.  The  fits  of  Jacksonian 
epilepsy  are  rarely  generalized  ;  the  condition  is  considered  below.  In  true  e])ilepsy  there 
is  no  known  organic  lesion  of  the  brain  ;  the  loss  of  consciousness  and  the  convulsions  are  due 
to  some  unknown  functional  disturbance  of  its  action  :  but  up|)arently  identical  fits  may 
occur  in  the  course  of  a  number  of  diseases  in  whicli  organic  lesions  are  present  either  in  the 
brain  or  elsewhere,  and  to  these  the  name  epileptiform  coiiriilsions  is  given.  They  are  seen 
most  often  in  unemia.  in  which  the  kidneys  are  severely  diseased  and  toxsemia  results  ;  the 
patient  exhibits  the  characteristic  picture  of  advanced  renal  disease,  with  headache,  high 
blood-pressure,  hypertrophied  heart,  albinninuria,  probably  retinal  changes,  and  anaemia ; 
or  may  have  a  stricture  of  the  urethra  or  an  enlarged  prostate  with  secondary  ascending 
nephritis  ;  or  may  be  the  subject  of  renal  tuberculosis  perhaijs.  It  must  not  be  forgotten 
that  transient  albuminuria  is  commonly  present  after  fits  due  to  any  cause  whatever.  In 
the  intervals  between  uraemic  convulsions  the  patient  may  remain  unconscious. 

The  convulsions  occurring  in  connection  with  pregnaney  are  known  as  eclamplic  fits. 
the  condition  as  eclampsia.  The  majority  of  such  convulsions  come  on  before  labour,  some 
during  labour,  and  15  or  20  per  cent  during  the  first  week  after  jiarturition  :  any  fits  occurring 
after  this  are  ])robably  due  to  some  cause — ura-mia.  for  exam])Ie — other  than  pregnancy  or 
jKirturition.  In  many  cases  the  fits  occur  suddenly  and  without  any  warning,  or  after  no 
more  than  a  brief  period  of  lieadache  or  restlessness,  or  after  vomiting.  Eclampsia  appears 
to  be  an  auto-intoxication  accompanied  by  a  profound  disturbance  of  the  protein 
metabolism  ;  its  primary  cause  is  in  the  placenta.  Its  diagnosis  can  rarely  be  difficult. 
There  is  nearly  always  albuminuria,  and  some  observers  regard  puerperal  eclampsia  as  one 
variety  of  uraemia. 

E]iile])tiform  convulsions  may  occur  in  severe  heart  or  lung  disease,  and,  indeed,  in  the 
terminal  stages  of  many  disorders,  due  in  part  to  asphyxia,  in  part  to  toxaemia.  Like 
certain  obstinate  infantile  convulsions,  they  may  often  be  stoi)ped  by  the  administration 
of  oxygen. 

In  Stokes-Adams'  disease  (]>.  83),  epileptiform  or  apoplectiform  cf)nvulsive  seizures 
occur  from  time  to  time,  no  doubt  due  to  the  asphyxia  and  cerebral  ana'mia  resulting  from 
temporary  cessation  of  the  heart's  action.  The  radial  pulse  is  habitually  slow  in  this 
disorder,  but  becomes  suddenly  slower  at  the  time  of  the  '  attacks,'  beating  jjerhaps  forty 
or  thirty  or  even  only  twenty  times  to  the  minute  ;  the  cardiac  auricles,  on  the  other  hand, 
beat  at  the  normal  rate.  The  patients  are  usually  arteriosclerotic  people  in  the  second 
half  of  life  ;  if  they  are  seen  in  their  convulsions,  the  diagnosis  of  apoplexy  will  ))robably 
be  made,  only  to  be  corrected  later  when  it  is  found  that  the  attack  leaves  no  ))aralysis  or 
paresis  behind  it,  that  similar  seizures  have  occurred  before,  and  that  the  pulse  becomes 
excessively  slow  during  the  seizures. 

General  convulsions  due  to  direct  irritation  or  disease  of  the  brain  may  occur  in  a 
large  number  of  cerebral  lesions,  unilateral  or  bilateral,  most  commonly  in  the  latter.  In 
most  of  these  there  will  be  other  signs  or  symptoms  of  disease,  especially  optic  neuritis, 
that  should  suffice  to  clear  up  the  diagnosis.  Such  convulsions  may  be  seen  in  meningeal, 
subdural,  or  arachnoid  hcemorrhage  ;  in  meningitis  due  to  the  B.  tuberculosis,  Weichsell^aum's 
meningococcus,  or  other  microbes  :  in  eerebritis  ;  in  congenital  anomalies  of  the  brain  such  as 
porericephalus,  hydrocephalus,  and  the  abnormalities  met  with  in  idiots  and  mentally  defective 
children  generally  ;  and  in  cerebral  or  cerebellar  abscess,  tumour,  or  aneurysm,  when  sufficient 
growtli  has  taken  place  to  raise  the  intracranial  pressure  generally.  In  another  group  may 
be  placed  those  cases  in  which  extensive  degenerative  changes  have  taken  place  in  the  brain  ; 
fits  are  common  in  the  second  and  third  stages  oi  general  parcdysis  of  the  insane,  when  other 
signs,  such  as  defective  memory  and  judgement,  grandiose  ideas,  inequality  or  reflex  im- 
mobility of  the  pupils,  blurred  speech,  tremors  of  the  tongue  and  face,  loss  or  exaggeration 
of  the  deep  reflexes,  and  nniscular  weakness  may  be  looked  for  :  in  the  insanity  of  chronic 
alcoholism,  with  its  tremors  and  inco-ordination,  its  marked  sensory  perversions,  and  its 
paramnesia  or  illusions  of  memory  ;  and  in  cerebral  syphilis,  where  the  lesions  may  be  either 
vascular,  gummatous,  meningeal,  diffuse,  or  a  combination  of  any  or  all  of  these,  and  the 
main  symptoms  are  headache,  insomnia,  attacks  of  aphasia  and  hemiplegic  or  epileptiform 
convulsions,  paralysis  of  cranial  nerves,  and  in  addition  dementia  in  the  diffuse  cases. 
Chronic  plumbism  may  produce  cerebral  symptoms  of  the  most  varied  kind   (saturnine 


CONVULSIONS  147 

cuccplialopalh}/).  from  simple  headache  to  acute  mania,  and  amongst  the  phenomena, 
convulsions  of  epileptiform  type  may  be  prominent.  The  diagnosis  is  based  upon  the 
iiistory,  the  occupation,  the  other  symptoms  of  lead  jjoisoning  (p.  34).  and  ])crhaps  upon 
the  discovery  of  lead  salts  in  the  urine. 

Lastly  must  be  mentioned  the  general  convulsions  of  the  hysterical  and  of  malingerers. 
In  lij/sleria.  the  fits  are  noisy  and  protracted  performances,  the  movements  more  or  less 
purposive  and  (]uite  unlike  clonus  ;  the  patient  becomes  red  in  the  face  rather  than  blue 
or  white  ;  consciousness  is  not  lost,  attempts  to  open  the  eyes  are  resisted,  pressure  into 
the  supra-orbital  notch  causes  withdrawal  of  the  head,  the  sufferer's  hand  is  withdrawn 
if  pressure  is  made  between  a  nail  and  its  matrix  ;  the  sphincters  are  not  relaxed,  and  the 
tongue  or  cheeks  are  rarely  bitten.  The  convulsions  are  brought  on  by  some  emotional 
upset,  and  tend  to  cease  when  unsympathetically  received.  The  malingerer  may  display  no 
little  art  and  skill  in  his  convulsions,  which  are  modelled  on  those  of  epilepsy  ;  here  again 
the  sufferer  is  red  in  the  face  rather  than  blue,  although  he  may  breathe  stertorously,  and, 
with  the  help  of  a  little  soap,  foam  at  the  mouth  ;  consciousness  is  not  lost,  the  corneal  reflex 
is  present,  the  head  and  hand  are  withdrawn  from  ])ainful  impressions  ;  the  sphincters  are 
not  relaxed  :  perspiration  is  usual  :  it  is  said  that  in  epilepsy,  if  the  hands  are  clenched,  the 
thumb  is  buried  in  the  palm,  whereas  the  malingerer  clenches  it  outside  the  fingers  ;  on  the 
detection  of  its  character,  the  simulated  fit  ends  as  suddenly  as  it  began. 

Unilateral  Convulsions. — The  convidsions  in  apoplexy  are  habitually  limited  to  one 
side  of  the  body.  The  onset  of  apoplexy,  more  often  gradual  than  sudden,  is  generally 
preceded  by  headache,  dizziness,  and  tingling  or  weakness  in  some  part  of  the  body  ;  and 
it  is  more  marked  in  cerebral  hajmorrhage  than  in  embolism  or  thrombosis.  The  loss  of 
consciousness  comes  on  earlier  and  persists  longer  in  cerebral  haemorrhage  than  in  the  other 
two  conditions.  When  the  convulsions  are  prominent  the  case  is  described  as  one  of  epilepti- 
form (ipople.cij.  Cerebral  Itcemorrhage  is  commoner  in  middle-life,  in  persons  with  high 
blood-pressure  and  hypertrophied  hearts,  and  in  the  subjects  of  arteriosclerosis  ;  cerebral 
embolism  is  associated  with  endocarditis  or  intracardiac  thrombosis,  and  occurs  oftenest 
in  young  patients  with  heart-disease  ;  eerebrnl  thrombonis  is  seen  in  syphilitic  patients,  and 
in  those  with  vascular  disease,  and  is  characteristically  of  slow  onset  after  premonitory 
warnings. 

In  cerebral  abscess  and  cerebral  tumour  convulsions  are  not  very  common,  and  usually 
appear  only  after  the  diagnosis  has  been  made  clear  by  the  occurrence  of  such  cardinal 
symptoms  as  headache,  vomiting  on  change  of  position,  optic  neuritis  (choked  disc),  and 
localizing  signs  pointing  to  intracranial  tumour  :  but  it  may  happen  that  an  epileptiform 
fit  with  unilateral  or  bilateral  convulsions  is  the  first  sign  that  anything  is  wrong,  or  at  any 
rate  the  lirsl  thing  that  makes  the  |)atient  consult  a  medical  man.  The  headaelie  that 
follows  a  coiuulsivc  seizure  is  likely  to  be  very  severe  and  prolonged.  Of  the  two.  cerebral 
abscess  is  the  more  likely  in  patients  with  chronic  suppurative  disease  of  the  ear  or  nose,  or 
of  the  facial  and  frontal  sinuses.  Meningitis — especially  tuberculous  meningitis  in  its  later 
stages — often  exhibits  imilateral  or  bilateral  convulsions,  si(uint  and  other  local  ))aralyses, 
more  or  less  coma  or  mental  apathy,  gastro-intestinal  symptoms.  t'heync-Stokes  breath- 
ing, and  irregularity  of  the  ])ulse-rate  and  temperature  :  lumbar  puncture  and  examination 
of  the  eerebrdspiiial  lluid  (|).  :H)i}  may  be  ie(iuire(l  in  establisliiiig  the  diagnosis  and  in 
<listinguishing  between  thi  tuberculous,  the  suppurative  and  t  h<'  cpidemie  <  irchrospinal — 
■  spotted  fever  ' — forms. 

The  unilateral  convulsions  of  Jacksduian  epilcpsif  are  rarely  dillieull  to  diagnose.  The 
patient  usually  gives  a  history  of  head  injury,  and  often  a  cranial  sear  or  irregularity  is  to 
be  found.  There  is  no  loss  of  consciousness  during  the  attack,  except  in  very  severe 
and  inveterate  cases  ;  usually  only  one  limb  is  involved,  and  an  aura  of  some  sort  usually 
piccedes  the  convulsions,  which  exhibit  a  characteristic  "spread' — beginning  in  a  single 
muscle  or  group  of  muscles,  and  spreading  thence  to  the  muscles  whose  cortical  areas  ol 
representation  adjoin  that  of  (he  nniscic  hrst  involved.  In  .lacksonian  epilepsy  there  is 
almost  always  an  irritative  lesion  of  the  motor  cortex  or  its  immediate  vicinity,  due  to 
trainna.  syphilitic  meningitis,  or  new  growth  ;  ])aresis  or  ])aralysis  of  the  affected  muscles 
follows  the  convulsions,  and  in  the  course  of  time  becomes  marked.  The  "  spread  ' 
is  fre(|ueiitly  characteristic;  if  the  face  is  involved  first,  the  arm  follows,  and  then  the 
leg  :    11  the  iiand  is  attacked  first,  the  eonvuisiiins  spread  up  the  aim,  llicn  lo  the  lace,  last 


148  CONVULSIONS 

to  the  leg.  In  tlie  severer  cases,  where  the  whole  side  of  tlie  iiatient  is  convulsed,  con- 
sciousness is  lost,  and  then  the  convulsions  may  become  bilateral. 

Unilateral  convulsions  do  not  occur  often  in  epilepsy  or  infnnlile  convulsions,  or  epilepti- 
form convulsions,  and  when  they  do  there  is  a  danger  lest  the  diagnasis  of  apoplexy  or  some 
focal  organic  lesion  of  the  brain  be  made.  There  is  nothing  in  the  character  or  distribution 
of  the  convulsions  in  these  cases  to  enable  a  diagnosis  to  be  made,  and  it  is  only  after  they 
are  over,  and  it  is  found  that  no  evidence  of  organic  cerebral  mischief  is  left  behind,  that 
their  functional  nature  can  be  established.  They  are  not  followed  by  any  permanent 
paresis,  paralysis,  or  atrophy  of  the  muscles  on  the  affected  side.  It  must  be  remembered 
that  unilateral  convulsions,  the  so-called  "  apoplectiform  '  convulsions,  may  occur  excep- 
tionally in  some  of  the  conditions  detailed  under  Grou|)  2. 

In  disseminated  sclerosis,  hemi]3legic  apoplectiform  attacks  like  those  seen  in  general 
|)aralysis  are  not  rare,  often  accompanied  by  aphasia.  These  attacks  are  both  transient  and 
recurrent.  The  patients  are  likely  to  exhibit  other  evidences  of  disseminated  sclerosis — 
a  childish  and  optimistic  mental  attitude,  optic  atrophy,  nystagmus,  impaired  articulation, 
intention  tremor,  undue  muscular  fatigability  ;  the  deep  reflexes  are  commonly  increased. 
Babinski's  extensor  plantar  reflex  is  present,  sensation  is  but  little  affected,  and  control 
over  the  sphincters  is  rarely  lost  until  late  in  the  disease,  .1.  J.  Jex-BIahc 

CORNEA,  ULCERATION  OF.— (See  Ulceration  of  the  Cornea,  p.  733,) 

CORYZA.— (See  DisciiAUGE,  Nasal,  p.  178.) 

COUGH. — Cough  is  a  signal  that  something  is  irritating  a  brandi  of  the  vagus  nerve 
or  the  cough  centre,  and  is,  in  fact,  nature's  effort — often  ill  directed — to  remove  that 
something.  Hence,  to  diagnose  the  cause  of  a  cough  it  is  necessary  to  know  the  branches 
of  the  vagus  ;    they  are  as  follows  : — 

(1)  A  small  meningeal  branch,  of  no  interest  as  causing  cough,  though  it  may  possibly 
account  lor  vomiting  in  meningitis  ;  (2)  Arnold's  branch  to  the  ear — a  cause  of  cough, 
though  a  rare  one,  due  to  affections  (wax,  eczema,  etc.)  of  the  external  ear  ;  (3)  Pharyngeal 
branch — a  frequent  source. of  cough  :  (4)  Superior  laryngeal  branch — sensory  to  base  of 
tongue,  larynx,  etc.,  the  most  frequent  source  of  cough,  with  or  without  visible  changes  : 
(.5)  Inferior  laryngeal  branch — motor  for  action  of  coughing,  not  a  cause  of  cough,  but  of 
inefficiency  and  other  peculiarities  in  the  act  of  coughing  :  (6)  Cardiac  branches — indirect 
causes  through  circulatory  failure  ;  (7)  Pulmonary  branches — concerned  in  the  cough  of 
gross  pulmonary  or  pleural  disease  ;  (8)  and  (9)  CEsophageal  and  jjericardial  branches — 
possible  but  most  rare  causes  :  (10)  Gastric  branches — occasionally  dyspepsia  causes  a 
cough. 

The  irritants  to  which  the  .surfaces  of  the  distribution  of  these  nerves  are  exposed  may 
be  classified  into  :  (1)  Foreign  bodies,  e,g.,  dust,  food,  tobacco  smoke,  etc.  ;  (2)  Excess 
of  natural  secretion  ;  (3)  Pressure  and  inflammation  :  (4)  Acute  or  chronic  simple  debility 
or  increased  irritability,  e.g.,  after  influenza,  etc. 

In  dealing  with  the  treatment,  there  is  no  better  division  of  coughs  than  into  those 
which  are  helpful  and  those  which  are  not,  and  the  same  division  is  most  useful  in  arriving 
at  a  diagnosis  of  the  cause  of  a  cough,  for  if  the  cough  succeeds  in  its  object — the  removal 
of  the  offending  material — we  can  see,  or  at  least  enquire  about,  its  nature,  and  this  wiH 
at  once  give  a  strong  clue  to  the  locality  of  the  irritable  point,  and  very  possibly  also  to 
the  morbid  process  going  on.  Hence  the  first  questions  to  ask  a  patient  with  a  cough  are  : 
'•  Do  you  bring  anything  uj)  '?  "      '■  What  do  you  bring  up  '?  " 

Cough  without  Expectoration. — If  the  answer  to  the  flr.st  question  be,  "  No.  the 
cough  is  just  a  troublesome  dry  cough,  witli  no  expectoration  at  all,"  we  at  once  begin  to 
think  of  the  purely  reflex  coughs  produced  by  an  irritant  which  the  cough  itself  is  powerless 
to  remove,  and  though  we  may  often  make  a  short  cut  to  a  diagnosis  by  other  means  of 
investigation,  or  observation  of  the  general  condition,  the  following  routine  should  be 
followed  if  no  prominent  clue  oflers  itself  : — 

1.  Examine  the  external  ear  for  wax,  eczema,  etc.,  although  this  is  a  comparatively 
rare  cause  of  cough,  excejjt  in  the  si)ecial  experience  of  aurists. 

2.  Enquire  whether  any  ordinary  irritant,  such  as  tobacco  smoke,  etc.,  brings  it  on  ; 
this,  of  course,  at  once  raises  the  suspicion  that  the  nasopharynx  or  larynx  is  unduly 


COUGH 


149 


sensitive,  and  should  lead  to  a  careful  examination  of  the  region,  whereupon  a  cause  may 
be  detected  at  once,  such  as  chronic  inflammation  of  any  sort,  or  a  long  pendulous  uvida, 
somewhat  oedematous,  or  showing  other  signs  of  acute  inflammation.  Conditions  of  imdue 
irritability  without  anything  to  see  occur  after  influenza  or  whooping-cough,  and  indeed 
remain  long  after  the  acute  trouble  has  passed  away  from  the  regions  :  therefore  enquiry 
must  be  made  for  some  such  illness.  Such  a  cough  is  often  seen  when  convalescents  go 
into  a  cold  bedroom,  or  get  into  cold  sheets  at  night. 

8.  .Ask  the  patient  to  cough  voluntarily  :  the  curious  barking  or  rough  cough  of 
laryngitis  and  of  pressure  on  the  trachea  from  aneurysm  or  growth,  also  tlic  very  striking 
oough  of  jmralysis  of  the  vocal  cords,  at  once  betray  themselves  ;  there  is  no  mistaking 
them  when  they  have  been  once  or  twice  heard  in  a  hospital  ward  ;  the  same  remark  applies 
to  the  cough  of  whoo])ing-eough. 

4.  l^xaiiiiiic  the  chest  carefully  for  heart  disease  or  early  phthisis  :  the  cough  of  both 
these  conditions  is  commonly  dry  ;  so  too  is  the  cough  of  the  early  hours  of  an  oncoming 
hvonehitis  or  ])neumonia,  but  these  can  scarcely 
f;iil  to  give  other  indications.  Children  often 
suffer  from  very  troublesome  dry  cough,  some- 
times ])ersisting  for  months,  as  the  result  of 
reflex  irritation  from  caseous  or  inflamed  bron- 
chial glands  ;  the  latter  may  be  impossible  of 
diagnosis  from  ])hysical  signs,  but  they  can 
often  be  seen  verv  elearlv  with  the  ,r-ravs 
(F/e.  (il). 

.■).  If  no  cause  reveals  itself  by  now,  the 
sliimaeli  nuist  be  thought  of.  and  its  functional 
and  physical  conditions  enejuired  into  and 
examined,  and  only  after  negative  results  from 
all  these  cnfpiiries  and  })rocedures  may  we  think 
of  a  siiii|>le   hysterical  cough. 

Cough  with  Expectoration. — Expectoratimi 
generally  makes  the  task  of  diagnosis  nuieh 
easier,  and  from  the  simple  insi)eetion  of  a 
spittoon  il  is  frcfpiently  possible  to  make  an 
alniiisl  eiiMiplcIc  diagnosis  of  a  case  :  the  xcry 
stiik\  sputum  of  any  acute  inflanunalion  in  its 
early  stages,  tlic  rusty  sputum  of  pueunioniM. 
the  stink  of  abscess  or  gangrene  of  the  lung  ami 
of  liniiiehieetasis.  the  numnuihilion  of  ]jhthisieal 
spiila.  the  lidlhy  s|iutuiii  iif  liicjiichitis.  are  very 
eiiiiinioiily  (|iiile  typiciil  and  unmistakcable. 
.SniMll  liliiod-elots  make  us  apprehensive  of  early 
liiit  \Mll-marked  -phthisis,  or  of  pharyngeal 
condition'*,  or  of  mitral  stenosis:  streaks  of 
blooil  point  to  acute  laryngitis  or  br<)n<'hitis  :  pi 
I>lithisis  in  tlie  absence  of  signs  of  an  aueur\sn 
all  inllaiumat  ions  of  iniieous  niciiihnincs.  and  II 
\alur.  thoiiiih  lis  (|iiaiilil\.  colouv.  and  odour-  in: 
<\ea\ation.  or  of  an  hepatic  abscess  ruptured  int 
empyema.  With  hepatic  abscess  the  spidurn  sonu 
anchovy -sauce  appearance. 

In  any  case  of  cough  with  sputum  il    i 
llii^li'tter,  particularly  for  tubercle  bacilli. 

The  Aiif  of  tlic  I'liliciil.  In  babies  and  (|nite  yonng  ehildirn  niosi  ol  I  he  more  iinusnal 
causes  of  cough  <-aii  be  excluded  :it  once  on  I  lie  iimim'  lail  ol  ;imc.  bill  I  lie  |ii(siiiee  of  a 
foreign  hodr  in  the  larynx  is  one  of  the  unusual  ones  to  be  rerneinbered.  especiall\-  if  the 
cough  has  come  on  suddenly  in  the  midst  of  Ilea  1 1  h.  Rronchilis,  bronchi  ipneumoiiia.  tubercle, 
pneumonia,  whooping-cough,  and  <liplilheria.  are  far  and  away  the  most  eoinmou  causes 
in  lliese  young  subjects,  and  owing  to  the  alisenee  of  e\peel(ual  ion  lliey  ilo  nol  icvial  llieir 


/•■..;.  i;l.-.~ki,-.L.'r 

i-\|)Uftoriition,    urn 
H,  Heart;  S,  Oris 


illls 


■r-eh 


lr;r-rnopl\sis 
■nwllr.  I'lis 
■  iir  itself  is 
he    \  crx      SI 


llll 


rlia 


th' 


lirir 
has 


>f  hut  lit  He  rliagnosti 
.'geslixc  ol'  riliseess  (i 
garrurcrri  .  or-  slinkiir 
rlrrrosi    pirl  lioguirnrirni 


lo   h: 


'al 


rrrMi  roii 


150  COUGH 

presence  witliout  careful  examination  of  the  chest  and  throat.  From  infancy  to  middle 
life,  the  age  of  the  patient  gives  but  little  assistance  in  determining  the  diagnosis  ;  but 
about  middle  age  chronic  bronchial  troubles,  quiet  pleurises,  growths,  aneurysms  etc.. 
become  increasingly  obtrusive,  giving  rise  to  a  persistent  cough,  and  only  careful  routine 
examination  of  the  chest  will  reveal  their  presence. 

Hoxv  long  have  yon  had  the  eough  ?  Much  information  may  be  deri\'ed  from  the  answer 
to  this  question,  for  a  cough  that  lias  only  lasted  a  few  days,  but  in  that  time  has  become 
sufficiently  severe  to  cause  the  patient  to  seek  advice,  is  practically  certain  to  belong  to 
the  group  caused  by  acute  trouble,  easily  detectable  when  the  chest  is  examined  carefully  ; 
whereas,  on  the  contrary,  a  cough  that  has  lasted  some  months,  and  yet  seems  to  the  patient 
uncertain  in  its  causation,  is  very  likely  to  be  due  to  some  of  the  obscurer  conditions, 
pressures  of  aneurysms  or  glands,  etc.,  which  need  care  to  discover.  The  .r-rays  are  valuable 
in  detecting  thoracic  aneurysms  and  new  growths,  and  they  are  also  of  service  in  demon- 
strating phthisical  and  other  lesions  in  many  cases  :  skiagraphic  evidence  must  never  be 
relied  upon  by  itself,  however  ;  it  shoidd  always  be  interpreted  in  terms  of  the  other  clinical 
data  and  physical  signs.  In  an  obscure  case,  however,  .r-ray  screen  observation  should 
not  be  omitted,  as  it  will  now  and  again  be  the  only  means  of  clearing  up  the  diagnosis. 

\Mien  does  the  eough  eome  on  ?  A  cough  in  the  morning  only  is  suggestive  of  bronchial 
catarrh  with  accumulation  of  secretion  during  sleep.  A  cough  on  getting  into  bed  suggests 
laryngeal  irritability  or  a  long  i)endulous  uvula  :  but  one  that  wakes  the  patient  alter  he 
has  gone  to  sleep  makes  one  apprehensive  of  phthisis  in  the  absence  of  other  indications 
of  obvious  acute  chest  changes.  A  cough  on  exertion  suggests  heart  weakness,  and  in 
determining  the  presence  of  this,  the  finest  discrimination  is  required  in  auscultation,  for 
these  are  typically  the  ca.ses  of  morbus  cordis  without  a  bruit  in  which  frecpiency  of  rhythm 
and  good  dilTei-enliation  of  the  first  and  .second  sounds  are  all  ini])ortant  for  a  diagnosis. 
.Shortness  of  breath  will  generally  be  a  marked  symptom  associated  with  the  eough  in  these 
eases  (see  Breath.  Shortness  of,  p.  87). 

Has  the  iviee  altered  since  the  cough  appeared  ?  Laryngeal  inflanunations  or  jiaralysis 
of  a  vocal  cord  are  suggested  by  an  affirmative  answer,  and  the  larynx  must  be  examined 
carefully,  the  more  carefully  the  more  nearly  the  patient  is  approaching  to  the  period  of 
life  when  growths  are  more  common. 

Cough  and  Vomiting. — These  two  complaints  are  not  infrequently  made  together 
by  patients,  and  there  is  a  very  useful  but  often  forgotten  question  to  put,  viz.,  "  Are  you 
sick  indei)endently  of  the  cough  ?  or  do  you  cougli  till  you  are  sick  ?  Yes  to  the  first  sug- 
gests stomach  trouble  ;    yes  to  the  second  suggests  bronchial  trouble  or  whooping-cough. 

Fred.  J.  Smith. 

CRACKLING,  EGG-SHELL.— This  is  a  condition  closely  allied  to  Crepitus  (p.  152)  ; 
if  subcutaneous  emphysema,  arthritis,  and  tenosynovitis  can  be  excluded,  it  is  nearly  always 
a  .symptom  cither  of  osteosarcoma,  if  it  occurs  in  connection  with  a  long  bone,  or  of  hydro- 
cei)halus  or  craniotabes  in  the  case  of  the  occipital  or  other  cranial  bones.  The  .r-rays 
may  assist  the  diagnosis  (p.  673)  :  if  there  is  a  tumour  connected  with  the  end  of  a  long 
bone  which  exhibits  egg-shell  crackling  with  or  without  pulsation,  it  is  almost  certainly 
an  osteosarcoma.  Herbert  French. 

CRAMPS  arc  involuntary  tetanic  nuiscular  contractions  accompanied  by  sharp  pain 
in  the  voluntary  muscles  involved.  Temporary  paralysis  of  movement,  partial  or  com- 
plete, is  often  associated  with  cramp.  Similar  painful  spasms  of  the  involuntary  muscles 
are  referred  to  as  colic.  In  most  instances,  cramps  result  from  over-exertion  of  the  affected 
muscles.  The  eram]i  comes  on  at  once,  or  after  a  short  delay,  or  when  the  attempt  is  next 
made  to  use  the  muscles  involved.  The  most  striking  example  of  this  is  swimmer's  cramp  ; 
in  this  the  victim  is  overtaken  suddenly  by  painful  spasm  and  paralysis  of  the  nniscles  of 
the  leg  or  legs,  or  of  the  legs  and  arms  ;  he  is  likely  to  drown  unless  help  is  .speedily  forth- 
coming. Similar  but  less  extensive  cram]3s  are  not  rarely  experienced  by  persons  taking 
part  in  the  more  violent  of  outdoor  games — football,  hockey,  lacrosse,  etc.  :  some  par- 
ticularly sudden  or  violent  effort  may  be  followed  by  cramp  in  the  thigh-  or  calf-muscles. 
Similar  cramps  of  the  legs  are  familiar  to  rowing  men  and  ballet-dancers.  Certain  people 
have  a  great  proclivity  to  cramp  during  the  night,  and  it  seems  to  return  with  less  and 
less  provocation  the  more  often  it  is  experienced.     Stokers  and  iron-founders  who  do  heavy 


CRAMPS  151 

bodily  work  in  much  overheated  atmosphere  are  liable  to  heat  cramps,  severely  painful 
spasms  in  the  muscles  of  the  limbs  and  abdomen,  in  attacks  lasting  for  many  hours  and 
followed  by  great  weakness.  The  diagnosis  of  cramps  due  to  over-exertion,  directly 
associated  as  they  are  with  a  definite  history  of  muscular  strain,  should  not  be  difficult. 
They  rarely  become  so  severe  as  to  prevent  their  victims  from  continuing  to  take  part  in 
the  occupations  that  provoke  their  occurrence. 

It  is  f|uite  otherwise,  however,  with  jjatients  who  are  afflicted  with  the  so-called 
profcssioiiiil  iriinips  or  occupation  neuroses  that  result  from  chronic  strain  and  over-use 
of  certain  groups  of  muscles.  They  occur  in  such  persons  as  writers,  typists,  telegraph 
operators,  compositors,  painters,  tailors,  seamstresses,  dairymaids  (from  milking  cows), 
pianists,  flute-players,  violinists,  'cellists,  drunuiiers,  blacksmiths,  file-makers,  cigarette- 
rollers,  and  so  forth.  In  all  these  employments,  |)articular  groups  of  muscles  are  in  constant 
and  special  employment.  If  they  are  overworked  they  may  become  the  seat  of  cramps 
and  aching  i)ains — professional  cramps — as  soon  as  they  are  used  :  their  movements  lose 
their  delicacy,  and  become  inco-ordinated  and  spasmodic.  A  fine  tremor  is  very  connnonly 
to  be  observed  in  the  affected  limb.  It  is  probable  that  over-use  alone  is  not  enough  to 
set  up  these  eramjis.  Anxiety,  ill-health,  local  injury  or  disease,  and  the  inheritance  of 
a  neurotic  tcm])crauient,  all  contribute  to  the  establishment  of  professional  cramps.  These 
cramjjs  have  also  been  recorded  in  other  occuiiations,  and  as  affecting  other  grou|)s  of 
nuiscles  :  in  treadler"s  cramp,  the  hamstring  nuiseles  and  glutei  are  affected  ;  in  cornet 
player's  the  tongue,  in  watchmaker's  the  orbicularis  oculi,  may  be  attacked.  As  a  rule, 
the  diagnosis  of  a  professional  cramp  is  not  hard,  but  it  is  necessary  to  make  sure  that 
neither  organic  nervous  di,sorder  nor  local  di.sease  is  present.  Thus  the  physical  signs, 
f  JKMigli  hardly  the  symptoms,  of  writer's  cramp  may  be  present  in  such  diseases  as  paralysis 
agitans,  dissemiiialed  sclerosis,  tabes,  general  j)aralysis  ;  brachial  neuralgia  niiglit  sinuilate 
the  neuralgic  loniis  of  occupation  neurosis,  but  it  is  free  Ironi  (iam))s.  .\gaiii,  atreelions 
of  the  joints  or  of  the  tendons  at  the  wrists,  such  as  chrome  rlieumatism,  rheumatoid 
arthritis,  tenosynovitis,  tuberculous  infection,  may  all  give  rise  to  pain  in,  and  interfere 
with  the  movements  of,  the  hand.  Again,  writer's  cramp  may  be  so  much  feared  by  nervous 
patients  that  their  right  hand  may  become  so  stiff,  or  weak,  or  ))ainful,  that  they  can  no 
longer  write  :  ohjeeti\e  signs  of  the  cramp,  however,  are  lacking  in  such  cases,  which  are 
cured  by  the  re-establishment  of  the  patient's  self-conlideuee. 

Cramps  are  the  main  feature  of  tetany,  a  disease  eharacteri/.ed  by  the  occurrence  ol 
paioxysmal  or  continued  tetanic  spasms  of  the  extremities,  and  increased  excitability  ol 
I  lie  nerves  and  nuiscles  to  electrical  or  mechanical  stimulation.  Tetany  occurs  in  many 
diircrcnt  conditions,  and  at  any  age.  In  infants  and  young  children  it  is  a  complication 
of  rickets,  improper  feeding,  and  acute  gastro-intestinal  disorders,  either  with  or  without 
diarrho-a  and  xoniitiiig.  Mpidcinies  of  tetany  in  young  aduMs,  pnil)a.l)ly  resulting  liiiiii 
liioil-poisonjng,  lia\i-  been  dcse;il)cd  on  the  t'ontinent,  though  not.  apparently,  in  (ileal 
Hi'ilaiii,  In  mirsing  woiniii.  tetany  may  follow  jjrolonged  laclalidii  :  or  it  inaN  dcNclop 
during  picgnaney  and  recur  in  successive  pregnancies.  It  may  result  from  I  he  riino\al 
of  too  much  or  all  of  the  th>roid  gland  in  either  sex.  Tetany  complicates  a  certain  pro- 
portion ofjllie  cases  of  gastrectasis,  occurring  whether  the  dilated  stomach  has  been  waslie<l 
out  or  no.  A  few  instances  are  on  record  in  which  tetany  followed  the  acute  spicilic  levers, 
enteric  li\  ir.  or-  poisoning  by  chloroform,  lead,  or  ergot .  In  line,  it  may  be  said  that  tetany 
is  u--ually  <lue  to  acuti-  or  clironie  digestive  troubles,  the  painful  spasms  being  evidence 
111'  I  he  al)s(uption  of  some  lux  in  Irom  the  gastro-inlcsl  inal  had  in  inosi  (•a>cs.  The  cramps 
III  Iclariy  are  maitdy  in  tlir  i\l  i<inities  and  parowsinali  lli(\  ina\  ((inliniie,  however, 
lor  lidurs  or  days,  and  are  \(ry  painful.  During  Hie  spasms.  Ilic  lingers  arc  extended  at 
llir  Icrminal  ami  llexed  at  the  inetaearpophalangeal  joints  ami  pressed  together,  while  tin- 
Ihinnh  is  addueled  and  llexed  into  the  palm,  so  thai  tli<'  so-called  'accoucheur's  hand' 
{l''iii.   1.  p.  :i)  is  pniducrd.      The  wrisi    ami   elbow  are   llexed.  I  he   aims  lieing   usually    folded 

over    the   chest   ;    exeeplionall>     I  he    cIIkiw    \    he   extended    slillly.       The   Iocs   are   drawn 

together  and  llexed.  the  loot  is  arched  and  turned  inwards,  and  the  ankles  and  knees 
extended,  (siially  the  limbs  only  arc  involved,  but  in  severe  cases  cram[)s  occur  in  the 
face,  neck,  and  even  the  trunk,  when  respiration  may  be  embarrassed  seriously.  The  rigid 
nuiscles  are  very  tender  to  the  touch.  Three  special  signs  are  present  in  the  intcr\als 
between  the  attacks  of  tetany,  and   are  valuable  in  diagnosis  :    these  are  Trou.sseau's  sign. 


152  CRAMPS 

or  reproduction  of  the  paroxysm  by  nuiiuial  compression  of  the  nerves  or  blood-vessels 
supplying  the  affected  parts  ;  ]<;rb"s  sign,  or  hyperexcitability  of  the  motor  nerves  to 
electrical  currents  (0-5  to  2-0  milliamperes)  ;  and  Chvostek's  sign,  or  reproduction  of  the 
spasm  in  the  facial  muscles  by  tapping  either  on  the  muscles  themselves  or  on  the  facial 
nerve.  Tetany  must  be  diagnosed  from  letmius,  in  which  the  spasms  begin  in  the  head 
and  neck,  and  trismus  is  an  early  symptom  ;  and  from  strychnine  jjoisoning,  where  the 
spasms  are  clonic  rather  than  tetanic,  and  affect  the  whole  body,  and  not  the  extremities 
primarily  or  principally.  In  the  carpo-pednl  spasms  of  rickety  children  or  of  infants  with 
severe  gastro-intestinal  catarrh,  the  cramps  are  similar  to  those  of  tetany,  but  are  tran- 
sient, and  perhaps  affect  the  hands  only,  or  the  hands  and  arms.  Such  spasms  may  justly 
be  regarded  as  identical  with  mild  tetany.  Hysterical  tetany  occurs,  and  is  to  be  distin- 
guished from  true  tetany  by  its  association  with  other  hysterical  stigmata  on  the  one 
hand,  and  on  the  other  by  the  absence  of  Trousseaus  and  Chvostek's  signs.  Hysterical 
tetany  may  also,  perhaps,  be  distinguislied  by  its  failure  to  respond  to  the  exhibition 
of  calcium  salts  ;  the  .most  recent  view  of  true  tetany  regards  it  as  the  expression 
of  Iiyper-excitability  of  the  nerve-cells  due  to  lack  of  calcium  salts,  and  connects 
it  with  the  ))arathyroid  ghuuls  by  sui)i)Osing  that  they  control  tlie  caleium-metabolisiu 
of  the  l)0(ly. 

|{elerenee  may  again  be  made  to  the  fact  that  cramps  are  prone  to  occur  in  patients 
il(l)ilitated  by  the  acute  fevers  or  enteric  fever;  severe  cramjjs  in  the  legs  and  arms  are 
olten  a  liighly  troublesome  feature  of  the  convalescence  from  cholera.  In  many  chronic 
diseases  noctiu-nal  cramps  may  give  rise  to  no  little  distress,  or  may  interfere  seriously 
with  sleep  :  in  gout,  chronic  Bright s  disease,  urwmia,  alcoholic  neuritis,  and  almost  any 
chronic  wasting  disorder,  complaint  of  cramp  is  not  infrecpicnt,  but  in  such  instances  more 
serious  signs  or  symptoms  ot  disease  will  be  evident.  A.  J.  Jex-Blala\ 


CREPITUS  is  a  term  generally  used  to  denote  the  grating  or  crackling  sensation  and 

noise  jiroduced  wlien  two  ends  of  a  broken  bone 
grate  together.  It  is  the  most  conclusive  sign 
of  a  fracture  :  but  it  causes  the  ])atient  so  much 
pain  that  whenever  the  a'-rays  can  be  employed 
attempts  to  obtain  crepitus  should  not  be  made 
with  any  vigour.  Apart  from  fracture  of  a 
bone,  crepitus  is  also  to  be  felt  and  heard  in 
joints  affected  by  dendritic  synovitis,  or  still 
more  so  in  cases  of  oslco-artliritis  :  the  term 
■  silken  crepitus  '  has  been  used  for  tlie  sensa- 
tion felt  on  moving  such  a  joint,  comparable 
to  the  rubbing  together  lietween  the  fingers  of 
two  pieces  of  stout  silken  ribbon.  Tenosynovitis. 
especially  around  the  flexor  tendons  at  the 
wrist,  may  also  produce  a  very  marked  feeling 
of  crei)itus,  especially  in  cases  where  the  tendon 
sheaths  contain  melon-seed  bodies. 

\\hen  there  is  an  enlargement  of  a  bone 
without  fracture,  and  when  on  palpation  a 
feeling  of  crepitus  or  egg-shell  crackling  is 
obtained,  it  is  an  indication  that  the  tumour  is 
a  deposit  of  secondary  carcinoma  or  a  ])riinar\ 
rarefying  osteosarcoma,  which  may  sometimes 
be  felt  to  pulsate  also.  The  diagnosis  may  be 
/'•/.;. (52  -Ski. lt;itii  of  :i  -rn«iii  in  ii.f  iiMiiicnis  in  :i  assistcd  by  tlic  usc  of  the  .r-Tays  (Fis-  62). 
'•T.n  '-"um' M,inl!ni '' m"'i'. '"••!'"  ^u.n  In  i'i,"'!"",!i 'i "  Harcfaction  of  the  bones  of  the  skull,  either 

ary  di'|i"-ii  "I  <  i  imit  i.  ii  , ,  II.  ,1  , u,  ii,,.i -rn  ,.(        as  the  result  of  syphilitic  lesions  in  adults,  or  of 

tip  liiiniH.i  '■-'''J'y^'|^^'|^'.||'^^")|^''y^'^"J!''|^^'^^^.[|"^^  lii/droccplialus   or  craniotahes,  especially   in  the 

occipital  region  of  congenital  syphilitic  and 
rickety  infants,  may  make  the  skull  bones  so  thin  that  they  readily  bend  on  pressure,  anil 
sometimes  the  result  is  a  sensation  of  crepitus.     The  diagnosis  is  generally  obvious. 


CTKVATURE.     SPINAL  153 

Quite  apart  from  bony,  arthritic,  or  synovial  changes,  a  characteristic  fecHng  of 
crepitus  may  be  felt  beneath  the  skin  when  gas  or  air  has  accumulated  in  the  subcutaneous 
tissues  as  the  result  of  surgical  KMrnysKMA  (p.  203).  Ilerherl  Frciirh. 

CRUSTS  ON   THE  SKIN.— (See  Scabs,  p.  599  .) 

CUD-CHEWING. -(See  Meryci.sm,  p.  388.) 

CURSCHMANN'S  SPIRALS  consist  of  a  liiglily  refraetilc  central  fibre,  and  a 
sinuous  wa\y  sheatli  of  mucus.  They  may  be  half  an  inch  in  length,  but  they  are  very 
slender.  Tliey  occur  in  the  s])Utum  of  i)atients  suffering  from  true  spasmodic  astlmia. 
and  they  may  be  associated  witli  cosino|)hilc  corpuscles  and  Charcot -Leyden  crystals. 
They  are  pretty  objects,  best  seen  in  fresh  sputum,  but  tlieir  diagnostic  significance  is  very 
limited,  first  because  they  are  so  often  absent  in  cases  of  undoubted  asthma,  and  secondly 
because  they  have  been  found  in  bronchiolitis  without  asthma.  They  seem  to  be  casts 
of  the  finest  bronchioles.  It  is  probable  that,  if  there  were  doubt  as  to  whether  a  given 
case  were  one  of  ]>rimary  emphysema  and  bronchitis,  or  of  spasmodic  asthma  that  had 
led  to  cm])hyscma  and  bronchitis,  the  occurrence  of  tyjjical  C'urschmann's  spirals  would 
point  to  the  latter.  There  are,  however,  other  means  of  arriving  at  the  same  conclusion, 
particularly  the  history,  the  age  at  wliich  tlie  first  attack  began,  and  the  presence  tiv 
ab.sence  of  Eosinopuim.v  (p.  219).  Herbert  Fre»cli . 

CURVATURE,  SPINAL.— In  the  diagnosis,  the  first  thing  is  to  distinguish  between 
latcial  and  antero-jjostcrior  deformities  ;  but  in  a  good  many  cases  scoliosis  or  lateral 
ciuvaturc  is  complicated  by  antero-iiosterior  deformity,  kyphosis,  or  lordosis  as  well,  and 
in  a  few  instances  of  angular  kyphosis  due  to  caries  there  is  some  lateral  deviation,  which 
is  generally  nuich  more  abrupt  than  is  the  curve  of  scoliosis.  A  good  way  of  demonstrating 
lateral  curvature  is  to  pencil  the  skin  over  the  spinal  processes. 

LATERAL    CURVATURE. 

The  following  arc  the  niosl   irii]Hirtaut  causes  of  lateral  curvature  : — • 

Iric.|ii;ilil\    III  Ihi-  I(iil:IIis  iif  the  ioucr  limbs  I   Paralysis  of  the  muscles  of  the  back,  as  in  iufan- 

\\(  .ikiicss  ol   I  III-  mhimIcn  of  tlic  luuk  associated  I  tile  paralysis,  peripheral  neuritis,  especially 

with   bail   lialiits  of  standing;   di'  sitting  '  that   following  diphtheria,  and  some  of  llir 

(  MirviiiL'  li<:i\  V  weights  with  one  .■uni  or  on  nnc  MinscMlar    dvslropliies 

sliiMil(l(  1    '  '  SiMivclliiii;  (if  (iiie  side  iif  the  chest  as  the  result 

Hirkcts  (if  ciiiiiyi ma  or  lilnnid  Inng 

\\i\-ii((k.  (11-  (itlier  causes  of  asymmetry  of  the  |   IIy>tiria 

head    anil     shoidders.    such     as     .SpreiigePs  ' 

-luinldcf 

Iiiniiiiililji  of  the  liii'itlis  of  the  hnccr  linilis  is  oiic  of  I  lie  (■(iiiuiioiiest  causes  of  laleral 
eiir\aturc  ;  therefore  it  is  \ery  iinporlaiil  (o  litid  out  al  once  if  (lie  legs  arc  e(pial.  The 
most  reliable  and  easy  method  of  dclciiiiiniug  this  is  to  gel  I  he  palient  to  stand  up  with 
bolli  knceV  straiglit  aiul  witliout  resting  a  hand  upon  anylliing.  Tlie  ol)server  then  stoops 
in  fi'dtil  of  tlu'  ])atient  and  jjlaccs  his  thumbs,  with  their  extremities  upwards,  exactly 
u|ioii  the  proMiinenee  of  each  anterior  superior  >.piiie.  The  eye  can  then  detect  even  a 
slight  difference  in  tlie  level  of  the  two  s|)ines.  This  method  is  hir  m<nc  reliable  than 
measurement  from  the  anterior  superior  spines  to  the  malleoli.  .Moreover,  the  latter 
method  does  not  show  shortening  due  lo  llcxion  and  adduction  of  the  hip  Joint.  Further, 
I  In-  fool  may  be  lixed  in  a  position  of  talipes  c(piimis,  which  may  make  a  shorl  limb 
:i|ipai-eiill\-  l(ini;cr  llian  ils  fellow,  so  that  llic  aiilcrior  spine  on  the  eorrespoiiding  side 
may  lie  clcx  .'it  cd .  When  llic  anterior  spines  arc  (in  :i  diricrciil  level,  tile  truid<  leans 
louards  the  lower  spine,  lint  ill  older  lo  iiiaiiitaiii  llie  erect  |i(isiti(ili  the  upper  |iail  of 
the  li(id\-  hecoiiies  Hexed  to  the  opposite  side.  Thus,  the  spine  in  the  limibar  region 
(l(  \(lo|)s  a  ciir\e  with  its  convexity  to  llie  side  of  the  shorl  limb.  Liiteral  cur\alure  due 
1(1  a  shortened  limb,  in  its  early  stages,  is  corrected  al  oiiee  by  coinpeusating  the  shortened 
limb,  and  it  also  disajipcars  when  the  ))atient  sits  on  a  Hal  le\il  surface.  In  the  al)sencc 
of  iiieipiality  of  the  limbs,  wiinciilar  urnlnirss  is  by  far  tlic  most  common  cause  of 
lateral    eiir\aliire.       The     spine    does    not    lieeoine  slraiiilil    when    the   palieiil    sits  (Ul  a  Hat 


154  CURVATURE,     SPINAL 

level  siirfaee  :  hut  in  the  early  stages  of  the  deformity  the  shape  can  be  corrected  some- 
what by  muscular  effort. 

Asymmetry  of  the  chest  following  upon  empyema  or  fibroid  lung  is  easily  detected. 
The  shrivelled  side  is  generally  less  resonant  on  percussion,  and  there  are  other  signs  of 
pulmonary  disease. 

Scoliosis  secondary  to  wry-neck  is  usually  slight,  and  limited  to  the  cervical  and  dorsal 
regions.  In  growing  youths  the  carrying  of  heavy  iveights  with  one  arm  or  upon  one  shoulder 
is  a  common  and  important  cause  of  scoliosis,  and  it  is  therefore  necessary  to  go  into  the 
question  of  occupation  and  liabits.  For  instance,  nursery-maids  and  butchers'  boys  are 
very  apt  to  develop  lateral  curvature  as  the  result  of  carrj-ing  burdens  upon  the  right  arm. 

The  lateral  curvature  due  to  rickets  is  recognized  by  the  unusually  early  onset,  during 
the  first  or  second  year,  and  the  signs  of  rickets  in  other  parts,  especially  thickening 
of  the  lower  end  of  the  radius.  The  direction  of  the  primary  curve  is  sometimes  explained 
by  the  pressure  of  the  arm  of  the  nurse  who  carries  the  baby  too  exclusively  on  one  arm. 
Actual  paralysis  of  the  spinal  mascles  is  a  rare  cause  of  scoliosis,  and  is  to  be  recognized 
by  the  wasting  of  the  spinal  muscles,  especially  when  this  is  more  marked  on  one  side. 
The  sinking  of  the  muscles  due  to  rotation  of  the  spine  must  not  be  mistaken  for  wasting. 
There  is  usually  paralysis  of  other  muscles,  especially  those  of  the  leg.  Scoliosis  is  often 
seen  in  the  various  primary  muscular  atrophies  (p.  513).  and  in  Friedreich's  hereditary 
ataxy  (p.  51'2). 

Peripheral  neuritis  as  a  cause  is  nearly  always  due  to  diphtheria  or  sore  throat.  Tlic 
history,  may  indicate  this,  or  there  may  have  been  other  post-diphtlieritic  paralyses, 
notably  that  of  the  soft  palate,  with  nasal  voice  and  regurgitation  of  lUiid  through  the  nose. 
Cultivations  should  be  taken  from  the  throat,  and  the  Klebs-LiWUcr  bacillus  {Plate 
XXV HI,  Fig.  L.  p.  614)  may  be  found  if  sought  early  enough.  Ocoasii)nally  the  abdominal 
muscles  may  also  be  paralyzed  in  these  cases,  and  this  is  a  contriljutory  cause  of  the 
curvature. 

ANTERO-POSTERIOR    CURVATURES. 

These  may  take  the  form  of  (1)  Kyphosis,  (2)  Lordosis. 

1.  Kyphosis  or  "  hunip-baek,"  means  a  bending  forwards  of  the  upper  part  of  the 
back  on  to  the  lower.  The  curve  may  be  (a)  Angular,  and  limited  to  a  small  portion  of 
the  back  ;  or  it  may  be  (h)  Diffuse,  or  even  general,  extending  from  the  coccyx  to  the 
eraniiuu. 

(a).  Angular  Kyphosis. — The  causes  of  angular  kyphosis  are: — (i)  Tuberculous  caries 
of  the  vertebnc  ;    (ii)  Growth  of  the  spine  ;    (iii)  Hydatid  disease  of  the  vcrtebrse. 

(i).  Caries  is  by  far  the  conmionest  cause,  and  it  is  very  imj)(>rtant  to  recognize  the 
disease  before  the  deformity  becomes  well  marked.  I'nfortunately,  it  may  be  treated 
lor  a  long  time  as  stomach-ache  or  intercostal  neuralgia,  because  the  pain  is  referred  to 
the  abdomen  and  the  intercostal  regions.  During  its  active  stages  it  is  easy  to  recognize 
it  from  its  classical  symptoms  and  signs.  The  patient  avoids  all  jerky  movements,  walks 
with  a  stooping  gait,  and  grasps  with  the  hands  any  convenient  article  of  furniture.  The 
sjiine  is  tender  on  percussion,  also  on  pressure  ujjon  the  head  or  shoidders.  Local  rigidity 
of  the  back  is  noticed  when  the  patient  attempts  to  stoop.  In  later  cases,  paralysis  of 
the  legs  may  complicate  the  deformity.  In  the  quiescent  stages,  the  diagnosis  is  based 
on  the  characteristic  local  deformity  and  rigidity.  Skiagrams,  especially  (hose  taken 
from  side  to  side,  may  afford  material  help  by  showing  evidence  of  destruction  of  the  bodies 
of  the  vertebnc  {Fig.  195,  p.  460).  In  some  cases,  lateral  curvature  may  complicate  or 
follow  caries,  and  then  the  diagnosis  is  not  easy.  The  disease  may  have  affected  the 
bodies  of  the  vertebra;  imevenly.  leading  to  some  lateral  deviation,  which  is  usually  rather 
abru])t  and  associated  with  the  local  rigidity  characteristic  of  caries. 

(ii).  Groivth  of  the  spine  is  a  rare  cause  of  angular  curvature.  Ra])idly  developed 
curvature  in  a  patient  after  middle  age  may  be  due  to  secondary  carcinoma  in  the  bodies 
of  the  vertebra-,  and  bearing  this  possible  cause  in  mind,  the  surgeon  should  go  carefully 
into  the  history,  and  examine  every  ])ossiblc  source  of  primary  carcinoma,  particularly 
the  breast.  Primary  or  secondary  sarcoma  may  also  lead  to  deformity  of  the  spine,  and 
in  some  cases  an  x-v&y  examination  may  give  evidence  of  the  development  of  new  bone 
in  the  growth,  or  of  the  absorption  of  the  vcrtebr;c. 


CURVATURE,     SPINAL 


155 


(iii).  lii/dalid  disease  is  a  very  rare  cause  of  spinal  curvature,  and  it  is  usually  not 
limited  to  tlie  spine. 

(b).  Diffuse  KfipJiosis. — The  back  may  be  bent  forwards  in  a  uniform  curve  extending 
from  the  coccyx  to  tlie  cranimn.  This  variety  is  common  in  rickets,  owing  to  the  premature 
assumption  of  the  sitting  position  when  the  bones  are  soft  and  the  muscles  of  the  back  are 
weak.  When  the  patient  is  lying  prone,  the  deformity  can  easily  be  corrected  by  raising 
the  legs.  Moreover,  there  are  other  signs  of  rickets,  such  as  enlargement  of  the  lower  end 
of  the  radius,  beading  of  the  ribs,  and  delay  in  the  erui)tion  of  teeth.  A  similar  deformity 
arises  from  muscular  iceakness  due  to  other  causes,  such  as  idiocy  and  congenital  spastic 
paraplegia.  In  all  of  these  there  is  an  entire  absence  of  rigidity  of  the  spine.  An  extensive 
an<l  luiiform  curve,  affecting  the  cervico-dorsal  region,  is  common  dining  adolescence,  and 
is  due  to  muscular  weakness,  la/.v  habits,  and  the  carrvin"  of  luaw  weights.     In  its  earlv 


^^^^^HmB^L'3^^1^^1 

^pj 

^^^IV 1          iff'S''  '^ '         ' 

Ipl 

\ 

^^m 

■—} 

stages  llii-  ilduiinity  is  easily  icdiicililc,  :iii(l  ;is  :i  rule  is  (•(iMip<iis;il(  il  by  ;i  iu:irked  lordosis 
in  the  luirilj;ir  region,  and  sonic  lilliiig  b:i(k\v:inis  of  Ike  occipul.  II  is  ol'leii  associated 
witli  hilcnil  curvjiliirc,  and  in  some  cases  iii:iy  be  Jiartly  due  to  shortness  of  siglil.  The 
eoiiililidn  is  ilisliiigiiislicil  riiiiii  caries  by  llic  dilTuseness  of  the  curvaltne,  llic  aliseiicc  of 
pain  and   local  lenderiiess.  and  llie  cornpaial  i\e  suppleness  of  the  back. 

Kyphosis  due  lo  s/)())iili/lilis  (h'fdniiuiis  or  to  oslcilis  ilcfiiniKiiis  (h'iiis.  (i;t  and  (it)  is  ol' 
a  more  uniform  character  without  complicating  lorilosis,  and  the  deformity  is  iricdueible. 
There  is  generally  cviilence  of  the  disease  in  other  parts,  such  as  ostco-arthritis,  or  the 
bending  of  the  legs,  and  increase  of  tlie  si/.e  of  the  head,  which  arc  due  to  osteitis  deformans. 
I'orlers  carrying  heavy  weights  on  the  np|icr  p;irl  ol  the  ]i:\rk  prcrniil  nrclx  (l(\il<ip  the 
kyphosis  which  is  usually  asso(  iiilcd  uilh  old  ;inv.  Tiny  tncininlly  li:i\c  a  bursa  over 
the  seventh   dorsal   spinous   ))roeess  (/•'/!.'.  (!."•). 


156 


CURVATURE.     SPINAL 


2.  Lordosis,     Hollow-Back. — This   deformity   is    only   common    in    the    ]uml)ar   and 
lower  dorsal  reirjon.     The  natural  hollow  of  tlie  ]oin  is  exaggerated,  and  usually  there  is 

either  primary  or  compensatory  kyphosis  in  the 
cervico-dorsal  region  {Fig.  fiO).  Lordosis  is 
rarely  primary,  but  it  may  be  so  in  the  early 
stage  of  lumbar  or  lumbo-dorsal  caries  in 
children,  when  the  real  cause  of  the  deformity 
is  a])t  to  be  overlooked.  Tlie  abdomen  is  very 
prominent,  and  the  back  is  not  only  hollow, 
hut  rigid  and  tender.  Pressure  upon  the  head 
also  causes  pain  in  tlie  back.  In  some  cases 
the  deformity  is  exaggerated  by  induration  or 
suppuration  in  the  psoas  muscle,  which  com- 
plicates this  disease.  I.,ordosis  is  not  uncom- 
monly due  to  weakness  or  paralysis  of  tlie  muscles 
of  the  back  {Fig.  CO).  It  is  particularly  impor- 
tant to  look  for  other  evidence  of  primary 
muscular  dystrophy.  The  upper  part  of  the 
back  is  then  thrown  backwards  to  facilitate  the 
maintenance  (jf  the  erect  position.  Lordosis  is 
often  secondary  to  the  flexion  of  hip  disease. 
which  must  not  be  overlooked.  Limitation  of 
movement — especially  of  rotation  of  the  hip 
joint — and  wasting  of  the  thigh,  serve  to  demon- 
strate the  existence  of  this  disease.  Lordosis 
and  the  waddling  gait  may  be  the  first  indica- 
tions of  congeniidi  dislocation  of  the  hip.  In 
this  condition,  whicli  is 
almost  confined  to  the 
female  sex.  the  erect 
position  is  maintained  only 
by  throwing  the  shoulders 
backwards  to  an  unusual 
degree  in  order  to  bring 
the  trunk  in  a  line  with  the  heads  of  the  femora,  which  are  dis- 
located backwards.  The  suspicion  of  congenital  dislocation  of  the 
hip  may  be  confirmed  by  skiagraphy,  by  the  gliding  movements  of 
the  head  of  the  femur  upon  the  pelvis,  the  unnatural  width  of  the 
lii|)s.  the  hollow  appearance  of  Scarpa's  triangle,  and  by  palpation 
of  the  head  of  the  femur  upon  the  dorsum  ilii  when  the  thigh  is 
flexed,  strongly  addueted.  and  inverted.  Contortionists  usually  have 
a  good  deal  of  lordosis  owing  to  the  unnatural  suppleness  of  the 
lumbar  spine  and  the  elongation  of  the  hamstrings.  In  all  these 
conditions,  the  back  is  supple,  and  can  be  restored  to  its  natural 
shape    by   placing    the    patient    in    the   supine  position  and  Hexing 


Fiif.  IJ5. — Deal  porter's  bursa 


■rtebra  p 


the  thighs. 


/?.  P.  noalaihls. 


CYANOSIS,  EXTREME.— Extreme  cyanosis,  blueness.  or  livi.l- 
ity,  is  gencially  most  marked  in  the  face  :  next  in  the  extremities. 
especially  the  hands,  feet,  ears,  and  penis  :  and  least  in  the  trunk. 
Cases  in  which  it  is  a  prominent  symptom  may  be  divided  into  two 
main  groups,  according  as  the  cyanosis  is  present  at  or  soon  after 
l)irth.  or  occurs  later  in  the  life  of  a  patient  originally  free  from  it.  .Myopathic  lordosis. 

Congenital    cyanosis    of    extreme    degree    is    nearly   always    due    to 

malformation  of  the  heart,  particularly  pulmonary  stenosis  {Fig.  07).  Patent  septum  ven- 
triculorum  may  also  produce  the  symptom,  though  not  in  so  marked  a  degree,  whilst 
patent  ductus  arteriosus,  when  it  occurs  by  itself,  is  generally  not  associated  with 
cyanosis  at  all.     These  three  conditions  all  give  rise  to   loud   universal   bruits,  of  which 


CYANOSIS.     EXTREME 


157 


that  due  to  pulnionary  stenosis  is  purely  systolic,  with  its  niaxinuim  intensity  in  the  second 
left  intercostal  space  close  to  the  sternum  :  that  due  to  patent  septum  ventrieulorum  is 
also  systolic,  but  has  its  maximum  intensity  lower  down  the  sternum,  usually  between 
the  two  third  spaces  or  fourth  ribs  :  whilst  the  bruit  of  i)atent  ductus  arteriosus  is  not 
purely  systolic,  but  continues  through  both  systole  and  diastole,  with  its  maximum 
intensity  at  the  time  of  the  second  sound,  and  it  is  best  heard  in  the  third  left  intercostal 
space,  about  half  an  inch  out  from  the  sternmn  :  all  these  bruits  may  or  may  not  be  accom- 
panied by  a  correspondinu  thrill,  the  latter  generally 
being  least  marked  with  patent  septum  ventrieulorum. 
Extreme  Cubbing  of  the  Fingers  and  of  the 
toes  accompanies  the  cyanosis  in  most  cases  {Fig.  46. 
p.  111).  In  addition  to  these  three  types  of  con- 
genital heart  disease,  there  are  other  cases  in  which 
extreme  cyanosis,  with  or  without  clubbing  of  the 
fingers,  occurs  without  any  definite  bruits,  and  the 
diagnosis  of  the  nature  of  the  lesion  can  only  be 
guessed  at.  There  may  or  may  not  be  transposition 
of  the  great  vessels  or  flf  the  viscera  at  the  same  time. 
Sometimes  there  is  a  single  large  vessel,  the  pulmonary 
artery  coming  off  from  the  aorta  :  or  there  may  be 
only  one  ventricle,  or  a  single  auricle.  It  is  almost 
impossible  to  decide  between  the  various  possible 
lesions,  unless  there  is  one  of  the  definite  bruits  just 
described.  Anomalous  cases  seldom  survive,  but  some 
cases  of  pulmonary  stenosis  or  patent  septum  ven- 
trieulorum reach  adult  life,  and  ])atent  <luctus  arteri- 
osus often  gives  little  inconvenience  to  the  patient  at 
all.  It  is  to  be  remembered  that  patent  foramen  ovale 
is  quite  undiagnosable,  that  it  causes  no  .symptoms, 
and  is  present  in  a  large  percentage  of  normal  people. 

Cyanosis  developing  in  children  or  adults  who  have  hitherto  been  healthy,  is  generally 
due  either  to  laryngeal  or  tracheal  obstruction,  to  lung  lesions,  cardiac  failure.- obstruction 
to  the  superior  vena  cava,  or  to  some  alteration  of  the  blood  itself,  such  as  is  found  in 
splenomcgalic  polycytha-mia.  metha'Uioglobina-mia.  suli)h-luemoglobina-mia.  or  the  later 
stages  of  diseases  associated  with  extreme  loss  of  Huid  from  the  tissues,  especially  cholera 
maligna.  Tlic  differential  diagnosis  is  usually  easy  up  to  a  certain  ])oint  ;  not  a  little 
cyanosis  may  result  from  taking  certain  drugs  either  in  large  (piantities  at  a  lime,  <u-  in 
less  quantities  continually — veronal,  trional.  sulphonal,  and  aeetanilide  in  paiticular. 
The  urine  in  these  eases  oflen  reduces  Kehiing's  solution,  and  may  conlain  metha'mogjohin 
recognizable  by  the  sjHctroscopc.  The  diagnosis  depends  on  a  knowledge  of  the  drug  that 
is  being  taken.  Caaes  nS  pancirntili.s  often  exhibit  a  peculiar  cyanotic  hue.  The  fact  of 
laryngeal  obstructiov  is  generally  obvious  from  the  stridor,  and  from  the  way  in  which  the 
larynx  moves  forcibly  up  and  down  with  respiration.  The  cause  of  the  obstruction  may 
be  less  easy  to  determine.  In  a  child,  a  digital  examination  of  the  back  of  the  mouth 
should  not  be  omitted,  lest  there  be  a  post-pliaripigcal  ahsrrss  or  a  foreign  hoili/  :  in  the 
absence  of  this,  the  most  probable  cause  is  iliplillicrifi :  though  it  may  be  dilliciilt  to  dia- 
gnose forthwith  belwcen  lari/iigilis  icilh  inlrrniittetil  spasm,  lari/iigiswiis  siriiliiliis.  acute 
obstructive  laryngitis,  and  diphtheria.  Swabbings  should  be  taken  from  the  throat  as  far  back 
as  possible,  and  examined  baeleriologleally.  The  bacillus  of  diphtheria  {I'late  XXVIII.Fig. 
h.  p.  (il  !•)  may  be  found  ou  direct  examinalion  of  films  stained  by  Xeisser"s  method  :  but 
sometimes  the\  eannol  be  found  until  eultivatiotis  have  been  made,  and  this  takes  upwards 
of  twenty-four  hours.  If  there  has  bi-en  no  obvious  cause  for  catarrhal  laryngitis,  such 
;is  the  inhalation  of  irritant  gases  or  a  re<'ent  attack  of  acute  l)r()ncliitis  affecting  the  large 
tubes,  it  is  better  to  assume  that  the  condition  is  diithfheria  until  it  is  |)rovcd  not  to  be  so. 
The  occurrence  of  other  cases  in  the  same  house,  or  in  the  neighbourhood,  may  assist  the 
diagnosis.  .Another  condition  which  may  simulate  diphtheria  from  the  extreme  dyspnfca 
and  cyanosis  that  result  is  the  iiihalatinn  (if  a  foreign  liody.  such  as  a  button,  small  shell, 
piece  of  food,   a  tooth,  and   so  on  :    or  ohstruelion   to   the  traelua    by    a    bulging   cascou.'t 


pulraonary   stenosis 


158 


CYANOSIS.     EXTREME 


gland  {Fig.  68).  In  an  older  person,  acute  sufforalive  lan/uaitis  due  to  pneumococci  or  strepto- 
cocci is  associated  witli  extreme  cyanosis  of  rapid  onset.  Tracheotomy  is  necessary,  and 
tlie  diagnosis  is  arrived  at  upon  bacteriological  grounds.  When  similar  acute  infective 
changes  occur,  not  in  the  larynx  only  but  in  the  root  of  the  tongue  as  well,  tlience  infil- 
trating the  deep  structures  of  the  neck,  as 
left  main  bronchus  ju  angina  Ludovici.  cyanosis  and  dyspnoea 

scarcely  visible  on  account  niay   be   vcrv   marked  :    the   diagnosis  is 

:>fthe  huig.ng  gland  above  it  suggested  by  the  acute  brawny   swelling 

of  the  neck  and  by  the  changes  in  the 
floor  of  the  mouth  and  tongue.  Severe 
dyspnoea  and  cyanosis  may  accompany 
goitres,  whether  simple,  exophthalmic,  or 
malignant  :  tlie  attacks  may  be  paroxys- 
mal even  though  the  thyroid  gland  itself 
does  not  seem  to  vary  in  size  ;  or  the 
cyanosis  and  dyspnoea  may  be  continuous 
when  there  has  been  rapid  enlargement 
of  the  gland  from  rarities  such  as  hspmor- 
rhage  into  it.  acute  suppuration  in  it,  or 
from  progressive  and  extreme  fibrosis  of 
the  organ  such  as  is  seen  in  ligneous  thy- 
roiditis, or  Riedel's  disease  (see  Thyroid 
Gland,  Enlargement  of,  p.  721).  It  is 
difficult  to  inspect  the  vocal  cords  in  a 
child  :  but  in  an  adult  this  is  easier,  and 
direct  examination  serves  to  distinguish' 
between  acute  or  ulcerative  lesions  of  the  larynx  and  laryngeal  paralysis  ;  the  latter,  some- 
times the  result  of  syphilitic  degeneration  of  part  of  the  vagal  centre  in  the  medulla,  is 
apt  to  produce  bilateral  abductor  paralysis  with  adductor  spasm,  which  may  come  on  acutely 
and  simulate  acute  asphyxia  from  a  foreign  body.     Tuberculous,  syphilitic  or  malignant, 


A  larg, 
inward  bulge  of     \ 

the  left    wall "ivf 

of  the  trachea  \ 
caused  by  a  caseousi 
gland  fvhich  is  embeddt 
in  the  bulge  "- 


Fig.  68. — Broiichoscopic  appearance  of 
compression  from  enlarged  glands.  There  w 
And  cyanosis  in  tliis  case,  relieved  at  one 
the  bronchoscope. 


a  c:xse  of  trachea 
.s  extreme  dyspntea 
'by  the   passage   of 


e  care 

h  for 
nil 


x'uriolous,  leprous,  lupoid,  and  traumatic  tilceration  of  the  larynx,  may  any  of  them  become 
acutely  infected  by  inflammatory  organisms,  and  lead  to  comparati^•ely  sudden  and  severe 
laryngeal  stenosis  with  acute  cyanosis  :  the  diagnosis  will  depend  upon  the  history,  bacterio- 
logical   examination,    and   direct    examination   of    the  vocal  cords.     Bright's    disease    has 


CYANOSIS.     EXTREME 


159 


sometimes  caused  similar  symptoms,  due  to  acute  oedema  of  the  larynx,  and  potassium 
iodide  may  do  the  same  in  those  who  are  particularly  prone  to  iodism.  Knee-jerks  should 
be  tested,  and  the  pupils  examined,  lest  acute  attacks  of  dyspnoea  with  cyanosis  simulating 
laryngeal  obstruction  are  due  to  the  laryngeal  crises  of  tabes  dorsalis. 

Groicths  of  the  lung,  particularly  if  they  give  rise  to  pleuritic  effusion  or  to  obstruction 
of  a  bronchus,  may  cause  progressive  cyanosis  :  the  diagnosis  is  not  as  a  rule  easy  in  the 
earlier  stages,  but  if  there  is  evidence  of  progressive  interference  witli  the  structures  within 
the  thorax,  with  ultimate  stenosis  of  the  superior  vena  cava,  and  the  results  of  this,  namely, 
oedema  of  the  face  and  arms,  together  with  cyanosis  of  these  parts  out  of  proportion  to 
any  similar  change  in  the  legs,  the  diagnosis  lies  between  growth,  aneurysm,  and  mediastinal 
fibrosis.  The  .c-rays  will  sometimes  be  of  material  assistance  in  deciding.  A  rare  but 
very  alarming  complication  of  thoracic  aneurysm  is  for  the  latter  to  open  suddenly  into 
the  superior  vena  cava  :  the  result  is  acute  dyspncca.  extreme  cyanosis  of  the  face  and 
hands,  and  bloated-looking  swelling 
of  the  head.  face,  neck,  arms  and 
upper  part  of  the  chest  and  back 
(Fig.  <>U).  The  diagnosis  is  suggested 
at  once  by  the  suddemiess  of  the 
onset  of  the  graver  symptoms  : 
though  these  have  also  been  pro- 
duced in  rare  cases  by  such  lesions 
as  sudden  liiemonliage  into  the  mrdia- 
stinum  or  thi/ttiiis  gland,  or  similar 
heeinorrlidge  into  an  inlr/ilhoratic 
sinionia  or  other  new  growth. 

Phthisis,  in  the  later  stages, 
particularly  when  it  advances 
rapidly  and  leads  to  generalized 
caseous  bronchopneumonia,  qauscs 
extreme  cyanosis  in  .some  instances. 
The  diagnosis  will  generally  have 
been  made  long  previously,  from 
the  symptoms,  such'  as  ha-moptysis. 
cough,  and  wasting  :  from  the  ab- 
normal physical  signs  which  started 
at  the  a|)iccs  of  the  lungs  and  were 
progressive  :  and  from  the  discoverv 
of  tubercle  bacilli  and  clastic  lil)r(s 
in  the  sputum,  though  there  arc 
many  cases  of  miner's  phthisis  (Fig. 
70),  or  pncumonocouulris.  in  which 
the  lung  trouble  may  he  extensive, 
yet  tubercle  bacilli  cannot  be 
found:  there  is  doubt  as  to  whether  ^ 
this  condition  is  always  tuberculous  ! 
and  not   sonu-tiiiics  syphililic.  ' 

I'nciimothora.r.  when    il    cdiius 
on   suddenly   in  a  patient    who  has   liai 
and  cyanosis,  which  present l\    pass  olT: 
cause  is  generally  tubercle. 

F.mli(dism  of  the  lung,  if  the  artery  i 
so   that    the  patient   hardly  has  time   t( 


till'   liillH 

U'ul'l  iMini  -         1  '  '< 

■■'•-    liistorv 

niiiri  liii.l 

WUtJ    :l    lllllr    [    I.   >       ... 

....     Now 

S|iUU.I]l 

I.Ul       «il M       .1 1 

I.I.    iiiherde 

iths  llftOI 

tlip  skmj.-r:irii  «;,»  t: 

ken. 

,.SA-ia//r«/ 

1  bn  Dr.  C.  Thurstai 

Holland.) 

no  symptoms   hitherto,  leads  to  acute  dyspuiea 
the  pliysieal  signs  are  pathognomonic,  and  the 


iC<-hMl((l  is  ol  large  si/.c.  may  cause  Middin  death, 
become  {vanoseil  ;  wlicu  the  cnilxilus  blocks  a 
smaller  \<ssel.  Ii\idity.  dyspncca,  intrathoracic  pain,  and  lucmoptysis  arc  the  most  promi- 
nent symptoms  ;  the  diagnosis  is  suggested  by  the  suddemiess  of  the  onset  in  a  ease  in 
wliieli  there  is  a  cause  for  embolism,  particularly  thrombosis  of  a  vein  such  as  the  femoral 
or  iliac,  or  a  recent  surgical  operation  in  the  neighboiuliood  of  a  large  vein  such  as  those 
m  the  abdomen,  or  otitis  media  with  lateral  sinus  thrombosis,  or  a  cardiac  Icsiorrsueli  as 
infective  endocarditis  of  the  right   side  of  the  heart.      Tlurc  may  bi-  no  ahnornial  plivsical 


160 


CYANOSIS.     EXTREME 


signs  ;  but  sometimes  the  resultant  infarct  may  be  detected  by  tlie  impairment  of  percussion 
note,  the  deficient  vesicular  murmur,  and  the  development  of  a  rub  over  it. 

In  childhood,  the  commonest  lung  affection  to  produce  extreme  cyanosis  is  broncho- 
pneiimoiiia  ;  the  diagnosis  is  generally  obvious,  though  it  is  not  always  easy  to  determine 
whether,  in  a  case  in  which  there  is  some  evidence  of  laryngitis  at  the  same  time,  tlie 
cyanosis  is  due  mainly  to  the  laryngeal  obstruction  or  to  the  intra-pulmonary  lesions. 
Each  may  cause  extreme  sucking  in  of  the  intercostal  spaces  and  convulsive  movements 
of  the  chest  as  a  whole  :  but  the  best  measure  of  the  degree  of  laryngeal  obstruction  is 
the  violence  of  the  up-and-down  movements  of  the  larynx  itself.  There  may  or  may  not 
be  empyema  associated  with  bronchopneumonia  ;  but  the  degree  of  cyanosis  will  not  help 
to  distinguish  between  these  two  ;  needling  of  the  chest  will  be  resorted  to  when  there  is 
ground  for  supposing  that  empyema  may  be  present.  Severe  bronchitis  and  emphysema 
in  middle  age  often  lead  to  marked  cyanosis  and  orthopncea,  owing  no  doubt  to  the  failure 
of  the  right  side  of  the  heart  to  which  the  lung  trouble  gives  rise.  The  over-distended 
condition  of  the  chest,  its  small  difference  between  maximum  inspiratory  and  maximum 
exj)iratory  girths,  the  deficiency  of  the  vesicular  nmrnuir,  the  rhonchi  all    over  it,  and 


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perha])s  non-consouating  rales  at  the  bases,  would  indicate  the  diagnosis,  particularly 
if  the  patient  has  inelasticity  of  the  skin  of  the  back  of  the  hands,  and  has  suffered  from 
similar  attacks  for  some  years  past,  especially  in  the  winter.  The  chief  difficulty  will  be 
to  determine  whether  the  cause  of  the  cyanosis  is  pulmonary  or  cardiac  (see  below).  Lobar 
piiriitnonia  as  a  cause  of  acute  cyanosis  is  diagnosed  chiefly  by  a  history  of  sudden  onset, 
the  continuance  of  pyrexia  for  a  week  or  ten  days  and  ending  by  crisis  (Fig.  272.  p.  642), 
the  rapid  respiration-rate  in  proportion  to  the  temperature,  the  viscid  rusty  sputum,  and 
herpes  labialis.  Occasionally  the  pyrexia  terminates  by  lysis  or  in  some  other  atypical 
way  {Fig.  71),  instead  of  by  crisis  ;  or  it  may  rise  again  after  the  crisis,  particularly 
when  empyema  follows  (Fig.  71).  Sometimes  the  diagnosis  is  made  when  no  abnor- 
mal physical  signs  can  be  detected  ;  but  if  over  a  large  portion  of  a  lobe  there  is  at  the 
same  time  impairment  of  note,  with  bronchial  breathing,  bronchophony,  pectoriloquy, 
without  rales  at  the  height  of  the  malady,  but  with  fine  crepitations  at  the  beginning  of 
the  attack,  and  with  redux  crepitations  as  the  bronchial  breathing  disappears  after  the 
crisis,  the  diagnosis  will  be  obvious,  especially  if  during  the  fever  there  is  a  great  deficiency 
or  complete  absence  of  chlorides  from  the  urine. 

Asthma  is  sometimes  very  difficult  to  distinguish  from  bronchitis  and  emphysema, 
because  it  ultimately  gives  rise  to  both  the  latter  (p.  535).  It  may  produce  extreme  cyanosis 
during  an  attack. 


CYSTIXUHIA 


161 


Cardiac  causes  for  extreme  cyanosis  include  any  of  the  conditions  wliicli  lead  to  chronic 
failure  of  the  right  side  of  the  heart.  These  may  be  classed  into  one  or  other  of  four  main 
groups,  namely  :  primary  valvular  disease  of  the  heart  ;  affection  of  the  muscle  of  the  heart 
or  pericardium  :  failure  of  the  heart  as  the  result  of  chronic  lung  lesions,  especially  eni])hy- 
sema,  bronchitis,  fibroid  lung  and  bronchiectasis  ;  and  cardiac  failure  when  the  heart  is 
unable  to  maintain  the  high  blood-pressure  due  to  granular  kidney  or  arteriosclerosis. 
When  a  late  stage  in  the  failure  of  compensation  has  been  reached,  it  is  often  difficult  to 
determine  whether  the  primary  condition  is  kidney,  heart,  lungs,  or  arteries  ;  the  differential 
diagnosis  between  these  is  considered  on  page  14. 

Cyanosis  due  to  splcnomcgalic  polycythccmia  (Plate  XXIX.  p.  634)  is  slowly  progressive, 
and  the  diagnosis  is  arrived  at  by  finding  in  the  patient  a  big  spleen  with  Polycythemia 
(p.  532),  and  no  other  very  definite  lesion. 

Cyanosis  due  to  inspissation  of  the  blood  as  the  result  of  loss  of  fluid  from  the  tissues 
in  fevers,  such  as  cholera,  dysentery,  yellow  fever  or  typhus,  is  a  late  symptom  in  a 
disease  that  will  generally  have  been  diagnosed  upon  other  grounds. 

Metha^moglobincemia  and  sulpli-hcemoglobincemia  are  diseases  which  have  been  grouped 
together  under  the  term  enterogenous  cyanosis.  Both  are  exceedingly  rare.  The  tint  of 
the  skin  by  itself  suggests  the  diagnosis,  being  altogether  different  from  that  of  ordinary 
cyanosis,  and  yet  not  to  be  mistaken  for  pigmentary  affections  such  as  Addison's  disease, 
argyria,  ochronosis,  or  hsemochromatosis.  There  is  no  polycythsemia.  The  diagnosis  is 
established  by  spectroscopic  examination  of  the  patient's  blood,  a  suitably  diluted  specimen 
exhibiting  a  well-defined  absorption  band  in  the  red  (Fig.  35,  p.  80)  in  addition  to  the 
two  bands  of  oxyhtcmoglobin  between  the  D  and  K  lines  (Fig.  30.  p.  80)  :  the  distinction 
between  sulph  -  haemoglobin  and 
methsemoglobin  is  not  easy  except 
in  the  hands  of  experts  in  blood 
chemistry  and  spectroscopy.  Some 
cases  arise  without  any  obvious 
external  cause,  and  are  to  be  dis- 
tinguished from  those  in  which 
the  blood-changes  are  directly 
attributable  to  the  effect  of  taking 
chlorate  of  potash,  aniline  deriva- 
tives, and  possibly  otlier  drugs. 

llrrbcrl   Frcinh. 


CYSTINURIA  is  the  term  used 
to  (Unolc  I  III-  iircsciicc  of  cystin 
(CII.^X.SO.J^  in  the  urine.  The 
latter  is  usuidly  pale,  turbid,  and 
oily  in  appearance  when  passed, 
slightly  acid  in  reaction,  with  an 
aromatic  odour  resembling  sweet- 
briar  :  after  standing,  alkaline  de- 
composition leads  to  the  formation 
of  sulphuretted  hydrogen  and  a 
change  in  coloin-  from  yellow  to 
green.  The  cystin  forms  a  light - 
yellowish  deposit,  which  consists  of 

colourless  microscopic  hexagonal  jtlalcs  (Fig.  72).-  The  condition  is  hereditary,  and  nicrcly 
indicates  a  peculiarity  of  mclahollsni.  The  crystals  have  occasionally  given  rise  to  calculi, 
which  are  of  a  light  fawn  colour  when  lirst  passed  or  removed,  changing  to  green  when  they 
arc  exposed  to  the  air.  Cystin  is  not  dissolved  on  heating  the  urine  or  by  adding  acetic 
acid,  but  it  is  by  mineral  acids  and  by  annnonia  ;  from  the  latter  it  can  be  recovered  by 
evai)oration  :  a  cIk  inical  test  that  has  been  rec'onuncnded  is  to  boil  some  urine  with 
acetate  of  lead  and  caustic  potash  ;  if  cystin  be  present,  a  dark  precipitate  should  form, 
as  the  resull  ni  Ihr  lormation  of  lead  sulphide.  The  best  evidence  of  the  condition,  how- 
ever, is  the  (lisc()\(iy  "I'  llic  lypi<'al  cr\slals  in  the  urine  microscopically.         Ihrlurl   French. 

i>  11 


162  DEAD    FINGERS 

DEAD  FINGERS. —  Most  individuals  are  familiar  with  dead  fingers  arising  in  ])erfectly 
normal  persons  -who  have  spent  more  than  the  usual  length  of  time  in  a  swimming  bath  or 
in  the  sea  ;  sometimes  all  the  fingers  of  both  hands  will  go  absolutely  white  imder  these 
circumstances  ;  e^en  the  whole  hand  may  go  dead-white,  but  more  often  it  is  the  fingers 
only.     The  toes  may  be  affected  in  a  similar  way. 

Very  similar  deadness  of  the  fingers  results  from  exposiue  to  cold  on  land,  though  the 
amount  of  cold  required  on  shore  is  much  greater  than  that  which  produces  dead  fingers 
in  the  water.  The  degree  of  cold  required  to  produce  this  deadness  of  the  fingers  is  much 
greater  in  the  case  of  some  individuals  than  in  that  of  others,  and  the  more  inured  the 
individual  is,  as  the  result  perhaps  of  his  occiii)ation  or  other  circumstances,  the  less  easily 
do  his  fingers  go  dead  with  cold.  This  being  so.  it  becomes  a  difficult  point  to  decide  just 
where  deadness  of  the  fingers  ceases  to  be  a  jjhysiological  phenomenon  and  begins  to  be 
evidence  of  a  pathological  change.  At  the  other  end  of  the  chain  one  has  Rajinaud's  disease. 
which  is  one  of  the  most  characteristic  of  maladies,  the  patienfs  fingers  going  dead  on  the 
least  exposure  to  cold,  and  sometimes  often  in  quite  warm  weather.  This  phase  of  local 
sjTicope  often  passes  on  quickly  to  one  of  local  asphyxia,  in  which  the  fingers  and  generally 
also  the  toes,  from  being  white,  go  more  or  less  purjjle  or  even  quite  black  (Fig.  125,  p.  256) 
and  remain  in  this  deeply  cyanotic  state  for  hours,  days,  or  even  weeks,  unless  artificial 
measui'es  are  resorted  to  to  restore  the  circulation.  In  the  most  severe  cases  some  portions 
of  the  affected  tissues  fail  to  recover  their  circulation  jiroperly.  and  die  in  patches,  with  the 
result  that  indolent  ulcers  develop,  healing  slowly  to  form  depressed  sears,  and  thus  simu- 
lating to  a  minor  extent  the  effects  of  fi'ost-bite.  Even  extensive  gangrene  and  loss  of 
fingers  results  sometimes. 

A  \ery  similar  condition  in  which  dead  fingers  may  be  a  symiitom  results  from 
ergotism  (p.  259)  ;  and  deadness  of  the  fingers  may  be  one  of  the  phenomena  of  pellagni 
(p.  225),  although  here  erythema  is  commoner  than  acute  jiallor.  Fortimately  both  pellagra 
and  ergotism  are  exceedingly  rare  in  this  coimtry. 

Between  the  jjhysiological  dead  fingers  of  exposure  in  cold  water  or  to  cold 
atmospheres,  and  the  pathological  deadness  resulting  from  Ra^^laud■s  disease  as  the  result 
of  exposure  to  temperatures  which  ought  not  to  cause  deadness  of  the  digits  in  normal 
persons,  one  meets  with  varying  degrees  of  precisely  similar  changes  to  which  it  is  difFiciilt 
to  give  an  exact  name.  For  instance,  an  ajsparently  healthy  individual  complains  that 
whenever  he  is  getting  up  on  a  winter's  morning  he  finds  one  or  other  of  his  fingers,  gener- 
ally a  -ring  or  little  finger,  goes  dead  and  white,  and  it  is  not  until  he  comes  down 
to  breakfast  and  gets  into  a  warm  room  with  a  fire  that  the  circulation  becomes  restored 
in  it  :  what  name  is  one  to  give  to  this  ?  There  is  no  generalized  syncope  of  all  the  fingers 
such  as  one  meets  with  in  Raynaud's  disease  ;  and  yet  the  patient  suffers  from  his  dead 
fingers  without  any  cause  which  should  be  adequate.  The  complaint  is  fairly  common  ; 
generally  it  is  no  indication  of  disease.  Four  things  in  particular  need  to  be  thought  of 
liowcver,  before  the  trouble  is  put  into  the  category  of  personal  idiosyncrasy,  namely  : 
(1)  Cervical  rib  ;    (2)  Aiterioselerosis  ;    (3)  Occupaiion  ;    (4)  Blue-brtiin. 

Deadness  of  the  ring  or  little  fingers  may  be  one  of  the  earliest  symptoms  in  the  case 
of  a  person  who  has  a  cervical  rib  {Fig.  186,  p.  443).  Later,  more  generalized  neurotic 
symptoms  in  the  arm  and  hand  may  be  expected,  or  even  atrophy  of  the  nmscles  supplied 
from  the  idnar  part  of  the  brachial  plexus.  Although  the  rib  dates  fi-om  birth,  it  is  remark- 
able how  it  often  produces  no  symjitoms  until  adult  life  is  reached  ;  it  may  produce  no 
symptoms  at  all  even  then  ;  when  it  does  so  the  patient's  attention  is  seldom  drawn 
directly  to  the  neck,  but  nearly  always  to  something  being  the  matter  with  the  hand  or 
forearm,  especially  the  ulnar  aspect  of  the  latter  and  the  little  and  ring  fingers.  If  one 
realizes  that  the  cervical  rib  or  the  fibrous  band  which  joins  the  end  of  a  buttress  cervical 
TihJ^Fig.  187.  p.  443)  to  the  first  rib,  is  liable  to  interfere  with  the  lower  trunks  of  the  brachial 
plexus,  one  can  imagine  the  various  vasomotor  and  other  nervous  symptoms  that  may 
result  ;  and  if  the  possibility  occurs  to  one,  the  diagnosis  is  established  by  means  of  the 
.r-rays.  Only  when  in  place  of  any  bony  rib  there  is  but  a  flbi'ous  cord  representing  it  will 
the  a-rays  fail  to  show  either  the  entire  rib,  or  more  commonly  perhaps  a  stimip  representing 
the  vertebral  end  of  such  a  rib,  sufficient  nevertheless  to  indicate  the  cause  of  the  nerve 
symptoms  in  the  hand  and  arm. 

Arteriosclerosis  or  atheroma,   or  both,   may   involve  the   vessels   supplying  the   hands 


DEAFNESS  163 

and  produce  in  the  latter  various  symptoms  of  deficient  circulation,  including  dead  finsers. 
The  patient  will  generally  be  past  middle  life,  and  as  a  rule  tlierc  will  be  other  indications 
of  arterial  degeneration,  especially  raised  blood-pressm-e,  though  when  atheroma  rather 
than  arteriosclerosis  is  the  cause,  the  arterial  affection  may  be  extensive  though  the  blood 
pressure  is  not  raised.  The  condition  in  the  arms  and  hands  comes  on  as  a  rule  spasmodic- 
ally, or  in  paroxysms  when  the  arms  and  hands  are  used,  and  the  remarks  made  on  page 
440  in  regard  to  intermittent  claudication  apply  here  just  as  they  do  in  the  case  of  the  leg. 
Dead  fingers  from  this  cause,  however,  are  not  met  with  frequently. 

Occupation  as  a  cause  for  dead  fingers  is  familiar  in  two  classes  of  persons  in  particular, 
namely  first,  those  whose  hands  are  immersed  for  many  hours  a  day  in  waters  of  different 
temperature,  especially  if  there  are  chemical  ingredients  such  as  carbonate  of  soda  in  the 
waters.  Dead  fingers  are  in  this  way  one  of  the  troubles  which  washerwomen  are  apt 
to  suffer  from  (p.  444).  The  nature  of  the  patienfs  employment  may  suggest  this  cause 
if  inquiry  is  made  as  to  exactly  how  the  jjarticular  individual  carries  on  his  work.  The 
other  group  of  persons  who  are  liable  to  develop  dead  fingers  in  one  hand  or  the  other  as 
the  result  of  their  occupation,  are  those  who  carry  heavy  loads  upon  one  shoulder  in  such 
a  way  as  to  depress  that  shoulder  and  push  the  head  far  over  towards  the  opposite  side. 
Apparently  what  happens  is  that  the  pushing  asimder  as  it  were  of  the  shoulder  and  the 
neck  throws  much  strain  upon  the  fibres  of  the  brachial  plexus,  and  in  some  indi\iduals 
this  strain  leads  to  degenerative  changes  which  extend  down  the  nerve  of  the  arm  into  the 
hand.  Pains  may  be  the  most  prominent  result,  and  these  jjuins  arc  generally  most  severe 
in  the  region  of  the  shoulder  and  the  upper  arm,  esijccially  in  the  parts  supplied  by  the 
circumncx  nerve.  In  other  cases,  besides  the  pain,  or  without  pain,  muscular  atrophy 
results.  In  a  few  instances  vasomotor  phenomena  predominate,  and  dead  fingers  or  even 
a  condition  similar  to  that  of  Raynaud's  dis^ease  has  resulted.  That  occupation  is  the 
probable  cause  will  be  suggested  by  the  symptoms  being  so  much  more  pronoimced  in 
one  han<l  than  in  the  other,  for  it  very  rarely  hajipens  that  the  man  will  carry  weights  first 
on  one  shoulder  and  then  u|)on  the  other,  so  as  to  affect  both  luaehial  ])lexuses  alike. 

IShic-hrtiiii  is  a  deserij)tive  term,  coined  by  Sir  .lames  Goodluut  to  cover  a  very  extensive 
class  of  ease  in  which  all  sorts  of  peripheral  phenomena  of  a  functional  type  have  their  root, 
in  his  opinion,  not  in  a  peripheral  cause  but  in  a  central  one  ;  and  as  the  individuals  generally 
have  what  is  called  a  poor  circulation,  with  a  tendency  to  blueness  of  the  ears  and  hands,  a 
liability  to  chilblains  and  oilier  phenomena  of  that  kind,  he  considers  that  they  also  have 
a  corresponding  tendency  to  poorness  of  the  circulation  in  the  cerebral  centres;.  Just  as 
they  have  blue  extremities,  so  they  have,  as  he  says  "  blue-brain.'  The  patients  are  not 
all  women,  though  the  majority  are  ;  they  have  aches  here  and  jiains  there  ;  the  abdominal 
aorta  is  often  unduly  pulsatile;  the  right  kidney  is  often  movable;  there  is  suliering  at 
the  monthly  periods  ;  the  knee-jerks  are  exaggerated  ;  the  patients  are  of  the  nervous, 
neurotic,  neurasthenic,  or  even  actually  hypochondriacal  type,  .\mongst  tlic  many  symp- 
toms that  they  may  complain  of,  deadness  of  the  lingers  on  the  slightest  proNocation 
may  be  one  ;  the  condition  may  then  simulate  Raynaud's  disease,  and  it  is  a  <iucstion 
whether  in  Itaynaud's  disease  itself  the  vasomotor  anomaly  is  not  central  rather  than 
peripheral*  livery  practitioner  has  met  with  dead  fingers  in  |)atients  for  whom  they  can 
recogtii/.e  at  once  that  the  term  '  blue-brain '  fits  as  an  ap])ropriate  label  ;  for  a  full 
description  of  the  types  of  case  in  question  he  should  read  Sir  .lames  (Joodharfs  original 
article  upon  the  subject.  Ilcrhcrl  French. 

DEAFNESS. — This  is  the  most  con-.tanl  sympldui  of  disiasc  of  the  ear.  It  ma\  be 
present  in  one  or  both  ears,  and  may  vary  from  a  slight  dclicicney,  \vlii<-li  ma\  be 
unnoticed  by  the  patient,  to  a  complete  loss  of  hearing.  The  causes  of  dcfci'tive  hearing 
arc  many.  In  some  cases  It  can  be  easily  relieved  :  in  others  I  he  prognosis  may  be  abso- 
hilcly  hopeless. 

The  organ  of  healing  consists  iif  («(]  inMJii  pinls.  Tlic  llisl  is  a  condiieling 
porlinn   (■(iiisisliiig    uT   tin-  cNlcriial    audil(ii\    nii;iliis.   Iyirip:uniiii.  iIpmmi.  .•mil    (issiclis      llie 

riiiiili r  wliii-li     is   |<j    (■(illcci     IJK'    sound     u:i\(s    .iriil    Iransniil     llii-    xibralions    lo    Ihe 

endolyniph  of  llic  internal  car.  The  second  porlido  conlains  Ilie  l.-ihyrinlli  (■(lelilea, 
vestibule,  and  semicircular  <'anals  in  which  arc  silualcd  Ihe  lerininalidiis  cil  Ihe  auclilni\ 
nerve,     De^d'ness  may  be  caused  by  a  lesion  either  of  the  conducting  port  ion  of  the  audilory 


164 


DEAFNESS 


apparatus,  or  of  the  internal  ear,  wliich  contains  the  receptive  mechanism.  The  latter — 
labyrinthine  or  nerve  deafness — is  tlie  more  serious  and  visually  the  more  severe,  but  the 
former  is  much  the  commoner.  Rarely,  deafness  may  be  due  to  some  disease  of  the 
auditory  nerve  or  to  some  tumour  of  the  brain  involving  the  fibres  of  the  nerve  in  their 
intracerebral  course. 

Tests  for  Hearing. — In  the  examination  of  a  deaf  patient,  a  careful  investigation 
of  the  sense  of  hearing  is  necessary  :  (a)  To  estimate  the  severity  of  the  deafness  ;  {b)  Tn 
ascertain  whether  the  lesion  is  situated  in  the  conducting  apparatus,  or  in  the  labyrintli 
or  auditory  nerve.  Before  carrying  out  these  tests  it  is  well  to  examine  the  external 
auditory  meatus  with  a  speculum,  to  make  sure  that  the  deafness  is  not  due  to  the  presence 
of  a  plug  of  cerumen,  in  which  case  elaborate  hearing  tests  are  unnecessary.  The  following 
are  the  tests  usually  applied  : — 

1.  The  Whispered  Voice  Test. — This  consists  in  noting  the  distance  at  which  whispered 
words  are  heard.  Vowel  sounds  are  usually  heard  better  than  consonants.  The  examine)- 
must  cultivate  a  whisper  of  uniform  intensity,  and  the  patient's  eyes  should  be  covered 

to  avoid  the  possibility  of  '  lip  reading.'  Each  ear 
must  be  tested  separately,  the  other  external  audi- 
tory meatus  being  covered  by  a  finger. 

2.    The    Watch    Test. — Here    the    distance    is 

measured  at  which  the  ticking  of  a  watch  is  heard. 

The  same  precautions  must  be   taken    as    in    the 

\oice  test.     The  observer  must  first    measure    the 

distance  at  which  it   can   be  heard    by   a  normal 

person.     Suppose  this  to  be  30  in.,  and  the  pnticnt 

Iiears  it  at  a  distance  of   12  in  ; 

the     patient's     hearing     is    then 

described    as    1  j;.     Instead    of   a  i  lli 

watch,  Politzer's  acoimieter  {Fig. 

73),    an  instrument  producing  a 

Fu/.  73.— Politzer's  acoumetei.  uniform  tapping  sound,   may   be 

used. 

The  results  obtained  by  these  tests  by  no  means  always  coincide. 

Sometimes  the  whispered  voice  may  be  heard  remarkably  well  wliile  the 

watch  is  almost  inaudible.     This  is  more  likely  to  be  the  case  when  the 

onset  of  the  deafness  is  late  in  life.     More  rarely  the  watch  is  heard 

more  easily  than  the  voice. 

3.  Tuning-fork  Tests  are  of  the  greatest  importance,  since  it  is  chiefly 
by  these  that  labyrinthine  or  nerve  deafness  can  be  distinguished  from 
deafness  due  to  a  lesion  of  the  external  or  middle  ear.  In  the  latter 
case  tlie  sound  waves  are  obstructed  on  their  way  to  the  receptive 
apparatus,  and  cannot  be  heard  when  the  fork  is  near  to,  but  not  in 
contact  with,  the  ear  ;  whilst  if  the  base  of  the  fork  is  applied  to  the 
mastoid  process,  forehead,  or  chin,  the  vibrations  are  heard  readily, 
because  they  are  now  conveyed  to  the  normal  receptive  mechanism 
directly  through  the  bone.  In  nerve  or  labyrinthine  deafness,  on  the 
other  hand,  though  the  vibrations  are  transmitted  by  the  bone,  the  sound  is  heard  poorly 
or  not  at  all,  for  the  receptive  apparatus  is  at  fault,  and  is  unable  to  respond  properly 
to  the  stimulus  of  the  soimd  waves,  whether  they  reach  it  viii  the  external  and  middle  ear, 
or  through  the  bone. 

The  tuning-fork  used  should  be  one  which  \ibrates  256  times  per  second  (C).  It 
should  have  a  flat  foot-piece  (Fig.  74),  so  that  it  can  be  applied  conveniently  to  the  bone, 
and  it  may  with  advantage  be  fitted  with  a  contrivance  to  prevent  the  occurrence  of  over- 
tones. In  addition,  tuning-forks  vibrating  64  times  per  second  and  1024  times  per  second 
should  be  at  hand,  for  testing  the  perception  for  high  and  low  tones.  In  an  elaborate 
investigation,  still  higher  pitched  timing-forks  may  be  necessary.  The  following  are  special 
tests  used  in  testing  bone  conduction  in  a  deaf  patient  : — 

1.  Rimie's  Test. — The  tuning-fork  is  struck  lightly,  and  the  flat  foot-^jiece  is  held 
steadily  against  the  mastoid  process.     Directly  the  patient  ceases  to  hear  the  sound,  he 


DEAFNESS  3  65 

raises  his  hand,  and  the  fork  is  then  held  close  to  the  external  auditory  meatus.  If  tlie 
sound  is  heard  again,  the  result  is  positive  :  if  it  is  inaudible,  the  result  is  negative.  The 
test  may  also  be  carried  out  by  holding  the  fork  opposite  the  external  auditory  meatus 
first,  and  then,  when  it  is  no  longer  audible,  apjilying  it  to  the  mastoid.  A  useful  modifica- 
tion of  this  test  is  for  the  examiner  to  wait  until  the  fork  is  no  longer  heard  by  the  patient 
tln-dugh  the  mastoid,  and  then  to  transfer  it  to  his  own  mastoid.  In  this  way  the  bone 
conduction  of  the  patient  is  compai'ed  with  the  bone  conduction  ot  a  normal  individual. 

2.  IVebefs  Test. — This  is  especially  useful  in  unilateral  deafness.  The  vibrating  fork 
is  a]>plied  by  the  flat  foot-piece  to  the  middle  of  the  forehead.  The  patient  is  then  asked 
in  which  car  the  sound  is  heard  best.  If  the  deafness  is  in  the  external  or  middle  car.  the 
sound  will  be  best  heard  on  the  deaf  side  (positive)  ;  if  due  to  a  lesion  of  the  internal  ear 
or  auditory  nerve,  it  will  be  heard  in  the  good  ear  (negative).  Great  care  has  to  be  exercised 
in  this  test  to  get  the  correct  reply  from  the  patient,  as  there  is  often  unwillingness  to 
admit  hearing  in  the  affected  ear. 

3.  GelWs  Test. — The  air-pressure  is  increased  in  the  external  auditory  meatus  by 
means  of  a  Siegle"s  speculum.  The  vibrating  fork  is  then  applied  to  the  mastoid,  or  to 
the  middle  of  the  forehead.  In  a  normal  person,  bone  conduction  is  diminished.  ^Vhcn 
it  is  unaffected  it  is  generally  considered  that  the  foot  of  the  stapes  is  lixed. 

The  hearing  of  liigh  or  low  tones  is  ascer- 
tained by  using  tuning-forks  of  a  rapid  or  low 
rate  of  vibration.  Galton's  whistle  (Fig.  7.">), 
which  produces  very  high  notes,  is  also  used  for 
this  purpose.  By  means  of  this  instrument  a 
note  as  high  as  50.000  vibrations  per  second 
can  be  produced.  If  notes  of  more  than  20,000 
or  2.5.000  vibrations  are  not  heard,  the  auditory 
ncr\e  is  probably  affected.  -f'!'-  '5-Galtous  «l.i=tlc. 

To  sum  up,   labyrinthine  deafness   is  indi- 
cated when  l)onc  conduction  is  diminislied  markedly,  i.e..  when  Rinne's  test  is  positive  and 
Weber's  is  negative.     (Jenerally  speaking,  in  this  form  of  deafness  the  perception  of  high- 
pitihed  sounds  is  diminished.     It  must,  however,  be  remembered  that  in  old  people  the  per- 
ception of  high  notes  is  generally  diminished  considerably  without  any  affection  of  the  nerve. 

Deafness  due  to  some  error  in  the  conducting  ajjjjaratus  is  indicated  when  bone  con- 
duction is  good,  i.e.,  when  Rinne's  test  is  negative  and  \Vel)(r's  jxisitive.  There  is  also 
likely  to  be  [loor  perception  of  low-pitched  notes. 

In  carrying  out  these  tests,  however,  it  must  be  remembered  that,  in  a  patient  over 
fifty,  bone  cotidiietion  is  nornially  diininislied.  so  tiial  llic  lists  are  olten  inconeiusixe  in 
an  elderly  pali<iit. 

Deafness  due  to  a  Lesion  ot  the  Sound-conducting  Apparatus. — When  lliis  is 
the  case,  eilher  the  external  or  the  middle  ear  may  I)e  at  fnull.  i^xamination  with  the 
speculum  will  readily  reveal  the  presence  of  a  jiliiil  of  venniiiti.  /joln/ii.  or  a  ftirciiiii  '""'.'/i 
.such  as  a  mass  of  wool,  which  is  not  inlii'(|uent!\'  inserted  and  forgotten  by  the  palienl. 

The  cihise  of  middle-ear  deafness  will  be  <liagnosed  by  considering  otiur  syin|)toms 
which  may  be  jirescnt,  such  as  pain  and  tinnitus,  together  with  an  examination  of  the 
tympanic  metubrane.  and  of  the  nose  and  naso-|)harvnx.  Deafness  is  more  or  less  marked 
in  all  iii/liiniDuildn/  ilisrti.trs  of  the  miildle  cur.  acute  or  chronic.  sK/i/iiiriitive  or  noii-sii/>i>iiriitirc. 
It  nuisl  be  reniemberi'd  that  there  is  not  necessarily  a  correspondence  between  the  intensity 
of  the  deafness  and  tlu-  condition  of  the  iTiembrane.  The  latter  may  be  destroyed  and 
hearing  may  remain  fairly  good,  while  with  a  small  perforation,  or  in  chronic  non-suppurative 
otitis  mi'dia.  with  but  little  alteralioii  in  llie  appearance  of  the  membrane,  the  deafness 
niiiy   be   profound. 

Ctit/irrh  of  the  Eiixtocliioii  tiilic.  iir  ubsliucliini  lo  Iliis  passage  l)\  the  |inMiice  lA'  uilcnoiils 
or  iiiliir!>cil  tonsils,  is  a  e(itiiiiion  cause  of  dealtiess.  especially  in  eliildren. 

In  Mime  eases  iif  iMiddle-car  deafness,  especially  in  otosclerosis,  where  llie  lnul -plale  of 
llie  stapes  is  lixed.  (he  patient  may  hear  ordinars  speech  belter  in  a  noisy  place  Ihan  in  a 
i|niel  idiiMi.  This  is  known  as  paracusis  U'illisii.  It  is  generally  cNpliiiiied  by  supposing 
Ihal  the  more  ext<'nsive  vibrations  caused  by  the  loud  noise  loos<ii  Ihe  juiiils  belween  the 
ossicles,    whieli   are  ollu'rwise  abiioriiiallv   slitl. 


166  DEAFNESS 

In  disease  of  the  ooiiductinii  apparatus,  the  patient,  though  deaf,  not  infrequently 
hears  liis  own  voice  very  loudly,  and  also  noises  in  the  nasopharynx  such  as  occur  on 
swallowing.     This  is  known  as  aiitoplionia. 

Hypencstliesia  aciiniica  is  a  term  a})])lied  when  sounds  produce  an  act\ial  j^ainful  sensa- 
tion in  the  ear.  It  may  be  present  in  acute  inflannnation  of  the  middle  ear.  fevers,  and 
migraine. 

Nerve  or  Labyrinthine  Deafness  may  be  due  to  a  lesion  of  the  auditory  nerve  itself, 
which  may  be  invohcd  in  a  iiniivth  of  the  temporal  bone,  or  may  show  degenerative 
changes  in  tabes.  It  may  also  residt  from  a  definite  intracranial  lesion  such  as  a  tumour 
of  the  mid-brain  or  pons.  A  diagnosis  in  these  cases  will  be  made  from  the  coexistence  of 
other  nervous  symptoms  associated  with  cerebral  tumour.  In  labyrinthine  deafness  the 
following  actual  pathological  changes  have  been  found  :  (1)  Degenerative  changes  in  the 
organ  of  Corti  ;  (2)  Hnemorrhage  ;  (3)  Organized  inflammatory  jirodiicts  ;  (4)  Rise  in 
pressure  in  the  endolymph. 

The  following  are  the  chief  causes  of  labyrinthine  deafness  : — 

1.  Extension  from  disease  of  the  middle  ear.  suppurative  (pyo-labyrinthitis)  or  non- 
sup])urative  (occasionally  in  otosclerosis). 

2.  Apoplectic  deafness  or  Meniere's  disease,  which  may  be  due  to  ha-niorrhage  or  a 
sudden  rise  of  intracranial  pressure. 

3.  Following  the  specific  infectious  fevers,  especially  numi|)s,  but  also  influenza, 
typhoid,  measles,  scarlet  fever,  and  others. 

4.  Syphilis.  In  the  acquired  disease,  deafness  may  occur  at  almost  any  stage.  The 
onset  is  usually  sudden,  the  trouble  is  usually  unilateral,  and  may  have  all  the  characters 
of  Meniere's  disease.  In  congenital  syphilis  the  deafness  usually  begins  between  the  ninth 
and  sixteenth  years.  Eustachian  obstruction  and  retracted  membranes  are  frequently 
present,  but  the  deafness  progresses  and  is  labyrinthine  in  character.  Other  signs  of 
congenital  sy])hilis  will  be  present  to  assist  in  the  diagnosis. 

Deafness  may  follow  an  injection  of  .talvarsan.  It  may  appear  after  an  interval  of 
se^■cral  days,  or  as  long  as  three  months.  The  short  interval  is  usually  after  an  intravenous 
injection,  the  longer  when  the  drug  has  been  injected  into  the  muscles.  The  deafness  is 
more  or  less  absolute  and  has  the  characters  of  nerve  deafness.  By  some  this  is  regarded 
as  due  to  the  drug  ;  others  regard  the  lesion  as  due  to  the  liberation  of  a  large  quantity 
of  endotoxin  consequent  upon  the  destruction  of  the  spirochaetes. 

.5.  In  Uright's  disease,  leukfemia,  pernicious  and  other  anaemias.  A  luemorrhage  is 
fre(iuently  the  cause  of  the  trouble  here. 

0.  Certain  drugs  cause  transient  deafness  of  labyrinthine  character  ;  notably  quinine. 
and  sodium  salicylate:  possibly  alcohol  and  tobacco.  Mercury  and  lead  also  are  stated 
to  cause  deafness  sometimes. 

7.  Traumatic.  Labyrinthine  deafness  may  follow  blows,  falls,  or  fracture  of  the  base 
of  the  skull. 

8.  Occui)ations,  such  as  caisson  workers,  or  workers  in  a  continuous  loud  noise  (boiler- 
makers'  deafness). 

9.  Meningitis,  especially  cerebrospinal  meningitis  ;    and  occasionally  in  epilepsy. 
Deafness  may  also  occur  in  hysterical  individuals.     This  may  usually  be  recognized 

by  the  manner  and  aspect  of  the  patient,  and  by  the  absence  of  abnormal  physical  signs 
on  examination. 

Lastly,  it  must  be  remembered  that  deafness  may  be  complained  of  by  a  malingerer  : 
the  fraud  is  usually  exposed  by  contradictory  replies  to  hearing  tests  with  the  eyes  bandaged, 
or  by  speaking  into  the  chest-piece  of  a  binaural  stethoscope  with  the  tube  to  the  sound 
ear  plugged  with  wool.  The  probability  is  that  the  patient  will  say  he  hears  words  sjioken 
into  the  stethoscope,  but  on  removing  this  and  covering  the  sound  car  with  the  finger,  he 
will  say  that  he  hears  nothing.  Philip  Turner. 

DEFORMITY  OF  THE  CHEST.— In  the  differential  diagnosis  of  alterations  in  the 
form  of  the  chest,  it  nuist  be  remembered  that  many  slight  deviations  from  its  typical 
form  are  not  produced  by  disease.  A  long  narrow  chest  {alar  ehest),  or  one  flattened 
anteriorly  (flat  ehest)  is  often  found  in  ])ersons  predisposed  to  phthisis  :  but  these  also  occur 
in  individuals  who  are  ne\ev  affected  by  this  disease.     A  long  neck  and  sloping  shoidders 


DEFORMITY    OF    THE     CHEST 


167 


are  also  associated  with  tliis  coiulitioii.  while  a  short,  tliiek  neel;  with  hiuh  shoulders  is 
found  in  persons  subject  to  apoplexy.  The  alterations  in  the  form  of  the  chest  which  may 
result  from  disease  may  be  considered  luider  the  following  headings  : — 

(1).  Deformities  the  result  of  rickets  ; 

(2).  General  ehnnges  in  the  form  of  the  chest  :  («)  Tlic  barrel-shaped,  (b)  I'nilateral 
enlargement,  (e)  Unilateral  shrinking  ; 

(3).  Local  changes  :    {a)  Bulging,  (b)  Retraction. 

Rickets. — The  following  deformities  of  the  chest  in  an  infant  are  due  to  rickets  : — 
Tlie  chest  is  somewhat  pear-shaped  on  transverse  section,  and  a  long  vertical  groove 
is  often  seen  on  each  side  of  the  sternum.  Beading  of  the  sternal  ends  of  the  ribs 
takes  place,  giving  rise  to  the  rickety  rosary.  The  pigeon  chest,  in  which  the  ribs  are 
flattened  on  each  side  in  front,  so  tliat  the  sternum  becomes  unusually  prominent,  making 
the  chest  appear  somewhat  triangular  on  transverse  section,  is  always  due  to  rickets 
(Fig.  78).  Harrison's  salens,  a  liorizontal  groove  in  the  lower  part  of  the  rickety  chest,  is 
due  to  tlie  sinking  in  of  the  ribs  above  the  attachment  of  the  diaphragm.     This  groove  is 


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-l-'ibiosis  of  the  left  luiu 


—mail,  ased  30  years.  Fiij.  SO.  -Emphysematous 

CVKTO.METRIO  TKACINGS   OP   VARIOUS    FORMS    OP    ClIKST. 


Traiisvei-sc  sections  ot   various  forms  ol  chest  at    the  level   of  the    stcnio-xiphoid 
cyrtometric   triuMiii.'s.      'I'lie  dotted  lines  indicate  the   natural  shajie  .at  the  same  iigc. 
'  I  iiiclies.    (Sawyer's  Physical  Signs,  1908.) 


exaggerated  because  the  lower  ribs  are  pushed  out  by  the  increase  in  size  of  the  abdominal 
viscera.  .Ml  these  deformities  are  associated  with  other  signs  of  rickets  in  the  cliild. 
which  make  the  diagnosis  easy. 

General  Changes. — (a).  The  Barrel-shaped  Chest  is  Idiinil  in  palieiits  suffering 
from  palaionarij  cnijilii/sema  {Fig.  80).  The  chest  is  enlarged  In  all  dircclions  and  gives 
the  appearance  which  is  assinned  by  the  normal  chest  only  after  deep  ins|)iration.  The 
antero-postcrinr  diameter  is  greatly  increased.  The  shoulders  arc  higher  and  squarer 
than  in  heallh,  Ihc  inlercoslal  spaces  are  enlarged  and  bulging,  the  dorsal  cm-vc  of  the  spine 
exaggerated.  'I'lic  mo\cmenls  of  Ihc  chest  during  respiralion  arc  extremely  restricted  ; 
there  is  elevation  of  the  chest  as  a  whole  during  inspiration,  but  very  little  real  expansion. 
The  neck  a|)pears  abnormally  short.  The  apex  beat  of  the  heart  cannot  be  I'elt.  On 
percussion  the  note  over  the  limgs  is  liyper-rcsonant,  the  cardiac  dullness  is  greatly  dim- 
inished and  often  obliterated,  and  the  upper  level  of  the  hepatic  dullness  is  lowered.  Tin- 
breath-sounds  upon  auscultation  arc  eiilccbled.  and  expiration  is  markedly  prolongcil. 
If  bronchitis  be  |ircsciil  alsd,  advcnl  ilious  sounds  arc  heard.  espcci;dl\-  sonorous  and  siliilaiil 
rlioiiclii  aoil  i-niiisc  hiilililini;  talcs.      Tlic  licarl-MHiuds  iiif  dlHictdl    In  hear. 


168  DEFOKMITV     OF     THE     CHEST 

Wheuevev  any  loss  of  symmetry  in  the  two  sides  of  tlie  chest  is  found,  the  vertebral 
column  must  be  examined  carefully,  as  the  alteration  may  be  due  to  spinal  curvature. 

(b).  A  Unilateral  Enlargement  of  the  chest  can  be  produced  by  an  extensive  pleuiitic 
effusion,  a  large  empyema,  pnenmothorax,  and  when  an  intrathoracic  tumour  affects  the  greater 
part  of  one  side  of  the  chest.  The  cause  of  the  enlargement  is  ascertained  by  tlie  physical 
examination  ;  thus  with  pleuritic  effusion,  either  serous  or  purulent,  the  movements  of 
the  affected  side  during  respiration  are  restricted,  while  those  of  the  opposite  side  are  exag- 
gerated :  dullness  is  foiuid  over  the  effusion,  while  above  it  the  note  is  usually  of  higher 
pitch  than  normal,  and  often  skodaic  ;  vocal  fremitus,  breath-sounds  and  voice-sounds  are 
diminished  or  absent  over  the  dull  area.  At  the  upper  level  of  the  fluid  asgophony  may  be 
present,  and  the  breath-sounds  frequently  tubular.  The  presence  of  ihiid  is  further  con- 
firmed by  finding  the  heart  pushed  over  to  the  opposite  side,  and  the  liver  depressed  when 
the  right  pleura  is  involved.  When  a  pneumotlwrax  is  present,  there  is  usually  a  history  of 
a  sudden  onset,  accompanied  by  a  severe  pain  in  the  chest  ;  the  affected  side  does  not  move 
as  freely  as  the  other  with  respiration  ;  the  heart  is  displaced  towards  the  opposite  side, 
and  vocal  fremitus,  breath-,  and  voice-sounds  are  diminished  or  absent,  though  the  affected 
side  of  the  chest  is  fully  resonant :  if  serum  or  pus  be  jsresent  in  addition  to  air,  the 
note  is  dull  or  greatly  impaired  at  the  base  of  the  lung,  with  hyper-resonance  but  absence 
of  breath-sounds  above.  When  much  fluid  is  j)resent.  the  note  changes  considerably  with 
the  position  of  the  patient.  The  metallic  tinkling  of  Laennec  is  sometimes  heard  over  a 
pneumothorax  ;  coughing  is  generally  required  for  its  production  ;  it  resembles  the  sound 
which  occurs  when  "  a  drop  of  water  falls  on  the  sin-face  of  a  fluid  contained  in  a  lialf-fllled 
decanter."  The  bell  sound  or  "  bruit  d'airain  "  is  very  characteristic  of  a  pneumothorax  ; 
to  hear  it,  auscultation  is  performed  over  a  portion  of  the  pneumothorax,  and  a  coin  placed 
on  another  portion  is  struck  with  a  second  coin  ;  the  sound  has  a  ringing  metallic  quality 
like  that  of  the  tinkling  of  a  small  bell,  or  like  the  ring  that  accompanies  hammering  upon  a 
blacksmith's  anvil.  Hippocratic  succussion  may  also  be  obtained  when  the  observer's  ear 
is  applied  to  the  chest  while  the  patient's  body  is  shaken  or  jolted. 

(c).  Shrinliing  of  tlie  tvhole  of  one  side  of  the  chest  is  due  to  contraction  of  one  lung, 
either  as  the  result  of  a  ))revious  compression  by  a  large  pleuritic  effusion,  and  especially 
by  an  empyema,  or  on  account  oi  fibrosis  of  the  lung  (Fig.  70).  The  history  of  the  patient 
often  indicates  the  cause  of  the  contraction  of  the  lung  ;  a  large  effusion  may  have  been 
aspirated,  or  an  empyema  may  have  been  drained  by  surgical  means,  leaving  the  scar  of 
the  operation.  In  other  cases  the  empyema  may  have  burst  into  the  lung,  and  there  may 
be  a  history  of  a  large  amount  of  pus  having  been  expectorated.  With  fibrosis  of  the  lung 
the  affected  side  is  retracted  and  .shrunken,  the  intercostal  spaces  are  very  narrow,  and 
the  ribs  may  even  overlap.  The  shoulder  is  lower  on  the  affected  side,  and  the  vertebral 
column  is  deviated  towards  the  diseased  lung.  The  heart  is  drawn  over  to  the  affected 
side,  in  which  there  is  very  little  movement  during  respiration.  If  the  left  lung  be  affected, 
the  heart  will  be  less  covered  by  lung  than  normally,  and  so  there  may  be  a  large  area  over 
which  cardiac  pulsation  is  visible.  The  note  over  the  contracted  lung  is  impaired,  while 
on  the  opposite  side  it  is  hyper- resonant.  The  breath-sounds  are  deficient  or  absent,  and 
may  be  tubular  or  cavernous,  while  at  the  base  there  may  be  numerous  coarse  bubbling 
rales,  especially  if  there  is  bronchiectasis.  Vocal  fremitus  may  be  decreased  or  exaggerated. 
The  expectoration  is  generally  copious,  semi-purulent,  and  often  fa?tid.  There  is  often 
marked  clubbing  of  the  tips  of  the  fingers. 

Local  Changes. — («)  The  cause  of  bulging  of  any  portion  of  the  chest  wall  may  be 
dilficult  of  diagnosis,  though  sometimes  it  is  obvious,  as  when  an  empyema  points  externally  ; 
even  this  is  sometimes  mistaken  for  a  localized  abscess  of  the  chest  wall,  unless  a  careful 
examination  reveals  the  sign  of  fluid  within  the  chest.  In  pulmonary  emphysema,  bulging 
is  often  present  in  the  supraclavicular  and  infraclavicular  regions.  Bulging  may  also  be 
due  to  an  intrathoracic  tumour,  to  an  aneurysm  of  the  aorta,  or  to  a  tumour  or  abscess  of  the 
chest  wall.  The  most  common  situation  on  the  chest  wall  for  an  aneurysmal  swelling  is 
to  the  right  of  the  sternum  in  the  first,  second,  and  third  intercostal  spaces  ;  it  may  erode 
the  upper  part  of  the  sternum  and  so  produce  a  swelling  there,  while  in  rare  instances  it 
may  produce  a  prominence  to  the  left  of  the  sternum  :  a  bulging  to  the  left  of  the  vertebral 
column  may  be  due  to  an  aneurysm  of  the  descending  thoracic  aorta.  The  expansile 
character  of  the  pulsation  suggests  the  diagnosis.     A  tumour  or  abscess  of  the  chest  wall 


DELIRIUM  169 

may  occur  in  any  situation.  The  pra^cordia  l)ecomcs  ])rominent  in  children  in  cases  of 
pcricardinl  effusion,  or  wlien  tlie  heart  is  enlarged  :  the  situation  of  the  prominence 
indicates  its  cardiac  orioin.  An  enlargement  of  the  liver  (p.  366)  may  also  produce  a  promi- 
nence of  the  ribs  under  which  it  lies  ;  a  hepatic  abscess,  a  subdiaphragmatic  abscess,  or 
an  empyema,  sometimes  point  over  the  lower  part  of  the  chest  in  front,  while  a  psoas 
abscess  may  point  over  the  lower  ribs  posteriorly.  A  prominence  over  the  s])inal  column 
in  the  dorsal  region  may  be  due  to  spinal  earies,  or  to  a  malignant  were  growth  of  the  spine. 
An  angular  curvature  of  the  spine  is  most  commonly  due  to  spinal  caries,  and  any  swell- 
ing which  is  associated  with  it  may  be  produced  by  an  abscess  arising  from  the  disease. 
Bulgings  which  give  an  impulse  on  coughing,  and  which  wax  and  wane  with  respiration, 
suggest  hernia  of  the  lung,  sometimes  of  considerable  size  in  marasmic  children  suffering 
from  whooj)ing-cough.  or  in  emaciated  phthisical  subjects  with  incessant  cough. 

(6).  lietraction  or  localized  shrinking  of  the  chest  wall  occurs  in  any  condition  in  which 
there  is  a  portion  of  hmg  contracted  by  disease.  When  present  over  one  or  both  apices 
of  the  hmgs,  as  shown  by  retraction  in  the  supra-  and  infraclavicular  regions,  it  is  nearly 
always  due  to  phthisis.  Unilateral  shrinkage  is  also  found  with  fibroid  eonditions  of  the 
lungs  which  are  not  tuberculous,  or  alter  the  absorption  of  a  pleuritic  effusion  or  the 
removal  of  the  pus  from  an  empyema.  J.  /■;.  //.  Sawyer 

DELIRIUM  occurs  in  an  overwhelmingly  large  proportion  of  cases  in  the  course  of 
some  well-known  disease,  commonly  pyrcxial.  and  beyond  the  fact  that  the  condition 
itself  in  such  diseases  is  a  symptom  of  somewhat  serious  import,  nothing  need  be  said  as 
regards  the  diagjiosis.  There  arc,  however,  a  few  prognostic  points  worthy  of  mention 
in  connection  with  such  cases.  Thus,  in  typhoid  during  the  height  of  the  fever,  in  measles, 
and  in  scarlet  fever,  the  delirium  is  eonuiionly  in  ])roportion  to  the  pyrexia  in  its  violence, 
aiKJ  can  usually  be  controlled  by  controlling  the  pyrexia,  if  necessary  :  in  the  later  stages 
of  (yphoid,  a  low  mutUring  delirium  is  of  very  serious  import.  In  pneumonia,  on  the 
other  hand,  .some  degree  of  delirium  is  an  almost  constant  factor,  no  matter  what  the 
temperature  may  be,  and  its  significance  depends  upon  the  previous  (alcoholic)  history  of 
the  patient,  u|)on  the  violence  or  .severity,  and  duration  or  persistence  of  the  mental 
phenomena.  In  rheumatic  fever  (unless  due  to  salicylates,  vide  infra)  delirium  is  of 
extreniely  grave  signilicanee.  being  commonly  associatcfl  either  with  hyperpyrexia  or  with 
dclinilc  iiil  racranial  inlliunmation.  neitlKr  of  which  is  at  all  ((iiiinHiii.  In  iiiMiienza,  too, 
it  is  a  sym|)tom  causing  great  anxiety. 

'I'he  flilliculties  of  diagnosis  arise  chiefly  when  wc  arc  cnllcd  to  a  case  of  delirium  of 
wliiih  we  have  no  previous  knowledge,  where  in  fact  our  sirv  ices  arc  sought  ])rimarily 
because  the  ])aticnt  lias  "  gone  off  Iiis  head  and  is  talking  nonsense."  and  we  must  consider 
to  what  <lilferent  factors  this  may  In-  due  Tlir  following  table  embraces  causes  ordinarily 
met  with  : 

Delirium  iliic  In  iiitiiiisic  l)niiii-       (      Mania  or  huiaey  in  all  its  forms 

(•ell  elianycN  or  to  pure  lurvc  I'ain.  oecasionaily  so  severe  as  Id  prnil  ice  it 

inllia-nccs  I       .SIkicU,   ilillo 

I ,   I-   .     *      .        .  I       I   r.rmia 

'":'"■';,"";'";■  '■'  l-;"-""  •"'^'"i^  nial.etes.  .\,u-mia.  l'»lv.vtli;.„,iM? 

'"  ""■  ^  (autogenetie)  ,      ,,„,,,.„,,i„j,  ,,,.,„|,  |,,„„  ,,„,.  ,.,,„,;.. 

Diliriiiiii  due  111  mil  idhieaetivi-       *      Fevers  of  any  kind,  known  ;iii(l  imUiiown  ms  In  llicir 
lies  I  specific  niicrobie  origin 

l'      Helladonna,    hyoscyanms,    and    llicir   allies;     mIcoIihI 

;ind  other  less  eiinimon   iiiloxicMiits,   :iii;esl  li<l  i/.iiifi 

DiliriiiTM  due  1 1 1  iliciiiiinl  ^ifriiils      I  Mibsl  anccs,  :iiid  liypiiolies.      Lead,  and  iillicr  milals 

inlrddiiccd  rniiti  williniil  i  (i((a>i(iMaily .      l'',X((|)li<)nally,  II   arises  rrcim  almosl 

liny  i)()ison  or  drug,  most  lypicidh  ,  pcrliiips.   IViitii 

'  iiriilieiul  salicylate  of  sodium. 

As  with  all  oth<-r  tables  of  diagnostic  i)roblcms,  the  difliculties  are  much  greater  on 
paper  than  in  praetiee.  for  in  almost  e\ery  case  there  is  some  one  overwhelming  and  out- 
st;in(ling  lact  in  the  history  which  settles  the  matter  olf-liand.  It  is  well,  however,  to 
lia\e  some  lixed  order  (d'  procedure  laid  down,  which  may  take  the  following  lines  :    - 

I.  Make  strict  iniiuiries  as  to  anything  umisual  having  been  taken  or  applied  lately. 


170  DKLIRIl^r 

Medicines  containing  belladonna,  drops  ])ut   into  the  eyes,  or  some  strange  or  unusual 
vegetable  eaten,  are  the  most  likely  things. 

2.  Enquire  as  to  the  recent  health  of  the  individual  bearing  on  the  urinary  secretion, 
amcmia,  etc.  ;  also  enquire  about  incidents  that  might  have  caused  shock,  and  incidents 
suggestive  of  a  simple  idiopathic  mental  disorder. 

3.  Take  the  temperature  ;  if  materially  raised  it  suggests  some  form  of  niicrobie 
iuduence.  although  in  some,  such  as  rabies,  the  pyrexia  may  not  be  great. 

4.  Note  the  pupils  ;  if  dilated  and  fixed,  they  suggest  belladonna  or  perhaps 
alcohol  — deliriiun  tremens  can  hardly  occur  without  a  definite  history  of  "  soaking,'  or 
an  accident  ;  contracted  and  immovable  pupils  suggest  urajmia  ;  unequal  pupils,  general 
paralysis  of  the  insane. 

5.  Test  the  urine  :  this  will  go  far  in  clearing  up  lu'inary  causes.  Further  details 
must  be  sought  under  the  appropriate  headings. 

6.  Note  the  skin,  whether  dry  or  sweating,  wliether  flushed  or  pale  ;  in  poisoning  by 
belladonna,  etc.,  it  is  often  dry  and  flushed  ;  if  connected  with  other  dangerous  chemical 
poisons,  it  is  commonly  pale  and  sweaty.  Fred.  J.  Smith. 

DIACETURIA — or  the  passage  of  diacetic  acid  in  the  urine — occurs  under  precisely 
similar  cin  iiinstanees  to  Acetoni'RI.v  (p.  3).  The  following  is  the  usual  clinical  test 
for  diacetic  acid  : — Tt)  one  inch  of  urine  in  a  test-tube  add  li(iU()r  ferri  perehloridi  (B.P.) 
drop  by  drop.  For  a  moment  a  white  ])recipitate  of  iron  phosphate  forms,  and  then,  if 
accto-acetic  acid  be  present,  the  liquid  becomes  deep  purple-red,  this  colour  being  dis- 
charged on  warming.  If  carbolic  acid,  salol,  or  salicylates  are  being  taken,  the  urine 
contains  jjhenyl  compounds  which  give  a  similar  reaction  with  ferric  chloride,  but  the 
colour  due  to  these  does  not  disappear  on  warming.  Herbert  Frciirli. 

DIARRH(EA. — It  is  important  to  remember  that  diarrhoea  is  a  symptom  and  not  a 
disease  in  itself,  and  in  every  case  one  must  try  to  discover  what  the  underlying  cause 
of  the  looseness  of  the  bowels  is.  In  order  to  do  this  it  may  be  necessary,  in  addition  to 
routine  physical  examination  in  the  ordinary  way,  to  employ  one  or  all  of  the  following 
special  methods  :  (1)  Digital  examination  of  the  rectum  ;  (2)  Inspection  of  the  lower 
colon  by  the  sigmoidoscope  ;  (3)  Investigation  of  gastric  digestion  by  test  meals  (see  p. 
319)  ;  (4)  Examination  of  the  stools  by  the  naked  eye  and  by  the  microscope.  Most  of 
these  methods  require  no  special  description,  or  have  been  dealt  with  in  other  articles, 
but  some  account  must  be  given  of  the  examination  of  the  stools. 

Various  '  test-diets  '  for  the  investigation  of  the  intestinal  functions  have  been  proposed,  hut 
it  is  sufficient  to  let  the  patient  include  the  following  articles  in  the  dietary  for  about  forty-eight 
liours  before  the  stool  is  examined,  viz  :  (1)  IMilk  ;  (2)  Eggs  ;  (3)  Meat  in  some  form  ;  (4)  Farin- 
aceous foods,  e.g.,  bread,  potatoes,  rice  ;  (5)  Green  vegetables  and  stewed  fruit  ;  (6)  Fats,  e.g., 
butter,  bacon,  fat,  ham,  etc.  The  choice  and  amoimt  of  the  individual  articles  may  be  left  to  the 
patient's  taste. 

In  order  to  examine  the  stool,  a  portion  the  size  of  a  walnut  should  be  rubbed  up  with  normal 
saline  solution  to  a  fluid  consistency,  and  examined  with  the  naked  eye  against  a  dark  background. 
Normally  one  sees  a  homogeneous  fluid  made  up  of  very  small  dark-grey  particles.  In  pathological 
conditions  one  may  recognize  mucus,  pus,  blood,  parasites,  the  remains  of  connective  tissue  in  the 
form  of  yellowish-white  shreds,  brown  muscle  fibres,  and  the  residue  of  potatoes  in  the  form  of 
glossy  granules. 

For  microscopical  examination  one  prepares  three  specimens.  The  first  is  examined  as  it  is  ; 
to  the  second  one  adds  a  few  drops  of  30  per  cent  acetic  acid,  and  heats  a  little  to  dissolve  fat  ;  to 
the  third  is  added  a  little  iodine  solution. 

A  normal  stool  shows  in  the  first  pre])aration  a  few  muscle  fibres,  some  yellow  lumps  of  lime 
salts,  and  a  few  empty  jtotato  cells.  In  the  secoud  iirrparatiou,  a  few  fatty  crystals  :  in  the  third 
a  very  few  violet-tinted  .starch  grains.  In  i)allioln;jiial  couditinns  one  may  "find  in  the  first  prepara- 
tion many  well-preserved  muscle  fibres,  nuuK mus  l:il  (hdplets  and  fatty  crystals,  and  abundance 
of  potato  cells  ;  in  the  acetic  acid  preparation,  niiiut  nnis  masses  of  crystals  of  fatty  acids  ;  in  the 
iodine  |)rc])aration,  an  excess  of  starch. 

In  order  to  test  for  Bile,  mix  some  of  the  stool  with  concentrated  corrosive  sidjlimate  solution 
and  allow  to  stand  for  twenty-foiir  hours.  Normally  it  turns  red  from  the  presence  of  urobilin  ; 
greenish  ]iailicks  show  the  presence  of  unaltered  bilirubin  ;  absence  of  green  or  red  colouring 
shows  thai  MIc  is  not  present  at  all. 

licacliun  of  the  Stool. — A  drop  of  the  stool  prepared  as  above  by  rubbing  up  with  water  is 
applied  with  a  glass  rod  to  a  piece  of  moistened  litmus  paper.  The  reaction  can  easily  be  seen  on 
the  other  side  of  the  paper.  .\  normal  stool  is  nearly  neutral  ;  marked  alkalinity  indicates  putre- 
faction ;    acidity  sliows  carbohy<lrate  fermentation. 


DIARRHCEA  171 

Test  for  "  Ociull '  Blood. — The  patient  must  have  eaten  no  red  meat  for  two  or  three  days. 
A  portion  of  tlie  stool  the  size  of  a  hazel-nut  is  rubbed  up  with  2  e.e.  of  distilled  water  in  a  mortar 
and  plaeed  in  a  test  tube.  Add  half  its  volume  of  glacial  acetic  acid,  and  shake.  Then  nearly 
lill  the  tube  with  ether,  and  reverse  several  times.  To  about  one  inch  of  the  resulting  yellow. 
translucent,  ethereal  solution,  add  :  (n)  a  few  drops  of  glacial  acetic  acid,  (6)  one  inch  o(  frculili/ 
jiri'/Kireil  KiUtratcd  solution  of  benzidin  in  rectified  s|)irit,  (r)  one  inch  of  liq.  hydrog.  perox.  Shake, 
and  pour  a  few  drops  (jti  tn  a  porcchiin  slab.      If  blood  be  |)resciit,  a  blue  colour  appears. 

diarkholA  in  infancy  and  early  childhood. 

1.  Acute. — Tlie  acute  diarrhoeas  of  infancy  are  either  dyspeptic  or  infective  in  ofigiu. 
Tlie  infective  diarrlioeas  are  usually  spoken  of  as  '  summer  '  or  "  epidemic  '  diarrhoea.  It 
is  often  impossible  to  distinguish  sharply  between  the  simple  dyspeptic  and  the  infective 
variety,  but  it  may  be  said  that  the  greater  the  signs  of  toxaemia  (collapse,  sinking  in  of  the 
foutanclle.  inelasticity  of  the  skin,  etc.)  the  more  likely  is  it  that  the  case  is  one  of  infection. 
High  body  tcmijcrature  and  epidemic  prevalence  of  the  disease  are  also  in  favour  of  such 
a  diagnosis.  Dyspeptic  diarrhoea  may  be  due  to  mal-digestion  of  any  of  the  constituents 
of  milk.  Kxamination  of  the  stools  may  enable  one  to  distinguish  which  constituent  is 
at    fault,  thus  : — 

Stools  containing  white  tough  particles,  insoluble  in  alcohol  and  ether  mixture  = 
casein  indigestion. 

tJrccn  slimy  stools  containing  small  granular  masses  soluble  in  alcohol  and  ether 
mixture  =  fat  indigestion. 

Frothy  sour  stools  =  sugar  indigestion. 

(irecn  stools  arc  of  no  special  diagnostic  value,  as  they  merely  indicate  that  the 
contents  have  been  hurried  unduly  through  the  intestine. 

If  the  stools  C(mtain  visible  blood  and  mucus,  and  are  passed  with  much  pain  and 
straining,  ticiile  colilis  may  be  diagnosed,  but  not  until  inlussiiscepiion  has  been  excluded 
(see  Blood  pkk  Anum,  p.  75). 

2.  Chronic. — Chronic  diarrha-a  in  infancy  may  follow  upon  an  acute  infective  diarrhica 
or  be  dyspeptic  from  the  outset.  The  history  and  a  consideration  of  the  ])oints  mentioned 
above  will  dctcrinine  the  diagnosis  in  most  cases,  but  it  must  be  rcniembcrcd  (1)  That  an 
intestinal  catarrh  set  up  by  an  infcctioTi  may  lea<l  to  mal-digestion  and  ])ersistent  chronic 
diarrhoea  in  consciiuence  ;  and  (2)  That  a  dyspeptic  diarrlujea  predisposes  to  the  develop- 
ment of  intestinal  infections.  The  two  classes  may  therefore  pass  into  each  other  and 
an  exact   dilTcrcntial  fliagnosis  be  impossible. 

There  is  a,  special  form  of  chronic  diarrlicca  in  early  lil'r  which  follows  a  very  prolongeil 
course,  and  to  which  the  term  '  cucliac  disease  "  or  "  the  caliac  affection  '  is  applied.  11 
usually  starts  in  the  .second  or  third  year  of  life,  and  is  eharactcrincd  by  the  passage  of 
stools  which  are  not  very  frequent  but  are  bulky,  pale,  and  extremely  offensive,  containing 
much  undigested  lal  and  free  fatty  acids.  The  abdomen  is  tumid  and  tympanitic,  and  the 
child  wasted  and  sliinhd  in  growth  and  dcNclopment.  'I'liis  form  of  diarrhtra  is  very 
apt  to  simulate  abdominal  hibcrculosis.  and  indeed  is  usually  diagnosed  as  such  ;  but  in 
abdominal  luliirc  iilosis  cidargeil  glands  or  a  rollcd-up  and  thickened  omentum  can  usually 
be  felt,  or,  there  is  ascites  or  evidence  (i(  tui)crculosis  elsewhere.  .Sometimes,  however,  a 
diagnosis  is  only  possible  after  watching  the  ])rogrcss  of  the  case.  If  the  stools  in  a  ease  of 
chronic  diarrhoa  contain  visible  mucus  and  blood,  and  are  passed  with  inucli  sirainirig, 
sju'cial  involveineril  of  Ihe  large  bowel  ma\  be  diagnosed  (chronic  colitis).  The  hislory 
will  usually  i)oint   lo  llie  preeeiling  oe(  urreriee  of  an  attack  of  acute  colitis. 

DIARRHtEA    IN    ADULTS. 

1.  Acute.  The  hislory  is  of  gical  iniporlaiiee.  II  may  elicit  some  iiitliscrclioii  of 
(lid  (the  eating  of  unripe  fruit,  etc.),  or  the  consumption  of  some  toxic  article  of  food 
(pUniKiiiic  /xiinoiihif')  or  irritant  drug  (e.g.,  arsenic).  In  such  cases  vomiting  is  often  i)resenl 
as  well.  In  toxic  cases  there  is  great  depression,  and  a  feeble  aiul,  perhaps,  irregular  pulse. 
If  there  be  fever,  oiu^  should  lhiid<  of  an  iid'eeli\e  cause,  such  as  typhoid  fever,  or  dyscnicry. 
In  Ihe  case  of  Ifijihoiil.  enlargeiiieni  of  Ihe  spleen  is  an  early  coidirnnitory  sign,  bul  is  some- 
liiMis  alisiril  :  spols  sliouid  also  !)<■  looked  foi'.  The  presence  of  leucopcnia  may  be  of 
help,  anil  Ilie  pnls(-ralc  is  Ion  in  propiiilion  lo  Ihe  temperature.  The  agghitinal  ion 
naelioii   is  iiol    nsiially  olil  a  ioalile   onlil    liic  rn.l   nl  lli>'  lirsl    week.       In  (///.sr/i/e///  Ihere  will 


17.2  DIAP.KHCEA 

be  teuesinus,  with  blood  and  mucus  in  the  motions.  In  the  amoebic  form,  the  Amoeba  colt 
may  be  found  in  the  stools  (see  Fig.  25,  p.  77).  In  the  specific  form,  the  blood  senmi 
agglutinates  Shiga's  bacillus.  Similar  symptoms  to  those  of  dysentery  are  produced  by 
acute  colitis,  especially  of  the  ulcerative  form. 

Appendicitis  may  begin  with  acute  diarrlui-a,  and  the  possibility  of  this  should  be 
borne  in  mind. 

In  })ernicious  aiiceniia,  cxoplithalmic  goitre,  and  Addison's  disease,  periodic  attacks  of 
acute  diarrhoea  are  apt  to  occur.  The  other  characteristic  signs  and  symptoms  of  these 
affections  will  be  present.  (See  AN.a;MiA,  p.  24:  and  Pigmentation  of  the  Skin,  p. 
528). 

Finally,  it  should  be  remembered  that  even  although  diarrhcea  is  due  to  a  new  growth 
in  tlie  bowel,  it  may  begin  acutely,  and  a  rectal  examination  should  never  be  omitted. 

2.  Chronic. — Chronic  diarrlifi-a  in  the  adult  may  be  the  residt  of  several  causes,  of 
wliieli  tlie  following  are  the  chief  : — 

Impaired  Gastric  Digestion  (gastrogenic  diarrhtea). — The  looseness  tends  to  occur  in 
Ijouts,  with  intervals  of  freedom.  The  stools  contain  fragments  of  connective  tissue  and 
show  inidcr  tlie  microscope  an  excess  of  unaltered  muscle  fibres.  A  test  meal  reveals 
absence  or  great  diminution  of  gastric  juice  (achylia). 

Impaired  Pancreatic  Digestion  (pancreatic  diarrhoea). — The  stools  are  pale  or  white 
in  colour,  very  offensive,  and  show,  on  cooling,  solidified  fat  masses  ;  microscopically  they 
exiiibit  excess  of  fat  globules  and  fatty  acid  crystals  along  with  undigested  muscle  fibres 
and  starch  granules. 

Local  Conditions  in  the  Colon  : — 

(a).  Fcecal  Impaction  (])aradoxical  diarrliu*a). — This  variety  is  commonest  in  elderly 
persons.  Rectal  examination  reveals  retained  faeces,  and  faecal  masses  may  perliaps  be 
felt  through  the  abdominal  wall.     A  thorough  evacuation  arrests  the  discharges. 

(6).  Neiv  Growth. — There  is  nothing  absolutely  characteristic  about  this  form  of  diar- 
rhoea, but  the  motions  are  often  explosive  and  tend  to  occur  in  the  early  morning.  Blood 
may  be  present  in  the  stools,  but  not  always.  Digital  examination  of  the  rectum  or  the 
use  of  the  sigmoidoscope  will  reveal  a  growth.  It  should  be  noted  specially  that  neither 
a  sudden  beginning  of  the  symptoms  nor  the  youth  of  the  patient  excludes  the  possibility 
of  growth. 

(f).  Chronic  Catarrh  of  the  Colon  or  Rectum. — The  diarrhoea  in  this  variety  tends  to 
be  ill  the  early  part  of  tlie  day  ("morning  diarrhoea'),  the  stools  are  well-digested  and 
may  or  may  not  show  visible  mucus.  Examination  with  the  sigmoidoscope  will  show  a 
catarrhal  condition  of  the  mucous  membrane  if  the  disease  affects  the  pelvic  colon.  In 
cases  in  which  the  chief  seat  of  the  affection  is  higlier  up,  it  may  only  be  possible  to  arrive 
at  a  diagnosis  by  the  method  of  exclusion. 

(d).  Ulcerative  Colitis. — The  stools  are  frequent,  usually  small,  often  passed  with  some 
straining,  and  contain  visible  mucus,  blood,  and  shreds.  The  sigmoidoscope  reveals  ulcera- 
tion of  the  mucous  membrane.  The  ulceration  may  be  dysenteric  or  non-dysenteric  in 
nature.  l)ut  tlie  history  will  usually  enable  one  to  make  the  distinction. 

Catarrh  of  the  Small  Intestine. — The  stools  are  usually  copious,  fluid,  free  from  visible 
nuieus  or  blood,  unless  the  colon  be  involved  as  well,  and  show  under  the  microscope 
impaired  digestion  of  all  the  food  constituents  and  the  presence  of  bile-stained  particles 
of  mucus.     Sometimes  tlie  diagnosis  can  be  arrived  at  only  by  exclusion. 

If  catarrh  of  the  small  intestine  be  diagnosed,  one  has  to  determine  its  cause.  The 
chief  things  to  think  of  are  :  cardiac  disease  or  cirrhosis  of  the  liver  producing  chronic 
venous  stasis  in  the  bowel  ;  phthisis  or  other  forms  of  tuberculosis  ;  chronic  nephritis  ; 
alcoholism  and  the  ingestion  of  irritants  (e.g.,  arsenic,  antimony). 

Lardaeeous  Disease  is  a  rare  cause  of  chronic  diarrhoea  nowadays,  and  is  not  likely  to 
occur  unless  there  be  signs  of  waxy  disease  elsewhere,  e.g.,  in  the  spleen,  liver,  or  kidneys. 
There  may  be  a  history  of  prolonged  suppuration  or  tertiary  syphilis. 

Tropical  Diseases. — Tlie  two  chief  tropical  diseases  causing  chronic  diarrhoea  are, 
besides  chronic  dysentery  already  mentioned,  sprue  and  hill  diarrliwa. 

/  In  s]3rue  the  jsale,  frothy  and  copious  stools  are  characteristic,  besides  the  presence  t)f 
a/painful  stomatitis  in\ol\ing  the  tongue  and  lining  membrane  of  the  mouth.  It  should 
ahv.ays  be  tliouglit  of  as  a  possibility  in  the  case  of  a  patient  who  lias  lived  in  the  East. 


DILATATION     OF    THP^    STOMACH  173 

Hill  (Uarrhcea,  which  is  closely  allied  to  sprue,  is  met  with  chiefly  in  Europeans  on 
their  going  to  the  hills  after  living  in  the  tropical  lowlands.  The  diarrhoea  tends  to  occm- 
chiefly  in  the  early  morning,  the  stools  being  copious,  pale  and  frothy.  The  diarrha-a 
is  accompanied  by  much  flatulence  and  distension. 

Nervous  Causes. — If  all  the  above  causes  of  a  chronic  or  recurring  diarrhoea  can  be 
excluded,  one  may  be  dealing  with  a  case  of  nervous  diarrhoea,  which  is  characterized  by  a 
tendency  for  the  bowels  to  act  directly  after  a  meal  (lientery)  or  on  excitement  or  under 
emotional  influences.  A  good  many  cases  of  so-called  '  morning  diarrhoea  '  are  of  this 
type,  though  in  many  there  is  a  catarrhal  basis  as  well.  The  history,  the  presence  of  other 
evidences  of  nervous  irritability,  and  the  fact  that  the  general  health  and  nutrition  are 
well  maintained,  all  yield  confirmatory  evidence.  Frequent  action  of  the  bowels  may 
accompany  tabes  dorsalis,  either  in  a  late  stage  when  sphincter  trouble  has  arisen,  or  earlier 
in  the  form  of  rectal  erises  analogous  to  the  more  familar  gastric  crises  of  this  disease. 

Robert  ITutcliison. 

DIAZO-REACTION. — Tlic  diazo-reaction  of  Ehrlich  is  obtained  in  certain  urines 
on  testing  thtni  with  the  following  solutions  : — 

(1)  .Sodium  Nitrite    -  -  -     0-5  gram    I       (2)  Sulphanilic  Acid        -  -     ()•.">  gram 

Distilled  Water  -         -         -     100  c.c.  Hydrochloric  Acid   -         -     0-.5  e.c. 

Distilled  Water  -  -    100  c.c. 

A  strong  solution  of  anunonia  is  also  required,  and  all  should  be  freshly  prepared. 
To  a  drachm  of  sulphanilic  acid  solution  add  a  drop  of  sodiiun  nitrite  solution,  mix  with 
a  drachm  of  the  urine,  and  add  ammonia  to  excess.  A  normal  urine  turns  brownish- 
yellow  :  when  the  reaction  is  positive  the  mixture  turns  deep  red,  and.  most  characteristic 
of  all,  the  froth  jjroduced  on  shaking  the  test  tube  is  rosy  red. 

It  is  often  regarded  merely  as  an  obsolete  test  for  tyjjhoid  fever  :  but  it  occurs  in 
many  other  conditions — it  is  an  indication  of  abnormal  protein  metabolism,  leading  to 
the  elimination  of  certain  aromatic  substances  which  react  in  this  way  to  diazo  compounds. 
The  following  are  some  of  the  conditions  under  which  the  diazo-reaction  has  proved 
pt)sitive  : — Many  fevers,  such  as  diphtheria,  erysipelas,  measles,  pneumonia,  scarlet  fever, 
typhoid,  tyjihus  ;  cachectic  states,  such  as  advanced  phthisis,  cancer,  cirrhosis,  syphilis, 
malaria,  gra\-c  an;cmias  :  and  as  the  result  of  jjoisoning  by  certain  drugs,  such  ^  chrysarobin. 
guaiacol,  carbolic  acid,  or  opitun. 

Clearly  a  reaction  which  occurs  under  so  many  different  circumstances  can  have  but 
a  limited  value.  There  are  some  who  say  that  it  has  no  value  at  all  ;  others,  however, 
find  it  of  clinical  use  in  the  following  respects  :  (1)  It  is  never  normal  ;  (2)  It  is  more 
constantly  present  in  cases  of  typhoid  than  in  any  other  fever,  so  tliat,  other  things  being 
e(|ual.  the  presence  of  the  diazo-rcaclion  may  help  in  diagnosing  typhoid  fever,  though 
the  converse  is  not  true  ;  (3)  In  cases  of  |)htliisis  a  positive  dia/.o-rcaction  is  a  sign  of  ill- 
omen,  whilst  should  the  diazo-reaction  disappear  alter  it  has  been  ])resent,  this  is  evidence 
of  material  improvement,  even  though  the  pli\sical  signs  remain  the  same. 

Ilirbcrl    I'rciirh. 

DILATATION  OF  THE  HEART.     (Sec  l-Xi.MtcKMKNT  ok  ti.i;  IIi-Aur    p.  200.) 

DILATATION  OF  THE  STOMACH  presents  ilself  .•linically  under  I  wo  lolally 
dilierciil   aspects:    (1)   Arule  :    (2)   Cliriiiiie. 

Acute  Dilatation  of  the  Stomach  is  generally  a  serious  complication,  or  often  rallicr  a 
fatal  cataslniplic.  arisins.'  jti  the  course  of  some  other  condition,  especially  : 

Allcr  (i|)(i:ili(iiis,  iKitnlilv    l:i|iiir(iliiniy.  per-       In    llic    course    oT   aeulc    levers,    csijccially 

loiiuiil   I'cir  uliMlevcj'  cmiisi'  lohar  piu'unionia 

Al'lir  iiliiloriiiriiil  injury  In     tile    course     iif    eluiinic     lie;nt      iMiluic. 

cspcciiilly  in  li.id  cases  ot  mitral  stenosis. 

'I'lu'  diagnosis  is  uenenilly  easy  :  it  is  the  reli<l'  of  Ihc  acute  dilatation  that  is  so  diflicull. 
The  l)lo\vn-up.  druinniy  abdomen,  the  conslani  cliorl  to  bring  up  wind,  somclimes  In  vain, 
somcliiucs  willi  copious  and  reenrretd  crucial  ions,  often  with  ominous  luc(ipni;li,  arc 
familiar  and  nnieli  to  be  dre.ided.      Sometimes  shortly  before,  sornel  imcs  just   nllir.  dciil  h. 

innnense  ((uantitics  of  blackish  brown  or  dull  greenish  brown  fluid   flow   IV Ihc  moulh 

and  luistrils,  and  the  wonder  is  how  it  c;ui  all  be  coming  from  one  stonia<h.  Tin-  (lilnlnliou 
itseIC  is  of  Ihc  iialurc  of  aculc  paralysis  of  Ihc  gastric  walls.  ;in.l   lh<-  linn!  oulllow  of  lluid 


174  DILATATION    OF    THE    STOMACH 

wliich  gushes  out  rather  than  is  vomited — is  caused  by  the  pressure  of  the  gas  associated 

with  it.  an<i  not  by  active  contractions  of  the  stomach  musculature. 

Chronic  Dilatation  of  the  Stomach  is  due  to  totally  different  causes,  which  may  be 
divided  into  two  main  i;rou])s.  namely  : — 

1.  Those  associated  ivith  stetwsis  at  or  on  either  side  of  the  pijloriis  due  to  : — 

Cicatricial  fibrosis  of  an  old  simple  gastric  ucler 

('i(;il  ri(i;il  liliicisis  of  ail  old  duodenal  ulcer 

.\illi(  si(.iis  aiiiiind  or  near  the  pylorus,  the  result  of  former  local  peritonitis  due  to 
sucli  causes  as  :  Former  gastric  ulcer:  Former  duodenal  ulcer:  Gall-stones.  In 
many  cases  adhesions  are  found  without  any  ascertainable  cause. 

Carcinoma  of  the   pylorus                           i  Rarities,   such    as    calcified  retroperito- 

Carcinoma  of  the  duodenum  ueal  cyst  ;  hydatid  cyst  at  tlie  portal 

Carcinoma  of  the  nall-bladdcr                   !  fissure  ;    huge   renal  tunioiu-. 
Carcinoma  of  the  head  of  the  parcrcas 

2.  Dilatation  without  obstruction  : — 

Atony.     Ovcr-distentioii  by  gas  or  excess  of  food  or  drink. 

In  the  consulting  room  tlic  two  most  suggestive  signs  of  dilatation  of  the  stomach  are  : 

(1)  A  gastric  succussion  splasli,  audible  or  palpable  over  a  much  wider  area  than  normal. 
Tlie  mere  presence  of  succussion  is  not  an  indication  of  dilatation,  for  a  normal  stomach 
containing  fluid  and  gas  gives  marked  succussion.  The  point  to  determine  is  the  area  over 
which  the  succussion  is  heard  :  and  if  it  extends  right  across  the  epigastrium  and  down  to 
the  umbilicus,  or  below  it,  when  the  patient  is  lying  down,  dilatation  is    almost  certain. 

(2)  Visible  gastric  peristalsis  over  an  unduly  large  area  (p.  521).  The  most  important 
symptom  when  there  is  pyloric  stenosis  is  the  vomiting  at  relatively  long  intervals  of  larger 
ipiantities  of  material  than  were  consumed  at  the  last  meal,  especially  if  remains  of  a  meal 
taken  the  day  before  can  be  recognized  in  the  vomit.  A  very  important  jioint  to  remember, 
however,  is  that  even  a  marked  degree  of  pyloric  stenosis,  with  extensive  dilatation,  may 
he  iiresent  in  a  patient  who  never  vomits  at  all.  This  has  been  proved  again  and  again 
1)\-  bisnuith  and  .r-ray  examinations  followed  by  ojieration.  It  is  by  the  a'-rays  that  the 
diagnosis  is  made  best,  especially  by  a  series  of  examinations  after  the  original  bismuth 
meal.  If  the  bismuth  is  taken  at  11  a.m.,  none  should  be  seen  in  the  stomach  at  6  p.m. 
Very  often  in  these  cases,  however,  the  black  shadow  is  still  obvious  in  the  stomach,  even 
at  11  a.m.  on  the  following  day — after  twenty-four  liours,  and  in  some  instances  for  longer 
still.  It  is  generally  easy  to  see  the  active  peristaltic  waves  of  the  stomach  at  the  same 
time,  and  thus  distinguisli  between  the  dilatations  due  to  obstruction,  and  atonic  dilatation 
in  which  the  stomach  wall  has  sagged  down  and  remains  motionless  when  seen  with  the 
.I'-rays  after  bismuth.  Skiagraphy  is  infinitely  superior  to  any  other  method  of  diagnosis 
in  these  cases,  and  is  replacing  diaphany,  lavage,  inflation,  and  gastric  juice  analyses  where- 
cver  available.  At  the  same  time  it  is  often  possible  to  detect  such  diHiculties  as  hour- 
glass stomach,  or  to  distinguish  ulcer  from  carcinoma.  Once  dilatation  from  stenosis  has 
been  demonstrated  in  this  way,  operative  measures  are  indicated,  for  medicinal  treatment 
cannot  cure  the  mechanical  stasis.  The  further  details  of  the  diagnosis  are  arrived  at  by  the 
surgeon  ;  even  when  the  abdomen  has  been  opened,  however,  it  is  often  exceedingly 
dillicult  to  decide  whether  a  given  hard  mass  at  the  pylorus  is  malignant,  or  due  to  inflam- 
matory matting  round  an  old  simple  idcer,  and  it  may  remain  in  much  doubt  which  of 
the  two  is  present  until  one  finds  that  the  patient  survi\es  for  years  after  his  gastro- 
enterostomy, and  thus  demonstrates  that  wliat  was  tliought  at  the  time  to  be  a  carcinoma 
must  after  all  have  been  not  malignant,  but  the  result  of  inflammatory  matting  round  a 
simple  ciironic  ulcer.  Herbert  Frciicli. 

DIPLOPIA,  or  double  vision,  may  be  citlier  monocular  or  binocular  :  that  is  to  say. 
an  object  may  be  seen  double  with  one  eye,  or  single  with  each  eye  separately,  and  only 
double  when  both  eyes  are  open.  To  distinguish  between  the  two  conditions  it  is  necessary 
that  each  eye  should  be  closed  in  turn.  If  with  either  eye  the  object  is  still  seen  double, 
the  diplopia  is  monocular  and  due  to  that  eye  alone  ;  if,  on  the  other  hand,  the  object 
is  seen  double  only  when  both  eyes  are  open,  the  diplopia  is  binocular,  and  due  to  some 
disturbance  of  the  balance  of  the  two  eves. 


DIPLOPIA  175 

Monocular  Diplopia  may  be  due  to  :  (1)  Dislocation  of  the  lens  ;  (2)  Incipient 
cataract  ;    (3)  Double  pupillary  apertures  :    (4)  I^ow  degrees  of  astigmatism. 

In  a  case  of  monocular  diplopia  it  is  necessary  to  examine  the  eye  by  light  reflected 
upon  tlie  pupil  from  an  ophthalmoscope  mirror  in  a  dark  room.  Diplopia  from  a  dislocated 
or  (Usplnccd  lens  will  only  occur  when  the  edge  of  the  lens  is  in  the  pupil,  some  rays  passing 
outsi<ie  tlie  lens  direct  to  the  macula,  and  other  rays,  passing  through  the  edge  of  the  lens, 
being  dellected  to  a  different  part  of  the  retina.  In  these  circumstances  the  edge  of 
the  lens  will  be  seen  in  the  pupil  as  a  dark  crescentic  opacity  of  unmistakable  form  and 
api)earance.  Other  sym])toms  which  may  serve  to  confirm  the  diagnosis  are  increased  or 
irregular  depth  of  the  anterior  chamber  (the  space  between  the  iris  and  the  cornea),  and 
tremor  of  the  iris  during  movements  of  the  eye. 

Early  cataract  usually  leads  rather  to  the  appearance  of  multiple  images,  than  of 
two  only,  a  candle  or  light  being  seen  as  live  or  six.  This  polyopia  is  due  to  the  fact  that 
till'  lens  is  broken  up  by  cortical  cracks  and  opacities  into  sectors  of  varying  refractive 
power,  very  often  set  in  slightly  different  planes.  These  cracks  and  sectors  of  the  lens 
will  be  seen  easily  as  black  radial  opacities  on  illumination  by  an  ophthalmoscope  mirror, 
or  as  opaque  white  striic  when  the  eye  is  ilhmiinatcd  from  the  front  by  a  lens. 

The  ])resencc  of  /a'o  piipillarii  apertarcs  will  be  at  once  ai)|)arcnt  f)n  a  careful  examina- 
tion of  the  eye.  They  may  be  congenital,  or  due  lo  accident  or  o])eration.  In  cases  of 
diploijia  due  to  multiple  pupillary  apertures,  tlu'  double  vision  is  most  evident  when  the 
ol)jecl  looked  at  is  not  in  accurate  focus. 

.Should  none  of  the  three  conditions  mentioned  above  be  foimd,  it  is  most  likely  that 
the  diplopia  is  due  to  a  fote  error  of  refraelioti.  In  this  condition  letters  and  test  tyi)es 
arc  often  seen  accompanied  by  faint  "  ghosts  "  ])laccd  either  above  or  to  the  side  of  the 
real  letters,  and  in  some  cases  over-lapping  them.  This  cause  of  monocular  diplopia  can 
only  be  determined  by  a  careful  examination  of  the  refraction  of  the  eye.  The  diplopia 
is  iMiicd  by  tlic  wearing  of  silitable  glasses. 

Binocular  Diplopia  may  be  either  (1)  Physiological  or,  (2)  Pathological. 

J'lii/sioloiiicdt  (lipyi/iia  occurs  imnoticed  in  all  normal  binocular  vision.  It  is  evident 
that  as  thf'  two  ejj^view  any  given  object  from  diflcrent  standi)oints.  the  retinal  images 
must  differ  as  •♦♦♦r  the  two  views  taken  by  a  stereoscopic  camera.  The  diplopia  is  not 
apparent,  however,  as  the  two  dissimilar  images  are  combined  by  the  higher  visual  centres 
of  the  brain  to  form  a  single  solid  conception  of  the  object  viewed.  The  amount  of 
dis-similarity  of  the  retinal  images  gives  the  impression  of  sjiace  and  distance,  near 
objects  causing  images  more  unlike  than  those  formed  by  things  remotely  ])laeed.  The 
dis-similarity  of  the  two  retinal  images  in  normal  binocular  vision,  giving  (he  idea  of 
s|)aee,  is  termed  in  psychology  '  disparateness  '  or  '  dis])aration." 

When,  however,  owing  to  some  failure  in  the  centre  which  eonlrols  llie  iuciiImI  fusion 
of  the  two  ocular  images,  they  arc  not  combined,  or  when  some  disturbance  ol  llic  :iceurately 
balanced  nmseular  mechanism  upsets  the  automatic  fixation  of  both  cv(  s  upnri  Ihc  same 
object,  pathological,  or  ob\ious  diplopia  results. 

I'litholdiiical   Dijiliijjia-    IJel'on-  discussing   the  various   forms  and  causes  of  this  con- 
dition il  is, necessary  to  have  a  elcMr  idea  of  the  visual  process  of  localizing  objects  in  space 
priijeelinn.  cir  orientation. 

Ill  normal  liiiioeiilar  vision,  looking  at  an  object  means  liial  both  eyes  are  so  turned 
that  the  image  of  the  object  looked  at  falls  upon  tlie  central  most  acute  area  of  the 
retina,  tin-  macula  or  yellow  spot,  in  each  eye.  and  objects  other  than  that  directly 
looked  at  lorni  images  upon  the  retina  which  are  more  or  less  peripheral.  From  our 
experience  of  such  sensations  and  their  localil\  on  the  retina  we  .arc  able  accurately 
to  (lelenniiie  Ihc  relative  i)ositions  of  objects  in  space.  The  image  of  any  object  will 
always  fall  upon  corresponding  areas  of  Hie  rcliii;e  of  Hie  two  eyes.  These  areas,  though 
always  corresponding,  are  not  in  Hie  line  sense  ol  Hie  vvoid  syiniiictrical.  The  image 
of  an  object  to  the  right  of  the  eyes  tails  upon  Hie  nasal  side  of  the  righl  and  the 
temporal  side  of  the  left  retina  :  but  the  corresponding  areas  arc  in  normal  cireuin- 
stanecs  always  stimulated  siiiinltaneonsly,  and  bcmi  these  retinal  images  is  derived  the 
idea    of   the    posilion   of   Hie    olijcci    in    space. 

n    llic   normal    iclalivc   posilion   ol    Hie   two  ey 
olijeel    no  longer   \;,\\^   upon   luo   iisu.ill\    idrres| 


np^ 

.el 

ill 

an\ 

way 

Hie 

Ini 

age   ( 

.1   an 

lie; 

IS. 

crri 

mil' 

oils  ill 

Ic.-is 

ofl 

iroje 

etioii 

176  DIPLOPIA 

are  formed,  with  consequent  diplopia,  and  it  is  from  an  examination  of  tliis  diplopia  that 
we  can  ascertain  the  displacement  of  the  eye  and  its  probable  cause. 

For  example,  Fig.  81  represents  diagrammatically  a  condition  in  which  the  left  eye 
is  looking  at  or  fixing  the  object  O,  while  the  right  eye  is  pointing  abnormally  inwards — 
a  convergent  strabismus.  In  consequence  of  the  abnormal  position  of  the  right  eye,  the 
image  of  the  object  O  does  not  fall  upon  the  yellow  spot  on  the  macula,  /,  but  upon  a  point 
internal  to  it,  a.  In  ordinary  circumstances,  with  proper  fixation  of  the  two  eyes,  any 
object  whose  image  fell  upon  a  would  be  to  the  right  of  the  object  O,  hence  under  the  exist- 
ing abnormal  conditions  the  right  eye  erroneously  projects  the  object  O  to  the  position  O', 
and  a  diplopia  results  in  which  the  right  of  the  two  images  seen  belongs  to  the  right  eye. 
and  the  left  to  the  left  eye.  This  is  termed  a  homonymous  diplopia.  Fig.  82  shows  in  a 
similar  manner  the  formation  of  a  crossed  diplopia  in  a  divergent  squint  or  strabismus. 
These  two  figures  illustrate  the  formation  of  a  diplopia  in  lateral  deviations  of  the  eyes.     A 


Fi'j.  SI. — Homonymous  double 


Fifj.  82. — Crossed  double  im;xges. 


moment's  consideration  will  show  that  deviation  in  a  vertical  or  oblique  plane  will  equally 
cause  diplopia,  owing  to  the  disturbance  of  the  normal  corresponding  areas  of  the  two 
retinae. 

It  will  be  seen  from  the  figures  that,  in  lateral  deviations,  a  convergent  squint  causes 
homonymous,  and  a  divergent  squint  crossed,  diplopia.  In  ocular  paralyses  the  diplopia 
will  increase  if  the  two  eyes  are  carried  in  the  direction  of  the  usual  action  of  the  paralyzed 
muscle.  As  an  example.  Fig.  81  may  be  chosen  as  a  diagrammatic  representation  of  a 
paralysis  of  the  right  external  rectus  muscle.  The  more  the  eyes  are  turned  to  the  right 
the  greater  will  be  the  convergence,  owing  to  the  inability  of  the  right  eye  to  turn  to  the 
right  to  the  same  extent  as  the  left  ;  the  greater  therefore  will  be  the  diplopia  as  the  image 
of  the  object  O  falls  farther  and  farther  round  on  the  nasal  side  of  the  right  retina,  the 
object  being  projected  farther  and  farther  to  the  right.  It  will  also  be  seen  from  this  con- 
sideration that  in  a  case  of  diplopia  from  a  muscular  paralysis  when  the  eyes  are  carried 
as  far  as  possible  in  the  direction  of  the  usual  action  of  the  paralyzed  muscle,  the  farthest 
displaced  image  always  belongs  to  the  paralyzed  eye. 

The  two  images  are  not  equally  distinct.  That  in  the  unaffected  eye  falls  upon  the 
macula  and  is  seen  most  distinctly  ;  this  is  called  the  real  image.  That  falling  upon  the 
retina  of  the  affected  eye  is  more  peripheral,  and  tlierefore  not  so  definite :  it  is  termed 
the  false  or  apparent  image. 

With  the  above  considerations  in  view,  and  with  a  knowledge  of  the  individual  actioiis 
of  the  ocular  muscles,  it  is  easy  to  elucidate  cases  of  simple  paralysis  of  one  or  more  ocular 
nuiscles,  but  for  convenience  of  reference  the  chart  giving  the  position  of  the  images  in 
paralysis  of  the  various  ocular  muscles  is  reproduced  on  the  following  page. 

Binocular  diplopia  may  be  caused,  as  suggested  above,  by  paralysis  of  ocular 
muscles,    but    it    may    also    arise    from    the    bodily    displacement     of    one     eye    from 


DIPLOPIA  177 

orhilal  groiLth.  ahsrcs.s.    t>v  iKvmorrliagf.       It   may   also   occur    after   some    operations   for 
tenotomii. 

Cases  of  displacement  of  the  eye  from  local  causes  can  usually  be  distinguished  from 
those  of  ocular  paralysis  by  the  indeterminate  character  of  the  diplopia,  which  is  accom- 
j)anied  by  more  or  less  fixation  of  the  eyeball,  and  by  proptosis. 

Fig.    83.  —  To    Il.H"STR.\TE   THE  BEH.iVIOUR    OF   THE    DoUBLE    I.M.^GES 

IN  Paralysis  of  the  Ocular  Muscles. 

T.eft-sideJ  Risht-sided 

I'aralysK.  Paralysis. 

The  dotlfid  lines  Tcjinsent  the  apparent  image. 

J  I  External  Rectus.  I  ! 

•  I  Diplopia  appears  in  looking  toward  the  paralyzed  side.  I  ■ 
I           I                  The  lateral  separation  of  the  images  increases  as  the  paralyzed  eve       I           ■ 

•  I  is  abduftcd.  ■  ■  I  ■ 

II  liiteniiil  Hccltis.  •  | 

■  Diplopia' on  looking  towards  the  sound  side.  J  | 

i  The  later  separation  of  the  images  increases  in  adduction  of  the  iiaia-  ■  I 

J  ly/cd  eye.  • 

Sujicritir   /{edits.  ^ 

f  Diplopia  on  looking  up.  o 

•  The  vertical  distap.ec  between  the  images  increases  as  the  paralyzed  % 

»                eye  is  elevated  and  abducted.  o     | 

I                                The  obliquity  increases  in  adduction.  D 

Tiie  lateral  separation  of  the  images  diminishes  when  the  eyes  are                  | 

turned  laterally  iu  either  direction.  | 

Ilttfetwr  Uerltts.  . 

Diplopia  on  looking  down.  I 

The  vertical  distance  between  the  images  increases  as  the  ]iaraly/,(il  I 

eye  is  depressed  and  abducted.  ,     I 

•  The  obliquity  increases  in  adduction.  f 

•  The  lateral  separation  of  the  images  diminishes  when  the  eyes  .ue  » 
«              lurued  laterally  in  either  clireetion.                                                                                 • 

Sit/iniDr  Olitiiiiir.  I 

I  Dipl<>]>ia  on  looking  douri.  I 

I  'I'lie  vertical  distance  between  the  iniaL'es  increases  as  the  paralwcd         I       \ 

/       I  eve  is  depressed  and  a.ldueted.  |         \ 

f         '  Til.'  ulili.|Mily   iuereasi-s  with   the  abduction.  \ 

,*  Tlic    iateial   distance   between   the   images  diminishes   when   tin-  eyes  ♦ 

*  arc  turned  laterally  iu  either  direction. 

litfiriiir  Ohiiijiii-. 

♦  Diplopia  on  looking  ii|i.  f 
\                              The  vertical  distance  lietw.cri  the  images  im-reases  as  llie  paialv/.rd                    ♦ 

\        I       eve  is  elevated   and   addu<-ted.  I        / 

•  I  The  oblicpdtv  im-reases  with  Die  abduction.  I      ♦ 
I                 Tlie  lateral    distance    bitwceu    tlie    images    increases    as    tlu-    e\c    is       I 

I        elevated   and   abducted.  I 

Isolated  paralyses  oi  iiidix  idiial  ocular-  rnus(-l(-s  or  gr-iiiips  of  muscles  an-  iK-arly  always 
niK-leai-  in  origin  :  basal  gi'owllis  rar-i-ly  (-aiisc  ocular  par-al\s(-s  of  any  cNl(-nt  on  out-  side 
iiidy.  the  aliection  sooner  or  later  becoming  bilali-ial. 

In  some  rare  cases  of  con\-cT-g(-id  or  ili\(-rgcid  sipiini  with  absiri(-i-  of  brno(-ular  \isioii 
and  good  vision  in  ca(-h  eve.  Ilii-rc-  may  bi-  tlu-  power  of  alternate  fixation  with  nioic  or  less 
evident  diplopia.  As  a  rule.  h(nv(-\er-  tlie  iirdividual  has  the  power  of  suppressing  the 
image-  of  the  si|uiiilirig  (-yi-.  nbtainirig  riiorio(-ular  vision.  Ilcrhcil  I..  AVvok. 

DISCHARGE  FROM  THE  EAR.     (.S.-(-  OioaumKA.  p.    i-ii.) 


DISCHARGE,     NASAL- 


DISCHARGE,  NASAL. — A  discharge  from  the  nose  may  be  acute,  subacute,  or  chronic 
and  it  may  consist  of  clear  fluid  almost  like  water,  of  mucus,  muco-pus.  pus,  food  regurgi- 
tated through  the  nose,  or  blood.  For  the  differential  diagnosis  of  the  causes  of  haemor- 
rhage from  the  nose,  see  Epistaxis.  p.  220. 

Regurgitation  of  Food  through  the  Nose  may  be  due  to  a  congenital  condition, 
especially  cli-fl-pfilatc  :  to  accpiired  pcrfoidtidii  of  the  palate,  especially  syphilitic  :  to  posl- 
(Uphlhcritir  panilfisis  :  or  to  nuich  rarer  n<  uro-muscular  lesions,  such  as  bulbar  paralysis, 
psei((l(ibiilbiir  paralysis,   or   iiiyaslhciiia  graiis.   all   of  which   are   discussed   elsewhere. 

Serous,  Mucous,  and  Muco-Purulent  Discharges  differ  from  each  other  chiefly 
in  degree,  for  that  which  may  begin  as  serous  may  later  become  muco-purulent  and  then 
purulent,  as  is  seen  during  the  course  of  a  common  cold.  A  watery  discharge  is  sometimes 
spoken  of  as  coryza,  though  for  the  latter  to  be  typical  there  should  at  the  same  time  be 
watering  of  the  eyes  ;  it  is  generally  acute  in  onset,  and  the  diagnosis  of  its  cause  is  not 
difficult  as  a  rule.     It  may  be  due  to  the  following  different  conditions  : — 


Comnioncold,  early  stage 

(Micrococcus  catarrhulis) 
Lachrymation 
Hay  fever  (coryza  e  feiio) 
Measles 
Indism  or   bromism 


Arsenic 

Local  irritants  sueli  as  snuff, 
ammonia  vapour,  sulphur 
dioxide,  chlorine,  and  other 
irritating  gases 

Fog 


Some     cases    of   spasmodic 

astlima 
Some    cases    of    trigeminal 

neuralgia 
Neurosis 


The  differential  diagnosis  of  these  conditions  needs  little  discussion,  a  careful  inquiry 
into  the  circumstances  of  the  ease  generally  pointing  to  its  nature  at  once.  Measles 
probably  ])resents  the  greatest  difficulty,  for  the  coryza  precedes  the  macular  erujition, 
and  the  iiatient.  generally  a  child,  may  seem  to  be  suffering  merely  from  a  severe  cold, 
when  in  reality  it  is  in  the  most  infectious  stage  of  measles.  Examination  of  the  buccal 
mucous  membrane  for  Koplik's  spots  (Plate  VIII)  may  sometimes  serve  to  distinguish  this 
malady  as  long  as  two  days  before  tlie  eruption  appears.  These  spots  are  individually 
small,  with  a  whitish  centre  the  size  of  a  pin's  liead,  surrounded  by  a  purplish  red  blush  ; 
in  many  cases  they  are  not  single,  but  collected  into  groups  of  from  two  or  three  to  thirty 
or  more  ;  a  common  place  to  find  them  is  on  the  inner  aspect  of  the  cheeks  in  much  the 
same  position  as  that  in  which  one  expects  to  find  brown  pigmentation  in  Addison's 
disease  ;  but  they  should  be  looked  for  also  on  the  gums,  the  inner  aspects  of  the  lips, 
and  on  the  hard  and  soft  palate. 

The  coryza  resulting  from  iodide  or  bromide  of  potassium  or  from  arsenic  may  be  very 
severe,  and  the  patient  generally  complains  of  constantly  catching  cold,  when  in  reality 
the  symptoms  are  due  to  the  drug. 

'I'he  term  iiijlaoiza  is  sometimes  applied  to  severe  febrile  colds  associated  with 
running  of  the  ejes  and  dripping  at  the  nose,  but  it  is  often  inaccurate  to  apply  the  term 
influenza  here,  for  the  symptoms  are  more  often  due  to  the  Microeoccns  catarrhalis. 
Haeteriological  detection  of  the  Bacillus  influenzce  in  the  discharge  is  essential  if  influenza 
is  to  l)e  diagnosed  with  accuracy. 

Excessive  secretion  by  the  lachrymal  glands  apart  from  emotion  may.  in  some 
instances,  lead  to  constant  dripping  of  water  from  the  nose  as  the  result  of  neurosis. 

One  rare  form  of  watery  discharge  from  the  nose  is  the  escape  of  cerebrospinal  fluid  : 
this  fluid  is  perfectly  transparent,  like  water,  and  it  may  be  difficult  to  recognize  its  true 
nature  unless  there  is  a  clear  history  of  the  commonest  cause  for  the  symptom,  namely, 
an  injury  to  the  head  leading  to  fracture  through  the  base  of  the  skull,  involving  one  of 
the  anterior  fossae.  The  fluid  may  dri])  steadily,  at  the  rate  of  a  certain  number  of  drops 
l)er  niiiuite.  and  if  it  is  collected  in  a  test-tube  it  may  be  found  to  reduce  Fchling's  solution. 

.\  purulent  discharge  from  the  nose  may  result  from  that  which  has  been  in  the  first 
place  serous,  mucoid,  or  muco-purulent  ;  or  it  may  have  been  purulent  from  the  beginning. 
If  it  is  acute  and  bilateral,  it  is  probably  due  to  a  local  infection  by  some  pyogenic  micro- 
organism, and  even  when  it  may  seem  to  be  due  to  nothing  more  than  a  common  cold, 
not  a  few  different  organisms  may  be  disco\ered  baeteriologically.  Sta|jhylococci,  strejjto- 
cocci,  and  pneumococci  (see  Plate  XX]'III.  p.  61-f)  are  associated  not  at  all  infrequently 
with  the  Micrococcus  catarrludis.  Influenza  bacilli  may  be  found.  In  rare  cases,  especially 
when  the  purulent  discharge  persists  longer  than  it  ought  if  it  were  the  result  merely  of  a 
cold,  and  especially  in  eases  in  which  it  is  so  acrid  as  to  produce  superficial  excoriation  and 


PLATE     VIII. 


KOPLIKS      SPOTS 


^^ 


INDEX     OK    DI.KINOSIS   -Tn  Ian  11.   178 


DISCHARGE.     NASAL  17'.) 

soreness  of  the  ctlges  of  the  nostrils  and  the  iiijper  lip.  diphtheria  haeilh  will  be  found  more 
often  than  might  be  expected.  Xnsal  diphtheria,  indeed,  is  not  altogether  iineoninion, 
but  it  is  difficult  to  recognize  except  by  bacteriological  examination  of  the  nasal  discharge. 
The  same  applies  to  two  very  mudi  rarer  purulent  lesions  of  the  nose,  namely  those  due 
to  gnitococci  and  to  ^hinders.  There  may  be  a  urethral  infection  or  a  vaginal  clischarge  to 
point  to  the  diagnosis  in  the  former  case,  the  patient  having  transferred  gonoeocci  direclly 
from  the  genital  source  to  the  nose  by  means  of  the  fingers  or  a  towel.  Purulent  rliiTiitis 
due  to  glanders  is  fortunately  rare,  though  when  it  does  occur  it  may  escape  recognition 
entirely  in  its  curable  stage,  unless  the  patient's  occupation  as  a  groom  or  horse-dealer 
suggests  the  source  of  the  infection,  or  unless  bacteriological  methods  are  resorted  to  in 
all  cases  of  nasal  discharge  that  are  not  perfectly  straiglit forward. 

Chronic  purulent  nasal  discharges  are  for  the  most  part  due  either  to  lesions  of  the 
iiiucous  membrane  or  to  the  emptying  into  the  nose  of  purulent  collections  from  tin 
antrum  of  Highmore.  frontal,  ethmoidal,  or  sphenoidal  sinus,  or  from  necrosis  of  the  nasal 
bones.  The  tliagnosis  may  be  ob\ious  enough,  but  very  often  it  is  by  no  means  easy.  It 
is  essential  that  both  nasal  cavities  should  be  insi)ected  directly  in  a  good  light  by  means 
of  a  speculum  and  mirror  :  the  various  kinds  of  chronic  rhinitis  may  be  recognized  in  this 
way  :  in  chronic  alni/iliiv  rliiiiilis  the  amount  of  discharge  is  usually  small,  the  cavities  of  the 
nose  are  relatively  spacious,  the  smell  offensive  (oza-na),  and  there  are  generally  crust-like 
deposits  upon  the  mucous  membrane.  Chronic  hypertrophic  rhinitis  may  also  produce 
a  very  offensive  smell,  a  considerable  purulent  discharge,  and  difficulty  or  even  inability 
to  breathe  through  the  nose  owing  to  the  bulging  of  the  inflamed  mucous  membrane. 
There  may  or  may  not  be  poli/pi  at  the  same  time,  and  perha])s  adenoids  and  enlarged 
tonsils  owing  to  the  necessity  for  breathing  through  the  mouth.  Mend/ranoiis  rhinitis  is 
not  a  distin<'tive  variety,  it  being  more  or  less  an  accident  whether  the  inflamed  mucous 
membrane  produces  a  membranous  exudate  or  not  ;  the  discovery  of  membrane  would 
suggest  diphtheria,  hut  bacteriological  examination  alone  can  determine  whether  the 
lesion  is  diphtheritic  or  not.  Si/philis  is  responsible  for  a  large  number  of  the  ca.ses  of 
oziena  and  chronic  rhinitis,  especially  of  the  atrophic  form,  but  it  is  not  responsible  for 
all.  and  the  iliagnosis  as  to  whether  the  lesion  is  syphilitie  or  not  will  rest  upon  eoiieoniitant 
signs  elsewhere,  upon  the  history,  and  upon  the  result  of  Wassermamrs  reaction.  Necrosis 
of  the  nasal  bones,  if  it  occurs  spontaneously,  is  often  syphilitie,  but  it  may  also  result 
from  an  injury,  such  as  a  blow  ;  the  deformity  which  follows  the  falling  in  of  the  bridge 
of  llic  nose   is  cliaracteristie. 

'ridx-nii/iiiis  rhinitis  is  rare.  There  is  a  \ariety  of  nose  affection  callcil  rliiiiilis  iiiscosa, 
but  this  is  acute  and  not  tuberculous:  the  appearances  might  at  llrsi  suggest  thai  the 
nose  was  lilled  with  a  yellowish  diphtlieritic  membrane,  but  on  culti\iition  no  diphtheria 
bacilli  are  to  be  foimd  :  what  micro-organism  is  the  cause  of  the  cheesy  exudate  in  these 
ca.scs  is  not  known  ;  if  left,  the  unclrrlyJMg  mucosa  is  apt  to  iileerate.  but  under  simple 
antiseptic  treatment  cure  rcsulls  in  a  week  or  a  little  more,  liliiiiiililhs.  although  they 
may  cause  persistence  of  a  nasal  discharge,  are  not  in  themselves  a  primary  condition, 
liiil  rather  tlie  result  of  preceding  rhinitis.  Kndotlielionia.  eareinoniii.  or  siircoinii  alleeting 
llic  nose  ftre  not  common  except  as  the  result  of  direct  s])read  to  its  interior  from  the  lip, 
jaw,  clicik.  (ir  forehead.  .Sometimes,  however,  considerable  nasal  discharge  may  result 
Irnm  the  ginwlh  of  a  semi-malignant  tumour  known  as  recurrent  JUiroma  lyr  Jilno-sareoma 
arising  fiDiii  llic  external  periosteum  of  the  basi-sphenoid  bone,  thus  ohsl  ruci  iiig  the  hack 
of  the  noM  .  and  detected  by  a  digital  examination  \ia  the  moutli. 

A  forciuii  hodij  inserted  into  the  nose  by  a  child  or  by  an  insane  person  max  produce 
damage  assdciatcd  with  a  purulent  discliarge,  wliicli  ma\  prrsisi  e\(ti  allir  llie  rorcign 
body  has  liccn  detected  and  n  inovcil. 

I.ii/His  of  llic  nose  is  hardly  (Mr  primarw  ami  although  it  may  destroy  the  margins 
and  lead  lo  :i  purulent  disiharge  Ikjiii  tin-  nusl  ills,  the  diagnosis  is  generally  clear  from 
I  111  appl(-|ell\  deposits  in  the  adjacent  skin  of  the  cheeks.  Ilodcnt  nicer,  on  the  other 
iiaiid,  lliougli  starting  in  the  skin,  may  spn^ad  deeply  into  the  nose,  causing  destruction  ot 
caililage  and  hone,  with  ))ain  and  purulent  discharge.  Whereas  lupus  starts  in  early  a<lull 
lilc.  lodeni  ulcer  begins  at  or  alter  middle  age.  Histological  examination  may  li<'  rei|uii(il 
111  dislinuuisli  it  from  e/iithclionia.  thouiili  the  latter  is  likely  lo  fimgate  in<irc  and  In  ha\<- 
advanced    mun-    rapidl\    than    nidciil    ulcer  does:     the   lallcr   may    ha\c    esislcd    fur  years 


ISO 


DISCHARGE.     NASAL 


without  any  rapid  advance.  Radium  treatment,  ediciently  applied,  will  cirre  most  rodent 
ulcers  of  the  skin,  but  this  therapeutic  test  is  no  longer  api)licable  when  the  cartilages  and 
l>ones  of  the  nose  have  become  involved,  for  raditmi  is  then  not  able  to  cure  the  rodent 
ulcer  any  better  than  it  can  cure  lupus  or  epithelioma. 

Kmpijetna  of  one  anlnim  of  IIis.hmore  may  cause  most  troublesome  jjurulent  discharge 
from  the  nose,  but  it  is  not  dillicult  to  diagnose  when  the  symptoms  arc  definite.  The 
patient  generally  complains  that  the  ])us  invariably  comes  down  one  nostril  ;  that  it  is 
associated  with  an  odour  which  is  offensive  to  himself  in  a  way  not  common  with  ozaena 
generally  ;  that  he  can  often  produce  the  discharge  by  tilting  his  head  sideways  in  the 
opposite  direction  to  that  from  which  the  discharge  comes,  and  that  he  experiences  dull 
aching  jsain  in  one  side  of  the  face,  often  sjioken  of  as  neuralgia,  but  upon  investigation 
proving  to  be  associated  with  tenderness  located  mainly  in  the  corresponding  superior 
maxilla.     There  may  be  a  carious  tooth,  particularly  a  canine,   from  which  infection  of 


Fig.  81.— Transillu 


ions  of  the  aiitnuii.     yi  shows  the  normal  appearance.     B  sliow^  no  inuminjition  of  the 
dit  side,  owiiis;  to  purulent  contejits.    f  From  ilaliail  Amiiial.  loOB.I 


the  anlrum  has  taken  [ilace.  though  in  a  small  number  of  cases  a  nH)re  serious  cause  exists, 
namely,  carcinoma  or  endothelioma  of  the  antrum,  which  can  seldom  be  diagnosed  until 
either  an  operation  is  undertaken  or  the  growth  itself  begins  to  cause  a  ])rotuberance  either 
info  the  nose  or  through  the  face  ;   the  nature  of  these  growths  is  determined  histologically 

Examining  the  patient  in  a  dark  room  by  the  introduction  of  an  electric  lamp  into 
the  mouth  or  posterior  nares.  may  reveal  empyema  of  the  antrum  by  the  trdnsilluniination 
of  the  superior  maxilla  of  the  normal  side  and  the  opacity  of  the  other  in  which  the  antrum 
is  full  of  pus  (Fig.  S4). 

Empyema  of  a  frontal  sums  has  generally  been  preceded  by  acute  nasal  catarrh,  which 
has  led  .subsctiucntly  to  severe  aching  above  one  or  other  eye,  with  tenderness  on  jjercussion 
over  the  affected  frontal  sinus,  and  so  much  pain  in  this  region  that  the  patient  may  be 
compelled  to  hold  his  head  before  he  is  able  to  cough  or  blow  his  nose,  because  of  the 
increased  pressure  within  this  sinus  due  to  either  of  these  acts.  The  condition  nearly 
alwa\s    starts    acutely,    though   if    untreated    it    may   become    chronic    and    come   under 


DISCHARGE.     URETHRAL  181 

observation  only  when  the ,  infection  has  tracked  its  way  through  into  the  subcutaneous 
tissue  so  as  to  point  above  the  eye  or  in  the  angle  between  the  latter  and  the  nose. 

Siippiirdtiun  in  connection  ivilh  the  etlimoidal  or  splienniilti!  sinuses  can  be  little  more 
than  guessed  at  unless  special  skill  has  been  ae(iiiired  in  the  direct  examination  of  these 
air-eells.  If,  however,  there  is  a  purulent  discharge  from  the  nose  coming  apparently 
from  high  up,  in  a  patient  who  has  neither  antral  disease  nor  infection  of  the  frontal  sinus, 
and  in' whom  local  conditions  of  the  mucous  membrane  of  the  nose  itself  can  be  excluded, 
infection  of  the  sphenoidal  or  of  the  ethmoidal  cells  is  to  be  suspected.         Herbert  French. 

DISCHARGE  FROM  THE  NIPPLE.— Discharges  from  the  nijiple  may  he  divided 
into  three  classes  :-(!)  Xon/ial  discharges;  (2)  Xiirniti!  discharges  at  (ilmornud  lime':; 
(3)  AhiKinnal  iliseliiirges. 

Normal  Discharges. — It  is  quite  natural  for  a  woman  during  the  period  of 
pregnancy  and  lactation  to  have  a  discharge  of  milk  from  the  breast.  It  is  usually  of 
small  amount.  exee|)t  when  the  child  is  ])ut  to  the  breast,  but  occasionally  the  flow  at  other 
times  may  lie  sullieient  to  be  distressing. 

Normal  Discharges  at  Abnormal  Times. — .^lilk  may  come  from  the  breast  at  other 
times  than  dming  pregnancy  and  lactation.  In  infants  it  may  be  found  as  the  result  of 
undue  stinuilation  on  the  part  of  the  nurse,  and  it  has  been  noted  in  the  breasts  of  both 
sexes  at  the  time  of  puberty.     Xo  great  imjMjrtance  attaches  to  it. 

Abnormal  Discharges. — Blood  or  Blood-stained  Discharge.  This  is  a  very  significant 
sign  and  should  not  be  neglected,  for  it  almost  always  indicates  the  presence  of  some 
abnormal  condition  in  the  breast  which  re<|uires  careful  in\  esfigation.  The  commonest 
is  some  growth  involving  the  larger  duets  in  tlie  neighbourliodfl  of  the  nipple.  This  may 
be  cither  innocent — a  duct  papilloma  ;  or  malignant — duet  carcinoma,  scirrhous  carcinoma. 
Ill-  sarcoma.  It  behoves  one  therefore  never  to  neglect  such  a  significant  sign.  When  a 
well-marked  lump  is  felt  the  diagnosis  can  usually  be  made  without  difficulty,  and  for  this 
the  reacler  is  referred  to  the  article  on  Swellim;,  M.v.M.M.Mtv  (|).  (IS.")).  DiHiculty  arises  when 
there  is  no  obvious  swelling.  In  these  cases  the  breast  nuist  be  palpated  carefully  with 
the  Hat  of  the  hand  and  also  with  the  tips  of  the  fingers,  special  attention  being  given  to 
the  part  imtncdiately  subjacent  to  the  nipple.  If  no  swelling  can  be  made  out,  and  the 
bleeding  remains  a  persistent  sign,  it  may  become  necessary  to  make  an  incision  into  the 
breast  for  diagnostic  purposes,  recognizing  the  fact  that  a  papilloma  may  be  so  delicate 
as  to  escape  detection  with  tlie  finger.  I'robably  the  commonest  cause  of  lileeding  is  a 
duet  carcinoma  ((Milumnar-cellcfl  carein(inia)  :  al'ler  Dial  (Incl  papillmna  ami  seirrlious 
can'inoma.  and  last  of  all  sarcrnna. 

.\  /Hirideiil  discharge,  nr  pus  mixed  with  milk,  generally  indicates  acute  suppiu'ative 
mastitis  ;  the  dtlicr  signs  of  inflanunation  or  abscess  are  well  marked  as  a  rule,  so  that  there 
is  no  difficulty  at  arriving  at  a  diagnosis.  Chronic'  mastitis  seldom  causes  a  discharge 
of  pus  from  the  nipple,  but  the  symptom  is  met  with  sometimes  when  the  lesion  is  tuliereu- 
hius  :  the  discovery  of  tubercle  bacilli  in  the  discharge  will  distinguish  this  from  carciiioina, 
with  which  it  is  often  confused. 

A  dimharge  of  serum  will  suggest  chionic  iiitcisl itial  mastitis  with  e\  s|  loi-mation. 
lint   the  symptom  is  rare. 

fli/datid  fluid  has  l)een  recorded  as  escaping  through  tlie  nipple  from  a  lii/didid  ei/st 
of  the  bn-Mst.  bill  it  is  so  rare  as  to  be  a  pathological  curiosity.  'I'lii-  naliiir  of  the  Ihiid 
would  lie  iceogiii/cd  liy  the  finding  of  hooUlels  in  it  {P'ig.  18.   p.    HI).  ^V^/i'.    /■;    r.-i.v/,- 

DISCHARGE,     URETHRAL.     Any    iiillainiiialorx     process    in    tin-    urethra    causes   a 

diseliaigc.      Allhongh    most    eoi iily    the    icsiill    of   inf'ectjoii    by    tin-  gonocoecus,    by    no 

means  e\<rv  urethritis  is  of  this  nalure.  and  bacteriological  examinations  show  thai  other 
organisms  besides  the  gonoeoc'cus  may  produce  a  urethral  discliaige  and  the  same  syrn- 
jitoms  as  an  acute  gonorrhiea.  Further  than  this,  a  piiriilent  discharge  may  occur  in 
wliieli  no  micro-organisms  can  be  found:  for  instance,  when  the  urethra  has  been  injured  or 
subjected  to  irritation  by  the  injection  of  strong  solutions,  or  when  it  contjiins  a  foreign  body, 
such  as  a  ealculns  or  a  retained  eallietir.  It  is  s|al<(l  that  a  urethral  discharge  may  be 
associated  with  gnul  and  rheuuidlisiii  :  liiil  alllioiit;li  a  leu  easi's  of  the  former  have  come 
under  my  care.    I    lia\c   been   unable   lo   pro\  e   llial    llie  small  amount   of  discharge  was  not 


182  DISCHARGE.     UKETIIHAL 

tlic  remains  of  a  former  uncured  uretliral  infection,  or  that  it  was  directly  due  to  the  same 
source  as  the  arthritic  symptoms. 

There  is  no  doubt  that  an  acute  urethritis  may  be  caused  by  otlier  organisms  than 
tlic  gonococcus,  and  sometimes  there  is  considerable  trouble  in  conijjletely  curing  it. 
These  cases  may  cause  complications  in  the  genito-urinary  organs  similar  to  those  due 
to  the  gonococcus,  such  as  prostatitis,  epididymitis,  or  cystitis.  They  may  arise  by  the 
infection  of  the  urethra  by  septic  instrumentation,  or  after  connection  with  a  woman 
subject  to  leucorrhoea.  A  careful  bacteriological  examination  should  always  be  made  ; 
more  than  once  the  reputation  of  a  wife  has  been  at  stake  until  it  was  proved  that  the 
husband's  urethritis  was  of  staphylococcal  and  not  gonorrhoeal  origin.  An  acute  urethritis 
may  accompany  a  ha?matogenous  urinary  infection  :  for  instance,  an  acute  pyelitis  due 
to  bacillus  coli  may  be  followed  by  acute  cystitis,  prostatitis,  and  urethritis,  in  which  no 
other  (irganism  liut  llai-iHiis  coli  can  be  found. 

Gonorrhoeal  Urethritis  is  due  to  the  infection  of  the  urethra  by  the  gonococcus  of 
Neisser  (Plate  XXVIII,  Fig.  R,  p.  614).  In  form  it  is  a  diplococcus  with  flattened  surfaces 
approximating  each  other  :  it  stains  readily  with  basic  aniline  dyes,  but  differs  from  other 
diplococci  in  being  decolorized  by  Gram's  stain.  The  gonococcus  is  seen  in  a  stained 
s|>eeimen  to  be  iiilidcclliiliir.  penetrating  not  only  the  leucocytes  but  also  the  epithelial 
cells  found  in  a  smear  ]jreparation,  and,  though  the  cocci  may  be  found  also  between  the 
cells,  their  appearance  in  the  cells  is  strong  evidence  of  their  specific  nature. 

In  any  case  presenting  a  purulent  discharge  from  the  urethra,  it  is  necessary,  in  order 
that  a])propriate  treatment  may  be  carried  out,  to  ascertain  the  extent  of  the  infection, 
not  only  in  the  urethra  itself,  but  also  in  the  other  organs  of  the  genito-urinary  apparatus. 
For  the  ]>urposes  of  clinical  investigation,  the  urethra  is  divided  into  anterior  and  posterior 
portions,  separated  by  the  membranous  urethra,  the  anterior  comprising  the  bulbous  and 
penile  urethra,  and  the  jiosterior  the  ]jrostatie  portion.  A  urethritis  is  also,  according  to 
its  clinical  aspect,  acute  or  chronic,  the  acute  form  being  characterized  by  a  thick,  creamy. 
])urulent  discharge,  with  pain,  and  the  chronic  by  a  thin,  greyish,  niuco]iurulent  discharge. 
Acute  gonorrhoea  affects  not  only  the  superficial  layers  of  the  urethral  mucous  membrane, 
but  also  the  subejiithelial  tissues  and  the  glandular  elements,  causing  a  leucocytie  infil- 
tration. The  tendency  of  the  inflanunation  is  to  spread  Iwckwards  along  the  canal,  so 
that  the  prostatic  urethra  may  become  infected,  even  in  the  acute  stage,  tfiougli  most 
frt'quently  this  occurs  at  a  later  period  :  the  prostatic  and  the  ejaculatory  duets  may 
become  infected,  and  the  inflammation  may  spread  to  the  seminal  vesicles,  epididymes. 
or  testes.  In  the  acute  stages  of  the  disease,  the  infection  of  the  anterior  urethra  is  accom- 
panied, as  a  rule,  by  redness  of  the  external  meatus,  scalding  pain  during  micturition, 
and  painful  erections  ;  occasionally  all  pain  is  absent,  especially  in  patients  ])reviously 
infected  with  gonorrhoea.  If  the  anterior  urethra  be  irrigated  with  .sterile  water  or  saline 
solution,  the  urine  passed  immediately  afterwards  will  be  quite  clear  ;  or  without  irrigating, 
if  the  urine  be  passed  into  two  glasses,  the  Hrst  portion  will  be  turbid  from  admixture  with 
the  urethral  discharge,  whilst  the  second  |)ortion  remains  clear. 

When  the  jjosterior  urethra  becomes  infec'ted  in  the  acute  stages,  the  symptoms  are 
nuieh  more  severe.  Micturition  is  more  painful  and  greatly  increased  in  freciuency,  Ijoth 
day  and  night,  the  patient  often  being  obliged  to  ])ass  urine  every  half-hour.  Even  after 
irrigating  the  anterior  urethra  the  urine  jjassed  will  be  turbid  with  pus  that  has  acciunu- 
lated  in  the  jirostatic  portion  or  passed  backwards  into  the  l^ladder.  and  tlie  terminal  lu'ine 
may  be  tinged  with  blood.  In  these  circumstances  it  may  be  necessary  to  eliminate  nnitc 
prostatitis  or  prostatic  abscess,  either  of  wliich  may  complicate  an  acute  posterior  urethritis. 
In  either  condition,  micturition  may  be  very  painful,  or  there  may  be  acute  retention  : 
the  temjierature  will  be  raised,  and  in  cases  of  abscess  there  is  often  a  rigor  ;  upon  rectal 
examination,  the  prostate  is  foimd  much  swollen,  hot  to  the  touch,  and  extremely  tender, 
wfiilst  with  an  abscess  a  soft  fluctuating  area  may  be  felt.  An  acute  posterior  gonorrhoea 
is  practically  always  accompanied  by  infection  of  the  bladder,  and  the  diagnosis  between 
it  and  cystitis  is  practically  impossible. 

Under  suitable  treatment  an  acute  urethritis  may  remain  confined  to  the  anterior 
urethra  and  clear  up,  Ijut  in  less  favourable  cases  a  slight  discharge  remains.  If  this 
continues  for  longer  than  six  weeks  after  the  initial  onset,  it  is  spoken  of  as  chronic  gonor- 
rhwa  or  gleet.     The  discliarge  is  small  in  amount,  thin  and  watery,  or  may  be  so  sliglit  as 


DISCHARGE,     URETHRAL  183 

only  to  be  present  in  the  morning  after  a  long  period  of  freedom  from  urination,  or  as 
filaments  in  the  urine.  There  is  no  pain  or  increased  frequency  of  micturition,  and  there 
is  no  difference  in  the  subjective  symptoms  between  an  anterior  and  a  posterior  infection, 
altliougli  in  most  cases  of  chronic  gonorrhoea  both  are  present. 

In  any  case  of  chronic  urethral  discharge,  examination  should  be  conducted  to 
ascertain  not  only  the  seat  of  infection,  but  also  the  nature  of  the  lesion  promoting  the 
discharge.  Thus,  the  patient  should  be  directed  to  hold  urine  for  at  least  three  iiours 
before  he  presents  himself  for  examination,  when  the  anterior  urethra  may  be  irrigated 
thoroughly  by  a  fairly  forcible  stream  of  sterile  water,  the  urinary  meatus  being  alter- 
nately occluded  and  opened  during  the  ])roeess,  so  that  the  whole  lengtli  of  the  anterior 
urethra  is  disten<Icd  by  the  fluid.  The  washing  is  then  examined  for  any  threads,  which, 
if  present,  must  proceed  from  the  anterior  urethra.  The  patient  is  then  directed  to  jjass 
urine  into  two  separate  glasses  ;  if  there  is  turbidity  due  to  excess  of  phosphates,  this  is 
cleared  by  the  addition  of  acetic  acid,  when,  if  any  threads  or  plugs  of  mueo-]}us  are  present 
in  the  first  specimen,  they  probably  arise  from  the  posterior  urethra,  whereas  pus  and 
turbidity  of  the  second  show  that  cystitis  is  present  in  addition.  If  there  be  any  threads 
in  the  posterior  urethra,  or  if  only  a  small  amount  of  discharge  is  present,  it  is  advisable 
first  to  fill  up  the  bladder  with  sterile  fluid  by  direct  Janet  irrigation,  after  which  the 
prostate  is  massaged  by  a  finger  in  the  rectum,  and  the  patient  is  again  directed  to  pass 
I  lie  fluid  from  the  bladder.  Plugs  of  muco-pus  will  be  found  if  chronic  prostatitis  is 
present.  In  any  case  the  threads  from  either  the  anterior  or  posterior  urethra  should 
be  spread  as  a  film,  stained,  and  examined  under  a  microscope  for  jnis  and  micro- 
organisms. 

If  the  remaining  infection  is  found  to  be  limited  to  tlie  anterior  urethra,  the  latter 
should  be  examined  under  direct  vision  by  the  endoscope.  A  few  minims  of  a  3  per  cent 
solution  of  cocaine  are  injected  into  the  urethra  and,  with  aseptic  precautions,  the  largest 
sized  endoscope  tul)e  that  the  meatus  will  admit  eond'ortably  is  passed  for  about  an  inch. 
The  canal  is  then  illiutiinated.  and  at  the  same  time  distended  witli  air  by  means  of  the 
inflating  bellows  attached  to  the  instrument  :  each  part  of  the  anterior  urethra  can  then 
be  examined  successively  as  the  endoscope  tube  is  jiassed  gradually  on  until  the  membranous 
])ortion  of  the  canal  is  reached.  It  will  be  found  much  better  to  examine  the  urethra  in 
this  manner  than  by  first  jjassing  the  instrument  to  the  full  extent  and  examining  the 
<'aiial  as  it  is  withdrawn,  for  any  infection  of  the  urethral  glands,  infiltration  of  the  walls, 
or  granular  areas  are  observed  under  aero-distent  ion  before  the  instrument  has  ])asse<l 
oxer  Ihcni.  When  the  whole  length  has  been  cxanilncd  imder  distention,  the  air  is  allowed 
to  cscMpi-  by  opening  tlie  wItkIow  of  the  instrument,  and  the  canal  again  examined  I'roni 
licliiriil  lorward  by  gradually  withdrawing  the  tube,  normal  urethral  walls  falling  togetlier 
ill  a  cliaiaeteristie  striated  manner,  which  is  altered  into  a  slight  rigidity  by  infiltration, 
whilst  al  the  same  time  glandular  infeetion  or  uleeratioii  is  again  seen.  .Similarly,  a  ilelinite 
stricture  or  a  small  polypus  which  may  keep  up  a  slight  uiclliral  disrliaigc  can  be  dia- 
gnosed with  certainty,  an<l  any  local  treatment  for  the  various  lesions  applied.  Hy  earerul 
examination  conducted  on  these  lines  we  are  able  to  determine,  not  only  which  part  of 
the  urethra  is  iirodiieing  the  discharge,  but  also  the  nature  of  the  lesion,  so  that  appropriate 
treatment  can  be  carried  out.  In  most  eases  in  which  a  gleet  remains  in  spite  of  treatment 
with  various  kinrls  of  injections,  it  will  be  found  that  there  is  an  infeetion  of  the  posterior 
iiicllira  or  prostatic  duets,  which  no  urethral  injection  except  a  comiilcte  irrigation  into 
Itic  liladder  will  reach.  There  is  often  no  abiiormalily  to  be  <leteeted  (Ui  digital 
iNaiiiinalioii  of  the  prostate  ])er  rectum;  but  after  urethial  irrigation  the  secretion 
s(|ii((/,cil  mil  from  the  ])rostatc  by  massage  will  usually  show  pus  corpuscles  in  addition 
ti)  till-  ictiaelile  globules  and  epithelium  which  are  contained  in  the  normal  jiroslatie 
secretion.  In  other  cases  of  obstinate  chronic  urethritis,  a  distinct  inlilt  lal  ive  proee>^ 
will  be  found  in  the  anterior  urethra,  a  process  which  results  in  rigidity  of  the  iirelliral 
wall,  and  in  severe  eases  leads  on  to  stricture.  The  uielliral  glands  are  implicated,  and 
llicir  secretion  gives  rise  to  the  filaments  in  the  urine.  This  inliltration  is  seen  readily 
l>\  urethroscopy,  but  it  may  be  imperceptible  on  I  lie  piissage  of  a  sound.  The  urethr.al 
meatus  is  the  narrowest  part  of  the  canal,  and  a  sound  uliidi  will  eoniplcdly  lill  I  he  meal  us 
may  still  pass  steadily  through  an  inliltnited  portion  of  Ilii-  iircllira.  e\eii  when  its  normal 
calibre  is  diniinish<d  eonsiihrablv. 


184  DISCHARGE,     URETHRAL 

In  spite  of  all  forms  of  treatment,  a  slight  urethral  discharge  occasionally  persists, 
and  the  physician  may  be  asked  if  any  infection  remains,  or  whether  a  patient  may  be 
allowed  to  marry.  A  chronic  urethral  discharge  may  contain  gonococci  or  may  be  entirely 
free  from  any  f)rganisms.  Obviously,  if  any  gonococci  are  found,  the  discharge  is  still 
infectious,  but  there  is  often  difficulty  in  detecting  the  organism  in  these  chronic  cases, 
whilst  in  some  they  may  be  found  if  any  slight  exacerbation  of  inflammation  occurs. 
Other  cases  again  show  a  chronic  urethral  discharge  which  resists  all  treatment,  but  which 
ct)ntains  a  few  pus  and  epithelial  cells,  though  no  organisms  can  be  found.  That  pus  cells 
are  present  in  this  small  urethral  discharge  is  no  detriment  to  marriage,  provided  that  no 
gonococci  can  be  found,  and  in  practice,  if  no  cocci  are  found  after  irritation  of  the  urethra 
by  irritant  injections,  instrumentation,  or  the  free  use  of  alcohol,  on  several  successive 
examinations,  marriage  may  be  permitted. 

.\  uretliral  discharge  may  in  rare  cases  be  present  in  other  conditions  than  that  produced 
till  iinnorrlid'a  or  septic  urethritis,  and  as  difficulty  may  arise  if  one  of  these  cases  be  met 
witli.   it   is  lueessary  to  mention  them. 

Herpetic  Urethritis. — The  mucous  lining  of  tiie  urethra  is  undduliteoly  affected  by 
herpes  in  the  same  manner  as  other  mucous  membranes.  fre<iuently  as  a  tertiary  lesion 
of  syphilis.  There  is  irritation  of  the  urethra  during  micturition,  and  a  slight  muco-puru- 
lent  discharge  from  the  meatus.  The  small  vesicles  may  be  seen  by  the  endoscope,  and 
may  be  associated  with  hcr|Hs  of  the  i)repuce. 

Soft  Sores  in  the  Urethra  are  distinctly  uncommon.  They  occur  in  the  terminal 
portion  of  the  urethra,  and  cause  painful  micturition  and  a  profuse,  thin,  purulent  dis- 
charge, which  contains  no  gonococci.  There  may  be  other  sores  on  the  glans  penis,  and 
an  ulcerated  surface  will  be  sten  on  endoscopic  examination.  They  occur  within  a  few 
days  of  infection,  and,  if  extensive,  may  produce  narrowing  of  the  urethra  on  healing. 

Syphilis  may  affect  the  urethra  either  as  a  hard  chancre  or  as  a  gunmia. 

The  Chancre  occurs  in  the  anterior  end  of  the  urethra,  forming  a  firm  indurated  mass 
which  can  be  felt  readily  on  external  palpation.  The  meatus  is  oedematous  and  swollen, 
so  that  the  introduction  of  an  endoscopic  tube  is  impossible  ;  there  is  a  thin,  purulent, 
and  often  blood-stained  discharge  from  the  meatus.  .V  urethral  chancre  nmst  be 
diagnosed  carefully  from  peri-urethra!  infiltration  due  to  urethritis  :  the  period  of  incuba- 
tion from  the  time  of  infection,  the  presence  of  small,  hard  inguinal  glands,  the  occurrence 
of  secondary  lesions  of  .syphilis,  and  Wa.ssermann's  serum  test  will  ])oint  to  the  diagnosis. 

(iunimata  of  the  urethra  give  rise  to  a  watery  urethral  discharge  when  they  break  down 
and  cause  ulceration.  They  may  ulcerate  through  the  canal  and  form  fistuloe,  but  may 
u.sually  be  recf]gnized  on  careful  examination. 

Papillomata  of  the  Urethra  may  occur  either  in  the  anterior  or  posterior  portion, 
as  small,  peduiuulated  tumours  in  the  canal,  and  frequently  as  a  sequel  to  a  chronic  gonor- 
rhoea. They  may  arise,  however,  in  the  urethra  of  a  patient  who  has  never  had  urethritis. 
They  cause  a  thin,  scanty  discharge,  which  does  not  yield  to  injections  ;  they  are  seen 
readily  through  the  endoscojje. 

Carcinoma  of  the  urethra  is  very  rare  as  a  primary  disease,  and  in  the  few  cases 
recorded  has  been  in  association  with  stricture.  It  forms  a  tumour  in  the  urethra  palpable 
from  the  exterior,  and  causes  painful  micturition  with  a  blood-stained  discharge,  and 
enlargement  of  the  inguinal  glands.  Suspicion  of  carcinoma  should  arise  if  a  hard,  irregular 
tumour  be  felt  in  the  course  of  the  urethra,  without  gonorrha?al  infection,  in  an  elderly 
patient,  but  the  final  diagnosis  depends  on  liistological  examination  of  a  portion  of  the 
growth. 

Tuberculosis  of  the  Urethra  is  always  secondary  to  disease  elsewhere  in  the  genito- 
urinary tract,  usually  of  the  jjrostate  or  seminal  vesicles. 

Foreign  Bodies  in  the  Urethra  may  cause  a  jjurulent  urethral  discharge  if  they 
remain  in  the  canal  for  any  length  of  time.  They  may  be  introduced  through  the  meatus 
by  intent — matches,  pins.  etc.  :  or  a  piece  may  be  detached  from  a  damaged  catheter  : 
or  a  small  calculus  may  come  down  from  the  bladder  and  be  arrested.  In  the  latter  ease 
the  history  is  usually  clear — sudden  stopi)age  of  the  .stream  of  urine  during  micturition 
with  penile  pain  :    a  calculus  may  lie  felt  from  the  exterior  or  seen  through  the  endoscope. 

R.  li.  Jocelyn  Swan. 


DISCHARGE.     VAGINAL  185 

DISCHARGE,  VAGINAL. — In  order  to  recognize  the  varieties  of  pathological  vaginal 
discharges,  it  is  hrst  important  to  realize  what  the  normal  secretions  found  in  the  vagina 
consist  of.  The  secretion  normally  present  must  he  a  mixture  of  those  from  the  uterine 
body,  cervix,  and  vaginal  wall.  That  from  the  uterine  body  is  watery  and  small  in  amount, 
whilst  that  from  the  cervix  is  thick  and  mucoid,  but  clear  and  transparent,  like  imboiled 
white  of  egg.  The  vaginal  secretion  is  merely  a  transudation  of  plasma  from  the  vessels, 
mixed  with  descjuamated  vaginal  epithelium,  and  in  virgins  looks  like  imboiled  starch 
mixed  with  water.  Naturally  it  is  very  small  in  amount.  The  bulk  of  the  secretion  found 
in  the  vagina  comes  from  the  cervix,  because  there  are  far  more  glands  there  than  in  any 
other  part  of  the  genital  tract. 

The  secretion  from  Bartholin's  gland,  which  is  thin  and  mucoid,  may  be  cojjious  under 
.sexual  excitement,  but  under  normal  conditions  is  absent,  and  so  does  not  contribute  to  the 
secretions  in  the  vagina.  The  vaginal  mixed  secretions  are  acid  in  reaction,  owing  to  the 
presence  of  lactic  acid  produced  by  a  long  bacillus  which  is  found  normally  in  the  vagina. 
On  the  other  hand,  the  unmixed  uterine  secretions  are  alkaline.  Normally,  the  amount 
of  mixed  vaginal  secretion  should  do  no  more  than  just  moisten  the  vaginal  orihee.  When 
the  amount  is  so  great  as  to  moisten  the  vulva  and  consc(|uently  stain  garments,  the 
secretion  is  pathological. 

The  composition  of  an  abnormal  secretion  varies  considerably  according  to  the  source 
from  which  most  of  it  eomes.  The  commonest  type  is  the  thick  white  or  yellow  discharge 
associated  with  infiammatory  changes  in  the  cervix.  It  contains  a  large  proportion  of 
mucus,  many  leucocytes,  masses  of  shed  epithelium  from  the  vagina  (•  squames  "),  and 
bacteria  of  various  kinds.  This  is  quite  typical,  and  is  produced  by  eiidocenicitls  and 
cervical  erosions  of  the  various  kinds.  \Vhen,  however,  there  is  a  corporeal  endometritis 
present  as  well,  the  discharge  becomes  thinned,  white,  or  yellow,  on  account  of  the  admixture 
of  much  watery  secretion  from  the  body  of  the  uterus.  The  yellow  colour  is  due  to  the 
admixture  of  red  blooil  coriniscks.  and  in  some  cases  the  fluid  may  become  actually  blood- 
stained. Menorrhagia  accompanies  these  discharges  and  serves  to  distinguish  a  mixed 
corporeal  and  cervical  endometritis  from  a  simple  cervical  catarrh.  Micro.scopically  the 
films  made  from  the  mixed  cases  show  proportionately  less  mucus,  but  otherwise  the 
constituents  are   the  same. 

Vaginitis  rarely  exists  alone,  but  when  it  does  occur  the  discharge  is  thick  and  ])asty 
if  it  is  a  simi)le  catarrhal  condition  :  pasty  on  account  of  the  large  admixture  of  destiuiimatcd 
vaginal  squamous  cpithcliiun.  On  the  other  hand,  in  granular  catarrh;. 1  vaginitis  the  dis- 
charge is  nnich  more  |)urulent  and  eo|)ious  owing  to  the  exudation  of  more  lluid  from  the 
exposed  blood  capillaries.  This  is  the  kind  of  discharge  associated  with  traumatism  of 
the  vagina,  especially  from  the  irritation  of  badly-litting  pessaries,  and  actual  ulceration 
as  in  decubitus  ulcers  on  prolapsed  portions.  Practically  no  mucus  is  found  in  such 
(liscliarges  unless  the  cervix  shares  in  tlie  inflammatory  process. 

'I'lierc  is  nothing  characteristic  it{  i;<inorrli(i-al  (liscliarges  to  the  naked  eye  or  on  simple 
microscopical  examination.  The  detection  of  the  gonococcus  alone  can  decide  the  {jucstion. 
This  is  often  a  matter  of  great  dilTicuIty.  because  it  is  only  in  the  few  days  immediately  after 
infection  that  the  gonococcus  can  be  found  free  in  the  vaginal  discharge.  In  chronic  cases 
llie  gonococcus  nnist  be  looked  for  in  two  places,  cither  the  interior  of  the  cervix  or  in  the 
urethra  and  Skene's  tubes,  which  open  by  the  sides  of  the  meatus  urinarius.  'I'hc  best 
plan  is  to  take  some  discharge  from  within  the  cervix,  after  carefully  wiping  away  discharges 
from  the  os  uteri  with  stcriU'  wool,  using  a  Kergusson's  speculum.  This  discharge  should 
be  spread  on  a  glass  shdi-  :iiicl  put  by  In  dry.  A  second  film  on  another  slide  should  then 
l)c  made,  by  sc|uee/.ing  IIk'  unlliia  tnim  liiliiu<l  forwards  and  mojjping  up  any  secretion 
thus  nuidc  to  appear  on  the  meal  us.  .\ftcr  drying  in  the  air  the  films  should  be  li\e<l  by 
l)assing  tlirough  a  flame,  and  then  stained  by  (Jrani's  method,  followed  by  neutral  red  as 
a  counter-stain.  In  films  prepared  in  this  way  gduococci  are  staiiu'd  red  whilst  organisms 
which  retain  (iram's  stain  appear  deep  violet  or  black.  The  gonoeoeei  arc  usually  found 
in  the  cytoplasm  of  the  polymorphonuclear  leucocytes  (Plate  XXl'1 1 1,  p.  (ill). 

Offensive  smelling  vaginal  discharge  is  associated  with  decomposition,  and  it  may  be 
that  the  discharge  itself  is  decomposing  because  it  cannot  escape  fast  enough  from  the 
passage,  or  that  the  source  of  the  discliargc  is  a  decomposing  substatu'c  like  a  slonghing 
jiliroiil  i\r  tii'crolic  iiuciiiiinia  of  the  irni.r.       In  the  I\mj  lullcr  cases  llic  discharge  is  copious 


186 


DISCHARGE.     VAGINAL 


watfi y.  aii'l  blood-stained,  with  a  horribly  foetid  smell.  When  the  discharge  itself  is  decom- 
posing, it  is  usually  thicker  and  purulent,  and  is  commonly  retained  by  pessaries  or  by 
redundant  folds  of  vaginal  mucous  membrane.  In  old  women  a  foul  discharge  may  come 
from  the  interior  of  the  uterus,  a  pyometra  ;  in  which  case  pus  can  be  made  to  flow  from 
the  OS  uteri  by  squeezing  the  uterus  or  passing  a  sound.  It  is  due  to  senile  endometritis. 
the  result  of  infection,  and  is  often  associated  with  cancer  of  the  body  of  the  uterus. 

Watery  blood-stained  discharge,  not  offensive,  occurs  in  cancer  of-  the  Imdij  of  the  nter)is. 
in  early  cancer  of  the  ceri'ix,  with  mucous  polypi,  placental  poUfpi.  and  hi/datidifonn  mole. 
The  differential  diagnosis  of  these  conditions  cannot  l)e  made  from  the  discharge  alone, 
hut  must  rest  upon  physical  examination  combined  with  the  use  of  the  microscope  upon 
materials  removed  from  the  uterus. 

J'dSiiiiil  casts  may  be  composed  of  coagulated  surface  epithelium,  the  result  of 
astringent  injections  or  ap|)lications.  and  are  easily  recognized  with  the  microscope. 
Membranous  flakes  may  be  passed  with  discharge  in  cases  of  membranous  vaginitis.  They 
consist  of  vaginal  epithelium  entangled  in  coagulated  blood  plasma,  and  present  quite  a 
different  appearance  to  casts  of  coagulated  epithelial  layers.  These  membranous  masses 
may  be  seen  lining  the  whole  vagina,  and  are  generally  due  to  special  organisms.  The 
diphtheria  bacillus  (Plate  XXl'llI.  y.  (iH)  has  been  found  to  be  the  causal  agent  in  such 
cases,  and  in  one  investigated  by  the  writer,  the  Bacilbis  coli  coniniiinis  was  the  offending 

T.  G.  Stevens. 


organism. 


DIZZINESS.     (See  Vehtigo.  p.  751.) 

DOUBLE  VISION.— (See  Diplopia,  p.  174.) 

DROP-FOOT.— (See     Par.\pi.egia,     p.     510  ; 
and     Pahai-isis     of    One     Extremity,    Lower, 

p.   4!Hi.) 


DROP-WRIST.— (See   Atrophy,    Mvsctlar, 
DROPSY.     (See  a:DEMA,   II.  411.) 


DWARFISM  (Microsomia,  Nanosomia). — For 

purposes  of  diagnosis,  dwarfism  may  be  divided 
into  two  classes,  namely,  dwarfism  the  result  of 
deformity,  and  divarfi.^tn  without  deformity.  Gener- 
ally S])eaking,  well-proportioned  dwarfs  owe  their 
defective  stature  to  a  generalized  delay  or  arrest 
of  development,  and  are  therefore  in  a  .state  ol 
infantilism,  whereas  deformed  dwarfs  are  stunted 
in  growth  only,  though  the  reduction  in  height 
may  be  due  rather  to  the  warping  or  collapse  ol 
the  bony  framework  than  to  actual  curtailment 
of  height. 

I.    DWARFISM  THE   RESULT  OF  DEFORMITY. 

This  kind  ol  dwarlism  is  due  mainly  or  solely 
to  shortness  of  the  legs.    In  most  cases  the  primary- 
fault  lies    in  the   skeleton,   but    occasionally    the 
dwarfism  has  its  source  in  deficiency  of  the  brain. 
and  still  more  rarely  is  brought  about  by  a  local  defect  of  development  implicating  the 
lower  extremities. 

A.  Skeletal    Dwarfism    is  occasioned  by  : — 

(1)  Rickets;     (2)  Achondroplasia;     (3)  Osteogenesis  imperfecta:     (4)  .Anosteoplasia  ; 
(5)  Osteomalacia. 

Rickety  Dwarfism  (Fii;.  85)  is  usually  moderate  in  degree,  and  is  due  partly  to  actual 
shortening  of  the  bones  of  the  lower  limbs  and  partly  to  bending  (bow-legs  or  knock-knees). 


s  mink-i-atc,  .ind  1=  due  to  biMLdu«  and  sliorteiung  of 
tlie  thigh  and  leg  bones.  There  is  knock-knee,  tlie 
tibiae  are  sabre-shaped,  the  feet  flat.  '  The  wrists  and 
ankles  are  large ;    the  muscles  are  not  affected. 


DWARFISM 


187 


It  may  also  be  the  outcome  of  antcro-posterior  or  of  lateral  curvature  of  the  spine.  The 
skull  looks  big  and  is  of  the  square  or  hot-cross-bun  type,  with  bulging  ferehead.  The 
shape  of  the  nose  is  not  affected.  There  is  often  a  pigeon  breast  or  a  transverse  groove 
round  the  lower  part  of  the  chest  (rickety  girdle.  Harrison's  sulcus),  and  an  hour-glass  shaped 
or.  at  times,  beaked  (rostrate)  pelvis.  The  nuiscles  arc  well-developed,  and  the  body  is 
scjuat   and   thickset. 

In  Achondroplasia  (Fig-  86)  the  limbs  are  shorter  than  in  rickets,  and  the  stature 
less.  The  ijrojjortions  are  of  the  dachshund  pattern.  The  shortening  of  the  limbs  is  chiefly 
of  the  i)roximal  segment,  and  the  body,  though  actually  short,  is  relatively  long.  The 
legs  are  often  bowed,  and  there  may  be  bending  of  the  upper  limb  bones.  The  joints  are 
usually  prominent.  The  forehead  is  bulging,  the  bridge  of  the  nose  depressed.  There  is 
conspicuous  lordosis,  and  the  pelvis  is  small  and  contracted.  The  muscles  arc  often  dis- 
proportionately big,  giving  the  achondroplasic  a  sturdy  appearance  and  a  surprising  degree 
of  strength.  The  fingers  are  broad,  the  three  middle  lingers  being  of  equal  length  and 
divergently  curved. 


i>>.   ^i;         \.l iv^ill.    -.\KO   1.-..      -I'l..-   run, I    i-     .1- 

1   ..I   ,..l   !.  ■.  Mh,  und  the  liiiil.-   >■  n     ',■■,!     n.- 

-Hh  il   I ■     Imiii.-i-  than  the  rlb^tiil     <    :im     i         I  ^"■ 

111-.-     .1 .r-i'.l.   ami  the  fore:inri-    m.l    I.-     ,r.- 

eel.      The   M.isi.   is  ilelk-icnt  at  the  l.n.l-.'.      In    thi, 
:  there  Is  infuntilLsm  as  well  as  dwarlisin. 


Fifj.   S7.— O^teotre-iesis  itnperfeL-tJi. — 
As;e  ;iJ.     lietidiiifl  of  the  tiliuu,  femora, 

tinned   for  nearly   ten  vear>  before  it 
TOLted.     There   «.is    no' .-idl'LyMid    en- 


Osteogenesis  Imperfecta  (osteopsathyrosis,  fragililas  ossium)  (/''/f.  S7)  is  cliaracteri/.ed 
l)\  lirilllciicss  Willi  sdtlciiinir.  Then-  is  not  iimcli  dwarling.  cxccpl  as  the  result  of  the 
ylcldinu  of  the  lidiics.  :iiiil  llic  niiiscles  are  usually  weak.  The  disease  piobably  somelimes 
runs  on  iiilo  iisli-nnialacia. 

Anosteoplasia,  m- cleidd-ciaiiial  dysostosis.  Willi  Miiicnil  iiiipiiiirnciil  (.1  Ikhic  grciwl  h. 
causing  moderate  dwarfism,  there  is  pronounced  deled  in  llii'  IoiiikiI  Ion  ol  llie  lueiiibrane 
bones.  The  skull  is  romidcd  and  broad,  the  face  small,  the  dcnlilioii  dchiM-.l  ;  I  lie  clavicles 
are  riidiiiieiilaiy  or  absent.     The  disease  is  often  liereililarv  . 

Ill  Osteomalacia  the  dwarfism  is  due  almost  solelv  to  the  eriimpliiig  ol  llie  decalcified 
lioiies  :  hill  uhcri  Ihe  disease  occurs  in  childhood  Ihere  is  also  some  dimimilion  of  stature 
ti-oin  aii-esl   ot  hone  mowlli.      The  muscles  are  eoiispieiiously  weak. 


188  DWARFISM 

DiagtMsis  of  Skeletal  Dwarfism. — Though  osteojjenesis  imperfecta,  rickets,  and  achon- 
(Intplasia  can,  as  a  rule,  be  distinguished  readily  one  from  another,  eases  occur  in  which 
one  of  these  diseases  seems  to  blend  with  another,  or  at  any  rate  to  partake  of  its  characters. 
In  distinguishing  rickets  from  achondroplasia  it  must  be  remembered  that  the  most  char- 
acteristic features  of  rickety  dwarfism  are  the  bending  and  the  post-natal  origin,  and  of 
achondroplasia  the  shortness  of  the  limbs  (micromelia)  and  the  pre-natal  origin.  The 
enlargement  of  the  ends  of  the  bones  which  is  so  distinctive  of  rickets  disappears  as  the 
disease  settles  down  and  the  bones  continue  to  grow,  whereas  in  the  hyperplastic  form  of 
achondroplasia  it  remains  throughout  life.  Extreme  softening  must  cause  us  to  suspect 
osteogenesis  imperfecta  or  osteomalacia,  even  if  there  are  rickety  enlargements  as  well, 
especially  if  the  bending  continues  to  increase  after  the  age  of  six  years. 

Dwarfism  may  be  due  solely  to  spinal  curvature.  If  a  kyphosis  it  is  usually  the  result 
of  tuberculous  disease  (caries)  of  the  spine,  but  is  occasionally  a  local  manifestation  of 
rickets,  or  possibly  of  osteomalacia.  When  of  rickety  origin  there  is  not  only  kyphosis  of 
I  lie  dorsal  region,  but  a  compensatory  lordosis  of  the  doi'so-lumbar.  If  it  begins  in  middle 
or  old  age  it  is  usually  osteoarthritic,  but  as  a  rare  event  it  may  be  due  to  osteomalacia 
.(o.  senilis).  In  the  latter  event  the  softening  is  usually  confined  to  the  spine  and  pelvis, 
and  may  take  place  with  extraordinary  rapidity,  and  be  followed  by  gradual  hardening 
and  fixation  in  the  deformed  position. 

Scoliosis  is  usually  of  mixed  origin,  the  main  factor  being  an  inherent  laxity  of  tissue 
showing  itself  in  weakness  of  the  back  muscles  and  of  the  spinal  ligaments.  This  laxity  is 
supplemented  by  faulty  i)ositi()ns  of  standing,  sitting,  etc.,  or  by  the  injudicious  use  of 
stays.  But  it  is  |)rohabk-  tliat  siiinal  curvature  of  sufficient  severity  to  produce  dwarfism 
is  invariably  the  result  either  of  rickets  or.  in  rare  cases,  of  a  mild  and  local  form  of 
osteomalacia. 

li.  Cerebral  Dwarfism. — This  form  of  microsomia  is  most  jironounccd  in  niicroceplial/i. 
but  hydroicplialy.  porencephaly,  imbecility,  or  any  degenerative  cerebral  affection  of  early 
progressive  development  may  be  associated  with  puny  growth.  The  microcephalic  dwarf 
is  characterized  not  only  by  the  relative  sniallness  of  his  head  (circumference  never  exceed- 
ing 17  ins.),  but  also  by  his  sloping  forehead,  projecting  nose,  and  receding  chin,  giving 
him  a  ferret-  or  rat-like  physiognomy,  lie  is  usually  (piiek  of  movement,  and  restless, 
and  is  either  imbecile  or  idiotic,  accor.ling  to  the  degree  of  his  microcephaly, 

C.  Dwarfism  from  Pre-natal  Deficiency  of  the  Lower  Limbs. — This  is  of  two 
kinds  :  phocnmehis  and  ectrt)melus.  In  pliocoinclus  the  defect  is  in  one  or  both  of  the 
l)roximal  segments,  leaving  the  hands  and  feet  unalleeted.  so  that  the  individual  affected 
resembles  a  penguin  or  a  seal  (jjhoea).  In  eclroineliis  there  is  absence  of  ]jart  or  whole  of 
the  limbs  from  the  feet  up. 

II.    DWARFISM    THE  RESULT  OF  DEFECTIVE  GENERAL    DEVELOPMENT.      INFANTILISM. 

Well-proportioned  dwarfs  are  not  invariably  of  backward  development,  for  we  meet 
with  men  of  excellent  development,  who,  if  not  actual  dwarfs,  are  so  dwarfish  in  stature 
that  we  have  to  admit  the  possibility  of  the  existence  of  a  true  dwarfism  in  which  there 
is  no  infantilism.  Xevertheless,  generally  speaking,  the  dwarf  of  correct  proportions  is 
affected  with  infantilism. 

To  Distinguish  Infantilism  from  simple  Dzcarfism. — Dwarfism  is  a  defect  of  growth, 
whereas  infantilism  is  a  defect  of  development.  In  determining  whether  development  is 
implicated,  stature,  ossification,  and  sex  development  are  of  great  but  not  decisive  import- 
ance. Thus  infantilism  may  co-exist  with  gigantism  ;  and  the  ossification  in  some  cases 
of  symptomatic  infantilism  is  not  only  not  delayed,  but  may  be  actually  premature.  It 
is  also  prematme  in  progeria.  Moreover,  a  sexually  mature  child  of  five  or  six  does  not 
cease  to  be  a  child  because  its  ossification  and  sexual  condition  resemble  those  of  an  adult. 
Evidently  therefore  neither  height,  nor  sex,  nor  ossification  is  a  cardinal  feature  of 
infantilism.  Indeed,  in  some  cases  of  sexual  ateleiosis  the  presence  of  infantilism  is 
determined  by  the  child-like  stature.  |)ro|)orti(>ns.  and  physiognomy  alone,  the  individual 
being  in  all  other  respects  a  well-developed  human  being. 

The  F(n-ms  of  Infantilism. — Infantilism  may  be  widespread  among  whole  races  or 
nations   (racial   infantilism),   or    may    select    certain    individuals    or    families,    and    occur 


DWARFISM 


189 


epidemically  or  sporadically  as  morbid  infantilism  among  people  of  ordinary  development. 
Morbid  infantilism  is  of  two  sorts,  namely,  symptomatic,  the  result  of  causes  :  and  essential, 
or  crvi)tosenctic. 

A.  Symptomatic   Infantilism. 

This  is  seldom  or  never  of  extreme  degree,  has  no  uniform  type  of  physiognomy,  and, 
being  an  ac(|uired  condition,  is  never  transmitted.  It  is  best  classified  according  to  the 
nature  of  the  cause  by  which  it  is  produced. 

It  may  be  the  result  of  intoxication  with  the  poison  of  syphilis,  wine,  tobacco,  or  with 
that  of  rheumatic,  scarlet  or  other  fever,  or  with  lead.  Herter  claims  that  the  intoxication 
may  arise  from  over-abundance  of  the  normal  flora  of  the  intestine  (intestinal  infantilism). 

It  may  be  the  result  of  correlation,  as  when  it  is  associated  with  kyphosis  or  with 
splenomegaly,  or  with  liyprrtrophic  cirrhosis  of  the  liver.     Perhaps  the  best  example  of  this 


uniform  and  extruiiic.  Tlie  intclliu'<;iicL-.  piuiiui  iinii.  . 
attitude,  muniicr,  correspond  witli  tliose  of  n  L-liild  ol 
18  moiitlis.  The  features  are  pulTcd  and.  disfigured 
U'itll  the  ciianieteristie  pseudo-(Pflenm. 


Idiin  (if  iiilaiil  ilisni  is  Ihal  wliicli  is  a-siieialcil  wilh  iiiicnin iiiidly.  In  sdinc  inici'occphahc 
dwarls  llicrc  is  mil  only  an  iinpaiiiiicnl  ol'  giduih,  cunslitiitiny  dwarllsm.  hut  Ihc  dexilop- 
nii  111  ol  the  whole  body  is  stayed,  apparently  because  it  is  the  custom  for  a  certain  develop- 
incnl  of  the  body  lo  go  witli  a  {•ertain  size  of  Ihc  brain,  and  such  cusloins  are  liable  to  be 
Miainlained  cxcn  under  abnormal  condilioiis.  Dwarfs  with  <liininulive  heads  may  be  of 
JMsl  proportions  and  ol  fairly  good  intelligence,  iirovided  the  growth  of  the  body  is  so 
I'ctarded  that  it  remains  in  keeping  wilh  the  growth  of  the  brain.  In  thymic  infantilism 
IlLcre  is  fatness  with  anuiiiia.  and  liability  to  syniopal  attacks,  which  often  end  in  (h'ath. 

It  may  be  dn<-  to  the  (h'/iciciici/  of  ii  hormone  which  oidinaiily  stinmlalcs  development, 
'riici-e  are  two  forms  :    («)  Tliyroid.  .and  ih)  i'itiiilary. 


190 


DWARFISM! 


Thi/rokl  infantilism  in  its  most  characteristic  form — cretinism  (Fig.  88) — is  unmis- 
takable :  but  cases  of  infantilism  occur  in  which  the  physiognomy,  stunting  of  growth, 
and  backward  sex  development  suggest  mere  thyroid  inadequacy.     Some  reserve  the  name 

of  thyroid  infantilism  for  these  cases  of 
■  myxccdeme  fruste,'  but  the  term  should 
only  be  applied  when  the  intelligence  is 
defective  and  imiform  improvement  sets 
in  as  the  result  of  giving  thyroid  extract. 
The  tliyroid  inadequacy  may  however  not 
be  primary,  but  a  mere  incident  in  some 
other  form  of  infantilism,  e.g.,  ateleiosis. 

In    Piliiitdry    infantilism    (Froelich's 
syndrome.    Fig.  8t))   there  is  fatness  with 
conspicuous  genital  backwardness  as  well 
Fuj.  wj.- M..!  j.oin,     \j.    II     Hi.-  ueiicrai  dPi-fiii|iTiir.iit        as     a     gcucral     defect     of     development. 
Lm  S|:.n!i  :    ":  ;  :'     u  "-I,,!"  „  r'S'S^ifeS  rSS?1^       Polyuria  or  glycosuria  is  often  present,  an.l 

flat.    The  i.n  i    .     ,i 1.  iniii.  i  ii..  thcrc    may    be    drowsiness   or   nutrition:;] 

changes  in  the  skin  and  its  appendages. 
Sickness,  headache  or  otlier  symptoms  of  a  cerebral  tumour  are  occasionally  present. 

Mongolism  {Fig.  9(»)  is  distinguished  from  cretinism  or  myxoedeme  fruste  by  the  pre- 
dominance of  the  imbecility  as  compared  with  the  slightness  of  other  cretinoid  symptoms. 
In  reality  the  physiognomy  is  only  cretinoid  because  it  remains  of  the  infantile  type.     It 

is  not  disfigured  by  the  thick  lips  and  general 
pseudo-oedema  of  cretinism,  and  the  tongue, 
though    sometimes    protruding,    is    not    large. 


FiG.  111. — Aiiansioplastic  infantilism. — -\2e  It;. 
Tliere  is  general  delay  of  development,  but  not  to  an 
extreme  degree.  The  physiognomy  and  proportions 
are  of  tlie   adult  pattern,   but  sc.v   development   is 


i-hil.h-li. 
developi 


A  liov  of  twelve  with  asesua 

■  niial  boy  of  six.     His  heiglit, 

i\-ioi.'nomy    are   conspicuously 

lii-^t.  hilt  in  reality  his  trunk 

uinal  type. 


DWARFISM 


19) 


The  eves  remind  one  of  the  obliquely-set  eyes  of  the  Chinaman,  but  it  is  sometimes 
difiieult  to  make  out  the  resemblance.  The  ligaments  are  lax.  and  niongols  are  liable  to 
become  ;knock-kneed  and  to  have  "  double-jointed  '  thumbs.  There  is  often  some 
valvular  afleetion  of  the  heart. 

In  a  given  case  of  infantilism  it  may  be  impossible  to  say  liow  much  is  due  to  correla- 
tion, how  much  to  intoxication,  how  much  to  hormonic  deficiency,  and  hew  much  to  mere 
lack  of  luitrition.  This  may  be  said.  e.g.  of  cardiac,  or  arterial,  of  renal,  and  of  pancreatic 
mfantilism. 

('(iiflidc  infantilism  exists  when  there  is  some  dominatini;  incapacity  of  the  cardiac 
valves.  Sometimes  there  seems  to  be  a  deficient  development  of  the  whole  arterial 
.sy.stem.  constituting  (inangiophislic  infantilism  [Fig.  91). 

In  paiirrentic  infantilism  there  are 
indications  of  pancreatic  incompetence. 
The  stools  are  fatty,  copious  or  frequent, 
pale  and  offensive.  Capsules  of  iodoform 
enclosed  in  a  glutoid  envelope  (Sahli"s 
capsules)  are  soluble  only  in  the  pan- 
creatic secretion,  and  are  therefore  not 
dissolved  in  this  form  of  infantilism. 
The  iid'antilism  is  improved  by  pan- 
creatic extract. 

Renal  infantilism  is  consecutive  to 
chronic  Bright "s  disease,  and  is  suggested 
when  there  are  polyuria,  albuminuria, 
or  other  symptoms  of  Bright's  disease, 
and  no  indication  of  a  ])rior  syphilitic 
or  other  intoxication. 

I}.  Essential  or  Cryptogenetic  In- 
fantilism. 

This  is  distiiiguisluil  from  symjitom- 
atic  infantilism  by  its  pronounced  degree, 
by  its  seemingly  s|)oiitaneous  appearance, 
anfl  occasionally  by  its  heredity.  There 
arc  two  forriis  :  rtleleio.si.s-  anrl  iirogiria. 

.ItelviiiHis  (Fig.  02)  is  primary,  spon- 
taneous iid'antilism.  H  may  begin  at 
any  age  <if  progrcssi\<'  development,  and 
its  eharacti'rs  arc  for  I  lie  most  part  those 
normal  to  the  ag'-  of  its  first  a,|)pearanec. 
It  usually  begins  in  infancy  or  earlN 
childhoorl,  and  the  ^i/,c.  priiportidiis.  and 
physiognomy  of  this  lime  of  lil'c  arc 
pcr[)etuate<V  It  is  pmrir  to  he  associ- 
ate<l  with  c'rv|)torchism.  or  \\\[\\  some 
cctrresponding  ill -<levelopMi(  iil  of  the 
ovaries,     causing     divergence     into     two 

varieties,  sexual  and  asexual.  In  iisv.niiil  itteleiasis  all  llic  physical  fcalmcs  of  inlantile 
life  are  stcreotypiil  :  Iml  in  sfiiial  nlr/riasi.'i.  though  the  physiognomy  and  ])ro|)ortions 
remain  intantile  or  (•liilclish,  Ihc  orisci  ol  piibcrtv  (often  greatly  delayed)  brings  with  it 
some  accession  of  growlli  and  Ihc  Mcldllioii  ol  Ihc  |iriiniii\  and  sccoiidarv  sex  characters 
<.f   Ihc  adult. 

J'logerifi  (Fig.  MM)  is  priiiiaiy.  spontaneous  infant  ilism  mingled  with  premature  senility 
(senilism).  Hence,  with  shortness  of  stature  and  other  indications  of  infantilism,  there 
are  baldness,  emaciation,  arterial  sclerosis,  and  general  decrepitude.  Death  from  angina 
pectoris  or  oilier  senile  disease  may  ensue  at    IS  or  even  earlier.  Ilnsliiigs  (iilford 

DYSARTHRIA.     (See  Sim;i;cii,  .Aunoiimai  itiks  ok,  p.  (i2(i.) 

DYSCHEZIA.-  (See  CoNsriCAiioN.   p.    I-j.) 


Ill  yrey 


,.|.i|,l,; 


DYSMENORRHCEA 


DYSIDROSIS.  -(See  Swi.ATiNc.  Abnormalities  of,  p.  654..) 

DYSMENORRHCEA  owes  its  origin  to  a  variety  of  causes,  wliich  must  be  differentiated 
carefully  iu  order  tliat  treatment  may  be  successful.  The  following  table  presents  the 
causes  of  the  three  common  varieties  : — 


1.  Spasmodic 
Congenital  malformations 
Deficient  uterine  muscle 
Long  conical  cervix 
Stenosed  external   or   inter- 
nal   OS 
Neurasthenia 


2.  Congestive. 
Endometritis 
Uterine   congestion 
Retrci\  cisiiin  ami  flexion 

Silll.lir-n-,.,.|,l,,,ritis 

Pelvic    peritonitis 
Small  cystic  ovary 
Neurasthenia 


3.  MembranoU! 


The  distribution  of  the  cases  into  these  three  classes  is  often  easy  ;  in  the  iirst  place, 
because  spasmodic  cases  are  practically  always  priniary.  that  is,  they  commence  with  the 
onset  of  menstruation  ;  whilst  congestive  and  membranous  cases  are  secondary,  that  is. 
acquired  as  a  result  of  some  definite  lesion.  Further,  the  nature  of  the  pain  is  often  char- 
acteristic of  the  type  of  case,  for  in  spasmodic  cases  the  pain  is  intermittent,  griping,  and 
■  colicky,'  commencing  at  the  same  time  as  the  blood-flow,  or  only  just  before  it.  In 
the  congestive  cases,  on  the  other  hand,  the  pain  is  continuous  and  aching,  and  begins 
some  hours  or  days  before  the  flow.  In  typical  eases  also  this  pain  is  relieved  by 
the  flow.  In  the  membranous  cases  the  nature  of  the  pain  partakes  of  the  characters  of 
both  the  former  types,  being  aching  and  continuous  first  :  then  becoming  colicky  and 
spasmodic  when  the  uterus  is  attcm])ting  to  expel  the  characteristic  membrane  or  cast, 
and  being  finally  relieved  when  this  comes  away.  Many  cases  are  met  with  in  which  the 
])ain  partakes  of  the  nature  of  both  the  congestive  and  spasmodic  types.  This  usually 
means  that  a  woman  who  originally  had  spasmodic  dysmenorrhoea  acquires  some  lesion 
which  in  its  turn  gives  rise  also  to  the  congestive  tyiJc  of  pain. 

Having  scttlcii  that  a  case  belongs  to  one  of  the  three  main  types,  it  is  not  very  difficult 
lo  work  out  the  actual  causation.  This  is  more  difficult  in  the  spasmodic  cases  than  in  tlie 
congestive.  Ijccause  the  latter  depend  upon  well-defined  lesions,  and  the  former  do  not. 

Spasmodic  Cases. — The  causation  of  this  type  of  case  is  often  obscure  ;  but  a  bi- 
manual examination,  or  a  recto-abdominal  examination  in  virgins,  will  usually  reveal  a 
condition  of  the  uterus  which  can  only  lie  described  as  a  congenital  nialformntion.  It  may 
be  small,  but  of  the  adult  type  :  it  often  has  an  exaggerated  anterior  bend,  the  '  cochleate  ' 
uterus  of  Pir/.zi  ;  and.  in  addition,  the  vaginal  portion  of  the  cervix  is  often  too  long,  with 
a  conical  slia])e,  and  a  \'ery  small  pin-hole  external  os.  Into  such  uteri  the  sound  may 
pass  with  dilficulty,  owing  to  stenosis  and  rigidity  of  the  internal  os.  The  underlying  true 
cause  of  the  ])ain,  however,  is  commonly  admitted  now  to  be  imperfect  development  of 
the  uterine  muscle,  in  itself  again  a  congenital  malformation  of  texture  occurring  in  an 
organ  whose  external  form  also  is  malformed  The  muscle  being  imperfect  it  is  also  possible 
that  the  ciKkunetrium  is  abnormal  in  these  cases,  unduly  fibrous  perhaps,  and  resistant  :  a 
l)oint  which  our  present  knowledge  does  not  prove  or  disprove.  One  proof,  however,  of 
the  truth  of  these  views  is  the  effect  of  pregnancy  and  labour  on  such  cases.  They  are 
nearly  always  cured,  owing  to  the  great  muscular  development  during  pregnancy,  and 
the  extreme  stretching  of  the  lower  segment  during  labour.  Neurasthenia  also  colours 
and  increases  the  ])ain  in  these  cases  ;  but.  by  itself,  will  not  start  a  spasmodic  any  more 
than  a  congestive  dysmenorrhoea. 

Congestive  Cases. — It  is  unnecessary  to  dilTerentiate  the  congestive  cases  as  tubal, 
ovarian,  or  uterine,  because  the  underlying  cause  in  all  is  uterine  congestion  accompanying 
such  lesions  as  are  shown  in  the  table.  The  differential  diagnosis  of  these  lesions  is  to  be 
made  by  a  careful  consideration  of  the  history,  combined  with  bimanual  examination  of 
the  pelvic  organs  and,  if  necessary,  curettage  of  the  uterus,  which  also  serves  to  cure  the 
cases  of  pure  endometritis.  Cases  due  to  endometritis  are  to  be  recognized  by  the  cardinal 
symjitoms  of  this  lesion,  namely,  menorrhagia,  Icucorrha'a,  often  blood-stained,  and  chronic 
backache.  These  symptoms  accompany  slight  enlargement  of  the  uterus  without  any  irregu- 
larity in  shape  such  as  would  occur  if  fibroids  were  present.  Simple  retroversion  and  flexion 
can  be  recognized  on  bimanual  examination  :   the  fundus  will  be  felt  posteriorly,  the  cervix 


DYSPAREUNIA  193 

lo(jking  directly  down  the  vagina  in  a  forward  direction.  Solpingo-ooplioritis  in  its  typical 
clnonic  form  gives  rise  to  irregular  very  tender  swellings  on  either  side  and  behind  the  uterus, 
sonietiines  forming  definitely  retort-shaped  swellings,  especially  if  ])us  is  present  in  the  tubes. 
Fixation  of  these  swellings  and  of  the  uterus  is  a  very  diliniti'  sign  of  the  disease  ;  whilst 
the  history  of  one  or  more  attacks  of  acute  illness,  with  pelvic  pain,  will  assist  to  make  the 
diagnosis  certain.  The  small  cystic  ovary  may  exist  without  obvious  salpingo-oophoritis, 
and  without  widespread  fixation.  The  ovary  is  foimd  to  be  permanently  enlarged  and 
irregular  in  shape  from  the  projection  of  cysts  from  its  surface.  Neurasthenia  is  included 
imder  this  heading  because  any  menstrual  pain  is  made  worse  by  it,  and  only  a  very  slight 
lesion  need  be  present  for  this  nerve  weakness  to  accentuate  any  pain  arising  from  it. 

Membranous  Cases. — The  membrane,  or  cast,  is  of  two  types,  and  is  easily  recognized 
and  distinguished  from  other  uterine  casts,  such  as  those  formed  by  the  decidua  of  preg- 
nancy. The  classical  cast  of  membranous  dysmenorrhoea  is  hollow,  triangular,  not  more 
than  one-eighth  of  an  inch  thick,  and  possesses  three  openings.  This,  however,  is  not  the 
common  form  ;  for  in  most  cases  the  cast  is  solid,  and  formed  by  the  mucosa  being  rolled 
upon  itself.  Tliese  casts  contain  connective-tissue  cells  and  uterine  glands  in  a  stroma 
which  is  crowded  with  leucocj'tes.  The  solid  cast  may  be  nearly  half  an  inch  thick,  and 
looks  microscopically  as  if  it  were  composed  of  endometrium  into  which  haemorrhage  and 
Icucocytic  infiltration  had  occurred.  The  glands  in  it  are  broken  up,  and  often  lie  on  the 
outside.  These  casts  never  contain  any  compact  masses  of  large  cells  of  the  decidual  type, 
but  an  occasional  hypertrophied  connective  tissue  cell  may  be  foimd.  Decidual  casts,  on 
the  other  hand,  are  the  result  of  pregnancy,  and  consist  of  compact  masses  of  large  poly- 
gonal cells  without  any  fibrillated  connective  tissue.  They  contain  glands  with  hyper- 
trophied e])ithelial  linings,  and  often  show  large  hiemorrhagic  foci.  The  occasional  (Jresence 
ill  I  hem  of  chorionic  villi  absolutely  settles  the  diagnosis. 

It  must  not  be  forgotten  that  cases  of  dysmenorrhaa  may  be  mistaken  for  those  of 
alxlominal  pain  due  to  other  lesions  unconnected  with  menstruation  :  and  the  differen- 
tiation of  such  cases  may  be  a  matter  of  considerable  im])ortanee.  It  is  conceivable  that 
dysmenorrlio-a  mav  be  mistaken  for  : — 


.■\pi)en(lieitis 

Colic,    intestinal,    renal,    i>r   hepatic 
Perforated  gastric  ulcer 
l{ii[)turcd  tubal  gestation 


Torsion  of  an  ovarian  cyst  ])edielc 
Haemorrhage  from  or  into  a  Graali:iii  Inlliek' 
Rupture  of  an  ovarian  cyst  or  pyosalpiiix 
Dyspepsia  with  tlat  ilent  distention. 


Obviously,  sonic  of  these  lesions  are  dangerous  to  life,  and  therefore  it  is  essential  that 
lliiv  be  not  oNcrlookcd.  The  danger  of  this  oci-in-ring  is  inenased  if  any  of  these  lesions 
stint  Ml  or  near  the  expected  time  of  a  menstrual  period,  and  would  hardly  arise  at  all  if  a 
nKiisliMal  period  had  taken  place  recently,  or  was  not  expected  for  some  days.  It  will 
be  iioUii  that  all  these  lesions  are  accompanied  by  stulden  abdomimd  pain,  which  might 
piiliaps  lead  lo  a  suspicion  of  spasmodic  dysnicnorrlKCM,  bill  hnrdly  of  eongeslixc,  owing 
lo   I  lie  cliaracler  ot  llic   pain.  7',  (!.  Stevens 

DYSPAREUNIA,  or  painlid  coitus,  may  depend  im  a  varicly  of  local  Icsidiis  which 
rcipiirc  carf'tnl  ilillcicril  iation  for  their  approprialc  trcatnu'nl,  or  il  may  <-xisl  when  no 
local  lesion  can  be  luund  at  all.  It  is  associated  <'losely  with  vaginismus,  or  paiid'ul  spasm 
of  the  levator  ani  ninsclc  mi  atlciiipts  at  coitus,  and  the  same  lesions  which  cause  sim])le 
dysparciinia  may  also  give  rise  to  vaginisnuis.  It  is  remarkable  that  in  sonic  women  a 
small  Inciil  lesion  will  produce  no  pain  upon  attempts  at  coitus  which  in  anollicr  will  cause 
pain  accompanied  by  \iolcnt  spasm  of  the  levator  ani.  In  some  cases  pain  arises  because 
there  is  a  dillieulty  of  penetration  of  the  vaginal  orifice,  whilst  in  others  there  is  no  dilli- 
ciiltv.  but  pain  is  caused.  The  lesions  which  cominoidv  give  rise  to  dvsparcimia  .ire  (lie 
following  :-^ 

('nii^rcMital    uhseiice  of  llie  Xciiiil  is  oil  lir  puliic  mii\  c  Cliniiiic  iiicl  lilis 

Inwi-r  p;iil  (if  llic  \:i-iMii  llcalcil    pciiiMal    laccraliniis  .S:il|iiiiL;ci-i"i|ilini  il  is        willi 

liiiiipliiicil    liviMcii  ficlliiMl     caiNMili-  adiicsiuiis 

iMllaiiicI    liviiiciiial  iirilicc  ficlliiilis  Aii.il    lissiiic 

\lllvilis  Cvstitis  ■|'lll(lllll,(.SC-li      MIhI       illllllllllMl 

li:iilli(iliiiilis  I'njhipscii  Iciiilcr  iivMiirswilj,  piles 

l..iiUti|,hikic   Milvilis  ic(ni\-ciled    iileiiis 

Kiiiiiiusis   \iilva' 


194  DYSPAREUNIA 

It  will  be  noted  from  a  perusal  of  the  above  that  the  lesions  fall  into  natural  groups, 
according  as  the  situation  of  the  lesion  is  at  the  vuha,  the  uterus  and  ovaries,  the  urinary 
passages,  or  at  the  anus  and  rectum.  Consequently  it  is  necessary  to  carry  out  a  detailed 
examination  of  any  case  of  dyspareunia  in  order  to  find  out  whether  any  of  these  well- 
defined  lesions  are  present. 

The  commonest  lesion  is  certainly  inflamed  hymeneal  remains,  very  often  gonorrhoeal 
in  origin  and  accompanied  by  redness  and  swelling  of  the  orifice  of  the  duct  of  Bartholin's 
gland.  The  lesion  is  self-evident  on  inspection,  and  the  parts  are  acutely  sensitive  to  the 
least  touch.  Leukoplakic  vulvitis  is  a  lesion  that  is  obvious  from  the  whit«,  sodden 
appearance  of  the  labia  minora,  and  causes  pain  on  account  of  the  sensitive  cracks  and 
fissures  which  accompany  it.  Kraurosis  vulva  causes  actual  contraction  of  the  vaginal 
orifice,  and  consequently  penetration  is  difficult  and  causes  pain.  The  red  projecting 
growth  from  the  meatus  urinarius,  earuncle,  is  self-evident  and  acutely  tender,  whilst 
urethritis  is  diagnosed  by  tlie  issue  of  pus  on  squeezing  the  urethra.  Cystitis  is  diagnosed 
l)y  the  presence  of  pus  and  mucus  in  the  urine,  accompanied  by  frequency  of  micturition, 
and  it  causes  pain  because  the  bladder  is  painful  in  such  cases  and  intolerant  of  the 
disturbance  caused  by  coitus.  Puclic  neuritis  is  not  a  well-defined  condition,  but  can  be 
recognized  by  tenderness  along  the  piidic  nerve  just  inside  the  vaginal  orifice,  where  the 
nerve  passes  along  the  inner  side  of  the  ischial  ramus.  In  prolapsed  tender  ovaries  and 
backward  displacements  there  is  no  pain  on  penetration  and  no  dilliculty,  but  coitus  gives 
acute  pain.  The  condition  is  recognized  by  a  bimanual  examination,  the  same  remarks 
apijlying  to  salpingo-oophoritis.  bearing  in  mind  that  there  is  usually  a  history  of  some 
acute  attack  of  pelvic  peritonitis  in  such  cases.  In  chronic  metritis  the  tubes  and  ovaries 
may  be  normal,  but  the  uterus  though  normal  in  position  is  tender  to  the  touch,  and 
consequently  coitus  causes  pain.  Anal  fissure,  thrombosed  and  inflamed  piles,  can  only 
be  recognized  by  a  careful  examination  of  the  anus  and  rectiun  by  the  finger  and  speculum. 

In  the  cases  which  occur  without  local  lesions  the  vaginal  entrance  will  be  found  to 
be  hj'persesthetic  as  a  rule,  and  penetration  is-  impossible.  Such  cases  are  almost  always 
accompanied  by  spasmodic  vaginismus.  The  most  careful  examination  fails  to  demon- 
strate a  lesion  in  such  cases,  and  they  are  usually  termed  '  neurotic  '  for  the  want  of  a 
better  term.  Such  cases  do  not  necessarily  mean  absence  of  sexual  desire  ;  on  the  con; 
trary,  many  such  patients  are  desirous  of  the  consummation  of  marriage.  Enlarging  the 
orifice,  or  even  child-bearing,  does  not  cure  a  true  case  of  this  nature  ;  it  must  be  in  sonre 
way  a  disorder  of  function  of  the  nerve  centres.  These  cases  must  be  distinguished  from 
those  in  which  the  underlying  factor  is  absence  of  sexual  desire  and  actual  dislike  of  the 
sexual  act.  Unhappy  and  imsuitable  marriages  conduce  to  this  state  of  affairs,  and  the 
patient  is  liable  to  complain  of  pain  when  dislike  is  really  what  is  meant.  There  is  no 
difficulty  in  penetration  in  such  cases.  T.  G.  Sleveiis. 

DYSPEPSIA. — (See  Indigestion,  p.  315  ;    and  Flatulence,  p.  240.) 

DYSPHAGIA  literally  means  difficulty  in  swallowing,  but  the  term  itself  does  not 
indicate  whether  the  dilliculty  is  mechanical,  nervous,  or  due  to  pain  :  there  are  conse- 
(|uently  several  entirely  different  groups  of  cases,  to  each  of  which  the  term  dysphagia  has 
been  applied  : — 

1 .  Dysphagia  due  to  Mechanical  Obstruction  to  the  (Esophagus. — The  usual 
history  of  ])rogiessive  mechanical  obstruct i(jn  to  the  (esophagus  is  as  follows  :  there  is 
little  or  no  pain,  but  the  j)atient  notices  that  whereas  formerly  lie  could  swallow  anv'thing 
with  case,  he  is  beginning  to  experience  difficulty  with  the  more  solid  kinds  of  food,  such 
as  meat,  dry  bread,  and  vegetables,  so  that  he  is  obliged  to  live  mainly  upon  pulpy  foods  : 
milk  puddings,  gruel,  and  the  like.  Later  he  can  swallow  only  liquids  ;  ultimately  he 
liuds  that  even  these  are  apt  to  be  regurgitated  soon  after  they  have  been  swallowed,  and 
there  is  often  a  sense  of  obstruction  at  some  point  between  the  level  of  the  cricoid  cartilage 
and  the  lower  end  of  the  gladiolus,  which  latter  corresponds,  as  regards  sensation,  with  the 
cardiac  end  of  the  cesophagus.  When  with  the  above  history  the  patient  gives  a  definite 
account  of  having  swallowed  some  strong  irritant  or  corrosive  substance,  such  as  an  alkali 
or  a  mineral  acid,  the  diagnosis  of  fibrous  stricture  from  corrosive  injury  is  easy.  ^Vhen 
similar  obstruction  succeeds  the  swallowing  o!  nfineign  body,  such  as  a  tooth-plate  {Fig.  U4). 


DYSPHAGIA 


195 


a  large  piece  of  bone,  or  a  coin,  the  diagnosis  is  also  easy  as  a  rule,  though  in  some 
cases  there  may  he  doubt  as  to  the  existence  of  a  foreign  body  in  the  cesophagus  unless  the 
cesophagosco)3e  is  used,  or  the  .i-rays  employed  with  or  without  bismuth  (Fig.  95).  Where 
the  symptoms  are  not  directly  attributable  to  anything  of  this  nature,  however,  but  come  on 
insidiously,  the  diagnosis  generally  lies  between  squamoiis-celkd  cnrcinonia  of  the  cesophagus. 
cairiiioma  of  the  stomach  directly  invading  the  lower  end  of   the  cesophagus.    and  aortic 

aiiciirijsm  stenosing  the  oesophagus  from 
outside.  The  actual  fact  of  obstruction 
has  first  to  be  determined,  and  there  is 
danger  in  passing  a  bougie  unless  aortic 
aneurysm  can  be  excluded  ;  this  exclu- 
sion is  by  no  means  easy,  however,  for 
that  variety  of  aneurysm  which  is  most 
liable  to  stenose  the  oesophagus  is  one 
atlecting  the  descending  thoracic  aorta, 
so  that  it  does  not  give  rise  to  any 
tumour,  or  pulsation,  or  bruit,  and  it  is 
placed  too  far  along  the  aorta  to  cause 
inecjuality  of  the  pulses,  inequality  '^of 
the  pupils  (from  interference  with  the 
cervical  sym))atlutic),  paralysis  of  a 
vocal    cord    (from    interference  with   the 


J'i'j.  'J  I. — Sudiiuii  ilualli  iruiii  acute  d!,ipiiu;a  ; 
tootli-plute  iinpjicted  in  tlie  laryn.x.  (From  a  < 
Warner  lAimj.  of  Wmhrich.) 


Iclt 


I'liirciil     l:nviit;( 
>r    pain    down 


tl  THr\c).  Ii-achcal  liig- 
■itlicr  arm.  Tlic  only 
other  cITccts  besirles  ci'sophageal  obstruction 
likely  to  be  due  to  aneurysm  in  this  position 
are:  pain  in  the  dorsal  region  of  llii-  spine, 
possibly  ra»liating  along  the  course  ul  (Mh-  or 
more  of  the  mid-dorsal  intercostal  ncrvcN 
towards  tin-  left,  and  ixrhaps  obstruction  to 
the  lower  part  of  the  root  of  the  left  lung, 
causing  impairment  i>\  mile,  of  air-entry,  or  of 
voice  sounds,  willi   or  willjout  some  crackling  HJ 

rales    over    the    left    lower    lobe    behind.      If   a  "' 

bougie  is  passed,  it  should  be  a  soft  one,  and 
extrenie  care  should  be  taken  :  but  lh<'  danger 
iniiy  be  avoided  In  towns  where  ,i-ray  installations 
be  demonstrated  by  making  the  p;itient  swallow  a  eap> 
or  barimn  chloride  and  watching  its  course  (Figs.  it(i.  it?)  ; 
characteristic  shadow  in  the  i)osterior  mediastinum.  'I' 
likely  is  it  to  be  eareinoina  ol'  the  (esophagus  and  not  luu  ii 
between  primary  growth  of  the  (esophagus  and  iiihltralio 
starting  at  the  cardiac  end  of  the  stomach,   is  ol'len  one 


fui.  'J.>.  -(I'.sopliagua  blocked  by  a  bean,  which  kIocs 
it  show,  but  susi)eiids  th(!  bismuth  food,  the  lower 
rdr-i-  of  which  arches  over  the  bean.  As  a  result  of 
e  x-ra.v  exainiiiHtiou  the  u'i^opluM^iLS  was  further 
plored  atal  the  forelKn  body  removed. 

{.ik'iayram  by  Dr.  C.  Ttiurstan  Holland.) 


I'Xlst 


.  for  the  obstruction  may  ol'len 
iile  or  gruel  containing  bistmith 
while  MM  iiiiciirysm  would  east  a 
II-  oiiici-  llic  patient,  the  more 
r\sin.  'I'lie  dilTercntial  diagnosis 
1  of  the  (esophagus  by  a  growth 
of  great   dillieulty,   tmless  there 


DYSPHAGIA 


liavc  been  definite  gastric  symptoms  before  flys])hiigiii  set  in.  Secondary  nodules  would 
naturally  be  looked  for,  especially  in  the  lynijihatic  glands  in  the  lower  part  of  the  neck 
and  in  the  liver.  A  history  of  syphilis  and  c^•idence  of  syphilitic  aortic  regurgitation, 
especially  in  a  man  between  the  ages  of  forty  and  fifty  who  had  been  a  hard  manual 
worker  and  not  teetotal,  would  render  aneurysm  probable. 

AVhen  aortic  aneurysm  can  be  excluded,  much  information  as  to  the  nature  of  an 
oesophageal  obstruction  may  sometimes  be  obtained  from  the    use  of   an  ocsophagoscope, 

and  the  latter  can  be  used  at  the 
same  time  in  facilitating  the  re- 
moval of  such  things  as  a  foreign 
l)ody. 

Di/spliagia  lusoria  is  a  very 
rare  condition  due  to  compression 
<if  the  ct'sophagus  by  the  right  sub- 
clavian artery  when  it  arises  from 
the  aorta  beyond  the  left  subclavian 
and  passes  to  the  right  side  either 
in  front  of  or  behind  the  oesophagus  : 
the  diagnosis  in  such  cases  will  be 
almost  impossible,  though  it  might 
lie  guessed  at  if  there  were  other 
congenital  deformities,  such  as  club- 
foot or  transposition  of  the  viscera. 
(Esophageal  pouches  cause 
symptoms  which  can  seldom  be 
interjireted  with  certainty  imless 
tlic  case  is  watched  for  some  time. 
IJencrally  the  patient  can  swallow 
with  ease  on  some  days,  but  with 
considerable  difficulty  on  others  : 
aneurysm,  new  growth,  and  trau- 
matic or  corrosive  obstruction  to 
the  oesophagus  will  be  excluded 
partly  by  the  residts  of  .r-ray  exam- 
itiation  and  ])artly  by  the  age — 
pouch  cases  are  relatively  young. 
'I'he  point  which  suggests  the  dia- 
gnosis of  a  pouch  is  that  the  patient 
who  has  been  able  to  swallow 
pirfectly  well  for  a  few  days,  and 
then  begins  to  have  difficulty  in 
getting  the  food  down,  finds  relief 
presently  on  the  regurgitation — 
clearly  not  from  the  stomach  but 
from  some  situation  higher  up — of 
a  larger  quantity  of  food  material 
than  had  been  swallowed  innnediately  before,  including  perhaps  articles  which  were  taken 
one  or  more  days  previously.  The  reason  for  these  symptoms  is  that  the  pouch  does 
not  obstruct  the  oesophagus  until  it  becomes  very  much  distended  by  the  gradual  accu- 
nuilation  in  it  of  portions  of  the  food  swallowed,  relief  coming  when  the  greatly  distended 
sac    em])ties    itself    back    into    the    (isopluigus. 

•2.  Dysphagia  due  to  Nervous  Causes  without  Obstruction. — The  two  commonest 
\arieties  of  dysphagia  due  to  purely  nervous  causes  are  probably  post-diphtheritic  and 
hi/sterical.  The  former  is  characterized  by  regurgitation  of  the  food  through  the  nose, 
due  to  i)aralysis  of  the  soft  palate  :  inspection  may  demonstrate  the  flaccid  condition  of 
the  latter  ;  there  may  have  been  a  history  of  sore  throat,  of  other  cases  of  dii)litheria  in 
the  patient's  neighbourhood,  or  Klebs-LofHer  bacilli  may  have  been  found,  or  may  still  be 
found  in  the  paticnfs  throat.      When  regurgitation  of  the  food  through  the  nose  develops 


Fiff.  9G. — Skiagram,  af'era  bismuth  meal,  sliowing  the  bismutli  lifl'i 
III"  by  a  malignant  stricture  of  the  cpsopha^us  at  about  the  level  of  the 
iiifiu-eatioii  of  the  trachea. 


DYSPHAGIA 


197 


in  a  ijerson  who  is  not  known  to  have  had  diplitlieria,  the  symptom  will  usually  arouse 
grave  suspicion  that  diphtheria  of  a  mild  type  has  occurred  but  has  been  overlooked.  There 
may  or  may  not  be  other  signs  of  peripheral  neuritis,  or  there  may  be  |)aralysis  of  the  ciliary 
muscles  of  the  eyes. 

Hysteria  as  a  cause  for  dysphagia  is  familiar  enough  under  tlic  heading  of  globus 
hystericus,  the  diagnosis  of  which  is  not  as  a  rule  dillicult.  especially  if  the  patient  be  a 
young  woman  who  has  suffered  from  other  functional  nervous  affections,  for  instance 
hysterical  a|)li<inia. 

Less  connnim  varieties  of  dysphagia  of  nervous  origin  are  : — 

liidlxir  jKiralijsi.s;  in  which  the 
characteristic  and  progressive  dilKculty 
in  the  use  of  the  lips,  tongue,  pharynx, 
and  larynx  point  at  once  to  the  dia- 
gnosis, the  only  difficulty  that  may 
arise  being  perhaps  in  distinguisliing 
true  bulbar  j)aralysis,  in  which  the 
lesion  is  in  the  motor  nuclei  of  the 
medulla  oblongata,  from  pseudo-bidliar 
])aralysis.  where  the  lesion  is  due  to 
bilateral  cortical  softening  :  in  the  true 
form  there  is  atrophy  of  the  tongue, 
in  the  pseudo  variety  the  tongue  does 
not  atrophy,  and  chieHy  upon  this 
point  is  the  differential  diagnosis 
made. 

S  !/j)li  i  I  i  I  i  (■  dciii' lie  rat  ion  of  the 
meilullary  centres  may  produce  syni- 
ploins  not  unlike  those  of  ordinary 
bulbar  iKUalysis.  but  it  is  generally 
<lillerentiated  by  the  fact  that  other 
cranial  nerves,  particularly  those  of 
the  eyeball,  are  probably  affected  at 
the  same  time,  and  there  may  also  be 
evidence  or  ii  clear  liistorv  of  syphilis, 
with  or  without  a  |)Osilivc  Wasscr- 
mann's  reaction. 

Lead  jioi.soniiifi  and  iiIiiiIidHsw  may 
also  be  responsible  for  degenerative 
lesions  affeeling  the  nerxcs  concerned 
in  the  process  of  swallowing. 

deinrnl  jiiiiiili/sis  of  llic  iiismic 
iilliiiiately  resiills  In  inability  to  swal- 
l<iw  ;  the  s*vallo\ving  rellcx  is  amongst 
I  lie  very  last  to  disappear,  and  the 
diagnosis  has   long  since   been   cstabiislurl    ii| nllin-  Lirouuds. 

Spanniiidic  (li/sphogia.  <luc  to  spasm  of  the  nuiscular  coals  of  the  (esophagus  and 
pharynx,  is  probably  the  cause  of  globus  hyslerieus.  but  similar  spasticity  may  prevent 
swallowing  in  much  more  serious  diseases,  and  eonslilules  a  prominent  symptom  in 
lii/rlniidiiihid.  in  uliicli  any  ifl<irl  to  swallow  licpiids  producer  the  s\inpt<im  in  extreme 
jlegree.  The  hisloiy  of  a  lioi; -bile  as  a  source  of  contagion  is  the  eliief  point  in  arriving 
at    the  diagnosis. 

Mi/iisdiiiiiii  finii-is  is  a  \cr\-  eliaraeterist  ic  <lisease.  in  wliicli  I  lie  muscles  tlial  are 
alleiled  are  perlcctly  abli'  to  do  their  wi)rk  when  they  lirsl  begin  to  e(intia<'t,  but  bicomc 
fatigued  with  great  rapidity,  so  that  after  the  lirst  few  eoni  ract  ions,  those  which  succeed 
become  less  and  less  effectual,  until  they  cease,  and  the  alfccled  nmscles  will  only  be  able 
to  work  again  when  tlies  lia\c  been  given  a  long  rest.  'I"hc  neck  nmscles.  and  those  of  the 
eye,  larynx,  and  nioulli,  hreome  involved  early  (/''/X'.  111.  p.  'I'A't).  and  dillicidly  in  swallow- 
ing after   the   first    IVu    r illifiils   is   sometimes   a   charai-tcrist  ic   li-atnic   of  the   ease.      The 


Fi'i.  '.17.    -Ski;m'nini 

Iiikoii    in    tlie 

selni-liitenil    position    nflor 

liisiiiiitli  :i.hniiiistmtior 

ill  a  CMC  of  s 

oiiosis  of  tlie  a-.sopliiii,'iis  hv 

;x  cariMiioiim  at  Uio  ca 

(line  oritice.    'I 

lie  .liiii,-iiosis  WHS  vcriliuil  lit 

subsenueiit  operation. 

Tlie  bismutli 

111.1   Imon  t.iki-H  -jn  minutc'H 

previou.s  to  tiie  .r-ray 

:;.\utniii.'itioii  nii 

1  none  liiul  vot  ontcrpcl  tli(> 

stoniiii-h. 

( Sk-iii'/nnn  It 

/  llr.  r.   Tliursliiii    llnllaiiil.) 

198 


DYSPHAGIA 


nivasthenic  electrical  reaction   (see  Reaction  of  Degeneration,   p.  584)  serves  to  dis- 
tinguish these  cases  from  those  due  to  bulbar  paralysis. 

Finally,  there  are  very  rare  cases  in  which,  without  any  known  pathology,  the 
oesophagus  becomes  enormously  hypertrophied  and  dilated,  and  the  patient  cannot  swallow, 
though  a  bougie  passes  perfectly  well.  This  so-called  idiopathic  dilatation  and  hypertropliy 
of  the  oesophagus  is  fortunately  very  rare  :  it  has  generally  been  regarded  as  due  to  cardio- 
spasm— an  erroneous  spasmodic  contraction  of  the  cardiac  orifice,  which  refuses  to  relax 
for  the  ingress  of  food  into  the  stomach  ;  but  a  more  recent  view  is  that  it  is  due,  not  to  any 
extra  spasm,  but  to  defective  relaxation  of  the  normal  tonicity — a  condition  to  which  the 
term  (tclialini/i  has  been  a])]ilied.     It  leads  to  dilatation  of  the  oesophagus  behind  it.  with 

much  hyjjcrtrophy,  the  latter, 
great  though  it  is,  eventually  fail- 
ing to  overcome  the  neuro-muscu- 
lar  constriction  of  the  oesophageal 
spliincter,  though  bougies  pass 
without  difficulty.  It  may  be  recog- 
nized by  tlic  use  of  Ijismiith  or 
barium  and  the  .c-rays  (Fi'<.  118). 
:>.  Dysphagia  due  to  Mechani- 
cal Defects  of  the  Mouth  or 
Pharynx,  the  CEsophagus  being 
Normal. — This  group  of  cases  in- 
chidis  patients  suffering  from  such 
eondilions  as  widely  cleft  palate. 
syphilitic  stenosis  of  the  pharynx, 
inabihty  to  use  the  tongue,  either 
because  it  •  is  acutely  swollen  from 
glossitis,  bee-sting,  or  angina  Ludo- 
\  iei,  or  because  it  is  fixed  from 
caieinomatous  infiltration,  and  so 
fortli.  There  is  little  need  to  enter 
into  the  differential  diagnosis  of 
this  variety  of  dysphagia,  for  it 
can  generally  be  determined  by 
direct  examination  of  the  buccal 
cavity.  Mumps,  quinsy,  and  post- 
pharyngeal abscess  belong  to  the 
same  group,  the  last-named  caus- 
ing more  dyspnoea  than  dysphagia, 
and  being  confined  to  quite  earl\- 
childhood. 

t.  Dysphagia  in  which  there 
is  no  Mechanical  Obstruction,  but 
in  which  the  Act  of  Swallowing 
causes  the  Patient  so  much  Pain 
that  he  hesitates  to  Swallow. — 
The  chief  causes  of  dysphagia  which  come  under  this  headinu  are  :  Inlhimmatorv  affections 
of  the  mouth  or  tongue,  including  the  different  varieties  of  .stomatitis  (p.  542)  :  pemphigus 
or  erythema  hullosum  of  the  buccal  cavity,  evidenced  by  similar  eruption  upon  the  skin 
(see  BuLLiE,  p.  96)  :  ulcers  of  the  tongue,  whether  malignant,  gummatous,  tuberculous, 
or  due  merely  to  erosion  by  a  carious  tooth  or  an  ill-fitting  tooth-plate  ;  sore  throats  of 
various  kinds  (see  Sore  Throat,  p.  613)  ;  pain  in  the  mouth,  larynx,  or  oesophagus  after 
swallowing  acute  irritants  or  fluids  that  are  either  exceedingly  cold  or  burning  hot  :  and 
injhimmatory  affections  of  the  larynx  and  its  immediate  neighbourhood. 

The  nature  of  the  buccal  lesions  will  generally  be  indicated  by  inspection. 
The  different  varieties  of  sore  throat  may  be  distinguished  to  some  extent  by  inspection, 
though  bacteriological  confirmation  is  usually  advisable. 

The  chief  dilHeulties  arise  when  the  cause  of  the  dysphagia  is  a  painful  affection  of 


medicines  in  tlio  pliarnKicoyana,"  but  wa:^  never  vlia'^'nosed  eorrectl3^  until 
bismuth  and  .c-ray  examination  was  resorted  to  previous  to  a  proposed 
gastro-enterostomy.  (Skioffram  by  Dr.  C.  Thurstan  Holland.) 


DYSTOCIA  199 

the  larynx.  Rarities  such  as  variolous,  lupoid,  lejjrous,  t^-jjlioidal,  decubital,  and  trau- 
matic ulcers  of  the  larynx  will  seldom  be  diagnosed  imless  there  is  obvious  collateral  evidence, 
such  as  the  eruption  of  sniall-pox  upon  the  skin,  residence  in  leprous  countries,  prolonued 
conlinenient  to  bed,  and  so  forth,  to  indicate  the  nature  of  the  case.  The  commoner 
varieties  of  laryncreal  trouble  which  produce  dysphagia  are  acute  laryngitis,  tiiberculoua 
lari/i}gitis  with  or  without  ulcers,  carcinomatous  ulceration  of  the  larynx,  and  syphilis. 
Laryngoscopic  examination  is  essential,  local  anaesthesia  by  the  use  of  the  cocaine  generally 
being  necessary  first.  If  tubercle  bacilli  can  be  found  in  the  sputum,  or  if  there  are  abnormal 
signs  at  the  apices  of  the  limgs,  the  diagnosis  of  tuberculous  laryngitis  is  probable,  and 
the  pallid  swelling  of  the  aryteno-epiglottidean  folds,  and,  still  more  so,  multiple  small 
ulcers  of  the  edge  or  posterior  surface  of  the  epiglottis  or  of  the  free  edges  of  the  true  or 
false  vocal  cords,  or  similar  ulcers  in  other  parts  of  the  larynx,  bilaterally  situated,  would 
indicate  the  diagnosis  with  certainty.  The  chief  dilficulty  arises  in  the  more  chronic  cases 
ill  which,  after  the  larynx  has  become  involved,  the  lung  condition  has  improved,  and 
tubercle  bacilli  may  not  be  found  in  the  sputum.  F^pitheliomatous  ulceration  of  the  larynx 
may  be  very  extensive,  and  yet  for  a  long  time  remain  confined  to  one  side  ;  this  unilateral 
distribution  of  the  infiltration  is  often  important  in  distinguishing  epithelioma  from  syphilis 
(if  the  larynx,  whilst  the  latter  may  also  be  distinguished  by  the  repair  which  may  ensue 
i\eii  after  extensive  destruction  of  the  tissues  has  led  to  much  deformity  of  the  parts.  The 
inlluence  of  salvarsan  or  potassium  iodide  and  mercury  upon  the  lesions  may  assist  the 
diagnosis,  and  Wassermann"s  serum  test  may  be  employed.  Doubt  may  remain,  however, 
and  sometimes,  where  it  is  very  important  to  arrive  at  a  certain  diagnosis  as  soon  as 
possible,  a  small  portion  of  the  affected  tissue  may  be  excised  and  examined  microscopically. 
When  tuberculosis,  syphilis,  and  new  growth  arc  excluded,  and  yet  laryngitis  is  present, 
the  probability  is  that  it  is  due  to  some  infecting  organism.  Probably  the  symptoms  will 
lia\c  started  more  or  less  acutely,  even  though  they  persist  and  become  chronic  ;  laryngeal 
inspection  may  show  acute  hypera-mia  and  injection  of  the  parts  with  extensive  u-dema 
without  ulceration,  and  the  nature  of  the  micro-organism  concerned — the  diphtheria 
bacillus,  streptococcus,  pncumococcus,  etc. — may  be  determined  baeteriologically  by 
preparing  cultures  from  local  swabbings.  It  is  possible,  of  course,  for  two  or  more  maladies 
to  occur  simultaneously,  and  it  is  particularly  difficult  to  distinguish  syphilitic  laryngitis 
from  tuberculous  in  a  syphilitic  patient  who  has  undoubted  phthisis  ;  similarly,  it  may 
lie  dilficult  to  distinguish  catarrhal  laryngitis  from  tuberculous  in  phthisical  patients,  and 
so  on  ;  indeed,  in  many  instances  the  diagnosis  may  be  one  of  (ipiiiion  only.  Measles  is 
very  ajit  to  be  accoiiipanicd  by  laryngitis,  which  ma\-  often  be  merely  (atairhal.  but  which 
not  infrc(|iieiitly  is  due  to  fliphtlicria  dcvehiiiiTig  synchronously  with  the  measles.  In 
order  to  exclude  diphtheria,  it  is  always  advisable  to  take  swabbings  for  bacteriological 
investigation  even  where  it  seems  almost  obvious  that  the  laryngeal  catarrh  is  merely  part 
of  the  gem  nil  coryza  of  measles.  In  all  these  cases  dysphagia  will  be  accompanied  by 
hnaiNciuss  or  other  alteration  in  the  voice  pointing  to  an  affection  of  the  larynx. 

Herbert  French. 

DYSPNOEA,  or  marked  dillicully  or  dislrcNs  in  lire  alliiiig.  mayor  may  not  be  associated 
x^ilh  o^Hlo|^ll(l•a  :  in  the  iiiilder  cases  a  patient  when  at  rest  has  no  dyspnoa.  the  dillicillty 
uitli  breathing  being  brought  out  only  by  exertion  :  nearly  all  eoiiditioiis  which  may  pro- 
duce dyspnua.  however,  are  capable  in  later  stages  of  producing  orthopnoa.  so  that  the 
causes  of  dyspn(pa  and  of  ortlmpiiciM  aic  similar  in  kind  though  they  differ  in  degree.  There 
is  no  need,  therefore,  to  repeat  wlial  will  lie  round  under  the  heailing  OiirnoPNa:.\  (p.  U8) 
whilst    the  article  on  Hukaiii.  Sikiium.ss  (ii-  (p.  S7 )  sliould  also  be  consultcel. 

UubrrI   P'rineh. 

DYSTOCIA  signifies  diirKiill  birth  or  labour.  The  dillieiilties  of  delivery  show 
thenisiKis  by  pniloiigation  or  delay  in  llic  cnniiilclion  of  the  stages  into  which  labour  is 
usually  di\ided.  Dilliciilt  labour  is  ac(  iiiii|iaiiiiil  by  progressiNC  symptoms,  objective  and 
subjective,  which  arc  to  be  explained  by  physiological  exhaiislioii.  especially  in  its  effect 
upon  the  central  nervous  system  of  the  patient.  The  results  of  dilliciilt  labour  are  thus 
of  such  importance,  affecting,  as  IIkn  dd.  Ilic  litr  of  llie  mollier  .ind  child,  tli.il  aiil  icip.il  ion 
of  it.  and  therefore  early  and  iippni|iri;il(  I  n:il  mcnl ,  arc  of  paraiiKinnI  inip<ii  laiici-  in 
scicntilie   niidwifcrv. 


200 


DYSTOCIA 


The  causes  may  be  tabulated  according  as  they  occur  in  the  first  or  second  stage,  the 
first  series  delaying  the  dilatation  of  the  cervix,  the  second  the  expulsion  of  the  child.  It  is 
not  out  of  place  in  this  connection  to  add  also  the  causes  of  difficulties  in  the  separation  and 
expulsion  of  the  placenta,  for  delivery  cannot  be  said  to  be  complete  until  the  placenta  is 
expelled. 

Causes  of  Delay  in  Completion  of  the  Three  Stages  of  Labour. 


I.s7  Sluge. 

Weak  uterine  contractions 

Rifiidity  of  cervix:  relative, 
spasmodic,  cicatricial,  new 
urowths 

Pendulous  belly,  causini;  ante- 
version 

Early  ruptiuc  of  membranes, 
line  to  malpresentations, 
morbid  adhesions  to  the 
lower  uteriiK"  sef;nient,  lui- 
<lll<'    ri[:.hililv 

,M;[|pics(  nl.ii  lull,      ill     general 
Any(liiiij:i   uliicli   ]irevents  the 

held     entering     the     lower 

uterine  segment 
Ilydramnios 

Delioienev  (if  liquor  anniii 
Twins. 


3rd  Stage. 
Weak  uterine  contractions 
Jlorbid  adhesion  of  placenta 
Uterine  spasm 
'  Hour  glass  '  contraction 
Adhesion  of  membranes 


•2ii(l  Stage. 
Weak  uterine  contractions 
Secondary  uterine  inertia 
Absence  of  accessory  muscular 

effort 
Rigidity   of  vagina    and   ]ieri- 

neum 
Loaded  rectum 
Distciiikd  lila.lder— evstoeele 
Coiitiactcd   prlvis 
Pelvic  tumours:   P^ibromyoma. 

ovarian  tumours,  growths  of 

the  pelvic  bones,  luematoma. 

varicose        veins,        vaginal 

growths 
.MaI])rcscntations  ;       Occipito- 

posterior,  breech,  face,  brow, 

transverse 
.\ny  abnormal  enlargement  of 

tiie   child  :    Hydrocephalus, 

meningocele,      ascites,      tu- 
mours,     double      monsters, 

very  large  child 
Excessive    ossification    of   the 

head 
Short  cord  :    absolute,  relative 
Locked  twins 

From  the  above  it  will  be  seen  that  the  causes  of  delay  are  very  numerous  and  im- 
portant ;  and  the  successful  delivery  of  the  child  under  many  of  these  conditions  depends 
\ery  much  on  their  anticipation,  rather  than  their  recognition  when  delivery  is  alreadx' 
dangerously  obstructed.  Conse((uently,  accurate  diagnosis  at  the  beginning  of  labour 
will  often  save  much  trouble  to  the  practitioner,  and  danger  to  the  mother  and  child. 
Indeed,  some  of  the  dangers  of  obstructed  labour  can  only  be  avoided  satisfactorily  by 
carcful  examination  of  the  patient  during  pregnancy,  say  at  the  thirtieth  week.  This 
applies  specially  to  the  recognition  of  contracted  pelves,  of  pelvic  tumours,  and  sometimes 
of  malpresentations,  and  constitutes  an  important  reason  why  every  ])atient  should  be 
urged  to  undergo  an  examination  during  the  later  weeks  of  pregnancy. 

The  routine  method  of  examination  of  the  juegnant  woman,  whether  in  labour  or  not, 
is  the  same  :  and  the  deductions  to  be  mafic  from  it  are  identical.  The  examination  is  made 
as  follows  :    lirst,  by  abdominal  ])alpation  :    secondly,  by  vaginal  examination. 

Abdominal  Palpation. — First  feel  for  the  foetal  head  in  the  pelvis  by  the  '  pelvic 
grip,"  or  Pawliks  grip.  In  a  primipara  the  head  shoidd  be  well  down  in  the  pelvis  ;  not 
necessarily  so  in  a  multiiiara.  Failing  to  find  the  head  in  the  )jelvis,  palpate  for  it  at  the 
fundus  ;  failing  to  find  it  hci-e,  it  will  be  found  in  one  or  the  other  lateral  situations.  If  the 
head  is  in  the  pelvis,  and  fixed,  there  can  be  no  pelvic  contraction  of  importance,  and 
tumours  of  the  uterus  or  ovaries  beloic  the  brim  are  quite  unlikely.  If,  however  the  head 
is  above  the  brim  and  movable  in  a  primipara,  pelvic  contraction  must  be  suspected,  whilst 
a  tumour  iireventing  entrance  into  the  pelvis  is  a  possibility.  Pelvic  contraction  may  be 
\erihed  by  ])elvimetry,  for  which  see  below.  Abnormal  presentations  are  recognized  by 
abdominal  palpation  ;  breech  and  transverse  by  the  actual  position  of  the  head  ;  occipito- 
posterior  by  the  presence  of  the  •  small  parts,'  arms  and  legs,  in  front,  and  tlie  absence 
of  the  back  of  the  foetus  ;  a  face  cannot  be  diagnosed  absolutely  excejit  in  mcnto-postcrior 
cases,  when  the  groove  between  the  extended  occiput  and  back  will  be  felt  in  front  whilst 
tlie  head  remains  above  the  brim.  Hydramnius  may  be  recognized  if  there  be  fluctuation, 
and  the  ftt'tal  parts  can  only  be  felt  by  dee])  dipping  through  the  fluid.      Trcins  may  possibly 


DYSTOCIA  201 

he  recoiiiiizcd  Ijy  feclini;  two  licads.  and  hearing  two  foptal  hearls  heating  with  (Uffeicnt 
rhythms. 

Vaginal  Examination. — It  is  iniixntaiit  to  reineTnl)ei'  that  very  httle  eaii  Ik-  iiukU'  out 
with  one  or  two  lingers.  As  a  rule,  all  that  can  he  noted  is  the  roiiditinu  of  the  aiiial.  whether 
narrow  or  rigid,  with  a  powerfully  acting  levator  ani  nuiscle.  and  the  coiuUtiuii  o/'  tlic  un  ;  note 
especially  its  consistence,  and  the  integrity  of  the  membranes.  It  may  not  even  be  possible 
to  recognize  the  presentation  if  this  has  not  been  made  out  by  abdominal  palpation.  If  con- 
tracted pelvis  is  suspected,  the  important  diameter,  namely,  the  diagonal  conjugate,  should 
be  nieasm-ed  with  the  fingers,  and  the  true  conjugate  estimated  by  subtracting  half  an  inch 
from  tills  measurement.  The  only  accurate  instrument  for  taking  this  measurement  is 
Shiil.srh's  pchiinelcr  :  but  its  use  requires  considerable  experience,  and.  in  general,  the  simpler 
method  with  the  fingers  is  sufficiently  accurate  for  most  ])ur])Oses.  External  measurements 
may  l)c  made  to  supplement  the  important  internal  one  ;  but  they  are  not  of  the  same 
Ijractical  importance.  AVhen  a  difficulty  arises  in  labom-,  accurate  diagnosis  is  indispensable, 
and  the  whole  hand  should  be  inserted  into  the  vagina  under  ansesthesia.  Tlie  presenting 
part  may  then  be  grasped,  and  its  absolute  character  determined.  In  this  way  oceipito- 
posterior  presentations  (the  commonest  cause  of  dilficult  labour)  can  be  diagnosed  with 
certainty,  and  rectified.  Hydrocephalus  may  be  recognized  by  this  manoeuvre  ;  the  hand 
may  be  pushed  on  above  the  head  without  danger  in  most  cases,  and  the  neck  felt  for  coils 
of  cord,  the  body  of  the  child  palpated  for  the  presence  of  tumours  or  enlargement  by 
ascites.  Tumours  obstructing  delivery  are  best  felt  from  the  vagina  :  they  are  usually 
wedged  l)etween  the  presenting  part  and  the  sacral  promontory,  part  below  and  part  above 
this  ])roininence.  If  fluctuating  and  soft  they  are  usually  ovarian  cy.sts  ;  if  hard  and 
unyielding  they  may  be  fibromyomata  of  the  uterus  ;  but  these  also  are  apt  to  soften  during 
pregnancy,  and  to  feel  like  fluid  tumours.  Tmnours  of  the  pelvic  bones  are  usually  bony,  or 
cartilaginous  :  growtfis  of  the  cervix  may  be  fibroid.  I)ut  more  commonly  arc  friable  carcin- 
oniata.  bleeding  freely  on  examination. 

Little  more  than  the  method  of  examination  can  l)e  indicated  in  a  short  ailicle  on  the 
diagnosis  of  a  case  ol'  dillicult  labour  :  but  too  much  stress  cannot  be  laid  on  the  \ahic  of 
abdominal  examination  and  palpation  as  the  most  important  means  of  gaining  inlormalion 
in  any  labour. 

Delay  in  the  Delivery  of  the  Placenta,  though  not  strictly  a  part  of  dilficult  labour, 
presents  dilliciiltics  in  the  completion  of  (leli\ery.  and  must  not  be  overlooked.  The 
placenta  may  he  sim|)ly  retained  in  utero  :  may  be  adherent  to  the  uterus,  totally  or 
[)artiall\-  :  or  may  be  retained  in  the  vagina.  In  the  first  ease,  if  there  is  no  luvmorrhagc 
the  placenta  is  likely  to  lie  in  the  lower  uterine  segment  and  vagina,  and  is  not  expelled 
owing  to  weakness  of  the  accessory  muscles.  If  partially  adlicrcnl.  bleeding  is  (•(  rtaiii  to 
occur,  whilst  total  adhesion  does  not  permit  of  any  bleeiling.  In  any  e;isc  of  this  kind  if, 
after  a  snITieienI  time  has  elapsed,  the  placenta  caimot  be  expressed,  the  hand  nnisl  be 
introduced  into  the  uterus  in  order  to  diagnose  the  condition.  It  nnist  not  be  forgotten 
that  the  plaeeiitii  may  be  retained  above  a  s|)asmodie  stricture  of  some  part  of  the  uterus, 
the  so-called  lioiir-glass  (•oiilraclioii.  Ila-morrliage  always  accompanies  lliis  coiKlil  ion  il  the 
placenta  ik  partl\-  separated. 

I'MnaJly.  the  siini/ildiiis  of  cilKlilslidii  cin\\ii]t[r\\\  upon  olisl  ruelecl  laliour  may  he  men- 
tioned. 'I'Ik'  lirst  are  rise  of  temperature  and  increase  in  rrei|n(ii<v  ot  the  pnlse-rale.  These 
allord  very  important  indications  of  obstructed  labour,  and  assist  us  to  distinguish  this 
from  simple  delay  from  weak  uterine  contractions,  in  which  the  pulse  and  temperature 
remain  normal.  The  later  syni|)toms  of  ol)struclion.  il  nol  iiiicMil.  are  Idc.il  and  general. 
].,ocally.  the  vaginal  secretions  fail,  the  parts  become  hoi,  ilry,  and  swollen.  The  uterus  con- 
tracts powerfully,  and  may  go  into  a  tetiuuc  condition,  usually  known  as  Ionic  contraction,  in 
which  case  the  nieriis  is  hard.  ncv<-r  relaxing,  and  is  lender  to.  the  touch.  The  exact  op|)osile 
occurs  in  uterine  inertia,  when  the  uterus  remains  llaccid,  along  with  a  normal  pulse  and 
temperature.  Later  still,  vomiting  may  occur,  signs  of  septic  iid'ection  may  appear,  and 
ruptm-e  of  the  uterus  may  take  place  owing  to  the  dangerous  thinning  of  the  lower  segmeni 
when  liinic  coiil  rael  i(]ri  siipei  \  iiies.  This  series  of  symptoms  shoidd  never  occur  in  properly 
eoiiducldl  midwilriy  ;  llicif  |inssililc  uceurrence  should  always  be  aidicipated  by  correct 
diai;ii(isis  e:iily   in   laliour.   rdlliiwcd   li\    immediate  a|i|iropri;d  e  Irealminl.  '/'.  (i.  SIcitiik. 


202  EARACHE 

EAR,   DISCHARGE  FROM.— (See  Otorrhcea.  p.  421.) 

EARACHE  is  tlie  term  usually  applied  to  the  pain  experienced  in  acute  inflammation 
of  tlie  niidille  ear.  It  is  most  acute  when  suppuration  ensues.  There  are.  however,  a 
number  of  other  conditions  -many  of  them  of  great  importance — which  also  give  rise  to 
otalgia  or  to  pain  roughly  localized  by  the  patient  to  the  ear. 

In  acute  otitis  media  the  pain  is  usually  dull,  continuous,  and  throbbing,  with  sharp 
exacerbations  in  which  the  pain  shoots  to  the  occiput,  to  the  top  of  the  head,  or  forwards 
to  the  temporal  region.  It  is  usually  worse  at  night — indeed  it  may  disappear  in  the  day — 
and  it  is  increased  by  pressure  over  the  tragus  and  on  ojiening  the  mouth.  Xot  infrequently 
there  is  some  tenderness  over  the  mastoid  process.  There  is  always  some  impairment  of 
hearing.  In  adults  there  will  probably  be  a  slight  rise  of  temperature  ;  in  children  the 
temperature  may  rise  to  103°  F.,  or  more,  the  pain  is  often  very  acute,  and  constitutional 
symptoms  may  be  very  marked,  with  convulsions,  vomiting,  and  delirium.  Such  cases 
may  be  mistaken  for  meningitis,  especially  in  children  too  young  to  talk  :  but  in  these  little 
patients  attention  may  be  directed  to  the  trouble  by  the  extreme  tenderness  of  the  affected 
ear.  the  least  manipulation  of  which  may  cause  the  child  to  scream.  In  young  children 
the  presence  of  cerebral  symptoms  with  pyrexia  should  always  lead  to  a  careful  examin- 
ation of  the  ears.  The  presence  of  optic  neuritis  favours  a  diagnosis  of  extension  of  the 
inflammation  to  the  Interior  of  the  cranial  ca\'ity,  but  this  is  not  a  universal  rule,  for  cases 
are  recorded  in  which  otitis  media  by  itself  has  caused  optic  neuritis.  Attacks  of  earache 
in  childhood  are  frequently  caused  by  adenoids,  and  indeed,  acute  otitis  media  is  prac- 
tically always  caused  by  an  extension  of  inflammation  from  the  nasopharynx  along  the 
Eustachian  tubes.  When  suppuration  occurs,  the  membrane  becomes  perforated,  pus 
escapes,  and  the  pain  usually  ceases.  When  it  persists,  the  perforation  is  probably  too  small 
to  allow  of  satisfactory  drainage  of  the  pus.  Examination  of  the  tympanic  membrane  by 
means  of  a  speculum  will  show  redness,  loss  of  lustre,  and  probably  bulging  of  the  mem- 
brane, with  blurring  of  the  handle  of  the  malleus. 

Chronic  middle-ear  suppuration  is  usually  painless.  When  necrosis  occurs  pain  is  often 
present  and  may  be  very  acute,  but  this  is  by  no  means  invariable,  and  some  cases  of 
extensive  caries  are  i-emarkably  free  from  pain. 

Pain  and  tenderness  over  the  mastoid  process  are  also  present  in  acute  mastoid  abscess 
and  periostitis. 

Pain  in  the  ear  may  also  be  caused  by  the  following  lesions  of  the  external  auditory 
meatus,  which  may  be  diagnosed  on  examination  through  a  speculum  : — 

A  foreign  body,  especially  if  an  insect  finds  its  way  into  the  meatus. 

Furuncles  ;  intense  pain,  often  throbbing  in  nature,  is  followed  by  a  discharge  of  pus, 
after  which  the  pain  diminishes  :  the  meatus  is  so  tender  that  it  may  be  impossible  for  the 
patient  tf)  endure  the  ])resence  of  the  speculum. 

Ccruiiicn  is  usually  painless,  though  sometimes  a  dull  pain  may  be  present. 

Kczetnn  of  the  meatus  may  be  the  cause  of  a  burning  or  smarting  pain. 

Sometimes  a  careful  examination  of  the  ear  will  fail  to  reveal  any  lesion.  Under 
these  circumstances  the  possibility  of  one  of  the  following  causes  of  referred  pain  must 
be  considered  : — 

A  carious  molar  tooth,  a  \ery  common  cause  of  pain  referred  to  the  car. 

Epithelioma  of  the  tongue  or  ulceration  of  the  pharynx  or  laryihr  ;  pain  in  the  ear  may 
be  a  very  troublesome  symptom  of  any  of  these. 

Acute  or  subacute  tonsillitis  often  causes  acute  pain  in  the  ear  without  any  inflammatory 
lesion  of  the  middle  ear.  Less  frequently,  suppuration  in  the  accessory  sinuses  of  the  nose 
has  a  similar  result. 

Otalgia  may  sometimes  be  neuralgic,  and  it  is  then  usually  associated  with  trigeminal 
tieurcdgia.  It  may  also  occur  in  nervous  anaemic  patients,  and  sometimes  must  be  regarded 
as  a  neurosis.  It  must  also  be  remembered  that  the  glenoid  lobe  of  the  parotid  gland  extends 
into  the  non-articular  portion  of  the  glenoid  fossa,  and  thus  parotitis  may  cause  pain  referred 
to  the  ear.  Similarly  otalgia  may  occur  with  osteo-arthritis  or  inflct'inmatory  trouble  in  tlic 
temporo-mandibular  joint. 

Certain  diseases  of  the  am-icle  may  cause  pain  more  or  less  severe  in  character.  Peri- 
chondritis is  by  no  means  uncommon.     It  may  be  traumatic  or  spontaneous,  and  in  the 


ENLARGEMENT  OF  THE  FOREHEAD  -lOo 

latter  syphilis  may  be  the  cause.  Herpes,  acute  eczema,  erysipelas,  Ra^^laud"s  disease, 
and  chilblains  are  all  accompanied  by  jjain  and  may  affect  the  auricle.  Sebaceous  cysts 
and  dermoids  also  occur  here,  and  when  inflamed  will  cause  more  or  less  severe  pain.  A 
condition  known  as  "  Telephone  ear  '  has  been  described  in  persons  who  constantly  use  the 
tele])honc.  More  or  less  severe  pain  is  present,  and  this  may  be  accompanied  t)y  tinnitus 
and  associated  with  the  presence  of  boils. 

Lastly,  it  must  be  remembered  that  there  is  a  lym])luitic  <rhind  situated  over  the  mastoid 
process  which  drains  lymph  from  the  side  of  the  scalp  :  when  inflamed,  this  gland  may  be 
the  cause  of  pain  and  tenderness,  which  may  lead  to  a  susjjicion  of  suppuration  in  the 
mastoid  process.  PJiilip  Turner. 

ECCHYMOSIS— (See  PuRPL-R.v.  p.  .552.) 

ECTHYMA.— (See  Sc.\bs,  p,  599.) 

EFFUSION,  PLEURAL.— (See  Chest.  Bloody  Ei-i  tsuin  ix.  ]>.  102  :  (  hkst.  Skrols 
Effcsion  in.   ]).  104:    and  C'ukst,  Pu.s  in.  p.  108.) 

EGG-SHELL   CRACKLING.— (See  Crackling.  Egg-.shell,  p.  150.) 

ELECTRICAL   REACTIONS.— (See  Re.vction  of  Degeneration,  p.  582.) 

EMACIATION.     (See  .Marasmus,  p.  384  :   and  Weu;ht.  Loss  of,  p.  768.) 

EMPHYSEMA,  SURGICAL. — Surgical  or  subcutaneous  emphysema  is  due  to  disten- 
tion ol  llic  miIk  utaiiidus  areolar  tissues  with  air  or  gas.  The  diagnosis  of  the  condition  and 
its  cause  is  not  as  a  rule  diflicult.  Its  commonest  starting-place  is  in  connection  with  the 
thorax,  particularly  when  there  has  been  injiiri/  to  the  linig  tissue  by  a  broken  rib,  a  stab 
with  a  knife,  a  bullet  wound,  the  rupture  of  alveoli  due  to  excessive  coughing,  as  in  whooping- 
cough  and  bronchitis,  or  during  great  strain,  as  in  dillicull  labour  ;  or  by  operative  injury 
lo  the  lung,  as  in  ex])loraton.'  needling  of  the  chest.  Tlie  gas  spreads  rapidly,  and  may 
extend  over  the  greater  part  of  the  trunk  in  a  short  time,  disappearing  again  in  the  course 
i>l  a  few  <lays.     It  may  do  so  similarly  after  the  operation  of  trachvoiomij. 

'I'he  face  may  sometimes  be  almost  suddenly  involved  unilaterally  by  the  escape  of  air 
into  the  Mibcutaneous  tissues  from  the  upper  pail  of  the  nose,  after  violent  sneezing  or 
energetic  hl(t;.K:in<i  of  the  nose. 

Rarer  causes  for  the  escape  of  actual  air  into  the  subcutaneous  tissues  are  nhrrnlive  or 
iniiimfilie  lesions  of  the  (I'soplingiis.  stomaeli.  duodenum,  ecvcnni.  hhidder.  or  rectum.  \\v 
escaping  in  the  areolar  tissues  arouiul  any  of  these  p:Mts  may  sometimes  extend  and  Ikcomic 
palpable  as  crepitus  under  tlie  skin. 

Quite  another  ty]je  is  that  in  which  the  gases  in  the  tissues  are  not  air.  but  the  results  of 
injection  lii/  giis-jjroducing  Ixictcriii.  Fortunately  <'ascs  of  this  kind  are  now  rare  ;  they  were 
less  uncommon  in  the  days  of  lu/spilul  giingrenc  and  putrefaction.  Tlic  J{(uillus  coli  com- 
munis, however,  not  infre(|ueiitly  liberates  gas  in  an  abscess  lo  which  it  may  give  rise — for 
instance  in  the  region  of  the  vermiform  appendix — and  sometimes  subcutaneous  emphysema 
results,  .\nother  gas-producinu  organism  that  attacks  maiL  though  less  often  as  a  primary 
aftcetion  than  intcrcurrcntly  during  some  oilier  malady,  is  the  Hiicillus  (icrooencs  cu/isulalus  ; 
this.  howe\(r.  more  often  produces  gas-coiitaiuing  loeuli  in  the  liver  ami  oilur  internal 
organs  than  in  the  tissues  beneath  the  skin.  Ilcrhcrl  Frcnrli. 

EMPYEMA.     (See  Cmi-.st.    I'i  s   in.   p.   lo;j.) 

ENLARGEMENT   OF    A    BONE.      (Sec   Swi-.i.linc;   on    \    Moni;.   p.   on?.) 

ENLARGEMENT  OF  THE  FOREHEAD.  Mans  indis  i.hials  hIh,  j.avr  passd 
iiiiildli-  -.iiic  mails  ni<)i<-  so  llian  Icinalis  Icnil  lip  dcMJiip  .in  iiicrciisiiig  pi<iiiiiiieiiee  of 
I  In  1 1  |i:ir  I  dI  II  ic-  ruirlicMd  which  corresponds  «  jlli  II  ic  milcr  ciisiii^  cif  II  ic  frontal  air  sinuses  ; 
«illi  llir  Ksiili  ||i:il  I  heir  eyebrows  seem  to  oxcrliaiii;  llic  i  yes  iiioic  and  more,  and  the 
eoiiiiteiiaiicc  looks  dilferent  to  what  it  did  ten  or  lifleen  ncmis  Ix  Ion'.  This  is  due  to  slow 
enlaigeinent  of  the  air  cells  of  the  frontal  sinuses,  and  it  is  not  pathological.  This  normal 
enlargement  of  the  forehead  has  to  be  distinguished  froin  two  diseases  which,  though  rare, 


204  ENLARGEMENT  OF  THE  FOREHEAD 

arc  generally  recognizable  with  ease  if  the  patient  is  watched  over  a  jjeriod  of  months  or 
years,  namely,  leontiasis  ossea  and  acromegaly. 

The  commonest  symptom  that  a  patient  suffering  from  leontiasis  ossea  complains  of  is 
fluit  in  former  years  he  always  took  a  certain  size  of  hat,  and  was  able  to  order  hats  without 
having  to  go  and  try  them  on  ;  of  recent  years,  howe^■er.  he  has  found  that  he  has  had  to 
get  progressively  increasing  sizes,  so  that  whereas  formerly  a  number  7  may  have  fitted  him, 
he  may  now  require  even  so  large  a  size  as  a  number  8  ;  in  a  few  exceptional  cases  special 
hats  have  had  to  be  made  for  the  patient  because  the  enlargement  of  the  head,  especially 
of  the  forehead,  has  become  tremendous,  whilst  at  the  same  time  it  may  very  likely  not  be 
quite  symmetrical.  The  general  health  remains  good,  and  if  the  patient  docs  not  mind  his 
])ersonal  appearance  and  the  size  of  his  hats,  he  lives  for  years  without  suHcriug  any  other 
inconvenience.  On  the  other  hand,  the  bony  changes  may  not  be  confined  to  the  skull, 
but  may  affect  the  bones  of  the  limbs  as  well,  especially  the  tibise  ;  there  is  probably  a 
relationship  between  leontiasis  ossea  and  osteitis  deformans  or  Paget's  disease  of  the  bones 
(see  p.  135).  If  the  cranium  is  examined  after  death,  it  is  found  that  there  is  no  longer  any 
distinction  between  the  hard  ivory  bone  upon  the  sin  face  of  the  cancellous  bone  in  the  centre  ; 
both  have  assumed  an  intermediate  character,  so  that  the  whole  bone  is  more  or  less  of  the 
same  texture,  very  thick  and  heavy,  and  in  a  condition  which  used  to  bespoken  of  as  osteo- 
porosis.    In  some  cases  the  change  is  syphilitic. 

In  acromegaly  it  ha])pens  very  rarely  that  the  frontal  bone  is  affected  alone  :  much  more 
often  the  affection  of  the  forehead  is  much  slighter  than  the  increase  in  size  of  the  lower 
jaw  and  of  the  phalanges  of  the  hands  and  feet  (p.  237).  If,  however,  the  changes  were 
more  marked  in  the  frontal  bone  or  in  the  bones  of  the  skidl  generally  than  in  those  else- 
where, it  is  probable  that  a  case  of  acromegaly  woidd  be  diagnosed  as  one  of  leontiasis 
ossea,  and  one  does  not  really  know  what  essential  difference  there  is  between  these  two. 
Whereas,  however,  in  acromegaly  the  bigness  of  the  lower  jaw  makes  the  characteristic 
fiuies,  in  leontiasis  ossea  the  )3rominence  of  the  forehead  gives  the  face  that  leonine  character 
from  which  the  name  of  the  disease  is  taken. 

No  other  maladies  in  adidts  are  likely  to  cause  uniform  increase  in  the  size  of  the  fore- 
liead,  but  occasionally  one  meets  with  tumoiu's  of  the  frontal  bone  which  cause  a  symmetrical 
enlargement  of  the  forehead,  the  most  important  of  these  being  the  ivory  exostosis — a  non- 
malignant  tumour  which  may  arise  from  any  of  the  flat  bones  of  the  skull  ;  it  grows  very 
slowly  but  enlarges  progressively,  and  in  so  doing  is  apt  to  displace  anything  which  comes 
in  its  way,  and  in  the  course  of  many  years  great  deformity  of  the  eye  or  nose  may  thus 
result.  The  slowness  of  the  growth,  and  its  very  hard  character  gencrall\'.  ])oint  to  the 
diagnosis  at  once,  and  an  .r-ray  examination  may  help  to  confirm  it. 

Other  asymmetrical  enlargements  of  the  forehead  may  result  from  syphilitic  nodes 
caused  by  gummatous  periostitis  terminating  in  bony  organization  ;  sareoTna  of  the  peri- 
osteum, a  very  rare  primary  growth  in  this  region,  but  when  met  with  suggested  by  the 
relative  softness  of  the  mass  and  its  rapid  increase  in  size  ;  secondary  iiiatignaiit  disease. 
likely  to  be  mistaken  for  jirimary  sarcoma  if  no  jjrimary  growth  elsewhere  is  known,  but 
readily  diagnosed  correctly  if  the  existence,  now  or  formerly,  of  a  carcinoma  of  the  breast, 
thyroid  gland,  or  other  part  is  known. 

.\ny  other  tumours  in  connection  with  the  frontal  bone  are  exceedingly  rare.  The 
\  ery  extensive  disease  of  the  frontal,  as  of  any  other  cranial  bone,  which  used  to  be  met 
^\  itli  in  syphilitic  subjects,  is  now  practically  imknown  on  account  of  the  greater  adequacy 
of  the  treatment  of  syphilis  in  its  earlier  stages. 

Leproiy  maj-  be  mentioned  as  a  cause  of  enlargement  of  the  forehead  (,Fig.  173,  p.  404), 
for  in  the  nodular  form  any  part  may  be  affected  ;  but  it  must  be  very  rare  for  leprosy  to 
allect  the  forehead  region  only,  and  the  diagnosis  will  be  suggested  by  the  lesions  elsewhere 
and  l)y  the  history  of  the  case. 

The  above  remarks  apjjly  to  enlargement  of  the  forehead  in  adults  ;  in  children  quite 
<lilferint  causes  will  suggest  themselves,  the  three  most  important  being  :  (1)  Ilydro- 
cephaUis.  (2)  Rickets.  (3)  Congenital  syphilis. 

It  happens  not  infrequently  that  a  child's  forehead  enlarges  very  considerably,  and 
bulges  with  much  convexity  to  such  an  extent  as  to  make  both  the  parents  and  the  physician 
fear  hydrocephalus  when  the  child  is  suffering  from  nothing  more  serious  than  rickets. 
The  diagnosis  may  be  quite  difficult  if  there  are  not  at  the  same  time  the  other  familiar 


EXLARGEMENT  OF  THE  FOREHEAD  205 

signs  of  rickets  mentioned  on  page  167  :  and  there  are  not  a  few  instances  in  which  it  is 
only  wlien  the  ease  has  been  watelied  for  months  or  years  that  one  can  be  sure  that  there 
is  not  hydroeepliahis.  The  same  applies  to  the  swelling  of  the  frontal  bone  that  may  result 
from  congenital  syphilis.  In  the  case  of  both  rickets  and  congenital  syphilis,  one  will 
examine  the  whole  of  the  head  carefully,  to  try  and  make  upone"s  mind  whether  the  enlarge- 
ment, which  usually  allects  not  only  the  forehead  but  also  other  parts  of  the  skull,  is  a  more 
or  less  uniform  stretching  such  as  hydrocc])halus  gives  rise  to,  or  whether  tliere  are  not 
some  parts  which  are  enlarged  and  other  jiarts  which  are  more  or  less  normal.  Both 
congenital  syphilis  and  rickets  are  apt  to  produce  diffuse  round  prominences  of  the  parietal 
regions  as  well  as  of  the  frontal  regions,  so  that  there  are  four  main  bulges  with  an  antero- 
posterior and  a  transverse  groove  between  them,  constituting  the  hot-cross-bun-shai)ed 
type  of  head  :  but  the  difficulty  of  excluding  hydrocephalus  is  made  greater  still  when,  as 
sometimes  hap))ens.  there  is  such  tliinning  of  the  bones  in  the  occijiital  region  from  cranio- 
tabes  that  the  bones  can  be  dented  inwards  like  stiff  parchment  :  such  cranio-tabes  may 
result  either  from  rickets  or  from  congenital  syphilis.  One  woidd  then  pay  special  atten- 
tion to  the  regions  of  the  sutures  ;  if  these  arc  obviously  stretched  asunder  the  case  is  almost 
certainly  hydrocejjhahis.  and  not  rickets  or  congenital  sy])hilis.  One  would  also  be  able  to 
draw  some  conclusion  perhaps  from  the  a])i)caranccs  of  tlie  eyes,  for  the  eyeballs  will  be 
in  normal  position  when  the  cause  of  the  forehead  enlargement  is  rickets  or  congenital 
sy|)hilis,  whilst  with  hydrocephalus  the  eyes  will  give  the  impression  of  being  displaced  ; 
sometimes  they  look  very  much  deeper  set  than  normal  ;  in  other  cases  they  look  as  though 
they  are  depressed  as  the  result  of  the  downward  ])ressure  exerted  by  the  excess  of  fluid 
upon  the  roofs  of  the  orbits.  If  the  enlargement  and  prominence  of  the  forehead  dates 
from  birth  or  soon  afterwards,  this  will  be  an  argument  in  favour  of  hydrocephalus  ;  if  the 
change  develops  later  in  the  infant's  or  child's  life,  there  will  almost  certainly  be  a  history 
of  a  se\ere  attack  associated  with  symi)toms  of  increased  intracranial  pressure,  for 
])robably  the  commonest  cause  of  acquired  hydrocephalus  is  a  preceding  attack  of  meningo- 
coccal meningitis,  from  which  the  child  has  reco\ered.  The  history,  therefore,  may  help 
in  deciding  the  diagnosis.  The  optic  discs  should  also  be  examined,  for  in  a  certain  number 
of  cases  of  aeipiired  hydrocephalus  there  is  optic  atro|)hy  (PIfitc  A'A'.  /•'/«•  "•  P-  US),  and 
this  is  practically  never  met  with  as  the  result  of  rickets  and  \ery  seldom  as  the  result  of 
congenital  syjihilis.  It  is  of  course  only  when  the  degree  of  hydrocephalus  is  medium  that 
it  is  dillicult  to  distinguish  it  from  the  forehead  enlargements  due  to  rickets  or  congenital 
syphilis.  .Major  degrees  of  hydrocephalus  cause  such  extreme  enlargement  of  the  whole 
head,  conpied  with  such  thiiuiing  of  the  bones  and  stretching  of  the  sutures  that  the  dia- 
gnosis is  almost  umnistakablc. 

Although  either  sim|)le  or  malignant  tumours  may  affect  the  frontal  bones,  even  in  an 
inl'ani  or  cliild,  they  are  very  rare.  They  should  be  diagnosed  in  the  same  way  as  similar 
tumours  in  adults.  Chloroiiia  may  (jerhaps  be  mentioned  specially,  rare  though  it  is.  'I'lic 
tumours  in  such  a  ease  are  never  single,  but  as  they  may  develop  ujjon  bones,  they  some- 
times attract  notice  first  in  coimeetion  with  the  cranial  bones,  and  tluis  perhaps  a  local 
enlargement  of  the  forehead  may  be  the  first  symptom  in  the  case.  There  isa  tendene.y  for 
the  glands  geneiaily  to  become  enlarged  and  siimctimes  the  spleen  also,  and  in  some  respects 
the  iiiahiiiy  sininhiUs  lyrnplialic  leuk;einiii.  \<'ci|ilnsm  of  some  kind  will  he  an  early 
siis|ii(jori.  and  llic  naluir  iif  llic  gr.iulli  is  indieatiil  by  llie  gnciiisli  ciilnur  of  llie  tinnour 
ulirn  it  lias  been  excised.  Tlic  a<'lual  diaiiuosis.  iiowcMr.  is  made  inoic  ollcri  post  mortem 
lliaii  (luring  life. 

The  eomnionest  local  swelling  of  the  forehead  in  a  child  is  a  h(riiiiiliiiii<i  resulting  from 
injury,  and  as  the  blood  clot  is  often  (juite  deep-seated  there  is  sometimes  no  discoloration 
ol  the  skin,  and  some  more  serious  tumour  may  lie  thought  of  until  the  disappearance  of 
the  mass  in  the  eciiiise  of  a  week  or  two  proxcs  its  simple  cliaraeter.  Such  a  lucmalom-i 
altera  day  or  two  sollens  in  ilsccniial  part  in  a  remarkable  way.  leaving  very  hard 
raised  edges,  and  on  palpation  it  feels  almost  as  if  there  were  a  hanl  bony  ring  with 
an  absence  of  any  bone  at  all  in  the  centre  ;  the  lirst  time  such  a  softening  Inenudoma 
of  the  foreliead  is  fell,  one  can  hardly  believe  that  it  is  only  a  ha-niatonia  and  not  an 
actual  hole  in  the  bone  covered  ni<i(ly  by  scalp  an<l  skin.  The  feeling,  however,  on 
l)alpation  is  so  characteristic  that  once  felt  llie  condition  is  rea<lily  recognizable  in  any 
subseiinent   case.  lUrbert  I'rciiili. 


206  ENLARGEMENT     OF    THE     HEART 

ENLARGEMENT  OF  THE  GALL-BLADDER.     (S«  G ali  Hi  auui.u  Enlaugement, 

p.   -'.-,12.) 

ENLARGEMENT  OF  THE  HEART  may  be  due  to  hypertrophy  of  the  walls  of  any 
of  its  cavities,  but  especially  of  the  ventricles  ;  to  dilatation  of  the  cavities  ;  or  to  these  two 
conditions  combined. 

The  most  important  physical  signs  of  enlargement  of  the  heart  are  :  (1)  Displacement 
of  the  cardiac  impulse:  (2)  .An  increased  area  of  cardiac  dullness.  .After  puberty  the  normal 
cardiac  imiiulse  is  usually  situated  in  the  fifth  left  intercostal  space,  about  three-quarters 
of  an  inch  internal  to  the  left  nipple  line.  Before  puberty  it  is  normally  in  the  fourtli  left 
space  in  the  nipple  line.  Wiien  the  heart  is  enlarged,  the  impulse  is  displaced  outwards  and 
also  downwards.  Particular  care  must  be  taken  to  determine  the  exact  position,  as  from 
this  observation  a  good  idea  of  the  particular  part  of  the  heart  which  has  enlarged  may  be 
obtained.  When  the  left  ventricle  is  much  hypertrophied,  the  cardiac  impulse  is  displaced 
more  in  a  downward  direction  than  outward,  e.g.,  it  may  be  found  in  the  sixth  or  even  the 
seventh  left  intercostal  space  in  the  nipjjle  line  or  outside  it.  When  the  enlargement  is  due 
to  hypertrophy  of  the  right  ventricle,  the  cardiac  impulse  is  displaced  more  in  an  outward 
direction  than  downward,  and  frequently'  there  is  also  considerable  pulsation  in  the 
epigastrium. 

Where  the  cardiac  impulse  is  thus  displaced,  before  cardiac  enlargement  is  diagnosed 
the  possibility  of  its  mechanical  displacement  by  fluid  or  air  in  the  right  pleural  cavity 
pushing  it,  or  a  retracted  left  limg  pulling  it,  over  to  the  left,  must  be  excluded  by  careful 
physical  examination  of  the  front  and  the  back  of  the  chest.  In  the  case  of  pleuritic  effusion 
the  dullness  on  the  right  side  of  the  chest,  and  the  absent  or  deficient  vesicidar  murmur 
would  point  to  fluid  :  in  the  case  of  retraction  of  the  left  lung  the  left  side  of  the  chest  would 
be  smaller,  there  woidd  be  deficient  movement,  didlness  and  deficient  voice  soimd  and 
vesicular  murmur,  or  possibly  broneliial  breathing,  consonating  rales,  and  pectorilociuy  over 
the  left  lower  lobe. 

The  chnracler  of  the  impulse  must  be  noted  carefully,  for,  when  forcible  and  heaving, 
it  denotes  hypertrophy  ;    when  feeble  and  dittused,  dilatation. 

The  cardiac  impidse  is  invisible  and  impalpable  in  some  cases  of  enlargement  of  the 
heart,  on  account  of  emphysema  of  the  lungs.  In  these  circumstances  even  the  .r-rays  may 
be  required  before  one  can  be  sure  of  the  diagnosis  of  cardiac  enlargement. 

Careful  mapping  out  of  the  area  of  cardiac  dullness  may  afford  valuable  information 
as  to  the  j)art  of  the  heart  involved  in  the  enlargement.  If  the  area  of  deep  dullness  is 
increased  downwards  and  outwards,  an  increase  in  the  size  of  the  left  ventricle  is  indicated  ; 
if  upwards  and  to  the  right,  hypertrophy  of  the  right  ventricle  ;  if  in  all  directions,  enlarge- 
ment of  both  ventricles. 

Enlargement  of  the  heart  in  children  may  produce  definite  local  bidging  of  the  chest 
wall  in  the  cardiac  area. 

Having  determined  the  position  and  character  of  the  impulse,  ma]3ped  out  carefidly 
the  area  of  cardiac  dullness,  and  thus  arrived  at  the  conclusion  that  the  heart  is  increased 
in  size,  the  next  step  is  to  determine  not  only  what  particular  part  is  enlarged,  but  also  the 
actual  cause  of  the  enlargement. 

ENLARGEMENT     OF     THE     LEFT     VENTRICLE. 

The  left  ventricle  may  become  enlarged  in  ; — 

1.  Aortic  Disease: — Stenosis  and  regurgitation;  regurgitation;  stenosis;  aneurysm 
of  the  first  ])art  of  the  aorta  involving  the  aortic  ring. 

2.  Mitral  Regurgitation  : — Disease  of  the  mitral  valve  ;  dilatation  of  the  kit  ventricle 
involving  the  mitral  ring. 

:5.  Arteriosclerosis   and   Granular   Kidney. 
1.  Alcoholism. 

5.  Long-continued  Over-exertion:  -  ,\fhktes  ;  workers  at  laborious  occupations, 
e.g.,  stokers,  firemen,  funiaeemen,  blacksmiths. 

6.  Exopbthalmic    Goitre. 

7.  Congenital    Heart    Disease. 


ENLARGEMENT     OF    THE    HEART  207 

1.  Aortic  Disease. 

Aortic  disease  may  cause  very  great  enlargement  of  the  heart — cor  boviniim  or  bovine 
heart.  In  the  Guy's  Hospital  Museum  there  is  a  heart  of  this  kind  whicli  weighs  53  ounces, 
the  normal  weight  being  about  10  ounces. 

Stenosis  and  regurgitation  is  the  commonest  form  of  aortic  disease,  tlien  regurgitation, 
and  pure  stenosis  is  the  rarest. 

Aortic  Stenosis  and  Regurgitation. — Tlie  cardiac  impulse  is  displaced  downwards 
and  outwards,  and  the  cardiac  dullness  much  increased  towards  the  left. 

It  may  be  in  the  hfth.  sixth,  seventh,  or  even  eighth  space  in  or  outside  the  left  niniile 
line,  and  may  be  as  far  out  as  the  anterior  axillary  line.  The  further  the  impulse  is  down 
the  larger  the  left  ventricle,  and  the  further  it  is  out  tlie  more  the  dilatation.  AVhen  the 
impulse  is  forcible,  heaving,  and  limited,  it  indicates  that  hypertrophy  predominates  ;  when, 
on  the  other  hand,  the  impulse  is  diffused  and  feeble,  dilatation  preponderates.  Young 
people  may  present  well-marked  bulging  in  the  jjrecordial  area. 

A  systolic  thrill  may  be  felt  <>\er  the  base  of  the  heart,  especially  over  the  second  right 
intercostal  space  clo.se  to  the  right  border  of  the  sternum.  More  rarely  a  diastolic  thrill 
may  be  felt  also  or  independently,  either  to  tlic  right  or  to  the  left  of  the  upper  part  of  the 
sternum. 

On  auscultation,  a  systolic  and  early  diastolic  nuirmur  are  heard  over  the  base  of  the 
heart.  The  former  usually  replaces  the  first  sound,  is  loudest  in  the  second  right  intercostal 
space  close  to  the  sternum,  and  is  transmitted  upwards  towards  the  clavicle  and  into  the 
carotids.  It  varies  in  character,  being  in  some  cases  soft  and  faint,  and  in  others  harsli, 
rough,  and  loud.  The  diastolic  might  be  described  as  post-systolic,  for  it  replaces  the 
second  sound  :  it  is  generally  soft  and  blowing,  though  in  rare  instances  it  is  harsh  or  e\'en 
musical.  It  may  be  heard  over  the  upper  part  of  the  sternum  and  on  both  sides  of  it.  When 
the  aortic  incompetence  is  due  to  fibrosis  resulting  from  endocarditis  following  acute 
rluumatisni  or  chorea,  it  is  usually  best  heard  to  the  left  of  the  sternum,  loudest  in  the  third 
intercostal  space  dose  to  the  sternum.  When  the  incompetence  is  due  to  syphilitic  atheroma 
or  to  aneurysm  of  the  first  part  of  the  aorta,  the  bruit  is  generally  loudest  and  best  heard 
in  the  second  space  to  the  right  of  the  sternum.  The  early  diastolic  bruit  which  denotes 
aortic  regurgitation  may  also  be  heard  at  the  cardiac  impulse,  and  in  some  cases  may  even 
be  traced  outwards  into  the  left  axilla.  It  cannot  be  mistaken  for  a  mitral  stenotic  bruit, 
because  there  is  no  inler\al  between  the  second  sound  and  it.  If  there  is  complete  com- 
pensation, the  first  sound  may  be  loud  and  clear  at  the  u))ex,  but  if  dilatation  of  the  left 
ventricle  has  occurred,  there  may  be  a  loud  blowing  systolic  murnnu-  re|)laeing  the  first 
sound  and  traceable  outwards  into  the  left  axilla.  Another  bruit,  which  is  rumbling  In 
character  and  prc-systolie  in  time,  may  be  heard  at  the  cardiac  im])ulse  when  the  ventricle 
is  dilated,  the  s<.-<allcd  Flhil'.s  bruit  (/•'('«.  4.0,  p.  95). 

I'iitieiUs  arc  usually  anauiic,  and  the  carotid,  brachial,  and  (itlur  superficial  arteries 
are  seen  |)ulsatiug  forcibly.  .\  feeling  of  faintness  on  rising  fioui  the  supine  to  the  creel 
posture,  di/./incss.  headache,  a  sensation  of  throbbing  in  the  extremities,  palpitation, 
dyspiura,  und  precordial  pain  on  exertion  arc  early  manifestations  of  this  disease.  .Vs 
compensation  fails,  the  dys])n(ra  and  palpitation  increase,  (cdema  of  the  legs  su|)crvcnes. 
pain  becomes  worse,  and  is  felt  not  only  over  the  region  of  the  heart,  but  tends  to  radiate 
info  the  left    shoulder  an<l  arm.  and  it  may  be  followed  by  attacks  of  true  angiiui  pectoris. 

The  ciiridiis  splasliirig  or  '  waler-liammer  "  pulse  is  palhogridinonie  :  it  is  appreciated 
best  if  the  radial  pulse  is  fell  whcti  the  arm  is  raised,  the  pulse-wa\-e  striking  the  finger  with 
a  .sudden  sharfi  jerk,  and  then  as  suddenly  collapsing.  \Vheu  eomi)ensation  fails,  the  pulse- 
rate  may  become  rapid  and  the  beats  irregular  and  intermittent,  as  in  mitral  disease,  but 
earlier  in  the  disease  the  rale  and  rhythm  are  normal. 

('fi/>illiiii/  piitsdtiiiii.  which  may  be  detected  in  the  lips,  finger-nail--,  and  skin,  is  a  \  (  i y 
characteristic  sign.  It  can  be  demonstrated  by  drawing  a  linger  nail  two  iir  three  liuics 
across  the  skin  of  the  forehead  <ir  abdomen,  so  as  to  produce  a  line  of  hypera-mia.  wliieh. 
if  watclud  carefully,  will  be  seen  to  blush  and  pale  alternately,  each  blush  being  synchronous 
with  the  pulse. 

Aortic  Regurgitation.  The  symptoms  arc  praeli(all\  iiie  same  as  in  aortic  stenosis 
and   rcgiugitalioii.   but    Ihirc  is  no   svslolic  thrill   ami    no   well-marked   s\sl()!ie  l)ii]il    in  the 


208 


ENLARGPLMENT    OK    THE     HEART 


aortic  area.  The  pulse  is  of  the  typical  water-hammer  type.  The  presence  of  a  soft  systolic 
l)riiit  in  the  second  right  intercostal  space  close  to  the  sternum  does  not  indicate  aortic 
stent>sis  unless  there  be  at  the  same  time  a  thrill  there. 

Aortic  Stenosis  is  the  rarest  form  of  aortic  disease.  In  addition  to  the  absence  of  a 
diastolic  Ijruit  at  the  base,  there  is  a  pulse  very  different  from  that  of  the  water-hammer 
ty|)e.  If  there  is  full  compensation  the  pulse  is  slow,  frequently  below  60,  and  it  may  be 
only  40.  or  less,  to  the  minute.  It  is  usually  regidar,  long  sustained,  and  of  good  tension. 
A  sphygmographic  tracing  shows  a  slow  rise,  often  with  an  anacrotic  break  in  the  upcur\c, 
a  broad  summit,  and  a  gradual  decline.  The  mere  presence  of  a  systolic  murnuu-  in  the 
aortic  area,  even  if  its  point  of  maximum  intensity  be  in  this  region,  is  not  sufficient  evidence 
on  which  to  base  a  diagnosis  of  aortic  stenosis.  A  little  roughening  of  a  segment  of  the 
aortic  valves,  slight  sclerosis  of  a  valve,  atheroma  or  dilatation  of  the  first  part  of  the  aorta, 
and  even  anjemia,  may  give  rise  to  a  well-marked  systolic  bruit  in  this  region.  Before 
diagnosing  aortic  stenosis  of  clinical  degree,  one  should  have  a  big  heart,  a  harsh  systolic 
bruit  in  the  aortic  area,  and  a  corresponding  well-marked  systolic  thrill. 

Aneurysm  of  the  First  Part  of  the  Aorta  is  another  important  cause  of  hypertrophy 
(if   the   kit    ventricle    il    the    dilatation   of   tlie    aorta    involves    the   aortic    ring,    increases 

its  circumference,  and  thus  renders 
the  aortic  valves  incompetent, 
though  the  cusps  may  be  indi- 
vidually healthy.  In  addition  to 
the  characteristic  pidse  and  the 
usual  signs  and  syniptoms  of 
aortic  regurgitation,  there  may  be 
several  indications  which  point  to 
an  aneurysm  of  the  first  part  of 
the  aorta  as  the  cause  of  the  aortic 
incompetence  : — 

There  may  be  a  distinct  bulg- 
ing of  the  thoracic  wall  involving 
the  first  and  second  interchondral 
spaces  close  to  the  right  border  of 
tlie  sternum. 

There  may  be  well-marked 
pulsation  in  the  second  right  inter- 
chondral  space  and  also  in  the  ad- 
jacent spaces,  according  to  the  size 
of  the  aneinysm,  close  to  the  ster- 
nimi  ;  when  not  obvious  to  the 
hand  this  may  sometimes  be  de- 
tected by  the  ear  laid  flat  on  the 
chest. 

In    addition   to   an   increase  of 
the  cardiac  dullness  downwards  and 
to  the  left,  there  will  be  dullness  in  the  second  right  space  close  to  the  sternum. 
There  may  also  be  some  signs  of  intrathoracic  pressure  : — 
The  right  carotid  pulse  may  be  weaker  than  the  left. 

The  face  and  neck  may  be  deeply  cyanosed  if  the  aneurysm  has  extended  outwards 
and  has  stenosed  the  superior  vena  cava,  though  this  is  a  rare  occurrence  in  this  disease 
{Fig.  69,  p.  158).  There  may  be  a  loud  systolo-diastolic  bruit  audible  in  the  second  right 
sjjace  over  the  superior  vena  cava,  with  maxinunn  intensity  an  inch  or  more  to  the  right 
of  the  sternum.  The  superficial  veins  over  the  upper  part  of  the  riglit  side  of  the  chest  in 
front  may  be  varicose  {Fig.  93),  and  the  direction  of  the  blood-current  in  them  may  be  from 
above  downwards,  instead  of  from  below  upwards. 

The  right  bronchus  may  be  stenosed  if  the  aneurysm  ])rojects  posteriorly,  and  this  leads 
to  impairment  of  percussion  note  and  deficiency  in  the  vesicular  murmur  over  the  upper 
lobe  of  the  right  lung.  The  ,r-rays  might  be  used  to  determine  the  diagnosis  {Fig.  100), 
though  the  aortic  diastolic  bruit  should  serve  to  distinguish  aneurysm  from  new  growth. 


Fig.   09.— Obstruction    tn   tlie    siilierior   tcim    cava   hy   an    a 
mysm  ;  collateral  circulation  tllrougii  the  distended  superficial  ^ 


exlar(;e.mext   of   the   heart 


A  diannosis  of  aortic  disease 
determined.     It  may  be  due  to  :- 
1 .  Lesions  of  the  J^alves  : — 


incomplete  until  tlie  aetvial  cause  of  the  lesion  has  tieen 


Acute  endocarditis 

Fibrosis   after   former   endocarditis 

Infective  endocarditis 


Sclerosis  due  to  :    Strain  (persistent),   Sypliilis, 

Alcohol 
Rupture  of  a  segment 
Congenital  malformation. 

2.  Dilnlalioii  iij  llic  Aniiic  liiiii;  from  Aneurysm  of  the  first  portion  of  the  Aorta. 

Lesions   of   the  Valves. 

Aeiite  Endocarditis  occurs  most  frequently  as  a  complication  of  acute  rheiunatism, 
chorea,  or  scarlet  fever.  The  indications  of  acute  inflammation  of  the  aortic  valves  will  be 
a  systolic  murnuir  in  the  aortic  area,  and  less  commonly  an  early  diastolic  (post-systolic) 
murnuir,  which  first  becomes  audible  in  the  third  left  space  close  to  the  left  border  of  the 
stcrnimi.  If  the  bruits  arc  already  j)resent 
when  the  ])aticnt  is  first  seen,  it  may  be  dillicult 
to  <lccidc  whether  they  are  due  to  existiny 
acute  inflammation  or  to  fibrosis  after  former 
inflannnation.  They  may  be  noticed  to  arise 
whilst  the  patient  is  under  treatment  in  bed 
for  acute  rheumatism,  and  then  their  acute 
nature  will  be  obvious.  In  cases  in  which  the 
bruits  are  <lue  to  acute  aortic  endocarditis  and 
not  to  |)crmancnt  fibrosis,  the  ])ulse  will  have 
little  of  the  watcr-hannner  type,  the  heart  will 
not  be  nnich  hyijcrtrophied,  though  it  may  he 
dilated  from  acute  rheumatic  toxa'inia,  and  the 
bruits  will  be  found,  as  the  days  go  by,  either 
to  diminish  or  increase  in  intensily.  according 
as  the  inllanunation  of  the  valves  resolves  or 
passes  on  into  permanent  fibrosis. 

Fibrosis  from  Previous  Endocarditis. — 
When  aortic  disease  is  due  to  fibrosis  from 
previous  endocarditis,  there  will  generally  be  a 
history  of  attacks  of  acute  rheumatism,  chorea, 
scarlet  fever,  or  tonsillitis.     The  diastolic  bruit 

which  indicates  the  presence  of  aortic  regurgi-       tiieali.  h.in,  •  i'.  ,i'i  .,1  i'lu   nvi,  ,,1  iii mi  ■  1  bi  tnmsverse 

tatiou  is  heard  best  along  the  left  border  of  the       phr',,.',',!  '  '  "ei'  'i  '    " '^  i"i  \.'°r*:sV  '/!)'//■.'  Ifirnf'c. 
steriuun,  the  point  of  maxinnun  intensity  being       ./oni,,,,. 
in   the   lliinl   left    intercostal   space   close  to   the 

left  border  of  the  stermun.  There  will  generally  be  evidence  of  organic  mitral  disease  at 
the  same  time,  and  if  mitral  stenosis  be  associated  with  aortic  disease,  whether  there  is  a 
history  of  acute  rheumatism  or  not,  the  vjilvular  lesions  may  be  considered  without  doubt 
to  be  due  to  the  cITccts  of  former  cndocarditiN.  The  patients  arc  gcniiiUly  cliildren  or 
young  adults,  though  a  few  survive  into  middle  life. 

Jnfectiic  Endocarditis. —  In  this  form  of  endocarditis,  in  addition  to  the  signs  and 
symptoms  of  aortic  disease,  there  may  be  others,  described  on  p.  ;i  t.  In  some  cases  bac- 
teriological examination  of  the  blood  fleteets  such  organisms  as  the  Strcjitococras  jii/oficiics. 
.Stdjilii/lococciis  pifo/ienes  aureus.  Micrococcus  rlicunialictis.  I'licuiiioinccus.  or  ollicrs. 

Sclerosis  not  due  to  former  Endocarditis  : 

Strain.  -Persistcid  strain  is  an  imporlaid  factnr  in  the  production  of  aortic  disease. 
Occupations  ciUailing  long  and  contitujcd  manual  labour,  and  exccssi\c  in<lulgcncc  in 
athletics,  may  thus  lead  to  incompetence.  The  tendency-  is  not  nearly  so  great,  however, 
in  lliosc  who  have  not  had  sy|)hilis  as  in  those  who  have  :  so  that  sclerosis  from  strain 
alimc  nnist  not  be  diagnosed  uidcss  there  be  neither  a  history  nor  evidence  of  rheumatism, 
chorea,  syphilis,  or  alcoholism, 

Si/pliilis. — A  history  of  syphilis,  and  any  nianilcstal  ions  oi'  this  <liscasc  in  the  form  of 
piiimented  scars  on  the  legs.  bo(l\.  and  lace,  nici  laliim  ol  llic  tongue,  patches  o!  lenkophikia, 

I)  '  It 


•210  ENLAKdE.MENT     OF    THE     HEART 

ulci'iatiim.  ,sciuiint>,  or  perforation  of  the  jnilate,  necrosis  of  the  nasal  bones,  etc.,  would 
point  to  this  disease  as  the  cause,  and  this  conehision  would  be  strcnathincd  if  there  were  no 
previous  history  of  rheumatism,  scarlet  fever,  or  chorea.  The  AVasserniann  reaction  may 
be  positive.  The  patients  are  nearly  always  males  who  have  worked  hard,  and  their  first 
symptoms  are  often  brought  on  by  some  undue  muscular  effort  which  strains  the  enlarged 
heart,  or  even  bursts  an  atlieromatous  patch  in  the  diseased  valve.  Uncommon  before  forty, 
the  lesion  is  met  with  often  enough  between  forty  and  fifty  ;  in  many  cases  the  heart  lias 
been  passed  as  normal  at  forty,  whilst  at  forty-five  the  aortic  regurgitation  is  extreme. 
These  patients  often  suffer  from  verj-  severe  attacks  of  angina  pectoris,  to  which  they  are 
much  more  liable  than  are  rheumatic  aortic  cases. 

Alcohol. — The  constant  use  of  alcohol  raises  arterial  tension  and  may  be  followed  by 
sclerosis.  The  general  apjiearanee  of  the  patient,  and  the  signs  described  on  p.  726,  would 
suggest  alcohol  as  the  cause  in  the  absence  of  any  evidence  of  rheumatism  or  syphilis,  but 
alcoholism  without  sypliilis  leads  to  definite  aortic  disease  less  often  than  it  does  to  a  generally 
hy|)ertrophied  heart,  which  sooner  or  later  exhibits  fibroid  or  fatty  degeneration. 

Rupture  of  a  Segment  of  the  Aortic  f'alve  is  a  rare  occurrence,  usually  brouglit  about  by 
some  severe  and  sudden  muscular  exertion.  The  following  is  a  good  illustrative  case  of 
aortic  regurgitation  caused  by  rupture  of  a  valve  segment.  A  sailor,  who  had  been  examined 
just  previously  and  passed  as  sound,  was  one  day  pulling  on  a  rope,  when  suddenly  the  strain 
on  it  was  unexpectedly  and  much  increased.  He  made  a  tremendous  effort  to  prevent  the 
rope  slipping  through  his  hands,  in  doing  so  fainted,  and  was  picked  up  in  an  unconscious 
condition  :  on  coming  round  he  was  very  dyspnoeic,  and  complained  of  pain  in  the  pre- 
cordial region.  When  the  doctor  examined  him  again  he  foimd  a  well-marked  musical 
early  diastolic  miu-mur  in  the  third  and  fourtli  left  intercostal  spaces  close  to  the  sternum, 
and  came  to  the  conclusion  that  as  his  heart  soimds  were  normal  before  the  accident,  he 
must  have  rujjtured  one  of  the  segments  of  his  aortic  valve  and  thus  caused  the  incompetence. 
Tiiere  is  always  the  proli;il)ility  of  sucli  a  valve  having  been  jjreviously  the  site  of  syphilitic 
atheroma,  without  bruit,  until  the  extra  strain  caused  a  weak  spot  to  give  way  suddenly. 

Cougenital  Malformations  of  the  Aortic  Talves  are  extremely  rare,  and  tliey  are  to  be 
diagnosed  with  great  caution. 

Dilatation  of  the  Aortic  Ring  from  Aneurysm  of  the  first  portion  of  the  Aorta  is 
nearly  always  due  to  sy|)liilitit-  atluronia  of  the  aortic  walls,  and  in  such  a  case  it  will  be 
probable  tliat  there  is  syi)hilitic  disease  of  the  aortic  valves  themselves  also.  The  dilatation 
of  the  aorta  ("  fusiform  aneurysm  ')  will  be  indicated  by  definite  impairment  of  note  in 
the  second  right  intercostal  space  near  the  sternum  ;  and  the  .r-rays  will  confirm  it.  It  will 
be  next  to  impossible  to  assess  with  any  degree  of  accuracy  how  much  of  the  aortic  regurgi- 
tation is  due  to  the  dilatation  of  the  ring,  and  how  much  is  due  to  the  concomitant  valve 
changes. 

2.   .AIlTRM.  Kegurgitatiox. 

As  a  residt  of  mitral  regurgitation  the  left  aiuiclc  becomes  dilated  and  hypertrophied, 
the  left  ventricle  dilated  and  hy])crtniphied.  and  later  from  backward  pressure  the  right 
ventricle  and  auricle  may  be  affected  similarly.  The  chief  symptoms  are  dyspnoea  on  exer- 
tion, palpitation,  congestion  of  tlie  face  and  lips,  cough,  possibly  hiemoptysis,  oedema  of 
the  feet  and  legs,  and  later  albuminuria,  ascites  and  enlargement  of  tlie  liver.  In  the  early 
stages  the  pulse  may  be  regular,  full,  and  of  low  tension.  When  compensation  begins  to 
fail,  tlie  pulse  becomes  rapid,  irregular,  and  intermittent.  The  cardiac  impulse  is  displaced 
downwards  and  outwards.  It  may  be  in  the  fifth  intercostal  space  in  the  left  nipple  line, 
or  outside  it,  or  in  the  sixth  space  outside  the  nipple  line.  It  is  usually  diffused,  and  there 
may  l)e  epigastric  pulsation.  There  may  be  marked  bulging  of  the  precordial  area  in 
children.     A  systolic  thrill  is  rare,  but  it  may  be  felt  at  the  cardiac  impidse. 

The  cardiac  dullness  is  increased  outwards  and  downwards,  but  also  upwards  and  to 
the  right  wlien  the  right  side  is  involved. 

At  the  impulse  there  is  a  systolic  nunniur.  usually  of  a  fjlowing  character,  wliich  may 
cither  follow  or  rej)lace  the  first  sound.  It  is  Ijest  heard  at  the  cardiac  impidse,  but  it  can 
generally  be  traced  outwards  into  tlie  left  axilla,  can  sometimes  be  heard  behind  at  the 
inferior  angle  of  tlie  left  scapula,  and  can  also  be  traced  inwards  towards  the  left  border 
of  the  sternum.  Tlie  pulmonary  second  sound  is  accentuated  or  reduplicated  in  the  second 
interspace  close  to  the  left  border  of  the  stermuii. 


ENLARGEMENT    OF    THE     HEART  -211 

When  coiiiptiisatiou  fails,  in  addition  to  the  above  there-  may  be  : — 
A  systohc  nuniiiur.  softer  tlian  and  different  in  ehavaeter  from  that  at  the  impulse, 
over  the  lower  part  of  the  stermmi  and  the  fonrth  aiifl  fifth  left  interspaces,  due  to  tricuspid 
regurgitation  :  (I'dema  of  the  feet,  legs,  and  lower  part  of  the  body  ;  abdominal  distention 
from  ascites  :  enlargement  and  ])ulsation  of  the  liver  ;  signs  of  hydrothorax  ;  albiunimu'ia. 
A  diagnosis  of  mitral  regurgitation  is  incomplete  by  itself,  for  it  may  be  due  to  different 
conditions.     It  is  necessary  to  determine,  if  possible,  the  actual  cause  of  the  defect. 

Causes  of  Mitral  RegiirgitatioN. 

1.  Lesions  of  llic  Milral  f'alve  : — 

.\cute   cndocMfditis  i        Fihrosis  the  result  iif  former 

Infective   endocarditis  I  ciulocarditis 

2.  Dilatation,  or  Ilypertropliij  anil  Dilatation,  of  the  Left  Ventricle,  without  organic  changes 
ill  the  Mitral  Valve  itself  : — 

Secondarv  to  aortic  disease 

Secondary  to  increased  systemic  blood-pressure  : — 

Chronic  Bright's  disease  |      Arteriosclerosis. 

3.  Diseases  of  the  Myoeardiuiu  and  Pericardium  : — 
Myocarditis  Pcrieioditis 

Fatty  degeneration  Adherent  jjcricardiuiu. 

Fibroid  degeneration 

4.  Acute  Dilatation  of  the  Heart  fruni  :  — 

Over-exertion  |  .\cute  febrile  diseases  |       .\cute   ne])lultis. 

Lesions    of    the    Mitral    Valve : — 

Acute  Endocarditis. — Simple  acute  endocarditis  is  not  a  disease  per  se,  but  occiu's  as 
a  eom]>lication  of  some  other  disorder,  especially  acute  rheumatism,  chorea,  and  .scarlet 
fever.  It  sometimes  complicates  tonsillitis,  which  is  in  many  instances  a  numifeslation 
of  rheumatism  occurring  without  any  changes  in  the  joints  :  and  in  children  acute  endo- 
carditis may  be  the  only  indication  of  an  attack  of  rlicumatism.  There  are  no  characteristic 
.symptoms  which  point  to  acute  endocarditis.  If  in  the  course  of  acute  rheimiatism  the 
I)atient  complains  of  a  little  jjalpitation,  precordial  pain,  and  distress,  and  it  is  foimd 
that  the  licart  action  has  increased  in  rapidity  without  any  increase  in  the  Joint  affection, 
endocarditis  should  be  suspected.  The  tempcratiu'e  chart  seldom  indicates  the  complication. 
.Vt  first  the  position  of  the  cardiac  impulse  and  the  heart-sounds  rcnuiin  normal,  bid  if 
watched  froML  day  to  day.  endocarditis  having  developed,  the  impulse  will  be  found  lo  have 
nu)vcd  outwards,  the  first  sound  becomes  prolonged  and  roughened,  then  doubled,  and  in 
a  lew  days  it  is  either  followed  or  replaced  by  a,  loeali/cd  soft  blowing  systolic  murmur. 

Fdirosis  the  result  of  Previous  KniUiearditis.  If  aeulc  endocarditis  of  the  nutral  valves 
docs  not  resolve,  the  vahe-llaps  become  sclerosed,  and  in  the  later  stages  even  calcilied. 
In  many  cases  the  circumfercnee  of  the  orifice  is  narrowed,  so  that  the  valve  is  not  only 
ineompctcid  but  also  slcnosed.  A  diagnosis  of  librosis  after  endocarditis  as  the  cause  of 
milral  incompelencc  may  be  made  if  there  is  a  previous  history  of  acute  rheumatism  or 
clinrea,.  and  independently  of  such  a  history  if  there  is  evidence  of  stciu)sis  as  well  as  regurgi- 
laliiin.  If  actual  mitral  stenosis  can  be  diagnosed  with  certainly,  if  must  be  due  lo  librosis 
liiiin  cn(|.)carditis.  Ihougli  there  may  of  course  be  recent  endocarditis  as  well. 

Infective  Endocarditis  of  the  mitral  valve  suggests  itself  if  fhcrc  is  a  milral  broil,  and 
if  any  of  I  he  symptoms  and  signs  meidioned  on  page  ;!  t  are  picsriil  a  I   I  lie  same  lime. 

Hypertrophy    and    Dilatation    of    the    Left    Ventricle. 

Seeiinihirii  In  Aortic  Disease.  ,\<)rfic  disease  leads  lo  hypertrophy  of  the  left  veufriclc. 
Ibllowcd  after  a  lime  by  diialafion  of  that  cavity  and  milral  rcgurgilafion.  Marked  pulsa- 
linii  of  the  superficial  arteries,  a  splaslung  pidsc.  capillaiy  pulsation,  and  llie  systolic  and 
early  diastolic  murmur  at  the  base  of  flic  heart,  flic  former  best  heard  in  Ihc  second  rigid 
space  close  to  the  sfernmn.  and  flic  latter  in  llie  lliird  left  space  close  lo  Ihe  left  border  ol 
the  sferniim.  would  indicate  the  presence  of  aorlic  disease.  If  flic  palicnl  has  siilfcred  from 
eilher  rlieiimatisni  or  cliorea.  Hie  milral  regiirgif  al  ion  might  be  ilui'  lo  primary  endocardilis 
of  Ihr  inilral  valve,  bill   if  Ihc  aorlic  disease  is  the  resull  (d'  sypliilis.  hard  work,  or  aiiemysm 


212  ENLARGEMENT    OF    THE     HEART 

of  the  first  part  of  the  aorta,  tlien  it  may  be  assumed  that  the  mitral  regurgitation  is  tlic 
result  of  secondary  dilatation  of  the  left  ventricle,  and  not  of  primary  mitral  disease. 

Secondary  to  Increased  Systemic  Blood-pressure  due  to  Chronic  BrighVs  Disease. — 
Associated  with  the  increased  blood-pressine  of  chronic  Bright's  disease,  the  left  ventricle 
hypertrophies  first,  and  after  a  time,  when  compensation  fails,  dilates  ;  mitral  regurgitation 
follows,  and  may  be  succeeded  by  all  the  signs  of  backward  pressure,  such  as  oedema  of  the 
feet  and  legs,  ascites,  enlargement  of  the  liver,  hydrothorax,  ha^moj^tysis  from  congestion 
or  infarction  of  the  lungs,  and  so  forth.  A  patient  presenting  such  a  group  of.  symptoms 
may  at  a  first  glance  be  considered  to  be  a  case  of  primary  disease  of  the  heart,  but  a  careful 
investigation  will  often  enable  one  to  determine  that  the  jirimary  changes  liave  occurred 
in  the  kidneys.  The  radial  artery  may  be  thickened  and  tortuous,  the  ten.sion  of  the  pulse 
higher  than  in  mitral  regurgitation  from  ])rimary  heart  disease  ;  there  may  be  albimiinuric 
retinitis  and  retinal  lucmorrhages  :  the  urine  is  variable,  for  whereas  it  may  formerly  have 
been  abundant,  of  low  sjiecifie  gravity  {1((08  to  1012).  with  only  a  trace  of  albumin,  heart 
failure  may  lead  to  its  being  diminished  in  amount,  of  specific  gravity  1020  or  more,  and 
albumin  may  be  abundant  ;  microscopical  examination,  however,  will  generally  re\-eal 
renal  tube-casts. 

Secondary  to  Increased  Systemic  Blood-pressure  due  to  Primary  Arteriosclerosis. — In  this 
disease  there  may  be  signs  of  enlargement  of  the  heart,  mitral  regurgitation,  backward 
|>ressure,  and  a  thickening  of  the  arteries,  but  in  contrast  to  chronic  Bright's  disease  the 
urine  will  be  of  higher  specific  gxavity,  and  there  will  be  no  albuminm'ic  retinitis.  It  often 
becomes  merely  a  matter  of  opinion,  however,  whether  a  given  patient  is  suffering  from 
arteriosclerosis  or  from  granular  kidney  ;  post-mortem  examination  may  reveal  both,  or 
arteriosclerosis  may  predominate  when  granular  kidney  had  been  diagnosed,  and  vice  versa. 

Diseases    of    the    Myocardium    and    Pericardium. 

Myociirdilis — InHannnation  of  the  myocardium  is  associated  most  frequently  with 
either  pericarditis  or  endocarditis,  but  occasionally  it  may  occur  in  acute  rheumatism  as 
a  primary  condition.  In  one  form  of  the  disease  there  is  an  infiltration  of  leucocytes  between 
tlie  muscular  fibres — interstitial  myocarditis  :  in  another  form  the  actual  muscle  fibres 
are  involved — parenchymatous  myocarditis  :  and  tliere  is  a  third  variety  wliich  occurs  in 
])^•a■mia,  especially  from  bone  disease,  characterized  by  the  formation  of  abscesses  in  the 
myocardium.  The  weakened  condition  of  the  heart  muscle  leads  to  dilatation  of  the 
\entricles,  and  thus  to  enlargement  of  the  heart.  When  accompanied  by  pericarditis  or 
endocarditis,  the  signs  of  myocarditis  are  overshadowed  by  the  symptoms  associated  with 
these  other  conditions.  The  diagnosis  of  myocarditis  is  therefore  a  dilHcult  matter.  If  in 
a  case  of  acute  rheumatism  there  is  no  evidence  of  either  pericarditis  or  endocarditis,  but 
there  are  signs  of  cardiac  failure,  a  feeble  irregular  pulse,  a  good  deal  of  precordial  pain  and 
distress,  dyspna?a  and  palpitation,  a  tendency  to  sudden  collapse,  and  signs  of  dilatation 
of  the  left  ventricle,  with  a  feeble  cardiac  impulse  and  a  weak  first  sound,  myocarditis  may 
be  suspected. 

F(dty  Heart. — The  heart  may  be  covered  with  fat  (fatty  sujK'rposition)  ;  fat  may 
infiltrate  between  the  muscular  fibres  (fatty  infiltration)  :  the  muscle  fibres  may  be 
degenerated,  losing  their  striation,  and  containing  fat  granules  (fatty  degeneration)  ;  or  all 
these  conditions  may  be  associated.  Fatty  degeneration  may  occur  in  ])atches  or  be  general. 
When  general,  the  heart  becomes  enlarged  from  dilatation  as  the  muscle  becomes  flabby, 
lias  less  contractile  force,  and  is  more  yielding.  It  is  a  condition  wliich  may  be  associated 
with  general  obesity,  severe  auiemia,  wasting  diseases  sucli  as  cancer,  jjlithisis,  phosphorus 
poisoning,  and  alcoholism^,  It  may  be  a  secjuela  of  severe  attacks  of  typhoid  and  other 
specific  fevers.  The  symptoms  and  signs  of  the  condition  are  due  to  the  diminished 
contractile  power  of  the  ventricles  which  leads  to  dilatation.  The  pulse  may  be  small, 
feeble,  and  slow — 30  to  40  beats  i)er  minute — or  It  may  be  frequent  and  irregular.  The 
cardiac  impulse  is  very  feeble  or  imperceptible.  There  may  be  an  increased  area  of  cardiac 
dullness  from  dilatation,  and  the  first  sound  may  be  very  faint.  The  patient  is  usually 
feeble  and  anaemic,  and  suffers  from  faintness  or  severe  syncopal  attacks  which  come  on 
suddenly  and  are  characterized  by  coma,  convulsive  twitching,  and  stertorous  breathing. 
CEdema  of  the  legs  and  venous  congestion  of  the  lips  and  face,  which  are  common  in  valvular 
disease,  are  usually  absent.  There  is  dyspnoea  on  exertion,  a  feeling  of  coldness  and  depres- 
sion, and  a  general  impairment  of  the  nutrition  of  the  nuiseles,  which  are  soft,  flabby,  and 


EXLARGE31EXT    OF    THE    HEART  213 

(iiininished  in  power.  In  some  cases  attacks  of  cardiac  '  astliiua  '  in  the  early  morning 
arc  conijjlained  of,  and  in  the  later  stages  of  the  disease  there  may  be  Cheyne-Stokes 
breathing.  The  chief  diagnostic  signs  are  the  feeble  cardiac  impulse,  the  feeble  pulse,  and 
the  weak  first  sound,  associated  with  dyspnoea  and  attacks  of  syncope,  and  the  absence  of 
evidence  of  other  causes  for  the  heart  symptoms. 

Fibroid  Ilciiii. — Fil)roid  degeneration  of  the  myocardium  is  usually  associated  with 
some  obstructive  lesion  of  the  coronary  arteries  caused  by  syphilis.  It  may  be  general, 
or  rarely  localized  to  the  apex  of  the  left  ventricle  ;  in  the  latter  case  there  may  be 
thinning  and  weakening  followed  by  aneurysm  of  the  heart,  and  then  by  rupture.  It  is 
one  of  the  causes  f)f  sudden  death.  The  most  important  symptoms  are  :  dyspnoea  on 
sligiit  exertit)n,  palpitation,  and  precordial  pain.  The  physical  signs  are  those  of  dila- 
tation of  the  left  ventricle.  The  pulse  is  slow,  and  in  late  stages  feeble  and  irregular. 
Tluic  inay  be  severe  attacks  of  angina  j)ectoris.  The  diagnosis  is  more  or  less  a 
matter  of  guesswork.  Such  signs  and  symptoms  in  a  patient  who  has  had  syphilis, 
but  neither  acute  rheumatism  nor  chorea,  and  who  has  neither  aortic  disease  nor  signs 
of  granular  kidney  or  arteriosclerosis,  might  be  considered  indications  of  this  form  of 
cardiac  degeneration. 

Periciirditis. — In  j)ericarditis  the  cardiac  impulse  is  usually  displaced,  and  the  area 
of  cardiac  duUness  increased.  These  ])liysical  signs  may  be  due  to  enlargement  of  the 
heart,  or  to  cllusion  of  serous  fluid  into  the  pericardial  sac,  and  it  is  very  difficult  to  differen- 
tiate between  these  two  conditions.  Enlargement  of  the  heart  due  to  dilatation  is  generally 
the  result  of  the  myocardium  being  affected  as  well  as  the  pericardium,  and  the  cardiac 
impulse  is  diffused  and  displaced  outwards.  If  there  is  an  effusion  of  serous  fluid  into  the 
|)eri(iirdial  sac,  it  is  said  that  the  impulse  is  displaced  iipzctirrls  as  well  as  outwards,  so  that 
it  iiia\-  be  found  on  a  level  with,  or  above  and  ixtciiial  lo.  I  lie  left  nip|)le,  but  this  is  a  very 
umchable  sign.  The  dullness  is  increased  laterally  and  upwards,  and  when  carefully 
mapped  out  it  is  said  to  have  a  triangular  shape,  with  the  base  on  the  diaphragm  and  a 
somewhat  roimded  apex  pointing  towards  the  left  clavicle,  and  reaching  to  the  second 
left  intercostal  spiiee  or  higher.  Percussion.  Iu)wever,  is  (|uile  unable  to  distinguish  between 
a  pericardial  effusion  and  a  much  enlarged  heart  without  i  IfusioM.  The  intercostal  spaces 
are  filled  out,  and  may  be  almost  obliterated,  so  that  the  ribs  feel  nmeh  less  prominent  on 
this  piirl  of  the  chest.  On  auscultation,  in  addition  to  a  systolic  murmur  at  the  impulse 
due  lo  mitral  ineompetenee  from  the  accompanying  dilatation  of  the  left  ventricle,  a  triple 
"cantering'  sound,  and  perhaps  a  definite  rub,  may  be  heard  in  some  ))art  of  the  piecordial 
region,  especially  near  the  stermmi,  independently  of  respiration,  and  generally  increased 
in  inlensily  by  lirni  pressure  of  the  stethoscope.  The  rul)  is  audible  whether  en'usion  is 
priMMl   or  not . 

.Icllififiil  I'liiidriliiini.  -Adiiesions  belwceri  Ihc  vIsccimI  and  paiii-tal  laNcrs  of  I  he 
|)(iii-anliuMi  arc  found  frecpiently  j)ost  niorlcni  win  ii  lliiy  IkhI  ucNcr  l)een  suspected  <luring 
Mfc.  Soniclliucs,  lu)wever,  they  arc  assoeialeil  with  chroMic  lucdiMstiiiil  is.  or  wlial  should 
mure  correct ly  be  termed  mediastinal  fibrosis,  the  outer  surface  of  the  pericaidial  sat 
beeoiuing  adherent  to  the  thoracic  wall  and  to  adjacent  structures.  This  condilioii  usually 
leads  to  cojisiderable  hypertrophy  and  dilatation  of  the  heart.  There  may  be  marked 
bulging  of  the  precordial  area  to  the  left  of  the  sternum.  The  cardiac  impulse  may  be  seen 
not  only  in  the  sixth  space  outside  tlu'  left  nipple  line,  but  also  in  the  fifth,  fourth,  and  third 
left  spaces,  and  the  pulsation  may  extend  in  these  s))aees  from  the  left  border  of  the  sternum 
to  the  left  nipple  line,  or  even  outside  that  line.  The  impulse  has  a  curious  wavy  character, 
and  il  may  be  noticed  that  eoineident  with  the  im|)ulse  in  the  sixth  space  there  may  be 
a  systolic  retraction  of  tin-  sp:iees  abo\c.  or  of  llie  lower  libs  below  and  outside  the  cardiac 
urea,  best  seen  when  the  patient  lies  over  lo  the  other  side  with  his  left  arm  raised  above  his 
head.  If  the  liciul  is  aillicicnl  lo  the  diaphragm,  there  may  be  a  systolic  relraetion  of  tlu- 
eleventh  aiul  twcMlli  rihs  un  Ihc  kit  side  behind.  Some  eases  of  adhereul  pericardium  of 
this  type  exhibit  dilatation  of  the  superficial  veins  in  the  precordial  area.  Diastolic  collapse 
of  th<-  eer\ieal  veins  is  said  to  occur  also.  On  rolling  I  lie  pal  ien  I  from  side  to  side  i  I  is  found 
in  many  cases  tlial  the  cardiac  impulse  remains  nearly  in  the  same  position,  not  altering 
so  niui'li  as  it  does  in  health  under  similar  cireumstances.  The  hand  placed  over  Ihc  heart 
ni:i\  \vr\  II  diastolic  shock  or  rebound,  which  is  regarded  by  some  as  ;i  characteristic  sign 
III   llie  I'liiKJII  Ion.      On  aiisciillal  i'lii  llicrc  iii:i\    lie  a  systolic  innrinnr  al   llic  a|icN.  iniliealive 


214  enlarge:ment   of  the   heart 

of  mitral  regurgitation,  and  frequently  there  is  also  a  ])re-systolic  nunnuu-  due  to  a  relative 
stenosis  of  the  mitral  orifice. 

There  is  also  a  therapeutic  sign  which  may  help  in  doubtful  cases.  Mitral  regurgitation 
in  yoimg  people,  if  due  simply  to  fibrosis  of  the  valve  after  endocarditis,  will  usually  improve 
under  treatment  by  rest  in  bed  and  the  administration  of  appropriate  doses  of  digitalis. 
Where  the  mitral  regurgitation,  however,  is  associated  with  adherent  pericardium,  similar 
treatment  has  little  effect,  and  very  slight,  if  any,  improvement  follows.  If,  in  a  young 
person  who  is  presumably  rheumatic,  the  size  of  the  heart  and  the  symptoms  are  not  easily 
accountable  for  by  the  extent  of  valvular  disease  suggested  by  the  bruits,  the  patient 
probably  has  adherent  pericardium  with  mediastinal  hbrosis.  The  diagnosis,  therefore,  is 
guessed  at  rather  than  made. 

Acute    Dilatation    of    the    Heart. 

From  Ovcr-c.rerlioii. — Acute  dilatation  may  result  from  over-exertion.  For  example, 
if  a  man  who  lias  been  run  down  from  excessive  mental  work,  and  in  consequence  is  in  poor 
condition  or  l)ad  training,  takes  a  holiday,  and  attempts  the  ascent  of  a  mountain  or  engages 
in  some  violent  form  of  exercise,  his  heart  is  very  liable  to  give  way  under  the  strain.  The 
chief  indication  of  such  an  occurrence  will  be  a  feeling  of  pain,  distress,  and  discomfort  in 
the  region  of  the  heart,  dyspnoja,  and  palpitation.  The  pulse  will  be  rapid,  weak,  and 
irregular.  The  cardiac  impulse  will  be  displaced  outwards,  diffuse,  weak  and  undulating 
in  character,  and  althougli  a  maximum  ])oint  of  the  impulse  may  be  visible,  it  cannot  be 
located  clearly  by  palpation.  There  will  be  epigastric  pulsation,  the  cardiac  dullness  will 
be  increased  outwards,  and  tlie  first  sound  will  be  feeble,  reduplicated,  or  rei)laced  by  a  soft 
blowing  systolic  murmin-. 

From  Acute  Specific  Fevers. — Similar  signs  and  symptoms,  especially  weakness  of  the 
first  sound,  occurring  in  the  covn'se  of  diphtheria,  typhoid  fever,  typlius,  scarlet  fever, 
erysipelas,  and  other  fevers,  woidd  point  to  dilatation  of  the  heart  in  consequence  of  the 
tox;enn'a  ])roducing  loss  of  tone  in  the  cardiac  muscle  from  parenchymatous  degeneration. 

3.  Arteriosclerosis  and  Granular  Kidney  (see  p.  14). 

4.  Alcoholism. 

Patients  who  have  been  addicted  to  alcoholism  are  hable  to  enlargement  of  the  heart. 
It  is  a  cause  of  which  the  importance  is  frequently  overlooked.  The  usual  signs  of  hyper- 
trophy and  dilatation  may  be  present,  with  mitral  and  tricuspid  incom])etence  and  signs  of 
backward  pressure.  The  enlargement  may  be  considerable.  At  a  post-mortem  examination 
it  is  by  no  means  unusual  to  find  the  heart  weighing  as  much  as  from  20  to  SO  ounces.  The 
valves  are  liealthy,  the  aorta  normal,  and  evidence  of  arteriosclerosis  and  granular  kidney 
is  absent.  Alcoholism  may  be  suspected  as  the  cause  of  enlargement  of  the  heart  where 
there  is  no  evidence  of  primary  valvular  disease,  adherent  pe^^icardium,  arteriosclerosis, 
or  chronic  Bright's  disease.     Other  signs  of  alcoholism  may  also  be  present  (p.  720). 

').  Long-continued  Over-exertion 

produces  hypertroiihy  of  the  ventricles  ;  for  a  considerable  ]Deriod  there  may  be  no  symptoms, 
but  after  a  time,  when  compensation  fails  owing  to  tfie  hypertrophy  being  insufficient  to 
continue  the  excessive  work,  dilatation  is  produced,  and  mitral  incompetence  and  signs 
of  backward  pressure  ensue.  The  subjects  of  this  form  of  enlargement  of  the  heart  are 
usually  eitlier  middle-aged  men  who  are  robust  and  healthy  in  appearance,  but  have  had 
to  follow  for  many  years  a  laborious  occupation  entailing  severe  manual  labour,  or  else 
young  men  of  good  physique  who  have  indulged  in  excessive  athletic  exercises,  sucli  as 
rowing,  football,  boxing,  and  running,  often  with  insufficient  preliminary  training.  At 
first,  palpitation,  dyspnoea,  and  irregular  cardiac  action  arc  noticed.  Later  the  ventricles 
dilate  and  the  mitral  valves  become  iiieonipetent,  and  all  the  signs  of  backwai'd  pressure 
may  follow.  Enlargement  of  the  heart  from  this  cause  is  much  more  liable  to  occur  where 
the  patient  is  accustomed  to  take  a  considerable  amount  of  alcohol.  As  a  cause  of  enhirge- 
ment  of  tlie  heart  it  should  not  be  diagnosed  until  primary  valvular  disease,  granular  kidney, 
and  arteriosclerosis  can  be  excluded. 


ENLARGEMENT    OF    THE     HEART 


6.  ExopiiTiiAi-Mic  Goitre. 


In  this  disease,  moderate  enlargement  of  the  heart,  as  shown  by  the  displacement 
outwards  of  tlie  cardiac  impulse  and  the  increased  area  of  cardiac  dullness,  is  common,  and 
is  probably  the  result  of  the  long-continued  increased  rapidity  of  cardiac  action.  It  is  rarely, 
however,  the  most  prominent  sign  of  the  disease.  It  is  distinguished  from  other  forms  of 
enlargement  by  the  presence  of  tachycardia — the  pulse-rate  in  a  well-marked  ease  varying 
between  120  and  160,  or  being  even  higher  than  this — the  marked  pulsation  of  the  carotids 
and  other  superficial  arteries,  the  exophthalmos,  the  enlargement  and  pulsation  of  the 
thyroid  gland,  the  fine  tremor  of  the  extremities,  the  loss  of  weight,  the  excitability,  and 
the  pigmentation  of  the  skin  of  the  eyelids.  There  is  very  often  a  loud  blowing  systolic  bruit 
in  the  pulmonary  area,  less  often  one  at  the  impulse,  but  frequently  one  over  the  thyroid 
gland.  Certain  signs  associated  with  the  names  of  von  Graefe,  Stellwag,  and  Moebius, 
are  not  of  the  least  value  in  making  the  diagnosis. 

7.  CoNOExiTAi,    Heart    Disease. 

When  there  is  a  patent  interventricular  septum  there  may  be  considerable  enlargement 
ul'  the  heart  from  hypertrophy  and  dilatation  of  both  ventricles.  It  is  frcfiuently  associated 
with  some  narrowing  of  the  ])ulmonary  orifice.  In  addition  to  the  symptoms  common  to 
most  forms  of  congenital  heart  disease,  viz.,  cyanosis,  clubbing  of  the  fingers  and  toes, 
dyspnoea,  and  polycythsemia,  the  cardiac  impulse  will  be  displaced  downwards  and  outwards, 
there  will  be  epigastric  pulsation,  perhaps  a  prolonged  systolic  thrill,  best  felt  over  the  third 
left  intercostal  space  close  to  the  sternum,  an  increased  area  of  cardiac  dullness  in  all  direc- 
tions, and  a  loud  systolic  murmur  at  the  base  of  the  heart,  the  ])oint  of  maxinuim  intensitv 
being  the  tnird  or  fourth  left  intercostal  space  close  to  the  left  border  of  the  sternum.  It  is 
often  very  dillicult  to  say  whether  the  lesion  is  pulmonary  stenosis  or  jiatent  interventricular 
septum.  A  well-marked  thrill  is  associated  more  constantly  with  the  former  than  with  the 
latter,  but  the  point  of  maxinnmi  intensity  of  the  murmur  produced  by  pulmonary  stenosis 
is  in  the  second  left  space,  close  to  the  left  border  of  the  sternum,  whereas  in  i)atent  inter- 
\cntricular  septum  the  murmur  is  loudest  lower  down. 

ENLARGEMENT    OF    THE    RIGHT    VENTRICLE. 

Wlien  the  eiilargcincnt  of  the  heart  is  i\w  to  hyperhnphy  or  dilatation  of  the  right 
Nciilricle.  Ihc  cardiac  impulse  is  displaceil  outwards  more  than  downwards,  tliere  is  fre(|ucntly 
well-marked  epigastric  |)ulsation.  and  ttie  (hillness  is  increased  upwards  and  to  tlie  right 
rallicr  than  to  the  left.      The  causes  of  enlargement  of  the  right  \  eritriele  are  as  follows  : — 

1 .  Diseases  of  the  Left  Side  of  tlie  Heart : 

-Mitral  stenosis 

All   the   eoTiilitioiis   wliieli   cause   eiihn^eiiieiil    of  llie    Icjl    \eiiliiele    (p.  200). 

2.  Diseases  of  the  Lung  : — 

Kil>roj>l    liiii^ 

(linjriie  JM-orieliitis  ;iii(l  eiiipliyseinii. 

:s.  Diseases  of  the  Right  Side  of  the  Heart : — 

('on;{('iiil:il   piilinoiiarv  stenosis 

I'lilnii y   ineoinpet'enee  :    (i)    Due   In   ililal:ilion    ol'llir   pul larv     artery; 

(ii)    line   to   infective   eiuloeanlilis   of   lije    pnirnonary    \:i\\r. 

1.  Disi.Asi'.s  oi-   riii;  Li;i-r  Smr,  ov  iiii-;  IIi^Aur. 

Mitral  Stenosis. — This  is  a  common  and  most  important  eanse  of  enlargenient  of  the 
riylit  veiilricle.  The  obstruction  to  the  How  of  blood  from  the  lelt  auricle  into  the  left 
ventricle  leads  to  hypeitrophy  and  dilatation  of  the  left  auricle,  passive  congestion  of  the 
lungs,  red  and  brown  indnrat  ion  of  these  organs.  I  liieki'iiing  dilatation  and  allieroina.  of  the 
branches  of  the  pulmonary  arteries  in  the  hmgs  as  a  result  of  the  iner<ased  tension  in  these 
vessels.  .Ml  these  changes  increase  the  amount  of  work  to  he  perlormed  by  the  right  side 
of  the  heart,  and  arc  rcsixaisihle  foi-  the  hyp<rt  ropliy  of  the  right  xciitiicle,  by  which 
means  compensation  niav  lie  maintained   for  some  time.      When  the  right   \-entriele  dil.-itcs. 


216  enlarge:ment   of   the   heart 

compensation  fails.  In  the  early  stages  the  pulse  shows  little  variation  from  the  normal, 
and  there  may  be  no  obvious  symptoms  pointing  to  the  existence  of  mitral  stenosis.  In  more 
advanced  phases  the  pulse  becomes  rapid,  small,  and  irregular.  The  cardiac  impulse  is 
displaced  outwards,  and  pulsation  occurs  in  the  epigastrium  and  in  the  third,  fourth,  and 
fifth  intercostal  spaces  close  to  the  sternum.  On  placing  the  palm  of  the  hand  over  the 
region  of  the  cardiac  impulse  and  the  adjacent  fourth  and  fifth  intercostal  spaces,  a  character- 
istic thrill  may  be  felt.  It  usually  has  a  curious  rough  grating  quality.  It  is  diastolic  in 
rhythm,  and  may  be  felt  to  terminate  suddenly  in  a  sharp  shock  which  is  synchronous  witii 
the  apex  beat.  The  dullness  is  increased  upwards  from  the  third  left  rib  to  the  second, 
or  even  higher  ;  it  extends  well  to  the  right  of  the  sternum,  but  it  does  not  reach  far  to  the 
left,  though  in  a  few  cases  it  extends  to  the  left  ni])])le  line,  even  when  mitral  stenosis  is  the 
only  lesion  present.  The  more  the  dullness  extends  to  the  left,  however,  the  less  likely  is 
the  diagnosis  of  mitral  stenosis  alone  to  be  correct.  At  or  just  inside  the  cardiac  impulse, 
a  loud,  rough,  rumbling,  vibrating  bruit  may  be  heard,  which  rims  up  to,  and  is  continuous 
with,  a  loud,  accentuated,  slapping  first  sound,  which  may  or  may  not  be  followed  by  a 
systolic  murmur.  This  characteristic  bruit  may  occupy  tiie  whole  of  the  diastole,  and  may 
commence  with  a  doubling  of  the  second  sound.  It  increases  in  intensity  until  it  finally 
ends  in  the  loud  first  sound.  It  may.  however,  be  shorter,  and  commence  in  the  middle  or 
latter  jiart  of  diastole.  It  is  usually  termed  presystolic,  as  it  runs  up  to  and  is  continuous 
with  the  first  sound.  The  other  alinormal  signs  to  which  mitral  stenosis  may  give  rise  are 
described  on  pages  93  and  94. 

All  the  Conditions  which  cause  Enlargement  of  the  Left  Ventricle. — Whenever 
com|)ens;itiiin  begins  to  fail  in  cases  of  mitral  regurgitation  from  any  cause,  aortic  disease, 
enlargement  of  the  left  ventricle  from  chronic  l?riglit"s  disease,  arteriosclerosis,  alcoholism, 
or  other  causes  discussed  above,  and  there  is  backward  pressure  through  the  lungs,  hyper- 
trophy of  the  right  ventricle  serves  to  maintain  compensation  for  a  time.  The  increase  in 
the  size  of  the  right  ventricle  would  be  indicated  by  the  advent  <jf  epigastric  pidsation  and 
a  further  increase  of  the  dullness  to  the  right  of  the  sternum,  but  the  diagnosis  of  its  cause 
would  rest  upon  data  already  discussed  under  the  heading  of  mitral  regurgitation  (see  p. 
210). 

2.  Diseases  of  the  Lung. 

Fibroid  Lung  gives  rise  to  symptoms  and  physical  signs  so  characteristic  that  there 
is  rarely  any  dillieulty  in  making  a  diagnosis.  The  hypertrophy  of  the  right  ventricle  is  of 
secondary  ini|)ortancc.  and  does  not  become  manifest  until  late  in  the  disease.  The  retraction 
of  the  lung  draws  the  heart  over  towards  the  affected  side,  and  in  consequence  of  the 
displaced  cardiac  impulse  and  the  increased  area  of  pulsation,  it  may  ajspear  to  be  much 
larger  than  it  really  is.  When  the  right  lung  is  affected,  there  may  be  well-marked  epigastric 
pulsation,  and  the  cardiac  impulse  may  be  to  the  right  of  the  sternum  in  the  fifth  intercostal 
space,  the  maximum  point  being  in  some  cases  as  far  out  as  the  right  nipjile  line.  When 
the  left  lung  is  affected,  the  heart  may  be  pulled  over  towards  the  left,  so  that  the  cardiac 
impulse  is  situated  in  the  anterior,  or  even  in  the  mid-axillary  line.  In  consequence  of  the 
shrinking  of  the  lung,  more  of  the  anterior  surface  of  the  heart  will  lie  in  contact  with  the 
thoracic  wall,  and  there  may  be  therefore  an  increased  area  of  visible  pulsation  in  the  second, 
third,  or  fourth  intercostal  space.  In  addition  to  displacement  of  the  cardiac  impulse,  there 
is  diminution  in  the  size  and  decrease  in  the  movement  of  the  affected  side  of  the  chest, 
the  shoulder  is  drawn  down,  the  s])inc  curved  with  the  concavity  towards  the  affected  side  ; 
there  is  increased  tactile  vocal  fremitus,  impairment  of  note  on  percussion,  and  possibly 
a  cracked-pot  sound  :  and.  should  there  be  dilated  bronchial  tubes,  there  are  cavernous 
or  amphoric  breathing,  bronchophony,  pectoriloquy,  and  loud  crackling  rales.  With  the 
exception  of  compensatory  eni])hysema.  there  may  be  no  sign  of  disease  in  the  other  lung, 
a  point  which  helps  to  distinguish  this  condition  from  phthisis.  The  chief  symptoms  are 
chronic  cough,  dys|)n(ra,  abundant  expectoration  on  rising  in  the  morning,  the  sputum 
often  being  foetid  on  account  of  the  bronchiectasis  so  frequently  associated  with  fibroid  lung. 
The  patient  may  be  well  nourished  and  show  no  signs  of  loss  of  flesh.  Haemoptysis  occurs 
occasionally,  but  no  tubercle  bacilli  will  be  foimd  in  the  sinitum.  There  is  often  extreme 
clultbiiig  (il  tlic  fingers. 

Chronic    Bronchitis   and    Emphysema    may  so  increase  the  volume  of  the  lungs  that 


EXOPHTHAL.MOS  I    217 

they  cover  the  anterior  surface  of  the  heart  completely  :  consequently  the  cardiac  impulse 
niay  be  invisible,  the  superficial  cardiac  dullness  diminished  or  absent,  and  the  heart  sounds 
faint  or  even  inaudible.  In  these  circumstances  it  is  not  an  easy  matter  to  diagnose  enlarjie- 
ment  of  the  heart.  Sliould  there  be  dilatation  of  the  riuht  ventricle  as  well  as  hypertrophy, 
an<l  also  tricusjjid  regurgitation,  a  systolic  murnuir  may  be  heard  over  the  lower  part  of  the 
sternum  and  in  the  fourth  and  fifth  left  intercostal  spaces  close  to  the  sternum,  and  oedema 
of  the  legs,  ascites,  enlargement  of  the  liver,  and  albuminuria  may  also  be  present.  If,  in 
addition,  there  are  signs  of  pulmonary  emphysema,  viz,,  the  cubical  chest,  wide  epigastric 
angle,  increased  tactile  vocal  fremitus,  hyper-resonant  percussion  note,  diminished  area 
of  hepatic  and  cardiac  dullness,  increased  voice  sounds,  diminished  vesicular  nuinnur  with 
prolongation  of  the  expiratory  sound,  with  or  without  non-consonating  rales  and  rhonchi, 
and  if  there  are  no  indications  of  fibrosis  of  the  heart  valves  from  former  endocarditis, 
chronic  Bright's  disease,  or  primary  arteriosclerosis,  enlargement  of  the  heart  with  failure 
of  com]iensation  as  a  result  of  chronic  bronchitis  and  emphysema  may  be  diagnosed. 

3.  Dlse.vses  of  the  Right  Smje  of  the  Heart. 

Pulmonary  Stenosis. — This  is  the  commonest  form  of  congenital  heart  disease.  In 
addition  to  eviinosis.  clubbing  of  the  hngcrs  and  toes.  ])olycytha'mia,  dyspnoea,  and  signs 
of  hypertrophy  of  the  right  ventricle,  there  is  usually  a  well-marked  systolic  thrill  over  the 
second  left  intercostal  space  close  to  the  stermmi,  and  a  loud,  rough  systolic  niurmur  in  the 
same  position.  The  murmur  is  not  transmitted  to  the  carotids  in  the  neck,  as  is  that  of 
;!ortic  stenosis. 

Pulmonary  Incompetence. — This  lesion  may  be  associated  with  congenital  pulmonary 
stenosis,  or  may  be  due  to  infective  endocarditis  (especially  gonococcal),  but  by  far  the 
conunonest  cause  is  functional  incompetence  from  dilatation  of  the  pulmonary  artery  and 
orilicc  secondary  to  the  high  tension  produced  in  the  pulmonary  circulation  by  mitral 
stenosis.  It  may  be  difTicult  to  distinguish  from  aortic  regurgitation  :  the  early  diastolic 
bruit  of  pulmonary  incompetence  is  most  audible,  liowcver,  in  the  third  and  fourth  left 
intercoslal  sjiaces  midway  between  the  left  nippk'  line  and  the  left  border  of  the  sternum, 
whereas  in  aortic  <lis(ase  the  diastolic  bruit  is  usually  heard  best  in  the  third  left  space  close 
to  the  left  border  of  the  sternum.  The  visible  pulsation  of  the  snperlicial  arteries,  and  the 
collapsing  pulse,  which  are  so  characteristic  of  aurtie  inconi)Htence.  are  not  present  in 
cases  of  iiuhnonary  incompetence.  Ilnhiil  Fifiic)i. 

ENLARGEMENT  OF  THE  KIDNEY.     (See  Kidney.  IOm.auck.mknt  ok.  p.  -.K-yl.) 

ENLARGEMENT  OF  THE  LIVER.     (See  l.ivi-.it.  I'Ini.ahci-.mknts  of  tmi:,  p.  :t(i(i.) 

ENLARGEMENT  OF  THE  LYMPHATIC  GLANDS.  (Sec  LvMi-nvru  (;..and 
I';m,au(;i;.meni,   p.  ;!7<j.) 

ENLARGEMENT  OF  THE  SALIVARY  GLANDS  (Se(   Swellino  of  the  Su.ivauy 

(Jl.ASOS,     p.     (i!)l). 

ENLARGEMENT  OF  THE  SPLEEN.  (See  Sci.kkn.  I-;m,\i!(;i:mi:nt  of  p.  (i-JS.) 

ENLARGEMENT  OF  THE  THYROID  GLAND.  (S,,  I  nv i.  (;f\m.  Km  akoe- 

mi;nt.  p.  721.1 

ENOPHTHALMOS  (or  Retraction  of    the    Eyeball).     Ihis  may  ..(.nr:    (i)   In 

wasting  diseases  :  (2)  In  paralysis  of  the  eerxieaj  syiiipal  lielie  :  (.'!)  In  \arions  eorigenilal 
alTeeiiiins. 

The  enophllialiiK.s  in  n;istii,:i  ,lis,'iisr':  is  due  h.  Hie  absorplioii  ,,r  llie  iirhilal  lal, 
:uhI    llie  diagnosis  as   regards   the  eye   presents   ikj  dillieulty. 

iMiophlliahnos  due  to  piinih/sii  nf  Ihr  icnii-al  siii>ij>iilhili<-  is  alua\s  assiieialed  \\i{\\ 
the  iither  wcll-deliTied  syniplouis  (if  this  eniidiliiin,  iiMnieis'.  diniinuliou  in  the  si/e  of  the 
palpebral  aperlnrc.  <Minsl  rid  ion  of  the  pupil,  and  aliseiiee  of  sweating  and  blushing  on  the 
|)araly/.cd  side.  The  pupil  is  constricted  owing  Id  IIk  p.iralysis  of  Ihc  dilator  librcs.  (he 
pupil   therefore  not   dilating  in  a   IV-ebie  light. 


218  ENURESIS 

In  certain  congenilal  cases  there  is  well-marked  retraction  associated  with  defective 
or  irregular  movements  of  the  affected  eyeball.  The  ocular  muscles  are,  as  a  rule,  inserted 
much  farther  back  in  the  sclerotic  than  is  normally  the  case.  The  condition  appears  to 
be  due  to  the  absence  or  defective  insertion  of  the  extrinsic  muscles  of  the  eye,  and  may 
be  recognized  by  its  existence  since  birth.  Herbert  L.  Eason. 

ENURESIS  occurs  almost  exclusively  in  children,  and  although  most  frequently 
confined  to  the  night,  it  may  occur  in  the  day.  It  must  be  distinguished  from  incontinence 
of  urine  ;  the  patient  has  usually  full  control  of  micturition  during  the  day,  altliough  some- 
times the  desire  to  urinate  must  be  satisfied  quickly  or  a  little  dribbling  may  take  place. 
The  child  completely  emjjties  the  bladder,  often  without  waking,  once  or  several  times 
during  the  nignt.  The  bladder  need  not  be  quite  filled  for  micturition  to  occur,  for  it 
takes  place  in  the  early  hoin's  of  the  night. 

Enuresis  is  often  accompanied,  and  may  be  caused,  by  slight  affections,  such  as 
phimosis,  balanitis,  small  urinary  meatus,  vulvitis,  constipation,  or  intestinal  worms,  the 
correction  of  which  remedies  the  trouble,  but  in  other  cases  there  seems  nothing  to  promote 
the  excitabihty  of  the  detrusor  muscle.  It  is  cured  not  infrequently  by  an  operation  for 
the  removal  of  enlarged  tonsils  and  adenoid  growths,  or  after  the  administration  of  small 
doses  of  thyroid  extract.  It  has  been  stated  that  the  condition  is  due  to  faulty 
development  or  deficient  innervation  of  the  sphincter  muscle,  or  to  spasm  of  the 
detrusor  ;  but  this  is  difficult  to  prove.  If  the  sphincter  muscle  were  paralyzed  or 
deficient,  there  would  be  true  incontinence  of  urine,  whereas  this  is  not  so,  and  the 
children  are  often  of  good  development  and  health.  It  is  probable  that  the  infantile 
condition  in  which  the  detrusor  muscle  holds  the  mastery  over  the  sphincter  persists, 
a  relative  disparity  between  the  innervation  of  the  two  sets  of  muscles  allowing  the 
detrusor,  which  normally  is  held  in  check  by  the  sphincter,  to  overcome  the  compara- 
tively weak  action  of  the  latter.  When  enuresis  persists  throughout  childhood,  it  may 
disappear  at  puberty,  wlien  tiie  ])rostate  gland  enlarges  and  strengthens  the  action  of 
the  sphincteric  apparatus. 

It  is  important  to  exclude  both  pyelitis,  phosphaturia  and  oxaluria  before  a  diagnosis 
of  simple  enuresis  is  made.  In  either  case  nocturnal  micturition  may  be  the  chief 
symptom  ;  microscopical  examination  of  the  centrifugalized  deposit  will  detect  the  pus 
cells  or  the  excess  of  calcium  oxalate  crystals,  and  a  bacteriological  examination  of  a 
specimen  of  urine  passed  directly  into  a  sterile  bottle  or  obtained  by  a  catheter  should  be 
made  in  order  to  diagnose  or  exclude  coli  bacilluria  (p.  0!)). 

In  most  cases  no  source  of  irritation,  alteration  in  tlie  urine  or  disease  of  the  bladder 
can  Ijc  found.  The  child  is  nervous  and  sensitive  from  a  feeling  of  shame  due  to  attempts 
by  the  parent  to  cure  the  trouble  by  punishment.  In  some  the  enuresis  may  accompany 
a  minor  epileptic  attack,  in  which  case  there  may  be  longer  intervals  than  is  usual  in  simple 
enuresis,  or  there  may  be  a  history  of  epilepsy,  insanity,  or  other  nerve  trouble  in  the 
parent.  7f.  //.  Jocelyu  Svcan. 

EOSINOPHILIA  denotes  a  relative  increase  in  the  coarsely  granular  cosinophile  cells 
of  tlie  blood  {Phile  II,  Fig.  L.  p  22);  it  is  determined  by  preparing  blood  films  and  making 
a  differential  leucocyte  count.  Normally,  the  coarsely  granular  cosinophile  cells  vary 
from  0  to  2  per  cent  :  the  point  at  which  eosinophilia  begins  is  quite  arbitrary  ;  but  one 
may  say  that  although  it  is  imusiial,  under  perfectly  healthy  conditions,  to  find  more  than 
2  per  cent  of  these  cells  in  the  differential  count,  they  should  reach  5  per  cent  or  more 
before  the  term  eosinophilia  is  applied  to  the  condition.  It  is  probable  that  some  normal 
people  have  upwards  of  5  per  cent  of  these  cells,  but  beyond  this  point  they  are  nearly 
always  pathological. 

One  may  divide  the  causes  of  eosinophilia  under  main  headings  as  follows  : — 

1.  Conditions  in  which  Eosinophilia  is  slight,  inconstant,  and  of  little  diagnostic 
significance : — 

Post-febrile  states,  after  :  — 

Scarlet  fever  .\cute  articular  rliciiinatism  Varicella 

I'neiimonia  Measles  Malaria. 


EOSINOPHILIA  219 

Affections  of  the  bone-marrow  : — 

SplenomeduUary  leukaemia        Rickets  i     Osteomalacia 

Sarcoma  of  bone  '     Osteomyelitis  ] 

Addison"s  disease. 

From  certain  cliemicals,  particularly  camphor,  Milphurettcd  hyr  );icn. 
In  ovarian  maladies. 
Gcnorrhira.  - 

During  tlic  positive  stage  of  tuberculin  reaction. 

.Some  cases  of    malignant  disease,  especially  when  there  are  metastases — carcinoma, 
lymphosarcoma. 

2.  Conditions   in   which   Eosinophilia    may   be   marked. 

(ii).  SpiisiiKidir  Aslhiiiii. 

(b).   CerUiiii  Skin   Discrises.   more  particidarly  the  bullous  dermatoses  : — 

Pemphigus  Dermatitis  herpetiformis  (Diili-        Herpes  iris,  or  erytlicma  iris 

Krytliema     l)ull(isiim       ;         ring's  disease)  Herpes    gestationis 

Hydroa 

It  is  much  rarer  in  other  cases  of  skin  disease,  but  is  noted  occasionally  in  psoriasis, 
eczema,  and  exceptionally  in  some  other  affections  of  the  skin. 

(f).  Certain   Prirnsitic  Affections,  ijarticularly  : — 

.Vnkylostomiim     duo-  Bothrioeephalus  latiis  Filaria  sanguinis  lioniinis 

denale  i     Ta;nia  solium  I     Trichina  spiralis 

Hllliar/.ia    ha-matohia      |     Ta;nia  medioeancllata 

It  is  nuich  less  constant,  and  indeed  generally  absent,  in  oases  of  : — 

.\s(aris  lumlirieoides        |     Oxyuris   vermicularis  !     Pediculus  corporis 

Triclioecphalus   dispar    j      Pediculus  capitis  Acarus  scaMei 

[      Pedieidus   puhis  I 

The  list  aljovc  almost  s|)caks  for  itself,  and  little  discussion  is  needed.  Xone  of  tiie 
conditions  named  is  necessarily  as.sociated  with  eosinophilia.  but  the  coarsely  gramdar 
eosinopliile  cells  often  reach  a  figure  between  ,5  aiid  15  per  cent  in  the  differential  count 
in  many  of  the  diseases  thai  come  lUKhr  headings  (n).  (I>).  and  (c).  whilst  sometimes  during 
I)aroxysmiiI  asthma  they  may  rcacli  25.  50,  or  even  more  per  cent,  and  they  arc  often  over 
2((  per  cent  in  the  severer  forms  of  jiarasitic  disease.  The  eosiuoiiliilia  of  leuk;emia  has 
often  had  stress  laid  u|)(m  it  in  text-books,  but  as  a  matter  of  fact,  although  the  coarsely 
graiudar  eosiiu)phile  cells  per  cubic  millimetre  of  blood  may  be  considerably  aljovc  the 
normal  along  with  all  tlie  other  corjjuseles,  yet  when  reiluee<l  lo  perceiilages  in  the  diffcr- 
ential  leucocyte  count,  the  eosino|)liilc  corpuscles  seldom  niunber  more  than  2  or  W  per 
<iiit  <d'  all  the  white  cells  |)rcsent. 

'I'he  yaluc  of  eosinophilia  in  discriniinatiiig  helwcen  arlilicial  bleb-loi  rnation  ami  a 
true  liiilloiis  ilrrmalosi.s  is  mentioned  in  the  article  upon  Ml  i.i.i;  (p.  '.)(>). 

The  dilliculty  sometimes  present  in  jleeiding  whether  in  a  given  case  I  he  lesion  is 
primary  emphysema  and  bronchitis,  or  primary  (isllinid  sueeeeded  by  emphysema  and 
Itronehitis.  is  discussed  on  page  5;i5  :  and  Ihe  value  of  (■()sir\ophilia  in  discriminating 
between  truly  asthmali<-  <ases  and  those  which  simulate  asthma  but  are  really  cardiac, 
renal,  or  broMchitie.  is  there  referred  to.  It  should  bi-  noted  that  tic  eosinophilia  is  not 
eouliiied  to  the  IjIocjcI.  Iicini;  present  also  in  the  cells  in  the  s|)Mtinn  ;  it  o<(ims  durint;  the 
paroxysm's  ol  asthma.  an<l  rapiilly  disappears  in  the  inlerxals. 

When  a  patient  is  sidlering  from  an  obscure  form  of  ana'mia.  and  when  Ihe  IiIinkI  al 
the  same  lime  exhibits  considerable  eosinophilia.  the  latter  nuiy  sometimes  be  the  tirsi 
suggestion  that  tlicre  is  a  serious  parasitic  itifcctioti  in  the  case,  and  careful  examination 
of  the  fa'ces  or  urine  for  the  parasites  Ihemsehcs  or  for  their  ova.  with  the  adnunislration 
of  anthelmiidic^  drugs,  may  then  be  resorted  to  for  conlirmation  cd'  Ihe  diagnosis  (see 
Pahasi  ri'.s,  lNri:sriNAi..  p.  51!)).  Persons  who  have  been  resident  in  the  tropics  are  more 
liable  to  misusnccted  infietion  of  this  kind  than  are  others.  Ilrrhnl  l'\ni<h. 


J20  El'IPHOKA 

EPIPHORA,  or  overflow  of  the  tears,  may  be  due  to  (1)  Increased  secretion  ;  (2)  The 
pinirlii  liiclni/Diiilifi  not  being  in  close  apposition  to  the  globe  ;  (3)  Obstruction  of  the  lachrymal 
canaliculi  or  duct. 

1.  The  most  familiar  cause  of  epiphora  due  to  increased  secretion  of  tears  is  the  act 
of  weeping,  in  which  the  flow  is  due  to  psychical  stimuh.  Epiphora  may  also  occur  in  the 
laehrymation  caused  by  conjunctiintis,  corneal  ulcers,  and  other  inflammatory  affections 
of  the  eye  (p.   231). 

2.  Tears  only  find  their  way  down  the  canaliculi  by  capillary  attraction,  the  pimcta 
laohrymalia  being  applied  closely  to  the  surface  of  the  globe.  In  facial  paralysis,  owing 
to  the  failure  of  the  orbicidaris  palpebrarum  muscle,  the  lids  are  no  longer  braced  up  against 
the  eye,  and  the  lower  lid  droops  away  from  the  globe.  The  tears  collect  in  the  sulcus 
thus  formed,  and  run  over  on  to  the  cheek.  The  condition  is  easily  diagnosed  by  the 
inability  to  close  the  eye  entirely,  either  by  passive  or  active  movements.  In  cases  of 
chronic  marginal  blepharitis.  hv]X'rtropliy  of  the  lid-edge  and  the  conjunctiva  results  in  a 
slight  eversion  or  ectropion.  The  punctum  lachrymale  of  the  lower  lid  is  no  longer  in 
apposition  with  the  eye,  and  epiphora  follows,  causing  continual  moisture  of  the  edge  of 
the  lids  and  aggravation  of  the  original  condition.  Cicatricial  ectropion  from  burns,  injury, 
sclerodermia.  or  lupus  of  the  cheek  may  also  residt  inepii^hora  ;  and  so  may  severe  proptosfs 
(see  Exophthalmos,  p.  229),  resulting  from  tumours  or  inflammation  at  the  back  of  the 
orbit,  or  from  Graves's  disease. 

3.  The  lachrymal  ducts  may  be  congenilally  obstructed.  The  obstruction  is  usually 
imilateral,  and  is  due  to  a  plug  or  septum  of  uncanalized  epithelium  situated  in  the  lower 
part  of  the  duct.  The  epiphora  is  as  a  rule  not  evident  till  the  seventh  or  eighth  day,  at 
which  period  the  infant  first  begins  to  shed  tears,  and  owing  to  the  suppuration  of  the  tears 
collected  in  the  lachrymal  sac  the  malady  may  be  mistaken  for  a  chronic  conjunctivitis. 
The  unilateral  nature  of  the  affection,  and  the  presence  of  tears  or  pus  in  the  sac,  are  the 
diagnostic  signs,  and  the  obstruction  may  generally  be  cured  by  a  single  probing  of  the 
duct  through  the  dilated  but  uncut  canaliculus.  Congenital  absence  of  one  or  both  canaliculi 
has  been  recorded.  Stenosis  of  the  lachrymal  duct  may  also  occur  as  the  result  of  catarrhal 
congcstidti  ol  tlic  iiincdus  iiietnbrane,  or  from  some  organic  obstruction,  due  to  cicatrization 
following  abscess  in  the  lachrymal  sac  or  necrosis  of  the  bones  forming  the  walls  of  the  duct. 
The  diagnosis  can  oidy  be  made  by  syringing  through  the  canaliculi  ;  in  catarrhal  obstrue- 
ti(jn,  fluid  can  usually  be  forced  into  the  nose,  but  in  organic  stricture  it  is  returned  through 
the  other  canaliculus.  In  such  cases  the  stenosis  can  be  relieved  by  the  pas.sage  of  a  probe, 
after  slitting  the  lower  or  up]3er  canaliculus,  or  by  various  operations,  which  are  now  on 
their  trial,  for  the  formation  of  a  permanent  direct  opening  from  the  lachrymal  sac  into 
the  nasal  cavity. 

ICxcision  of  the  lachrymal  sac  for  chronic  sujjpuration  is  always  followed  by  epiphora, 
but  this  condition  may  often  be  preferable  to  the  discomfort  caused  by  recurrent  lachrymal 
abscess  and  to  the  risk  of  corneal  ulcer  with  hypopyon. 

Injuiv  to  the  duet  or  canaliculus  may  also  cause  permanent  ejjiphora.     Herbert  L.  Eason. 

EPISTAXIS — rhinorrhagia.  or  bleeding  from  the  nose,  may  be  due  to  local  or  general 
causes,  or  to  a  combination  of  both.  In  many  eases  it  occurs  spontaneousl\'  and  no  cause 
can  be  indicated. 

Local    Causes. 

Injury. — A  blow,  fracture  of  the  base  of  the  skull,  a  foreign  body  in  the  nose,  operation 
on  the  nose,  violent  coughing,  sneezing  or  nose-blowing,  nose-picking. 

Ulceration. — Traumatic,  syphilitic,  malignant,  tuberculous,  leprous. 

New  Growth. — Adenoid  growths,  jjolypi,  fibroma,  angioma,  malignant  disease. 

Varicosity  of  the   J'eins  of  the  nasal  mucosa  :    multiple  hereditary  telangiectases. 

.Lcnic  Infective  Iiijt<tnnnati(ni. — Severe  catarrh,  diphtheria,  scarlet  fever,  influenza. 

General   Causes. 

Higli  .irterial  Blood-pressure,  such  as  obtains  in  granular  kidney  and  chronic  renal 
disease,  arteriosclerosis,  gout,  cirrhosis  of  the  liver,  heart-disease. 

High  Venous  Blood-pressure  in  bronchitis,  emphysema,  dilatation  of  the  right  heart  ; 
in  cerebral  congestion,  when  blood  ])asses  from  the  superior  longitudinal  sinus  by  an 
emissary  vein  going  through  the  foramen  circinn  to  the  nasal  mucosa  :  in  "  determination 
of  blood  to  the  head  "  ;    in  schoolbovs  and  children  after  takini;  \iolcnt  exercise. 


EPISTAXIS  221 

Altered  Conditions  of  the  Blood. — Hjemophilia,  pernicious  anaemia,  purpura,  scurvy, 
leukaemia,  chlorosis,  jaundice,  and  the  onset  of  acute  specific  fevers,  particularly  enteric, 
scarlet  fever,  and  measles. 

Alterations  in  Attnosplieric  Pressure. — Mountaineering,  diving,  caisson  disease. 

Epistaxis  of  Obscure  Origin,  often  attributed  to  conuestion,  and  occurring  : — In 
childhood  :  at  puberty.  es])ecially  in  girls  ;  »s  'the  &llgged_  vicarious  menstruation  ;  as 
the  result  of  sexual  irritation  in  citlier  sex  :   in  women  at  tlie  menopause. 

In  some  cases  the  blood  issues  from  both  nostrils  ;  in  the  majority,  particularly  when 
the  cause  of  the  bleeding  is  local,  from  one  only.  But  it  must  be  remembered  that  nose- 
bleeding  may  occur  without  any  blood  coming  from  the  anterior  nares  :  if  the  jjatient 
is  lying  down  the  effused  blood  rims  down  the  sides  or  floor  of  the  nose,  passing  through 
the  posterior  nares  .iind  entering  the  nasopharynx  ;  when  this  occurs  the  patient  may 
cough  and  spit  it  up,  when  hEemoptysis  will  be  observed  ;  if,  on  the  other  hand,  he  swallows 
the  blood,  he  may  vomit  it  later,  when  hsematemesis  will  take  place.  In  the  not 
uncommon  instances  in  which  either  of  these  events  occurs  from  epistaxis,  careful  enquiry 
should  suHice  to  make  the  diagnosis  clear  ;  but  it  should  not  be  forgotten  that  either 
heematemesis  or  ha?moptysis  may  indicate  nothing  more  serious  than  an  attack  of  nose- 
bleeding- 

In  every  case  of  epistaxis,  the  history  of  the  attack  should  be  gone  into  carefully. 
Particular  enquiry  should  be  made  as  to  any  sort  of  trauma  that  might  accoimt  for  it. 
and  also  as  to  the  occurrence  of  previous  attacks  of  nose-bleeding.  More  important  still 
is  a  carefvil  examination  of  the  local  conditions  of  the  nose,  with  use  of  a  nasal  si)eeulum 
to  dilate  the  nares,  and  of  a  mirror  and  lani))  to  secure  a  good  illumination.  In  many  cases 
tlie  bleeding  point  can  be  seen,  whether  the  haemorrhage  be  arterial  or  venous,  the  so- 
called  ■  .seat  of  election  "  of  epistaxis  being  a  small  and  perhaps  ulcerated  spot  on  the 
cartilage  of  the  se])tinn  not  far  from  its  junction  with  the  ethmoid  and  vomer.  In  other 
instances  no  such  bleeding  point  can  be  seen,  the  blood  oozing  from  the  mucous  membrane 
generally.  The  urine  should  be  tested  for  albumin  and  the  arterial  blood-pressure  measured 
instrumentally. 

Recurrent  Epistaxis  at  irregular  intervals  is  likely  to  be  due  to  some  local  cause. 
For  exam))le.  a  small  ulcer  on  the  septum  nasi,  due  perhaps  to  injury  in  the  first  instance, 
may  scab  over  from  time  to  time  but  never  heal  satisfactorily  ;  a  comparatively  trilling 
injury,  such  as  that  occasioned  l)y  blowing  the  nose,  may  sulTice  to  detach  the  scab, 
epistaxis  following.  Malignant  disease  of  or  about  the  nose,  and  also  adenoid  vegetalloiis, 
often  give  rise  to  repeated  nose-bleeding.  I-;pistaxis  has  been  ;i  prominent  symptom  in 
the  rare  hereditary  disease  in  which  numerous  friable  telangiectases  ajjpear  about  the 
surfaces  of  the  body  and  on  nnicous  membranes. 

Considerable  aid  in  diagnosing  the  probable  cause  of  an  epistaxis  is  afforded  by  the 
age  of  the  |)aticnt.  In  infiiney.  the  cause  is  likely  to  be  local  injury  by  a  fall,  a  foreign 
body,  the  habit  of  nose-picking,  or  syphilitic  disease  of  the  nasal  bones.  In  eliildliood. 
falls  and  blows  on  the  nose  arc  common,  the  temptation  to  insert  foreign  bodies  up  the 
nose  still  asserts  itself,  adenoid  growths  in  the  nasopharynx  arc  common  ;  and  geiuriil 
causes  such  as  heart-disease,  diseases  of  the  blood,  or  obscure  conditions  of  local  congestion, 
may  exist  and  account  for  the  onset  of  epistaxis.  About  the  age  of  piiherti/  nose-bleeding 
may  occur  in  cither  sex.  and  particularly  iri  girls,  not  only  in  ci)nsc<|ucnce  of  the  causes 
cmnnerated  already,  but  also  spontaneously.  In  the  healthy,  or  apparently'  healthy, 
!liiiiii<i  adult,  almost  any  of  the  list  of  local  and  general  causes  may  account  for  nosc- 
bleediiig  :  diagnosis  here  must  rest  upon  the  results  of  the  exatninal  ion  into  the  local 
conditions  ol  the  nose,  and  the  geiiii:il  sliilc  i>\'  the  organs  of  the  bodv  .  In  liie  old.  on  the 
other  hand,  and  in  middle-aged  piilicnts  ol  plethoric  habit,  high  lilddd-prissurc  with  or 
without  general  arterial  disease  is  the  most  important  cause  of  epistaxis  ;  it  may  be  a 
natural  remedy  for  the  plethora  from  which  such  persons  suffer,  ami  not  itd'rc(|uently  does 
relieve  them  I'nini  such  symptoms  as  a  sense  of  fidlncss  and  congestion  of  the  head,  tinnitus 
aurium,  or  the  api)carancc  of  Hashes  of  light  or  muscie  volitanles  before  tlu'  eyes.  In 
other  inslaiu'cs,  il  may  scr\-c  as  a  warning,  <lrawing  attention  to  the  abnormidix  high  blood- 
l)rcssurc  and   lo   lli<-  clirDnic   inlcrstitial   ncplirilis  or  arlerioscjerosis   that    underlies  il. 

.1.  ./.  .Icx-Blake. 

ERUCTATIONS.      fSc-  Im,ati  i,i;n(i;.  y.  2  K)  :    an,l   IIp.m.ihi  as,   |..  2!Hi.) 


ERYTHE.^IA 
ERUPTIONS,  BULLOUS,  VESICULAR,  Etc.     (See  Bille,  Vesicles,  Etc.) 


ERYTHEMA  signifies  a  pathological  reddening  of  the  skin  from  vascular  hypercpmia, 
the  re(hKss  disappearing  on  pressure,  to  return  when  the  pressure  is  removed.  There  is  no 
strict  Hue  at  which  one  can  say  mere  redness  of  the  skin  ends  and  actual  erythema  begins. 
For  instance.  Fia'siiin(;  (p.  2H)  would  hardly  merit  the  term  erythema  in  some  cases, 
though  it  would  in  others  :  clinically,  however,  there  is  seldom  dilheulty  in  deciding  what  is 
erythema  and  what  is  not.  It  may  be  local  or  general,  and  may  be  due  to  many  causes, 
including  the  following  : — 

1.  Drugs. 

{a).  External  Ajtjjlicalions.  hicludhig  nil  liiibcfdciciits  : — 


Tur])entine 
Poultices 
Mustard  plasters 
Ammonia 
C'roton  oil 
Cantliy  rides 
Capsiciun 
Carbolic  acid 


Mineral  acids 
Alkalies 

Alcohol  and  alcoholic  prepar- 
ations 
Chrysarobin 
Oil  of  cade 
Strong  merciuials 
Iodoform 


(b).  Medicines  taken  by  the  Moutli  : — 

Co]);iiba  TriounI 

Cubcbs  Chloral 

SaiKhilwood  oil  :    Chloral  hvdr;itc 

Belladonna  Butyl  chloral  liydrntc 

Atro])ine  Chloralamidc 

Salicylates  Antipyrin 

Aspirin  Arsenic 

Suiplional  Quinine 

^'cronal  •    Boric  acid 

((■).  Therapeutic  .igents  injected  Hypodermicalli/  :- 


Normal    horse   scrum 
Antidi])hthcritic 

serum 
Anti-anthrax  scrum 


Antistreptococcus  serum 
Antitetanic  .serum 
Antipneumococcus  seium 
Salvarsan 


Arnica 
Slesotan 

ilethyl-salicylic  acid 
Certain  soa]>s 
A'-ray  dermatitis 
Radium  ;i]pplications. 


Rhubarb 
Benzoic  acid 
Mercury 
Bromides 
Iodides 
Pilocaqjine 
Valerian 
Chlorate  of  ])otasIi 


Xco-salvarsan 

Atoxyl 

-Sodium  cacodvlate. 


((/).  Tlierapeiitic  Agents  injected  per  Fcclnm  : — 

Soap  and  water  enemata  I       Other  encmata 

•2.  Erythema  Artefactium  (Malingering). 

a.  Irritants  affecting  Workers  at  Certain  Trades,  in  which   they  have  to  handle  or 
come  in  contact  with  erythcnui-producing  substances,  such  as  : — 

Turjientiue  Fishermen   handling  ielly-fisli.  Satin-wood  sawdust 
Varnish  .sea  cats,  wcevers  and   other  Leaves  of  Primula  obconica 
Aniline  dyes  Tar  products                           |lisli  Leaves  of  Rhus  toxicodendnui 
Volatile  oils  Resins  .biiec     of     knot-grass     (Poly- 
Scents  Vanilin                                                         i.mnum  avienlarc) 

1.  After  Operations   sometimes,  [jerhaps  the  result  of  the  anicsthctic. 

5.  Extremes  of  Heat  or  Cold  : — 

Erythema  solare  |     Erythema  ab  igne  |     Erythema  a  frigorc 

(i.  Around  Inflammatory  Foci,  such  as  : — 

Over  ^my  alisccss  as  it  nears  the  surface — appendicular,  mastoid,  dental, 
lie])atie,   axillary,   inguinal,   a  ]>ointing  empyema,   and   .so   on. 

Round  suijcrficial  inflammations  of  the  skin,  such  as  boils,  carbuncles,  furuncles, 
malignaut  ])ustules,  and  so  on  :  or  as  part  of  other  skin  lesions,  such  as  eczema, 
lupus  erythematosus,  urticaria,  ringworm,  tinea  versicolor,  er\-thema  iris, 
liydroa,    erytluina  uddiisum,  phlebitis,  cellulitis,  lymiihaugitis. 

7.  As  part  of  a  General  Illness,  in  which  other  symptoms  are  likely  to  be  even  more 
prominent  : — 

Cerebrospinal  mcnin-        I^tomaine  poisoning  <    Leprosv 

gitis  Malaria  Densiue. 


ERYTHEMA 


8.  As    a  Prominent  Symptom  of  a  Disease  whkli   may 
symptoms  at  tlic  timt-. 


(a).  Lnralizcd  Eii/tlienia  :  - 

Erysipelas 
Sniall-])()X 
Gout 

Er\-thionielal<£ia 
Raynaiul's  disease 

(h).  Generalized  Erytliema 

Scarlet  fever 
Measles 

(ierman  measles 
■  Foiirtli  "  disease 


Erytlicma  indnratuni  (Bazin's 

disease) 
Polymyositis 
Triehinosis 
Rat-bite  fever 


Aeiite  rehumatism 

Parasitie  toxaemias,  e.g.,  from 

Hydatid  disease 

Tapeworm 


)]■    may   nut    piescnt  other 


I'ellaara 
Meige's  disease 
Ansioneurotie  cedeii 


Filariasis 
Trypanosomiasis. 
Snake  bite 


9.  Generalized  Erythema  without  obvious  cause  : — 

Erytliema  simplex         1     l-^rytlicina  inultirdniie  |    Erythema       exfoliativum 

I  I        sen  scarlatinifornie. 

In  arriving  at  the  cause  of  erythema  in  any  particular  case,  the  diagnosis  is  very  often 
()1)\  ious  when  the  possibilities  are  borne  in  mind.  Indeed,  many  of  the  conditions  men- 
tioned in  tlie  list  above  do  not  require  any  further  discussion.  The  appearance  of  the  part 
affected  will  often  suggest  that  some  external  application  is  the  cause  :  vesiculation  may 
result  from  almost  any  of  the  substances  which,  in  weaker  solution,  ])roduce  er\'thema 
only  :  there  is  nothing  ])athognomonic  about  the  naked-eye  appearances  from  which  to 
tell  the  application  used  :  the  history  as  to  what  the  ])aticnt  has  been  ajiplying  to  the  skin 
is  needed  ;  anrl  if  malingering  by  surreptitious  ai)])lication  is  suspected,  the  cessation  of 
the  lesions  when  the  patient  is  placed  under  circtmistances  where  further  a])|)lications  are 
not  possible  will  confirm  this.  One  point  of  importance  is  that  the  red  patches  produced 
by  carbolic  acid  may  be  such  as  to  simulate  tinea  circinata  ;  but  the  absence  of  spores  upon 
the  hairs  removed  fiom 
this. 

Local  reaction   from    I 
differs  from  ,i-ray  eane<- 
develop   into  a   vesiculai 
resistant  to  treatment 
a'-ray  cancer  progresse 


the   paleh   when   they  are  examined   micr(>sco|)ieally  will  exclude 
in   rt'peated  oecasiiins    is    lamiliiir  :     it 


applicatjoM   of    .r-r:i\s     on    rt'peated   oecasiiins 

n  llial.  thougli  the  ervlhema  may  persist  for  weeks,  or  ma>- 
rupliiin  (,i-iay  dermatitis  or  .r-iay  burn),  wliieli  may  be  very 
it  ultimately  subsides,  leaving  a  brown  pigmented  stain,  whereas 
in  spite  of  cessation  of  the  use  of  the  rays,  leads  to  progressive  if 


slow  destruction  of  the  alfectcd  parts,  and  ultimately  behaves  like  an  ordinary  e|)ithclioma. 

Ilddhim  hiinia  are  less  common  than  they  used  to  be.  because  of  greater  knowledge  ol 
the  methods  of  screening  the  skin  from  the  effects  of  the  supcHicial  rays  by  means  of  lead 
or  siKcr  sheets  :  but  most  radium  applications  are  followed  by  some  degree  of  local  reaction, 
of  uliieli  iryllirma  is  a  prominent  feature,  for  a  week  or  ten  days,  after  which  the  reaction 
subsides  rapidly  though  often  followed  by  local  brown  pigmentation  of  the  skin. 

'I'he  phenomena  of  scniiii  iciicUiiiis  are  familiar  :  the  ell'ects  are  due  to  the  siiuin 
itself  rathej-  than  to  the  antitoxin  it  contains,  and  they  form  part  of  what  is  known  as 
ana|)hylaxis.  The  injection  of  any  foreign  proteid  into  the  system  is  followed  by  chemical 
reactions  in  the  body  antagonistic  to  the  injected  proteid,  and  when  these  reactions  are  at 
their  height  the  body  is  extra-sensitive  (ana|)hylactic)  to  a  lurlher  injection  of  the  same 
foreign  proliid.  Iti  the  case  of  hor.se-serum  this  stale  of  anaphylaxis  reacOies  its  height 
about  eight  or  nine  days  after  the  original  injection  :  it  is  at  this  time  that  the  symptoms 
of"  serum  disease'  show  themscKcs  clinically.  The  patient  begins  to  ache  all  over,  with 
more  or  less  acute  pains  in  the  back  and  limbs,  sometimes  referreil  particularly  to 
the  jiiinls  ;  liea<laclie  is  usual,  and  llicre  m:i\  lie  \iimilini;;  the  leiii|i(ial  lu-e  rises  modei- 
alil\.  Ilie  tongue  is  coated,  ami  appctilc  tails:  at  llie  same  lime  a  lilnlehv  red  eruption 
appears  upon  the  skin,  sometimes  nnixcrsally.  lint  geneially  with  maNirnum  inlensit>  round 
th<-  site  of  the  inoculation.  There  is  irdense  itching,  the  patieid  may  not  be  able  to  sleep, 
and  ma\  not  ha\e  enough  lingers  to  scratch  himself  with.  The  eruption  is  sometimes  a 
pmr  iirliearia,  but  <piite  as  often  generali/.cd  erythema  preponderates,  with  multiple  mti- 
carial  wheals  amongst  the  erythema,  X'esieation  is  uncommon.  These  symptoms  last 
lull    a    (la\    ill    milil   e;ises.       Iwii,    lliree   or   even   lour   (la\s   in   iilheis.      The\    neaiK    alwaxs 


224  ERYTHEMA 

subside  spontaneously,  but  in  a  few  instances  the  serum  reaction  has  been  so  intense  as  to 
|)r<)ve  fatal. 

The  erythema  which  sometimes  follows  the  injection  of  salvnrsaii,  neosalvarsan , 
(ilo.ri/l,  or  sodium  cacodylale  may  be  severe  for  a  time,  but  it  is  usually  transient,  and  it 
only  develops  in  a  small  minority  of  eases.  It  is  probably  due  to  the  arsenic  which  is 
present  in  relatively  high  proportions  in  organic  combination  in  these  drugs. 

The  erythema  that  may  follow  ctiemata  is  generally  universal,  and  for  the  time  being 
the  ]>aticnt  looks  \cry  much  as  if  he  had  scarlet  fever.  Indeed,  the  physician  may  be 
unable  at  the  moment  to  make  sure  that  it  is  not  scarlatina,  especially  if  the  case  is  febrile 
already.  The  erythema  disappears  in  about  twenty-four  hours  or  less,  is  not  accompanied 
by  vomiting,  sore  throat,  or  albuminuria,  and  is  not  followed  by  desquamation.  The  fact 
that  it  has  followed  directly  after  the  administration  of  an  enema  is  the  main  point  in  the 
diagnosis. 

Erythema  due  to  the  various  trade  causes  mentioned  under  Group  3  in  the  above 
list  may  not  be  relegated  to  its  correct  cause  unless  the  nature  of  the  patient's  occupa- 
tion is  fully  understood :  but  a  general  indication  which  is  common  to  all  this  group  of 
erythemata  is  that  the  patient  does  not  suffer  when  he  is  away  from  his  work,  but 
gets  recurrences  when  he  returns  to  his  old  surroundings.  The  same  applies  to  the  effects 
of  certain  garden  and  hot-house  plants,  though  here  the  source  of  the  irritant  may  escape 
diagnosis  unless  the  ])ossibility  is  borne  in  mind  ;  particularly  in  the  case  of  persons  living 
in  houses  upon  which  libus  to.ricodeudron  is  growing  in  place  of  ampeloijsis  as  a  Virginia 
creeper.  Knot-grasa  is  a  common  weed  in  some  districts,  but  it  is  not  likely  to  produce 
erythema  unless  the  patient  has  recently  been  indulging  in  extensive  weeding  operations 
in  the  garden. 

The  slings  of  jellij-Jisli  are  familiar  to  bathers  as  well  as  to  fishermen,  and  in  addition 
to  intense  itching  and  irritation,  acute  oedema  may  result  and  generalized  erythema  and 
urticaria.  The  skin  eruption  may  not  be  confined  to  the  part  actually  stung  by  the  jelly- 
fish, for  sometimes  after  a  latent  period  of  from  twelve  to  twenty-four  hours  there  may  be 
a  generalized  erythematous  eruption  although  the  jelly-fish  sting  may  have  been  purely 
local.  It  is  not  so  nuich  the  small,  fiat,  gelatinous  jelly-fish  that  are  the  worst  offenders  in 
this  respect,  as  the  nuich  larger  ones  with  long  red  streamers. 

The  effects  of  being  pricked  by  the  spines  on  the  gills  or  fins  of  certain  fish,  especially 
sea-cdls  and  iveever  fish,  are  familiar  to  most  fishermen  ;  in  addition  to  acute  irritation  of 
the  skin,  with  or  without  urticaria,  there  may  be  intense  swelling,  vomiting,  headache,  and 
a  feeling  of  such  illness  that  the  patient  may  be  confined  to  bed  in  a  temporarily  serious 
condition  for  several  days.  Sometimes,  indeed,  the  local  spot  which  has  been  pricked  may 
fester  and  remain  a  sore  for  many  months. 

Most  of  the  trade  irritants  are  apt  to  go  further  than  the  ijroduction  of  erythema,  an 
acute  vesicular  dermatitis  being  even  commoner  as  the  result  of  irritants  mentioned  on 
page    222. 

Little  need  be  said  about  the  erythema  following  upon  operations,  or  that  which  follows 
ujjon  f.rtrcmes  of  heat  or  eold.  Local  erythema,  especially  of  the  feet,  was  very  common 
amongst  those  who  had  to  man  the  trenches  in  the  Great  War  :  in  most  instances  it  stopjied 
short  of  actual  frost-bite  with  gangrene,  but  the  erythema  jjersisted  for  weeks  or  months, 
accompanied  by  swelling,  and  great  local  pain  and  conserjuent  limping  gait. 

One  need  not  discuss  from  the  jjoint  of  view  of  the  erythema  itself  the  reddening  that 
may  be  associated  with  abscess  formation,  phlebitis,  cellulitis,  lymphangitis,  etc.,  men- 
tioned in  (iroup  6  in  the  above  list.  The  diagnosis  is  indicated  by  other  symiitoms  that 
will  ]>v  ]jresent. 

Ptomaine  poisoning  is  characterized  nuich  more  by  aeute  vomiting,  accompanied  or 
followed  by  severe  recurrent  diarrhoea,  than  it  is  by  erythema  ;  but  in  some  cases  in  which 
erythema  is  a  prominent  feature  it  may  make  the  diagnosis  less  easy  than  when  it  is  absent. 
When  a  single  patient  is  attacked,  the  nature  of  the  condition  may  be  iliHicult  to  determine 
unless  en(|uiry  into  the  previous  dietary  shows  that  siime  ])urticul:ir  food  likely  to  jjroduee 
ptomaine  poisoning  has  been  partaken  of  ;  the  erythema  generally  comes  on  either  at  once 
or  else  twenty-four  hours  or  more  after  the  food  in  question.  It  is  noteworthy  that  ])recisely 
similar  erythema  may  result  in  some  cases  from  the  ingestion  of  foods  which  do  not 
make   other   persons  ill  at  all,  in  which  r(s|)eet  there  are  personal  idiosyncrasies  to  crab, 


ERYTHEMA  225 

strawberries,  and  occasionally  to  other  quite  ordinary  foods  whicli  the  patient  can  never 
take  without  suffering  from  erythema  or  urticaria,  or  both. 

In  cerebrospinal  meningilis  generalized  erythema  is  only  one  of  many  possible  skin 
eruptions  ;  herpes  facialis  is  much  commoner,  and  a  vesicular  eruption  on  the  trimk  and 
limbs  is  more  usual  than  one  whicli  is  purely  erythematous.  Most  characteristic  of  all, 
however,  are  purpuric  spots,  varying  in  size  from  mere  petechiae  to  relatively  large  purple 
blotches,  though  this  purpura  develops  in  less  than  half  the  cases  ;  at  the  same  time  there 
will  in  most  cases  be  somnolence,  headache,  green  vomit,  and  pyrexia  to  indicate  the  nature 
of  the  malady,  the  diagnosis  of  wJiicli  is  confirmed  by  finding  meningococci  after  lumbar 
puncture. 

In  malaria  acute  erythema  is  not  common  ;  the  patient  will  generally  gi\e  a  charac- 
teristic history  of  recurrent  rigors  with  intervals  of  jserfect  health,  and  he  will  have  lived 
or  be  living  in  a  malarial  district  ;  haematozoa  (I'lalc  \l..  p.  :52)  will  be  looked  for  in  the 
blood. 

Leprosy  is  discussed  on  page  403,  and  dengue  on  page  460  ;  patchy  erythema  is 
almost  constant  in  the  latter,  but  is  not  so  frequent  in  the  former. 

The  main  characters  of  each  of  the  various  diseases  that  may  be  associated  with  local- 
ized erythema  mentioned  in  Group  8  (n)  in  the  list  abo\'e,  are  described  in  other  parts 
of  this  volume  :  erysipelas  on  page  674  ;  small-pox  on  page  360  :  erythromelalgia  on  page 
236  ;  Raynaud's  disease  on  page  256  ;  erythema  induratum,  or  Bazin's  disease,  on  page 
404  ;   polymyositis  and  trichinosis  on  page  464  ;   and  rat-bile  fever  on  page  598. 

Pellagra,  rare  though  it  is  in  this  country,  has  now  been  recognized  in  so  many 
in(livi<lual   patients   and   in   such   various   parts   of  Great   Britain,  that    it    merits   speeia! 


e  chiirt  of  tlic  hi 
TlR.l'iitic-„tl,;H 


idmitted  to  hospit;! 


MKiitioM.  for  altlKjugh  it  is  nmch  eonunoner  in  other  countries,  especially  Italy,  it  seems 
likely  that  it  would  be  diagnosed  correctly,  and  more  often,  if  its  chief  characters  were  more 
familiar.  The  malady  is  one  of  months  or  years  as  a  rule,  and  a  certain  proportion  of  the 
eases  recover.  The  disease  starts  as  a  rule  with  acute  gastro-intestinal  disturbances  in  the 
form  of  nausea,  vomiting,  and  diarrha-a,  which  last  is  generally  severe  and  sometimes  hitra.'t- 
able.  .\ente  i)tomaine  jmisoning  may  be  simulated  at  this  stage:  but  the  diarrlura.  which 
is  seldom  absent,  persists  in  a  way  that  will  exclude  ptomaine  poisoning,  whilst  at  the  same 
time  there  is  generally  a  remarkable  soreness  of  the  montli  and  tongue  and  considerable 
salivation,  such  as  does  not  acc^ompany  ])tomaine  poisoning.  Such  an  attack  may  subside, 
to  recur  after  an  interval  of  days  or  weeks,  and  sooner  or  lalci-  lurxous  symptoms  of  a 
serious  nature  are  added.  These  nerve  symptoms  may  take  the  form  sitni)ly  of  progressive 
weakness,  but  more  ol'ten  they  may  simulate  some  gross  intracranial  change  on  account  of 
the  severity  of  headache  with  vomiting  and  giddiness,  semi-coma,  and  e\iii.  in  exceptional 
cases,  optic  neuritis  or  optic  atrophy.  Hallucinations  are  eonmion.  and  moI  a  lew  of  the 
patients  become  actually  insane,  though  this  does  not  hap])en  as  a  rule  until  I  lie  disease 
has  been  present  for  some  time.  During  exacerbations  there  may  be  ))yrexia,  sometimes 
of  long  duration  {Fig.  101),  though  generally  not  of  severe  degree.  The  two  chief  groups 
of  symptoms  which  call  attention  to  the  seriousness  of  the  patient's  illness  in  its  earlier 
stages  are  the  gastro-intestinal  on  the  one  hand,  and  the  cenbral  upon  the  other.  If  cither 
of  these  were  present  alone  the  correct  diagnosis  would  probal)ly  never  strike  one,  but  the 
characteristic  feature  which  may  very  likely  call  one's  alterdion  to  the  luiture  of  the  case, 
rare  though  the  contlition  is,  arc  the  changes  in  the  skin.  A  few  days,  weeks  or  months 
after  the  lirsl  onset  there  develops  on  the  backs  of  the  hands  a  remarkable  discoloration 
I)  1"> 


•226  ERYTHEMA 

whicli,  at  first  red  and  erytliematous,  presently  becomes  more  pigmented,  so  as  to  resemble 
a  condition  of  extreme  sunburn.  The  skin  soon  becomes  not  only  dark  but  thickened  and 
rough,  and  jjresently  also  cracks  or  fissures  may  occur  and  desquamation  follows.  Such 
an  attack  of  erythema  of  the  dorsal  surface  of  the  hands  may  subside,  to  recur  again  after 
an  interval,  and  it  may  then  spread  to  the  face  or  other  parts,  remaining  nearly  always 
symmetrical  (Plate  IX.).  There  is  a  well-defined  line  of  demarcation  between  the 
erythematous  or  pigmented  ])arts  and  the  normal  skin  immediately  above  it.  It  is  by 
these  skin  changes  that  the  disease  is  recognized,  and  it  is  generally  upon  looking  back 
over  the  history  that  one  realizes  that  the  previous  cerebral  or  gastro-intestinal 
attacks  were  part  of  the  same  malady.  Cases  have  been  recorded  in  ])atients  who  have 
never  been  out  of  London,  whilst  in  some  village  districts  in  Hampshire  and  in  some 
parts  of  Scotland  several  consecuti^•e  cases  have  been  recognized  in  the  same  valley, 
and  there  is  a  belief,  not  yet  proved,  that  the  disease  is  microbic,  and  spread  by  infection 
from  water  derived  from  particular  soil  ;  though  there  is  an  alternative  theory  that  it  is 
a  malady  of  diet,  pellagra  having  been  attributed  to  maize  in  much  the  same  way  that 
beri-beri  is  to  decorticated  rice. 

Both  Meige's  disease  and  angio-neurolic  oedema  are  characterized  by  oedema  rather 
than  by  erythema  in  the  great  majority  of  cases  (p.  -HI)  ;  in  each  of  these  two  conditions, 
however,  which  are  doubtless  in  their  primary  pathology  related  to  one  another,  both  being 
functional  disorders  of  the  vasomotor  system,  the  patient  is  liable  to  acute  attacks  associ- 
ated with  vomiting,  possibly  diarrhoea,  malaise,  generalized  backache  and  limb  pains, 
pyrexia  amounting  to  101°  or  102°  F.,  and  acute  erythematous  eruptions  which  may  be 
localized  or  general.  The  erythema  is  very  similar  to  that  of  erysipelas,  especially  when 
the  attack  is  localized,  and  it  is  more  than  probable  that  when  the  first  attack  occurs 
erysipelas  will  be  diagnosed.  The  attack  may  last  a  day  or  two,  or  a  week,  and 
then  subside  either  completely,  or,  in  Meige's  disease  particularly,  there  may  be  a  tempo- 
rary or  even  permanent  increase  in  the  localized  oedema.  The  exact  nature  of  such  an 
attack  may  escape  recognition  until  familiarity  with  them  is  established  by  their  recurrence 
in  the  same  patient  at  intervals  of  months  or  years,  each  subsequent  attack  being  \'ct\ 
similar  to  the  one  before  ;  another  point  which  may  assist  the  diagnosis  even  in  a  first 
attack  is  the  occurrence  of  similar  pyrexia!  and  erythematous  bouts  in  other  members  of 
the  same  family,  for  both  Meige's  disease  and  angio-neurotic  oedema  are  familial  disorders. 
The  erythemata  due  to  parasitic  toxaemia,  especially  to  hydalid  disease,  tapeworm 
infection,  filariasis  and  tn/paiiosomiasis  may  sometimes  be  extreme,  and  in  a  case  of 
severe  erythema  with  constitutional  symptoms  in  which  no  apparent  cause  can  be  found, 
examination  of  the  hcces  for  tapeworm  ova  should  not  be  omitted.  In  some  cases  of 
hydatid  disease,  generalized  erythema  has  been  the  first  symptom  to  draw  attention  to 
the  fact  that  anything  was  wrong,  but  to  attribute  such  erythema  to  hydatid  infection 
would  be  exceedingly  dilficult  unless  upon  physical  examination  some  evidence  of  a  cyst 
in  the  liver,  in  the  peritoneum,  or  elsewhere  could  be  found.  If  the  possibility  were 
suspected,  but  no  confirmatory  signs  discovered,  an  additional  test  is  the  specific  hydatid 
serum  reaction,  for  which  blood  can  be  taken  from  the  patient,  as  in  testing  the 
Wassermann  reaction,  and  sent  to  a  special  laboratory  for  examination.  If  there  were 
acute  erythema  from  hydatid  disease,  the  hydatid  would  almost  certainly  be  active  and  the 
patient's  blood  serum  woidd  give  a  positive  hydatid  precipitin  reaction  ;  whilst  Eosinophilia 
(p.  218)  would  probably  be  pronounced  also.  The  erj'thema  of  filariasis  and  of  trypanoso- 
miasis may  occur  early  in  the  infection  :  the  nature  of  the  malady  would  be  proved  by 
the  discovery  of  filaria  embryos  (Plate  XXVIII,  Fig.  i*",  p.  614).  or  of  trypanosomes  (Plate 
XXVIII,  Fig.  G,  p.  61-1)  in  the  patient's  blood,  though  the  nature  of  the  infection  would 
first  be  suggested  by  the  history  of  residence  in  countries  in  which  one  or  other  of  these 
parasites  is  prevalent. 

There  remain  for  discussion  erythema  simplex,  erythema  multiforme,  erythema 
exfoliativum  sen  scarlatiniforme  ;  scarlet  fever  ;  German  measles  ;  '  fourth  '  disease  ; 
and  the  erythema  of  acute  rheumatism.  When  erythema  due  to  any  of  these  causes  is 
met  with,  the  main  object  in  the  diagnosis  will  be  to  either  recognize  or  exclude  scarlet  fever. 
It  will  be  found  in  practice  that  it  is  sometimes  quite  impossible  to  be  certain  whether  a 
given  generalized  erythema  is  that  of  scarlet  fever  or  not.  So  much  a  matter  of  opinion 
may  it  be  that  even  at  a  consultation  between  the  highest  physicians  some  will  consider 


PLATE     IX 


PELLAGRA 


TluB  iKilieiit  is  a  man  wlio  Imd  a  sevoro  attack  o£  pellagra  during  tho  summer  of  lillO,  ami  won!  inlo  complete 
rirni.-vsiou  in  aljoiit  two  moiitln.  Ho  has  not  come  unjer.  observation  siuce.  Note  lesions  on  liaml-i,  lower  part  of 
n>rL'arms,  lorcUeail,  side  of  the  nose,  and  cWm.— The  PImtograiih  is  In/  Dr.  ISncrlni  I;    TiiektT    r  s   \ 


Itrprailiiml  hu  imminxion  Imin  •T/i-  M'jdical  Annual: 


TM>1K     m-     lil\r;x<,-.IS-rr/  /ore  /i. 


ERYTHEMA  227 

the  lesion  to  be  that  of  scarlet  fever,  others  will  say  that  in  their  opinion  it  is  certainly  not 
scarlet  fever.  The  importance  of  the  decision  lies  in  deciding  whether  the  patient  should 
be  sent  to  a  fever  hos|3ital  or  not.  If  the  condition  is  not  scarlet  fever,  then  by  so  sending 
the  patient  to  a  fever  hospital  one  renders  him  liable  to  get  scarlatina  if  his  erythema  is  of 
some  other  kind.  If,  on  the  other  hand,  his  condition  is  really  one  of  scarlet  fever,  and  it 
is  regarded  as  non-scarlatinal  from  the  atypical  character  of  the  rash,  other  individuals 
in  the  household  or  community  may  catch  the  infection  if  the  patient  is  treated  as  suffering 
from  some  other  form  of  erythema.  The  right  thing  to  do  under  such  circumstances  is  to 
isolate  the  patient  as  though  it  might  be  scarlet  fever,  until  the  jirogress  of  the  case  and 
other  circumstances  prove  that  it  is  not  :  carrying  out  the  isolation  in  a  separate  room, 
in  which  the  patient  himself  runs  no  risk  of  infection  from  other  scarlatinal  cases.  In  not 
a  lew  such  instances  there  will  be  doubt  for  all  time  as  to  whether  the  patient  has  had 
scarlet  fever  or  not  ;  because,  especially  now-a-days,  the  scarlatinal  rash  is  sometimes 
almost  transient  and  is  often  atv-pical.  The  important  points  to  pay  attention  to  are  : 
the  onset  of  the  illness  on  the  day  before  the  rash  appears  with  vomiting  as  an  early  sym- 
ptom ;  the  extreme  redness  of  the  throat,  fauces  and  pharynx  :  the  coated  tongue,  perhaps 
with  red  fungiform  papilL-c  projecting  through  the  pallor  of  the  fur  ;  pyrexia  of  102°  or 
10;j"  F.,  which  if  the  case  be  followed  shoidd  fall  by  lysis  and  reach  normal  about  the  end  of 
the  first  week  if  there  are  no  complications  such  as  otorrhoea  or  adenitis  ;  tender  swellings  in 
the  neck  ;  absence  of  all  rash  upon  the  face,  forehead,  scalp,  or  behind  the  ears,  associated 
with  a  bright  scarlet  erythematous  eruption  all  over  the  trunk  and  limbs,  beginning  at  the 
root  of  the  neck  and  extending  thence  downwards.  This  erythematous  eruption  will  be 
found  on  careful  inspection  to  he  not  jjurely  erythematous,  but  an  erythema  associated 
with  very  tine  red  dots,  which  show  up  best  if  some  affected  part  of  the  skin  is 
pressed  gently  with  a  glass  s])atula  or  microscope  slide,  so  that  after  the  redness  of  the 
erythema  has  disappeared  by  the  compression  the  minute  red  dots  can  still  be  seen.  It  is 
a  '  punctate  '  erythema.  If  with  these  characteristics  the  patient  also  has  a  mild  degree 
of  albuminuria,  the  diagnosis  of  scarlatina  is  exceedingly  likely  ;  and  if  after  ten  days  or  a 
fortnight  the  characteristic  iiccling  develops,  starting  roimd  small  pin-prick-likc  foci  and 
extending  tlience  concent rically  away  from  the  central  niimitc  hole,  the  diagnosis  is  almost 
certain.  L'pon  the  hands  and  feet  the  descjuaniation  tloes  not  have  this  jjin-hole  ty|)e, 
the  surface  epidermis  coming  off  rather  in  Hakes  or  casts  than  in  fine  scales. 

One  of  the  most  dillicult  skin  allections  to  distinguish  from  true  scarlatina  is  (ii/thcma 
scail'iliiiifoniie.  which  lias  also  been  Vi\\k\\  <n/llirmri  e.rfolidliviim  :  with  this,  either  at  the 
same  time  that  (he  rasli  appears,  or  a  few  hours  before  it.  the  patient  becomes  suddenly 
ill,  with  shivering  and  loss  of  appetite,  and  there  may  be  reddening  of  the  tonsils  and  fauces, 
and  a  condition  of  tongue  very  like  the  strawberry  tongue  of  scarlet  fever,  with  pyrexia. 
Krythema  scarlat in i forme  is  apt  to  recur  in  the  same  patient,  and  the  dilliculty  ol' diagnosis 
will  be  much  less  after  a  second  or  later  attack  than  it  is  in  a  first,  but  most  cases  arc  dia- 
gnosed as  scarlet  fever  in  their  first  attack.  Owing  to  the  close  resemblance  between  the 
two  diseases,  it  is  certainly  right  that  such  patients  should  be  isolated  in  any  case.  Two 
points  of  (listinelion  iKlwecn  the  two  thai  are  worthy  of  special  note  arc:  (irsl.  that  with 
scarlet  fever'the  dcs(|iiaiMalioii  seldom  begins  before  the  end  of  the  (irsl  week  and  is  usually 
not  at  all  marked  until  cncii  hilir  Ih.in  lliis;  in  irythema  scarlatiniforme  des(|uamatioii, 
which  nia\-  be  extreme,  geiieially  sliiiK  wliilsl  Hie  erythema  is  still  present,  often  on  the 
second  or  third  day.  ami  niarJN  always  no!  later  llian  the  third  or  Iburlh  ;  and  secondly, 
that  the  er\tliema  <il' scarlel  lever  may  last  twelve  hours  or  less,  and  seldom  has  a  duration 
of  as  inueli  as  a  we<k.  whilst  tliMt  of  erylhema  scarlatiniforme  iiia\-  persist  for  two  or  three 
weeks,  or  in  some  eases  even  I'ur  a  iiionlli  or  more. 

Kii/lhcnni  iiiiiltifuniic  wlii<'li  is  mie  of  the  ervtlieniata  which  may  be  classed  as 
appiircntly  idiopatliic.  seeing  llial  i]ii  cause  is  known,  is  generally  distinguished  from  other 
forms  by  the  fact  that  it  is  \(iy  seiiiorn  purely  erythematous.  There  are  nearly  always 
vesicles  or  even  l)iilla-  al  the  same  lime  (p.  7.j(i),  whilst  scarlet  fe\cr  and  the  other  erylhe- 
niala  we  are  discussing  pi'aelieally  never  hecome  vesicular. 

Kii/llicuKi  .•iitiijilc.r.  which  may  also  resemble  mild  scarlel  lever,  iir  be  mislMken  for  it, 
is  perhaps  e\-eii  moic  liable  lo  In-  iiiislaU'ii  Inr  iiiiM  <'r\sipelas  :  jl  is  seldom  universal  ; 
Innieh  more  ol'len  il  occurs  in  local  |ialelies.  It  llniv  are  se\i  i;il  palehes  on  diri'erent  parts 
lof  Hie  body  a  I   Hie  s:ime  Hiiie.  erysipelas  would  he  unlikely,  nor  is  Hie  e.igi'  of  each  reil  patch 


228  ERYTHEMA 

as  mucli  raised  or  as  shai])Iy  defined  as  is  that  of  erysipelas  :  in  addition  to  wliicli  tliere 
are  few  if  any  constitutional  symptoms,  and  little  pyrexia  or  none.  Sometimes  the  patches 
come  and  go  over  a  ])eriod  of  days  or  weeks,  either  in  the  same  or  in  different  parts  of  the 
body,  and  then  the  term  eri/thetiia  fiignx  is  apjjlied.  The  diagnosis  of  erythema  simplex 
can  only  be  made  wlien  the  lireumstanccs  of  the  case  lead  one  to  exclude  all  other  possi- 
bilities, and  the  main  dillicidty  will  be  to  be  certain  that  the  patient  is  not  having  a  very 
mild  and  atypical  attack  of  scarlet  fever.  In  all  such  cases  very  careful  watch  should  be 
kept  upon  the  condition  of  the  urine,  lest  there  should  be  nephritis  really  of  scarlatinal 
origin,  which  if  not  looked  for  in  this  way  may  escape  detection  altoi>ether  ;  the  patient 
coming  under  observation  ten  or  fifteen  years  later  with  a  Host -Hradlord  kidney  (p.  11) 
arising  out  of  a  condition  which  was  so  mild  as  to  be  diagnosed  erythema  simplex,  when 
it  was  really  scarlatina. 

Acute  rlieiimalisrn  is  liable  to  be  associated  with  various  skin  eruptions,  including  not 
only  subcutaneous  nodules  (p.  405)  and  erythema  nodosum  (p.  404),  but  also  generalized 
erythema.  Doubt  has  been  expressed  as  to  whether  some  of  the  cases  in  which  joint  pains, 
transient  bruits  and  erythema  have  been  attributed  to  acute  rheumatism  are  really 
rheimiatic  at  all:  but  in  the  absence  of  proof  to  the  conti-ary,  one  must  in  the  meanwhile 
allow  that  the  older  teaching  may  be  correct,  and  that  acute  generalized  erythema  closely 
simulating  scarlet  fever  may  be  associated  with  rheumatic  fever.  If  there  are  no  joint 
pains  in  such  a  case  the  diagnosis  will  be  very  dillicult,  but  if  there  are  joint  pains  and 
]iyrexia.  and  if  both  the  pyrexia  and  the  joint  pains  disappear  within  thirty-six  or  forty- 
eight  hours  after  the  administration  of  salicylate  of  sodium  in  appn>])riate  doses,  the 
probabiMty  will  be  that  the  patient  is  suffering  from  acute  rheumatic  erythema.  The 
erythema  itself  is  of  little  moment  in  such  cases  ;  the  main  point  in  the  case  is  to  eliminate 
the  possibility  of  scarlet  fever  with  joint  pains,  and  if  there  is  doubt  it  will  be  better  to 
treat  the  patient  as  a  possible  case  of  scarlet  fever  than  to  assume  too  readily  that  the  con- 
dition is  rheumatic.     Sore-throat  may  be  a  marked  feature  in  either  case. 

This  leaves  for  discussion  measles,  German  measles  and  ^fourth  '  disease.  Both  measles 
and  German  measles  are  nearly  always  inaculo-papular  rather  than  purely  erythematous 
as  regards  the  skin  eruption,  and  the  rash  in  both  these  diseases  affects  the  face  and  the 
neck  as  much  as,  and  even  sooner  than,  the  body  or  limbs  ;  whereas  in  scarlet  fever  the 
actual  exanthein  does  not  attack  the  face  at  all,  though  the  latter  often  has  a  characteristic 
appearance  of  pinkness  of  the  cheeks  with  pallor  round  the  nose  and  mouth,  the  general 
tone  and  appearance  having  been  described  as  the  '  peach-blossom  '  fades.  In  measles, 
moreover,  there  will  almost  certainly  have  been  some  constitutional  symptoms  for  about 
three  days  before  the  rash  appears,  especially  running  at  the  eyes  and  nose  simulating  a 
common  cold  ;  in  addition  to  which  a  very  helpful  point  in  differential  diagnosis  is  the 
develo|)ment  of  Koplik's  spots  (Plate  VIII.  p.  178)  within  the  mouth.  These  may  occur 
singly,  but  more  often  they  are  in  groups  varying  in  number  from  two  or  three  to  a  score 
or  more,  each  spot  ha\ing  a  pale,  almost  white,  centre,  the  size  of  a  small  pin's 
head,  surrounded  by  a  deep-red  injected  periphery  ;  they  are  to  be  expected  upon  the  inner 
surface  of  the  cheeks,  upon  the  mucous  surface  of  the  lips,  and  sometimes  upon  the  gums, 
generally  at  some  little  distance  from  the  teeth.  They  may  also  develo])  upon  the  mucous 
membrane  of  the  soft  or  hard  palate,  though  here  they  may  be  simulated  by  particles  of 
milk  if  care  is  not  taken  to  see  whether  or  not  they  are  removable  by  means  of  a  soft  brush. 
German  measles  is  more  apt  to  simulate  scarlet  fever  than  ordinary  measles  is,  and 
with  German  measles  there  are  no  Koplik"s  spots  to  help  one.  The  rash,  however,  if 
inspected  carefully  in  different  parts,  will  generally  be  found  to  be  a  characteristic  macular 
one  somewhere,  and  it  will  be  found  u])on  the  face  or  forehead,  or  behind  the  ears,  which 
will  not  be  the  case  with  scarlet  fever.  The  constitutional  symptoms  are  generally  slight, 
even  though  the  rash  is  very  extensive,  and  a  very  lielpful  point  in  diagnosis  is  the  presence 
in  German  measles  of  generalized  enlargement  of  the  lymphatic  glands,  including  not  only 
those  in  the  neck,  axillse,  and  groins,  but  also  those  in  the  occipital  region.  In  scarlet  fever, 
although  the  glands  in  the  neck  may  be  swollen  and  very  tender,  those  in  the  occipital 
region  and  elsewhere  are  not  generally  enlarged. 

The  chief  remaining  difficulty  is  in  connection  with  what  has  been  called  '  Fourth  ' 
disease.  Though  this  is  accepted  by  many  observers  as  being  a  distinct  entity,  its  exist- 
ence is  not  allowed  by  all.      It  has  struck  many  observers,   however,  that  patients  who 


PLATE     X 


PELLAGRA 


[/iff*.      ^^ 


'J'lip  liaiiij  of  a  polliii^rin.    Note  Mm  arena  of  sioiif^hhif?,  and  the  deep  Ilftsiiro  botwonn   the  Indix 
and  middle  lingers. —  Tlic  Pliiiltigraph  is  bij  Dr.  Uncrletj  It.  Tucker,   U.S.A. 

Itrproihinil  liij  lurmi.inion  Irani  •Tht  .Medial'.   .Ini'uuU.' 


iNi.i.x    or    nucNosis-  7V) /,ic  /,. -jjs 


EXOPHTHALMOS  229 

Imve  been  known  to  liave  had  German  measles  and  ordinary  measles  and  scarlet  fever 
defin.tely  m  the  past,  may  yet  develop  an  acute  erythematous  exanthem  which  has  some 
of  ti.e  characteristics  of  measles,  some  of  the  characters  of  German  measles,  and  some  of 
the  characters  of  scarlet  fever,  without  nevertheless  being  typical  of  anv  one  of  these  three 
The  malady  may  spread  through  a  school  or  a  household  or  institution." and  produce  similar 
characteristics  m  other  individuals  who,  not  having  had  scarlet  fever  or  measles  before 
If  seen  by  themselves  would  be  diagnosed  as  suffering  from  one  or  otiicr  of  the  three 
better  known  maladies.  As,  however,  in  such  an  epidemic  it  may  attack  those  who  have 
had  scarlet  fever  before  and  also  those  who  have  had  measles  before,  and  those  who  have 
had  German  measles  previously,  in  addition  to  those  who  have  liad  all  three  before,  those  who 
have  had  most  to  do  with  ca.ses  of  this  kind  incline  to  the  belief  that  there  is  a  definite 
fourth  disease-  distinct  from  the  other  three.  It  is  a  relativelv  mild  maladv.  with  some 
pN-rexia  and  some  constitutional  disturbance,  but  not  much  of  either,  and  in  all  cases  there 
IS  a  widespread  erythematous  or  maculo-eiNthematous  eruption.  There  are  no  points 
which  arc  distinctive  of  the  n,alady,  however,  and  if  it  exists  at  all  it  can  onlv  be  diagnosed 
when  circumstances  suggest  that  patients  are  suffering  from  it  who  ouoht  not  to  be^iable 
to  any  one  of  the  three  better  known  exantliems  of  similar  type.  The  weak  point  in  the 
argument  ,s  that  ,t  ,s  a  well-known  fact  that  although  German" measles,  measles  and  scarlet 
fever  protect  agamst  subsequent  attacks  of  the  same  maladies  in  most  individuals  there 
are  some  wl,o  may  have  not  only  two  but  three  or  even  several  separate  attacks  of  either 

dehn  ;.l"in  h"'  ",  "T'^"'  ^'"""  ''   '*"^'  '"  ''  «"  t'"«  =*"""»*  «>'^t  one  cannot  say 

dehnitcl     that  there  ,s  such  a  disease  at  all  as  the  ■  fourth '  disease.     Hence  its  diagnosis  in 
anx  pa, ticular  instance  must  necessarily  be  one  of  o,)inion  only.  „„,,„7  ^„„,,,_ 

ERYTHRvi;MIA.-(See  Polycyth.emia,  p.  532.) 

ERYTHRASMA.— (See  FrN-cors  Affections  of  the  Skix.  p.  2.51.) 

ERYTHROPSIA.  -  (.S,.c  A-,s,ox.  Defects  of.  p.  762.) 

EXOPHTHALMOS  (or  Proptosis)— May  be  bilateral  or  unilateral. 

Bilateral  Exopiithalmos.-Thc  commonest  cause  of  this  condition  is   Graves. s  disease 

swelling  of  the  thyroid  gland,  fine  tremors,  and  general  nervousness.     The  eves  are"  pushed 

orward  to  a  varying  extent  (/.'/«.  114.  p.  236).  in  some  cases  the  protrusionbeing  so  great 

mncr   n  iT"      •''">' ,"""'"  'f  "'^ered  entirely  by  the  lids.     The  protrusion  c^iuses  the 

ler  iKl    o  be.  unusually  raised,  and  the  eyes  look  wide  open,  giving  the  patient  an  exprcs- 

m  eri,  ri  ;""um''"  ""T  '''  /^'^-'I-ag's  sign,   due   to  spasn>  of  the  levator  palpebne 

a     h     .  r  ;       .     r;  "T  "?'  '""*'""■  ""'  ""'"■'■  '"'^  '^^  ""*  "'■^'•""'  t«  'h«  -""^  '-t"'t 

sign).     ^^  inking   fakes   phu^c   less   ire,,uently.   an.l   <„nvergeiuc   „(    the   eves    s   sometimes 

rendered  dimcull  (the  sign  of  Mobiiis).  i.ves   is   sometmies 

^lateral   .•xophthalmos   may   also  be  caused   by   timnnhoxis  of  the  owenwus  sinuses. 

Ih.s  c.nditK.M  IS  usually  secondary  to  some  furuncl,.  or  carbuncle  of  the  skin  of  the  face  in 

the  region  ol     h..  eye    to  orbital  cellulitis,  or  suppmati..,,  in  the  accessory  sinuses  of  the 

the  ;ft.  .L     "t''  ""  '""■  "'■'■•  ""•'  '■'^•"■•'='''l>   N-'-.ls  to  both  in  th"e  later  stages  of 

ro„r       n  i     7'/,'  T"  ="•'•.'■'•""•'"''■''  =""'  <i>^<<'-  "■<■  «yelids  are  red  an.i  engorged,  and  the 

front.  I  and  opht  haln.ic  veins  are  dilated  aiul  full.     .Movements  of  the  eves  are  verv  limite.i, 

;  H  it   r^rn  ".'"      .r     "'^'  '""'  '"''"■•''»'""  "'•  *'"•  '"•'•i<»l  tissues.     In  "association  with  the 
o  b  tal  inhltia  ion  therr  is  often  some  swelling  in  the  r<.gion  of  the  mastoid  process,  owing 

cate  ui.r   l'"  ■■'■'"""  "'""  '"'"""■'   '''"'  "'  '■"•""•'■''""  "i"'  •'■>■  sinuses  that  communi- 

cate «,th  the  two  cavernous  smuses.      This  eon.lilion  is  nenilv  mIumvs  ImImI.  as  il   is  lollowe.l 
In  a  Mippuialixc  iik  iiiiiuilis. 

tnilatcral   Exophthalmos  mav  Ik   diu   lo  : 

f,!^''"'-',  '■'"'"'' '^  Kxostosis 

ll.r.m,M,sis„ft|„.,.av<Tn.M.s  sinus  Tul.orele 

Men'n      '",'"-''';^            ,  .Vrterio-ven.n.s   aiuM.rvsn, 

r          e         '■  ""'   '"'■'■|''-'"''l''  l)isl,.,.ti,>u   .,!■  tl„.   a,;-..ss„rv   sinuses 

''"""";'  of  the  nose. 

New  {.rowlli 


230 


EXOPHTHALMOS 


The  diagnosis  of  orbital  cellulitis  and  thrombosis  of  the  cavernous  sinus  presents  little 
dillieulty,  owing  to  the  symptoms  of  acute  inflammation  that  are  present,  orbital  cellulitis 
being  distinguished  from  cavernous  sinus  thrombosis  by  the  fact  that  it  is  usually  unilateral 
and  there  is  no  oedema  in  the  mastoid  region. 

Orbital  periostitis,  especially  in  more  chronic  cases,  may  give  rise  to  varying  degrees  of 
proptosis,  and  in  tlie  absence  of  any  obvious  thickening  of  the  orbital  margins  the  diagnosis 
may  be  obscure.  In  any  periosteal  inflammation  of  long  standing,  a  skiagram  will  usually 
show  a  definite  increase  of  density  in  the  affected  bone. 

jMeningoceles  and  enceplialoceles  may  in  some  cases  be  difficult  to  diagnose  from  der- 
moid cysts.  The  latter  are  usually  placed  anteriorly  in  the  orbit,  and  do  not  therefore 
cause  any  jjroptosis,  though  they  may  displace  the  eyeball.  A  meningocele  usually  presents 
itself  through  a  gap  between  the  ethmoid  and  the  frontal  bones  (Fig.  lOii).  and  is  attached  to 
the  bone.  An  opening  may  sometimes  be  found  through  which  the  meningocele  communi- 
cates with  the  cranial  cavity.  Meningoceles  sometimes  pulsate  in  association  with  the 
arterial  and  respiratory  oscillations.  They  may  also  be  diminished  in  size  by  pressure  of 
the  fingers,  as  the  fluid  can  be  squeezed  into  the  cranial  cavity.  In  many  cases  an  explora- 
tory jiiincture  is  the  only  means  of  making  a  certain  diagnosis. 

A  gumma  of  the  orbit  can  only  be  diagnosed 
from  the  patient's  general  history,  evidence  of 
specific  disease  elsewhere,  a  rapid  improvement 
in  the  condition  after  the  administration  of 
salvarsan,  mercury,  or  iodide  of  potassium, 
and  perhaps  a  positive  Wassermann's  serum 
reaction. 

A  groivth  of  the  orbit  has  usually  no  distinc- 
tive feature,  and  can  only  be  diagnosed  by 
means  of  an  exploratory  operation  and  the 
removal  of  a  portion  for  microscopical  examina- 
tion ;  but  it  is  to  be  remembered  that  tumours 
of  the  o])tic  nerve  can  usually  be  diagnosed  with 
accuracy  by  the  fact  that  they  always  produce 
some  compression  of  the  eyeball  in  the  antero- 
jiosterior  diameter.  Cases  of  proptosis,  there- 
fore, in  wliich  there  is  increasing  hypermetropia 
on  the  affected  side,  may  be  ascribed  to  a 
primary  tumoiu-  of  the  optic  nerve. 

Ivory  exostoses  or  osteoniata  usually  arise 
from  tlie  frontal  bone  and  are  attached  by  a 
broad  base,  so  that  their  removal  presents  very 
great  difficulty  :  the  diagnosis  depends  on  their 
slow  growth  and  excessi\e  hardness  ;  a  skiagram  shows  their  presence  with  great  certainty. 
Some  cases  of  tuberculous  disease  of  the  orbit  may  closely  simulate  orbital  cellulitis  or 
distention  of  the  accessory  sinuses  of  the  nose,  and  the  diagnosis  can  only  he  made  with 
certainty  after  excision  of  a  portion  of  the  infiltrated  tissue  and  a  microscopical  examina- 
tion of  the  fragment. 

.An  arterial  aneuri/sm  is  nearly  always  associated  with  a  pulsating  exophthalmos,  in 
which  there  is  protrusion  of  the  eyiball  and  dilatation  of  the  blood-vessels  of  the  retina, 
lids,  and  conjunctiva.  There  is  distinct  pulsation  of  the  eyeball,  and  a  loud  blowing  murmur 
on  examination  with  the  stethoseojje.  Compression  of  the  carotid  on  the  same  side  dimi- 
nishes the  pulsation  and  the  sound.  The  usual  cause  of  arterial  aneurysm  is  the  rupture 
of  the  carotid  into  the  cavernous  sinus  as  the  result  of  an  injiuy.  Rare  cases  are  also  seen 
of  intermittent  exophthalmos,  which  appears  only  at  intervals  or  when  the  head  is  depressed. 
These  are  usually  due  to  varicose  veins  in  tlie  orbit  not  in  conmiimication  with  an  artery. 

The  protrusion  of  the  eyeball  in  dilatation  of  the  accessory  .minuses  of  the  nose  is,  as  a 
rule,  less  an  exophthalmos  than  a  displacement  of  the  eyeball  downwards  and  outwards. 
In  dilatation  of  the  frontal  sinus  there  may  be  some  thickening  and  fullness  of  the  supra- 
orbital ridge  associated  with  pain  and  tenderness  over  the  eyebrow.  In  dilatation  of  the 
ethmoidal  cells  there  is  usuallv  a  definite  swelling  to  be  felt  at  the  inner  side  of  the  orbit. 


Fiif.  102. — A1liuiuo<  ek  piojettm^  i 
t  of  thr  l.isc  ot  till 
f-rrfow    1/in  urn    (  lai 


PLATE     XI 


ACUTE      INFLAMMATIONS      OF      THE      EYE 


''{ 


A.   A.-iilr  poiijiiiictivili^.     B.  A.'Htc  iritis,     c,  (iliiui-nnia.     D.  riil.v.loiiulur  coiijinicllvilis.     E.   I'"llliuhir  .■onjiin.-ti 


INDIA-  or  iincxosis- ro  /arc  p.  •.':10 


EYE,     ACUTE     INFLAMMATION    OF  231 

which  is  compressible  though  not  distinctly  fluid.  Dilatation  of  the  sphenoidal  sinus  is 
sometimes  accompanied  by  neuritis  or  atrophy  of  the  optic  nerve.  In  all  cases  of  jiroptosis 
due  to  sinus  trouble  of  any  duration,  there  is  evidence  in  the  nose  of  inflammation  of  these 
cavities,  the  usual  symptom  being  the  existence  of  poh'pi  or  of  definite  swellings  in  the 
region  of  tlic  infun(lil)ulum.  Herbert  L.  Ea'^on. 

EXPECTORATION.— (See  Sputa,  p.  641  :    and  H.kmoptvsis.  p.  285.) 

EXTENSOR   PLANTAR   REFLEX. -(See  Kauinski-s  Skin,  p.  08.) 

EYE,   ACUTE   INFLAMMATION   OF.— Acute  inflammation  of  the  eye  may  be  due 

to  tluce  main  types  of  disease.  (Oiijiiiictivitis.  iritis,  and  glaucoma.  The  character  of  the 
inflammation  varies  with  the  type  of  the  disease,  but  certain  symptoms,  such  as  pniii. 
photophobia  (intolerance  of  light),  and  lachripnatioii.  are  common  to  all  intlanmiatory  condi- 
tions, and  are  therefore  of  little  diagnostic  value. 

In  roiijiiiictivilifi  the  conjunctival  vessels  are  dilated,  bright  red.  and  injected  :  they 
are  freely  movalde  over  the  subjacent  sclerotic,  and  the  injection  is  most  evident  in  the 
e(juatorial  region  of  the  ball  of  the  eye,  the  circumcorneal  portion  of  the  conjunctiva,  owing 
to  its  (irmer  attachment  to  the  sclerotic  in  this  region,  being  relatively  paler.  The  cornea 
is  usually  clear  and  polished,  unless  there  are  corneal  ulcers  (see  below) ;  the  anterior 
chamber  and  iris  arc  normal  in  appearance,  the  pupil  is  black,  and  the  iris  active.  There 
is  always  more  or  less  secretion  of  puriflent  material,  which  collects  at  the  inner  angle  of 
the  palpebral  aperture  and  on  the  edge  of  the  lids,  especially  after  sleep.  The  eye  feels  hot 
and  dry,  and  owing  to  the  tedema  of  the  inner  surl'ace  of  the  lids  and  the  enlargement  of  the 
lymphoid  follicles,  there  is  a  feeling  of  grittincss  as  of  sand  or  dust  in  the  eye. 

In  the  ordinary  infectious  or  catarrhal  ophthalmia  ("  pink  eye  ')  the  inner  conjunctival 
surface  of  the  lids  is  velvety  and  swollen,  but  there  is  little  or  no  (edema  of  the  conjunctiva 
covering  the  eyeball.  In  gotiorrhaal  conjiinclivilis  by  contrast,  a  brawny  a?dema  of  the 
lids  and  intense  swelling  and  rpdema  of  the  conjunctiva,  which  is  raised  all  round  the  corneo- 
selcrotic  margin  {choiiosis}.  is  a  prominent  symptom.  In  the  earlier  stages  of  the  infection, 
the  discharge  is  yellow,  serous,  and  blood-stained,  but  rapidly  becomes  purulent  and 
extremely  i)rofuse.  The  cornea  ulcerates  as  a  rule,  its  substance  apparently  melting  away 
in  a  charaeteristie  manner,  (ionorrhteal  oi)hthalmia  of  the  new  born  (ophthalmia  neona- 
tiiruiu)  exhibits  similar  symptoms,  early  and  destructive  ulceration  of  the  cornea  being  one 
of  its  most  serious  complications.  In  follinilur  conjunctivitis  the  conjunctiva,  especially 
of  the  lower  lids.  Is  studded  with  small  raised  lymphoid  I'ollieles,  which  are  transparent  and 
iiclatinons  in  appearance.  In  irarliiiitiu  the  ennjuncl  i\a  is  also  studded  with  eidarged 
liilliclis,  Ifiil  In  Ibis  disease  they  are  found  particularly  <im  Ihc  under  surface  of  the  upper 
lid  and  in  llir  upper  eonjtmetival  fornix.  The  follicular  enlargement  is  associated  with 
considerable  Ihiekening  and  (I'dema  of  the  tissues  of  the  upper  lid  causing  a  jtarlial  ptosis, 
with  profuse  laehrvmation  and,  in  the  later  stages,  with  a  vascular  o])aeity  {painiiis).  of 
that  |)art  of  the  cornea  which  is  usually  covered  by  the  up|)er  lid.  In  the  later  stages  ol 
lra<homa  the  inliltration  is  followed  by  the  forn\ation  of  libnuis  tissue,  causing  beufling  ol 
llie  tarsal •libro-carlilage,  entroi)ion,  and  trichiasis.  In  phlijclciiular  conjunctivitis  there 
arc  to  be  seen  one  or  more  round  yellowish  raised  masses  at  the  eorneo-sclerotic  margin 
surrounded  by  a  localized  area  of  vascular  conjunctiva.  In  some  cases  the  phlyetemdes 
may  encroach  upon  the  corneal  surface,  being  IVillowed  by  a  trail  or  leash  of  conjunctival 
vessels.  Clininic  conjnnctivilis  in  adults  is  somelimes  eliarMcleri/.ed  by  being  eonlined  to 
the  inner  and  onler  angles  of  the  palpebral  aperture  (angular  conjunctivitis),  the  iideelion 
being  <lMe  in  lliis  case  lo  llie  diplobacilhis  of  Morax-.\xenfcld.  In  this  form  of  conjunctivitis 
llic  cdnis  ol'  llic  lids  as  well  as  the  conjunctiva  are  moist  and  red,  especially  at  the  inner 
an<l  outer  cant  bus. 

In  nicinhranoKs  ciinjiinctivilis.  which  riiiiy  be  due  cillicr  In  IIk'  diplil  liciia  liaeillus  or 
more  commonly-  lo  staphylococci,  the  under  surface  ol  the  lids  is  eoMTed  with  a  yellowish- 
white  membrane  which  can  be  peeled  off.  leaving  a  raw  bleeding  surl'ace. 

Corneal  ulcers  arc  always  apparent  as  greyish  or  white  oj)acities  of  the  cornea  over 
which  the  cornea  has  lost  its  [jolish.  There  may  be  only  inliltration  of  the  cornea,  or  in 
mnre  serious  cases  actual  loss  of  substance,  wliieli  rn:i\  Mllimalely  lea<l  lo  perforation  ol 
llic   cornea.      In   ccrlain  eases  of  corneal    ulcer   llicrc   rn:i\    lie   pus   in   the  anterior   chamber 


■232 


F.YE.     ACUTE     INFLAMMATION    OF 


(hypopyon).  The  diagnosis  presents  no  dillieiilty,  as  their  existenee  is  always  obvious 
if  the  cornea  be  carefully  examined. 

In  iritis  the  inflammation  of  the  eye  presents  rather  different  characteristics.  As  the 
iris  receives  its  blood  supply  from  the  deeper  ciliary  vessels,  the  dilatation  of  these  shows  a 
marked  contrast  to  that  of  the  conjunctival  vessels.  The  injection  is  most  evident  in  the 
circumcorneal  region,  the  equatorial  region  of  the  eyeball  being  paler,  and  the  colour  of  the 
injection  being  not  bright  red,  but  rather  of  a  more  dusky  or  violet  character.  The  cornea 
retains  its  polish,  but  the  aqueous  is  usually  turbid,  and  there  may  be  actual  punctate  deposit 
of  fibrin  and  leucocytes  on  the  posterior  surface  of  the  cornea  {keralitis  punctata)  or  a  deposit 
of  pus  at  the  lower  part  of  the  anterior  chamber  between  the  cornea  and  the  iris  (hypopijon). 

Owing  to  the  increased  vascularity  of  the  iris,  and  to  the  exudation  into  its  substance, 
its  volume  is  increased  and  its  mobility  impaired :  hence  the  pupil  is  small  and  sluggish  or 
inactive.     The  presence  of  blood  and  exudate  in  the  substance  of  the  iris  also  changes  its 


1        ■          CONJUNCTIVITIS! 

Iritis                                    Glaucoma 

Conjiwcliva 

Conjunctival       vessels 
bright    red    and    in- 
jected :    movable 
over  subjacent  scler- 
otic :  injection  most 
marked   away   from 
corneo-sclerotic  mar- 
gin ;  colour  fades  on 
pressure 

Ciliary       vessels       in-      Both        conjunctival 
jccted,  deep  or  blu-  ,       and   ciliary  vessels 
ish-red  ;  most  mark-   |        injected 
ed   at   corneo-sclero- 
tic   margin  ;     colour 
does     not     fade     on 
pressure 

Cornea 

Clear,  sensitive 

Clear,  sensitive 

Steamy,  hazy,  insen- 
sitive 

Anterior  chamber 

Clear,  iioinial  dcptli 

Aqueous    turbid,    :  Very  shallow 
anterior        chamber  i 
slightly  shallow           j 

Iris 

Normal  colour 

Injected,   swollen,   ad-      Injected 
herent    to   lens,  and  1 
muddy  coloured 

Pupil 

Black,  active 

May     be     filled     with  !  Dilated,  fixed,  rather 
lymph,  small,  fixed          green 

Tension 

Normal 

Normal                                 Raised 

cdldur.  -a  blue  iris  becoming  greenish,  and  the  fine  detail  of  the  iris  structure  is  blurred  and 
obliterated.  In  the  later  stages  adhesions  will  occur  between  the  iris  and  the  lens  at  the 
point  of  their  immediate  contact,  the  edge  of  the  pupil  ;  in  the  constricted  state  of  the 
pupil  these  may  not  be  seen,  but  on  dilation  with  atropine  these  adhesions  or  posterior 
synechice  will  prevent  the  enlargement  of  the  pupil  at  certain  points,  and  it  will  therefore 
be  irregular  in  shape  ;  small  masses  of  iris  pigment  may  also  be  seen  on  the  anterior  surface 
of  the  lens  where  the  mydriatic  may  have  broken  down  some  of  the  weaker  adhesions. 
Lymph  may  be  exuded  into  the  pupillary  aperture,  where  it  will  be  recognized  as  a  filmy 
grey  membrane  completely  or  partially  blocking  the  pupil. 

Inflammatory  glaucoma  is  an  acute  disease  of  the  later  years  of  life,  attacking 
women  more  freipicntly  than  men,  hypermetropes  rather  than  myopes,  and  especially 
those  wlio  use  tlicir  eyes  for  close  work  to  a  considerable  extent.  It  comes  on  in  bouts, 
often  precipitated  by  ocular  strain  or  indiscretions  of  diet  or  regimen.  It  may  affect  one 
eye  only  at  first,  but  later  both  eyes  are  usually  attacked. 


PLATE     XII 


ACUTE      INFLAMMATIONS      OF      THE      EYE 


> 


I 


';  ..>,r^ 


ttW  ^        ■  -jW 


F.  Chronic  blrplmritis.    G.  liitiTHtitiiil  kor.ilili.s.    H.  Tni.-li<.ni:i.     |,   IIy|Mi|iyciii  ami  ulcer  of 


IShKV   (ir  liHliNdSIH— 7V,  /,„ 


FACIES,     ABNORMALITIES    OP 


233 


At  first  the  cliief  complaint  is  of  attacks  of  temporary  obscuration  of  vision,  the  appear- 
ance of  halos  or  rainbows  round  lights,  and  unusually  rapid  increase  of  presbyopia,  or  failure 
of  accommodation  for  near  vision.  During  a  mild  attack  there  is  often  a  feeling  of  tension 
in  the  eyes  and  a  dull  frontal  headache  in  addition  to  the  loss  of  vision.  In  severe  attacks 
the  pain  is  very  violent,  radiating  from  the  eye  to  the  head,  the  ears,  and  the  teeth,  and  is 
associated  with  sickness,  the  latter  symptom  often  causing  the  condition  to  be  mistaken  for 
migraine  or  sick  headache.  The  lids  may  be  ocdematous  and  the  conjunctiva  injected. 
The  cornea  is  hazy  and  ana;sthetic,  the  anterior  chamber  is  shallow,  the  iris  discoloured, 
and  the  pupil  dilated  and  fixed.  The  eye  is  hard  to  the  touch  and  very  tender.  Vision 
fails  rapidly,  diminishing  in  a  few  hours  from  normal  to  the  bare  perception  of  light.  In 
the  acute  stages  the  optic  disc  is  not  visible  owing  to  the  opacity  of  the  cornea,  aqueous 
and  vitreous  ;  but  ultimately,  when  the  media  clear,  the  optic  disc  will  be  seen  to  be  white 
and  excavated  (Plate  XX,  Fig.  v,  p.  418). 

Subacute  or  simple  glaucoma,  but  for  its  slower  course  and  tlie  absence  of  severe 
attacks,  resembles  acute  glaucoma. 

The  importance  of  discriminating  between  iritis  and  glaucoma  cannot  be  over-empha- 
sized ;  the  use  of  atropine  or  some  similar  mydriatic  is  the  sine  qua  non  of  the  treatment  of 
iritis,  whilst  in  glaucoma  it  is  disastrous. 

The  points  which  serve  to  differentiate  these  three  conditions  from  one  another  are 
summarized  in  tabular  form  on  the  page  232.  Herber!  I..  Eauon. 

EYE,   PAIN    IN.— fSee  Paix  ix  tue  Eyh;,  p.  445.) 


EYES,  BLACK  SPECKS  BEFORE  THE. 

p.  71.) 

FACE,  SWELLING   OF  THE. 

(See  S\vi;i.i.iN(;  of    vwv.   F\(  i;.   p.  (iT.'!.) 

FACE,  ULCERATION   OF  THE. 

— (See    I 'i.(i;i{,\ri()N    oi'  Tin;   Faci;.    p. 
73.-,.) 

FACIAL       PARALYSIS.      (See 

I'AitAi.vsis.  Factai..  p.    Md.) 

FACIES,  ABNORMALITIES  OF. 

—The  study  of  the  Imcc  in  health  and 
disease,  while  it  cannot  replace  carel'iil 
systematic  examination  of  the  body  as 
a  whole,  may  in  many  cases  direct  the 
experienced  ohserverV  attention  to  the 
most  likel\  held  in  which  to  find  data 
for  his  diagnosis.  OhscrN  alion  and 
experience  alone  i  an  IcmcIi  I  lie  student 
to  detect  all  tlu'  Icahircs  ol  a  face. 
Photographs  and  drawings  can  only 
illiislralc  I  he  coarse  and  obvious  defeels 
which  are  present  when  the  face  is  aL 
rest  or  when  some  particular  move- 
ment is  being  sustained,  'i'hc  more 
subtle  abnormalities  of  expression,  the 
l)lay  of  the  emotions,  and  the  response 
of  the  features  to  intelligence,  are  oftiu 
too  Heeling  anil  too  mobile  l<.  allow  (pC 
reproduction  on  paper,  and  somclinics 
so  intangible  as  to  defy  any  effort  to 
describe  them.  ]':ven  if  the  pen  of  a 
skilled  artist  could  succeed  in  portray- 
ing the  passive  vacant  aspect  of  a  cIiiot 
Iriiilorous  treinoi-  which  lio\crs  alioul  llic 


-(See  Black  Specks  nEFOUE  tue  Eyes, 


Fiij.  lO:).— A  fcriiuli!  cretin,  to  sljr 


ll    rrillsl 
.  Miolllll 


kv  the '  froLT- 

belly.' 

V  fail  lo 

depi 

.•1  the 

>p,-nsil  1 

..  pn 

iclaini 

234 


FACiES,   abn(:)r:malities   of 


Ftif.  inl. — :\lyx(i-tli'nia  :  the  character- 
i^'.ic  facics,  iUustraliut:  the  broadening  of 
the  features  and  tlie  malar  Hush.  (Com- 
pare Fig.  105.) 


he.,mPlMn,ntl./Y 
odiMloinnnitufnuM 
;;i/(<As  kiiidh(  hiil  h 
Hull    nhili  ) 


liis  temperance.     The  shifty  eyes  of  the  drug-taker,  the  fatuous  placidity  of  the  patient 
with  advanced  insular  sclerosis,  the  anxious  look  born  of  abdominal  disease,  the  explosive 

suddenness  with  which  the 
^•ictim  of  -double  hemi- 
plegia bursts  into  laughter 
or  tears,  are  only  a  few  of 
the  many  familiar  and 
striking  lessons  of  the  face 
whicli  must  be  seen  in  real 
life  if  they  are  to  be  learned 
and  utilized.  On  the  other 
hand,  there  are  facies  the 
description  and  illustration 
of  which  may  serve  to  im- 
])ress  their  more  important 
features  on  the  minds  of 
those  to  whom  they  are  not 
familiar. 

Cretinoid    Facies. — 

Compared  with  the  general 

stunted  growth  of  the  rest 

of  the   body,    the    head  is 

relatively  large.     The  face  is  broad   and  remarkable  for  thick   eyelids,  broad  flat  nose, 

thick  lips,  and  large   coarse  ears.     The  mouth   is   usually  open  and    expressionless,   the 

tongue  may  be   more   or  less  

constiiutly  protruded,  and  the 
chin  is  poorly  developed  (sec 
Dvv.\RFisM.  p.  186).  The  hair 
is  scanty  and  brittle,  the  skin 
coarse,  dry,  and  often  almost 
yellow.  Confirmation  of  the 
diagnosis  may  be  sought  in 
the  dwarfed  size  of  the  child, 
the  pendulous  'frog  belly'' 
{Fig.  103),  and  the  thick 
pads  of  subcutaneous  tissue 
especially  frequent  above  the 
clavicles.  The  lack  of  mental 
develo|>ment.  the  slow  pulse, 
and  subnormal  temperature 
complete  the  clinical  picture. 
Mil.t'uiieiiHitoiin  Fades. — 
The  dulled  iutelligenee  of  the 
patient  is  betrayed  by  the  apathetic  physiognomy  (Fig.  10 1).  Fig.  105  shows  the  same 
patient  previous  to  the  attack.  The  skin  of  the  myxoedematous  face  is  coarse,  dry,  and 
sallow,  with    occasional    cyanotic   areas   over  the  cheeks.  ^ 

The  pufflness  of  the  eyelids  may  suggest  nephritis,  but  the 
subcutaneous  tissue  is  everywhere  of  firm  consistence,  and 
podgy  rather  than  oedematous.  The  nose  is  broadened, 
the  ears  thickened,  and  the  lips  so  much  swollen  that 
more  than  the  usual  amoinit  of  mucous  membrane  is 
exjiosed.  The  hair  is  scanty,  receding  from  the  forehead, 
and  the  eyebrows  poorly  marked.  Similar  conditions  of 
hair  and  ski7i,  together  with  brittle,  striated  nails,  are  found 
elsewhere.  Masses  of  fatty  tissue,  like  those  described  in 
cretins,  may  be  found  scattered  about  the  neck  and  trunk. 
The  slow  speech,  the  expressionless  face,  and  the  general 
attitude  of  the  patient  may  suggest  paralysis  agitans,  but  the  diagnosis  may  be  made  by 


Fig.  lUO. — Congenital  syphilis,  showii 
prominent  foreliead  and  depressed  nas 
Lridge. 

(nolo  hji  T)r.  RonVe  fHiorl.) 


Fi'j.  107. — l-'acies  of  congenital 
syphilis,  showing  notclied  teeth  and 
sore  angles  of  the  mouth. 

iPliotohu  l)r.  S.  A.  K.  W!ho„.) 


Fig.  108. — Hutcliinsonian  notelied  teeth. 
(From  Introduction  lo  Surgeri/,  Prof. 
Rutherford  MorLson.) 


FACIES,     ABNORMALITIES    OP 


235 


paying   attention   to  the  features  just  mentioned,  and   by  observing  the  slow  pulse  and 
subnormal  temperature,  and  the  effeets  of  thyroid  treatment. 

Congenital  Syphilitic  Fades. — The  victims  of  eongenital  sypliilis,  after  ten  or  twehe 
years  of  age,  may  present  a  faeies  which  is  characteristic — an  overhanging  forehead, 
perhaps  frontal  bosses,  a  depressed  nasal  bridge  (Fig.  106),  striated  scars  radiating  from 
the  corners  and  other  parts  of  the  lips  (Fig.-  107),  ^with  a  sallow,  earthy  complexion. 
Closer  observation  of  the 
eyes  and  teeth  may  detect 
the  opacities  of  old  keratitis 
and  the  changes  in  the  upper 
incisors  which  are  claimed 
by  Hutchinson  to  be  patho- 
guoinonic  (Fig.  108).  These 
tcctli  are  wide-gapped,  irreg- 
ular, and  so  deficient  in 
enamel  over  the  anterior  and 
median  parts  of  their  cut- 
ting edge  that  the  resulting 
ereseentic  notch  gives  them 
a  striking  appearance.  Such 
a  faeies  may  accompany 
deafness,  menial  deficiency, 
j)hysieal  infantilism,  tibial 
deformities,  and  chronic  ar- 
thritis, especially  of  the  knee 
joints.     The  diagnosis  may  be  clinched  if  the  blood  jiives  a  positive  Wassermami  reaction. 

Miliqiathic  Fades. — Many  cases  of  myopathy  show  no  characteristic  faeies  ;  others  are 
remarkable  for  the  loose  pout  of  their  lips  at  rest  (Fig.  109),  and  the  •  transverse '  character 
of  their  siuile  (rire  en  travels.  Fig.  110).  Hoth  features  are  due  to  deficient  facial  nuiscula- 
ture,  and  |)artieul.irly  to  weakness  of  the  orbicularis  oris.     The  ])aresis  of  the  orbicularis 


Fig.  100.— Myopathic  fades :  tiK 
loose  pout  due  to  weakness  of  tlit 
orbicularis  oris. 

{P/alit  bij  Dr.  S.  .1.  K.  ^\lll:,m.) 


Fif/.    110. — Myopatliic     faeies  : 
L'ansverse  smile.     , 

{.Pholohij  Dr.  S.  .1.  K.  jrn.vni.) 


pal|)cbraniiu  is  only  striking  when  an  attempt  is  m; 
sometimes  lead  to  prommeiit   and  [icrhaps  starin 


veball 


/•v.;.     111.  -MyoBtli 
lip|iivirain-e   of   futiu'ne 
(iroopiiij;  of  the  eyelifls* 
the  jiiw  is  very  itppiireut. 


il!u^trnle  :i 
.■■ide  of  the 
Oil  the  rii;ht. 


lie  to  close  the  eye.  although  it  may 
In  other  instances  there  is  a 
droop  of  the  ujiper  eyelids 
rather  than  any  tendency 
to  exophthalmos.  The  in- 
;il)ilily  oil  the  part  of  the 
|i;ili(Ml  lo  whistle  or  to 
blow  (iiil  Ills  cheek  (|uickly 
(IciiKinsI  rales  llic  weakness 
(iC  llic  orbicularis  iiris,  if  it 
is  not  made  obvious  by 
llic  large  amount  of  labial 
mucous  membrane  exposed 
wliile  the  mouth  is  at  rest. 

.Mi/a.ttheiiic  Fades. — In 
lialiiiils  siillering  from  my- 
.islliciiia  gravis  there  are 
two  types  of  faeies  which 
can  liarilly  be  reproduced 
by  other  diseases.  The  liisl 
illiislialcs  Ihc  I'xhaiislioM  ■<( 
Die  iialicul  (Fig.  Ill);  she 
exliailsled  on  her  (licsl.  'I'hc 
omelimes   more   appropriately 


can  hardly  keep  her  eyes  open,  and  her  chin  tends  to  <lr 

second   depends    on    I  he    charaeteristic   myaslheiiic    smili 

named  a  sneer  (Fig.   112).     This  unfortunate  and  misleading  facial  expression  is  Ihc  result 

of  delKienl   aelion  on  the  part  of  the  zygomatic  and  risoriiis  muscles,  ;uid  exemplilies  the 

eiiiiiiiis  \v;iy  ill  wliich  some  muscles  are  alfeeteil  and    others  escape,   in   this  disease,  even 

when  llicy  (l(ii\c  llicir  inMir\al  ion  I'rom  the  same  siiiiree.      'I'lie  aeeiimpaiiyiiig  |ili(ilogra|ili 


236 


FACiES.   abn()r:malities   of 


shows  how   a  shght   asymmetry  in    the  muscular  aff'eetions  may   be  responsible  for  very 

dillercnt  exim'^sidiis  on  the  two  sides  of  the  face. 

The  Fades  of  Exophthalmie  Goitre. — The  facial  appear- 
ance in  Graves's  disease  depends  chiefly  upon  the  '  stare  ' 
{Fig.  113).  Surprise  or  fear  is  suggested  by  the  prominence 
of  the  eyeballs  and  the  retraction  of  the  eyelids.  The 
degree  of  exophthalmos  varies  greatly,  and  it  is  not  present 
in  all  cases  ;  sometimes  it  occurs  on  one  side  and  not  on 
the  other.  Close  observation  shows  that  the  sclera  is  visible 
between  the  edge  of  the  iris  and  the  eyelids,  and  that  the 
usual  harinony  of  movement  between  the  eyeball  and  the 
eyelid  is  lacking.  Normal  winking  is  frequently  much 
diminished  or  entirely  in  abeyance.  The  surface  of  the  con- 
junctiva may  be  abnormally  bright  and  glistening,  and  the 
secretion  of  tears  may  be  excessive.  In  contrast  with  the 
white  of  the  eyeballs,  there  is  often  considerable  dark  pig- 
mentation of  the  eyelids,  which  may  also  be  the  site  of  some 
oedema.  The  size  of  the  pupils  varies,  undue  dilatation 
occurring  only  in  exceptional  cases.  A  moist  skin  and  a 
readiness  to  flush  may  often  be  remarked  in  the  face. 
The  Fades    of   Panili/sis    Agitans. — In    this    disease    a 

cardinal   symptom   is  muscular  rigidity,    which    affects  tlu' 

skeletal   muscles  generally  as  well  as  those  of  the  face.     The 

ocular  nuiscles,  however,  escape.     It  is  due  to  this  fact  that 

while   the  face  as    a    whole   is   expressionless,    '  starchy  '   or 

'  masked  '  {Fig.  114),  the  eyes  appear  to  move  with  natural 

or  even    abnormal   rapidity  ;     for   instance,  they  will    turn 

in  the  direction  to  which  the  patient  desires  to  look,  before 

the  head  has  assumed  a  corresponding  position.     Frequently 

the   face   has  a   staring   expression,   the   eyelids   being  con- 
stantly  retracted    by   the    tonic   spasm    of   the    orbiculares 

palpebrarum.     An    absence    of    normal    winking    has   been 

noted  and  ascribed  to  the  same  cause.     In  contrast  witii  the 

slow  development  of  facial  expression  under  the  influence  <il 

emotion,  there  is  sometimes  marked  want  of  control  over  the 

fully-developed  emotional  movement,  and  the  patient  com- 
plains that  the  exuberance  of  his  laughter  or  tears  is  entirely 

out  of  proportion  to  his  Tcclings  of  merriment  or  sorrow. 

Tabetic  Fades. — In  a  considerable  percentage  of  cases  of 
locomotor  ataxy  the  appearance  of  the  face  is  sufficiently 
striking,  to  a  close  observer,  to  afford  a  clue  to  diagnosis. 
The  small  size  or  the  inequality  of  the  pupils  may  first  attract 
attention.  The  slight  drooping  of  the  upper  eyelids,  com- 
bined with  some  wrinkling  of  the  forehead  {Fig.  115),  due  to 
a  compensating  effort  on  the  part  of  the  frontalis  muscle, 
gives  a  sad  expression.  This  drooping  of  the  eyelid,  which 
may  be  termed  pseudo-ptosis  or  hypotonic  ptosis,  is  not  due 
to  any  paresis  of  the  levator  palpebral  superioris,  as  may  be 
shown  by  the  raising  of  the  lid  when  the  patient  is  looking 
up.  It  really  depends  on  the  fact  that  this  muscle,  like  most 
of  the  nuiscles  of  the  body,  is  in  a  condition  of  hypotonia. 
This  allows  the  action  of  gravity  to  assert  its  influence,  with 
the  result  that  the  lid  hangs  like  a  half-raised  curtain  in 
front  (if  the  eyeball.  In  other  respects  the  face  may  be 
normal,  but  the  majority  of  tabetics  have  a  sallow  com- 
plexion and  very  little  subcutaneous  fat.  two  facts  which 
contribute  to  their  generally  unhealthy  aspect.  The  writer 
r  this   disease  exhibit   a  deficienev  of  the   emotional    reflex 


Fig.  115.— Tabetic  facies.  The  photo- 

grapii  shows  the  partial  bilateral  ptosis 

and  the  wrinkling  of  the  forehead,  wliich 

contribute  to  the  expression  of  sadness. 

(Plwlo  by  Br.  S.  A.  K.  Wilson.)\ 


believes  that   many  victims 


FACIES.     ABNORMALITIES    OF 


237 


movements  of  the  ftieial  muscles.      During  conversation,  the  play  of    their  features   in 
response  to  the  subject  of  tiieir  talk  is  not  so  noticeable  as  that  of  healthy  individuals. 

Fades  of  Acromegaly. — In  the  course  of  acroniegalj-,  changes  in  appearance  frequently 
take  place  to  such  a  degree  that  the 
patient  becomes  unrecognizable  by 
friends  who  have  known  him  only 
before  the  onset  of  his  disease.  These 
changes  are  the  result  of  abnormal 
growth  on  the  part  of  the  bony  and 
subcutaneous  tissues  in  many  parts  of 
the  body,  and  especially  in  the  skull 
and  extremities.  The  characteristic 
facies  is  brought  about  by  osseous 
hyperplasia  of  the  frontal  ridges,  the 
mastoid,  zygomatic,  malar,  and  nasal 
processes,  while  the  lower  jaw  is 
usually  enlarged  in  all  directions. 
The  prominent,  arched  brows,  with 
retreating  and  wrinkled  forehead,  the 
massive  nose,  the  long,  thick  upper 
lip.  and  the  heavy  chin  (Fig.  IKi) 
form  the  most  conspicuous  featiu'cs. 
The  lower  set  of  teeth  may  project 
some  distance  in  front  of  the  upjicr, 
and  they  are  unduly  wide  a]>art. 
The  tongue  may  be  so  enlarged  as  to 
keep  the  mouth  open  and  to  display 
many  fissures  and  indentations  as 
the  result  of  its  pressure  against  the 
teeth.  The  increased  weight  of  the 
lower  part  of  the  face  tends  to  make 
the  head  lean  forward  and  p<rliaps 
ultimately  lo  rest  ujxin  the  sternum. 
In  some  cases  the  lower  jaw  is  not 
affected,  and  tlie  face  may  be  described  '''"'■  iH'-— a  ■•nin,  ^aiy. 

as  abnormally  s(|uare  (lifpe  carree). 

FacicH  (if  Moiigolitin  Idioe/i. — This  facies  is  so  charaeleristic  that    Ihc  diagnosis  iiiav 


Fiij.    IIS.— A     MoiiKoliiin    idiot 
infiliicy.     Tlio    photoi^'nipli    sliows    i 
ohlique  |)ii]iichnil  (IsHuri-s  ami  tlif  liii 


ritj.  ll'.l. — A  ^[onr?olinti  idiot,  sliow- 
iiitr  11  iiiivo  llabby  tongue,  which  is 
•  I'-cply  lits'siircfi. 

■t'tivto  bij  Dr.  S.  A.  K.   Wilson.) 


ofli  u  be  iiiadi'  al  sight  (FiU-  117  :   see  also  DwAiiirsM.  p.  l.sii).    'I'lie  head  is  bra<-hycepha1ic  ; 


the   palprhral    li 


slant    (il)li(|ii(iy    iliwaiils  ;ui 


pwnwai'ds  loxvards  a  broad  Hal   nose. 


238 


FACIES,     ABNOHMALITIES    OP 


Fuj.  12 


rendered  even  l>roader  by  the  presence  of  epicantlius  ;  the  eyelids  show  signs  of  chronic 
blepharitis  ;  the  ears  are  large  and  pitcher-shaped  ;  the  lips  are  fissured  and  often  left 
open  to  allow  a  coarse  tongue  to  protrude  (Figs.  118,  119)  :  the  forehead  is  downy,  arid  the 
hair  of  the  scalp  scanty,  wiry,  and  frequently  mouse- 
coloured  :  the  complexion  is  florid  and  mottled.  The 
almond-shaped  eyes,  the  presence  of  epicanthus,  the 
florid  complexion,  and  the  absence  of  fattj'  masses 
serve  to  distinguish  the  Mongolian  from  the  cretinoid 
idiot  :  in  case  of  doubt  the  benefit  or  otherwise  of 
thyroid  treatment  may  clinch  the  diagnosis. 

Fades  of  Familial  Lenticular  Degeneration. — The 
characteristic  fades  of  this  disease  is  only  seen  in 
advanced  cases,  and  may  be  described  as  one  of  fixed 
emotion.  The  slightest  attempt  to  engage  in  con- 
versation may  evoke  an  expression  of  exaggerated 
mirth  (Fig.  120)  which  takes  a  long  time  to  wear  off 
and  is  quite  unlike  that  seen  in  other  diseases  of  the 
nervous  system,  although  perhaps  related  to  the  spastic 
smile  of  double  hemiplegia.  The  accompanying  photo- 
graph also  illustrates  the  tendency  to  fall  to  one  side 
or  the  other  when  in  the  sitting  position. 

E.  Farquhar  Buzzard. 
FyECES,  BLOOD   IN.     See  Blood  per  Anum,  p.  75  :  and  Mel.ena,  p.  385.) 

F^CES,    FAT   IN.  -(See  Fatty  -Stools,  p.  239.) 

FiECES,   INCONTINENCE  IN.— (See  Incontinence  of  F^ces,  p.  313.) 

Fi4:CES,  MUCUS  IN.— (See  Mucus  in  the  Stools,  p.  398.) 

FyECES  passed  per  URETHRAM.— Faeces  or  faecal  fluid  are  only  passed  per 
urethram  when  the  bladder  is  in  fistulous  conunimication  with  some  part  of  the  bowel,  or 
with  some  faeculent  abscess  cavity  infected  with  the  Bacillus  coli  communis.  Pneuma- 
TURi.v  (p.  529)  is  liable  to  occur  at  the  same  time.     The  chief  causes  are  as  follows  : — 

Cancer  of  the  bladder  opening  into  the  rectum  or  into  some  loop  of  bowel  which  has 
become  adherent  to  the  bladder. 

„                1.  .,        ■         ■,  ■                  opening  into  the  bladder  either  directly,  or  through 

Cancer  of  the  sigmoid  colon        -.,,.           „         .,            •         , 

,,               i.  ,1  I          the  medium  ot  an  intervening  abscess. 

Cancer  ot  the  caecum  ) 

Cancer  of  the  uterus  opening  both  into  the  bladder  and  into  the  rectum. 

Proctitis  and  periproctitis  leading  to  the  formation  of  an  abscess  <vhich  opens  into 

the  bladder. 
Prostatitis  and  prostatic  abscess  opening  into  the  rectum. 
Rectovesical  fistula  from  injury  and  sloughing,  particularly  after  childbirth. 
Caseous  tuberculous  disease  ojjening  both  into  the  bladder  and  the  rectum. 
Appendicular  abscess  opening  into  the  bladder. 
An  abscess   resulting    from   acute    diverticulitis   (Telling's   disease)   opening   into   the 

bladder. 

The  passage  of  faeces  in  the  urine  may  be  simulated  by  some  cases  of  very  fietid  cystitis, 
wlien  the  bladder  has  been  infected  by  the  Bacillus  coli  communis. 

If  the  symptom  is  due  to  cancer,  it  matters  little  which  viscus  is  the  primary  site  by 
the  time  the  growth  has  involved  both  bladder  and  bowel.  The  diagnosis  resolves  itself, 
therefore,  into  one  between  malignant  conditions  on  the  one  hand  and  non-malignant  on 
the  other.  If  malignant  disease  is  not  obvious,  it  will  nearly  always  be  advisable  to  resort 
to  surgical  measures  in  the  hope  of  curing  the  primary  condition — rectal,  appendicular, 
prostatic,  or  otherwise.  The  commonest  causes  other  than  malignant  arc  local  sloughing 
of  the  parts  after  labour,  and  fteculent  appendicular  abscess  opening  into  the  bladder.  The 
diagnosis  will  be  suggested  by  the  history  and  confirmed  by  local  examination  or  explora- 
tion. Herbert  French. 


FINGER.     SORE  2.3i» 

FiECES,   PUS   IN.— (See  Pes  in-  the  Stools,  p.  557.) 
FjECES,   sand  in.— (See  Sand,  Intestinal,  p.  599.) 
FjECES,  worms  in.— (See  Parasites,  Intestinal,  p.  519.) 
FAINTING  ATTACKS.— (See  Coma.  p.  117.) 
FAT   IN   URINE.— (See  Ciiyluria,  p.  108.) 

FATTY  STOOLS.— .A.11  stools  contain  a  little  fat  :  many  contain  more  than  they 
should,  the  fact  being  discoverable  on  analysis,  although  it  may  not  be  obvious  to  the  un- 
aided eye  :  the  relative  proportions  of  saponified  and  of  unsaponifled  fats  may  have  an 
important  bearing  on  the  diagnosis  of  pancreatic  lesions  (see  Cammidge's  Pancre.vtic 
Reaction,  p.  100).  Fatty  stools  in  which  the  fat  is  obvious  to  the  naked  eye  are  rare  ; 
when  they  do  occur  they  indicate  one  of  three  things  :  either  that  enormous  amounts  of  fat 
are  being  ingested — more  than  can  be  absorbed  by  the  normal  mucosae  ;  or  that  the  secre- 
tions are  defective,  so  that  even  ordinary  amounts  of  fat  remain  unabsorbed  ;  or  that  the 
food  is  being  hurried  through  the  alimentary  canal  so  fast  that  mucli  fat  remains  imdigested. 

It  is  easy  to  exclude  the  first  of  these  three  possibilities  by  regulating  the  diet  ;  the 
other  two  factors  generally  occur  together,  and  the  chief  diseases  in  which  fatty  stools  may 
be  a  prominent  feature  are  : — 

1.  Those  associated  with  severe  diarrhea,  especially  where  the  patient  may  be  having 

an  abundance  of  milk,  as  in  : — Typhoid  fever  ;    Infantile  diarrhoea  ;    Sprue. 

2.  Those  associated  with  jaundice,  especially  where  the  cause  of  the  latter  also  prevents 

the  pancreatic  secretions  from  entering  the  duodenum,  such  as  : — Chronic  pan- 
creatitis :  Carcinoma  of  the  head  of  the  pancreas  ;  Carcinoma  of  the  duodenum, 
including  the  ampulla  of  Vater. 
The  diagnosis  of  Group  1  need  not  be  discussed  further  here,  for  it  will  be  indicated 
by  other  symptoms  than  the  fatty  stools.  The  diffei'ent  maladies  belonging  to  Grou]>  2, 
on  the  other  hand,  may  l)c  indicated  directly  by  the  fatty  condition  of  the  stools.  If,  for 
instance,  there  is  doubt  as  to  whether  the  ])aticnt  is  suliering  from  gall-stones  obstructing 
the  common  bile-duct,  or  from  chronic  pancreatitis,  the  occurrence  of  pale  abundant  stools 
upon  the  surface  of  which  an  iridescent  scum  of  fat  is  obvious,  will  be  in  favour  of  the  latter, 
for  fat  can  be  digested  to  a  far  greater  extent  without  bile  but  with  pancreatic  juice  than 
it  can  be  without  the  latter.  The  symptom  affords  no  means  of  distinguishing  inllaninia- 
tion  from  new  growth,  however  :  the  distinction  between  these  will  depend  mainly  upi>n 
the  duration  of  the  sym]jtoms — growth  of  the  pancreas  kills  within  a  few  months  of  produc- 
ing fatty  stools,  whilst  chronic  pancre;ititis  may  continue  for  years,  or  even  get  (|uite  well. 
Other  points  to  be  on  the  watch  for  would  be  the  presence  of  a  tumour,  of  a  dilated  gall- 
bladder, or  of  secondary  deposits.  The  age  of  the  patient  is  seldom  much  help,  for  neither 
disease  is  coiniiion  before  adult  life.  The  distinction  between  carcinoma  of  the  head  of  the 
pancreas  and  cMniiioina  of  the  ampulla  of  \atcr  and  duiidcmim  may  be  next  to  impossible 
without  laparotomy  or  post-morteni  exaMiiiiatioii  :  although  carcinoma  of  the  head  of  the 
I)anereas,  rare  though  it  is.  is  inucli  commoner  than  new  giowth  starting  in  the  duodenum. 

Ilnhni   l''reiirh. 
FEVER.      (See   I'viiKXiA,   p.   .")(i:i  ::iid  p.  .")7 1   :    and    II vi'i;iieviii;\iA.    p.   .■i09.) 

FINGER,  SORE.  Digital  lesions  ma\  be  erythematous.  pa|)ular.  vesicular,  bullous, 
])ustular.  s(|uamous,  or  uleerati\c.  represeiding  a  long  list  of  cutaneous  alTeetions.  The 
cri/llKinatoKs  alleetions  which  may  attack  the  lingers  are  erythema,  lupus  erythematosus, 
eczema,  urticaria,  chilblains,  and  frostbite  :  the  paputitr.  liclu^n  planus  and  lichen  amuilaris, 
l)ityriasis  rubra  pilaris,  angiokeratoma,  ec/.ema.  and  papular  syphilides  :  the  irsictilar. 
scabies,  cheiropompholyx  (dysidnisis).  ec/.ema.  dermatitis  herpetilorniis,  chilblains,  the 
irritation  set  up  by  the  habitual  handling  of  sugar,  or  (in  washerwomen)  by  iimnersioii  in 
water  containing  soda,  or  by  contact  with  such  \(g<tal)lc  irritants  as  rhus.  nuistani,  tliapsia, 
the  coriinioii  oi:irige,  eucalyptus  leaves,  arni<'a.  etc.  ;  the  hidliins.  pemphigus,  epidermolysis 
bullosa.  (IcirTialitis  herpetiformis,  scabies,  leprosy,  aixl  syphilis  (chielly  in  infants):  the 
liiifilii/iir.    scabies,    boils,    whitlow,    impetigo    contagiosa,    cc/.cma.    and    pustular    sypliilidc  ; 


240  FLATULENCE 

tlic  squdinoKS,  psoriasis,  eczema,  ichthyosis,  lichen  planus,  syphilis,  acanthosis  nigricans, 
and  verruca  necrogenica  ;  the  ulcerative,  bedsore,  chilblains  and  frostbite,  a-ray  ulcer, 
dissection  wounds,  lupus  vulgaris,  lupus  erythematosus,  leprosy,  chancre  and  syphilitic 
ulcer,  e|)ithelioma,  Raynaud's  disease,  diabetic  gangrene,  trojihic  ulcer,  and  scleroderma. 

The  diagnosis  of  these  various  affections  will  be  foimd  under  the  names  of  the  primary 
lesions — papules,  vesicles,  etc. — and  here  it  is  only  necessary  to  jjarticularize  bedsore, 
diabetic  gangrene,  verruca  necrogenica  and  dissection  wounds,  and  chancre.  Bedsore,  on 
the  fingers  is  caused  by  friction  between  the  knuckles  and  the  bedclothes  as  the  patient 
raises  himself  to  the  sitting  position.  It  begins  as  ervthema,  and  its  significance  can  hardly 
be  mistaken,  though  its  presence  in  such  a  situation  may  take  the  nurse  by  surprise. 
Diabetic  gangrene  most  frequently  attacks  the  toes  or  other  part  of  the  foot  ;  but  occasion- 
ally it  has  been  observed  in  the  penis,  and  I  have  seen  cases  in  which  the  fingers  have  been 
affected.  Post-mortem  ivart.  or  post-mortem  pustule,  the  condition  sometimes  met  with 
chiefly  on  the  knuckles  and  in  the  interdigital  folds  in  those  who  have  to  handle  dead  bodies, 
\\  hcther  of  human  beings  by  mortuary  attendants  or  of  the  lower  animals  by  butchers  and 
slaughterers,  is  a  form  of  tuberculosis,  caused  by  infection  with  living  bacilli  from  the  dead 
tissue.  It  is  sometimes  met  with  also  in  colliers,  in  whom  the  site  of  inoculation  is  probably 
an  abrasion  received  in  the  handling  of  coal.  The  pustule,  beginning  as  a  flat  papule, 
dries  up  and  forms  a  scab,  which,  when  it  falls  off,  leaves  a  surface  that  is  made  irregular 
by  overgrowth  of  papillie.  These  grow  and  become  harder,  imtil  they  form  a  warty  mass. 
The  avocation  of  the  patient  will  suggest  the  true  nature  of  the  lesion.  Of  dissection 
wounds,  consisting  of  pustules  or  small  abscesses  on  the  site  of  a  puncture  or  scratch,  or  of 
hniphangitis  and  cellulitis,  which  may  be  followed  by  pycemia.  the  history  will  supply  the 
diagnosis.  In  chancre  of  the  finger,  usually  met  with  in  midwives,  nurses,  and  medical 
men,  but  occasionally  in  others,  a  favourite  situation  of  the  sore  is  at  the  lateral 
nail-groove,  and  in  many  eases  the  lesion  first  attracts  notice  as  a  persistent  fissure.  If  the 
sore  undergoes  indmation,  and  there  is  general  enlargement  of  glands  with  the  other  well- 
known  secondary  symptoms,  the  diagnosis  can  no  longer  be  doubtful. 

Dair%niai(is,  milkers,  and  other  farm  hands  sometimes  develop  acute  or  chronic  sores 
upon  their  fingers  due  to  coiv-pox  caught  from  the  teats  or  udders  of  infected  cows,  and 
such  patients  may  inoculate  others  who  have  no  work  that  is  connected  directly  with  cows. 
The  appearances  are  those  of  persistent  boils  or  whitlows,  and  the  diagnosis  may  be  very 
dillicult  unless  the  source  can  be  traced.  Two  other  varieties  of  whitlow  may  pass  entirely 
without  recognition  unless  bacteriological  methods  are  resorted  to,  namely,  onychia  or 
pcrionychia  due  to  Klebs-Loeffler  bacilli  (digital  diphtheria)  and  similar  trouble  due  to 
the  Bacillus  coli  communis.  Mulmlm  Morris. 

FINGERS,  CLUBBED.— (See  Clubbed  Fingers,  p.  111.) 

FINGERS,  DEAD.     (See  De.\d  Fingers,  p.  162.) 

FINGERS,  NUMBNESS  OF.— (See  Sensation,  Abnormalities  oe,  p.  60J.) 

FITS.- — (See  Convulsions,  p.  148.) 

FLATULENCE. — It  is  important  to  distinguish  between  (1)  Gastric  flatulence,  in 
which  wind  is  eructated  ;  and  (2)  Intestinal  flatulence,  in  which  it  is  passed  per  anum. 

Gastric  Flatulence. — Before  concluding  that  excess  of  gas  is  being  produced  in  the 
stomach,  it  is  necessary  to  exclude  the  possibility  of  air-sivallozving  (a'trophagia.  eructatio 
nervosa).  This  is  common,  but  is  apt  to  be  interpreted  wrongly.  It  is  met  with  often  in 
women  about  the  menopause  ;  it  is  also  by  no  means  infrecjuent  in  young  men  prone  to  be 
"  neurotic,'  or  to  exhibit  signs  of  neurasthenia  or  psychasthenia,  though  otherwise  healthy. 
Eructatio  nervosa  is  recognized  by  the  violence  of  the  belching  and  the  excessive  amount  of 
wind  expelled.  It  comes  on  in  attacks  both  by  day  and  by  night,  sometimes  waking  the 
patient.  If  a  patient  can  belch  '  to  order,'  one  may  conclude  with  almost  perfect  cer- 
tainty that  he  is  suffering  from  this  form  of  neurosis  ;  and  by  watching  him  during  the 
attack  one  can  recognize  that  he  is  gulping  down  air. 

True  gastric  flatulence  is  present  to  a  greater  or  less  degree  in  many — one  might  almost 
say  in  all — forms  of  gastric  disorder.     For  purposes  of  diagnosis  one  must   distinguish 


FLUSHING  241 

between  the  cases  in  which  gas  is  produced  by  fermentation  in  stagnating  gastric  contents, 
and  those  in  which  no  sucli  fermentation  is  taking  place.  In  the  former  the  stomach  is 
dilated,  vomiting  is  almost  certainly  present  ;  if  examination  of  the  gastric  contents  shows 
delay  in  their  transmission,  and  the  presence,  probably,  of  sarcinoe  (Fig.  121)  and  yeasts, 
one  may  diagnose  pyloric  obstruction,  either  simple  or  malignant.  In  these  cases  the  eructa- 
tions are  sometimes  offensive,  revealing  the  existence  of  putrefaction  in  the  gastric  contents. 
Bismuth  and  a;-ray  examination  will  confirm  the  delayed  emptying  of  the  stomach. 

Son -fermentative  flatulence  occurs  in  almost  all  forms  of  functional  disorder  of  the 
stomach  ;  but  is  specially  prone  to  occur  in  gastric  atony.  In  that  case  there  will  be  a  well- 
marked  splash  over  the  gastric  area,  even  some  hours  after  a  meal,  but  without  any  evidence 
of  actual  dilatation  of  the  organ,  although  there  may  be  some  gastroptosis.  (See  also 
Inuigkstion,  p.  315.)  In  other  forms  of  gastric  disorder  flatulence  is  only  a  minor  sym- 
l)t(iiii.  and  of  little  diagnostic  value. 

Flatulence  is  also  not  an  unconmion  symptom  in  emplnjsema  of  the  lungs,  and  in  cases 
of  eardiac  disease,  especially  when  due  to  degeneration  of  the 
heart  muscle.  In  elderly  persons  these  conditions  should  always 
be  looked  for.  In  angina,  also,  flatulence  may  be  a  ])rominent 
symptom,  but  in  that  case  the  attacks  tend  to  come  on  after 
exertion,  and  are  accompanied  by  the  characteristic  pain  of 
angina. 

Intestinal  Flatulence  may  be  either  nciite  (see  MEXEORisir, 
p.  388),  or  elironic  (intestinal  flatulence  ])ro[)cr).  In  the  latter 
case  it  is  often  attinded  by  colicky  [jain,  whicli  is  relieved  by 
the  passage  of  wind.     It  is  important  to  note  that  flatulence  is 

not  a  feature  of  ordinarv  constipation.     When  marked,  it  is  sug-       „     ,  „     o  ,-,•,■ 

gestivc  cither  of  chronic  obstruction  or  of  intestinal  fermentation.  (jredium  power  o£  the 

If  obstruction   be  present,  coils  of  intestine  undergoing  peri-  microbcope.) 

staltic  contraction  are  often  to  be  seen,  and  there  is  pronounced 

consti|)ation,  sometimes  alternating  with  diarrhn?a.  .\  diagnosis  of  the  exact  cause  of  the 
■obstruction  may  necessitate  the  use  of  the  -sigmoidoscope,  bismuth  and  the  .r-rays,  or  even 
of  an  exploratory  operation.  In  cases  of  intestinal  fermentation,  either  constipation  or 
(liarrhtca  may  be  present.  Microscopic  examination  of  the  stools  is  often  of  help  in 
elucidating  the  nature  of  the  fermentative  process,  undigested  muscle  fibres  (proteid 
fermentation  or  putrefaction)  or  an  excess  of  starch  cells  (carbohydrate  fermentation) 
being  seen.     (See  also  Diaruihka,  p.  170.)  Hoberl  Iliilcliison. 

FLUSHING. -The  difference  between  llusliing  and  blushhig  is  that  the  former  only- 
occasionally,  llic  latter  invariably,  arises  rmin  cinolion — shyness,  shame,  and  modesty. 
.\  flush  may  begin  instantaneously  in  all  the  parts  in  which  it  is  felt,  or,  arising  in  a  lower 
rcgioii,  it  may  ascend  to  the  head,  or,  beginning  in  the  head,  it  may  descend  to  some  part 
of  the  body,  or  it  may  pass  both  u])wards  and  downwards.  The  sensation  varies  in  severity, 
and  may  be  aclually  painful.  The  nervc-slorm  generally  ends  in  a  cold  stage,  though  this 
may  prcce«le  the  hot  stage.  The  cutaneous  symptoms  may  be  accompanied  or  followed 
by  nausea,  vomiting,  fainting,  a  sense  of  suffocation,  mimbness,  tremors,  tinnitus,  giddiness, 
|>alpJtation.  paresis.  The  physical  states  and  conditions  from  which  flushing  arises  include 
menstruation  and  menstrual  irregularities,  the  cliiiiacterie,  pregnancy,  lactation,  chlorosis, 
indigestion,  l'((l)lc  circulation,  general  dchility  ;  it  may  also  be  an  expression  of  emotion, 
may  be  caused  by  alcoholic  iiidulgeiiee,  or  may  merge  info  an  ipileptic  aura.  If  it  becomes 
chronic,  the  skin  of  the  face,  especially  of  the  flush  area — the  middle  third  of  the  face — is 
reddened  |>crmanently,  and  the  case  becomes  one  o{  rosacea  •  sooner  or  later  the  superficial 
vessels  undergo  dilatation  ;  hyiiersecrction  and  retention  of  sebaceous  matt<T  follow,  and 
inllannnal  ion  may  be  set  U|)  ;  the  inllanunatory  process,  becoming  chronic,  may  give  rise, 
espeeiiilly  if  the  patient  is  much  exposed  to  the  weather,  to  hyperlropliie  Ihiekening  of  the 
skill  of  the  nose,  with  lobulation  (rhinophyma). 

The  condition  or  habit  which  is  the  cause  of  rosacea  will  be  deihieeil  from  the  history, 
espeeially  as  regards  tea,  alcohol,  and  dyspepsia,  and  from  examination  of  the  patient. 
Hosacea  is  distinguished  from  acne  vulgaris  by  the  absence  of  comedones,  the  redness  of 
the   alTeeled  surface,   the  limitation    of    the    eniplion    to    the  face,  the  telangiectasis,  the 

1)  l(i 


242  FRACTURE,     SPONTANEOUS 

hypertrophy,  and  by  its  being  an  affection  of  middle  life  rather  than  of  puberty.  It  differs 
from  lupus  erythematosus  in  the  absence  of  scaliness  and  of  atrophic  scarring,  in  the  border 
which  is  not  raised  and  shows  no  signs  of  active  spreading,  and  by  its  fluctuations. 
Seborrhceic  eczema  may  be  met  with  in  the  flush  area,  but  it  is  usually  associated  with 
seborrhcea  capitis,  there  is  no  telangiectasis,  and  the  affected  surface  is  oily  or  scaly.  From 
tertiary  syphilides,  rosacea  is  distinguished  by  its  slow  course,  its  symmetry,  the  dilatation 
of  blood-vessels,  and  the  absence  of  any  tendency  to  ulceration  and  scarring,  or  to  atrophy. 
In  syphilis,  further,  there  will  be  the  stigmata  or  the  history  of  earlier  lesions. 

Malcolm  Morris. 

FOOT-DROP. — (See  Paiiaplkgia,  p.  510  ;  and  Paralysis  of  one  Extremity 
(LOWEH),    p.    49G.) 

FOOT,  ULCERATION  OF  THE.— (See  Ulceration  of  the  Foot,  p.  735.) 

FOREHEAD,  ENLARGEMENT  OF.— (See  Enlargement  of  the  Foreiie.vd,  p.  203. ) 

FORGETFULNESS.— (See  Amnesia,  p.   19.) 

FORMICATION.— (See  Pruritus,  p.  540.) 

FOUL  BREATH.— (See  Breath,  Foulness  of  the,  p.  86.) 

FRACTURE,  SPONTANEOUS. — Sjiontancous  fracture  signifies  fracture  of  a  bone 
from  causes  which  ordinarily  would  have  been  inadequate.  Tremendous  muscular  efforts 
sometimes  lead  to  the  breaking  t>f  bones  without  any  external  violence,  but  this  variety 
would  not  be  included  under  the  heading  of  spontaneous  fracture  if  the  degree  of 
muscular  effort  seemed  adequate.  A  man  has  been  known,  for  instance,  to  dive  into 
shallow  water,  and  in  order  to  bring  himself  to  the  surface  quickly,  and  prevent  his  head 
from  striking  the  bottom,  he  has  used  his  neck  muscles  so  strenuously  in  bending  his  head 
back  as  actually  to  fracture  his  vertebrre.  This  fracture  is  not  spontaneous,  but  due  to 
excessive  muscular  exertion.  There  are  three  main  groups  of  causes  for  true  spontaneous 
fracture,  namely,  excessive  brittleness,  or  innate  lack  of  strength  of  the  bones — fragilitas 
ossium  ;  general  paralysis  of  the  insane  ;  and  unsuspected  lesions  of  the  bones,  particu- 
larly myeloid  sarcoma,  chloroma,  tuberculous  caries,  or  secondary  deposits  of  carcinoma 
or  sarcoma. 

Fragilitas  Ossium. — When  the  first  fracture  occurs  in  such  a  patient,  theje  may  be 
doubt  as  to  the  diagnosis  ;  but  when  repeated  breaking  of  different  bones  occurs,  in  each 
ease  from  apparently  trivial  causes,  the  diagnosis  becomes  clear.  The  undue  fragility  may 
show  itself  in  early  life,  but  more  often  not  until  the  patient  has  reached  adult  stature  and 
weight.  Tliere  is  a  very  remarkable  familial  type  of  the  disease,  in  which  .successive 
generations  contain  some  members  who  have  fragile  bones  amongst  others  who  are  healthy  ; 
the  latter  have  white  sclerotics,  whilst  those  exhibiting  fragilitas  ossium  have  sclerotics 
that  are  definitely  blue — sometimes  even  dark  blue.  Both  bones  and  sclerotics  lack 
part  of  their  proper  matrix  ;  the  diagnosis  is  easy,  though  the  condition,  termed  '  blue 
sclerotics  with  brittle  bones,"  is  rare. 

Two  maladies  which  differ  from  fragilitas  ossium,  and  yet  which  may  cause  undue 
bending,  or  partial  or  green-stick  fracture  of  bones,  are  rickets  in  children,  in  which  disease, 
for  a  time  at  least,  there  is  excess  of  preparation  for  bone  formation,  but  deficiency  in  com- 
pleting the  ossifying  process,  so  that  the  bones,  being  unduly  soft,  not  only  bend,  but  also 
give  way  as  a  green  stick  would,  causing  the  partial  or  green-stick  fracture  ;  and  moUities 
ossium,  a  rather  rare  affection  in  this  country,  though  reported  to  be  less  uncommon  in 
certain  parts  of  the  Continent,  notably  in  the  Rhine  valley,  coming  on  especially  after 
pregnancy,  and  associated  with  concentric  thinning  of  the  bones  from  the  marrow  outwards, 
so  that  they  eventually  consist  of  a  mere  shell,  which  bends  with  undue  ease,  and  may 
sometimes  break  sjiontaneously.  The  relationship  to  pregnancy  may  suggest  the  diagnosis, 
and  there  is  no  other  disease  which  produces  the  same  degree  of  pathological  softening  and 
fragility  of  the  bones  in  adults  ;  active  rickets  is  practically  confined  to  young  children, 
only  a  few  cases  having  been  recorded  during  adolescence  and  none  in  adult  life. 


FULLNESS.     SEXSE    OP  243 

Spontaneous  fractures  in  general  paralysis  of  the  insane  occur,  like  the  aural  haemato- 
niata  of  this  disease,  at  a  late  stage  when  the  patient  is  bedridden.  They  may  arouse 
suspicion  that  the  attendants  have  been  unduly  rough  in  their  handling  of  the  patient  ; 
but  so  atropine  do  the  tissues,  and  particularly  the  bones,  become,  that  the  latter  may 
fracture  from  slight  and  otherwise  inadequate  causes.  The  diagnosis  will  have  been  made 
months  or  more  previously,  by  reason,  first,  of  the  mental  changes  of  the  patient,  particularly 
ideas  of  grandeur  ;  and  secondly,  by  the  occurrence  of  convulsive  seizures  after  there  have 
been  changes  in  the  patient's  mental  condition  for  a  longer  or  shorter  time.  The  case  is 
generally  that  of  a  man  who  has  suffered  previously  from  syphilis,  for  which  treatment 
was  not  very  prolonged,  and  whose  business  has  entailed  much  mental  hard  work,  and 
possibly  worry,  in  a  city.  Confirmatory  evidence  may  be  obtained,  if  need  be.  by  finding 
relatively  large  numbers  of  small  lymphocytes  in  the  cerebrospinal  fluid  removed  by  lumbar 
puncture,  and  \Vassermann"s  serum  reaction  for  syphilis  may  be  positive. 

Before  concluding  that  spontaneous  fracture  of  a  bone  is  due  either  to  neurotrophic 
causes,  or  to  fragilitas  ossium,  it  is  important  to  exclude  the  possibility  of  primary  or 
secondary  neic  growth  in  the  affected  bone,  or  tuberculous  caries.  It  may  be  that  the  patient 
is  already  suffering  from  a  bony  swelling,  such  as  myeloid  sarcoma,  before  the  fracture  takes 
place,  or  it  may  be  known  that  there  is,  or  has  been,  a  primary  growth  elsewhere  ;  for 
instance,  in  the  pelvis,  breast,  stomach,  or  thyroid  gland,  in  which  case  the  spontaneous 
fracture  of  a  bone  would  suggest  that  a  second  metastasis  has  occurred  at  the  site  of  frac- 
ture, eroding  the  bone  until  it  finally  broke  from  a  trivial  cause.  The  chief  difficulties  arise, 
first,  when  there  arc  no  symptoms  of  the  primary  growth  itself,  for  instance  in  the  case 
of  a  diffuse  carcinoma  of  the  stomach  of  the  indiarubber-bottle  type  ;  and  secondly,  when 
the  i)atient  is  really  suffering  from  tuberculous  caries  whose  existence  has  been  entirely 
unsuspected.  As  an  instance,  one  might  mention  the  case  of  a  woman  fifty  years  of  age, 
who.  seeming  to  be  in  perfectly  robust  health,  was  standing  in  her  kitchen,  when  her  son 
entered  unexpectedly,  causing  her  to  start  suddenly,  giving  her  body  a  twist  at  the  same 
time.  This  movement  was  followed  immediately  by  paralysis  of  both  legs,  and  it  seemed 
as  though  the  sudden  muscular  exertion  had  led  either  to  a  haemorrhage  or  to  a  fracture- 
dislocation  of  the  spine  ;  the  cause  for  the  fracture  was  in  itself  inadequate,  however,  and 
it  woulfl  not  have  produced  the  symptoms  had  there  not  been  spinal  caries  which  had  been 
slowly  eroding  the  bones  for  some  time  previously,  until  they  now  gave  way  as  the  result  of 
what  would  otherwise  have  been  a  trivial  movement.  The  diagnosis  in  cases  of  the  kind 
depends  chiefly  upon  remembering  the  possibilities,  and  not  omitting  a  most  careful  exami- 
nation of  every  j)art  of  the  body.  \Vhen  the  j-rays  are  available,  they  may  sometimes  be 
of  considerable  value  in  detecting  a  neoplasm  (Fig.  "iSfi,  p.  07;$)  or  a  tuberculous  focus 
{Fig.  !!).">.  p.  KiO)  in  the  allccted  bone.  Herbert  Friiicli. 

FRAGILITAS    OSSIUM.     (See  Fhactiuf..  .Spontamcois.  p.  24.2.) 

FREQUENCY   OF   MICTURITION.— (See  Mktiuition,  AiiNouMAi.rnKs  of.  p.  :{!):{.) 

FULLNESS,  SENSE  OF.— .\  sense  of  fullness  is  experienced  when  the  tension 
<'xerted  on  the  muscle  fibres  of  the  stomach  or  intestines  is  greater  than  normal. 

Localization. — .\  sense  of  fullness  felt  in  the  upper  part  of  the  abdomen,  in  the 
neighlxjurliciod  of  the  uml)ilieus.  and  in  the  lower  |)arl  of  the  abdomen  is  generally  due  to 
distenliiiM  (if  the  --luinueli,  siiiiill  intestines,  and  colon  respect i\ely. 

I.  Gastric  Fullness. —The  bulk  of  gastric  contents,  whether  lluid  or  gas,  rec|uire(l  to 
pinduee  a  sense  of  fullness  depends  upon  whether  the  tone  of  the  muscles  of  the  stomach 
is  [a)  N'ormal,  (b)  Kxccssive.  or  (c)  Deficient.  The  sensation  is  the  same  in  each  ease  ;  the 
liatieni  eoininonly  believes  it  is  due  to  excess  of  gas  in  the  slomacli,  and  it  is  generally 
thought  that  tone  is  deficient:  but  the  former  is  rarely  true,  and  the  latter  is  certainly  not 
more  eonunonly  the  ease  than  the  reverse. 

{a).  In  normal  individuals  the  sensation  of  liillness  is  ])roduced  by  eating  very  rapidly, 
as  the  intragastric  pressure  rises  owing  to  the  relaxation  of  tone,  which  should  proceed 
pari  passu  with  the  iricr(  asiiig  Ijulk  of  the  gastric  contents,  taking  place  with  insullicient 
rapidity. 

(b).   When   the  tone  of  the  stornacli   is   increased,  a  eompaiatively   small  (|uaiitity  of 


•244  FULLNESS,    SENSE    OP 

food  ])roduccs  a  sensation  of  fullness  unless  the  food  is  eaten  with  extreme  slowness.  In 
rare  cases  the  stomach  is  abnormally  small,  owing  to  infiltration  of  its  walls  with  cancer 
(leather-bottle  stomach,  Fig.  132.  p.  270):  as  its  capacity  cannot  then  increase  at  all  by 
relaxation  of  its  muscular  coat,  a  very  small  quantity  of  food  produces  an  inmiediate  rise 
in  intragastric  pressure  and  a  corresponding  sensation  of  fullness. 

(c).  In  atonic  dilatation  of  the  stomach  the  muscle-fibres  arc  relaxed  completely 
before  any  food  is  eaten  :  the  weight  of  the  food,  however  slowly  it  is  eaten,  stretches  the 
fully  relaxed  fibres  from  the  minute  it  is  eaten,  and  a  sensation  of  fullness  is  felt. 

In  slighter  cases  (hypotonus)  the  muscle-fibres  are  not  relaxed  completely,  but 
complete  relaxation  occurs  as  soon  as  a  small  quantity  of  food  has  been  eaten  ;  any 
further  addition  to  the  gastric  contents  produces  a  sense  of  fullness. 

From  these  considerations  it  is  clear  that  :  (1)  If  a  sense  of  fullness  is  only  felt  when 
an  excessive  quantity  of  food  is  eaten,  the  size  of  the  stomach  is  probably  normal,  and  the 
excess  is  the  cause  of  the  symptom  ;  (2)  If  it  is  only  felt  when  food  is  eaten  very  rapidly, 
the  size  of  the  stomach  is  probably  normal,  and  the  bolting  is  the  cause  of  the  symptom  : 
(,3)  When  it  is  felt  in  spite  of  the  food  being  normal  in  quantity  and  eaten  at  the  normal 
rate,  it  is  due  to  hypertonus  or  hypotonus  if  it  can  be  prevented  by  eating  small  meals 
very  slowly,  and  to  atony  or  to  leather-bottle  stomach  if  this  is  not  the  case. 

The  distinction  can  only  be  made  with  certainty,  however,  by  estimating  the  tone  of 
the  stomach  directly,  or  indirectly  from  its  size,  a  hypertonic  stomach  being  small,  whereas 
a  hypotonic  or  atonic  stomach  is  large. 

Although  percussion  gives  some  idea  of  the  quantity  of  gas  in  the  stomach,  it  does  not 
hclj)  in  the  determination  of  its  size,  and  auscultatory  percussion  and  friction  have  been 
shown  by  means  of  the  .r-rays  to  be  (luite  valueless  so  far  as  the  stomach  is  concerned. 

Splashing  and  succussion  occur  in  the  normal  stomach  after  an  ordinary  meal  ;  if, 
however,  they  can  be  produced  after  drinking  two  oimces  of  water  on  an  empty  stomach, 
atony  is  probably  present. 

Inflation  is  the  only  method  apart  from  the  a-rays  which  gives  definite  information  as 
to  the  size  and  tone  of  the  stomach.  The  patient  drinks  on  an  empty  stomach  two  quanti- 
ties of  water  in  rapid  succession  :  li  drachms  of  sodium  bicarbonate  are  dissolved  in  one 
and  \h  drachms  of  tartaric  acid  in  the  other.  At  the  body  temperature  and  atmospheric 
pressure,  1700  c.c.  of  carbon-dioxide  are  evolved.  The  normal  stomach  has  a  capacity  of 
600  to  1200  c.c.  when  filled  rapidly  :  the  1700  c.c.  of  gas  are  therefore  subjected  to  a  con- 
siderable degree  of  tension  ;  a  certain  amount  of  discomfort  is  felt,  and  the  gas  is  expelled 
rapidly  on  sitting  Up.  When  the  tone  of  the  stomach  is  excessive,  the  capacity  is  less  than 
600  e.e.,  and  when  it  is  deficient  it  is  more  than  1700  c.c.  ;  in  the  former  case  a  sensation 
of  painful  fullness  is  produced,  and  the  gas  is  expelled  violently  on  sitting  up ;  whereas  in 
the  latter  case  no  discomfort,  and  sometimes  actual  relief,  is  experienced,  and  the  gas  can 
be  expelled  only  with  difticulty.  The  tumour  formed  with  a  hypertonic  stomach  is  gener- 
ally situated  too  high  to  be  accessible  for  pal))ation,  but  when  it  can  be  reached  it  is  found 
to  be  firm  and  well  defined  ;  with  a  normal  stomach  it  is  also  firm  and  well  defmed,  and  is 
often  visible  through  the  abdominal  wall,  whereas  with  a  hy])ertonic  stomach  it  is  soft, 
and  its  outline  is  less  easy  to  determine  by  i)alpation  and  percussion.  ^Vhen  the  inflated 
stomach  is  outlined  by  means  of  palpation  and  percussion,  the  distance  between  the  lesser 
and  greater  curvatures  of  the  stomach  should  be  between  3  and  4  in.,  and  the  greater  curva- 
ture should  reach  within  an  inch  of  the  umbilicus.  The  distance  between  tlie  eurvaturesJ 
in  a  hypertonic  stomach  is  less  than  3  in.,  and  the  greater  curvature  is  more  than  an  inchj 
above  the  umbilicus  ;  in  atonic  dilatation  the  distance  is  more  than  4  in.,  and  the  greater 
curvature  often  reaches  below  the  mnbilicus. 

The  size  and  tone  of  the  stomach  can  be  determined  most  accurately  with  the  .r-rays 
after  a  meal  of  porridge  containing  2  oz.  of  barium  sulphate.     Owing  to  the  adaptation 
of  the  tone  of  the  normal  stomach  to  the  volume  of  its  contents,  there  is  little  difference  in| 
the  upper  level  of  the  semi-fluid  chyme  as  seen  in  the  erect  position,  wliether  the  voluniel 
is  5  oz.  or  2  ])ints,  and  the  greater  curvature  is  not  more  than  an  inch  above  or  an  inchj 
below  the  umbilicus  (Fig.  122).    A  hypertonic  stomach  is  diagonal,  or  even  horizontal,  instead! 
of  almost  perpendicular,  as  in  normal  individuals,  and  its  lowest  extremity  is  situated  at 
least  an  inch  and  often  considerably  more  above  the  umbilicus.     An  atonic  stomach  does  not 
adapt  itself  to  the  volume  of  its  contents  :   food  taken  when  it  is  empty  drops  at  once  to  its 


FULLNESS.    SENSE    OF 


245 


most  dependent  part,  instead  of  being  held  up  for  a  few  seconds  by  the  tonic  contraction 
of  tlie  body  of  tlie  stomach.  As  more  and  more  food  is  taken,  the  upper  surface  of  the 
gastric  contents  gradually  rises,  but  it  never  reaches  the  height  observed  in  normal  and 
hypertonic  stomachs  after  the  first  two  or  three  niouthfuls  of  food  are  swallowed.  The 
gastric  tone  is  insulficient  to  withstand  the  weight  of  the  food,  and  the  greater  curvature 
consequently  sinks  as  the  quantity  of  gastric  contents  increases. 

Most  patients  ascribe  a  sense  of  fullness  in  the  epigastrium  to  '  wind,'  and  try  to 
relieve  their  discomfort  by  eructation  ;  as,  however,  it  is  rare  for  excess  of  gas  to  be  present, 
the  attempt  leads  to  aerophagy.  The  sense  of  fidlness  is  thus  often  aggravated  by  aero- 
phagy,  though  primarily  due  to  some  other  cause.  In  addition  to  ascertaining  the  tone 
and  size  of  the  stomach,  it  is  therefore  necessary  to  discover  whether  the  sense  of  fullness 
is  in  ))art  due  either  to  excess  of  gas  produced  by  fermentation  or  to  secondary  aerophagy. 
The  presence  of  excess  of  gas  in  tlie  stomach  can  be  ascertained  most  readily  by  means  of 
the.r-rays.  as  it  is  often  dilHcult  to  distin- 
guish by  jjereussion  whether  a  resonant 
area  corresponds  to  a  collection  of  gas  in 
the  stomach  or  in  the  s])lenic  flexure. 

PjXcess  of  gas  is  only  produced 
in  the  stomach  when  evacuation  is 
delayed  :  this  never  occurs  in  a  hyper- 
tonic stomach,  and  only  in  a  normal 
stomach  when  an  excessive  quantity  of 
food  has  been  eaten.  In  atonic  dila- 
tation of  the  stomacli  stasis  is  never 
sudiciently  great  for  much  fermentation 
to  occur,  the  only  condition  in  which  it 
is  really  active  being  dilatation  due  to 
pyloric  obstruction.  This  can  readily 
be  distinguished  from  atonic  dilatation 
with  the  iT-rays.  even  before  the  onset 
of  visible  peristalsis  and  the  character- 
istic vomiting  of  large  (|uaiitities  of 
food  eaten  many  hours  earlier.  l)y  the 
excessive  activity  of  peristalsis,  the 
occnrrence  of  retro-jieristalsis,  and  the 
presence  of  a  large  residue  in  llic 
stomach  six  hours  after  a  bariiiin  iti(:iI. 
The  diagnosis  of  pyloric  obstruct  ion  is 
confirmerl  if  the  passage  of  a  stoniaih- 
tnbe  at  !)  a.m.  shows  that  rerTuiants  of 
a  dinner  taken  at  !)  p.m.  flic  previous 
evening  arCjStill  in  the  stomach,  nothing 
having  been  eaten  (jr  diimk  ii]  thr- 
interval. 

-Verophagy  can  he  diauiKiscd  with  ccilainly  if  iructalion  occurs  six  or  more  times  in 
rapid  succession,  or  if  it  occurs  before  breakfast,  unless  food  is  jiresenl  in  the  stomach  as  a 
result  of  pyloric  obstruction.  Finally,  it  is  ipiitc  easy  to  watch  the  whole  process  of  aero- 
phagy will]  the  ,(-ia\s. 

2.  Intestinal  Fullness.  A  sense  dC  lulhicss  in  Ihc  Inwcr  pail  of  I  he  alidcinicn  is  alinosl 
invariMlil\  chir  lo  the  exeessi\e  tension  on  the  inleslinaj  walls  pn)du<-(il  \>y  the  [ircsence  ol' 
an  cscissivc  (|iiantity  of  gas.  'I'he  onl\  syinploni  which  proves  conclusively  that  this  is 
the  case  is  I  hi'  passage  of  excess  of  (lal  Us.  particularly  if  it  is  found  lo  relieve  the  diseoinlort . 
In  the  absence  of  evidence  of  a  liyperlonie  coiidilinn  <<t'  Ihc  eolcai,  siuOi  as  occurs  hi  spastic 
constipation  (FiU-  •'>-'.  p.  I'-M).  a  sense  of  liilhiess  hi  llie  Inuci-  pari  of  the  ahdoiiKii  may  be 
presumed  to  be  due  to  the  pressme  ol'  an  excessive  i|iiaiilily  of  gis.  Spastic  c<iiistipation 
is  much  more  often  aec'onipanied  by  pain  than  a  sense  of  fullness  :  it  can  be  ricogni/.cd  by 
the  contracted  condition  of  parts  cif  the  colon,  the  siluation  and  degree  of  the  spasm 
varying  from  one  examination  lo  annthei',  and  with  more  certainty  by  means  of  Ihc 
x-rays  after  a  bariinn  meal  or  a  bariiini  eiuiiiii. 


vertical   position,  showing  u 
al  adult  stomarh. 
Ill  hii  llr.  C.  Tliumlan  llillmul.) 


246  FUNGOUS    AFFECTIONS    OF    THE    SKIN 

Intestinal  flatnlence  may  be  due  to  the  excessive  production  of  gas  in  the  intestines 
from  excessive  fermentation  or  putrefaction,  retention  of  gas  behind  a  faecal  mass  in 
constipation,  the  passage  of  some  of  the  swallowed  air  into  the  intestines  in  severe  eases 
of  aerophagy,  and  deficient  absorption  of  gas  due  to  the  impeded  venous  circulation  in 
cirrhosis  of  the  liver  and  heart  failure.  The  stools  should  always  be  examined  :  if  thev 
are  bubbly,  acid  in  reaction,  and  contain  obvious  excess  of  vegetable  residue,  intestinal 
fermentation  is  probably  the  cause  ;  if  they  are  alkaline  in  reaction,  have  a  putrefactive 
odour  and  contain  obvious  fragments  of  meat,  excessive  putrefaction  is  probably  present. 
On  incubating  some  of  the  stool  made  thin  with  water  for  twenty-four  hours  in  an 
apparatus  in  which  the  gas  evolved  can  be  collected,  it  is  found  that  little  or  no  gas  develops 
and  the  stool  remains  neutral  in  reaction  if  there  is  no  abnormal  bacterial  activity.     When 

excess  of  gas  is  evolved,  it  is  due 
to  fermentation  if  it  is  odourless 
and  the  stools  have  become  very 
acid,  and  to  putrefaction  if  it  has 
an  unpleasant  odour  of  ])utrefac- 
tive  products  and  the  stool  is  very 
alkaline. 

In  the  absence  of  excessive 
I'crmentation  or  putrefaction,  a 
history  of  constipation  would  sug- 
grst  that  that  is  tlie  cause  of  the 
lUitulencc  {vide  Constipation,  p. 
]'21).  Atrophagy  only  leads  to 
intestinal  flatulence  when  it  is  so 
well  marked  as  to  be  easily  recog- 
nized (litle  siipra).  and  an  examin- 
ation of  the  liver  and  heart  show 
whether  it  is  due  to  deficient 
absorption  of  gas  from  cirrhosis  or 
heart  failure.  Arllnir   F.  Ihrlz. 

FUNGOUS      AFFECTIONS 

OF     THE    SKIN. -We    here    in- 

chiile  (1)  Fdviis  ;  (2)  Ringworm  : 
(;5)  Eczema  niargiiiafum ;  (i)  Tinea 
imbricatn  :  (5)  Tinea  versicolor; 
and    ((i)    Erytlirasma. 

1 .  FAVUS  in  man  is  due  in 
about  !»y  per  cent  of  cases  to 
inoculation  with  the  Achorion 
Schonleinii.  Four  other  achorions, 
of  animal  origin,  have  been  identi- 
fied, and  it  has  been  proved  that 
tlie  affection  can  be  commimi- 
cated  from  animals  to  man,  but 
the  instances  are  so  rare  as  to  be 
negligible.  Between  the  achorions 
on  the  one  hand  and  the  micro- 
sporons  and  trichophytons  on  the  other  (see  p.  247),  there  are  close  morphological  resem- 
blances, but  the  clinical  differences  are  well  marked. 

Favus,  while  showing  a  distinct  preference  for  the  scalp,  may  attack  any  part  of  the 
skin  (Fig.  12.3),  and  even  a  mucous  membrane.  The  characteristic  lesion — a  tiny  sulphur- 
yellow  disc  with  a  cup-hke  depression  in  the  centre,  resembling  both  in  colour  and  in  shape 
a  honeycomb,  and  in  hairy  parts  pierced  by  a  hair — can  hardly  be  mistaken  on  account  of 
its  peculiar  mousy  smell.  The  lesion  begins  as  a  collection  of  whitish  material,  somewhat 
resembling  a  pustule,  wliich  grows  and  presently  becomes  dry  and  friable.  The  cup-like 
disc  can  then  be  detached  from  the  epidermis,  leaving  a  piniijly,  smooth,  greasy  surface. 


Ip  ai-trilm 

tion  over  the  IjoJt 

scalp. 

0/  Ihe  Ski, 

,  Sir  .Malcolm  Jlcir 

FUNGOUS    AFFECTIONS    OF    THE    SKIN  247 

As  they  grow,  the  discs  often  run  together.  In  a  later  stage  roughish  crusts  are  formed, 
separated  by  pale,  bhiish-pink  scars.  The  crusts,  when  broken  up,  are  seen  under  the 
microscope  to  consist  of  spores,  varying  mucli  both  in  size  and  sliape.  and  of  sliort  threads 
of  mycelium,  which  may  penetrate  into  the  mucous  layer  of  the  epidermis,  and  may  even 
reach  the  derma  ;  this  never  occurs  in  trichophytosis.  Hairs  affected  with  favus  are  dis- 
coloured and  lustreless  ;  they  may  fall  out,  but  do  not  break  off  as  in  ringworm.  Under 
the  microscope  one  may  sec  in  favus-hairs  segments  of  fungus  12-15  jx  in  length,  dicho- 
tomised at  an  acute  angle.  If  the  nails  are  affected,  the  ungual  cells  will  be  found  to  be 
se[)arated  by  irregular  tlireads  of  mycelium,  or  by  spores. 

In  the  less  characteristic  cases  the  lesions  must  be  examined  closely  under  a  good  lens 
for  remains  of  the  yellow  discs  of  favus  or  the  broken  hairs  of  ringworm.  If,  owing  to 
applications  to  the  skin,  the  crusts  are  lacking,  treatment  should  be  sto|)ped  for  a  few  days, 
when  the  whitish  points  and  the  discs  will  usually  reappear,  lu  prolipngcd  cases  the  crusts 
may  be  replaced  by  an  irregular,  lumpy,  dirty-yellowish  accunuilation,  but  the  odour  of 
favus  will  still  remain.  At  this  stage  the  disease  may  resemble  psoriasis  of  the  scalp  ;  but 
there  is  a  much  greater  loss  of  hair,  the  scales  are  less  pearly,  and  even  when  no  discs  or 
sulpluir-yellow  scabs  can  be  seen  about  the  edges,  the  lustreless  hair  and  the  atrophic 
scarring  left  by  the  scabs  are  sufficiently  distinctive  of  favus.  The  scarring  may  suggest 
lupus  crt/llicmritosiis  of  the  seal]),  but  in  that  affection  the  crusting  and  the  mouse-like  odour 
arc  absent,  wliile  generally  there  arc  characteristic  lesions  on  the  face.  From  both  rczrnid 
and  schonliwa  favus  is  diHereiitiated  by  the  fact  that  its  lesions  are  never  diffuse,  but  always 
have  a  definite  margin.     In  alopecia  areata  there  is  no  scaling,  crusting,  or  cicatrix. 

2.  RINGWORM — whether  of  the  scalp,  the  beard,  the  hairless  skin,  the  mucous  mem- 
brane, or  the  nails,  is  due  to  fungi  belonging  to  two  different  families,  the  microspora  and 
the  trichophyta.  each  of  them  comprising  a  number  of  dilierent  species.  In  the  one  case 
the  alTectlon  is  styled  iiiicrosporosis,  or  tinea  with  small  spores  ;  in  the  other,  trichophytosis, 
or  tinea  with  large  spores.  Kleven  species  of  ringworm  microsporons  have  been  identified  ; 
of  the  trichophyta,  upwards  of  thirty.  Only  four  species  of  the  microspora,  and  the  same 
number  of  species  of  the  trichophyta,  are  of  importance.  The  four  microsporons  are  M. 
.liiiloiiiiii,  M.  felinetim.  M.  canis  and  M.  Inrdum  ;  the  four  trichophytons,  T.  crateriformey 
T.  iiciiinitintiiin.  T.  siilplturenm  and  T.  violaccum.  In  both  families  some  of  the  species 
are  of  animal  origin,  and  it  is  th<sc  wliicli  account  lor  nearly  all  the  inflammatory  forms  of 
ringworm,  iiichidiiig  kcrion. 

or  the  microsjjorons,  the  type  species  is  M.  Audoiiirii,  which  is  the  cause  of  some 
!)()  per  ((111  of  the  juvenile  ringworm  of  London.  It  is  also  the  cause  of  much  of  the 
juvenile  ringworm  of  Paris,  though  of  much  less  than  was  the  case  a  few  years  ago.  M. 
fi'linriiiii  and  .1/.  ciiiiis.  closely  allied  species,  are  responsible  for  an  appreciable  percentage 
of  human  ringworms  the  one  in  Kngland,  the  other  in  France.  M.  tarihim  is  met  with 
occasionally  in  France.  Of  the  four  clinically  im])ortant  species  of  trichophytons,  the  one 
en<'ountered  most  frc(|Ucntly  Is  T.  craleriforme  :  next  comes  T.  aciimiiititiim,  then  T.  slil- 
phiirciini.  which,  however,  is  not  known  in  France  ;  and  lastly  T.  violaceinn.  A  fifth  species 
of  tricliopli\ton,  T.  rosaceiim,  which  chiefly  affects  the  beard,  but  also  the.  hairless  skin,  is 
s-iid  Id  be  relatively  not  iid're(pient  in  Northumberland  and  Durham. 

The  division  of  the  ringworms  into  a  small-sporcd  and  a  laigc-spored  group  may  easily 
lead  to  coidiision  in  diagnosis,  for  among  both  microsporons  and  trichophytons  the  spores 
vary  considerably  in  size,  according  to  I  lie  species.  Those  of  the  microsporons  may  be  as 
large  as  t  fi,  while  those  of  the  trichoph\  Ions  may  be  as  small  as  .'!  p  ;  the  limits  of  the  one 
arc  2  to  \  p.  and  of  the  other,  .'J  to  H  /i.  Clinically,  therel'orc,  microsporosis  and  tricho- 
phytosis are  to  be  dillcrcntiated  from  each  other  not  alone  by  the  size  of  the  spores,  but 
also  by  their  slia|)e  and  arrangement  and  modes  of  growth. 

I'irst,  as  to  slia])c  :  In  microsporosis  the  spores  arc,  speaking  generally,  round  or  ovoid  ; 
in  Irichophylosis,  they  tend  to  be  square  with  rounded  angles,  or  oblong  with  sharper 
angles.  .Still  more  important,  for  diagnosis,  is  the  nrrdiigcnioil  of  the  spores.  In  micr,-)- 
sporosis  they  are  dotted  about  irregularly,  and  the  mycelium  interwoven  with  them  is 
curved  and  branching,  and  irregularly  joiiUed.  In  trichophytosis  they  are  arranged  in 
regular  chains,  and  the  mycelium  is  short  and  regularly  jointed.  In  microsporosis  the 
fungus  forms  a  greyish  slu  alli  around  the  hair  -whet  her  of  I  lie  scalp  or  of  the  body  -which 
it    cuts  a\v;iy,   I'raying   the  edges,   pcnci  lal  irig    to   llic    iiilcrior    (W    the    shaft,    and    growing 


248  FUNGOUS    AFFECTIONS    OF    THE    SKIN 

downwards  towards  the  root.  Presently  the  hair  breaks  off,  at  some  distance  from  the 
follicular  orifice,  and  the  parasitic  sheath  is  disintegrated  and  may  be  seen  as  a  patch  of 
ash-coloured  scales  on  the  epidermis.  In  trichophytosis,  the  parasite  attacks  the  root  of 
the  hair  first,  and  grows  upward.  The  hairs  are  broken  off  short,  and  no  sheath  is  to 
be  seen  outside  the  follicular  orifice.  It  should  be  added  that  some  snuiU-spored  tricho- 
])liytons  form  a  sheath  outside  the  hair  like  that  of  microsporosis,  but  the  spores  observe  the 
chain-formation  which  is  characteristic  of  trichophytosis,  and  this  is  never  present  in 
microsporosis.  These  small-spored  trichophytons  arc  all  ])yogenic,  and  are  the  cause  of 
many  cases  of  kerion. 

Trichophytons  may  be  either  endoihrix  or  einlo-eclollirix.  If  the  parasite  penetrates 
the  hair  between  the  cuticle  cells  and  develo])s  entirely  within  the  hair-structure,  it  belongs 
to  the  endothrix  class.  If  it  develojis  not  only  witliin  the  hair,  but  also  continues  to  pro- 
liferate in  the  follicle  outside,  it  must  be  allocated  to  the  endo-ectothrix  class.  The  great 
majority  of  the  cases  of  scalp  trichophytosis,  both  in  London  and  in  Paris,  are  due  to  endo- 
thrix infections  ;  but  the  endo-ectotriches  are  responsible  for  most  of  the  ringworms  of  the 
hairless  skin,  for  nearly  all  the  adult  ringworms,  and  for  the  majority  of  specially  inflam- 
matory- cases. 

Salxmraud  divides  the  endotriches  into  (1)  True  endotriches,  and  (2)  Xeo-endotriches, 
the  distinguishing  feature  between  them  being  that  in  the  latter  the  early  (neo)  stage  of 
the  attack,  the  stage  in  which  the  outside  of  the  hair  is  assailed,  is  prolonged.  If  tlie  parasite 
is  a  true  endothrix,  it  is  easy  to  miss  the  invasion  stage,  so  short  is  it  ;  if  it  is  a  neo-cndothrix, 
the  invasion-stage  is  so  protracted  that  it  is  possible  to  mistake  the  case  for  one  of  tricho- 
phytosis due  to  an  endo-ectothrix.  The  endo-ectotriches  are  sub-divided  into  those  with 
large  spores  (megaspores),  and  those  with  small  spores  (microides).  It  is  the  latter  which, 
as  mentioned  above,  may  be  mistaken  for  microsporons,  unless  the  chain-formation  be 
looked  for.  In  the  ease  both  of  the  microspora  and  of  the  trichophyta  cultures  may  have 
to  be  grown  to  distinguish  between  the  different  species.  There  are  four  microspora  of 
human  origin,  and  these  give  either  a  small  or  medium  culture  ;  to  this  group  belong 
i\/.  AiKlfiiiiiii  and  M.  tiudum.  The  seven  species  of  animal  origin  yield  a  large,  enduring 
culture  :  in  this  group  occur  the  two  remaining  species  of  clinical  importance.  M.  canis 
and  il/.  fflhieimi.  In  the  first  grou])  pleomorphism  is  never  met  with  :  in  the  second^ 
on  a  suitable,  medium,  a  white  downy  pleomorphism,  quite  different  from  the  mother 
culture,   is  exhibited. 

Of  trichophyton  cultures  there  are  four  main  ty])es  :  (1)  The  crateriform  or  acuminate  ; 
(2)  Those  with  large  white  growths,  cither  ])Owdery  or  velvety  :  (3)  The  faviform  ;  (4)  A 
single  species.  Epidiiiiiophylori  inguinale,  which  is  the  cause  of  eczema  marginatum.  In 
the  first  group,  to  which  belong  all  the  four  clinically  important  species,  the  culture  resembles 
the  crater  of  a  volcano,  and  is  white,  cream,  or  primrose-coloured,  or  it  is  like  a  mountain 
l)eak  ('  acuminate  ')  and  is  grey  or  yellowish  in  colour.  The  parasites  of  this  cultural 
group  are  all  endotriches.  In  the  second  group  the  cultures  are  very  large  and  white,  some 
of  them  powdery,  others  velvety.  The  species  which  yield  cultures  of  this  type  are  all 
endo-ectotriches,  and  are  of  animal  origin.  The  three  species  which  give  cultures  like  those 
of  the  parasites  of  favus,  although  the  clinical  course  of  the  lesions  and  the  appearance  of 
the  fungus  in  the  hair  leave  no  doubt  that  they  are  trichophytons,  are  also  of  animal  origin. 
The  Epidermophi/ton  inguinale  yields  a  yellow-orange  culture,  dry  and  powdery,  but  often 
white  and  vel\  ety  as  the  result  of  ])leomor])hism. 

Ringworm  of  the  Scalp  (Tinea  tonsurans). — Both  the  small-spored  and  the  large- 
spored  ringworm  of  the  scalp  begin  alike  as  a  small  red  papule,  which  develops  near  the 
orifice  of  a  hair-follicle  ;  the  size,  and  yet  more  the  shape  and  arrangement  of  the  spores, 
and  the  way  in  which  the  hair  is  attacked,  help  to  distinguish  between  them  ;  in  trichophy- 
tosis there  is  a  much  smaller  number  of  stumps  to  be  seen  with  the  naked  eye,  and  on  the 
surface  of  the  scaly  patches,  among  the  remaining  healthy  hairs,  one  may  detect  those 
dark  points  to  which  the  affection  owes  its  name  of  '  black-dot  ringworm."  These  dots 
are  pigmented,  coiled-up  hair-stumps.  If  the  whole  scalp  is  thus  affected,  the  ease  becomes 
one  of  '  disseminated  ringworm.'  In  trichophytosis,  again,  the  scales  are  scantier,  or  may 
even  be  absent,  and  the  outline  of  the  lesions  is  not  so  rounded  or  so  well-defined.  As  a  rule 
it  is  not  difficult  to  distinguish  tinea  tonsurans,  whatever  its  form,  from  other  scalp  affec- 
tions, the  clinical  picture — the  broken  hairs,  the  black  dots,  the  slight  scalincss.  the  pronii- 


FUNGOUS    AFFECTIONS    OF    THE    SKIN  249 

nent  follicles,  the  baldness,  in  varying  degrees,  of  the  involved  area — being  sufficiently 
distinctive.  In  favus  there  is  the  same  dull  and  brittle  condition  of  the  hair,  but  the  patches 
are  not  generally  circular,  while  in  ringworm  the  cuj)-shaped  crusts  are  absent,  there  is  no 
mousy  smell,  nor  is  the  skin  atrophic.  The  broken  hairs  distinguish  tinea  tonsurans  from 
])itfiri(isifi  of  the  scalp  and  from  psoriasis  of  the  hairy  skin,  in  both  which  affections  the 
hairs  fall  out  unbroken.  In  ])soriasis,  too,  there  is  a  greater  degree  of  scaliness,  generally 
it  is  not  the  scalp  only  that  is  affected,  nor  is  loss  of  hair  usual,  though  it  occurs  sometimes. 
In  the  anomalous  form  of  ringworm  known  as  iinea  decalvons,  or  bald  ringworm,  in  which 
the  hair  falls  out  in  places  leaving  smooth  bare  patches,  confusion  with  alopecia  areata  may 
be  avoided  without  much  diflieulty  ;  the  billiard-ball  smoothness  of  the  patches  in  the 
latter  condition  is  not  present  in  ringworm.  Another  differential  feature  is  tlie  shape  of 
the  short  hairs  found  at  the  edge  of  the  patches  :  in  tinea  tonsurans  they  are  bent,  whereas 
in  alopecia  areata  they  may  be  compared  to  a  note  of  exclamation.  In  the  latter  condition, 
too,  the  hairs  that  remain  are  free  from  fimgus.  In  the  infrequent  cases  of  inflammatory 
ringworm,  a  condition  somewhat  resembling  impetigo  or  eczema  may  be  set  up  ;  but  the 
broken  stumps  and  the  limited  area  of  the  affection,  together  with  the  history  of  tlie  case, 
should  prevent  confusion  with  those  affections.  In  these  forms  of  ringworm  again,  the 
lesions  are  sharply  defined,  and  the  pustules  are  invariably  situated  round  the  hairs. 
Seborrhaa  can  be  ruled  out  by  remembering  the  greasiness  of  the  scales,  the  diffusion  of  the 
condition  over  tfie  whole  scalj),  and  the  absence  of  patches  of  baldness. 

Ringworm  of  the  Beard  (Tinea  sycosis). — From  ordinary  sycosis  this  affection  is 
<listinguishal>le  l)y  its  more  rapid  spread,  and  the  greater  lumpiness  of  the  affected  surface. 
In  sycosis  vulgaris,  too,  the  pustules  are  usually  pierced  by  a  hair,  and  are  quite  small,  and 
unless  there  is  much  more  suppuration  than  is  usual,  the  hairs  do  not  fall  out.  Tinea  sycosis 
differs  from  cczematoiis  follicalitis  in  the  aljsence  of  the  serous  discharge  that  marks  the 
latter  affection.  In  the  eczematous  condition,  again,  there  is  but  slight  if  any  loosening  of 
the  hairs,  so  that  if  they  are  extracted  they  bring  with  them  their  root-sheaths.  The  affec- 
tion is  not  confinetf  to  the  hairy  parts,  as  in  tinea  sycosis,  nor  do  the  patches  assume  the 
ring-like  form.  The  ring-formation  is  absent  also  in  seborrliwa.  nor  is  the  hair  involved  as 
in  beard-ringworm.  In  the  circinate  tubercular  sypliilnderm.  the  border  of  the  lesion  is 
darker  in  colour  and  more  infiltrated,  and  there  is  either  atrophy  or  pigmentation,  or  l)oth. 
Occasionally  the  severer  cases  of  ringworm  of  the  beard  take  the  form  of  a  single  tumour- 
like formation  which  may  be  mistaken  for  a  carbuucle,  but  the  inllammation  is  almost  always 
less  active  than  in  carbuncle,  and  the  swelling  and  ])ain  are  correspondingly  less.  In  any 
clinically  doubtful  case  examination  of  the  hairs  under  a  microscoijc  will  show  whether  or 
not  the  ease  is  one  of  beard  ringworm  by  revealing  the  presence  or  the  absence  of  the 
tricliopliytie  fungus. 

Ringworm  of  the  Body  Skin  {Tinea  r/rciHoto).— The  small,  red,  slightly  raised 
spot  which  is  the  first  visible  lesion  of  ringworm  of  the  body,  gradually  spreads  at  the  edge 
and  becomes  scaly.  Fading  away  at  the  centre,  the  redness  leaves  a  slightly  discoloured 
branny  area  which  forms  the  inside  of  a  red  ring.  The  circle  slowly  enlarges  without  any 
widening  of  the  t'dge.  Isually,  tliough  not  always,  there  are  several  rings,  sometimes, 
though  seldom,  arranged  concentrically,  and  those  adjoining  each  other  may  run  together, 
Fretpiently,  as  the  i^dge  advances,  there  is  no  involution  in  the  centre,  the  lesions  then 
appearing  not  as  rings  but  as  j)atehes.  As  a  rule  inflammation  is  ])reseiit  in  varying  degrees, 
and  the  neighbouring  lymphatic  glands  may  be  slightly  enlarged. 

These  syniptonis,  with  the  tingling  and  ifehing,  form  an  ciisnnble  which  can  hardly 
be  niistaken  lor  iiny  other  idrccl  ion.  In  ccicuiii  sth(irrli<ricuni  the  seiiles  are  greasy,  aii<l 
often  there  are  projecl  ions  into  the  glandular  openings.  In  psoriasis  the  skin  is  affected  in 
ring-like  areas,  bul  nil  I  h<  other  characters  are  dilferent.  From  llie  circinate  tubercular 
sypiiilodcrm.  ringworm  ol  I  he  body  may  be  distinguished  in  the  smiuc  way  as  ringworm  of 
the  beard  (see  above).  .\s  a  rule  microscopic  examination  will  disclose  the  ringworm 
fungus-  usually  a  triehopliyte  —without  dilliculty  :  but  occasionally  the  |)arasitic  elements 
are  deep-seafed.  and  must  be  sought  in  a  section  of  Ihe  alfeeted  tissue. 

Ringworm  of  the  Nails  {Onyclmnn/cDsis)  usually,  though  not  invariably,  appears  in 
association  with  Iricliopliytosis  of  the  beard  or  of  the  body  skin.  The  hrst  \isible  lesion 
shows  as  greyish  stains  under  the  borders  of  the  nail  anil  at  the  root,  Inlhunmation  of  the 
matrix  follows  and  the  structure  of  the  nail  degenerates,  heeomitig  thickened,  s|)ongy,  and 


250  FUNGOUS    AFFECTIONS    OF    THE    SKIN 

more  or  less  brittle,  with  a  dulled  surface.     When  exfoliation  occurs  a  mass  of  disintegrated 
nail  substance  is  seen,  in  which  the  fungus  may  be  found. 

Similar  changes  may  arise  in  connection  with  gout,  rheumatism,  and  other  constitu- 
tional disorders — those  for  instance  in  which  there  is  impaired  nutrition — as  well  as  in  such 
inflammatory  affections  as  eczema  and  psoriasis.  From  all  such  cases,  the  presence  of  the 
parasitic  elements  will  sulTice  to  differentiate  onychomycosis.  In  the  onychomycosis  of 
favus,  the  stains  under  the  borders  of  the  nail  are  yellower,  and  the  mycelial  elements 
shorter  and  less  re»ular. 

3.  ECZEMA  MARGINATUM. — In  this  form  of  ringworm  of  the  body,  more  frequent 
in  tropical  climates  than  in  Europe,  the  parts  attacked  chieHy  are  the  lower  portion  of  the 
abdomen,  the  groins,  the  buttocks,  the  fold  of  the  nates,  and  the  axillae — parts,  that  is, 
where  the  skin  surfaces  are  in  contact.  The  hair  is  never  involved.  The  characteristic 
feature  of  the  lesions  is  their  broad,  bluff  margin  ;  it  is  scaly,  and  as  a  rule  papular.  They 
are  often  eczematoid,  but  they  can  be  distinguished  from  eczema  and  from  eczema  sebor- 
rhorieum  by  their  gradual  spread  and  broad,  elevated  margin  and  by  the  ring-like  forma- 
tion of  the  early  stage.  If  any  doubt  remains,  the  microscope  will  clear  it  up  by  revealing 
the  ])arasite,  the  Epidernioplii/lon  in<iiiinale. 

From  eczema  marginatum,  dliiihir's  itch  is  differentiated  very  imperfectly.  It  is  in 
fact  a  popular  name  for  all  epiphytic  skin  diseases  of  warm  climates,  but  usually  it  connotes 
diseases  of  this  group  of  which  the  sites  are  the  inguinal  regions  and  the  axillae.  Castellani 
distinguishes  two  fungi  as  the  cause  of  dhobie"s  itch,  besides  Epidermophylon  inguinale, 
namely  E.  Pcrneti  and  E.  riibnim  ;  and  Manson  holds  that,  in  many  cases,  the  parasites 
concerned  are  Micnisporon  minutissinium  and  M.  furfur.  For  practical  purposes,  dhobie"s 
itch  may  be  regarded  as  another  name  for  eczema  marginatiun. 

■1.  TINEA  IMBRICATA —known  also  as  Tokelau  ringworm,  was  formerly  peculiar 
to  certain  oceanic  tropical  climates  in  the  East,  but  now  has  a  wider  distribution.  The 
fungus  has  not  yet  been  classified  definitely.  Sabouraud  holds  it  to  be  a  trichophyton 
allied  to  s]3ecies  of  animal  origin  met  with  in  Eurojje  ;  by  other  authorities  it  is  regarded 
as  a  k'])id()pliyton  :  so  far  it  has  not  been  cultivated.  The  affection  to  which  it  gives  rise 
is  characterized  by  a  concentric  arrangement  of  closely-set  rings  of  scaly  epidermis.  The 
conditions  from  which  it  has  to  be  distinguished  are  tinea  cininata  and  ichthyosis.  From 
the  former  it  is  differentiated  by  the  greater  abundance  of  the  fungus  elements,  the  tendency 
of  the  process  to  spread  centripetally,  the  absence  of  marked  inflammation  or  congestion 
of  the  rings,  their  concentric  disposition,  and  the  greater  size  of  the  scales.  From  the  latter, 
by  the  presence  of  the  fungus,  the  concentric  arrangement  of  the  scales,  and  the  fact  that 
the  attached  border  of  each  scale  is  towards  the  periphery,  the  free  border  being  towards 
the  centre  of  the  circle,  or  group  of  circles,  to  which  the  scale  belongs. 

5.  TINEA  VERSICOLOR — often  styled  pityriasis  versicolor,  is  caused  by  the  Micro- 
sporon  furfur,  the  mycology  of  which  is  little  understood.  The  disease  is  contagious,  but 
only  in  a  k>w  degree.  The  lesions,  confined  to  the  horny  layer  of  the  epidermis,  take  the 
form  of  roundish,  scaly  patches,  with  a  definite  margin,  and  of  a  colour  varying  from  fawn 
to  liver — in  coloured  races,  grey  or  white  :  in  persons  who  have  lived  in  warm  climates,  it 
may  be  black.  The  hair  is  not  assailed,  nor  are  the  hands  and  feet.  As  a  rule  the  lesions 
are  limited  to  the  trunk,  particularly  the  front  of  the  chest,  but  occasionally  they  extend  to 
the  upper  parts  of  the  limbs  :  they  have  been  mistaken  for  secondary  syphilides,  but  th 
coloiu-  and  distribution,  and  the  large  patches  in  which  they  are  found,  should  serve  to 
obviate  the  confusion.  In  exceptional  cases  the  face  may  be  invaded,  and  the  affection 
might  then  be  confounded  with  chloasma.  From  pityriasis  rosea  and  from  eczema  sebor- 
rhivicuni  it  may  be  distinguished  by  the  absence  of  inflammatory  reaction,  except  in  persons 
who  perspire  freely  ;  in  pityriasis  rosea,  too,  the  upper  parts  of  the  limbs  are  affected  equally 
with  the  trunk.  The  lesions  of  tinea  versicolor  offer  some  resemblances  to  the  pigmentary 
patches  sometimes  met  with  in  leprosy  ;  but  from  these,  as  from  the  other  c\itaneous  mani- 
festations mentioned,  they  may  be  differentiated  almost  certainly  by  the  ease  with  which 
the  scales  can  be  detached  by  a  stroke  of  the  finger-nail,  and  quite  certainly  by  the  fungus 
elements  which  may  be  detected  in  the  scales  after  these  have  been  treated  with  potash. 
The  spores  are  rounded  and,  like  the  mycelium,  have  a  double  contour  with  a  diameter  of 
3  to  5  ^  :  they  are  generally  grouped  together  in  masses,  suggesting  a  resemblance  to 
bunches  of  currants. 


GAIT,     ABNORMALITIES    OP  251 

6.  ERYTHRASMA,  due  to  the  Microsporon  minutissimmn.  presents  several  points  of 
resemblance  to  tinea  versicolor.  In  both  it  is  only  the  horny  stratum  of  the  epidermis 
that  is  affected,  nor  is  the  hai^-  ever  attacked.  In  both  there  is  but  a  low  degree  of  con- 
tagiousness. The  lesions  offer  some  likeness  to  those  of  tinea  versicolor,  but  they  are 
reddish-brown  in  colour,  and  their  usual  site  is  the  genito-erural  region  or  the  axilla?,  or 
both,  though  occasionally,  in  fat  subjects,  there  may  be  extension  to  the  abdominal  and 
submammary  folds  and  those  of  the  large  joints.  In  rare  cases,  erythrasma  resembles 
one  type  of  eczema  marginatum,  but  is  distinguished  from  that  affection  by  its  low  degree 
of  contagiousness  and  slow  evolution,  and  by  the  absence  of  inflammation,  which  also 
distinguishes  it  from  eczema  seborrhoeicum  and  from  pityriasis  rosea.  Any  doubt  between 
erythrasma  and  any  other  affection,  including  tinea  versicolor,  may  usually  be  cleared  up 
by  examination  of  a  preparation  under  a  microscope  of  sufficiently  high  power.  The 
spores  of  M.  miniitissimum,  like  the  threads  of  mycelium,  are  extremely  minute,  having 
a  diameter  of  about  0-6  ^i.  The  mycelial  threads,  of  the  same  diameter,  are  so  abundant 
and  so  twined  together  as  to  form,  here  and  there,  a  network  over  the  epidermic  cells. 

Malcolm  Morris. 

GAIT,  ABNORMALITIES  OF.— .\s  a  genuine  aid  to  diagnosis  the  gait  cannot  be  of 
much  real  assistance.  There  are,  however,  several  diseases  and  affections  which  produce 
manifest,  and  in  some  cases  peculiar,  alterations  in  gait.  In  some  respects,  indeed,  the 
gait  is  a  diagnostic  point  in  identity,  though  this  probably  also  depends  on  the  total  back 
or  front  view  of  the  individual,  rather  than  on  real  ijcculiarities  of  gait  as  such. 

In  analyzing  gait  for  diagnostic  pur])oses,  we  find  that  it  consists  of  co-ordinate  and 
painless  movements  of  the  muscles  of  the  lower  limbs  and  pelvis — often,  indeed,  sinking 
into  ]>urely  reflex,  or  at  least  subconscious,  movements — and  these  are  associated,  in  easy 
and  ordinary  walking,  with  rhythmical  movements  of  arms,  body,  and  head.  The 
directions,  therefore,  in  which  it  can  be  disordered  arc:  (1)  hini-ordhiation  ■.  ('!)  Local 
loan  of  jiou-cr  :    (.'i)  J'diii  calling  attention  to  the  niovcincnts. 

1.  Inco-ordination. — The  test  for  the  presence  of  tliis  is  the  complaint  of  the  patient 
that  he  feels  unstiady  in  walking,  especially  on  turning  or  walking  on  uneven  ground,  or 
on  walking  or  stan<ling  with  the  eyes  shut  ;  and  if  co-ordination  only  be  at  fault,  it  will 
then  be  found  that  on  testing  the  legs  for  sim|)le  movements,  such  as  flexion  anrl  extension, 
the  power  of  the  muscles  is  unimpaired.  Having  discovered  inco-ordination,  the  next 
question  is,  to  what  may  this  be  due  ?  Tabes  dorsalis.  ataxic  paraplegia  (combined  lateriil 
and  posterior  sclerosis),  disseminated  sclerosis,  and  hereditary  ataxy  (Friedreich's  disease), 
are  far  and  away  the  connnonest  causes  of  this,  in  the  order  of  mention  ;  their  differential 
diagnosis  depends  on  many  other  symptoms  and  signs,  discussed  elsewhere.  Cerehcllar 
disease  causes  rather  a  reeling  in  the  gait  than  a  simple  inco-ordination  in  the  individual 
movements;  and  here  again,  other  symptoms  will  be  to  the  front.  Locali/,e<l  paralyses 
of  eye  muscles  may  also  cause  inco-ordination  ;  this  will  ])robal)Iy  cause  complaints  of 
double  vision,  and  may  be  diagnosed  by  the  fact  that  the  i)aticnt  walks  better  with  one 
'eye  shut  tlnin  with  both  open  —in  cases  of  some  din-ation  it  is  (juite  likely  that  this  simi)le 
test  will  Udt  iliscdvcr  which  is  the  aliectcd  eye. 

•_'.  Local  Loss  of  Power  is  urll  illuslialiil  l)\  llii' waildling  gait  of /j.sr«f/o-/////Je/7'o;j/iic 
jxiralysis.  cakidated  to  get  the  weigiit  (jf  the  body  as  speedily  as  possible  on  the  foot  as 
a  basis.  The  diagnosis  depends  on  the  peculiar  way  in  which  the  patient  climbs  up  himself 
(see  I*Aii.\iM.i;(;i.\.  p.  .">1(»).  .\nolher  condition  in  which  the  loss  of  power  is  due.  not  to  the 
muscles  Ihcir.scKcs.  hul  to  the  position  of  their  attachments,  is  seen  in  congenital  dislo- 
cation of  the  lii/is  :  the  ;;ail  here,  too,  is  waddling,  the  lower  part  of  the  back  exhibits 
extr<iiic  lordosis,  and  the  belly  is  thrown  forward  through  attempts  to  baliinee  the  ])elvis 
on   I  III-   loose   supports   at    the   hips. 

Other  forms  of  local  loss  of  power  licliav  IIicjmscIms  by  ii  limp  or  by  a  dragging  of 
Ihc  fool  (jr  leg.  aTKJ  (or)  |icciiliiir  positions  of  llic  led,  an<i  possibly  by  wasting  of  muscles 
^;(ii(rall\  or  loriillv  :  incasiircinciil  s  iiiiisl  orcouisc  he  made  if  wasting  be  suspected. 
Infiiiitile  jianilysis.  an<l  olil  Ik  mi-  or  iihuki-  or  iiiini-/il(';i(i\  an-  the  coinnion  causes  of  this. 
if  it  be  uiiassocialcd  willi  pain,  and  (nciiiiTy  iinisl  he  niiidc  as  lo  mode  ol'  oiisil  and 
duration,  in  completing  diagnosis. 

:!.  Pain  on  Walking  is  at  once  obx  ions,  because  complained  of  by  the  patient  ;  acute 
inllainmalory  troubles  of  nuiscles,  joints,  or  tissues  will  be  ol)\  ious  on  examination,  and 


252  GALL-BLADDER     EXLAR(iE3IEXT 

chronic  joint  troubles,  osteo-arthritis,  etc.,  may  be  discovered  easily,  chronic  gonorrhnea 
or  pyorrhoea  alveolaris  not  being  forgotten  as  possible  causes  of  these.  One  thing  that 
may  escape  observation  is  hip-joint  disease,  when  pain  in  the  knee  may  be  the  complaint. 
The  only  other  caution  we  can  administer  here,  is  to  warn  practitioners  against  any 
hasty  conclusions  as  to  the  nature  of  a  disease  from  the  gait  ;  the  high-stepping  gait  of 
tabes,  the  shuffling  gait  of  lateral  sclerosis,  the  festinating  gait  of  paralysis  agitans,  are 
all  easy  enough  of  recognition  when  a  diagnosis  is  made,  but  are  too  frequently  absent 
or  aty])ic;d  to  allow  much  diagnostic  superstructure  to  be  built  on  them  alone. 

Fred  J.  Smilli. 

GALL-BLADDER     ENLARGEMENT. 

Physical  Signs.-  The  (inly  physical  method  of  examination  which  is  of  material 
assistance  in  detecting  enlargcnKMit  of  the  gall-bladder,  is  pali)ation  :  inspection,  percussion, 
and  auscultation  seldom  help.  On  careful  palpation  one  may  feel  an  oval,  smooth  swelling, 
which  may  be  no  larger  than  a  hen's  egg.  or  as  big  as  a  swan's,  moving  downwards  close 
behind  the  anterior  abdominal  wall  when  the  patient  inspires,  descending  either  from 
beneath  the  right  costal  margin  near  the  tip  of  the  ninth  rib,  or  approaching  the  under 
surface  of  an  enlarged  and  ])alpal)lc  liver  in  the  right  nipple  line.  The  tumour  generally 
extends  inwards  as  well  as  ddwiiwards  as  it  grows,  so  that  it  may  ultimately  cross  the 
middle  line  below  the  level  of  the  umbilicus.  It  may  be  large  enough  to  be  palpable 
bimanually  in  a  thin  patient  ;  but  it  seldom  tills  out  the  loin  in  the  way  that  a  renal 
tumour  would.  It  may  or  may  not  be  tender,  according  as  the  cause  of  the  enlargement 
is  associated  with  inflammation  or  not  ;  it  feels  firm  and  tense  rather  than  hard  ;  on 
careful  jjcrcussion  it  may  be  foimd  to  give  an  impaired  note,  but  it  is  seldom  quite  dull 
indcss  it   is  very  big. 

Diagnosis  from  other  Swellings. — It  has  to  be  distinguished  particularly  from  four 
groups  of  conditions  which  may  sinudate  it  : — (1)  From  carcinoma  arising  in  the  bile- 
ducts  or  gall-bladder,  and  replacing  the  latter  with  new  growth  ;  (2)  From  tumours  in 
or  attached  to  the  liver  in  the  neighbourhood  of  the  gall-bladder  :  Riedel's  lobe  ;  secondary 
new  growth  ;  or  more  rarcl\'  gumma,  abscess,  or  hydatid  cyst  :  (3)  From  movable  kidney 
or  hydronephrosis  :  (4)  From  lunioiirs  in  organs  in  tlie  neiglihonrhood.  such  as  carcinoma 
of  the  |)ylorus,  carcinoma  of  the  duodenum,  carcinoma  of  the  transverse  colon,  carcinoma 
or  sarcoma  of  the  right  supiarcnal  capsule  or  right  kidney. 

Carcinoma  of  the  Gall-bladder. — It  may  be  dillicult  to  decide  whether  a  given  mass 
is  merely  an  enlarged  gall-bladder,  or  a  growth  replacing  the  latter  ;  in  either  case  there 
may  be  a  history  of  gall-stones,  with  biliary  colic,  pyrexia,  and  even  jaundice,  extending 
over  years  ;  for  primary  new  growth  of  the  gall-bladder  is  nearly  always  secondary  to, 
and  associated  with,  gall-stones.  The  rapidity  of  the  enlargement,  in  the  absence  of  any 
definite  cause,  may  suggest  growth,  particularly  in  a  person  of  the  cancer  age  ;  careful 
jialpation  may  show  that  the  mass  is  not  smooth  as  most  gall-bladder  enlargements  them- 
selves are,  but  more  or  less  nodulated  or  covered  with  bosses  or  irregularities,  which  in 
themselves  suggest  new  growth  ;  in  some  cases  there  may  be  secondary  deposits  in  the 
liver,  and  sonutimes  the  enlargement  of  the  left  supraclavicular  gland  points  to  malignant 
<lisease  with  metastasis.  Notwithstanding  these  points,  however,  the  differential  diagnosis 
may  be  so  dillicult  that  lajiarotomy  will  be  resorted  to  in  order  to  decide  it. 

The  Tumours  attached  to  or  in  the  Liver  that  are  most  likely  to  be  mistaken 
for  enlargement  of  the  gall-hladder,  or  vice  versa,  are  Riedel's  lobe,  secondary  carcinoma 
or  sarcoma  of  the  liver,  and  nuicli  more  rarely  gumma,  abscess,  or  hydatid  cyst.  A  Riedel's 
lobe  (see  p.  366)  may  be  ipnte  impossible  to  distinguish  by  physical  examination  from  an 
enlarged  gall-bladder  or  from  a  movable  kidney.  Owing  to  the  absence  of  symptoms, 
there  is  seldom  need  for  lajjarotomy  ;  but  sometimes  the  lobe  arouses  such  alarm  lest  it 
be  some  more  serious  condition  that  laparotomy  may  be  resorted  to  and  the  diagnosis 
verified  in  that  way. 

Secondary  nnv  groiclh  in  the  liver,  whether  carcinoma  or  sarcoma,  nearly  always  causes 
\erv  considerable,  and  sometimes  enormous,  enlargement  and  great  hardness  of  the  organ, 
not  infrecpiently  associated  with  Jaundice  (p.  331),  Ascites  (p.  .52),  or  both.  The  diagnosis 
depends,  first,  upon  the  discovery  of  a  primary  growth,  which  in  the  case  of  carcinoma 
is  likely  to  be  in  the  stomach,  duodenum,  pancreas,  colon,  or  rectum  ;  or  in  the  case  of 
sarcoma,  the  eye — some  of  the  greatest  enlargements  of  the  liver  being  due  to  secondary 


(JALL-BLADDER  ENLARGEMENT  25;! 

deposits  of  melanotic  sarcoma,  secondary  to  a  primary  ocular  growtli  ;  and  secondly, 
on  the  discovery  in  the  liver  of  several  separate  nodules,  some  of  which  may  be  felt 
to  be  umbilicated,  that  is  to  say,  depressed  in  their  central  part  and  raised  around  the- 
edges. 

Gumma  of  the  liver  is  not  very  frequent  nowadays,  and  when  it  occurs  is  apt  to  be. 
mistaken  for  new  growth  unless  there  is  an  obvious  history  of  syphilis,  or  the  effects  of 
tertiary  lesions  are  visible  elsewhere,  especially  gummatous  lesions  of  the  skin  or  tongue. 
The  diagnosis  may  be  confirmed  by  obtaining  a  positive  Wassermann's  serum  reaction, 
or  by  the  beneficial  effects  of  giving  salvarsan,  or  potassium  iodide  and  mercury,  though 
these  drugs  do  not  always  cause  a  gunmia  of  the  liver  to  disappear  rapidly.  In  cases  that 
have  come  to  laparotomy  the  diagnosis  between  ginnma  and  new  growth  is  by  no  means 
easy  even  when  the  liver  is  inspected. 

Abscess  of  the  liver  (see  p.  369),  if  it  is  to  simulate  an  enlargement  of  the  gall-bladder, 
is  likely  to  be  a  single  large  one,  which  if  it  has  not  arisen  in  some  pre-existcnt  mass,  such 
as  a  gumma,  new  growth,  or  hydatid  cyst,  is  likely  to  have  been  acquired  in  a  tropical 
country,  where  the  patient  may  have  suffered  from  anicEbic  dysentery.  The  diagnosis 
may  not  be  evident  until  laparotomy  is  resorted  to,  or  until  the  mass  is  punctured  with  an 
exploring  needle,  when 'the  ehocolate-and-milk  appearance  of  the  pus  obtained  may  be 
characteristic. 

Hydatid  cyst  of  the  liver  is  seldom  situated  in  such  a  position  as  to  cause  difficulty  of 
diagnosis  from  gall-bladder  enlargement,  the  cyst  being  more  often  embedded  in  the  liver 
substance,  or  projecting  from  its  upper  surface.  The  diagnosis  might  be  arrived  at  if  the 
patient  were  known  to  have  had  hydatid  cysts  elsewhere  ;  but  in  most  cases  it  is  only  when 
laparotomy  has  been  performed  that  the  correct  diagnosis  can  be  made.  It  might  have 
been  suggested  by  the  occurrence  of  eosinophilia,  and  also  by  a  specific  hydatid  serum 
reaction,  though  neither  of  these  is  likely  to  be  found  imlcss  the  hydatid  cyst  has  profluccd 
toxic  symptoms.  Itecause  latent  liMlatid  cysts  cause  no  syinplniiis. 

The  Distinction  between  an  Enlarged  Gall-bladder  and  a  Movable  Kidney  or 
Hydronephrosis  might  seem  to  offer  no  difficulty  ;  but  clinically  the  distinction  is  not 
always  easy.  There  is  often  no  jaundice  to  suggest  gall-bladder  trouble,  nor  need  there 
be  any  obvious  urinary  changes  to  suggest  kidney,  so  that  the  diagnosis  has  to  be  made 
cliielly  by  palpati<in.  Otic  would  lay  stress  upon  the  fact  that  the  gall-l)hul(l(r  is  more 
easily  felt  anteriorly  than  posteriorly,  whilst  the  reverse  is  the  case  witli  the  kiilncy  ;  that 
the  kidney  is  the  more  freely  movable  of  the  two,  as  a  ride  ;  that  it  is  seldom  possible  to 
<lcma7'cate  the  upper  pole  of  an  enlarged  gall-bladder  in  the  way  that  a  movable  kidney 
can  sometimes  be  made  out  :  that  with  a  kidney  tumour  the  loin  is  dull,  whilst  with  gall- 
bladder enlargement  it  is  resonant  ;  and  that,  on  rather  firm  bimanual  palpation,  the 
|)eculiar  sickening  sensation  tliat  the  i)atient  may  complain  of  is  more  characteristic  of 
kidney  Hum  it   is  of  gall-bladder. 

Tumours  of  other  Organs  simulating  Enlargement  of  the  Gall-bladder  have  to 
be  distinguished  partly  by  the  fact  that  new  growtlis  of  llie  pylorus,  duodenum,  transverse 
colon,  or  suprarenal  capsule,  big  enough  to  simidate  an  enlargement  of  the  gall-bladder, 
will  seldom  ha\c  the  smooth  oval  outline  that  the  lalter  nearly  always  possesses.  There 
may.  moreover,  be  dislincl  symptoms  altributable  to  the  primary  growth,  such  as 
dilatation  of  t lie  stomach,  corfec-groimd  Nomit,  or  there  may  be  scconfiary  deposits  in  the 
liver,  in  the  left  supraclavicular  gland,  or  elsewhere,  to  indicate  the  diagnosis.  It  is  not 
easy,  however,  to  exclude  enlargement  of  the  gall-bladder  without  resorting  to  laparo- 
tomy in    some  of  Ihesf  cmscs. 

The  Cause  of  Enlargement  of  the  Gall-bladder.  Ihuing  decidi-d  Ihal  a  given 
tumour  is  an  eiilarg<-meiil  of  the  gall-l)ladder,  it  is  luccssary  lo  delermine  to  which  of 
the  following  causes  it  is  due  :  — 


iMiipyenia  of  the  gall-lihuUlcr 
Cliroiiii'    paiKTcatitis 

('iiieiiiorna  (if  the  head  of  the  pancreas 
C'lidleeystitis      lioiii  :     (i)   (iiill-stdiies  ; 
(ii)  New  growtli 


Typhoid   l''(\ir 

Ohstriietiiia   of  the  eoiiinioii  hilc-duel  hy  a 

gall-stone 
Ohstruclidii  of  the  cyslic  duet  hy  gall-sloiie 
.Simple  nmeoccli' 


It  is  noteworthy  that  gall-stones  \viul  to  enlargement  ol'  the  gall-bladder  far  less  often 
than   might    be    expected  ;    if  the   inllammation   they   lead  lo,  and  which   leads  to  them. 


254  GALL-BLADDER    EXLAHGEMEXT 

does  not  go  on  to  empyema  of  the  gall-bladder,  the  latter  usually  becomes  thick-walled, 
contracted,  and  embedded  in  dense  adhesions,  the  latter  preventing  it  from  dilating  even 
when  the  cystic  or  common  bile-ducts  become  obstructed  by  a  stone.  It  is  the  exception 
to  find  a  very  big  gall-bladder  with  gall-stones.  Indeed,  in  a  middle-aged  patient  in  whom 
there  has  not  been  any  very  definite  attack  of  biliary  colic,  the  occurrence  of  progressive 
and  considerable  enlargement  of  the  gall-bladder,  associated  with  a  deepening  jaundice 
and  no  ascites,  should  always  arouse  serious  suspicion  of  there  being  a  lesion  of  the  head 
of  the  pancreas  which  has  extended  along  the  pancreatic  duct  so  as  to  occlude  tlie  common 
bile-duct  gradually,  the  commonest  cause  of  these  symptoms  being  either  chronic  jJancrea- 
titis  or  carcinoma  of  the  head  of  the  pancreas.  The  greater  the  epigastric  pain  in  such  a 
case,  especially  if  it  is  paroxysmal,  and  such  as  to  suggest  gall-stones,  the  more  likely  is 
the  lesion  to  he  chronic  pancreatitis  rather  than  new  growth,  and  the  suspicion  may  be 
confirmed  by  C'.\mmidge's  Pancreatic  Reaction  (p.  100).  There  are,  of  course,  cases  in 
which  gall-stones  are  the  cause  of  the  enlargement  :  but  when  this  is  so,  there  is  nearly 
always  tenderness  over  the  gall-bladder,  and  ])ain  when  it  is  palpated  firmly,  associated 
with  a  rise  of  temperature,  possibly  with  rigors,  especially  if  the  inflammation  has  spread 
to  the  bile-ducts  (infective  or  suppurative  cholangitis).  Leucocytosis,  with  a  relative 
increase  in  the  polymorphonuclear  cells,  would  indicate  that  in  addition  to  gall-stones 
there  is  sujjpurative  infianimation — that  is  to  say,  empyema  of  the  gall-bladder — requiring 
surgical  treatment. 

Another  important  cause  for  empyema  of  the  gall-bladder  is  typhoid  fever.  The 
diagnosis  is  not  dillicult  as  a  rule,  for  there  will  be  no  question  of  new  growth  or  of  gall- 
stones in  most  of  the  cases,  and  the  patient  will  have 
been  suffering  from  a  ])rolonged  asthenic  fever  which 
will  have  been  diagnosed  already  by  VVidal's  test.  In- 
fection of  the  gall-bladder  by  typhoid  bacilli  is  relatively 
common,  and  seeing  that  gall-stones  are  seldom  if  ever 
primary,  but  rather  the  result  of  preceding  microbial 
inflammation  in  the  gall-bladder,  it  is  not  surprising 
that  gall-stones  are  more  common  in  patients  who  have 
])reviously  had  typhoid  fever  than  in  other  persons. 
Apart  from  gall-stone  formation,  however,  slighter 
degrees  of  inflammation  of  the  gall-bladder  by  Bacillus 
typhosus  are  common,  and  it  is  thought  that  the  con- 
tinued infectivity  of  the  excreta  in  typhoid-carriers  is 
due  to  the  constant  discharge  of  infected  bile  from  the 
gall-bladder,  persisting  sometimes  for  thirty  years  or 
more.  In  a  certain  number  of  typhoid  patients  rapid 
enlargement  of  the  gall-bladder  occurs  owing  to  the 
baeillary  infection,  and  there  are  instances  in  which  the 
distention  has  become  so  great  that  the  gall-bladder  has  rujjtured  spontaneously  and 
produced  general  peritonitis.  Sometimes  the  inflammatory  products  discharge  themselves 
naturally  by  the  bile-passages  :  but  it  is  often  necessary  to  open  and  drain  the  gall-bladder, 
the  diagnosis  of  the  nature  of  tlie  empyema  being  settled  by  bacteriological  examination 
of  its  contents.  It  is  noteworthy  that,  whereas  in  uncomplicated  cases  of  typhoid  fever 
Widal's  reaction  rapidly  becomes  negative  during  convalescence,  when  there  are  persistent 
baeillary  complications  the  serum  test  may  remain  positive,  or  at  least  partly  positive, 
over  much  longer  periods.  When  an  empyema  of  the  gall-bladder  due  to  typhoid  fever 
remains  latent  for  weeks  or  longer,  the  nature  of  the  case  may  be  suggested  by  the  previous 
history,  and  by  the  persistence  of  the  positive  serum  reaction. 

Simple  mucocele  of  the  gall-bladder  is  probably  the  result  of  former  catarrh  of  the 
cystic  duct,  or  of  a  gall-stone  which  has  disappeared  :  in  many  cases  it  may  be  impossible 
to  determine  the  precise  cause  ;  the  gall-bladder  may  become  greatly  distended  with 
perfectly  colourless  mucoid  fluid,  free  from  bile  pigment,  though  sometimes  containing 
crystals  of  cholcsterin  (Fig.  124).  The  fluid  is  sterile.  There  are  usually  no  symptoms  ; 
the  patient  may  by  chance  have  discovered  the  tumour  for  herself.  Sucli  a  mucocele  may 
be  mistaken  for  a  movable  kidney,  and  the  diagnosis  of  the  nature  of  the  mass  is  some- 
times obscure  until  operation  is  resorted  to.  Herbert  Frencli. 


GANGRENE  255 

GANGRENE. — ^Vhen  any  necrotic  tissue  becomes  infected  with  putrefactive  micro- 
organisms, the  resulting  condition  is  known  as  gangrene — dry,  moist,  or  spreading.  (See 
also  Gangrene  of  the  Lung,  p.  259). 

CAUSES    OF    GANGRENE. 
Local    Traumatic    Causes  : — 

Severe  liiuisiivi  or  crushing  of  the  tissues 

l'roluni;eil  pressure  -  sijiint-sores,  bed-sores 

Extreme  heat  or  cold — burns,  frostbite,  etc. 

The  action  of  strong  chemicals — acids,  alkalies,  phenol,  etc. 

The  action  of  ])o\verful  electric  currents,  or  of  lightning. 

Lowered  Vitality  of  the  Tissues,  either  («)  Local,  or  (b)  General. 

Local  :    adjacent  to  the  infected  area  in  sucli  acute  infections  as — 
Septic  wounds  I       Gonorrhoea  I       .Scarlet  fever 

Erysipelas  Syphilis  Cancrum  oris. 

.\nthrax  I       Diphtheria  | 

General  :    occurriijg  after  some  slight  injury,  as  a  complication  or  sequela  of — 

Diabetes  i  Measles  I       Yellow  fever 

Enteric  fever  1  Infantile  marasmus  |       Malaria 

Small-pox  Cholera  I        I'oisoning   by   snake- 

Chicken-]>ox  Plague  venom. 

Disturbances  of  the  Innervation  of  the  Tissues,  such  as  occur  in — 

Raynaud's  disease  Tabes  dorsalis  [       Meningo-myelitis 

Erythroniclalgia  Leprosy  I       Lesions  of  the  spinal  cord 

Peripheral  neuritis  Hemiplegia  ]  and  cauda  etpiina 

.Syringomyelia  .Myelitis 

Stoppage  of  the  Circulation,  due  to — 

l<',mbolism  ]  ages,     splints  ;     Pressure     of     new 

Thrombosis  [  growths  ;      Pressure    of    aneurysms 

Endarteritis  ;    senile  gangrene  or  effused   blood 

Occlusion     of     vessels,      complete     or  The   arterial   spasm   of  ergotism,    the 

partial,    by-    Ligature,    tight    band-  '  so-called  'epidemic  gangrene.' 

Speaking  generally,  more  than  one  of  the  cau.ses  enumerated  above  will  be  at  work 
in  the  production  of  gangrene  in  any  particular  instance.  Thus,  in  the  gangrene  following 
severe  injury  to  one  of  the  cxtrcniities.  stoppage  of  the  circulation  through  the  affected 
part  is  usually  observed  in  addition  to  the  direct  injury  caused  by  the  mechanical  crushing 
of  its  tissues.  Again,  in  cancrum  oris  or  noma — the  name  given  to  tlie  spreading  gangrene 
of  the  soft  tissues  of  the  mouth  and  cheek  occurring  in  debilitated  children  after  measles 
or  scarlet  fever — great  feebleness  of  the  circulation  contributes  to  its  jiroduclion,  in  addition 
to  the  lowered  vitality  of  the  necrotic  tissues  (F/iJ.  21.  p.  7I-).  A  diabetic  patient  with 
gangrene  may  owe  it  partly  to  the  im|)ovcrishe(l  or  altered  (jualily  of  his  blood,  partly 
to  the  arteriosclerosis  that  is  often  associated  with  diabetes,  and  ])artly  to  pcriplural 
neuritis  occurring  as  a  further  complication  of  his  disease. 

In  tlrij  gangrene,  or  mummificalion,  the  affected  part  of  the  body,  usually  the  distal 
end  of  a  lind).  becomes  livid  and  cold,  and  gradually  blackens  as  the  blood-pigmcnt  dilt'uscs 
out  of  the  blood-corpuscles  and  enters  the  tissues  :  the  ])art  withers  as  the  lluid  in  it 
evaporates.  It  is  a  slow  process  ;  putrefaction  is  little  in  cvideiu'c.  and  there  is  no 
markedly  offensive  odour  about  the  part,  for  it  is  too  dry  to  afford  a  satisfactory  culture- 
medium  for  the  bacteria  of  putrefaction  ;  between  this  dry  gangrenous  tissue  and  the 
adjoining  healthy  pari  of  the  limb  is  an  inllanunatory  zoiu'  :  the  line  of  dcnuircation 
(Plate  A'/I'.  ]).  25H).  Dry  gangrene  is  conmioii  in  cases  of  cndjolism  or  other  complete 
obstruction  of  the  arteries,  in  senile  gangrene,  and  in  HayiuuKTs  disease  (I'liilc  XIII)  :  the 
affected  ])art  is  converted  ultimately  into  a  shrunken,  black,  and  mouldy-smelling  mass. 

Moist  gangrene,  .ipliacelns.  or  sloughing,  may  often  be  .seeti  after  severe  crushing  of  a 
leg  or  an  arm,  when  the  distal  |)ortion  of  the  limb  dies  and  i)Utrelies.  At  first  hot,  rc<l. 
and  paiidid,  the  crushed  extremity  i)rescntly  becomes  mottled,  (jurplish,  and  cold,  as  the 
circulation  through  it  stops.     Putrefaction  soon  appears  in  the  dead  tissue,  the  skin  rising 


256 


GANGRENE 


into  discoloured  blebs,  which,  on  rupture,  give  issue  to  offensive  sanious  fluid.  A  dusky 
red  line  of  demarcation  separates  the  gangrenous  from  the  adjoining  healthy  part. 
'  Sloughing  ■  is  the  name  commonly  given  to  the  putrefactive  separation  of  smaller  parts 
of  the  soft  tissues  from  the  body  ;  sloughs  are  the  localized  gangrenous  patches  that  result 
from  most  of  the  injuries  described  under  the  first  heading. 

Sprcnding  gangrene  is  the  form  due  to  infection  by  special  virulent  bacteria  such  as 
BaeiHus  a  rogenes  eapsuhiliis,  which  cause  death  of  the  tissues  in  which  they  grow  and 
spread.  Fatty  acids,  sulphides  and  gases  are  among  the  chemical  compounds  formed  by 
these  micro-organisms,  and  it  is  to  them  that  the  offensive  odour  is  due. 


THE  DIAGNOSIS. 
Traumatic  Local  Causes  and  Lowered  Vitality  of  the  Tissues. — Gangrene  being 
an  infective  necrosis  of  some  part  of  the  body,  [iroducing  changes  obvious  to  the  eye  and 
nose,  the  fact  of  its  occurrence  can  rarely  be  dillicult  to  determine.  The  history  of 
exposure  to  one  or  another  of  the  forms  of  severe  injury  or  infection,  or  of  exposure  to 
some  injury  or  infection  that  would  be  unimportant  if  it  occurred  in  a  healthy  person, 
but  may  lead  to  gangrene  in  severely  debilitated  |)atients,  ought  to  be  elicited  readily. 

Disturbances  of  the  Innervation  of  the  Tissues. — Gangrene  due  to  disturbances 
in  the  innervation  of  the  tissues  is  commonly  described  as  a  trophoneurosis  or  trophic 
change.     It  may  be  either  chronic  or  acute  in  its  onset. 

Gangrene  of  a  Chronic  Type. — In  Raynaud's  disease  gangrene  may  affect  the  tips  of 

the  fingers  or  the  toes,  less 
often  the  edges  of  the  ears  and 
the  end  of  the  nose  or  tongue. 
It  is  often  synmietrieal,  and  is 
preceded  by  the  other  two  well- 
known  stages  of  the  disease, 
namely,  local  syncope,  in  which 
the  affected  extremities  become 
cold.  numb,  and  white  :  and 
local  asphyxia  {Fig.  125),  in 
which  they  turn  from  white  to 
blue-grey  or  purple.  Rarely, 
Raynaud's  disease  is  character- 
ized only  by  recurring  attacks 
of  necrosis  in  the  extremities 
{Fig.  126).  It  is  a  chronic 
affection,  and  gangrene  only 
occurs  in  marked  cases  and  in 
their  later  stages,  although  it  may  be  seen  at  any  age.  As  a  dry  gangrene  attacking  the 
superficial  and  terminal  parts  of  some  of  the  digits,  it  may  bear  some  resemblance  to 
senile  gangrene  {Plate  A'/I'.  p.  238) :  this,  however,  generally  attacks  only  one  limb,  usually 
a  foot ;  it  is  more  extensive  and  progressive  than  the  gangrene  of  Raj-naud"s  disease  ; 
and  it  is  associated  with  well-marked  disease  of  the  arterial  walls. 

Gangrene  may  be  a  part  of  the  manifestations  of  erythromelalgia,  a  rare  and  chronic 
disease  of  adults  who  do  hard  work  while  exposed  to  considerable  changes  of  temperature. 
It  is  characterized  by  ])ain,  lieat.  and  flushing  of  one  or  more  of  the  extremities,  all  aggra- 
vated when  the  limb  is  allowed  to  hang  downwards.  The  colour  varies  from  rosy  red  to 
purple,  and  the  affected  parts  are  hot  :  hence  the  condition  should  not  be  confused  with 
Raynaud's  disease.  The  gangrene  of  erythromelalgia  is  confined  to  the  extremities  and 
may  be  symmetrical  ;  as  a  rule  it  is  more  narrowly  localized  and  less  superflcia!  than  the 
gangrene  met  with  in  Raynaud's  disease. 

Gangrene  is  a  rare  complication  of  peripheral  neuritis  due  to  alcoholic,  arsenical,  or 
otlier  forms  of  poisoning  (p.  65)  ;  it  occurs  only  in  patients  exhibiting  the  vasomotor 
type  of  neuritis.  This  closely  resembles  Raynaud's  disease,  with  which,  indeed,  some 
hold  it  to  be  identical.  The  gangrene  is  symmetrical  ;  the  patient  will  very  probably 
exhibit  other  symptoms  of  peripheral  neuritis — disturbances  of  sensation,  tremor,  paresis, 
wasting,  trophic  changes — and  a  history  of  alcoholic  excess  may  be  obtainable. 


K 

-<f:' 

stage  of  local  asphyx 


PLATE     XIII 

SYMMETRICAL      GANGRENE      OF      THE      FINGERS     IN       RAYNAUD'S      DISEASE 


/ifftrodiiced  by  /termission  of  the  House  CommiHff  "/  -V/.  (Imnje'x  //on/iitnl 
from  a  water-colour  drairiny  &//  the  fate  Ur.  A'.  .-1.  Wilson. 
v.\    or    iii.\uxosis— To  face  p.  256 


GAXGREXE  2.-,7 

Gangrene  of  the  skin  and  su]>erftcial  tissues  of  the  hands  or  feet,  or  of  the  finocr-ends. 
may  lie  met  with  in  syringoDiijelia  ;  this  disease,  if  associated  with  painless  whitlows  on 
the  fingers,  is  known  as  Morvtin's  disense.  This  gangrene  is  to  some  extent  traumatic, 
and  may  be  synnnetrieal  ;  but  the  diagnosis  should  not  be  difficult,  for  in  most  cases  three 
prominent  symptoms  are  seen  in  syringomyelia  :  (a)  Loss  of  the  sensations  of  pain  and 
of  temperature,  tactile  sense  being  preserved  over  the  anaesthetic  area — the  •  dissociated 
anaesthesia  '  of  t'harcot.  (b)  Trophic  changes  about  the  extremities,  often  originating 
in  some  neglected  or  unnoticed  injury  :  hypertrophy  or  atrophy  of  the  skin  or  nails  : 
trophic  changes  in  the  joints,  the  so-called  "  Charcot's  joints  "  ;  brittleness  of  the  long 
bones,  with  a  tendency  to  spontaneous  fracture,  (c)  Progressive  muscular  atrophv. 
invading  the  hands  first,  later  the  forearms,  arms,  and  shoulders  :  atrophy  of  the  spinal 
nuiscles  may  ensue,  giving  rise  to  spinal  curvature.  Thus  the  gangrene  of  syringoniyeha 
is  characterized  by  its  painlessness,  and  by  its  combination  with  other  well-marked  special 
symptoms  ;  in  addition  the  hands  often  present  certain  deformities,  "  Ci.aw-iiand  "  (p. 
10!))  resulting  when  the  nuiscular  atrojjhy  of  the  liands  is  marked,  '  succulent  hand  ' 
when  much  hyperplasia  and  redimdaney  of  the  soft  parts  <if  the  hand  and  fingers  occur. 

Gangrene  of  the  toes  ma>  occur  in  hihes  ddisalis.  usually  in  connection  with  a 
perforating  ulcer  about  ^lie  ball  of  the  big  toe  (Fig.  297,  p.  736).      Ttie  process  is  slow 


i'i'"i" I 


and  painless,  not  symmetrical;  and  is  associated  with  the  otlier  main  signs  of  tabes 
(p.   (it)!)).      (Jangrcne    of   a    similar   sdit.    and    similarls     sl.-utcil     by   some   ulceration    or   a 

ncglcctid  injury,   is  eonmion   in  /r/y/i/.v//  of  lln-  si Ih.  or  anasi  lictic  l\|>i'.      It  occurs  only 

in  llic  latci-  slaiics  of  lliis  disease,  anil  IVom  its  raril\  calls  loi-  no  rnillicf  consjdii'al  ion 
Urn-. 

Ctin^iiiir  of  III!  (iriilr  li/jir.  at  t  rihnl  able  (o  trophic  changes,  occurs  in  llie  Inrm  of 
iliiiihiliis  (lentils,  or  iiiiilr  lii'ihiiii'  in  eeilain  acute  disorders  or  itd'cctions  of  the  central 
n(i\i>us  system  oi  spinal  eiird.  producing  both  |)aralysis  and  ana'sthesia.  Within  a  few 
days  or  e\en  hours  of  the  primai\  lesion,  secondary  changes  are  seen  in  the  skin  and  soil 
tissues  where  they  are  nmsl  exposed  to  pressure  about  tlie  buttock,  sacrum,  coccyx, 
iliac  crest,  great  trochanter,  tibia,  or  liccl.  according  to  the  position  in  which  the  paialy/.ed 
palient  lies.  When  the  pressure  is  undul\-  great  or  protracted  the  skin  (urns  red  or  purple, 
and  unless  most  carefully  protected  presently  undergoes  extensive  and  spreading  necrosis 
and  gangrene.  Ilol-waler  liollNs  thai  would  expose  an  o'-dinary  palieni  lo  no  discomfort 
or  danger,  ma\  set  np  aTialn^uns  neeiosis  and  gangri'ue  if  allowed  to  remain  too  long 
or   I -losclv   in   eontael    uilli    llie   skin   of  a    paralytic  |>alienl    liabU-  lo  llie  Inrmalion  of 

l>  '  !7 


258  gangrexp: 

bed-sores.  The  prolonged  application  of  an  ice-bag  may  do  the  same  ;  indeed,  the  use  of 
ice-bags  over  long  periods  may  be  followed  by  gangrene  even  in  patients  who  are  free  from 
any  nervous  disorder,  and  jjarticularly  in  patients  who  are  very  fat.  The  chief  nervous 
lesions  in  which  the  acute  bedsore  is  seen  are  the  following  :  hemiplegia,  whether  due  to 
cerebral  embolism,  haemorrhage,  or  thrombosis  ;  acute  infections  of  the  spinal  membranes 
or  cord,  such  as  meningitis,  myelitis,  or  menipgo-myelitis,  whatever  the  nature  of  the  infec- 
tion ;  transverse  lesions  of  the  spinal  cord  or  cauda  equina,  such  as  are  caused  by  fractures 
or  fracture-dislocations  of  the  spinal  column,  or  by  penetrating  wounds  involving  the 
spinal  cord.  These  bedsores  occur  only  in  the  anjesthetic  areas,  and  hence  tend  to  escape 
the  notice  of  the  patient,  who  may  also  be  imeonscious  or  delirious.  It  is  most  important 
to  keep  a  sharp  look-out  on  the  skin  over  all  the  bony  prominences  exposed  to  pressure 
in  these  patients,  so  that  an  incipient  bedsore  may  be  detected  at  once,  and  its  spread 
cheeked  by  suitable  treatment.  Once  well  established,  the  acute  bedsore  tends  to  spread 
in  area  and  in  depth  in  .spite  of  the  most  careful  treatment,  and  brings  about  the  death  ol' 
the  patient  by  septic  absorption,  pya?mia,  or  the  exhaustion  consequent  to  prolonged 
suppuration. 

Stoppage  of  the  Circulation. — Among  the  most  important  and  extensive  causes  of 
gangrene  are  those  in  which  the  exciting  factor  is  some  more  or  less  complete  vascular 
obstruction,  with  consequent  stoppage  of  the  circulation,  and  the  death  of  those  tissues 
whose  blood-supply  is  cut  off.  Occlusion  of  arteries  is  more  important  than  that  of  the 
veins,  but  in  exceptional  cases  moist  gangrene  of  some  distal  jiart  follows  blocking  of  the 
veins  by  thrombosis  or  by  pressure  from  without,  while  the  arteries  are  still  patent.  The 
importance  and  amount  of  the  pathological  changes  following  vascular  obstruction  depend 
on  the  extent  to  which  collateral  channels  are  able  to  carry  on  the  circulation  through  the 
affected  area.  If  they  are  ill-developed,  the  consequences  of  the  stoppage  are  serious. 
Embolism  is  likely  to  occur  in  patients  who  have  valvular  disease  of  the  heart,  with  vege- 
tations on  the  mitral  or  aortic  valves  that  may  be  swept  off  into  the  blood-stream  :  or 
the  embolus  may  be  derived  from  a  blood-clot  formed  in  a  diverticulum  of  one  of  the 
chambers  of  the  left  heart,  or  in  an  aneurysm,  or  upon  the  surface  of  a  rough  atheromatous 
aorta.  Thrombosis,  whether  arterial  or  venous,  may  be  suspected  in  patients  in  whom  no 
source  for  an  embolus  can  be  detected,  but  who  exhibit  widespread  arterial  degeneration, 
phlebosclerosis,  or  local  disease  that  may  spread  to  some  vessel  and  set  up  clotting  in  its 
contents.  The  occurrence  of  arterial  embolism,  in  the  leg  for  example,  is  marked  by  a 
sudden  and  very  severe  pain  in  the  limb  about  the  level  of  the  blockage.  The  parts 
beyond  become  numb,  cold,  insensitive  ;  pulsation  can  no  longer  be  felt  in  the  arteries 
distal  to  the  obstruction.  The  gangrene  that  follows  is  usually  of  the  dry  type.  Very 
similar  symptoms  may  mark  the  occlusion  of  an  artery  in  the  leg  by  thrombosis,  but  the 
onset  is  usually  much  more  gradual,  and  the  pain  may  be  terribly  protracted  and  severe. 
Senile  gangrene  occurs  in  patients  of  advanced  years  with  extensive  arterial  sclerosis  ; 
in  many  instances  they  also  give  a  history  of  gout,  or  suffer  from  diabetes  mellitus.  It 
is  in  reality  a  form  of  occlusive  gangrene,  due  either  to  the  clotting  of  blood  on  the  diseased 
and  roughened  arterial  intima,  or  to  increasing  obstruction  of  the  arterial  lumina  by  a 
proliferative  endarteritis.  It  is  often  of  insidious  onset  and  confined  to  one  lower  limb, 
just  as  embolic  gangrene  may  be  ;  but  it  tends  to  spread  upwards  slowly  and  indefinitely, 
a  tendency  that  finds  a  natural  explanation  in  the  extensive  character  of  the  arterial 
degeneration  that  goes  with  it.  It  is  not  often  synnnetrical  ;  if  more  than  one  limb  is 
affected  the  lesions  are  successive  in  their  development. 

Little  need  be  said  about  the  gangrene  that  follows  complete  or  jjartial  occlusion  of 
the  vessels  by  the  other  causes  enumerated  above.  The  gangrene  will  be  secondary  to 
some  primary  lesion  that  will  seldom  fail  to  be  obvious.  The  ligature  of  an  artery  in  the 
course  of  a  surgical  operation — of  the  femoral,  for  example,  in  the  treatment  of  popliteal 
aneurysm — has  caused  gangrene  of  the  leg  in  patients  whose  collateral  circulation  unfortu- 
nately proved  to  be  inadequate.  The  application  of  tight  bandages  round  a  limb,  possibly 
to  check  haemorrhage,  may  cause  similar  gangrene  if  they  are  left  on  too  long.  Neio 
growth  readily  compresses  or  invades  veins  or  even  arteries  in  exceptional  cases,  and  renders 
tliem  impervious  ;  in  either  case  gangrene  of  some  distal  part  may  result.  The  new  growth 
may  be  primary,  or  a  secondary  deposit  growing  perhaps  in  a  lymphatic  gland.  Thus 
carcinoma  in  the  manmiary  gland,  or  endothelioma  of  the  lung  or   pleura,  may  lead  to 


PLAT  J':   xn- 


GANGRENE      OF      FOOT 


Koto  tho  line  of  ilcrii.n-cilion  at  (a). 


J''ri>m  •  /iilmhic/hH  l„  tfiin/irii: 

IjI/  /.-imt  pirmLnian  of  J'rn/.  Jl,il/i,r/„rd  At,r 


GANCiREXE    OF    THE    LUN(i  2r,9 

secondary  deposits  about  the  axillary  and  subclavian  vein  and  artery  ;  and  these  may  be 
so  extensive  as  to  obstruct  the  circulation  through  the  arm.  and  set  up  moist  gangrene 
in  the  fingers.  Similar  gangrene  of  the  fingers  may  result  from  the  vascular  obstruction 
caused  by  a  large  intrathoracic  (ineiirysm,  or  by  hlooil  that  luis  escaped  and  clotted  round 
the  vessels  of  the  arm. 

The  epidemic  gangrene  of  ergotism  is  only  of  historic  interest  in  Great  Britain,  although 
it  is  said  to  occur  still  in  Russia.  It  is  seen  only  in  persons  who  consume  quantities  of 
mouldy  rye  :  it  appears  not  to  occur  in  human  beings  as  the  result  of  excessive  doses  of 
ihc  ])harmaceutical  preparations  of  ergot.  Minor  degrees  of  ergotism  may.  however, 
simulate  Raynaud's  disease  or  erythromelalgia.  Gangrene  due  to  ergot  is  dry,  chronic  in 
progress,  extremelj'  jaainful,  and  usually  asymmetrical  ;  it  results  in  much  disfigurement 
from  loss  of  tissue,  and  has  had  a  high  mortality  in  many  of  its  epidemics. 

A.  J.  Je.r-Blake. 

GANGRENE  OF  THE  LUNG  occurs  when  a  ]>ortiun  of  this  organ  undergoes  necrosis 
and  tlien,  owing  to  invasion  by  one  or  more  of  many  kinds  of  bacteria,  putrefies. 
It  usually  occurs  in  senile,  intemperate,  diabetic,  or  debilitated  patients.  Most  often  it 
affects  a  circumscribed  area  of  lung  tissue  only,  but  it  may  be  a  diffuse  process  involving 
a  whole  lung.  It  occurs  as  a  rare  complication  of  pneumonio  or  bronchopneumonia  : 
and  as  a  comparatively  common  complication  of  aspiration  pnenmonia  due  to  direct 
infection  of  the  lung  by  bacteria  contained  in  food,  mucous  secretions,  or  foreign  bodies 
generally  (peas,  beans,  fish-bones,  extracted  teeth,  etc.).  that  have  made  their  way  past 
the  larynx  and  into  the  trachea  or  bronchi.  Gangrene  may  also  result  from  an  extension 
of  the  infectio:i  in  such  chronic  su])purative  affections  of  the  lungs  as  clironic  piilmoniiri/ 
tnhercidosis,  l>ronchiectasis.  or  fwiid  bronchitis.  In  other  instances  the  infecting  agent 
reaches  the  lungs  by  the  blood-stream  :  thus  gangrene  may  follow  pidmunary  emlmlism 
if  the  emboli  contain  septic  or  putrefactive  bacteria,  secondary,  for  instance,  to  lateral 
simis  thrombosis  the  residt  of  middle-ear  disease  ;  or  it  may  result  horn  penetrating  iconnds 
of  the  lung,  or  from  the  spread  of  infection  from  the  pleura,  peritoneum,  or  ])ericardium 
to  the  tissue  of  the  hmgs. 

(iangrene  of  the  lung  is  characterized  by  great  prostration,  irregular  fever,  cough, 
and  in  most  cases  the  exijcctoration  of  copious,  fluid,  frothy  sputum  of  disgusting  odour. 
The  sputum  settles  into  three  layers  on  standing,  and  the  lowermost  of  these  contains 
fragments  of  clastic  tissue.  Severe  haemoptysis  from  gangrenous  erosioti  of  a  blood-vessel 
may  be  noted  in  chronic  eases.  In  a  few  eases  the  sputmn  lacks  the  indescribable  hut 
characteristic  fotor.  oflencst  so  in  diabetics  or  children.  The  pliysical  signs  of  gangrene 
of  the  lungs  are  in  no  way  distinctive  :  more  or  less  extensive  consoliflation  or  infiltration 
of  the  ari'ected  part  will  be  indicated  early  in  the  disease,  and  later,  when  the  gangrenous 
tissue  has  softened  and  been  expectorated,  the  signs  of  a  cavity  may  appear.  Occurring 
as  a  terminal  event,  shortly  before  the  death  of  an  exhausted  and  debilitated  patient. 
|nilmiinary  gangrene  may  not  be  suspected,  and  so  may  escape  detection. 

.\s  a  Mule.  however,  the  diagiKjsis  presents  no  great  dillicully.  being  suggestid  l)\  tlie 
su|)erventioM  of  cuiiiinis  and  highly  offensive  exi)ectoration  in  a  patient  known  to  be 
sulTering  from  one  or  another  of  the  diseases  already  mentioned.  The  gangrene  may, 
however,  be  sinudtaneous  with  the  dcv  (IdpiiK'iit  oC  an  /is/iinitiaii  jiin'iinKiniii.  and  lliis  con- 
dition may  therefore  be  eonsidiicd  nion-  liilly.  Il  is  (ill<n  sd  up  by  I  he  iril  r  y  nl'  a  foreign 
body  into  the  trachea  or  a  broiielius  :  il  may  lollow  stenosis  of  a  hidnehus  I'roni  any  cause, 
such  as  syphilis,  or  tlie  pressun-  of  an  aneurysm  or  ofa  new  growth  :  it  may  result  from  the 
estalilishment  of  a  lislula  from  I  he  (esophagus  to  the  trachea  or  a  bronchus  as  a  tcrminid 
event  ill  mahgiiaiil  disease  of  llic  air-passages  or  (eso|iliagus  :  il  is  sciii  in  patients  with 
spicadiiig  iiilicl  ions  of  I  he  iikhiI  h.  pharynx,  or  larynx:  il  oe<-uis  in  Ihc  insane,  or  in 
persons  witli  e\teiisi\c  laiyiigeai  or  bulbar  paralysis  who  are  eoiistantly  exposed  to  Ihc 
danger  of  swallowing  food  directly  into  their  air-passages  :  and  it  is  observed  occasionally 
oiler  opciations,  particularly  those  on  the  mouth,  pharynx.  lar\rix.  or  trachea,  when 
iiilrclivr  matter — e.g.,  nuK-us.  sputum,  a  fragment  ofa  tooth  that  has  just  been  extracted 
has  made  its  way  into  the  bronchi  while  tlie  patient  was  under  the  inlluencc  ofa  general 
ana'sthetie.  .Ml  the  <-anses  just  enumerated  are  dependent  on  <'xeeptional  eiremnstances 
or  conditions  that  should  be  distinguished  fairly  easily  or  reiin'mhered  by  the  patient  : 
hill   in  iiol  a   few  instances  gan;;rene  of  the  lung  has  followed  bathing.  di\ing,  or  aeeidental 


•JGO  GANGRENE    OF    THE    LUNG 

iiiiinersion,  though  the  patient  could  not  call  to  mind  that  he  inhaled  any  water  ;  in  the 
same  way  the  origin  of  other  cases  of  pulmonary  gangrene  has  remained  obscure  until 
the  patient  has  coughed  up  a  piece  of  bone,  a  fragment  of  a  tooth,  part  of  an  ear  of  corn, 
or  some  other  foreign  body  that  he  had  no  recollection  of  having  inhaled  down  his  trachea. 

In  patients  with  injwmia,  gangrene  of  the  hmg  due  to  multiple  embolic  pulmonary 
abscesses  would  be  suggested  if  the  patient  should  develop  the  signs  of  pulmonary  con- 
solidation, cough,  and  offensive  ex])ectoration.  Similar  symptoms  occurring  after  imunds 
or  coiiliisioNs  (if  llie  hiiigs  would  make  the  same  diagnosis  highly  probable. 

(Jrcatcr  didiculty  is  experienced  in  deciding  whether  gangrene  of  the  lung  has  occurred 
in  a  patient  suffering  from  bronchiectasis,  foetid  bronchitis,  chronic  pulmonarif  tuberculosis 
7vilh  cavilij  formation,  or  putrid  empyema  discharging  through  the  lung,  where  expectoration 
of  highly  offensive  sputum  was  already  ])resent.  Elastic  fibres  and  shreds  of  pulmonary 
tissue  may  be,  and  often  are.  present  in  the  sputa  of  all  these  conditions  ;  but  they  are 
commonest,  and  present  in  greatest  amount,  in  pulmonary  gangrene.  Again,  the  onset 
of  pulmonary  gangrene  is  often  acute,  and  accompanied  by  mucli  prostration,  no  doubt 
due  to  septic  absorption  ;  these  facts,  coupled  with  evidence  of  appropriate  changes  in 
the  physical  signs  of  the  patient's  lungs,  should  assist  in  arriving  at  the  diagnosis. 

Pulmonary  gangrene  may  occur  so  soon  before  death  as  to  be  luisiispected  ;  in  a  few 
instances  the  sputum  is  not  fcetid  :  in  others,  particularly  in  children,  the  gangrene  may 
lead  to  no  expectoration  at  all.  In  these  circumstances  the  diagnosis  is  impossible,  and 
the  gangrene  of  the  lung  may  be  described  as  latent.  A.  J.  Jex-Blake. 

GASTRECTASIS.-(See  Dilatation  of  tiik  Stomach,  p.  173.) 

GIDDINESS.— (See  \'i:uTi(:o.   |).  Tol.) 

GIRDLE  PAIN,  or  '  girdle  sensation  " — whicli  is  often  a  better  description  of  the 
pluiKinunon — is  a  sense  of  constriction,  sometimes  of  painful  constriction,  as  though  a 
tight  band  encircled  the  trunk.  The  band  may  be  narrow  or  broad,  and  may  be  referred 
to  any  level  of  the  thorax  or  abdomen.  Although  a  common  symptom  of  tabes,  it  is  not 
jiathognomonic  of  that  disease,  and  may  occur  with  any  morbid  condition  involving 
symmetrically  the  posterior  spinal  roots,  such  as  syphilitic  spinal  meningitis. 

.\nother  form  of  girdle  sensation,  having  a  different  pathological  basis,  is  often 
deseribeci  by  patients  suffering  from  spastic  paraplegia  due  to  focal  disease  within  or  out- 
side the  dorsal  region  of  the  spinal  cord.  In  such  a  case  the  tight  feeling  is  found  to  corres- 
|iond  with  the  highest  level  of  spasticity,  sometimes  with  the  highest  level  of  sensory  loss. 
Thus  a  girdle  sensation  may  be  a  sym]}tom  of  dis.scniiualcd  sclerosis,  of  myelitis,  or  of  com- 
pression paraplegia.  In  the  last  it  may  hel])  the  ])liysieian  to  localize  the  level  of  the  disease, 
but  it  is  rarely  so  reliable  for  this  purpose  as  the  information  which  can  be  obtained  from 
a  careful  investigation  of  the  distribution  of  motor  and  sensory  paralysis  and  of  the 
superficial  reflexes  (see  P.^r.vplegia.  p.  .510).  E.  Farquhar  Buzzard. 

GLANDS,  LYMPHATIC,  ENLARGEMENT  OF.-  (See  Lymphatic  Gi  and  Enlarge- 

.Aii-.NT.  |i.  :!?(>.) 

GLYCOSURIA. — Tlie  diagnosis  of  glycosuria  falls  naturally  into  two  divisions  : — 
(I)  Tlw  recognition  of  glucose  in  the  urine:  and  (II)  The  inference  as  to  the  disorder  icilh 
uiiicli  it  is  associated. 

I.  THE    RECOGNITION    OF    GLUCOSE    IN    THE    URINE. 

Certain  conditions  are  met  with  so  eoiiiiiionly  in  connection  with  glycosuria  that 
their  presence  makes  it  imperatively  necessary  to  test  the  urine  for  sugar.  Thus  irritation 
(eczema,  intertrigo)  in  the  neighbourhood  of  the  glans  penis  or  vulva  may  be  caused  by 
the  direct  local  action  of  the  sugar  contained  in  the  urine,  while  boils  and  carbuncles  arise 
in  the  skin  owing  to  diminished  resistance  to  the  attack  of  micro-organisms.  Peripheral 
neuritis,  perforating  ulcers,  and  gangrene  of  the  extremities  may  own  a  similar  cause. 
Obese  persons  are  often  the  subjects  of  a  chronic  form  of  glycosuria.  Early  symptoms  of 
diabetes  are  :  unexplained  weakness  and  lassitude,  increased  hunger  or  thirst,  increased 
frequency  of  micturition  owing  to  the  polyuria.     Dimness  of  vision  may  be  the  condition 


GLYCOSURIA  261 

of  which  eoni])hiint  is  made,  and  may  be  due  either  to  commencing  cataract  or  to  a  form 
of  retinitis  closely  resemblino-  that  met  with  in  cases  of  chronic  nephritis. 

Urine  containing  sugar  is  usually  large  in  quantity,  pale  in  colour,  and  jjcculiarly 
bright  and  clear  in  appearance.  Its  specific  gravity  is  high,  any  reading  over  1030,  except 
in  a  dark  concentrated  specimen,  suggesting  the  need  for  careful  examination  for  sugar. 
It  is  acid  in  reaction,  and  seldom  gives  rise  to  any  deposit  on  standing,  but  occasionally 
it  may  become  contaminated  with  torulic  which  form  a  turbidity,  or  even  a  white  sediment. 
In  all  cases  in  which  sugar  is  found  in  the  urine  it  is  important  to  ascertain  whether  acetone 
and  diacetic  acid  are  also  present,  such  abnormal  constituents  pointing  to  a  condition  of 
considerable  gravity,  a  true  diabetes  rather  than  a  simple  glycosuria. 

The  following  are  the  more  important  chemical  tests  for  the  presiiicc  of  dextrose  in 
the  urine  : — 

1.  Trommer's  Test. — This — and  the  two  succeeding  tests,  which  are  modifications 
of  it — dei)end  on  the  power  possessed  by  glucose  of  reducing  alkaline  solutions  of  salts  of 
copper,  with  formation  of  red  oxide  of  copper.  To  perform  Trommer's  test,  a  small  amount 
of  solution  of  potassium  hydrate  is  poured  into  a  test-tube  (say  J-in.  depth),  and  to  it  are 
added,  first,  a  few  drops  of  solution  of  copper  sulphate,  which  will  produce  a  precipitate 
of  copper  hydrate  ;  and  secondly,  a  small  quantity  of  the  suspected  urine.  On  boiling  the 
mixture,  'i  red  precipitate  or  suspension  of  cuprous  oxide  a])pears  if  glucose  be  present ; 
while  if  ghicose  is  absent,  black  cupric  oxide  is  formed  instead. 

2.  Fehling's  Test. — This  is  Trommer's  test  modified  by  the  addition  of  sodio-potassic 
tartrate,  which  holds  the  black  oxide  of  copjier  in  solution.  Two  solutions  arc  prejjared 
as  follows  :  (i)  Dissolve  36-6t  grams  of  copper  sulphate  ci'ystals  in  dislilU-d  water  and 
make  up  to  .500  c.c.  :  (ii)  Dissolve  12.5  grams  potassic  hydrate  and  173  grams  sodio-potassic 
tartrate  (Rochelle  salt)  in  distilled  water  and  make  up  to  500  c.c.  These  two  fluids  should 
be  kept  in  separate  stoppered  bottles.  For  use,  take  equal  quantities  of  each  (say  |-in. 
deep  in  a  test-tube),  mix,  and  boil.  Add  to  the  hot  fluid  a  few  drops  of  boiling  urine.  11 
ghicose  is  present  a  red  suspension  of  cuprous  oxide  is  formed  ;  if  it  is  absent,  the  fluid 
retains  its  blue  colour. 

3.  Pavy's  Test. — This  is  practically  the  same  as  Fehling's,  with  the  exception  that 
a  certain  amount  of  ammonia  is  added  to  retain  the  red  oxide  of  copper  in  solution.  The 
solution  is  made  thus  :  Copper  sulphate,  4'16  grams  ;  sodio-potassic  tartrate,  20'4  grams  : 
strong  solution  of  anunonia,  300  c.c.  ;  and  distilled  water  to  1  litre.  On  boiling  this  with 
urine  containing  gluco.sc  it  is  decolorized.  The  blue  colour  returns  on  contact  with  the 
air.     This  test  is  seldom  used  except  for  ({uantitativc  ])urposes  (see  below). 

Sources  of  Error  in  the  Above  Tests. — Error  may  l)e  caused  by  the  presence  in  ihc  mine' 
of  other  bodies  besides  glucose  which  have  the  power  of  reducing  copper  salts.  The  most 
important  of  these  are  Lactose  and  Pentose.  Both  of  these  sugars  form  "  osa/.one  ' 
crystals  with  phenyl-hydra/.ine.  but  tlicy  <lo  not  ferment  with  yeast.  Pentoses  give  a 
cherry-red  colour  when  heated  with  hyilrocliloric  acid  and  a  little  phloroglucin.  They 
also  react  with  the  following  solutions  (Bial's  Test)  :  Orcin,  1  gram  :  10  |)er  cent  solution 
of  ferric  ehloriile,  25  drops  ;  strong  hydrochloric  acid,  .500  c.c.  On  heating  5  c.c.  of  the 
urine  with  10  c.c.  of  this  solutif)n  a  greenish-blue  colour  is  produced,  and  finally  a  i)recipi- 
tatc  of  this  colour  is  formed. 

Other  substances  which  may  cause  irror  in  tesling  willi  l>'eliling's  solution  are — 
(lli/nironie  Aciit.  Uc/c  ami  Hi/iiiitrir  .Icids.  Xiinlliin.  Crealhiin.  and  .\ll;ii})l(Hi.  Asa  rule. 
liowc\cr.  lluy  <lo  not  produce  more  than  a  chill  grccnisli-yellow  precipitate.  instca<l  of 
the  golden  colour  given  witli  glucose.  They  arc  none  of  them  fermented  by  yeast.  (Jlycu- 
ronic  aciff  gives  the  reactions  described  as  characteristic  of  pentose.  Alkaptonuria  is 
suggested  by  the  dark  colour  of  the  urine  (see  Uuink,  .Abnohmal  Cor.ou.vriON  oi'.  p.  7  K>). 
The  reduction  sometimes  seen  on  testing  the  urine  of  patients  who  have  been  taking 
certain  drugs,  such  as  morphine,  chloroform,  chloral,  salol,  camplioi-.  phciia/.oiu-.  benzoic 
acid,  or  carbolic  acid,  is  probably  due  to  glyeuronic  acid. 

If  the  urine  to  be  tested  for  glucose  by  the  co|)per-reduction  method  cniilains  any 
large  amount  of  albumin,  this  shoifld  be  remr)vcd  first  by  boiling  and  filtration.  II'  the 
urine  be  anunoniaeal,  Fehling's  tisl  may  be  converted  iniwittingly  into  I'avy's,  and 
decolori/.ation  be  i)rodiiccd  instead  of  a  red  precipllate.  Strongly  alkaline  urine  should 
\v  rcndrnil  sliiihtlv  acid  with  acetic  aci<l. 


•262 


GLYCOSURIA 


4.  Bbttger's  Test. — Put  a  small  ciuantity  of  urine  (freed  if  necessary  from  albumin) 
into  a  test-tube,  and  add  an  equal  quantity  of  liquor  potassce  and  a  couple  of  grains  of 
bismutli  suljuitrate  (as  nuieh  as  will  lie  on  the  point  of  a  small  ])enknife).  On  boiling,  a 
black  ])recipitate  is  formed. 

5.  Nylander's  Test. — Make  up  tlie  following  solution  :  Bismuth  subnitrate,  2  grams  : 
sodio-potassic  tartrate,  4  grams  ;  caustic  soda  solution  (sp.  gr.  1'12),  to  100  c.c.  On 
boiling  5  c.c.  urine  containing  glucose  with  5  or  10  drops  of  this  solution  a  black  precipitate 
is  formed.     Glycuronic  acid,  pentose,  and  lactose  also  reduce  bismuth. 

6.  Moore's  Test. — Put  a  small  quantity  of  urine  into  a  test-tube,  add  an  equal 
amount  of  H(iuor  potassa>,  and  boil.  If  sugar  is  present,  a  dark  brown  colour  is  produced 
and  gradually  deepens  to  an  almost  black  tint.  This  test  is  not  of  much  value,  as  it  reqviires 
the  presence  of  a  considerable  percentage  of  sugar,  and  a  dark  colour  may  be  produced 
by  other  substances,  such  as  indican  and  alkapton. 

7.  Picric  Acid  Test. — Pour  about  5  c.c.  of  urine  into  a  test-tube  ;  add  2  c.c.  of 
saturated  solution  of  picric  acid  in  water  and  a  few  drops  of  liquor  jjotassse,  and  boil.  .\ 
dark  brown   colour  is  produced  if  glucose  is  present.      This  test   also  is  of  little  value,  as 

a  dark  colour  is  produced  also  by 
lactose,  and  even  by  creatinin  ; 
while  impure  picric  acid  alone  may 
darken  on  boiling. 

.s.  Phenyl-bydrazine  Test. — Fill 
a  test-tube  about  a  quarter  full  of 
urine,  and  add  as  much  phenyl- 
hydrazine  as  will  lie  on  the  point  of 
the  large  blade  of  a  penknife,  and 
a  rather  larger  amount  of  sodic 
acetate.  Boil  some  water  in  a 
beaker,  jjlacc  the  test-tube  in  this 
and  keep  it  boiling  for  half  an  hour. 
Then  remove  it,  and  allow  it  to 
cool.  If  glucose  be  present,  crystals 
of  phenyl-glucosazone  will  form  in 
the  shape  of  shea\es  of  bright  yellow 
needles,  as  seen  under  a  low  power 
of  the  microscope  (Fig.  127).  Other 
sugars,  such  as  lactose  and  pentose, 
as  well  as  glycuronic  acid,  form 
crystals  with  this  test  ;  but  these 
differ  somewhat  in  shape,  phenyl- 
lactosazone.  for  example,  being 
shorter  and  rather  in  the  form  of 
bundles  than  of  sheaves.  The 
melting-points  of  the  different,  com- 
pounds also  differ :  phenyl-glucosazone  crystals  melting  at  200°  F..  phenyl-lactosazone 
at  200"  F,  phenyl-pentosazone  at  160' F.  In  all  cases  of  doubt  the  crystals  should  not 
only  be  inspected  under  the  microscope  :  their  exact  melting-point  should  be  determined 
also.  Glycuronic  acid  usually  gives  rise  to  an  amorphous  precipitate,  or  scales,  not  to 
crystals.     The  urine  to  be  tested  should  be  free  from  albumin. 

9.  Safranin  Test. — Place  in  a  test-tube  about  a  i-inch  of  >irine  (free  from  albumin)  : 
lual  (|uantities  of  litpior  potassie  and  of  solution  of  safranin  (1-1000).     A  dark  red 


Fig.  IL'7. — Phenyl-glucosazone  crj'stais  as  seen  under  the  medivr 
power  of  the  microscope.  Note  their  vellow  colour,  finer  rays,  ai 
larger  size  than  the  slieaves  of  tvrosiu  crystals  (Fin.  WS,  ji.  333J. 


adi 


fluid  is  produced,  which  turns  yellow  or  brownish  on  boiling  if  glucose  is  present.  This 
test  is  seldom  used.  Inil  apjiears  to  be  a  sure  indication  of  the  presence  of  glucose  (Bedford). 
10.  Fermentation  Test. — Boil  some  urine  (200  c.c.)  in  a  beaker,  and  allow  it  to 
cool  ;  stir  into  it  a  piece  of  yeast  the  size  of  a  small  cherry  till  it  is  thoroughly  mixed. 
Alkaline  urine  should  first  be  rendered  acid  with  a  few  drops  of  acetic  acid.  Fill  the 
graduated  limb  of  a  ureometer  with  the  fluid,  and  let  it  stand  for  twenty-foiu-  hours  in  a 
warm  place.  If  glucose  is  present  carbon  dioxide  gas  will  be  formed  and  will  accumulate 
at  the  top  of  the  tube.     If  performed  carefully  this  test  is  a  certain  indication  of  the  presence 


GLYCOSURIA 


263 


of  glucose.  A  small  ainoiiiit  of  fermentation  may  be  produced  by  bacterial  action  on 
other  sugars,  but  by  boiling  the  urine  this  error  is  eliminated.  Leevulose  may  also  ferment 
with  yeast,  but  its  presence  in  urine  is  so  exceptional  that  it  may  practically  be  disregarded. 
A  rough  indication  of  the  amount  of  sugar  present  may  be  gained  by  taking  the  specific 
gravity  of  the  urine  after  fermentation,  and  comparing  it  with  that  of  a  specimen  kept 
under  similar  conditions  but  without  yeast.  It  is  said  that  a  fall  of  one  ])oint  in  the  specific 
gravity  takes  place  for  every  grain  of  sugar  per  ounce  of  urine  :  but  this  mode  of  cjuantita- 
tion  is  very  inaccurate. 

QuANTrrATivE  Measurement  of  the  glucose  ])resent  may  be  made  by  either  Fehling's 
or  Pavy"s  lluid. 

If  Fehling's  Fluid  is  used.  10  c.c.  of  the  mixed  fluid  (i.  and  ii.)  are  placed  in  a  porcelain 
dish  along  with  about  -tO  c.c.  of  distilled  water,  and  heated  to  boiling  over  a  flame.  A 
burette  is  filled  up  to  a  known  mark  with  the  urine,  diluted  to  1  in  10  (10  c.c.  in  90  c.c. 
of  distilled  water),  and  this  is  allowed  to  run  slowly,  a  few  dro])s  at  a  time,  into  the  boiling 
fluid,  which  is  stirred  meanwhile  with  a  glass  rod.  A  precipitate  of  red  oxide  of  copper 
forms,  and  the  blue  colour  is  gradually  discharged.  When  this  has  comiiletely  disappeared, 
the  (piantity  of  diluted  urine  is  read  off  ;  and  the  amount  of  sugar  in  this  is  known  to  be 
0-05  gram.  Sup])ose  that,  for  example,  8  c.c.  of  urine  diluted  to  1  in  10  have  beeii  used  ; 
then  8  c.c.  of  undiluted  urine  will  contain  10  x  0-05  gram  glucose,  or  0-5  gram.  Knowing 
this,  the  percentage  of  sugar  is  easily  calculated  to  be  O-o   x   100  ~  8.  or  6-25  per  cent. 

The  nictliod  of  using  Pavy's  Solution  is  similar,  with  the  exception  that  it  must  be 
boiled  in  a  dosed  flask,  and  the  no/./.le  of  the  bm-ette  coimected  to  this  by  a  piece  of  tubing 
which  passes  through  the  cork  of  the  flask.  The  eomjilete  reduction  of  the  coi)per  is  known 
In"  the  decolorization  of  the  fluid.  Ten  c.c.  of  Pavy's  solution  arc  equivalent  to  ()-00.5  gram 
sugar  (it  is  thus  only  one-tenth  the  strength  of  F'ehling's). 

Bang's  Method  consists  in  lioiling  a  portion  of  urine  with  a  standardized  solution  of 
cijpric  ^uljjliati'  and  titrating  the  amount  of  copper  remaining  unreduced  with  a  solution 
of  hydroxylamine  sulphate.  The  reagents  are  as  follows  :  (i)  Dissolve  500  grams  ])Otassic 
carbonate,  400  grams  potassic  sulphocyanate.  100  grams  potassic  bicarbonate,  by  heating 
in  1200  c.c.  water  ;  add  25  grams  cupric  sulphate  crystals  dissolved  in  150  c.c.  water,  and 
make  up  the  whole  to  2  litres,  (ii)  Dissolve  6-55  grams  hydroxylamine  sulphate  and 
200  grams  potassic  sulphocyanate  in  water  and  make  up  to  2  litres.  Thus  1  c.c.  of  (ii) 
decolorizes  1  c.c.  of  (i).  To  perform  the  (juantitative  test,  take  10  c.c.  of  urine  (t)r  of 
urine  diluted  to  1  —  5  or  1 — 10  if  there  is  much  sugar  present)  and  boil  with  ,50  c.c.  ol 
solution  (i)  for  three  mimites.  Cool  the  mixture  under  the  tap  :  it  must  remain  blue, 
otherwise  the  ojieralion  must  be  rc|)cafed  with  10  c.c.  of  more  dilute  urine.  Titrate  with 
solution  (ii)  in  the  cold  till  the  colour  disappears.  The  (luantity  of  sugar  present  in  the 
amouni  of  (iiinlilutcd)  uiiiic  originally  used  is  calculated  from  the  following  table  : — 


(  ..    Iii.h..xy|. 
iii.n  n.'^-.k-il 

.Mi;r.  sim'iii- 

m  nrliie 

used 

C.c.  liv<lroxyl- 
aiiilne  solu- 
tion needed 

Mgr.  siiKtiv 
fn  urine 
used 

C.c.  llvdroxyl- 
amine  solu- 
tion n<*eded 

Mer.  suKar 

In  uiiuo 

used 

C.c.  hydroxyl- 
amlue  solu- 
tion needed 

MSl'.  SUfiuV 

in  ui-lue 

used 

■u     .. 

4!t 

;i:i 

15-4 

22 

27-7 

n 

II  •« 

4:j 

.■)•« 

:i2 

l(i-.-| 

•Jl 

2IIII 

1(1 

i:!:i 

42      .  . 

(••7 

:!1 

17-.-. 

20 

:i0-2 

!l 

44'7 

41 

7f> 

:io 

IS  (i 

H) 

:il-4 

8 

K!;{ 

4(1 

.S-.") 

2!l 

l!t(i 

1,S 

:j2(i 

7 

48(1 

:i!l      .  . 

!)•!■ 

2H 

20-7 

17 

:t:!!» 

<) 

49-8 

.-iS      .  . 

l()-4 

27 

21  S 

III 

35- 1 

5 

51  (i 

:i7     .. 

11-4 

2() 

2:!(l 

1.-, 

:i(i-4 

4 

53-4 

:«>     . . 

12-4 

25 

24- 1 

1  i. 

:!7-7 

3 

550 

35      .. 

13-4 

24 

25'2 

i;! 

300 

2 

57-3 

34      .. 

14-4 

23 

26-5 

'-    : 

40-4 

1 

59-4 

Till-  I'lildiiniilcr  mas  aKo  in-  used  lor  (|ii:inl  ii  :ili\c  estimation  of  glucose  :  but  as  the 
iiisliiinicnt  IS  not  likch  lo  be  a\ailiililc  in  oriliiKiix  iiicdieal  praefiee,  it  will  not  be  described 
here. 

II.   DIAGNOSTIC    IMPORTANCE    OF    GLUCOSE    IN    THE    URINE. 

In  llic  great  iiiajoril\  of  iiislancis,  if  glycosuria  persists  for  any  lenglh  of  lime  e.g.. 
if  sugMi-  is  found  in  llic  mine  ;il    fiiMiueiit   examinalions  during  six  weeks  or  Iwo  moiilhs    - 


264  GLYCOSURIA 

the  patient  is  suffering  from  sonic  form  of  diabetes  mellitus.     Two  main  varieties  may  be 
(listinjiuislied  : — 

1.  True  or  Acute  Diabetes. — This  occurs  usually  in  youngish  subjects;  the  urine 
is  increased  largely  in  amount,  and  the  condition  is  accoinjianied  by  muscular  weakness, 
wasting,  marked  thirst,  and  increased  appetite.  The  face  may  be  flushed,  and  the  tongue 
often  looks  large  and  deejj-red  in  colour.  The  amount  of  sugar  in  the  urine  is  influenced 
but  slightly  by  diet.  As  the  disease  advances,  acetone,  diacetic  acid,  and  oxybutyric  acid 
make  their  appearance  in  the  urine.  (See  Acetonuria,  p.  3.)  The  presence  of  acetone 
in  the  breath  may  be  recognized  by  the  peculiar  sweet  smell.  The  knee-jerks  are  often 
lost.  Death  occurs,  usually  within  two  or  three  years,  in  a  condition  of  coma.  It  may 
be  hastened  by  the  su]jervention  of  acute  pneumonia  or  of  a  rapidly  progressive  tuber- 
culosis of  the  lungs. 

2.  Chronic  Glycosuria. — This  occurs  in  elderly  subjects,  who  are  often  obese,  and 
may  show  gouty  tendencies.  The  urine  is  not  markedly  increased  in  amount,  and  does 
not  contain  acetone  bodies.  The  anioimt  of  sugar  present  is  reduced  considerably  by 
strict  dieting.     There  is  no  wasting,  and  little  alteration  of  thirst  or  appetite. 

Forms  of  intermediate  severity  are  met  with,  the  rapidity  of  the  progress  of  the  disease 
diminishing  somewhat  as  age  advances. 

There  are  a  few  conditions  associated  with  temporary  glycosuria  which  have  to  be 
distinguished  from  true  diabetes.     The  following  are  the  most  important  : — 

1 .  Cerebral  Injuries,  Haemorrhage,  and  Tumours  may  be  associated  with  glyco- 
suria. In  the  case  of  ccrcliral  tunK)urs  it  may  jKi'sist  till  death,  and  is  by  some  writers 
described  as  diabetes  due  to  this  affection.  It  will  usually,  however,  be  associated  with 
the  carr^inal  signs  of  cerebral  tiunour — headache,  vomiting,  and  o])tic  neuritis.  None  of 
these  are  common  in  diabetes,  though  optic  neuritis  may  occur.  If  a  patient  is  seen 
Ibi-  tlie  first  time  during  the  coma  which  is  caused  by  a  cerebral  haemorrhage  or  injury, 
the  jjresence  of  glycosuria  may  lead  to  a  mistake  in  diagnosis.  It  must  be  borne  in  mind 
that  in  diabetic  coma  there  are  usually  acetone  bodies  present  in  the  urine  ;  also  that 
cerebral  haemorrhage  is  most  often  seen  in  elderly  subjects,  diabetic  coma  in  younger 
persons,  and  that  the  amount  of  sugar  found  in  cases  of  cerebral  disease  is  not  as  a  rule  large. 

■J.  In  Alcoholic  Subjects  considerable  quantities  of  sugar  may  occur  in  the  urine 
and  persist  for  some  weeks,  and  may  yet  disappear  entirely  on  careful  dieting  and  complete 
abstinence  from  alcoholic  liquors.  This  condition  may  be  due  to  disturbance  of  the 
pancreatic  or  hepatic  function^  by  the  poison,  and  may  really  be  an  early  stage  of  true 
diabetes  which  is  amenable  to  treatment.  It  is  well,  therefore,  not  to  make  a  diagnosis  of 
hicurable  dialetes  in  an  alcoholic  subject  until  the  effects  of  careful  regime  have  been  noted. 

•i.  Pancreatic  Disease,  acute  and  chronic,  may  be  accompanied  by  glycosuria. 
Pancreatic  ha-morrhage  and  acute  pancreatitis  are  signalized  by  severe  pain  in  the  upper 
part  of  the  abdomen,  constipation,  vomiting,  and  collapse — symptoms  suggestive  of  acute 
intestinal  obstruction.  In  only  a  minority  of  these  cases  does  sugar  appear  in  the  urine  : 
when  it  does,  it  is  an  important  aid  in  diagnosis  of  the  affection  present.  In  chronic 
jiancrcatitis — as  also  in  some  cases  of  gall-stones,  in  which  this  condition  is  probably 
[jresent — glycosuria  is  eneoimtered  ;  indeed,  the  condition  may  go  on  to  true  and  fatal 
diabetes.  Wasting,  pigmentation  of  the  skin,  repeated  rigors,  and  the  passage  of  undigested 
meat-fibres  and  of  an  increased  quantity  of  fat  (especially  neutral  or  unsplit  fats)  in  the 
fseces,  accompany  this  form  of  pancreatic  disease.  (See  imder  Cammidge".s  Reaction, 
]).   100.)     .laundice  is  often  a   marked  symjjtom. 

I.  Oilier  cimditiiins  in  which  small  ()uantities  of  sugar  may  be  found  in  the  urine  are 
Graves's  Disease,  Starvation,  and  so-called  Alimentary  Glycosuria,  in  which  glucose  is 
excreted  after  meals  containing  large  quantities  of  this  substance  or,  more  rarely,  of 
starchy  food.     These  conditions  should  not  lead  to  difficulties  of  diagnosis. 

It  is  well  to  bear  in  mind  that  the  onset  of  true  diabetes  may  be  signalized  by  the 
Ininsiiory  appearance  of  glucose  in  the  urine.  This  symptom  may  disappear  once  or  twice, 
with  or  without  special  treatment,  but  may  finally  return  and  persist.  This  occurrence 
may  be  observed  sometimes  in  connection  with  pregnancy,  sugar  being  found  in  the  urine, 
or  increased  thirst  and  apjjctite  noted  along  with  polyuria,  the  patient  subsequently 
regaining  her  health  ;  then,  at  a  subsequent  pregnancy,  the  symptoms  may  recur  and 
persist.  W.  Cecil  Bosmujiiet . 


GOITRE. — (Sec  Tiiviioin  Gland  Exi.argkment,  p.  7'21.) 

GRINDING  OF  THE  TEETH  DURING  SLEEP  is  a  symi)tom  whifh  trouhk-s  the 
patient  little,  but  may  disturb  those  who  sleep  with  him  eonsideiably.  In  itself  it  is, 
however,  a  symjjtom  of  little  importance.  It  is  popularly  held  that  iirinding  of  the  teeth 
at  night,  especially  in  children,  is  an  indication  of  the  presence  of  intestinal  worms,  particu- 
larly of  the  O.ri/iirifi  vcrniiciilaris  ;  it  would  be  well,  therefore,  to  have  the  fieces  examined 
in  all  cases  of  the  kind,  both  for  parasites  and  for  their  ova.  The  popular  belief  of  the 
association  of  intestinal  parasites  with  the  teeth-grinding  habit  is  seldom  verified  clinically, 
however,  and  the  habit  may  be  very  bad  and  ])ersistent  in  children,  or  even  adults,  who 
are  in  perfect  health.  Very  often  it  is  rather  a  rattling  of  the  upper  teeth  against  the 
lower,  owing  to  lateral  movements  made  by  the  lower  jaw  as  the  patient,  when  half  roused, 
turns  over  in  bed  ;  actual  gritting  of  the  teeth  during  sleep  is  far  less  common.  It  is 
possible  that  in  its  beginning  there  was  a  gumboil  or  other  local  irritation,  which  led  to 
jaw-movements  that  persisted  as  habitual  grinding  of  the  teeth  long  after  the  primary 
cause  was  gone.  Jlcihcil  French. 


GUMS,   BLEEDING.— (See   Bi.ekding   Gi-ms.  p.  72.) 

GUMS,   RETRACTION   OF.  -(See  Rktraction  of  thk  Glms,  p.  .589.) 
GUMS,    SPONGY. -(See  Blickding  Gu.ms,   p.  72.) 

HytlMATEMESIS  is  a  term  indicating  vomiting  of  blood.  It  has  to  be  dilTe 
tiated  from  liaimiptysis.  but  the  distinction  is  not  dilHcuU  if  attention  is  ))aid  to 
|)oints  discussed  on  p.  2.S.j. 

Having  arrived  at  the  conclusion  that  the  patient  is  suffering  from  lueniateniesis. 
next  point  is  to  determine  the  cause. 


the 
the 


A.  Swallowed    Blood. 

IspistMXis 

Iheinoptysis 


I{.  Diseases   of   the   (Esophagus ; 

lOpithelioiiui 

.■\ortic   aneurysm    iiiptuiiiig    into 

oesophagus 
Hupture  <>('  v;iri(i)se  (esopluigeal   veil 


CAUSES    OF    H/EMATEMESIS. 


Bleiiliiij;  I'loin  the  nioiith  and  Maliimciing 

lliioat 


.Mediastinal   giowlh   perloiatini;   Ihe   osopliagus 
the      I  and  aorta 

'     [      Foreign    hcidy    pei  loialinL;    llie   u-MjpliaiiUs   and 
aorta 


C.  Diseases   of   the   Stomach : 

Acute  gastritis  Gastrointestinal  irritant 

Chronic  gastritis 
Toxic  gastritis 
Corrosive     poisons, 


such  as  strong  aeids 
)r  alkalies 


as  arsenic,  |)hospliorus, 

mony 
Ulcer 

Gastrostaxis 
II.Tniorrlia"ie  erosions 


siieli 
lllli- 


Cai'einonia 
IiijiM'ies 
.-Vtheronia 
Alxloniinal 
into  (he  > 


I).  Diseases   of    the    Duodenum  : 

I'leer  |       taieiiiciina 

E.  Portal    Obstruction  :  - 

Cirrhosis  of  the  liver     — 
Pylephlebitis  (adhesive) 
Presbipc  on   the   portal   veil 


^Soi 


ironic  heart   and   lung  ilisease 
oine  eases  of  enlarged  spleen 


F.  Acute   Febrile   Diseases :- 


.\Ia 

>il> 

ani 

variola 

.Malaria 

.Ma 

1 

i«i 

ant 

seailel 

Yellow 
Den^n.- 

qiiile   rarely 


Cllole 

.Veil  1 1 

yell. 

walropl.v 

Kuiigi 

ting 

■  ndoeaiilili 

266  H.^jlMATEMESIS 

(.'.  Blood    Diseases  : — 

Purpura  I      Leukaemia  Pernicious  anaemia 

Scurvy  Hodgkin's  disease  Malarial   cachexia 

Haemophilia  |      Chlorosis  (?)  Splenic  ana>niia 

H.  Miscellaneous : — 

Clxronic  Bright's  disease  I      Prolonged  jaundice 

Following  abdominal  operation  |      Syphilis 

It  may  be  said  at  once  that  there  are  only  three  common  causes  o( profuse  ha-matemesis 
— namely,  gastrostaxis,  gastric  ulcer,  and  cirrhosis  of  tlie  liver.  The  differential  diagnosis 
between  these  is  by  no  means  always  easy.  The  older  the  patient  and  the  greater  the 
history  of  alcoholism,  the  more  likely  is  the  symptom  to  be  due  to  cirrhosis  of  the  liver  ; 
at  this  stage  of  the  malady  there  may  be  neither  jaundice  nor  ascites,  but  the  liver  may  be 
felt  enlarged  and  unduly  firm,  and  the  spleen  may  also  be  pal])able.  Hiseniatemesis  in 
a  young,  ana?mic  woman  is  more  likely  to  be  due  to  gastrostaxis  than  to  ulcer,  whereas  in 
older  patients,  especially  in  males,  gastric  or  duodenal  ulcer  is  the  jjrobable  diagnosis  if 
cirrhosis  can  be  excluded.  The  distinction  between  gastrostaxis  and  gastric  ulcer  often 
becomes  one  of  opinion  only,  unless  operation  is  resorted  to.  The  longer  the  preceding 
history  of  gastric  symptoms,  and  the  more  definitely  localized  the  epigastric  pains,  the 
more  likely  does  ulcer  become. 

The  diagnosis  is  often  arrived  at  quickly  enough,  but  sometimes  a  routine  discussion 
of  all  the  possible  causes  is  required  :   so  that  we  will  take  each  of  the  above  groups  in  turn. 

A.  Swallowed    Blood: — 

Episla.ris. — If  there  is  obvious  bleeding  from  the  nose  as  well  as  ha^matemesis,  the 
jirobability  would  be  that  some  of  the  blood  had  trickled  down  the  posterior  nares  into 
the  pharynx,  and  had  been  swallowed  and  subsequently  vomited.  It  should  be  remembered, 
however,  that  the  two  commonest  causes  of  epistaxis  in  adults  are  cirrhosis  of  the  liver 
and  chronic  interstitial  nephritis,  so  that  the  possibility  of  bleeding  having  occurred  from 
the  stomach  as  well  as  from  the  nose  would  have  to  be  considered.  If  a  moderate  degree 
of  epistaxis  has  taken  place  during  the  night,  blood  may  have  been  swallowed  uncon- 
sciously. In  some  cases  in  which  no  blood  has  come  from  the  anterior  nares.  examination 
may  reveal  blood  trickling  from  the  posterior  nares.  and  the  epistaxis  may  become  evident 
if  the  patient  blows  his  nose. 

Ilcemopiijsis. — When  blood  comes  from  the  air-passages,  some  of  it  may  How  back 
into  the  pharynx  and  be  swallowed,  especially  if  the  haemorrhage  occurs  during  sleep.  If 
the  patient  has  a  cough,  or  expectorates  blood-stained  sputum  and  presents  signs  of  chronic 
l>ulmonary  disease,  the  possibility  of  swallowed  blood  must  be  considered  as  a  cause  of 
the  liiematemesis,  though  difficulties  may  arise  in  forming  a  correct  conclusion,  for  cirrhosis 
of  the  liver,  for  instance,  is  not  infrequently  complicated  by  phthisis,  and  so  on. 

Bleeding  from  the  Mouth  and  Throat. — The  gums,  tongue,  and  fauces  should  be 
examined  carefully,  as  blood  from  any  of  these  sources  may  be  swallowed  and  later  vomited. 
Bleeding  from  the  gums  is  most  likely  to  occur  when  they  are  spongy,  as  in  scurvy  or 
mercurial  stomatitis. 

Malingering. — The  possibility  of  blood  having  been  drunk  in  secret  and  afterwards 
\omited  with  intent  to  deceive  must  be  considered  in  some  cases  when  no  cause  can  be 
found  to  account  for  its  occurrence.  Should  fraud  be  suspected,  it  may  generally  be 
detected  by  careful  observation.  The  red  corpuscles  should  be  examined  microscopically 
in  case  the  oval  corpuscles  of  a  bird  may  reveal  their  extraneous  source. 

B.  Diseases   of   the    (Esophagus. 

Epilhclioma. — IlaMuorrhage  is  rare  in  the  commonest  form  of  epithelioma  of  the 
oesophagus  which  leads  to  an  annular  stricture,  but  it  may  occur  from  erosion  of  small 
blood-vessels  as  the  result  of  the  ulcerative  foi'm  of  the  disease,  the  amount  of  blood  which 
is  brought  up  being  small.  When  the  ulceration  is  deeper  and  more  extensive  it  may 
finally  lead  to  perforation  of  a  larger  vessel,  even  the  aorta,  a  condition  which  causes 
sudden,  profuse,  and  rapidly  fatal  haemorrhage.  The  diagnosis  of  this  cause  does  not. 
as  a  rule,  give  rise  to  nuich  difficulty  ;  dysphagia  is  the  earliest  symptom  in  nearly  all  the 
cases  (see  p.  194). 


h.emate.mp:sis  ae? 

An  Aiieuri/sm  of  the  Thoracic  Aorta  compressing  the  a?sophagus  may  finally  erode  and 
open  into  it,  with  profuse  and  fatal  haematemesis. 

Rupture  of  Varicose  CEsophageal  J'eins. — Varicose  veins  occur  in  the  lower  end  of 
the  a?sophagus  as  a  result  of  portal  obstruction,  especially  that  form  which  is  due  to 
cirrhosis  of  the  liver,  and  the  rupture  of  such  veins  is  often  followed  by  profuse  haematemesis. 
It  is,  however,  practically  impossible  to  determine  whether  the  blood  comes  from  the 
lower  end  of  the  oesophagus  or  from  the  stomach,  so  that  the  diagnosis  resolves  itself  into 
one  of  cirrhosis  of  the  liver. 

Mediastinal  Groicth  perforatin<<  llic  (Esojthaaus  and  Aorta. — Hicmatemesis  fit)m  this 
cause  is  exceptionally  rare,  for  mediastinal  growth  is  by  no  means  a  common  disease,  and 
vomiting  of  blood  is  an  infretiuent  complication  of  it.  Ha-morrhagc  may  occur,  however, 
if  the  growth  compresses  and  erodes  the  oesophagus.  It  is  most  likely  to  be  mistaken 
for  thoracic  aneurysm  or  epithelioma  of  the  ojsophagus.  The  tendency  of  new  growth 
to  compress  and  invade  the  large  veins,  leading  to  oedema  of  the  neck  and  upper  extremities, 
cyanosis,  and  dilated  superficial  veins,  is  characteristic,  and  serves  to  distinguish  it  from 
aneurysm,  in  which  severe  venous  obstruction  is  much  rarer.  The  following  case  of 
mediastinal  sarcoma  perforating  the  ccsophagus  and  aorta  is  an  cxam])le  of  haematemesis 
from  this  cause  : — 

Michael  H.,  aged  ."iO,  was  admitted  for  dyspn<ra  anil  pain  in  the  oliest.  He  had  buffered  from 
several  attacks  of  what  had  been  considered  to  be  haemoptysis  similar  to  that  of  ])hthisis,  the  first 
occurring  seven  months  before  his  admission.  He  was  found  to  have  impairment  of  note,  with 
diminished  breath-soimds,  over  the  whole  of  the  left  side  of  his  chest.  About  a  month  after  his 
admission  he  suddenly  brought  up  a  large  quantity  of  blood,  and  died.  .\t  the  post-mortem  examin- 
ation, the  stomach  and  duodenum  were  full  of  blood.  There  was  a  large  sarcomatous  mediastinal 
growth,  which  had  surroimded  the  lower  end  of  the  oesophagus,  trachea,  and  aorta.  The  wall  of 
the  (esophagus  at  the  level  of  the  bifurcation  of  the  trachea  had  been  destroyed,  and  the  aorta  was 
perforated  at  the  origin  of  the  left  subclavian  artery,  so  that  a  direct  communication  between  the 
(esophagus  and  the  aorta  had  been  established. 

Foreign  Body  perforating  the  (Esophagus  and  Aorta. — t'opious  lucmorrhage.  which  may 
cause  death,  may  be  ])roduccd  as  a  result  of  a  foreign  body,  such  as  a  ))in.  fishbone,  or 
tooth-plate,  jjcrforatiiig  both  the  oesophagus  and  some  large  vessel,  or  even  the  aorta. 
.\  history  of  such  a  foreign  body  being  swallowed,  followed  by  a  feeling  of  discomfort  in 
the  oesophagus,  would  suggest  such  a  coiiditioM.  wliicli  might  be  confirmed  by  the  use  ol' 
.r-rays,  bougies,  or  the  oesophagoscope. 

C.  Diseases   of   the    Stomach. 

.Iculc  (l<i:dritis.  The  nmcoiis  mcndjrane  of  tlic  stomach  in  this  disease  is  congested, 
and  small  lia-morrhagcs  and  erosions  may  be  present.  They  can  be  seen  clearly  with  the 
gastroscope.  The  lucmorrhage  which  occurs  is  slight,  in  the  form  of  streaks  of  blood  mixed 
with  mucus  in  the  vomit,  and  it  hardly  merits  flic  term  luematemesis.  .\cute  gastritis 
is  caused  most  frctpicntly  by  errors  in  diet,  irritating  or  decomposing  foods,  alcohol,  corro- 
sive or  irritant  poisons,  or  sepsis  from  septic  teeth,  stomatitis,  or  |)yorrli(ra  alveolaris. 
The  chief  symptoms  arc  :  a  feeling  of  discoml'ort  and  tenderness  in  the  epigastrium, 
nausea,  eructations,  vomiting,  constipation  ;  or  in  children,  diarrho'a  :  headache,  a 
feeling  of  depression,  furred  tongue,  foul  breath,  and  concentrated  urine.  I'lis  corpuscles, 
or  micro-organisms  such  as  streptococci,  pncumococci,  or  diphtheria  bacilli,  have  been 
ii((i\cred  from  the  gastric  contenl.%  on  appropriate  examination  in  some  cases. 

Clirojiir  Castritis.  The  nmeous  niemhrane  of  the  slomaeb  may  be  tllickened  and 
e()ngestcd.  with  lucmorrhagie  erosions  scattered  o\er  its  surface.  The  vomit  usually 
consists  of  a  goorl  fical  of  mucus,  and  occasionally  a  little  blood.  It  may  follow  acute 
gastritis,  but  most  frc<picntly  is  caused  by  the  continual  and  excessive  ingestion  of  alcohol, 
tea,  coffee,  and  irritating  and  indigestible  articles  of  diet.  The  main  symptoms  are: 
tenderness  in  the  epigastrium  aggravated  by  the  taking  of  food,  nausea,  vomiting  — 
especially  in  the  early  morning  if  due  to  alcohol  llatulence.  foul  breath,  a  furred  tongue 
indented  by  the  teeth  at   the  edges,  constipation,  concentrated  urine,  and  slight  pyrexia. 

Toxic  (iastrilis  due  to  Corrosive  I'oisoiis.  Strong  acids  or  alkalies  destniy  the  mucous 
iiK  iiiliiaiic  of  the  sloinach  as  well  lis  injure  llial  of  llic  inoulb.  Iludal,  iirid  (esophagus. 
More  Ol-  less  coiisl.iiil  MJMiiliiig  of  blood  mihI  lilood-st.iiiird  iinicus  is  one  of  llie  most 
pi-oniiiicnl    syiiiploiiis,   iiiid    il    may   lie  assoiialcd   willi    iiiliiisc   pain   in    llic   inoulb.    Ibroat. 


268 


h,e:\iatemesis 


and  abdomen,  dysphafiia,  jiain  and  tenderness  behind  the  lower  end  of  the  sternum  or 
in  the  epigastrium,  distention  of  the  abdomen,  coHapse,  and  a  rapid,  feeble  pulse.  The 
urine  may  contain  blood  and  albumin,  and.  if  the  poison  is  oxalic  acid,  crystals  of  oxalate 
of  lime.  If  corrosive  poisoning  is  suspected,  an  insjjection  of  the  mouth  and  pharynx 
will  show  signs  of  corrosion,  and  an  examination  of  the  vomit  will  furnish  evidence  of  the 
nature  of  the  j)oison. 

Arsotic. — The  mucous  membrane  of  the  stomach  is  red.  inflamed,  ])artly  detached, 
and  covered  with  blood-stained  mucus.  The  chief  sym])toms  are  nausea,  violent  and 
incessant  sickness,  burning  pain  in  the  epigastrium,  diarrhoea,  faintness,  and  depression. 
The  vomit  is  usually  a  brownish,  turbid  fluid,  mixed  with  mucus  and  streaks  of  blood. 
Later,  there  may  be  severe  diarrhoea,  with  rice-water  stools.  Arsenic  may  be  detected 
in  the  vomit. 

Pliosphoius,  iiiilhiKiiiii.  and  other  irritant  poisons  may  also  cause  inflanunation  of 
the  mucous  membrane  of  tlic  stomach,  and  lead  to  slight  liaMiiatemesis. 

Gastric  Ulcer. — Hiematemesis  is  the  most  important  symi)tom  of  gastric  ulcer,  though 

it  occurs  in  only  about  50  per  cent  of 
the 'eases  both  in  the  acute  and 
chronic  forms  of  the  disease,  being- 
due  in  the  former  to  erosion  of  small 
\i--scK,  and  in  the  latter  to  the 
ulcerative  process  extending  to  and 
f)penini;  up  larger  gastric  vessels,  and 
<)ccasi(jnally  even  the  pancreatic  or 
splenic  artery.  The  amount  of  blood 
varies  within  wide  limits.  If  the 
(piantity  is  small,  or  if  it  isgradually 
|)ourerl  out  into  the  stomach,  it  may 
remain  (here  a  suflicient  time  for  the 
acid  uastrie  juice  to  act  on  it  and 
convert  the  haemoglobin  into  hae- 
matin.  which  gives  to  the  vomit  a 
characteristic  dark-brown  "  coffee- 
grounds '  appearance.  In  some  eases 
the  blood  is  not  vomited  but  appears 
in  the  stools  as  melsena  (p.  385).  If 
a  medium  or  large  vessel  is  eroded 
the  bleeding  may  be  very  copious, 
a  cjuart  or  more  of  blood  being 
vomited,  either  liquid  and  arterial  in 
coloin-  or  in  large  red  clots.  A 
profuse  htemorrhage  causes  sudden 
pallor,  a  feeling  of  faintness.  rest- 
lessness, syncope,  and  a  rapid,  feeble 
pulse.  It  is  rarely  fatal  imless  a 
large  vessel  such  as  the  splenic  artery 
has  been  eroded.  Occasionally  hse- 
matemesis  is  the  first  intimation  of 
the  presence  of  a  gastric  idcer.  but  in  the  majority  of  cases  there  are  other  symptoms  and 
signs  which  have  preceded  it.  The  disease  was  formerly  said  to  occur  most  frequently  in 
females  especially  of  the  servant  class,  between  the  ages  of  twenty  and  thirty,  but  not  a 
few  of  these  cases  diagnosed  as  gastric  ulcer  are  probably  examples  of  gastrostaxis,  or 
bleeding  from  a  spongy,  oozing  mucosa  without  any  definite  and  macroscopic  ulceration. 
-Vn  analysis  of  101  fatal  eases  showed  59  males  and  42  females,  and  it  is  quite  as  common 
in  later  as  in  early  adult  life.  It  does  occur  before  puberty  sometimes,  but  very  rarely. 
Like  duodenal  ulcer,  it  seems  to  be  commoner  in  the  North  of  England  than  in  the  South, 
and  in  mining  and  manufacturing  rather  than  in  rural  districts.  In  addition  to  haemat- 
emesis,  the  signs  most  characteristic  of  gastric  ulcer  are  abdominal  pain,  nausea,  vomiting, 
and  melaena.     Pain  is  felt  in  the  epigastrium  just  below  the  ensiform  cartilage  ;   it  usually 


Firj.  1L>S.— Ski.iijr! 


H.EMATEME8IS 


269 


begins  a  few  minutes  after  the  ingestion  of  food,  but  in  some  cases  is  not  experienced  until 

an  hour  or  two  afterwards.     Pain  may  also  be  felt  in  the  back,  between  the  tenth  dorsal 

and  first  lumbar  spines.     Its  character  and 

intensity    are    very    variable,     but     it    is 

usually  severe.     Hyperrcsthesia  of  the  skin 

and   tenderness  on  jiressure  in  the  e|)ii;Ms- 

trium  may  also  be  present.     Vomiting  may 

come  on  immediately  after  food  is  taken, 

or   may   be   deferred   for  an   hour  or  two. 

being  preceded  usually  by  a  good  deal  of 

pain.     The  vomit  has    a    very    acid   taste 

and  an  abnormally  acid  reaction.     .'Mela'na 

follows  lucmatemesis  ;    occasionally  it  nui\ 

precede  it.  and  rarely  occurs  independently. 

The   tongue    in    the    majority    of  cases   is 

clean,    red,    moist,    and   steady.     There" is 

more  or  less  anaemia  :    the  points   of  dis 

tinction  between  gastric  ulcer  and  anicmic- 

vomiting  are  discussed  on  page  36. 

.Simi)le  ulcer  is  sometimes  diHieult  to 
dilTerentiate  [^from  cirrhosis  of  the  li\er 
or  carcinoma  of  the  stomach.  Examina- 
tion of  the  stomach  with  the  ,r-rays 
after  a  bismuth  or  barium  meal  some- 
times affords  positive  evidence  of  the 
nature  of  the  lesion  (Pig.  128),  especially 
when  there  is  some  stenosis  of  the  pylorus  ; 
but  it  is  possible  to  have  an  active  ulcer 
and  yet  for  the  .r-ray  appearances  of  the 
stomach  to  be  normal. 


/*/;/•  •-•'• — Skiagram  of  a 
\pnl.     I'cmale,  age  28. 


normal  stomach  after  a 'bismuth 
III/  Dr.  C.  Tliiiisrnn  llnlland.) 


lIlO.^SkijittriMii  taken  in  the  erect  posture  after 
bismuth  meal  in  a  ca^c  of  malignant  disciiRC  of  t)ic  midiili 
of  tlie  stoniacli.  The  pyloric  end  was  normal.  Tiie  diiivnnsi-. 
was  verilied  by  operation. 

(■•ikiatjmm  liii  lir.  C.   Tlmntan   llnlhiml.) 


.\hoiil     fiO 


iT    I  he  cases   occur  bctw 


(lii.strosta.ris  (sec  A.n.k.mia,  p.  ."iO). 

Hiemorrhagic  erosions  arc  ijrobably  the 
earliest  stage  of  gastric  ulcer,  though  they 
may  not  develop  beyond  the  phase  of 
minute  erosions.  They  may  be  the  actual 
ctiusc  of  gastrostaxis,  and  pcrhjips  the  dis- 
linctions  between  gastrostaxis.  ha-inorrhagic 
ciosions,  and  mulliple  small  gastric  ulcers 
arc  dilferences  of  degree  and  not  of  kind. 
There  are  certain  conditions,  however, 
especially  acute  malignant  fevers,  pinpura, 
iiircclixc  endocardills.  and  similar  se|)tic 
states,  ill  whicli  a  general  tendency  to 
subcutaneous  and  submucous  hicniorrhages 
leads  to  multiple  small  gastric  erosions, 
uliich  produce  ha-miifcmcsis  without  being 
directly  related  to  ordiuiiry  gastric  ulcer. 

('(iniiioiiia.  Ha'Tualcmcsis  is  a  less 
l're(|Uent  and  important  sign  of  eareinoma 
of  the  stomach  tlian  of  gastric  ulcer,  for  it 
occurs  In  liul  a  ill  lie  (i\  cr  20  (jcr  cent  of  the 
i:is(-~,  and  ex  ill  I  lieu  Is  generally  slight. 
Hrlglit-rcd  blood  is  rarely  seen  in  the 
vomit,  lor  the  slow  oo/.c  Irom  tlic  ulcerated 
surface  of  the  growth  allows  the  blood  to 
remain  in  contact  with  the  gastric  juice  and 
develop  the  "  colfcc-grounds  "  a|>pearance. 
■en   tlic    ages  of  t\n[\  and   si\t\.       Tin-  cliief 


270 


H.^5MATEMESIS 


symptoms  and  sions  of  the  diseasc^are  :    ])ain  in  the  epigastric  region,  nausea,  vomiting, 
anorexia,  loss  of  weiglit  and  strength,  pyrexia,  anaemia,  cachexia,  and  the  presence  of  an 

abdominal  tumour.  Pain  is  one  of  the  earliest 
symptoms,  but  it  varies  considerably  in  degree  and 
position.  It  is  referred  most  frequently  to  the 
e])iuastrium,  but  is  not  as  a  rule  so  severe  as  in 
gastric  ulcer.  Vomiting  is  another  early  symptom 
which  varies  in  frequency  and  character  according 
to  the  position  of  the  growth.  When  the  pylorus 
is  involved  and  stenosed,  the  stomach  dilates  and 
:i  large  quantity  of  frothy,  brownish  vomit  is  eva- 
luated  every  two  or  three  days  ;  in  cases  of 
dilfuse  carcinoma  the  capacity  of  the  stomach  is 
iliminished,  and  a  small  quantity  may  be  vomited 
two  or  three  times  a  day  :  when  the  growth  is 
situated  at  the  cardiac  orifice,  the  .symptoms 
resemble  those  of  epithelioma  of  the  oesophagus,  and 
I  lie  food  immediately  after  swallowing  is  regurgi- 
tated rather  than  vomited  ;  whilst  in  cases  of 
growth  which  involve  neither  of  the  orifices  of  the 
stomach,  there  may  be  no  vomiting,  or  if  present  it 
ma\'  have  no  special  characteristics,  the  symptoms 
being  mainly  those  of  dy.spepsia  or  gastritis.  A 
chemical  analysis  of  the  vomit  may  show  deficiency 
of  hydrochloric  acid  and  the  presence  of  lactic  acid  : 
first  because  there  are  a  great  manv  other  conditions 


Fig.  131. — Skiagram  after  a  bismutli  moal  in  :i 
case  of  carcinoma  of  pylorus  and  pyloric  end  of 
stomach 

(fikiarfmm  hij  Dr.  V.  Tlmrslnn  ilvllaml.) 


but  the  value  of  this  test  is  limited  : 
besides  carcinoma  of  the  stomach  in  which 
there  is  deficiency  or  absence  of  free  IK  1 
in  the  gastric  contents — cachexia  of  any 
kind,  cirrhosis  of  the  liver,  heart  discast 
with  failing  compensation,  enteric,  pneu- 
monia and  other  fevers,  achylia  gastrica. 
pernicious  anicmia.  and  many  other  con- 
ditions under  which  the  patient  is  ill 
enough  for  all  his  secretions  to  suffer, 
amongst  them  the  gastric  juice  ;  and 
secondly  because  insufficient  care  is  some- 
times taken  to  recover  the  gastric  contents 
at  the  right  time  after  a  meal.  All  persons 
fail  to  show  free  hydrochloric  acid  in  the 
gastric  juice  for  some  while,  generally  three- 
quarters  of  an  hour  at  least,  after  a  meal 
containing  proteid.  The  more  the  ])roteid 
the  longer  it  takes  for  the  stomach  to 
accumulate  sullieient  HC'l,  first  to  combine 
with  all  the  molecules  of  proteid  as  com- 
bined HC'l,  and  later  to  permit  of  a  surplus 
ol  uncombined  or  free  Ht'l.  Merely  to  test 
a  vomit  obtained  at  hazard  is  little  use 
therefore  ;  one  must  know  what  food  was 
taken  previously,  and  how  long  before  ;  it 
is  on  this  account  that  test  meals  of  known 
composition  are  employed,  followed  by 
lavage  at  such  an  interval  afterwards  that 
Iree  HCl  is  to  be  expected  unless  there  is 
some  disease  interfering  with  the  jiroper 
formation  of  the  gastric  juice.  A  growth  in 
the  stomach  may  be  seen  with  the  aid  of  the  gastroscope. 


(.s'Amj/r(//«  hy  li< 


The  loss  of  weight  and  strength 


H.EMATEMESIS  271 

are  usually  progressive,  and  tliey  are  amongst  the  most  constant  and  characteristic  signs  of 
the  disease.  Anaemia  of  tlie  secondary  clilorotic  tjTje,  with  a  low  colour-index,  may  be 
so  prominent  a  symptom  that  a  primary  an;cmia  may  be  suspected  until  a  careful  blood 
examination  has  been  made.  A  very  careful  investigation  of  the  abdomen  must  be  made, 
for  in  about  70  ])er  cent  of  the  cases  a  tumoiu-  may  be  felt,  though  it  is  to  be  hoped 
that  the  gastroscope  will  lead  to  the  diagnosis  of  carcinoma  ventriculi  before  this  stage 
is  reached,  and  when  surgical  cure  is  still  possible.  The  position  and  character  of  the  tumour 
vary  according  to  the  part  of  the  stomach  which  is  involved.  Pyloric  growth  may  cause 
the  abdomen  to  be  distended  as  a  result  of  gastric  dilatation,  and  a  movable  tumour  may 
be  felt  above  the  umbilicus,  near  the  middle  line  and  to  the  right  of  it.  When  the  cardiac 
orifice  is  involved,  there  may  be  no  tumour  to  be  felt,  and  the  same  applies  to  the  small 
■  indiarubber-bottle  '  stomach  of  diffuse  carcinoma  ventriculi  {Fig.  132).  Tumours  of  the 
body  of  the  stomach  may  be  felt  in  the  epigastriimi.  or  below  tlie  left  costal  margin.  It 
may  be  necessary  to  examine  under  a  general  anaesthetic  in  some  cases  :  .r-ray  examina- 
tion aftei  a  bismuth  or  barium  meal  may  assist  in  some  cases  (Fig.  131)  :  and  even 
laparotomy  may  be  advisable  as  a  diagnostic  measure  under  some  circumstances.  If  the 
|)atient  is  weighed  carefidly  twice  a  week,  and  is  proved  to  increase  in  weight  steadily  under 
treatment,  carcinoma  is  improbable,  provided  this  increase  does  not  prove  transient  after 
a  week  or  two. 

Injuries. — Haematemesis  may  follow  blows,  stabs,  or  gunshot  wounds  in  the  epigastric 
region,  or  the  passage  of  instruments  or  foreign  bodies,  such  as  a  broken  thermometer, 
into  the  stomach.  The  history  and  the  evidence  of  any  sucli  occurrence  would  make  the 
diagnosis  sufficiently  obvious. 

Aiheronift  in  association  with  arteriosclerosis  or  granular  kidney  and  high  blood- 
pressure  may  lead  to  haematemesis  in  very  exceptional  cases  by  causing  weakness  and 
rupture  of  small  gastric  vessels.  Such  a  diagnosis  should  be  made  with  extreme  caution, 
even  when  other  symptoms  and  signs  of  atheroma  are  present,  for  haematemesis  as  the 
residt  is  exceedingly  rare.  It  is,  however,  not  uncommon  in  splenomegalic  jiolijci/tlicemia 
(\).  5311,  in  whicli  malady  the  blood-pressure  is  generally  high. 

Ah(t(ii)ii)i(il  .Ineiiri/siii  opening  into  the  Stomnch. — Aneurysm  of  the  abdominal  aorta  is 
uneonnnon.  'i'he  sac  may  rupture  into  the  stomach,  however,  and  lead  to  a  sudden, 
profuse,  and  fatal  attack  of  hamatemesis.  The  chief  diagnostic  signs  are  :  an  epigastric 
tumour,  witli  distinct  expansile  pulsation  and  severe  pain  both  in  the  abdomen  and  in  the 
back  over  the  site  of  the  bulge,  in  a  patient  who  has  sidicred  fnmi  syjiliilis  and  has  been 
accustomed  to  repeated  and  violent  muscular  exertion. 

I).  Diseases   of   the   Duodenum. 

Dnoiteniil  L'lcer. — Ilicniateniesis  is  caused  in  I  lie  same  manner  in  this  disease  as  in 
gastric  ulcer,  viz.,  by  the  erosion  of  small  duodenal  blood-vessels  or  by  the  ulcerative 
j>roeess  spreading  to  and  opening  larger  and  deeper  blood-vessels  outside.  The  ulcers  are 
in  the  first  part  of  the  duodenum  in  a  very  large  jjroportion  of  eases.  They  are  about 
eight  times  as  eonunon  in  men  as  in  women.  Some  of  the  symptoms  are  similar  to  tliosc 
of  gastric  ulcer,  viz..  haniatemesis,  mela;na,  abdominal  pain  and  tenderness,  anu-mia,  and 
vomiting.  Ihematemesis,  however,  is  not  so  frcfpient  as  it  is  in  gastric  ulcer  :  il  i-- 
generally  less  marked  than  is  the  melaena,  and  the  latter  may  occur  indei)endenlly  ol 
ha-matemesis  or  before  it.  In  the  Scute  form  of  the  disease  there  may  be  a  copious  hdes- 
tinal  hiemorrhage  in  an  apparently  healthy  person,  accompanied  by  acute  pallor  an<l 
followed  by  the  evacuation  of  a  mixture  of  black  altered  blood  and  briglit  arterial  blood 
from  the  reetuni.  The  more  the  bleeding,  the  greater  the  tendency  lor  the  blond  passed 
to  be  still  bright  red.  There  may  be  no  pain  at  all,  but  more  often  it  is  eonsideralile  ; 
I  lure  i,s  hardly  any  part  of  the  abdoiuen  to  whieli  it  may  not  be  referred,  but  geiu-raily 
il  is  deep-sealed  In  the  upper  part,  about  an  inch  below  the  tip  of  the  ninth  right  rib.  more 
to  the  right  of  the  middle  line  than  is  that  of  gastric  ulcer,  and  usually  its  onset  is  two  or 
three  hours  after  the  ingestion  of  food.  One  point  about  this  pain  that  is  almost  patho- 
gnomonic is  the  way  in  which,  coining  on  when  the  patient  is  begiiming  to  get  hungry 
'  hunger  pain  ' — it  is  often  relieved  entirely  l)y  taking  food.  Vomiting  is  another 
im|)ortant  symptom  which  may  be  very  troublesome.  Iliongli  in  some  cases  it  is  entirely 
ahseril.      One   cliMraelcrislic    of   sninc    cases   of   diKidcnal    nicer    is    llie    \cry    r;ipi(l   way    in 


•272  H.EMATEMESrS 

wliich.  under  the  ,i-rays.  bisnuith  may  he  seen  emptying  out  of  the  stomach  into  the 
duodenum. 

C(irciii(niia  of  tlw  J)iioilc»inii  is  very  rare,  and  would  only  be  diagnosed  if  there  were 
general  symptoms  of  malignant  disease  together  with  a  fixed  tumour  in  the  situation  of 
the  duodenum. 

Gall-slones  ulcerating  through  from  the  Gall-bladder  into  the  Duodenum  may  cause  haemat- 
emesis  and  melacna.  Previous  attacks  of  pain  occasioned  by  the  gall-stone  might  lead 
to  a  diagnosis  of  gastric  or  duodenal  ulcer  :  but  if  the  pain  was  colicky  in  character,  and 
was  associated  with  tenderness  and  enlargement  of  the  liver,  paiu  over  the  gall-bladder, 
and  jaundice,  it  would  point  to  a  gall-stone.  The  diagnosis  might  be  confirmed  by  the 
discovery  of  the  stone  in  the  fteces,  or,  in  the  case  of  a  larger  calculus,  by  the  occurrence 
of  acute  intestinal  obstruction  from  its  impaction  in  the  small  intestine.  As  a  cause  of 
h.-cmatemesis  this  condition  is  naturally  very  rare. 

E.  Portal    Obstruction. 

As  a  result  of  obstruction  to  the  flow  of  blood  through  the  portal  vein,  passive  con- 
gestion and  hicniorrhagic  erosion  of  the  mucous  membrane  of  the  stomach,  and  varicose 
gastric  and  oesophageal  veins,  may  be  produced.  Hiiematemesis  may  then  arise  through 
oozing  of  blood  from  the  congested  mucous  membrane,  or  from  an  actual  escape  of  blood 
in  the  case  of  htemorrhagic  erosion  or  the  rupture  of  one  of  the  varicose  veins.  The  signs 
which  are  common  to  portal  ob.struction  in  addition  to  ha?matemesis  are  :  nausea, 
vomiting,  ascites,  a>dema  of  the  legs,  albuminuria,  and  the  presence  of  dilated  and 
tortuous  superficial  abdominal  veins  ;    the  chief  cause  is  : — 

Cirrhosis  of  the  Liver. — This  disease  is  one  of  the  commonest  and  most  important 
causes  of  profuse  hieniatemesis,  and  it  is  often  difficult  to  diagnose  from  gastric  ulcer  or 
carcinoma  of  the  stomach.  Ha?matemesis  may  be  one  of  the  earliest  symptoms,  and  it  is 
frequently  profuse,  and  very  liable  to  recur,  though  it  is  seldom  fatal.  There  may  be  a 
history  and  the  signs  and  symptoms  of  chronic  alcoholism  (p.  726).  The  liver  may  be 
enlarged,  its  surface  rough  and  hard,  and  its  edges  irregular  and  beaded.  The  spleen  may 
be  enlarged  as  a  result  of  the  jwirtal  obstruction,  bitt  in  adults  rarely  attains  to  such  an 
enormous  size  as  it  does  in  the  splenomegalic  variety  of  cirrhosis  in  children  and  young 
adults.  In  distinguishing  this  disease  from  carcinoma  of  the  .stomach,  it  is  very  important 
to  determine,  if  possible,  the  absence  of  a  stomach  timiour  and  of  large  nodules  projecting 
from  the  surface  of  the  liver. 

Adhesive  Pylephlebitis. — Xon-suppurative  thrombosis  of  the  portal  vein  is  very  rare, 
and  dillieult  to  diagnose.  It  may,  however,  give  rise  to  sudden  and  jjrofuse  ha-matemesis. 
It  is  distinguished  from  other  forms  of  portal  obstruction  by  the  relatively  sudden  onset 
of  ascites,  hscmatemesis,  mela?na,  and  enlargement  of  the  spleen,  and  by  an  absence  of 
signs  and  symptoms  of  cirrhosis  of  the  liver  and  other  causes  of  portal  obstruction. 

Pressure  on  the  Portid  J'cin. — Ha-matemesis.  when  due  to  this  cause,  is  generally 
associated  with  ascites  and  intense  jaundice,  since  the  common  bile  duct  is  liable  to  be 
compressed  as  well  as  the- portal  vein,  on  account  of  tlieir  close  proximity  to  each  other. 
(See  Jaundice,  p.  829.) 

Some  eases  of  Enlarged  Sjih'en  (see  Spleen,  Enlargement  of,  p.  628). — Hicmatemesis 
is  a  fairly  common  symptom  in  cases  of  enlarged  spleen,  even  when  the  enlargement  is  not 
associated  with  cirrhosis  of  the  liver  or  leukuniia.  Osier  explains  the  occurrence  as  being 
due  to  the  "  intimate  relation  between  the  vasa  brevia  and  the  splenic  circulation  "  ;  .some- 
times, however,  it  results  from  actual  thrombosis  of  the  splenic  vein,  though  the  diagnosis 
of  this  is  scarcely  possible  without  laparotomy  or  autopsy, 

F.  Acute   Febrile   Diseases. 

Malignant  J'ariola.  — ILvmatemesis  occurs  in  about  a  tliird  of  the  cases  of  lucmorrhagic 
small-pox.  It  is  associated  with  cutaneous,  subcutaneous,  and  submucous  hiemorrhages, 
ha'maturia,  epistaxis,  melsena,  and  bleeding  from  the  gums.  The  sudden  initial  rigor, 
intense  backache  and  headache,  severe  vomiting,  epigastric  pain,  cutaneous  ha?morrhages, 
and  the  diffuse  hypera?mic  rash  with  small  punctiform  hajmorrhages  which  appears  first 
on  the  groins  and  lower  part  of  the  abdomen,  would  point  to  a  diagnosis  of  h;cmorrhagie 
or  black  small-pox  if  such  a  ease  occurred  during  an  epidemic  of  the  disease. 


H.EMATEMESIS  273 

Malignant  Scarlet  Pezzer. — In  the  lioemorrhagic  form  of  scarlet  fever,  haematemesis  may 
occur  ;  but  hseniaturia,  epistaxis,  and  cutaneous  haemorrhages  are  more  frequent.  The 
sudden  and  severe  onset,  the  very  high  temperature,  the  extremely  rapid  and  feeble  pulse, 
the  headache  and  delirium,  and  the  appearance  of  the  characteristic  rash  on  the  second  day 
would  point  to  scarlet  fever. 

Yelloxv  Fever. — '  Black  vomit  "  due  to  the  presence  of  altered  blood  is  one  of  the  most 
cliaracteristic  features  of  this  disease.  Hyperipmia  and  catarrhal  swelling  of  the  mucous 
membrane  is  the  only  change  which  is  found  in  the  stomach.  It  is  essentially  a  disease 
of  tropical  and  sub-tropical  cmmtries.  The  onset  is  sudden,  with  a  chill,  headache,  and 
severe  pain  in  the  back  and  limbs.  The  face  is  flushed,  and  very  soon  jaundice  appears. 
After  the  first  day  the  pulse-rate  drops,  so  that  with  a  temperature  of  lO.'J'  or  104°  the 
pulse  may  be  only  70  or  80.  Albiuninuria  is  another  early  symptom,  which  may  appear 
on  the  third  day.  In  addition  to  the  black  vomit,  there  may  be  cutaneous  petechia?  and 
bleeding  from  the  gums.  It  is  often  diHicult  to  distinguish  from  malignant  malaria, 
though  in  the  early  stages  of  malaria  jaimdice.  albuminuria,  and  ha?maturia  are  extremely 
rare,  wliilst  an  examination  of  the  blond  may  reveal  the  presence  of  malarial  ]jarasites. 

Cliolera  may  be  associated  with  haniatemesis  sometimes.  The  sudden  onset  of  acute 
gastro-intestinal  symptoms,  the  rapidly  repeated  rice-water  stools,  and  the  epidemic  nature 
of  the  malady,  all  point  to  the  diagnosis,  which  may  be  confirmed  by  recovering  the  vibrio 
from  the  motions  baeteriologically. 

Aciile  Yello'M  Atrophy  (if  the  Liver. — Haematemesis  is  the  conmionest  form  of  ha>mor- 
rliage  in  this  rare  disease.  Women  between  twenty  and  thirty  are  alTected  more  frequently 
than  men,  especially  during  and  just  after  pregnancy.  It  sometimes  follows  fright  and 
mental  emotion.  The  first  symptoms  are  indistinguishable  from  catarrhal  jaundice — 
viz.,  malaise,  loss  of  appetite,  nausea,  vomiting,  and  jaundice.  The  vomiting  soon  becomes 
intractable,  the  jaimdice  increases,  and  drowsiness,  restlessness,  and  delirium  supervene. 
The  vomit  is  black,  and  may  resemble  treacle,  its  ajipearance  being  due  to  altered  blood. 
Meltena,  epistaxis.  and  subcutaneous  petechiic  may  be  noticed.  The  tongue  becomes  dry 
and  brown  :  the  liver  dullness  diminishes  ;  the  mine  shows  characteristic  changes  in  the 
marked  diminution  in  the  amount  of  urea  and  the  presence  of  bile  pigment,  whilst  leucin 
and  tyrosin  crystals  in  it  (Fig.  148,  p.  333)  are  an  important  diagnostic  sign  of  this  disease. 

G.  Blood    Diseases. 

Piirpitra  Ihrinorrliagica. — Iliemorrhage  from  the  stomach  is  rare  in  this  disease. 
IliiMiiatemesis  may  occur,  however,  as  a  result  of  blood  derived  from  the  mucous  membrane 
(if  the  nose  or  mouth  being  swallowed.  .\s  purpura  is  a  symptom  rather  than  a  disease 
in  the  majority  of  cases,  before  making  a  diagnosis  of  purpura  haemorrhagica  or  idiopathica, 
those  diseases  which  lead  to  symptomatic  purpura  must  be  excluded  (see  Purpura, 
|).  .5.52).  .\n  examination  of  llie  bloid  must  als:)  be  imule,  to  exeluilc  pernicious  anaemia 
and  ieuka-mia  :    and  blood  cultures  may  be  reiiuired. 

Sciirvij.  Iluinalcnicsis  is  uneiinuiion,  only  occurring  in  severe  and  well-marked  cases, 
so  thai  the  diagnosis  is  not  ilillicull.  The  swollen  and  spongy. gums,  ana-mia,  cutaneous 
liainorrliages  around  I  lie  hair  sms.  and  subcutaneous  indurations,  in  a  patient  who  is 
lnuiid  to  have  been  li\ing  nri  a  diet  dclicicnl  in  (|UMnlity  and  in  vegclables,  would  [)c)int 
to   scurvy. 

II<rni<ij>liilia.  Out  of  .'i.'i  l.  cmsks  analy/ed  l)y  (Jrandidier,  there  were  only  lifleen 
examples  ol'  ha-morrhage  from  the  stomach.  I'ixccssixc  bleeding  from  slight  cuts  or  after 
tooth  extraction,  <|)istaxis.  bleeding  from  the  mouth,  and  lia'inorrhage  into  the  joints, 
are  the  earliest  and  the  commonest  manifestations  of  I  lie  disiasc.  The  association  oC 
hainatcmesis  with  lucmorrhage  from  other  parts,  and  willi  liiiiiioiiliagc  into  joints  in 
particular,  in  a  palieni  whose  near  male  relations  show  a  Icndency  (o  bleed  on  tiie  slightest 
provocMlioii.  would  point  to  lianuiphiiia.     Then'  are  no  palhognoinonie  blood  changes. 

Liiil.diiiiti.  I  hemorrhages  from  and  into  \arious  parts,  especially  epistaxis,  are 
ciJinirKin  in  lliis  disease.  Hicmatemesis  may  be  the  actual  cause  of  death.  Its  association 
with  (iKirnious  eidargement  of  the  spleen  is  liy  no  means  iiathognomonic  of  Ieuka-mia, 
for  the  two  conditions  may  be  present  in  chronic  malaria,  splenic  aiKemia,  and  spleno- 
megalic  cirrhosis.  .\n  accurate  diagnosis  camiot  be  made  until  I  hi'  blood  has  been 
examined    and    a    high    degree   of  leucoeytosis    found    (lOD.OIK)    to    1,01)0,01)0   white    blood 

I)  ~  IS 


274  H.EMATEMESIS 

«)ri)iiscles  per  c.  nini.),  with  a  large  proportion  of  myelocytes  in  the  case  of  splenomcdullary 
leukseniia  and  a  high  percentage  of  lymphocytes  (90  per  cent)  in  lymphatic  leukaemia. 

Ilodgkin's  Disease. — In  the  late  stages  of  this  disease  there  is  a  tendency  to  haemor- 
rhage from  and  into  various  jjarts  of  the  body,  e.g.,  epistaxis,  bleeding  from  the  mouth, 
cerebral  haemorrhage,  and  rarely  hoemateniesis.  There  should  be  little  difficulty  in  making 
a  diagnosis,  as  ha>matemesis  would  be  a  late  symptom  ;  the  characteristic  features  of  the 
disease  are  described  on  pages  37  and  635. 

Chlorosis. — It  is  difficult  to  determine  whether  haematemesis  occurring  in  an  anaemic 
woman  under  thirty  is  due  to  gastric  ulcer  or  to  gastrostaxis  (p.  36).  That  chlorosis  has 
something  to  do  with  haematemesis,  apart  from  the  formation  of  macroscopic  ulcers,  is 
probable  :  it  is  also  probable  that  chlorosis  predisposes  to  ga.stric  ulcer.  The  precise 
nature  of  tlic  syinjitiim  in  a  chlorotic  girl  is  therefore  very  difficult  to  determine,  some 
observers  diagnosing  gastric  ulcer  wlure  others  jirefer  to  label  the  condition  gastrostaxis. 
The  former  withliold  solid  food  longer  than  tlie  latter,  and  are  jjerhaps  inclined  to  recom- 
mend operation  more  readily  ;  these  are  the  main  grounds  for  striving  to  draw  a  clear 
distinction  between  the  two  conditions. 

Young  women  sidfering  from  chlorosis  are  usually  well  nourished.  The  skin  may 
liave  a  greenish  tinge  and  tlie  sclerotics  a  distinct  bluish  appearance.  (Edema  of  the  feet, 
dyspn(jca,  palpitation,  and  amenorrhoea  are  prominent  symptoms  ;  but  the  diagnosis 
cannot  be  made  with  any  certainty  until  the  blood  has  been  examined.  II  is  pale  and 
thin  ;  the  red  blood-corpuscles  are  reduced  in  number,  biit  rarely  are  under  3,000,000  per 
e.nun. ;  the  average  size  of  the  red  blood-corpuscles  is  below  normal :  the  haemoglobin  is 
reduced  much  more  in  proportion  than  are  the  red  blood-corpu-cles,  so  that  the  colour- 
index  is  low,  being  as  a  rule  about  0-5  or  under  ;  the  white  blood-corpuscles  are  not 
increased,  and  the  differential  leucocyte-coimt  is  almost  normal.  Seeing  that  amenorrhoea 
and  hcematemesis  are  both  lial)le  to  occur  in  an;emic  girls,  the  gastric  haemorrhage  has 
sometimes  been  regarded  as  vicarious  menstruation  ;  there  is  little  evidence  to  support 
this  view  of  its  pathology,  however,  and  when  the  bleedings  recur,  the  attacks  do  not  show 
any  monthly  regularity. 

Pernicious  Anwmia. — Haematemesis  is  a  very  rare  symptom  in  pernicious  anaemia  ; 
when  it  occurs,  the  difficulty  in  distinguishing  between  this  disease  and  carcinoma  of  the 
stomach  is  much  increased.  A  correct  diagnosis  cannot  be  made  imtil  the  blood  has  been 
examined  (p.  24).     The  urine  contains  pathological  urobilin. 

]\Ifiliirial  Cachexia. — Anaemia  and  enlargement  of  the  spleen  may  follow  repeated 
attacks  of  malaria,  and  severe  haematemesis  may  be  a  prominent  symptom.  In  making 
the  diagnosis,  the  history  of  residence  abroad,  of  attacks  of  ague,  and  the  condition  of  the 
blood,  must  be  relied  on.  A  normal  or  a  diminished  number  of  leucocytes,  with  a  relative 
increase  in  the  large  mononuclear  cells  beyond  15  per  cent,  is  strong  presumptive  evidence 
of  a  previous  malarial  infection. 

Splenic  ancemia  may  rim  its  course  without  any  luematemesis  ;  on  the  other  hand, 
the  latter  is  sometimes  one  of  the  most  serious  symptoms  in  the  case,  and  may  be  the  cause 
of  death.     The  chief  features  of  the  malady  are  described  on  p.  37. 

//.  Mlscelianeous. 

Chronic  Intcrstilial  ycphritis. — H;cmateniesis  occasionally,  but  very  rarely,  occur? 
in  this  disease.  Its  association  with  anaemia,  thickened  and  tortuous  superficial  arteries, 
high-tension  pulse,  hypertrophy  of  the  heart,  albuminuric  retinitis,  polyuria,  and  urine 
of  low  specific  gravity  containing  a  variable  quantity  of  albumin  and  renal  tube-casts, 
would  point  to  chronic  interstitial  nephritis  as  the  cause.  It  is  most  important  that  the 
blood-pressure  should  be  measured  instrumentally,  and  not  guessed  at  by  palpation. 

Following  Abdominal  Operations. — Hicmatemesis  may  occur  after  severe  abdominal 
operations,  independently  of  any  injury  to  the  stomach  or  duodenum.  Should  death 
occur,  no  obvious  lesion  can  be  found  in  the  stomach  to  account  for  it  in  the  majority  of 
cases.  The  reason  of  the  occurrence  of  such  an  alarming  symptom  remains  a  mystery 
in  many  cases,  but  in  some  infective  conditions,  such  as  appendicitis,  nudtiple  minute 
ulcers  have  been  found. 

Prolonged  Jaundice. — The  ini])ortancc  of  this  condition  as  a  cause  of  almost  any 
variety  of  bleeding  lies  chiefly  in  the  added  danger  attending  operations  in  such  cases. 


H.EMATURIA 


27a 


Si/pliilis  of  the  Liver  is  sometimes  cited  as  being  itself  a  cause  of  haematemesis  ;  tlie 
dilliculty  is  to  exclude  the  possibility  of  alcoholic  cirrhosis  in  such  a  case  ;  it  is  doubtful 
whether  syphihs  alone  can  cause  the  vomiting  of  blood.  Herbert  French. 

H^MATOPORPHYRINURIA.— (See  fnixi:.  Abnormal  Cui.ouation  of.  p.  744.) 

HyEMATURIA.— Blood  may  appear  in  the  urine  as  the  result  of  injury,  of  disease 
in  some  portion  of  the  urinary  tract,  or  of  other  organs  involving  the  urinary  apparatus, 
or  of  a  few  general  diseases  of  other  parts  of  the  body.  The  blood  may  be  present  in  large, 
small,  or  microscopic  amounts,  it  may  continue  for  days  or  even  weeks,  or  appearing  sud- 
<leiily  and  witliout  apparent  cause,  may  disap])ear  completely  for  a  variable  period. 
Further,  it  may  be  present  in  the  urine  either  as  corpuscles  or  as  haemoglobin,  and  it  is 
necessary  to  distinguish  between  the  two  conditions.  In  ha?moglobinuria  the  urine  is 
dark  brown  from  the  presence  of  methaemoglobin,  and  any  deposit  is  found  to  consist  of 
brownish  debris  in  which  no  red  blood-corpuscles  can  be  found  (see  Hemoglobinuria, 
p.  2S4).  Occasionally  the  colouring  matter  of  the  blood  may  escape  from  the  corpuscles 
if  the  stained  urine  has  been  retained  for  any  length  of  time  in  the  bladder,  when  erenated 
or  disintegrated  corpuscles  will  be  found  on  microscopic  examination  of  the  sediment. 
The  following  list  gives  the  chief  causes  of  haematuria  : — 


I. H.EM.\TIRIA    FROM    AfFHCTIOX    OF    SOME    PART    OF    TUE    I'rIXARV    OrG.\NS. 

A.  Renal   Causes. 


Prafiise. 
Jliilignant  tumours  of  the  kidney  : 

Hyperneplironia 

Embryonr.i 

Carcinoma 

.Sarcoma 
Innocent  tumoius — papilloma  of  pelvis 

angioma 
Injurv  of  the  kiiliuv 
(•alcnkis 
Tuberculosis 
So-called  '  essential  '  hx'maturia 

li.  Ureteric   Causes. 

C'iileiilu=   in  the   ureter. 


Slight. 
Calculus 
Tuberculosis 
Renal  mobility 
Hydronephrosis 
Polycystic  disease 
Injury 
Oxaluria 

Nephritis,  acute  and  subacute 
Coli   l)Licilluria 
Drugs  :    tiupentinp,   carbolic  acid,   cantharidcs. 


C.  Vesical   Causes. 

Profuse. 
Villous  tumour 
Papilloma 

Villus-covercd   carciiioiua 
J'rostalic  ailcnoMia  or  carcinoma 


1).  Urethral   Causes. 

Acute  iHCtlirilis,  iru|iiictiou  of  calculus 
injury  ' 


.S7/i!///. 
Epithelioma 

TubiTculosis  of  bladder  or  prostate 
Calculus 
Acute  cystitis 
Bilharz.ia  ba;matobia 
Injury 


Acute  s|icrmiito-eystitis 
Na'vus 


II.—  II.i;ma  [  iiiiA    iiu>\T    1)isi;asi:   oi-    rui-.  Nfkuiboikini:    Viscera    involving    the 

I'llINAHV  OllGANS. 

Carciiinniii    (it    llir'    uterus,    \ii;;ina,    or  Pelvic  abscess 

rccduu  Dysenteric    or    luliciiMilous    ulccraliuu    (if    the 
Acute  appendicitis  intcstin(_'. 

Acute  sal|)ingitis  I 

III.    -II.E-\L\TIUIA     IN  (;|-.M;RAL    DiSI'.ASl-.S. 


lienal    iutarclion    in   cudoearditi 

Artcridsclerosis 

I.cukaniia 

I'urpurn   and   scurvy 


Ibcmopliilia 

Acute    levers,    nialai'in,    small-p(i\,    and    yellow 
lever. 


276  H.EMATURIA 

In  considering  the  diagnosis  of  a  case  presenting  haematuria  as  a  symptom,  it  is 
seldom  that  tliere  are  not  other  symptoms  present,  such  as  pain,  tumour,  or  increased 
frequency  of  micturition,  whicli  will  point  to  one  or  other  organ  as  the  source  of  the  bleed- 
ing ;  but  in  some  cases  ha^maturia  may  be  the  only  symptom.  The  following  points  will 
often  hel]>  in  the  differential  diagnosis  : — 

T)ic  Colour  of  the  Urine. — If  the  urine  is  stained  a  bright  red  colour,  the  lia?morrhage 
is  most  likely  to  arise  from  the  bladder  or  lower  urinary  tract.  Dark-coloured  blood  in 
the  urine  may,  however,  be  due  to  the  retention  of  blood  in  the  bladder  for  some  time,  or 
from  the  large  amount  present  in  the  urine. 

The  Distribution  of  the  Blood  in  the  Urine  during  yiietiirilion. — If  the  urine  during 
micturition  is  only  tinged  with  blood  during  the  final  expulsive  efforts,  or  if  the  terminal 
urine  is  stained  more  deeply  than  the  rest,  the  source  of  the  luematuria  is  almost  certainly 
in  the  bladder.  If  the  first  urine  passed  is  blood-stained  and  the  remainder  clear,  the 
bleeding  is  probably  from  the  urethra  or  prostate  ;  whereas  if  the  urine  is  evenly  stained 
with  blood  throughout,  it  suggests  that  the  source  of  haemorrhage  is  in  the  kidneys, 
although  a  vesical  lesion  which  causes  more  than  a  slight  haemorrhage  may  also  give  rise 
to  a  deeply  blood-stained  urine  throughout  micturition. 

Tlie  Quantity  of  Blood  Present  in  the  Urine. — A  large  quantity  of  Iilood  in  the  urine, 
in  the  absence  of  traumatism,  suggests  some  form  of  growth  in  the  bladder  or  kidney. 
Pa])ill()mata  and  villus-covered  carcinomata  in  the  bladder  may  cause  sudden  profuse 
ha'morrhage  without  pain  or  other  symptom,  whilst  equally  j^rofuse  hfenx)rrhage  may 
arise  from  a  malignant  tumour  in  the  kidney  whicli  has  invaded  the  renal  pelvis.  Exam- 
ination of  any  clots  of  blood  passed  may  occasionally  afford  useful  information  in  deter- 
mining the  seat  of  hsemorrhage.  The  urine  should  be  poured  into  a  large  flat  tray  con- 
taining water,  and  the  clots  floated  out,  when  some  may  sliow  the  triangular  or  pyramidal 
shape  indicating  their  formation  in  the  renal  pelvis,  or  others  the  thin,  worm-like  form 
with  tapering  or  decolorized  ends  from  their  formation  in  the  ureter;  their  passage  down 
the  ureter  is  accompanied  by  the  same  acute  renal  colic  that  is  caused  by  renal  calculus. 
Clots  foi'med  in  the  bladder  are  flat,  disc-like,  but  often  broken  up  in  their  passage  through 
the  urethra. 

If  the  quantity  of  blood  is  increased  by  movement  or  exercise,  suspicion  of  renal  stone 
or  growth  will  arise.  In  a  recent  case,  profuse  ha?maturia  occurred  after  three  successive 
railway  journeys,  when  the  lesion  found  at  operation  was  an  early  carcinoma  of  one  kidney 
which  had  recently  invaded  the  renal  pelvis. 

The  Association  of  other  Elements  from  the  Urinary  Organs  icilh  Blood  in  the  Urit}e. — 
Microscopical  examination  of  the  deposit  obtained  by  centrifuging  the  urine  may  reveal 
cellular  elements  distinctive  of  the  renal  pelvis  or  vesical  mucous  membrane  or  epithelial, 
granular,  and  blood-casts  from  the  renal  tubules  {Plate  I.  p.  6),  which  may  help  in  the 
diagnosis  in  a  case  of  ha?niaturia.  The  presence  of  a  number  of  urinary  crystals  in  a  urine 
of  acid  reaction  will  point  to  renal  calculus.  Occasionally,  small  pieces  of  growth  may  be 
passed  in  the  urine  from  the  delicate  villous  papilloma  or  villus-covered  carcinoma  of  the 
bladder,  and  more  rarely  plugs  of  muco-pus  from  a  caseous  tuberculous  cavity  in  the  kidney 
may  be  found.  It  is  important  to  remember  that  the  presence  of  a  villous  tuft  in  the  urine 
gives  no  indication  whether  it  is  derived  from  an  innocent  pajjilloma  or  a  villus-covered 
carcinoma,  as  it  becomes  detached  only  from  the  surface  of  the  growth. 

The  association  of  pus  with  blood  in  the  urine  does  not  give  much  assistance  in  deter- 
mining the  seat  of  the  bleeding.  Both  pus  and  blood  will  often  be  present  with  either 
calculus  or  tuberculosis  of  the  kidney  or  bladder,  and  may  both  be  present  with  vesical 
growth  or  with  prostatic  enlargement. 

The  Amount  of  Albumin. — If  the  amoinit  of  albumin  in  the  urine  is  in  excess  of  that 
which  would  be  due  to  the  amount  of  blood  present,  the  bleeding  is  probably  renal  in  origin. 

The  Reaetion  of  the  Urine  is  of  very  slight  assistance  in  determining  the  source  of  bleed- 
ing. Generally  speaking  blood  in  an  acid  urine  is  more  likely  to  be  derived  from  tlie  kidney 
than  from  the  bladder  ;  this,  however,  is  no  universal  rule,  for  blood  may  be  present  in 
an  acid  urine  in  a  case  of  vesical  calculus  or  growth:  whereas,  on  the  other  hand,  there 
may  be  blood  in  alkaline  urine  in  a  case  of  renal  calculus  as  well  as  in  pathological  con- 
ditions of  the  bladder. 

The  association  of  unilateral  lumbar  pain,  situated  in  the  angle  between  the  last  rib 


H.EMATURIA  277 

and  the  border  of  the  erector  spinje  muscle,  passing  forwards  above  the  iliac  crest  into  the 
groin,  with  occasional  attacks  of  colic,  would  suggest  a  renal  lesion  ;  whilst  liEematuria. 
accompanied  by  increased  frequency  of  micturition,  or  by  penile  pain  immediately  following 
micturition,  would  indicate  vesical  disease.  This  statement  must  of  necessity  be  taken 
in  a  very  general  sense,  for  exceptions  to  it  are  frequent.  Thus  a  vesical  tumour  causing 
hfematuria  may  implicate  an  ureteric  orifice  sulliciently  to  cause  increased  intra-renal 
tension  on  that  side  with  lumbar  aching  or  even  enlargement  of  the  kidney  :  whilst  on  the 
other  hand  a  tuberculous  lesion  in  the  kidney,  with  descending  ureteritis,  may  cause  increased 
frequency  of  micturition  before  there  is  any  vesical  infection.  Equally  important  is  it  to 
take  into  consideration  the  age  of  the  patient  ;  thus,  in  a  young  adult,  continued  slight 
hsematuria  with  increased  frequency  of  micturition  are  highly  suggestive  of  tuberculous 
disease  of  the  kidney,  whereas  slight  h:ematuria  in  a  more  elderly  patient  suggests  vesical 
carcinoma  or  calculus.  At  any  age,  severe  hiematuria  may  be  present  with  a  villous  tumour 
of  the  bladder,  or  in  a  |)atient  more  advanced  in  years  with  renal  growth  or  prostatic 
enlargement. 

Further  evidence  of  the  source  of  the  Inemorrhage  may  be  obtained  upon  the  physical 
examination  of  the  patient.  This  should  be  carried  out  systematically,  and  not  only  should 
the  urinary  organs  be  examined,  but  any  evidence  of  disease  elsewhere  in  the  body,  as  in 
the  heart,  lungs,  blood,  liver,  or  pelvic  organs,  sought  for  also.  Each  kidney  should  be 
examined  bimanually,  one  hand  being  placed  in  the  angle  made  by  the  last  rib  and  the 
margin  of  the  erector  sjiinae  muscle,  and  the  other  in  front,  immediately  below  the  costal 
margin  ;  the  ijaticnt  is  then  directed  to  breathe  deeply  whilst  pressure  is  maintained  by 
the  two  hands,  when  an  enlarged  or  unduly  mobile  kidney  may  be  felt  to  descend,  or  may 
be  grasped  on  deep  ins[)iration.  Any  ))ain  or  undue  tenderness  on  either  side  should  be 
noted,  especially  any  sharp,  pricking  [jain  experienced  by  the  patient  if  the  anterior  hand 
be  depressed  suddenly,  a  sign  said  to  be  indicative  of  renal  stone. 

Examination  of  the  bladder  by  palpation  in  the  suprapubic  area  may  elicit  pain  in 
acute  inflammatory  conditions,  or  may  give  evidence  of  a  distended  bladder  in  a  case  of 
hiematuria  from  prostatic  obstruction  ;  l)ut  much  more  knowledge  may  be  gained  by  a 
thorough  recia!  examination.  For  this  purpose  the  patient  should  assume  the  knee-elbow 
position,  when  the  examining  fmger  can  explore  not  only  the  prostate,  but  the  vesieula? 
seminales,  the  lower  end  of  each  ureter,  and  the  bladder  base,  as  well  as  the  lateral  pelvic 
wall.  The  prostate  may  show  adenomatous  enlargement,  or  may  be  inhltrated  with 
primary  carcinoma — which  has  recently  been  shown  to  be  far  from  uncommon, — when 
the  gland  will  present  marked,  lirm,  rounded  nodules,  and  will  often  be  immovable. 
Search  should  be  made  f(jr  any  nodules  in  the  prostate  or  vesicles,  or  thickening  of  the 
lower  end  of  the  ureter.  suggestiNc  of  tubereulous  disease,  or  thickening  or  infiltration  in 
the  bladder  base,  which  may  often  be  felt  in  a  ease  of  vesical  carcinoma,  l^xamination 
in  the  lateral  pelvic  space  may  show  infiltration  of  the  pelvic  lymphatics,  or  enlargement 
of  the  lymphatic  glands  in  a  case  of  carcinoma  of  the  bladder  or  prostate.  Examination 
of  the  testes  should  always  be  made.  A  nodule  in  either  e))ididymis  may  indicate  tuber- 
culous disease  which  may  have  spread  to  the  urinary  organs,  but  care  must  be  taken  not 
to  mistake  a  nodule  dating  fniin  a  gonorrho'al  cpididyniitis  I'or  one  due  to  tuberculous 
disease. 

(Jrcat  assistance  may  be  (ibtaincd  by  the  use  of  the  riisliisrojie  {I'lates  W .  p.  2S2.  aiul 
XVI,  J).  284).  Needless  to  say,  the  greatest  gentleness  must  be  used  in  carrying  out  any 
instrumentation,  to  avoid  any  further  hajmorrhage,  which  would  obscure  a  view  by  tlii' 
<'Vstoseope.  and  if  any  l)lee<ling  is  present,  an  attempt  should  I.e  made  lo  arrest  it  by  irriga- 
tion of  the  liladdci-  wilh  sihcr  nilral<'  1  lOOO.  or  with  adrenalin  solul  ion  of  the  same 
strength.  If  I  he  I )!(•(■<! ing  is  inofuse,  it  is  probably  impossihie  to  obtain  a  satisfactory  view  of 
llic  iiilciidr-  111  llic  iiladilcr.  bill  wilh  even  moderate  ha'Uiorrhage  going  on  a  rajiid  disten- 
tion (if  llic  Ijjaddc  r  iiia\  produce  a  medium  clear  enough  to  obtain  a  view  which  will  show 
the  seal  of  lia-niorrhage.  Thus  in  renal  h;ematuria  blood-stained  urine  may  be  seen  to  be 
emitted  from  one  ureteric  orilice  (Plate  .VI',  I-'ifi,  .1.  p.  2K2)  and  clear  urine  from  the  other 
before  the  nie<lium  is  ton  obscured  :  or  with  vesical  lueniorrhagc  a  vesical  tumour  may  be 
seen.  Even  slight  ha-morrhage  will,  however,  rapidly  render  the  medium  in  the  bladder 
too  hazy  for  a  salisfa<-tory  examination  of  any  minute  changes  in  the  vesical  wall  to  be 
nhlainrd      tuhcreulnus   disease   Utr  exainiilc.      Ilcnci'   il    is   heller,   if  possible,   to  nnderlake 


•27ft  HEMATURIA 

any  cystoscopic  examination  in  the  interval  between  attacks  of  bleeding,  when  the  bladder 
can  be  examined  thoroughly  and  any  pathological  lesion  found.  If  no  evidence  is  obtained 
in  this  way,  a  further  examination  may  be  conducted  during  an  attack  of  bleeding. 

I.  H.EMATURIA    FROM   AFFECTION    OF    SOME    PART    OF    THE    URINARY    TRACT. 
.1.  Renal    Causes. 

The  Malignant  Tumours  of  the  Kidney,  hypernephroma,  embryoma,  carcinoma,  and 
sarcoma,  are  all  associated  with  jjrofuse  ha?maturia  at  intervals.  Hypernephromata  are 
the  most  common  ;  they  arise  in  the  cortical  portions  of  the  kidney,  and  are  of  compara- 
tively slow  growth.  The  embryomata  may  occur  in  small  children  or  in  elderly  persons, 
whilst  the  true  earcinomata  and  sarcomata  are  much  more  imcommon.  Tliese  tumours 
cause  an  aching  in  the  loin,  and  may  lead  to  considerable  enlargement  of  the  kidney  before 
any  hematuria  occurs.  In  the  progressive  growth  of  the  tumour,  the  renal  pelvis  is 
involved  gradually  and  ha>maturia  is  evoked.  This  is  usually  severe  in  type,  so  that  clots 
may  be  formed  in  the  caiices  of  the  renal  pelvis  or  in  the  ureter,  and  cause  the  typical  pain 
of  renal  colic  in  tlieir  descent  of  the  latter.  The  renal  tumour  usually  maintains  the  shape 
of  the  kidney,  but  in  some  eases  may  present  a  nodular  form.  Hence  profuse  h;ematuria, 
with  clots  of  ])yramidal  or  worm-like  shape,  associated  with  renal  enlargement,  is  strongly 
suggestive  of  a  renal  malignant  growth. 

The  only  common  form  oi  innocent  tumour  in  the  kidney  is  ])a|)illoma  of  the  renal  pelvis. 
This  gives  rise  to  profuse  ha-niaturia  and  to  renal  enlargement,  which  in  this  instance  is 
due  to  hydro-  or  hiemato-ncphrosis  from  the  obstruction  to  the  ureter  by  the  ]>aijillary 
growth  or  by  blood-clot.  Thus  the  renal  timiour  may  vary  in  size.  Papillomata  of  the 
nuicous  membrane  of  the  renal  pelvis  are  accompanied  occasionally  by  similar  growths 
in  the  ureter,  and  may  also  show  a  similar  growth  at  the  ureteric  orifice  ujion  inspection 
of  the  bladder. 

.\n  angioma  of  the  kidney,  fcjrming  a  distinct  tumour  in  tlie  renal  tissues  and  causing 
))rofuse  hainaturia.  has  recently  been  described  by  the  writer,  whilst  Hurry  Fenwick  has 
described  easis  of  angioma  of  the  apex  of  a  renal  papilla  causing  luematuria. 

Injuries  to  tlic  Kidiieij  may  cause  ha?maturia  ;  the  diagnosis  is  usually  obvious.  The 
history  of  the  accident,  a  blow  or  squeeze  to  the  lumbar  region,  associated  with  ha?maturia, 
would  point  to  an  injury  to  the  kidney.  There  may  be  renal  enlargement,  but  this  must 
be  diagnosed  from  an  extravasation  of  blood  in  the  |KTinephric  tissues  from  the  rupture 
of  the  renal  cortex.  Comparatix  ely  slight  injury  to  the  loin  nuiy  ])roduce  luematuria  from 
a  small  lesion  in  the  renal  tissues,  whilst  in  some  eases  there  is  no  sign  or  recollection  of 
external  violehec.  In  any  ease  of  ha?maturia  following  traumatism,  it  is  essential  to  dia- 
gnose an  injury  to  the  kidney  from  injury  to  the  urethra  or  bladder.  In  urethral  injury  the 
canal  may  be  merely  contused,  or  partially  or  wholly  ruptin-ed  ;  blood  may  be  found  at 
the  urethral  meatus  or  may  be  marked  in  the  first  portion  of  any  urine  that  may  be  passed, 
whilst  if  the  urethra  be  entirely  divided,  signs  of  extravasation  of  urine,  with  inability  to 
micturate,  will  appear. 

If  the  bladder  be  injvued.  blood  may  Ije  i)resent  in  any  urine  drawn  off  :  or  after  rupture 
of  the  bladdej-  -involving  the  peritoneal  coat  fluid  may  be  found  in  the  abdominal  cavity. 
The  length  of  time  between  the  last  passage  of  urine  and  the  occurrence  of  the  accident 
should  be  ascertained,  and  a  catheter  passed  :  very  gentle  irrigation  of  the  bladder  with 
sterile  lluid  should  be  carried  out  in  any  susi)ected  rujjture  of  the  viseus.  to  sec  if  the  amount 
of  fluid  run  into  the  bladder  is  duly  returned.  At  the  same  time,  a  thorough  examination 
of  the  bony  pelvis  should  be  made  for  any  sign  of  fracture,  which  is  fre(|uently  the  cause 
(il  direct  injury  to  the  bladder  or  urethra. 

In  Renal  Calealiis  the  bleeding  is  seldom  profuse,  is  usually  associated  with  a  small 
amount  of  pus.  and  fre(|uently  is  increased  after  exertion  or  the  jolting  of  a  journey.  The 
subject  of  a  renal  stone  will  usually  complain  of  jjain  in  one  loin  of  a  constant  aching 
character,  which  will  remain  of  this  character  so  long  as  the  stone  remains  embedded  in 
the  renal  tissues,  in  which  condition  slight  hajmaturia  is  often  present.  When,  however, 
the  calculus  projects  into  or  is  free  in  the  renal  pelvis,  the  urine  also  contains  a  small  quan- 
tity of  pus,  and  attacks  of  renal  colic  come  on,  characterized  by  very  acute  pain  in  the 
loin,  passing  forwards  and  downwards  to  the  groin,  upper  jjart  of  the  thigh,  and  testicle 
of  the  same  side,  and  accompanied  by  frequent  desire  to  pass  urine.     The  calculus  may 


H.EMATURIA 


•279 


be  passed  into  the  bladder  alcino-  the  ureter,  may  become  impacted  in  the  course  of  the 
ureter,  or  may  remain  in  the  renal  pelvis,  in  which  case  successive  attacks  of  renal  colic 
may  occur.  The  previous  passage  of  a  small  calculus  per  urethram,  following  an  attack 
of  renal  colic,  is  an  important  point  in  the  history  of  such  a  patient,  but  in  any  case  an 
examination  by  skiagraphy  should  be  carried  out,  when  a  calculus  may  be  proved  present 
in  the  kidney  {Fig.  133).  A  calculus  in  the  kidney  may  attain  a  size  too  large  to  become 
engaged  in  the  upper  end  of  the  ureter,  when  renal  colic  will  be  absent,  or  it  mav  cause 
liydronephrosis,  renal  abscess,  or  pyonephrosis,  of  which  symptoms  may  be  present. 

lientil  Tuberculosis,  a|)art  from  the  miliary  form  of  children,  is  not  uncommon  as  a 
primary  disease  of  one  kidney.  The  jjatients  affected  are  usually  young  adults,  who  com- 
plain of  a  constant  aching  in  one  loin,  with  occasional  attacks  of  more  acute  pain  resembling 


renal  (■(.lie.  Al  Ihc  oiisci  cT  I  he  diseiisr.  when  llir  fcjci  ;irc  liinilcrl  Id  Ihc  renal  I  issues,  there 
is  no  ehaiige  in  Ihc  urine  IxNond  llic  occasional  presenee  of  albumin  :  but  as  il  ad\anees 
the  foci  coalesce  and  form  a  softened  area  wlii<-h  opens  into  the  renal  pelvis,  when  Ihcre 
is  a  constant  discharge  of  small  (|uanlities  of  pus  and  blood  in  the  urin<'.  The  liberation 
of  tuberculous  material  into  the  renal  pcK  is  and  luclcr  causes  infrclion  of  the  mneous 
lining  of  these  passages,  and  is  marUe.l  almost  constant  l\  by  increased  IVe(|neney  of 
nueturition  during  both  da\  and  night.  c\cn  IkIotc  an\  tnix  renlons  ird'ection  has  oceinred 
in  the  bladder.  These  cases  are  often  mistaken  for  renal  calculus,  but  in  anx'  ease  of  per- 
sistent slight  ha-malnria  or  pNuria  a  earefnl  search  should  l.e  made  for  lubereh-  bacilli  in 
Ihc  nrinc.      II   slionM  be  noh'd  also  lljat  a  skiagram  may  show  a  distinct   shadow  proiliiecd 


280 


H.EMATURIA 


by  a  tuberculous  focus  in  the  kidney  {Fig.  134),  but  its  outline  aeneially  differs  from  that 
due  to  a  calculus  in  its  less  definite  border.  In  renal  tuberculosis  the  hoematuria  is  rarely 
increased  by  exertion  on  the  part  of  the  patient,  as  is  frequently  the  case  with  calculus, 
and  pain  in  the  loin  is  less  mitigated  by  rest  in  bed.  In  renal  tuberculosis  the  lower 
end  of  the  ureter  of  the  affected  side  may  often  be  felt  to  be  thickened  on  examination 
per  vagina,  or  per  rectum,  whilst  in  the  male  tuberculous  nodules  may  be  felt  in  the 
[jrostate  or  vesicles. 

In  Renal  Mobility,  h;ematuria  is  certainly  uncommon,  but  occurs  occasionally.  In 
the  case  of  a  patient  with  markedly  increased  renal  mobility,  haematuria  may  follow  any 
exertion,  such  as  hunting  or  dancing.  Renal  mobility  is  so  common,  however,  that  the 
occurrence  of  li:enialuria  should  in  any  case  arouse  suspicion  of  some  other  lesion  of  the 

urinary  tract,  and  a  thorough 
examination  both  of  the  urine 
especially  for  tubercle  bacilli, 
and  of  the  bladder  (by  the 
eystoseope)  and  of  the  kidney, 
should  be  made  before  any 
attempt  at  fixation  is  under- 
taken. Movable  kidney  may 
be  entirely  painless  and  give 
rise  to  no  symptoms  what- 
ever, or  may  cause  lumbar 
aching  or  attacks  of  acute 
pain  resembling  renal  colic 
(DietTs  crises).  It  frecpiently 
causes  ga.stro  -  intestinal  dis- 
turbance from  the  drag  upon 
the  duodenum  in  relation  to 
it.  and  occasionally  also  poly- 
uria and  increased  frequency 
of  micturition.  The  kidney 
can  be  felt  to  be  movable, 
but  care  must  be  taken  not 
to  mistake  other  abdominal 
swellings  for  a  kidney  (see 
Kidney,  Enlargement  of, 
p.  352). 

IlydroiKphrosis  occasion- 
ally gives  rise  to  ha-maturia, 
and  the  combination  of  renal 
tumour  and  luematuria  would 
suggest  a  growth  in  the 
kidney.  The  blood  from  a 
hydronephrotic  kidney,  how- 
ever, is  very  rarely  copious, 
and  the  other  symptoms  of 
hydronei)hrosis  would  distinguish  the  two,  in  particular  intermittcney  with  corres])onding 
changes  in  the  amount  of  the  urine. 

Polycystic  disease  of  the  kidneys  is  conunonly  accompanied  by  ha'maturia  in  the  later 
stages  of  the  disease.  It  occurs  in  early  childhood  or  in  adult  life,  and  is  most  commonly 
bilateral,  forming  an  enlargement  of  each  kidney  which  may  reach  large  dimensions, 
although  on  the  other  hand  a  tumour  may  only  be  felt  on  one  side.  In  the  early  stages 
the  diagnosis  is  diHicult  :  but  later,  pain,  bilateral  tumour,  haematuria,  and  signs  of  renal 
inellieiency  will  be  jjresent.  The,  renal  tumour  caused  by  polycystic  disease  is  smooth 
and  rounded,  but  differs  from  hydronephrosis  in  that  fluctuation  can  seldom  be  obtained. 
Bilateral  hydronephrosis  will  be  diagnosed  from  polycystic  disease  by  the  finding  of  some 
lesion  obstructing  the  normal  urinary  flow,  such  as  stricture  of  the  urethra,  prostatic  or 
vesical  disease,  or  carcinoma  of  the  pelvic  organs  invading  the  lu-eters. 


Fit/.  134. — Skiagram  in  a  case  of  tuberculous  kidney  with  pyonephrosis,  the 
condition  due  to  marked  deposit  of  calcium  salts  in  the  old  tuberculous  lesions 
mii?ht  be  mistaken  for  a  large  antlered  calculus. 

(Stiaipviii  III/  Ilr.  C.   Thurstan  Ilcltanil.) 


H.EMATURIA  2W1 

Oxahiria  (p.  423)  may  give  rise  to  slight  haeniaturia.  The  passage  of  large  numbers 
of  oxalate  crystals  in  the  urine  occurs  in  some  patients,  especially  after  a  diet  containing 
rhubarb,  gooseberries,  or  tomatoes,  and  is  often  acconijianied  by  dyspepsia.  An  examina- 
tion of  the  urine  on  successive  days  will  demonstrate  the  condition.  The  aching  in  one 
loin  and  the  presence  of  envelope  crystals  in  the  urine,  may  simulate  renal  stone,  but  the 
absence  of  a  shadow  in  a  skiagram  will  disprove  the  latter. 

Acute  yephritis  is  acconi]ianied  by  lueinaturia.  but  is  usually  obvious  by  the  sudden 
onset  of  the  disease,  by  the  history  of  some  specific  fe\er,  or  of  a  chill,  and  by  the  subcu- 
taneous crdema.  The  urine  is  scanty  and  of  high  specific  gravity,  and  contains,  in  addition 
to  blood  discs,  hyaline  and  epithelial  tube-casts,  many  renal  epithelial  cells,  and  abundant 
albumin.  There  arc  some  cases  of  acute  nephritis  in  which  no  oedema  occurs,  and  then 
the  abundance  of  renal  tube-casts  in  the  urine  affords  the  main  evidence  as  to  the  diagnosis. 

Essential  lienal  Hirnintiiria  is  the  name  given  to  a  group  of  cases  in  which  definite 
unilateral  haeniaturia  is  present,  but  in  which  examination  of  the  kidney  on  exploration 
lias  failed  to  show  the  cause  of  the  ha-morrhage.  The  bleeding  is  profuse  and  comes  on 
suddenly  without  any  apparent  cause  ;  it  is  intermittent  and  may  be  accompanied  by 
lumbar  aching,  but  there  is  no  tenderness  and  enlargement  of  the  kidney,  and  on  cysto- 
scopic  examination  it  is  jjroved  to  be  unilateral.  In  tlie  intervals  of  Inematuria  there  may 
be  no  albumimnia.  The  kidney  on  exploration  appears  to  be  normal,  but  if  a  piece  is 
removed  for  microscopic  section,  evidence  of  nephritis  will  usually  be  found.  The  evidence 
tends  to  show  that  these  eases  are  probably  due  to  a  unilateral  nephritis.  ; 

li.  Ureteric  Calculus  may  cause  ha^maturia,  either  during  the  descent  of  the  stone 
or  when  the  latter  becomes  arrested  in  the  duct  without  causing  complete  obstruction  to 
the  How  of  urine.  The  diagnosis  is  usually  easy  from  the  history,  and  the  character  of  the 
pain.  accom|)anicd  by  the  increased  desire  to  micturate  ;  but  in  some  cases  on  the  right 
side  it  may  be  mistaken  for  acute  appendicitis.  Tlie  pre\  iuus  history  of  the  passage  of  a 
calculus  or  of  renal  symptoms  of  stone  will  usually  be  elicited.  A  skiagram  should  be 
ol)talned  (Fig.  !!)•_'.   p.   4.55).  1 

('.  Vesical  Causes.  The  profuse  hicmaturia  of  a  paiiillotiKi.  villous  liuiunir.  or  of  a 
villiis-covrrrd  larciiioDin  of  the  bladder,  fre<iuently  (jccurs  without  any  other  symptom^ 
<'i)ming  on  suddenly  without  any  exciting  cause  :  it  may  last  a  variable  time,  and  then 
disappear  entirely,  or  continue  as  a  slight  lucmaturia  for  some  days.  With  the  carcino- 
matous form  there  may  be  some  increased  frequency  of  micturition  in  the  absence  of  bleed- 
ing, but  in  either  variety  the  clotting  of  blood  in  the  bladder  may  cause  urgent  desire  to 
micturate  or  even  retention  of  urine.  A  rectal  examination  may  give  evidence  of  infil- 
tration of  the  base  of  the  bla<ldcr  or  of  the  ijelvic  lym])hatics  in  the  malignant  form,  but 
it  is  oidy  ran'ly  that  an  iimoccnt  tumour  is  large  enough  to  be  felt  per  rectum.  In  the 
intervals  between  Iwcmorrliagcs,  a  cystoscopic  examination  will  demonstrate  the  |)rcsencc 
of  a  vesical  growth  H'lalf  All.  Figs.  F  and  (>).  It  should  he  noted  that  the  common  situ- 
ation for  a  vesical  Inindur  is  at  the  base  of  the  bladder,  in  close  i)roximity  to  a  ureteric 
orifice  ;  the  latter  may  be  obstructed,  or  dragged  U|)on  by  the  growth  in  such  manner  as 
to  cause  renal  disl(  nliim  or  hydronephrosis,  so  that  a  vesical  tumour  may  give  rise  to  renal 
pain  and  tumour,  and  in  this  way  be  mistaken  for  a  renal  growth.  This  dilliculty  will  be 
overcome  by  a  cystoscopic  examination  of  the  bladder. 

Prostatic  piilargenieiit  of  the  acfenomatous,  or  more  frequently  of  the  carcinomatous 
\aricty,  may  cause  lucmaturia.  The  age  of  the  jiaticnt  (.54  or  more),  the  increased  fre- 
<|ueney  and  dilliculty  in  micturition,  the  evidence  obtained  by  rectal  examination  and  by 
catlicterizalion,  snllicc  to  diagnose  the  disease.  The  liaMuaturia  of  jirostatic  enlargement  is 
often  profuse,  and  may  occur  early  in  the  disease;  but  on  careful  {'nquiry  it  will  usually  be 
lound  tliat  there  has  been  for  some  OKpnl  lis  a  gradually  increasing  frequency  of  inicliirilion. 

rcsical  F/iiHuli(ittia  occurs  In  eNUrly  ])aticiits,  and  causes  sliglit  but  fairly  constant 
liainal  III  i:i.  I'or  li:iiiiori  liag<'  to  take  place  froin  a  Msjeal  epithelioma  there  must  be 
iilecraliun  nl'  llir  siirlacc  of  the  growth,  anil  oilier  syniploins  will  be  present,  namely, 
increased  fiiqucncy  of  niictiirition  both  day  and  night,  penile  pain  following  the  act  of 
niieliirilion,  and  pyuria.  'J'he  blood  often  occurs  as  a  lew  drops  at  the  terniinalion  of 
urination,  or  may  be  mixed  throiigliout  the  act.  I'sually  a  vesical  epithelioma  is  situated 
on  the  base  of  the  bladder,  and  may  be  felt  as  a  distinct  inllltration  per  rectum. 

I'esical  Tuljcrriilosis  gives  rise  to  exactly  the  .same  symptoms  as  an  epithelioma,   but 


H.^^MATURIA 


it  occurs  conimonly  in  young  adults.  Persistent  slight  hapniaturia  and  jiyuria  in  a  young 
patient  will  always  suggest  tuberculous  disease,  and  a  very  careful  search  should  be  made 
in  the  centrifugalized  urine  for  tubercle  bacilli,  whilst  other  evidence  of  tuberculous  disease, 
especially  in  the  testes,  vesicute  seniinales,  and  prostate,  should  be  looked  for.  Difficulty 
may  arise  in  the  diagnosis  between  vesical  and  renal  tubercle,  for  in  the  latter  persistent 
luematuria  and  pyuria,  together  with  increased  frequency  of  micturition,  may  be  present 
before  the  bladder  becomes  infected.  With  renal  tubercle  some  renal  enlargement  and 
pain  will  usually  be  found,  the  ureter  may  be  felt  per  rectum  to  be  thickened,  and  the  blood 
in  the  urine  will  not  be  more  apparent  at  the  end  than  during  the  rest  of  micturition,  unless 
the  bladder  is  also  affected.  When  tuberculosis  attacks  tlie  urinary  organs,  it  is  much 
more  common  as  a  primary  disease  in  the  kidney  tlian  in  the  bladder,  l)ut  the  infection 
finally  spreads  by  the  ureter  to  the  bladder  as  soon  as  a  renal  focus  discharges  into  the 
pelvis  of  the  kidney,  and  may  at  the  same  time  attack  the  prostate  or  seminal  vesicles. 
When  a  tul)erculous  nodule  in  a  vesicle  or  the  prostate  ulcerates  into  the  bladder,  a  sharp 
attack  of  luematuria  may  result.     Great  assistance  may  be  gained   in   the  diagnosis  of 

urinary  tuberculosis  by  a  carefid  cystoscopic 
examination  [Plate  AT,  Fig.  E),  and  by- 
rectal  examination. 

Vesical  Calculus  also  causes  slight  hae- 
maturia,  usually  as  a  few  drops  in  the 
terminal  urine.  The  subject  of  a  calculus 
in  the  bladder  unaccompanied  by  cystitis 
will  complain  of  increased  frequency  of 
micturition  during  the  day  or  during  exer- 
cise, but  is  usually  free  from  micturition 
during  the  night.  There  is  pain  of  a 
pricking  character  in  the  glans  penis  after 
micturition,  and  there  may  fjc  a  history  of 
sudden  stoppage  of  the  stream  during  the 
act.  The  patients  arc  usually  men,  and 
there  may  be  a  history  of  previous  calculi 
in  the  bladder  or  of  attacks  of  renal  colic 
with  the  descent  of  a  renal  calculus  which 
has  not  been  passed  per  urethrani,  but 
which  has  increased  in  size  since  it  entered 
the  bladder.  The  stone  may  be  felt  with  a 
sound,  or  better  still,  seen  by  a  cystoscope, 
when  small  calculi  which  may  be  missed  with  a  sound  may  be  diagnosed  with  certainty 
(Plate  A'l'/,  Fig.  U).  The  a,'-rays  are  also  useful  in  detecting  the  stone  in  many  cases  (Fig. 
185).  If  the  calculus  has  caused  cystitis,  there  will  be  in  addition  ])yuria  and  nocturnal 
micturition. 

Aeiitc  Ct/\titis  is  accompanied  by  haMiiaturia  :  but  the  other  symptoms,  such  as  vesical 
tenesmus,  suprapubic  pain,  and  pyrexia,  together  with  pyuria  and  a  cause  for  the  condition, 
will  point  to  the  disease. 

Bilhariia  Ila'matobia  causes  slight  haematuria,  and  gives  rise  to  symptoms  very  similar 
to  vesical  tuberculosis.  The  discovery  of  the  typical  ova  in  the  urine  (see  Fig.  26,  p.  79). 
together  with  a  history  of  residence  in  an  affected  district,  notably  Egypt  or  certain 
parts  of  South  Africa,  will  make  the  diagnosis  clear.  The  cystoscopic  appearance  in  the 
bladder  of  small,  glistening  yellow  nodules  and  small  areas  of  raised  granulation  tissue, 
is  distinctive  of  the  disease  (Plate  XI  I.  Fig.  K). 
I).  Urethral    Causes. 

Acute  L'rellirilis.  whether  gonococcal  or  septic,  may  cause  blood  to  appear  in  the  urine 
from  the  acute  congestion  of  the  urethral  mucous  membrane.  Tlie  history  and  the 
presence  of  an  acute  urethral  discharge  (p.  181)  make  the  diagnosis  evident. 

The  Iiiipaelion  of  a  Calculus  in  the  urethra  causes  .some  bleeding  from  direct  injury 
to  the  urethral  mucous  membrane.  There  is  usually  retention  of  urine,  so  that  true 
luematuria  uuiy  not  occur  ;  but  the  history  of  sudden  stopjjage  of  the  stream  of  urine  during 
micturition,  with  acute  jtenile  pain,  together  with  the  ])revious  history  of  renal  or  vesical 


aUite  ami  j»hospliato) 
;  S,  ^yinpliyj^is  pubis, 
r.  A/frctl  C.  Jordan.) 


PLATE     XV 


BLADDER      APPEARANCES      SEEN      THROUGH      THE      CYSTOS  CO  P  E 


Cnpurhjhl  FlQ,   D  Fig.   E.         \V.II,-.iHh,„sl,idti,,dd. 


Fill.  .1.     l:luo.|.M:iiiic.|  uriMu  i^Miiiij;  tniui  llii-  iirL-tcr. 

l-'iii.   /(.  -I'urulcnt  urine  issuini,'  from  the  ureter. 

/'"';/.   ('.   -('oriKCHtion  iirolliid  »  ureteric  oridcc  in  culcuIouB 
|..vcliii». 

(^■|V/.«.   /;  ami  i:  are  jriim  sirlchs  k-iiiilli,  .la/iiilird  Inj  lir.  C.  P.   ll'aftrrj,  nj  rli/loii.-; 
l.NDKX  yl--  niAIINOSIS    -■/•„  far,-  ,i.  iK'J 


/'I./.  II.  The  rc^tiM.Kci  inuter  lonunon  willi  .lescOTiiliiib' 
reniii  tuhen'ulosi^. 

Fig.  H. — Tuherculous  ulecrutiou  iirouinl  tlie  ureteric 
orillee  itt  (iesreiiilJTitf  reiml  tuI)ereulosis. 


H.EMATURIA  283 

stone,  will  usually  make  the  diagnosis  clear.  ■  It  is  not  uncommon  in  male  children.  The 
calculus  may  be  felt  from  the  outside  in  the  course  of  the  urethra,  often  at  or  near  the 
meatus,  or  seen  by  an  endoscopic  examination. 

Nanuis  of  the  urethral  mucous  membrane  is  a  rare  but  important  cause  of  severe  and 
recurrent  hematuria,  the  patient  generally  presenting  no  other  symptoms  beyond  the 
spontaneous  bleeding  and  serious  anaemia  resulting  from  it.  The  blood  is  passed  both 
with  and  apart  from  micturition.  There  may  or  may  not  be  bleeding  nievi  elsewhere  :  but 
the  condition  is  precisely  analogous  to  the  small  bleeding  n;evi  of  the  tongue  and  mouth 
that  have  been  described  in  conjunction  with  n;cvi  of  the  skin  by  Osier  and  others.  The 
diagnosis  of  a  urethral  n;cvus  could  scarcely  be  made  with  certainty  except  by  urethroscopy. 

11.  H/EMATURIA    FROM    DISEASE    OF    THE    NEIGHBOURING    VISCERA    INVOLVING 
THE    URINARY    ORGANS. 

The  direct  spread  (jf  ctiiciiioma  of  the  pelvic  organs  may  in  its  progress  involve  the 
bladder,  as  is  not  unconmion  in  the  later  stages  of  carcinoma  of  the  uterus,  vagina,  rectum, 
or  jielvic  colon.  The  infiltration  of  the  bladder  wail  before  actual  ulceration  has  occurred 
is  usually  indicated  by  vesical  irritability,  followed  by  ulceration  and  lurmatinia.  together 
with  the  passage  of  urine  by  the  vagina  or  I'iccal  matter  in  the  urine.  Occurring  as  a  late 
stage  of  carcinomatous  disease,  there  is  usually  little  difficulty  in  the  diagnosis. 

lliematuria  may  occur  during  an  attack  of  tiaiie  appendicitis  from  the  direct  spread 
of  the  inflanmiatory  process  to  the  vesical  wall.  In  some  eases  in  which  the  inflamed 
a|)pendix  turns  downwards  over  the  jjclvic  brim,  it  may  become  adherent  to  the  l)ladder 
or  an  abscess  may  form  in  inuuediate  relation  to  the  bladder  wall.  The  localized  inllam- 
iiiation  of  the  vesical  nuieous  membrane  causes  h;ematuria,  whilst  the  sudden  appearance 
of  a  <|uantiy  of  pus  in  the  urine  has  been  noticed  when  an  appendicular  abscess  has 
ruptured  into  the  bladder.  The  history  of  acute  pain  low  down  in  the  right  iliac  fossa, 
the  ])yrexia,  and  general  symjjtoms  of  peritoneal  inflammation  before  any  urinary  symptom 
was  noted,  will  i)oint  to  the  disease  :  a  rectal  examination  may  reveal  the  inflammatory 
jirocess   in   I  lie   right    pelvic  region. 

Aciilr  ,Siilpiii!<itis  or  Pelvic  Abscess  may  similarly  cause  hiematuria  from  direct  inflam- 
matory extension  to  the  vesical  wall,  but  this  is  rarer  than  in  appendicitis. 

TiibercKloiis  and  Di/seiileric  Vlceration  of  the  Intestine  have  both  caused  h;ematin-ia  by 
the  adhesion  of  the  bowel  to  the  fundus  of  the  bladder  and  the  subseciuent  inllamniatory 
condition  of  the  mucous  membrane.  In  a  case  of  slight  luematuria,  a  cystoscopic  exam- 
ination showed  a  localized  area  of  intense  congestion  at  the  fundus  of  the  bladder  \\ithout 
any  other  vesical  lesion,  and  on  opening  the  abdomen,  a  coil  of  small  intestine,  obviously 
ulcerated  by  tubercle,  was  found  adherent  to  the  peritoneal  aspect  of  the  bladder.  In 
mo^t  eases  the  symptoms  due  to  the  intestinal  disease  woidd  be  apparent. 

III.  HEMATURIA    IN    GENERAL    DISEASES. 

Tlie  sudden  plugging  of  a  renal  vessel  by  embolism  {renal  infarcliini)  is  udl  uiicouuikim 
in  cases  of  endocarditis,  and  may  be  accompanied  by  luematuria.  Tlie  eml)olism  is  seen 
most  eonuiionly  in  infective  endocarditis  :  it  is  indicated  by  sudden  pain  in  the  loin,  followed 
by  ha'inatmia.  The  oeeurrcncc  of  acute  endocarditis  in  tlie  course  of  acute  septic  pro- 
cesses, sueli  as  acnt<-  oslcomycHtis.  pneumonia,  or  acute  ilicuniatism.  is  not  nneonuuon, 
aiul  will  usually  lie  (jiayiioscil  before  there  is  any  e\  ideiiee  <i(  icnal  embohMii.  On  the 
other  hand,  tiiere  are  certain  eases  of  chronic  heart  disease  in  which  the  lirst  e\  idenjc  of 
inlceted  endocarditis  lia\ing  become  superadded  may  be  the  occurrence  of  svidden 
hainaluria  :  and  in  scjinc  sueli  eases  there  may  be  dillieulty  in  excluding  acute  Uright's 
disease,  liceausc  around  each  inlaicl  liici'e  is  lo<-al  aeulc  inllanunat  ion.  and  therefore  the 
urine  will  eoulaiii  I  ubc-e:is|s  as  well  as  lilood  :  llic  ol  hei-  signs  of  iiilcel  i\  c  eiuloeardil  is 
(p.  .-it)  slionid   be  watched   for. 

Leakatiiia  may   be  acconipanic  d    \i\    h.r Iiiiia  ;     but    I  hr   cnlaTiirriicMl    ol'  the   spleen, 

^'eiK  ral  symptoms  of  ainemia.  ami  Mie  tola  I  ariri  (bneicriliai  l>l I   e(iun|s  (p.  •_' I )   Hill   point 

to  the  diagnosis. 

ScaiTji   and    the    \aiious    I'orrns   of   I'l  iii'i  ii  \    (p.    ."i.'i'J)    ma\    ea<-h    lie   aec ipanii'il    by 

ha-maturia.  Iiut  the  i;eneral  s\niploms  of  eaeli  disease  ari'  usuall\  well  iiiarkeil  before 
ha-nialNria   oiiins.  /,'.  //.  .Inccli/n  .S'uyih. 


284  H.EMOCJLOBINURIA 

HEMOGLOBINURIA  differs  from  ]urmatiiria  in  tliat  the  l)loo(i  pigment  is  passed  in 
j-olution  in  the  urine  apart  from  red  corpuscles  ;  small  numbers  of  red  corpuscles,  or  their 
yliosts  may  be  found  microscopically,  but  these  constitute  hematuria  in  association  with 
the  lisenioglobinuria  ;  the  essential  part  of  the  latter  is  the  passage  of  the  blood  pigment 
dissolved  out  of  the  red  corpuscles.  It  gives  the  same  chemical  tests  as  ordinary  blood  ; 
spectroscopically  it  is  almost  as  conunon  to  find  the  bands  of  methcemoglobin  (Fig.  35,  p.  80) 
as  those  of  oxyhfemogiobin  (Fig.  3Q,  p.  80)  ;  by  the  addition  of  ammonium  sulphide  the 
spectrum  is  changed  to  that  of  reduced  haemoglobin  (Fig.  31,  p.  80),  and  by  the  further 
addition  of  a  few  drops  of  concentrated  caustic  soda,  that  of  alkaline  h;cmatin  (Fig.  33,  p.  80) 
is  produced.  The  diagnosis  depends  upon  the  discovery  of  blood  pigments  in  the  urine, 
whilst  the  microscope  shows  no  red  corpuscles,  or  so  few  as  to  be  out  of  all  proportion  to 
the  pigment.  It  is  important  that  the  urine  slioidd  be  examined  fresh,  for  otherwise, 
owing  to  the  disintegration  of  red  cells  after  they  have  been  passed  as  such,  it  is  possible  to 
mistake  for  ha-moglobinuria  that  which  is  really  haematuria.  To  the  naked  eye  the  urine 
may  be  only  just  tinged  with  a  colour  that  suggests  blood  pigment,  or  it  may  be  absolutely 
blood  red.  brown,  nunky,  or  even  black,  as  in  tropical  blackwatcr  fever.  It  is  seldoai 
<le:ir  ;    but  clouded  by  mucus,  casts,  amorphous  masses  of  pigment,  and  debris. 

Iliemoglobinuria  results  from  any  condition  which  leads  to  ha-moglobinaemia  by  laking 
the  red  cor])uscles  within.the  living  vessels.  It  has  been  produced  in  animals  ex])erimentally 
by  the  injection  of  various  ha<molytic  sera  and  other  substances.  It  may  occur  in  man  as 
the  result  of  the  oral  administration  of  certain  chemical  substances,  such  as  potassium 
I'hiorate,  phenylhydrazine,  turpentine,  ether,  carbon  bisulphide,  pyrogallic  acid,  naphthol, 
carbolic,  hydrochloric,  sulphuric,  nitric,  oxalic  and  chromic  acids,  glycerine,  chloroform, 
sul])honal,  \eronal,  trional,  tannin,  saponin,  strychnine,  urotropine,  and  po.ssibIy  quinine  ; 
after  the  inhalation  of  certain  toxic  gases,  notably  carbon  monoxide,  carbon  bisulphide, 
naphtha  vapour,  arseniuretted,  antimoniuretted  or  sulphuretted  hydrogen  ;  after  the 
transfusion  of  certain  foreign  sera,  or  after  the  introduction  of  such  poisons  as  those  of 
snakes,  or  venomous  toads  or  spiders  ;  from  ricin,  abrin,  robin,  crotin,  phallin  ;  after  eating 
poisonous  mushrooms,  toadstools,  or  truffles  ;  after  frostbite  and  extreme  exposure  to 
cold  ;  after  severe  burns  ;  after  large  internal  extravasations  of  blood,  especially  those 
within  the  abdominal  cavity  ;  in  a  few  cases  in  "which  pregnancy  is  associated  with 
toxieniic  symptoms  ;  in  some  new-born  infants,  occasionally  in  an  obscure  epidemic  form  : 
in  association  with  certain  functional  disorders  of  the  vasomotor  system,  especially 
IJaynaud's  disease,  factitious  urticaria  and  angio-neurotic  oedema  ;  after  very  long-sus- 
tained excessive  physical  exertions  and  fatigue  ;  in  association  with  .severe  forms  of  micro- 
bial —or  jiresumably  microbial — tox:emia,  especially  malaria  and  blackwatcr  fever,  and  to 
a  nuich  less  extent  in  severe  sy]}hilis,  tyi)lu)id  fever,  scarlet  fever,  acute  pyogenic  septi- 
caMiiia,  generalized  anthrax,  yellow  fever  ;  Henoch's  purpura  ;  in  certain  cases  of  nephritis  ; 
and  in  that  remarkable  affection  known  as  paroxysmal  haemoglobinuria. 

Although  the  above  list  may  ajipear  formidable,  the  differential  diagnosis  between  the 
ilillVrint  diseases  nientioncd  will  seldom  depend  solely  ii])on  the  presence  or  absence  of 
iuemoglobinuria.  The  chief  importance  of  the  latter,  indeed,  lies  first  in  the  necessity  of 
not  mistaking  it  for  hicmaturia,  and  secondly  in  that  its  occurrence  is  a  sign  that  consider- 
able lurmolysis  is  taking  place  and  that  the  prognosis  is  proportionately  less  good.  It  is 
enough  if  the  fact  that  it  may  be  a  eomi)lication  of  any  t)f  the  above  conditions  is  borne  in 
mind. 

The  (juestion  of  whether  blaclavater  fever  is  due  to  the  effects  of  quinine  in  a  patient 
whose  blood  is  already  susceptible  to  haemolysis  on  account  of  malaria,  or  whether  the 
blackwatcr  is  due  to  a  distinct  and  specific  malady,  has  not  yet  been  settled  ;  the  diagnosis 
is,  however,  generally  obvious,  the  geographical  circumstances  under  which  the  disease 
develops  pointing  to  its  nature. 

Piiro.vi/.siiKil  iKfiiKiglohiiiiiiid  is  rare  :  but  in  (ireat  Britain  it  is  jjrobably  the  commonest 
cause  of  considerable  Inemoglobinuria  without  symijtoms  of  extreme  illness.  It  may  affect 
adolescents  or  grown-u])  peojjle,  males  or  females  :  it  has  ])rol)ably  several  different  ulti- 
mate causes  ;  amongst  the  latter,  however,  previous  syphilis  stands  out  pre-eminently,  and 
probably  heredity  is  also  a  factor.  Males  are  affected  rather  than  females.  The  remark- 
able feature  of  the  malady  is  the  way  in  which  an  attack  can  be  brought  on,  almost  at  will, 
by  certain  immediate  causes,  of  which  the  most  potent  is  exposure  to  cold,  others  being 


PLATE     XVI 


iLADDER      APPEARANCES      SEEN      THROUGH      THE      CYSTOSCOPE 


■api/rii/lil  Fig.    I  Fig.    K.  II'.    7li„r,il,ni  .Slarlls,  ,M. 

I'hi.  ^'.— rcrlunciilutcrl  cari-lnonm  of  the  lilmldrr.  I  Fifi.    /.— Appciirance  ul  the  iircllinil  oiilUo  in  l.iliili'iiil 

l''i[l,   (S. — I'cdilliculiilpil  bjilii  rarciiiulnu  of  the  blaililcr.  ailonomatoUH  GiilarKOiiient  of  tlip  j)rosIiiI»'. 

/'ly.  //. — l.'ric  acid  i-alculus  in  tliC  bladiicr.  |  /'ly.   A'.— liillmrzia   liiulnatobia. 

(/•'i;/.  «  i»  /rem  a  iktici,  bij  Dr.    WalUm,  ami  I'uj.  K   is  niimhiml  bij  kind  inrmisswli  nl  Mr.   II.   .1.    Hi/.w.ii.; 


IXlJKX   OF   iUACIXOSIS— 7'f<  /rl.r  p. 


HAEMOPTYSIS  285 

excessive  exercise  or  mental  excitement.  Soriietimes  the  exposure  has  to  be  considerable 
before  hsenioglobinuria  results  :  on  the  other  hand,  it  may  be  impossible  for  the  patient  to 
keep  his  hands  immersed  in  cold  water  for  any  lenjith  of  time  without  an  attack  ensuing. 
The  lu'ine  may  look  like  blood,  and  the  output  of  pigment,  together  with  considerable 
albuminuria,  persists  for  a  day  or  two  as  a  rule  ;  the  attack  may  be  unaccompanied  by 
other  symptoms,  but  sometimes  there  is  a  shivering  attack  or  an  actual  rigor  with  rise  of 
temperature,  and  a  general  feeling  of  illness,  necessitating  rest  in  bed.  Sooner  or  later,  if 
repeated  attacks  occur,  the  patient  becomes  severely  anaemic,  with  all  the  symptoms  that, 
result  from  such  anspmia.  The  diagnosis  may  be  very  dillicidt  at  the  time  of  the  first  attack, 
but  it  is  relatively  easy  when  the  attacks  recur,  especially  when  there  is  distinct  relationship 
to  some  definite  immediate  cause,  such  as  exposure  to  cold,  to  undue  fatigue,  or  mental 
excitement.  The  main  mistake  to  avoid  is  a  diagnosis  of  lurmaturia,  such  as  a  villous, 
tumour  of  the  bladder  might  cause.  The  way  to  obviate  this  error  is  to  employ  both  the 
microscopic  and  the  spectroscopic  tests  for  blood,  much  pigment  and  few  corpuscles  point- 
ing to  hemoglobinuria.  If  there  is  .still  doubt  as  to  whether  the  patient  has  hfemoglo- 
binuria  or  hsematuria,  a  little  of  his  blood  serum,  obtained  by  venepuncture,  may  be  exam- 
ined in  the  laboratory  for  Eason's  reaction,  a  complex  scrum  test  wliicli  is  positive  in  essen- 
tial luemoglobinuric  cases,  negative  in  otliers  :  the  Wassermann  reaction  would  probably 
be  tested  at  the  same  time  to  determine  wluther  the  cause  of  the  symptom  was  syphilis 
or  not.  Herbert  French. 

HillMOPTYSIS  litirally  means  blood-spitting,  but  clinically  it  is  restricted  to 
expectoration  of  Ijlood  flerived  from  the  lungs,  bronchi,  or  trachea,  to  the  exclusion  of 
blocjd  from  the  mouth,  nose,  or  ])harynx.  Some  include  blood  coming  from  ulceration 
of  the  larynx  under  the  heading  of  ha-moptysis  :  others  do  not.  so  that  the  meaning  of  the 
term  is  arbitrary  :  for  ])ractical  purposes  it  is  sim])ler  to  inehule  the  larynx  as  a  source  for 
luemoptysis. 

The  differential  diagnosis  resolves  itself  into  two  main  |)()rti(>ns.  namely.  (I)  .\  deter- 
mination of  wlielher  the  symptom  has  really  been  lucmo|)tysis  in  the  rtstrieted  sense,  or 
wliethcr  the  blood  has  been  derived  from  the  mouth,  ncjse,  or  pharynx  on  the  one  hand,  or 
the  stomach  on  the  other  ;  and  (II)  If  true  luemoptysis  has  really  occurred,  a  determination 
of  its  exact  cause  in  the  particular  case. 

I.  THE    DISTINCTION    BETWEEN    TRUE    AND    SPURIOUS    HEMOPTYSIS. 

True  haemoptysis —that  is  to  say.  h;cmorrhage  from  the  lungs,  bronchi,  trachea,  or 
larynx  can  sometimes  be  <iistinguislicd  at  once  from  the  spitting  of  blond  derived  from 
the  nose,  mouth,  or  pharynx.  The  occurrence  of  epistaxis,  bleeding  gums,  sore  throat, 
ulcerative  stomatitis,  epithelioma  lingua-,  injury  to  the  mouth,  gingivitis  from  a  carious 
tooth,  or  from  pyorrluea  alveolaris,  pharyngitis,  septic  conditions  of  the  antrum  of  High- 
more,  or  frontal,  ethmoidal,  or  sphenoidal  air-cells,  or  rarer  conditions,  such  as  lupus  of 
the  palate  or  pharynx,  sarcoma  of  the  tonsil  or  of  the  basisphenoid,  may  generally  be 
detected  by  a  careful  examination  of  the  nose,  mouth,  gums,  and  pharynx  :  moreover 
the  blood  in  these  conditions  is  usually  mixed  with  salisa,  watery.  It  is  important,  how- 
ever, to  be  decidedly  guarded  in  cdneluding  that  blood  comes  from  the  moidh,  nose,  or 
throat,  and  not  from  the  lungs:  and'a  earel'ul  examination  for  tubercle  bacilli  should  he 
carried  out  in  every  such  ease,  lesl  the  early  stage  of  [)hlhisis  be  missed. 

The  distinction  betw.'cn  luemoptysis  anil  hainalcmcsis  is  often  easy,  but  somelimes  \-erv 
dillicull.  The  history  may  help,  or  the  palienfs  own  sensations  may  make  him  eerlain 
that  lie  eouglKil  up  the  blood,  and  did  not  vomit  it.  The  follnwing  is  a  sununary  of  the 
iiiiinls  ot  ilislirii'lii)n  :  — 


II.K.MOPTVSIS. 

The  |)atieiit  cimiilis  the  IiIiiimI  ii|i 
I'art  iifllie  blood  is  often  trnlliv 
The    lilodil    niav    oeeiir    bv    itseH,    lull    il    is 

(itliii      MiiMil'    Willi     s|i'iila.      i-e(<i'.Mii/;il.li- 

iiilcriisc(i|iicallv 
Till'  lilnoil  is  :ilk:iliiie  in  ie:ieti<iii 


Il.r.M.\'n:.Mi;sis. 

1.  The  liliioil  is  vomiird 

2.  The  hlooil  is  not  Irotliv 

:!.   The    1)1 1   may   (leeur   by    ilsilt,    but    il    is 

nl'leii  mixed  «ilh  viiiiiil,  reeogiii/.alile 
by  the  preseiiee  of  Ibiiil  parlieles 

1.  The  blood  may  be  Mikaliiie  it  il  is  abiiiulant. 
but  it  is  (il'leii  acid  riiiiii  adiiiixliire  willi 
gastric  jui<e 


ose  H.-EMOPTYSIS 

H.EMOPTV.SIS,  conli,„.e,l.  H.ematemesis,  coiUiuued. 

-,.  Tubercle    bacilli    or    elastic    fibres    may    bt-        :,.  Tubercle  l)iieilli  Will  be  absent 

6  Therrm'w   be  a  previotis  history  of  acute         0.  There    uu.y     i,e    a    definite    history,     with 

rheumatism   or  of  cough  and  night  sweats,  or   without    phys.eal   signs^   P"/"*'"^  ,  !'   ''' 

indicative   of  heart   or   lung  disease,   eon-  gastne  lesxm  or  to  cirrhosis  of  the  Inc. 

firmed  by  abnormal  cardiac  or  pulmonary 

7  Before'The"brood   is   coughed   up,   there   is        7.  Before  the  blood  is  brought  up  there  ma>- 
■      Xn  a  sense  of  tickling  or  gurgling  in  the  be  a  feeling  of  sickness,  nausea,  oppression 

throat,  always  suggestive  of  true  hsmo-  in  the  epigastrium,   faintness,  and  giddi- 

8.  The^  motions    are    not    altered    afterwards   ,      8.  The  motions  are  often  tarry  afterwards 
unless  the  blood  has  been  abimdant  and 
much  of  it  has  been  swallowed,  when  they 

may  be  tarry  as  in  hiematemesis  |  „  t 

n.   Blood-stained"  sputa    may   be   expectorated         9.  There  arc  usually  no  sputa 

for  several  days  after  ;i  severe  attack  .  .         c^      e    ■  i 

10.   A  history  of  cough  .    10.  A  history  of  abdominal  pains  after  food 

XotwithstandiiKT  all  these  points  of  distinction,  however,  one  may  be  misled  unless  the 
patient  can  be  kept  under  observation  for  a  time  ;  moreover,  hsematemesis  may  be  caused 
by  hcemoptysis,  especiallv  when  the  bleeding  takes  place  in  the  night,  the  blood  being 
swallowed  as  soon  as  it  gets  into  the  pharynx  whilst  the  patient  remains  asleep  and  quite 
unconscious  of  the  occurrence.  The  frequency  with  which  ha-moptysis  occurs  during  the 
night  when  the  patient  is  at  rest  is  remarkable  ;  but  in  the  majority  of  instances  the 
incidence  of  bleeding  excites  coughing,  and  the  patient  wakes. 

MUinocrin..  by  the  production  of  blood-spitting  by  gum-sucking  is  diagnosed  upon 
eireunistantial  evidence.  It  has  sometimes  happened  that  a  patient  has  produced  the 
blood  of  fowls  with  the  statement  that  this  has  been  coughed  up— a  fallacy  that  can  be 
detected  by  examining  the  red  cells  under  the  microscope. 

Redness  of  the  sputum  is  not  always  proof  that  the  colour  is  due  to  blood  ;  the 
presence  of  red  cells  should  be  verified  under  the  microscope,  and  the  guaiacum  and 
ozonic  ether  test  also  applied  :  occasionally  patients  have  been  regarded  as  suffering 
from  recurrent  phthisical  ha-moptysis  when  in  reality  the  redness  of  the  sputum  has  been 
due  to  infection  of  the  respiratory  passages  by  relatively  unimportant  pigment-producing 
micro-organisms,  generally  of  the  Bacillus  prodigiosus  type  :  this  source  of  fallacy  is 
to  be  avoided  by  having  careful  bacteriological  examinations  of  the  sputum  made  in  all 
cases  that  are  not  ijcrfcctly  straightforward. 

II.  DETERMINATION    OF    THE    CAUSE    OF    THE    HAEMOPTYSIS. 

Having  arrived  at  the  conclusion  that  a  patient  has  had  haemoptysis,  the  next  point 
is  to  ascertain  its  cause.  Bv  far  the  commonest  causes  of  ha-moptysis  are  phthisis  and 
mitral  stenosis.  The  heart  aiid  lungs  need  jjarticular  examination  therefore,  and  the  family 
and  personal  history,  both  as  to  acute  rheumatism  or  chorea,  and  as  to  consumption,  ina> 
assist  If  there  are  no  abnormal  physical  signs  in  the  thorax,  it  does  not  follow  that 
phthisis  is  absent— even  phthisis  wiih  cavitation  may  exist  without  any  definitely  abnormal 
physical  signs  being  detected  :  microscopical  examination  of  the  sputum,  therefore,  both  for 
tubercle  bacilli  and  for  elastic  fibres,  should  never  be  omitted,  especially  after  the  hiemo- 
i)tysis  has  ceased  ;   repeated  examinations  may  be  required  if  the  first  proves  negative. 

"    .\lthoiigh  these   are   the  commonest,   there  are  a  great   many   other  causes,   as   the 
following  tables  indicate  : — 

A.  Haemoptysis   due    to    Changes    in    the  Lungs : — 

1.  Phthisis:  (<;)   Early;    (fc)  Later  5.   Injury  to  the  chest  : 

"    Cirrhosis   of   lung  :     pneuniouoeoni-  ;  («)  Blows  upon  the   chest   wall 

osis  ■  1  (*)  t^ractured  rib 

(a)  Knife-grinder-s  Uim;  I  (c)  Exploratory  needling 

(6)  Stonemason's  lung  '  (rf)  At  the  end  of  paracentesis  thoracis 

3.  Cardiac    disease,    especially    mitral  !  6.  Lobar  pneumonia 

stenosis  "i-  Bronchopneumonia 

4.  Violent     coughing     efforts,     as     in  i  8.  .Seiitic    pneumonia,    with    or    without 

whooping-cough  or  bronchitis  abscess 


H.EMOl'TYSIS 


.1.  II.?;moi'tvsis  due  to  Changes  ix  the  Lungs,  continued  :- 


9.   (ianjrrcne  of  the  lung 
10.  Infarction  of  the  huij;  ; 

(a)  Enihohf  ;    (b)  Thrombotic 
n.  Neoplasm    of    the    hmrr.     whether 
primary  or  secondary  : 

(fl)  Sarcoma  :    (6)  Carcinoma 
12.  Sporotrichosis  of  the  luni>  : 

(a)  -Aspergillosis  ; 

(6)  .Actinomycosis 

((■)   Other   forms 


13.  Aortic     aneurysm     pressing     on     and 

opening  into  the  lung 

14.  Em])yema   bursting   through    the    lung 
.15.  Hcjiatic  abscess   bursting  tlirougli  the 

(iiapliragm  into  the  lung 
IG.  Hydatid  cyst 
17.  Primary   atheroma   of  the    pulmonary 

arterioles 


B.  Haemoptysis    due    to    Changes   in    the    Bronchioles,    Bronchi,   or    Trachea : — 

1.  Uronchitis  : 

(a)  .Acute  :   {b)  Chronic  ;  (c)  Plastic 

2.  Uroncliorrhrra 


3.  Hronchieetasis 

4.  .Aortic   aneurysm   opening   into   the 

trachea  or  a  bronchus 
.J.   I'lceration     of    the     trachea     or     a 
bronchus  : 
{(I)  Tertiary  svpliilitic 
(6)  .Maligiuint' 

(i)  I'rimary      epithelioma      of 
bronchus 


(ii)  Invasion    of   a  bronchus  by    a 
mediastinal  sarcoma,  lympho- 
sarcoma,  frsophageal    epithe- 
lioma, or  other  neoplasm. 
((■)  Secondary  to  a  foreign   body,    such 
as  a  button,  a  fruit-stone,  a  tooth, 
etc.  ;   or  to  a  tracheotomy  tube 
(d)  .Secondary  to  a  caseous  or  calcareous 
bronchial  gland 
G.  Parasitic  infection  by  Disloiiiii  jmlmonale 
wcslermanni 


C.  Haemoptysis   due    to    Changes    in    the    Larynx : 


.Acute   laryngitis 
I'uberi'uious   ulceration 
Syphililic  ulceration 
iialignant   idceratioii  : 
(a)  Kpitheliomatous 
(6)  Sarcomatous 
Post-typhoidal   ulceratii 


(>.    l'ost-<liplitheritlc    ulceration 

7.  Injinv    to    the     larynx,    by    a    blow 

throat  grip,  a  cut   thoat,  Intuliati 
or  operation 

8.  Lupus  of  the  larynx 

9.  Variolous  ulceration 

10.  Leprosy  of  the  larynx 

11.  Angioma  of  the  larvnx 


D.  Haemoptysis   due    to   Changes    in    the    Blood  :- 


1.  Purpura  and   its  various   causes  (p 

2.  Scurvy 

3.  Spleuomcdullary  lcuk:cniia 

4.  Lymphatic  leuka-inia 

E.  Doubtful    Causes    of    Haemoptysis : 

1 .  (iranular   kidney 

2.  .Arteriosclerosis 

3.  Vicarious  nienstniallon 


.'>.   Pernicious  an:emia 
(i.   Lympliadenonui 

7.  Malignant   types  of  specific  fevers,    such 

as   variola  or  measles 

8.  Haemophilia 


Keeurrciit  haemoptysis  In  ar 
jeets  (.Vndrew  Clark) 

Ilainoptysis  in  apparently 
healtliy  young  subj<'ets 


Copious   Haemoptysis  I 

trachea,  hniiu-lius.  or  lung  : 
cavilfi  or  jililhisiidl  votnica. 


s  only  two  causes,  namely,  miihiic  iif  an  tiorlic  aneurysm  into 
and  nipliirc  (if  (in  (inciiri/sni  of  a  /nilnioiiari/  arteriole  in  a  lung 
The  former,  when  once  it  causes  severe  lia'ni()|)tysis,  nearly 
always  proves  iniiiiediately  fatal  ;  the  latter  nuiy  also  cause  rapid  death,  hut  soinetinics  the 
severe  bleedinj;  stops,  and  recovery  inuy  ensue.  In  eilher  case,  liowe\(r,  there  is  ol'Icn  a 
stage  of  slight  or  prerrionitorN  bleeding  for  <lays,  weeks,  or  c\cn  inonlbs  before  the  liiial 
rupture  occurs. 

There  arc  sonu'  causes  of  lui-iiio|)tysis  in  the  above  list  about  which  little  need  be  .said. 
The  whole  of  flronp  K.  for  instance,  is  open  to  much  doubt  :  it  is  true  that  apparently  .sound 
young  subjects  may  ba\e  transient  haemoptysis  and  lu'vcr  de\(lop  phthisis  :  on  the  other 
hand  a  certain  proportion  of  such  cases  do  Ix-eoiiu-  consumptive  later.  ,so  llial  the  prcsuinp- 
tion  is  that  in  all  of  tlicni  the  ha-inoptysis  really  has  a  tuberculous  origin,  cure  resulting 
rapidly  in  some,  but  mit  in  others.  Particular  care  should  be  taken  in  the  examination  of 
the  sputum  ami  of  the  chest  by  the  ordinary  physical  methods,  and  perhaps  by  the  ,r-rays 
also,  and  <'ven  although  the  cause  of  the  ha'inoptvsis  may  not  be  dctcrmlTU'd  precisely,  the 
patient  would  be  well  iid\ised  to  live  as  healthily  as  possible,  h'sl  a  further  stage  of  ])htliisis 
<ievclop.  The  same  applies  to  so-called  \  Icarious  nicnsl  ruation  :  and  in  not  it  few  cases  in 
wliicli  the  luenioptysis  luis  been  atlribuled  lo  llic  arlbrilie  dialbesis,  lo  arteriosclerosis,  or 


•28S  H.^ilMOPTYSIS 

to  renal  lesions,  the  cause  may  really  be  an  intercurrent  infection  of  the  lung  by  tubercle 
bacilli  even  in  middle-aged  or  elderly  people. 

Causes  in  Group  D  seldom  give  rise  to  extensive  true  haemoptysis,  though  there  may  be 
nnich  ei)istaxis,  bleeding  from  the  gums,  and  so  on.  The  diagnosis  between  the  different 
conditions  in  this  group  will  be  found  elsewhere. 

Phthisis  is  by  far  the  commonest  cause  of  haemoptysis.  It  may  be  tlie  very  first  sign 
of  the  disease,  it  may  be  the  last,  or  it  may  occur  at  any  intermediate  stage.  The  amount  of 
blood  brought  up  is  very  variable  ;  the  sputum  may  be  only  streaked,  or  a  pint  or  more  may 
stream  from  the  mouth.  In  advanced  stages  the  diagnosis  is  not  difficult.  There  is  the 
history  of  cough,  loss  of  appetite  and  weight,  night  sweating,  and  expectoration  ;  there  are 
the  wasting  and  flattening  of  the  chest  wall,  especially  above  and  below  the  clavicles,  often 
more  on  one  side  than  the  other  :  the  deficient  movement  on  respiration,  the  imequal  tactile 
vocal  fremitus,  the  impairment  of  note,  over  one  upper  lobe  more  than  over  the  other,  with 
the  bronchial  breathing,  consonating  rales,  bronchophony  and  pectoriloquy  at  one  apex, 
with  signs  of  similar  but  less  advanced  disease  at  the  other.  Detection  of  pus  cells,  tubercle 
bacilli,  and  perhaps  elastic  fibres  in  the  sputum,  is  conclusive.  Ha-moptysis  may,  however, 
be  the  earliest  evidence  of  phthisis  :  the  diagnosis  is  then  difficult,  for  the  physical  examina- 
tion may  not  reveal  any  abnormal  signs.  Particular  stress  may  be  laid  upon  greater  promi- 
nence of  one  clavicle  than  of  the  other,  prolongation  of  the  expiration,  and  the  constant 
presence  of  one  or  more  apical  clicks,  or  rales,  perhaps  brought  out  only  on  coughing.  In 
some  cases  the  mottled  shadows  seen  with  the  a'-rays  may  assist  the  diagnosis  {Pig.  41, 
p.  103),  although,  taken  by  themselves,  they  may  be  misleading  ;  tubercle  bacilli  may  be 
found  in  the  sputa  quite  early,  so  that  a  careful  examination  even  of  the  most  insignificant 
amount  of  sputimi  must  always  be  made  before  a  definite  opinion  as  to  the  cause  of  the 
hsmoptysis  can  be  given.  In  the  early  stages  of  phthisis  hirmoptysis  results  from  local 
inflammatory  hypersemia  with  rupture  of  capillaries  ;  the  amoimt  of  blood  expectorated  is 
then  usually  small,  and  it  may  amount  only  to  streaking  of  the  sputum.  A  little  later, 
small  vessels  may  themselves  become  inflamed  and  softened,  or  directly  invaded  by  the 
tuberculous  process,  consequently  rupturing  if  any  extra  strain  is  suddenly  put  upon  them, 
— for  instance,  during  attacks  of  coughing.  This  may  lead  to  a  more  profuse  haemoptysis 
even  quite  early  in  the  disease.  When  the  malady  is  more  advanced,  caseation  and  break- 
ing down  of  lung  tissue  may  lead  to  softening  of  the  external  wall  of  a  considerable  branch 
of  the  ]5ulmonary  artery,  resulting  in  an  aneurysmal  bulge,  which,  if  thrombosis  does  not 
occur  within  it,  will  sooner  or  later  rupture,  and  cause  a  profuse  and  possibly  fatal  litemor- 
rhage. 

Cirrhosis  of  the  Lung — Pneumonoconiosis,  Miners'  Phthisis — is  a  jjarticular  variety 
of  fibrosis  due  to  tlic  inhalation  of  irritating  particles,  especially  amongst  workers  at  certain 
occupations.  Coal  miners  seldom  get  it  ;  although  their  limgs  become  packed  with  carbon 
— aiitliracosis — these  particles  do  not  seem  to  inflame  the  tissues.  Knife-grinders  sufler 
from  it — siderosis  ;  so  do  workers  in  certain  limestone  quarries,  rock-drilling  gold  mines, 
and  diamond  mines — silicosis.  The  chief  point  in  the  diagnosis  is  the  history  as  to  occupa- 
tion ;  there  is  much  doubt  as  to  whether  these  conditions  are  not  really  of  a  chronic  tuber- 
culous nature,  and  tubercle  bacilli  should  be  looked  for  in  all  these  cases,  whilst  the  blood 
should  also  be  tested  for  Wassermann"s  reaction,  because  recent  evidence  points  to  syphilis 
being  another  im])ortant  factor  in  many  of  these  patients.  The  haemoptysis  is  far  less 
frequent   and   less   abundant   than  it  is  in  ordinary  phthisis. 

Mitral  Stenosis  is  the  second  commonest  cause  of  h;emoptysis.  Other  forms  of  heart 
disease  seldom  lead  to  it  direct,  though  mitral  regurgitation  may  do  so  occasionally,  and  so 
may  aortic  stenosis  or  regurgitation  when  they  have  caused  secondary  mitral  regurgitation. 
Coiiaenital  heart  disease,  unlike  the  acquired  forms,  is  so  liable  to  lead  to  phthisis  that  any 
hicmoptysis  associated  with  it  would  arouse  suspicions  of  the  latter.  Fungaling  endo- 
carditis may  also  cause  hsemoptysis,  but  as  the  result  rather  of  the  septic  state  or  of  infarc- 
tion than  of  the  valvular  lesion.  Mitral  stenosis  is  the  chronic  valvular  heart  disease  par 
excellence  to  produce  haemoptysis,  and  it  may  do  so  either  when  there  is  complete  compensa- 
tion or  when  there  is  evidence  of  failure.  When  compensated,  the  right  ventricle  pumps 
blood  into  the  lungs  with  vigour,  and  causes  great  rise  of  pressure  in  the  pulmonary  vessels 
because  the  blood  cannot  escape  freely  through  the  stenosed  mitral  orifice.  This  is  indicated 
clinically  by  accentuation  or  reduplication  of  the  second  sound  in  the  second  left  intercostal 


HAEMOPTYSIS 


289 


space  close  to  the  sternum.  At  the  impulse,  which  is  often  not  materially  displaced,  the 
first  sound  will  have  a  slapping  character,  and  it  will  generally  be  preceded  by  a  shorter  or 
longer  presystolic  rmnbling  bruit.  The  latter  is  so  short  sometimes  that  it  may  be  over- 
looked, but  there  may  be  a  history  of  chorea  or  rheiunatism  to  assist  the  diagnosis,  and  the 
accentuated  pulmonary  second  sound  will  arouse  suspicion  in  other  cases,  particularly  if 
the  precordial  impairment  of  resonance  is  increased  upwards  and  to  the  right,  but  not  much 
to  the  left.  The  result  of  the  great  rise  of  blood-jjressure  in  the  lungs  is  that  capillaries 
rupture  from  time  to  time  ;  the  resultant  hicmoptysis  alarms  the  j)atient.  but  it  is  really  no 
sign  of  danger  ;  sometimes  patients  have  this  h;emoptysis  whenever  the  heart  is  at  its  best, 
losing  it  again  when  failure  threatens.  Far  diflerent  is  it  when  blood-spitting  occurs  in 
failing  cases  of  mitral  stenosis  ;  it  is  then  generally  due  to  infarction  or  to  pulmonary 
"  apoplexy."  The  infarction  is  less  often  due  to  embolism  from  an  ante-mortem  clot  in  the 
right  auricular  a])pendix  or  other  part  of  the  right  side  of  the  heart  than  it  is  to  thrombosis, 
which  results  as  follows  :  atheromatous  degeneration  of  the  pulmonary  arterioles  is  brought 
about  by  the  greatly  increased  tension  within  them  :  rupture  of  small  branches  of  such 
degenerated  pulmonary  arterioles  gives  rise  to  "  apoplexies."  and  the  alteration  in  the 
tunica  intima  due  to  the  atheroma,  together  with  the  deficient  rate  of  blood-flow,  strongly 
predispose  to  thrombosis  and  consequent  infarction.  An  embolic  infarct  occurs  suddenly, 
and  causes  acute  pain  in  the  corres])onding  part  of  the  thorax,  orthopnoea,  increased  cyanosis, 
dyspncea,  and  ha-moptysis  ;  a  thrombotic  infarct  arises  gradually,  and  causes  hicmoptysis 
without  the  other  symptoms. 

Violent  Coughing  efforts,  as  in  whooping-cough,  or  emphysema  and  bronchitis,  may 
cause  such  pressure  of  the  frsenum  lingua?  against  the  teeth  as  to  abrade  its  surface  and  lead 
to  the  expectoration  of  blood-streaked  salivary  sputum — spurious  haemoptysis  ;  it  is  said 
that  they  c^n  also  produce  true  haemoptysis  ;  this  is  possible,  but  before  blood-spitting  in 
any  given  case  is  attributed  merely  to  violence  of  coughing,  every  care  should  first  be  taken 
to  exclude  both  tubercle  and  heart  disease. 

Injury  to  the  Chest  is  not  an  uncommon  cause  of  blood-spitting.  There  need  h;!\  e 
been  no  fracture  of  a  rib —a  severe  blow  on  the  thorax  sometimes  sulfices.  The  only  dilli- 
culty  in  the  diagnosis  is  to  be  sure  that  the 
injury  is  the  sole  cause,  and  that  it  has  not 
merely  been  the  final  factor  in  |)roducing 
luemorrhage  from  a  latent  tuberculous  focus 
or  an  aneurysm. 

In  Lobar  Pneumonia  the  amount  of  blood 
expectorated  is  slight  in  the  majority  of 
cases;  the  sputum  is  thick,  viscid,  tenacious, 
and  generally  there  is  no  more  blood  than  will 
give  it  a  rusty  or  russet -brown  colour.  II 
may,  however,  be  bright  red,  and  in  a  lew 
cases  copious  enough  to  be  in  itself  alarming. 
The  didieulty  then  is  to  distinguish  it  from 
phthisis,  or  from  lobar  pneumonia  superposed 
upon  phthisis.  The  diagnosis  is  often  ol)vious 
enough  ;  but  sometimes,  notwithstanding  the 
acute  onset,  the  continued  fever,  the  high 
ratio  of  the  respiration  to  the  pulse-rate,  the 
viscitlity  of  the  sputum,  the  presence  of  cap- 
sulated  diplococci  in  it,  the  abtiormal  physical 
signs,  and  the  absence  of  chlorides  from  the 
subse(|uent  course  of  the  case  has  been  watched. 


/••/-/.  W:  -Skiiuin 
..(  left  lun','  (A):  1 
liuljlilc  (C);    liver  (■( 


1  of  lohiir  iiiidimonU-  consoh.lM 

■mill   ri-lit    luiii;  (B):    ■^■■i.^u-ir 

(Ilil  In.  Alfreil  C.  Jnrilaii.) 


urine,    serious    doubt    remains    until    I  he 
When  tlie.r-ra\s  can   be  iitili/ed   at    the 


bedside,  a  skiagram  may  s( 
anil  lobar  piuiimnMia  (/■'/■;. 
Bronchopneumonia  is 
children  at  an  age  when  lut 
ally  either  inllucnzal,  or  eh 
operations  under  anicstlu-lics, 
tongue,    or    otitis    media    with 


irve  to  diirei-eiiliale  between  phthisis  (/•'(;; 


H, 


Mielnn 

l.-ili). 

a  rare  cause  of  lia'Mioptysis.  because  the  disease  mainly 

spitting  occurs.      In  older  patients  linmeliopneuinonia  i' 
e  due  to  the  inhalation  of  sept  ie  particles  from  tl 


p.  io:;) 

alTeels 

gener- 

mout  h  alter 


ir   111   a: 
lateral 


(leiation   with   such 
siims    llironilxisis. 


i-plie 


as  epithelioma   of  th< 
liroiieliopneumoni.'i     i 
1!) 


290  H.-EMOPTYSIS 

diagnosed  by  reason  of  its  being  a  hing  complication  of  some  otber  malady  likely  to  give 
rise  to  it.  Influenzal  broncho]3neimionia  is  apt  to  cause  characteristic  sticky  rales  at  the 
bases,  with  less  pyrexia  but  more  asthenia  than  does  lobar  pneumonia  ;  and  the  minute 
Bacilli  iiijliienza'  may  be  foimd  in  the  sputiun  in  large  numbers.  If  the  signs  are  apical 
rather  than  basal,  it  will  be  ilillicult  to  be  sure  that  the  condition  is  not  tuberculous,  except 
by  watching  the  case,  and  lindiug  that  ra])i(l  and  complete  resolution  and  recovery  ensue. 

Gangrene  of  the  Lung,  due  to  whatever  cause  (p.  259).  is  characterized  by  the  extreme 
stench  of  the  breath  and  sputa.  The  only  conditions  which  ])roduce  similar  stench  are 
foetid  decomposition  of  the  retained  s|)utum  in  bronchiectatic  cavities  or  old  phthisical 
vomica",  or  similar  dccom|)ositi(in  in  the  ])us  of  an  empyema  which  has  ruptured  through 
the  lung,  and  which  empties  out  its  contents  periodically.  Gangrene  of  the  lung  can  be 
differentiated  from  all  these  by  the  pulmonary  elastic  fibres  to  be  found  in  the  sputum, 
and  by  the  history  being  shorter  than  woidd  probably  be  the  case  with  the  others. 

Infarction  of  the  Lung,  embolic  and  thrombotic,  has  already  been  mentioned  in 
connection  with  licart  disease,  its  most  fre(iuent  cause.  It  only  remains  to  add  that  it  may 
also  occur  as  the  result  of  embolism  secondary  to  thrombosis  of  systemic  veins,  infective 
endocarditis  of  the  pidmonary  or  tricuspid  valves,  or  from  primary  thrombosis  in  some 
blood  diseases,  such  as  leucocythsemia.  A  large  embolus  causes  sudden  death  without 
lia'inoptysis  ; '  a  smaller  one  may  give  rise  to  sudden  acute  pain  in  some  part  of  the  chest, 
and  a  local  patch  of  crepitant  rales  with  a  pleuritic  rub,  and  perliaps  impairment  of  percus- 
sion note  with  bronchial  breathing.  Hscmoptysis  associated  with  such  physical  signs  and 
accompanied  by  evidence  of  endocarditis  or  venous  thrombosis  would  suggest  an  infarct  ; 
difficulty  arises  mainly  when  there  is  no  obvious  phlebitis  in  the  case,  when  the  vein  affected 
is  deep-seated — in  the  pelvis,  for  instance,  after  childbirth  or  some  operation.  The  diagnosis 
is  not  so  difficult  when  there  have  been  repeated  sudden  acute  pains  in  different  parts  of  the 
chest,  each  followed  by  a  little  pyrexia  and  sometimes  by  ha'mo|)tysis,  due  to  rejieated 
small  emboli. 

Carcinoma  and  Sarcoma  of  the  Lung  (Fig.  42,  p.  105)  are  usually  secondary.  Tlie 
diagnosis  is  sometimes  oli\ious.  sometimes  very  obsciu'c  indeed.  The  primary  seat  of  the 
growth  may  l)e  near  the  hmg.  for  instance  in  a  bronchus,  the  a"sophagus,  breast  or  media- 
stinal glands  ;  or  it  may  be  distant,  in  the  stomach,  or  a  bone,  and  so  on.  The  sputum  may 
be  merely  blood-tinged,  or  it  may  be  dark  like  red  currant  jelly  ;  occasionally  the  h.Tmor- 
rhage  is  profuse.  A  large  number  of  cases  of  malignant  disease  in  the  lung  are  accompanied 
by  ))leinitie  eflusion.  and  indess  the  existence  of  a  primaiv  neoplasm  elsewhere  is  known, 
growth  may  not  at  first  be  suspected.  If  aspiration  is  performed,  the  fluid  is  generally 
found  to  contain  blood  :  indeed,  the  discovery  of  blood-stained  pleural  fluid  at  a  first  tapping 
of  a  case  that  is  not  absolutely  acute,  is  always  very  suggestive  of  neoplasm  ;  microscopically 
large  cancer  cells,  with  aty|)ical  mitosis,  or  even  fragments  of  new  growth,  may  be  foimd 
either  in  the  s])utum  or  in  the  ])leuritic  exudate  to  clinch  the  diagnosis.  Increasing  vari- 
cosity of  the  veins  on  the  chest  wall,  with  reversal  of  the  blood  current  in  them,  also  points  to 
intrathoracic  growth  obstructing  the  superior  vena  cava.  The  neoplasm  may  also  stenose  a 
bronchus,  leading  to  unilateral  deficiency  of  movement  and  tactile  vocal  fremitus,  impair- 
ment of  note,  and  deficient  or  absent  breath-sounds,  with  or  without  faint  bronchial  breath- 
ing and  crackling  rales  ;  whilst,  accompanying  these  physical  signs,  no  tubercle  bacilli 
would  be  found  in  the  s|nitum.  and  yet  the  weakness  and  emaciation  would  be  progressive. 

Sporotrichoses  of  the  Lung  are  being  recognized  with  increasing  fretiuency.  Hither- 
to they  have  generally  Ijeen  mistaken  for  phthisis.  They  are  due  to  various  moulds  of 
the  nature  of  Actinomi/ces,  Aspergillus  niger,  and  others,  and  the  diagnosis  depends  upon 
bacteriological  investigations  of  the  sputum  by  cultural  methods.  \Vhen  no  tubercle 
bacilli  can  be  detected  on  repeated  examination  in  the  ordinary  way.  the  possibility  of- 
sporotrichosis  should  be  borne  in  mind,  particularly  if  the  patient's  occupation  leads  to 
contact  with  vegetable  products  such  as  hay  or  straw,  grain,  bird  foods,  or  even  cotton,  as 
in  file  case  of  seamstresses  and  tailors. 

Aortic  Aneurysm  far  less  often  opens  into  the  hmg  itself  than  it  does  into  a  bronchus  ; 
the  symptoms  are  similar  in  either  case,  and  if  the  history  is  long  the  diagnosis  will  already 
have  been  made  on  account  of  some  other  symptom  than  hamioptysis,  especially  pain  in  the 
chest  or  in  the  back.  The  ,r-rays  are  a  \ahiable  means  of  deciding  the  diagnosis  {Fig.  100, 
p.  209).     Two  points  are  worthy  of  jjarticular  attention,  and   these  are  :    first,  that  the 


H.B.MOrTYSIS 


rupturing  of  an  aortic  aneurysm  into  a  bronchus,  with  copious  and  rapidly  fatal  haemoptysis, 
may  be  the  very  first  sign  that  anything  is  wrong  ;  and  secondly-,  that  in  not  a  few  cases 
there  may  have  been  slight  hsemoptysis  and  blood-streaking  of  the  sputum  for  weeks  or 
months  before  the  fatal  rupture  ensues  ;  these  preliminary  slight  attacks  of  hicmoptysis  are 
])robably  due  to  erosion  of  small  vessels  in  the  wall  of  the  bronchus,  and  if  the  aneurysm  is 
jjartially  obstructing,  say,  the  left  upper  l)n>nchus,  so  as  to  produce  inipairnient  of  note 
over  the  left  apex,  with  a  few  rales  there,  and  hiemoptvsis.  it  is  clear  tliat  a  mistaken  dia- 
gnosis of  phthisis  might  readily  be  made.  Tubercle  bacilli  will  be  persistently  absent  from 
the  sputum,  there  will  very  likely  be  a  previous  history  of  syphilis,  hard  manual  work,  and 
perhaps  drinking  :  without  the  .r-rays  to  show  the  pulsating  shadow  of  the  aneurysm,  how- 
ever, the  correct  diagnosis  may  be  missed,  and  even  when  the  fatal  ruptiu-e  occurs,  the 
condition  may  still  be  erroneously  attributed  to  phthisis,  unless  a  post-mortem  examination 
is  made. 

Empyema  bursting  througli  tlie  Lung  may  or  may  not  cause  hanioptysis  :  tlie 
main  features  of  the  case  will  generally  be  an  obscure  febrile  illness  subsequent  to  pneu- 
monia, followed  by  a  sudden  eruption  of  pus  from  the  respiratory  passages,  and  a  repetition 
of  a  similar  copious  expectoration  of  pus  at  intervals  ;  in  many  cases  there  are  comparatively 
few  abnormal  ])Iiysieal  signs,  for  had  the  eiii])ycma  not  been  hidden  away  deeply  in  the 
thorax,  its  existence  would  have  been  diagnosed  earlier,  and  it  would  have  been  relieved  by 
operation  before  it  burst  into  the  lung. 

A  Hepatic  Abscess  that  has  burst  through  the  lung  is  a))t  to  give  rise  to  anchovv- 
saucc-coloured  sputum  which  is  characteristic  :  no  amoebir  may  be  discovered,  and  the  pus 
will  very  likely  be  sterile  :  the  dia- 
gnosis is  generally  based  upon  the 
history  of  residence  in  the  tropics, 
l)ossibly  of  an  attack  of  amoebic 
d.vscntery,  and  of  hepatic  symptoms, 
pyrexia,  and  rigors  previous  to  the 
expectoration  of  the  bIof)d-stained 
pus.  'l"he  abscess  occurs  on  the  right 
side  more  often  than  on  the  left,  and 
till  re  may  be  the  t.v]jical  dome-shaped 
dullness  at  the  base  of  the  right  lung. 

Hydatid  Cysts  are  much  rarer  in 
EurojK'  than  in  .\ustralia  and  New 
Zealand  :  those  of  the  lung  are.  as  a 
rule,  secondary  to  hydatid  of  the  liver. 
They  may  give  rise  to  neither  signs  or 
.symptoms  :  on  the  other  li.ind.  Ilii\ 
may  cause  ha-moptysis.  ;mi(I  plilliisis 
may  he  sinuilated.  The  ,i'-rays  are 
very  ellieieiit  in  detecting  their  spheri- 
cal shadows  (/'(■«.  i:{r).  The  blood 
may  exhibit  eosinophilia  or  t  he  spccili  ■ 
hydatid  serum  reaction.  ' 

Primary  Atheroma  of  the  Pul- 
monary Arterioles  is  sn  i:uc  as  |o  be 
undiagnosable.  There  is  no  relation- 
ship between  systemic  and  pulmonary 
atheroma,  and  the  cormiionest    cause  ( 


I  of  tlif;  ujiinT  loho  ot  the  left  luvn,'. 


f  the  latter  is  mitral  stenosis,  as  described  above. 


Haemoptysis  due  to  chanftes  in  the  Bronchioles,  Bronchi,  and  Trachea,  as  illsiinet 
from  clianges  in  llie  lung,  have  lo  some  extent  been  ineideidallv   cdnsidrn'd  willi  Ihe  latter. 

Bronchitis  should  never  be  diagnosed  as  the  cause  of  liainnplysis  uiilil  phlhisis  and 
mitral  shiinsis  liiive  been  llion>uglily  excluded. 

Bronchorrhoca  is.  in  most  respects,  only  a  variety  of  bronchitis. 

Bronchiectasis  may  be  associated  with  recurre?it  slight  or  excn  scncic  liainoplvsis 
somelimes.  or  when   llic   hriiMriiiiTlasis   is  dui-   Id  cibsl  ruci  ion  ot  a   brunclnis   l>\    :i   llioraeic 


292  HAEMOPTYSIS 

aneurysm  there  may  be  copious  and  fatal  haemoptysis,  as  described  above.  Bronchiectasis 
seldom  occurs  apart  from  fibrosis  of  the  lung  ;  indeed,  fibroid  lung  is  commoner  than  bron- 
chiectasis ;  when  fibrosis  and  bronchiectasis  occur  together  and  affect  one  lung  in  particular, 
the  diagnosis  is  relatively  eesy,  for  there  is  deficiency  of  bulk,  movement,  and  resonance, 
tactile  vocal  fremitus,  vesicular  murmur,  and  voice  sounds  over  the  affected  lung  ;  the 
heart  is  materially  displaced  towards  that  side  :  niuuerous  loud  crackling  rales,  with  or 
without  bronchial  breathing,  bronchophony,  and  jjectoriloquy,  will  be  heard  over  scattered 
patches  of  the  affected  lung,  wliilst  in  the  intervening  areas  there  will  be  little  to  be  heard 
at  all  ;  the  rales  will  be  brought  out  best  when  the  patient  coughs  ;  the  lung  on  the  other 
side  may  give  relatively  normal  signs.  Clubbing  of  the  fingers  may  be  extreme.  The 
diagnosis  of  fibroid  lung  and  bronchiectasis  itself  is  not  complete,  however,  until  the  precise 
cause  of  the  latter  has  been  ascertained  ;  sometimes  so  complete  a  diagnosis  is  not  possible. 
The  following  is  a  list  of  the  chief  causes  of  the  condition  : — 

1 .  Causes  in  the  lung  : — 

Congenital  atelectasis  l    Delayed    resolution    of    lobar       Chronic  tuberciilosis 
Recurrent  attacks  of  pneumonia  Sporotrichosis 

bronchopneumonia  |    Pncumonoconiosis  Recurrent  l)ionchitis((loul)tfiiI) 

2.  Causes  which  act  by  partially  stenosirig  a  bronchus  : — 

(a).  Causes  within  the  broneluis  : —  (t).   Invasion  of  the  bronchus   I'roin  without  : — 

A  foreign  body  ■\ortic  aneurysm 

Inspissated  bronehitic  mucus.  >Iediastinal  new  growth 

Hodgkin's  or  lymphadenonuitous  ghiiuls 

(6).  Causes  in  the  wall  of  the  bronchus  :  Caseous  bronchial  glands 

-      Syphilitic  stenosis  -\  liypertrophied  left  auricle  in  some  eases 

Primary  epithelioma.                     |  of  mitral  stenosis. 


3.  Causes  which  have  long  compressed  the  lung  from  llic  pleural  side  : — 

Subdiaphragmatic  abscess 
Hepatic  tumour 
Splenic  tinnoiir. 
lymph  I    Ascites 


Pleuritic  effusion  l    Empyema 

Pleural   effusion  A  large  heart 

Thick     pneumonic  Pericardial  elTusion 


There  will  be  no  need  to  discuss  each  of  these  here  ;  if  the  different  possibilities  are 
kept  in  mind,  a  probable  diagnosis  can  be  made  fairly  easily  in  most  cases.  Amongst 
modern  methods  of  diagnosis  one  must  not  forget  the  bronchoscope,  through  which,  in 
skilled  hands,  it  is  often  possible  to  get  visual  proof  of  the  nature  of  a  tracheal  or  brondiial 
obstruction.  The  only  bronchial  causes  of  )ia'niO])tysis  that  need  l)e  dealt  with  further  arc 
sy])hilitic  ulceration  and  infection  by  the  Dislomu  pulmouidc. 

Syphilitic  Disease  of  a  Bronchus  is  a  tertiary  lesion  of  gununatous  nature  and  as  it 
heals  it  causes  bronchial  stenosis  and  con.sequent  fibrosis  of  the  lung,  with  or  without  bron- 
chiectasis. It  will  hardly  be  diagnosed  luiless  there  are  other  very  definite  means  of  know- 
ing that  the  ]jaticnt  has  had  syphilis,  or  is  still  suffering  from  its  tertiary  effects,  or  has  a 
positive  Wassermann  reaction  :  and  even  then  care  must  be  taken  to  exclude  the  possibilit\ 
of  the  luetic  patient  having  developed  jjlithisis.  The  inlluence  of  iodide  of  potassium  in 
such  a  case  does  not  afford  conclusive  evidence  one  way  or  the  other,  for  even  though  the 
syphilitic  lesion  heals,  it  leaves  behind  it  the  fibrous  stenosis  of  the  bronchus. 

The  Dlstoma  Pulmonale  Westermanni  is  very  unlikely  to  be  the  cause  of  ha-moptysis 
in  any  ](atient  who  has  not  been  resident  in  (.  liina,  Japan,  or  Formosa.  History  of  residence 
in  those  countries,  on  the  other  hand,  would  suggest  the  diagnosis,  confirmation  of  which 
would  be  afforded  by  examination  of  the  sputum  for  the  parasites  or  tlieir  ova. 

The  differential  diagnosis  of  Haemoptysis  due  to  changes  in  the  Larynx  depends 
mainly  on  two  things  :  the  history  of  the  case,  and  the  condition  seen  locally  with  the 
laryngoscope.  The  history  and  course  are  the  chief  factors  in  diagnosing  acute  simjilc 
laryngitis,  post-typhoidal.  jjost-diijlitlieritic,  or  variolous  ulceration  of  the  larynx,  or  condi- 
tions due  to  injury  of  the  larynx  by  a  blow,  a  hand-grip,  a  cut  throat,  or  intubation  or  other 
()I)eration.  Leprous  ulceration  of  the  larynx  seldom,  if  ever,  occurs  in  any  patient  who  has 
not  lived  in  leprous  lands,  and  who  has  not  for  a  long  time  exhibited  subcutaneous  and 
cutaneous  evidence  of  bis  disease.     Of  the  remaining  five  conditions  given  in  the  list,  namely, 


HEADACHE  293 

tuberculous,  syphilitic,  and  malignant  ulcerations,  lupus,  and  angioma  of  the  larynx,  the 
last  two  are  very  rare  indeed,  though  both  may  be  diagnosable  by  their  laryngoscopic 
appearance,  particularly  if  there  is  also  lupus  of  the  face  on  the  one  hand,  or  a  tendency  to 
cutaneous  or  buccal  blood-oozing  nani  on  the  other  (Piale  XVII).  Between  the  remaining 
three  conditions  there  may  be  some  doubt  for  a  time,  but  if  it  can  be  seen  that  the  ulcera- 
tion is  extensive  and  yet  unilateral,  it  is  probably  epitheliomatous  :  if  tubercle  bacilli  are 
present  in  the  sputum,  if  there  are  apical  lung  signs,  and  if  multiple  shallow  ulcers  can  be 
seen  along  the  epiglottis,  as  well  as  in  the  larynx,  tuberculous  ulcej-ation  is  probable — it 
practically  never  occurs  except  secondary  to  pulmonary  tubercle,  though  the  latter  may  be 
slight  and  may  remain  in  abeyance  whilst  the  laryngeal  tubercle  advances  rapidly  ; 
syphilitic  laryngitis  may  be  diagnosed  by  exclusion,  but  if  there  is  a  tendency  to  healing,  with 
marked  deformity,  after  extensive  bilateral  destruction  of  the  laryngeal  and  neighbouring 
tissues,  and  if  tliere  is  decided  collateral  evidence  of  tertiary  syphilis,  inchuling.  pcrliaps. 
a  positive  serum  reaction,  the  diagnosis  may  often  be  made  directly.  The  chief  dilliculty 
arises  in  cases  in  which  there  may  be  both  syphilis  and  tubercle  at  the  same  time.  This 
brings  us  back  once  more  to  the  fact  that,  once  it  has  been  decided  that  true  haemoptysis 
has  occurred,  the  next  step  is  to  examine  the  sputum  and  the  chest  carefully  for  signs  of 
tubercle,  and  not  to  diagnose  any  other  condition  until  both  tubercle  and  mitral  stenosis 
have  been  excluded.  Herbert  French. 

Hyi:MORRHAGE,  GASTRIC— (See  ILematf.mesis,  p.  265.) 

H.€:M0RRHAGE  from  gums.     (.See  Hi.KKDiNG  Gums.  p.  72.) 

H.«:M0RRHAGE,  intestinal.     'See    Hi.ood    PKTi    Axrii.  ]).  7.5:    and    .Mkl.ena, 

p.  :!«.-,.) 


HEMORRHAGE  FROM   LUNG.     (See  II.kmoi  rvsis.  p.  285.) 

HAEMORRHAGE,  NASAL.     (See  Im-istaxis.  p.  220.) 

HAEMORRHAGE,   RETINAL.  -(See  OpnTuALMOscoric  Ai-pkaraxci-.s.  p.  415.) 

HEMORRHAGE,  SUBCUTANEOUS.     (See  Pi  rpi  ra.  p.  552.) 

HEMORRHAGE,  URINARY.    (S.-r  ILkmaitria.  p.  275.) 

HEMORRHAGE,  UTERINE  AND  VAGINAL.  (Se.  Minorruagia.  p.  385  ; 
-Mi;ii!()ui(ii Ai.i  \.    |).  ;!!»!):    ami   Mi/riiosr axis,  J).  .'!!)2.) 

HEMOTHORAX.      (.See  tiii.sT.   Hi.oudv   IMTISION   IN.   p.   102). 

HALTING.       (Sec   (;aIT.    AliNOKMAI.Mll-.S   ()]■.    p.   251.) 

HAND,  CLAW.     (S.r  (  i,\\\ -11  snu.  p.  io!i.) 

HEAD,  RETRACTION   OF.     (S,c  IJi.ni ac  tIon  oi'  tiii;  Hkad.  p.  .58!).) 

HEADACHE  i--  'inc  of  llic  cnimiuiiicst  symptoms  met  with  in  medical  practice,  and 
tlie  \arious  eniKiiticiiis  willi  wlileli  il  is  associated  arc  luuneraus,  as  the  list  given  below 
demonstrates. 

Headache  may  be  the  first  synipluiii  calling  attention  to  the  existence  of  grave  organic 
disease,  and  the  corrcet  diagnosis  of  the  cause  of  this  symptom  is  obviously  of  the  greatest 
import«ince.  Too  often,  unfortunately,  treatment  of  a  headache  precedes  a  careful 
invesligatlon  as  to  Its  cause,  anrl  an  Increased  risk  may  thereby  be  incurred  by  the  i)atlent 
through  the  delay  In  rcccignl/.lng  snnie  one  of  lis  more  serious  causes. 

The  explanation  of  the  mode  of  ])niduetlou  of  the  pain  known  as  liaiddrhr  is  not  easy, 
seeing  dial  llic  l)raln  substance  Itself  is  Insensible  to  mechanical  stimulation.  The  men- 
inges arc  supplied  with  sensory  nerves,  and  abnormal  stunuli  received  therefrom  reach  the 
cortex  and  give  rise  to  the  Impression  (if  pain.  .\l)iiofmal  stales  of  the  Intracranial  blood- 
vessels may  cause  pain,  which  Is  more  diHicuIl  of  cxplaiialion.  as  il  is  uncertain  that  they 
have  any  sensory  nerve-supply.  It  seems  probable  that  the  headache  produee.l  by 
increased    \aseiilar   tension    Is  a   pressure  elleel    acting  on    the   brain   as  a    whole,   or  on    Its 


294 


HEADACHE 


coverings  the  nicninwes.  The  sco])e  of  this  article  does  not  allow  further  discussion  of  this 
part  of  the  subject.  Certain  general  lines  of  diagnosis  may  be  laid  down.  The  closest 
attention  should  be  paid  to  the  character,  situation,  and  time  of  occurrence  of  the  pain, 
and  also  to  accompanying  symptoms. 

Cliaracler. —  \yhether  throbbing,  paroxysmal,  or  affected  by  movement  or  position. 
Headaches  associated  with  alimentary  disturbance,  and  raised  blood-pressure,  are  often 
throbbing  in  character,  are  relieved  by  rest  in  a  recumbent  position,  and  are  increased  on 
movement.     Severe  paroxysmal  attacks  would  suggest  a  neuralgia. 

Situation This   may    be    frontal,    vertical,  occipital,  or    unilateral,  and    in    cases  of 

organic  disease  of  the  cerebrum  may  be  an  important  indication  and  an  aid  in  localizing 
the  situation  of  the  lesion.  In  renal  disease,  the  headache  associated  with  chronic  uraemia 
is  usually  frontal,  but  may  be  occipital.  It  is  vertical  in  constipation,  the  '  bilious  "  head- 
ache. It  may  be  unilateral  in  migraine,  tumour,  abscess,  middle-ear  disease  ;  or  occipital 
in  cerebellar  disease.  Occijiital  headache  may  also  be  sinndated  by  myalgia  in  the  muscles 
and  tendons  of  the  nape  of  the  neck. 

Time  of  Occurrence. — Headache  associated  «ith  organic  disease  of  the  brain  or  its 
meninges  often  jjersists  or  becomes  worse  at  night,  and  may  wake  the  jiatient  from  his 
sleep,  whereas  that  due  to  toxic  and  functional  causes  is  relieved  by  rest  in  a  horizontal 
position.  Grave  suspicion  of  the  organic  nature  of  the  headache  should,  therefore,  attend 
a  case  in  whicli  pain  in  the  head  disturbs  the  patienfs  sleep  at  night.  A  lieadache  experi- 
enced on  rising  in  the  morning  may  be  due  to  a  stuffy,  ill-ventilated  room,  or  to  the  slighter 
degrees  of  combined  astigmatism  aiid  hypermetro]}ia,  or  to  faulty  adjustment  of  the  pillows. 
Pillows  piled  too  high  may  cause  interference  with  the  cerebral  circulation  and  result  in 
headache.  Persistent  morning  headache  may  be  associated  with  chronic  nephritis,  and 
careful  observation  should  therefore  be  made  of  the  patienfs  urine.  Evening  headaches 
are  most  commonly  due  to  mental  overwork,  or  eyestrain,  especially  where  some  visual 
defect  exists. 

For  the  purposes  of  classification  it  is  convenient  to  divide  the  causes  of  headache 
into  three  main  groups  : — (A)  Organic  disease  (brain,  intracranial  vessels,  meninges,  skidl, 
special  sense  organs)  ;    (B)  Tome  Mates  ;    (C)  Functional  conditions. 


A.  Causes  due  to  Organic  Disease. 

These  may  be  classified  anatomically  as  follows  :- 
1.  Diseases  of  tlic  brain  : — 


C'(ineussi(iri 

't'unKnirvs 

Al)scess 


(Jumma 

Cysts 


Hydrocephaly 
Disseminated  .sclerosis 


General  paralysis 
of  the  insane. 


2.  Diseases  of  intracranial  vessels  :- 

Htemorrliage     1   Thrombosis 
(rupture)        ,   Embolism 

3.  Diseases  of  the  meninges  : — 


Aneurysm 

Sypliilitic  eiuiartcritis 


.\rterioseIerosis. 


Pachymeningitis 
Syphilis — meningeal  type 


Meningitis,  various  forms 
— localized  or  diffuse 

4.  Diseases  of  the  skull : — 

( Innocent 
Tumours  ... 

(Malisnant    '  ^'""i^^ 

'^  I  necondary. 

Tertiary  sypliilis. 

.Sii])pui:ition  or  new  growth  in  frontal,  antral,  or  mastoid  sinuses 
.Suppuration  or  tumovu'  in  the  orbit 
Dental  diseases. 


5.  Diseases  of  special  sense  organs  : — 

Eye — errors  of  refraction,  iritis,  glaucoma,  etc. 
Ear — middle-ear  disease. 

Nose — adenoids,    polypi,    nasopliaryngeal    catanli.        Inllanuuation    of    one    of    tlic 
accessory  air  sinuses — frontal,  ethmoidal,  sphenoidal  ;    empyema  of  a  frontal  sinus. 


HEADACHE  295 

Headache  in  Organic  Cerebral  Disease. 

Time  of  Occurrence.  Organic  cerebral  disease  should  be  suspected  if  a  history  of  recur- 
rent nocturnal  headache  be  obtained. 

Severitfi. — The  pain  is  often  intense,  and  sometimes  paroxysmal  in  character. 

Situntioti. — This  may  give  some  clue  as  to  the  existence  of  an  organic  lesion.  In  cases 
of  cerebral  tumour  the  pain  may  be  unilateral  or  frontal,  or  occipital  with  a  cerebellar 
lesion.  In  middle-ear  and  mastoid  disease  with  unilateral  headache  and  localized  tender 
ness.  occipital  headache  may  be  one  of  the  earliest  symptoms  of  meningitis. 

Associated  Signs  (iiiil  Sijtnplonis. — One  or  more  of  the  following  signs  and  symptoms 
may  present  themselves  at  an  early  j)eriod  in  cases  of  headache  due  to  organic  cerebral 
disease,  and  their  early  recognition  is  of  great  importance  : — 

Vomiting — that     is     of    the     '  cerebral   i  Optic  neuritis  (Plate  -Y/.V.  p.  416) 

type  '    (see    \'o.miting,    p.    703)  :     it  Irregularity  in  force   and   frequency  of  the 

usually  bears  no  relation  to  food,  and   |        pulse 

Is  not  pj;ececled  hi^nausea  '  The  onset  of  drowsiness 

Inequality  of  the  pupils  Fits. 

Squint  , 

Tapping  (he  skull  over  the  site  of  the  pain  may  reveal  local  teiuierness. 

The  onset  of  any  of  these  signs  associated  with  headache  would  point  to  the  existence 
of  some  organic  lesion,  such  as  are  enumerated  above.  As  in  many  of  these  conditions 
the  diagnosis  is  unattended  with  dillieulty,  it  will  sullicc  to  direct  attention  to  a  few  of 
them 

The  headache  occasionally  met  with  in  ilisscDiiiiatcd  sclerosis  is  sometimes  ])aroxysmal 
and  accompanied  by  vomiting,  and  is  situated  most  frequently  in  the  back  of  the  head  and 
neck.  The  absence  of  o[)tic  neuritis  and  the  presence  of  the  special  signs  of  disseminated 
sclerosis  should  leatl  to  a  correct  diagnosis. 

Cerebral  lavniorrliafie.  thrombosis,  and  embolism  are  often  followed  by  headache  of 
varying  severity.  In  cerebral  anenrysm  a  rhythmic  beating  or  pulsation  is  sometimes  felt 
and  rushing  noises  are  lieard,  more  particularly  when  the  internal  carotid  is  involved. 
Rhythmic  beatings  or  noises  in  the  head,  however,  do  not  by  themselves  suggest  an  intra- 
cranial aneurysm,  for  they  are  complained  of  commonly  by  many  anicmic  jjcrsons  and  by 
.sufferers  from  \aseular  degeneration,  especially  atheroma  of  the  cerebral  arteries. 

.\dvanced  arteriosclerosis  is  sometimes  attended  by  severe  headache  accompanied  by 
x'omititig  :  and  cases  have  been  describeil  presenting  features  closely  resembling  those  of 
cereljral  tumour,  in  arrixiug  at  the  diagnosis  instrumental  measurement  of  Ihc  blood- 
])ressure  is  all-imporlani . 

In  meniiiflitis.  especially  in  the  epidemic  cerebrospinal  and  the  post-basal  varieties, 
the  character  of  the  headache  is  significant.  It  is  usually  very  intense,  is  occipital,  and 
even  at  an  early  stage  may  be  attended  by  stiffness  of  the  neck  and  retraction  of  the  head. 
Kxaiiiination  of  the  cerebrospinal  lluid  (p.  .'{04.)  obtained  l)v  lumbar  pimeture  is  of  great 
iniportauce  in  (Iclcrnuiiiiig  the  ijresence  of  meningilis. 

Sjiecial  Siiisc  Organs.  —ICije.  Headaches  due  to  errors  of  rcl'raclion.  glaucoma,  iritis, 
elc.  arc  gcnerall\-  frontal  or  temporal.  A  slight  error  of  refraction  may  cause  what  appears 
to  be  a  dis|)roportionately  severe  headache,  particularly  in  children.  This  headache  is 
frontal,  occurs  mostly  in  the  evening  or  after  school  hours,  and  is  oflcn  attended  by 
a  burning,  pricking  or  watering  of  the  ey<'s.  Corrcelion  of  Ihc  drlrcl  by  suitable  glasses 
settles  the  diagnosis  by  curing  the  headache. 

li.  Toxic  Causes. 

'Ihisc  may  be  subdi\ideil  into  two  groups,  one  in  wliicli  tlic  toxic  inllucnee  is  actpiircd 
fiiirii  wilhoiil.  (ji-  is  erogenous:  the  other  in  which  llic  disturbing  element  or  toxin  is 
priMlNccil  williiii   Ihc  body,  auil  is  nl'  I'liilogenoas  origin. 

1.   Of  e.eogeiioas  origin  :-- 

ImiuI  ail',  as  in  <-li)se.  ill-\eiililal(il  looins 

Poisonous  fiascs,  CO,,  CO,  cliloroldnii,  ellicr,  elc. 

Druys,  c.i;.,  i|Miuine,  iron  in  some  iiMli\iiiii:ils,  s:ilicvlalcs,  iipiuiii, 

Alcnli,.!  I  Tobacco  |  Lead   pi.isnuin-. 


52<)6  HEADACHE 

2.  Of  endogenous  origin  : — 

Uraemia  I  Gout 

ClioUumia  |  Diabetes 

Gastro-intestinal  disturbances  :    dyspepsia,  constipation 
Toxa!mias  :    specific  fevers,  pyrexia]  phthisis,  sup])iiration,  etc. 

As  regards  the  toxic  Cduses  of  headache  little  further  need  be  said  as  to  the  diagnosis 
of  the  exogenous  poisons. 

Urtcmia  is  classed  for  ]iurposes  of  convenience  as  a  condition  due  to  endogenous  bodies, 
or  substances  |)roduced  within  the  body.  It  stands  out  as  one  of  the  most  important 
causes  of  headache,  and  sjiecial  attention  must  always  be  given  to  ensure  its  recognition. 
Uraemic  headaches  may  be  met  with  in  all  degrees  of  severity,  from  a  slight  frontal  head- 
ache felt  on  rising  in  the  morning  to  an  intense  vertical  or  general  cephalalgia.  Other 
ura^nic  manifestations  may  be  present,  such  as  vomiting,  drowsiness,  dyspncca,  affections 
(if  vision,  and  retinal  changes.  Examination  of  the  urine  in  all  cases  of  headache  should 
never  be  neglected,  as  regards  its  specific  gravity,  the  presence  of  albumin,  blood  and  casts. 

C.  Functional  Causes  : 

.,  1111  '   lii"li.  in  arteriusekTo.si.s  and  renal  disease 

Abnormal   blood-pressure  ,  ,    ^     .  .  ,  i-       >  i  i-       >      i- 

'  low,  ni  ana^ma,  morbus  cordis,  Addison  s  disease. 


Venous  congestion 

Rxcessive  mentLiI  strain 

I'rcssure    (in     tlic     head — heavy    hats, 

carrvinii  weinlits  on  the  head 
Persistent  noises — '  gun  headache  ' 


Menstruation 

Hysteria — ("  clavus  hystericus  ') 

Migraine 

E])ilepsy 

Kve  strain,  '  academy  headache  ' 


Sea-sickness — movement  of  boat,  train   i    Simstnikc. 

Iligli  blood-pressure  is  often  a  cause  of  headache,  usually  of  a  throbbing  character, 
acc(iiii|ianie(l  by  a  sense  of  fullness  of  the  liead.  The  headache  tends  to  come  on  towards 
evening  and  after  meals.  The  vascular  condition  should  be  ascertained  by  means  of  some 
suitable  apparatus  for  estimating  blood-jiressure. 

Headache  associated  with  low  blood-pressure  (cerebral  anemia),  as  in  some  forms  of 
morbus  cordis  and  an;cmia  with  feeble  cardiac  action,  is  relieved  by  rest  in  the  horizontal 
])osition  and  cardiac  tonics  such  as  digitalis  and  iron. 

Venous  congestion  may  cause  headache.  This  is  also  met  with  in  heart  disease  with 
failing  compensation.  It  may  also  account  for  the  headache  felt  on  rising  in  the  morning 
as  the  result  of  sleeping  with  pillows  too  high  or  too  low. 

The  '  clavus  hystericus  '  is  a  boring  pain  felt  in  the  vertex  and  in  hysterical  states. 

Headache  in  migraine  is  often  unilateral,  though  quite  commonly  bilateral,  and 
frequently  it  is  accompanied  by  vomiting.  Transitory  visual  disturbance  usually  precedes 
the  headache. 

In  epilepsy  headache  is  of  frequent  occurrence  in  the  post-epileptic  state,  and  it  should 
be  borne  in  mind  that  it  may  also  follow  the  slight  manifestations  of  petit  mal. 

After  sunstroke,  chronic  headache,  usually  vertical,  may  persist  for  months,  and  the 
same  applies  to  many  head  injuries. 

It  is  sometimes  dillicult  to  distinguish  between  headache,  which  implies  pain  inside  the 
skull,  and  neuralgia,  which  is  pain  felt  in  the  peripheral  course  of  a  nerve  trimk  (see  Pain 
IN  THE  Face,  p.  446).  Neuralgia,  if  of  wide  distribution,  may  simulate  headache.  Careful 
examination  may  be  necessary  to  decide  whether  the  supposed  headache  may  not  in  reality 
be  a  neuralgia.  The  local  distribution,  the  often  intense  and  paroxysmal  character  of  the 
pain,  the  presence  of  •  tender  spots,'  the  existence  of  spme  definite  exciting  cause  such  as 
dental  caries,  sliould  point  to  the  diagnosis  of  neuralgia.  //.  Morley  Fletcher. 

HEARTBURN  is  a  connnon  symptom,  yet  didieult  to  define.  Apparently  it  is  due  to 
regurgitatidu  into  the  lower  end  of  the  a'sophagus  from  the  stomach  of  acid  products 
of  digestion,  and  it  is  thus  related  to  pyrosis  or  waterbi-ash,  in  which  similar  acid  products 
regurgitate  suddenly  as  far  up  as  the  ujnier  end  of  the  pharynx  and  the  back  of  the  mouth, 
causing  a  local  sense  of  burning  acidity  in  the  throat,  and  often  a  temporary  huskiness  of 
the  voice.  Neither  waterbrash  nor  heartburn  is  distinctive  of  any  particular  malady. 
F.ither  may  occur  in  a  perfectly  healthy  individual  who  for  some  transient  digestive  cause 


HEART     I.MI'ULSE.     DISPLACED  297 

has  ratlier  more  gas  in  his  stomach  than  tlie  latter  can  hold  comfortably  ;  with  the  escape 
of  some  of  this  gis  a  drachm  or  two  of  tlie  li(|iiid  gastric  contents  may  be  shot  up  into  the 
lower  end  of  the  (rsophagiis  to  cause  heartburn,  or  further  up  still  to  cause  waterbrash. 
On  the  other  hand,  if  the  symptoms  are  persistently  troublesome,  either  may  indicate  more 
serious  lesions,  such  as  flatulent  dyspepsia  (see  Flat;tlencf.,  p.  24.0)  or  pyloric  stenosis 
from  healed  ulcer  or  gastric  carcinoma  (see  Dilatation  of  the  Sto.macii,  p.  173).  If  the 
symptoms  are  obviously  not  transient,  analyses  of  test  meals  (pp.  270  and  319)  or  .r-ray 
examination  of  the  stomacli  {Fig.  122.  p.  245)  may  be  required  before  the  diagnosis  of  their 
cause  can  be  established.  Duodenal  ulcer,  gall-stone  dyspeijsia.  appendix  dyspepsia, 
find  ileoea^ca  kinking  will  also  need  to  be  borne  in  mind  as  possibilities. 

The  actual  symjjtoms  of  heartburn  take  two  forms.  The  first  consists  in  a  more  or 
less  acute  pain,  sometimes  of  a  really  burning  character,  more  often  of  a  sev^ere  aching, 
boring,  or  even  lancinating  type,  referred  to  the  mid-line  of  the  lower  end  of  the  gladiolus, 
especially  between  the  two  fifth  costal  cartilages,  coming  on  as  a  rule  an  hour  or  more  after 
food,  when  digestion  is  at  its  height,  beginning  either  gradually  or  suddenly,  often  increasing 
in  severity  for  half  an  hour  or  an  hour,  and  lasting  sometimes  for  several  hours  or  a  whole 
day  ;  this  is  generally  referable  to  its  cause — (latulencc — with  ease  ;  especially  if  simple 
treatment  with  bicarbonate  of  soda  and  a  little  rhubarb  relieves  or  cures  the  pain.  The 
other  type  consists  in  attacks  of  acute  gripping  pain  in  the  precordial  region,  especially 
near  the  ajjex  of  the  heart  ;  this  pain  comes  on  quite  suddenly,  and  it  often  lasts  less  than 
a  minute  and  seldom  more  than  a  few  minutes.  While  it  is  there  the  patient  may  lind 
himself  unable  to  take  an  ordinary  breath  without  increasing  the  pain  to  an  unbearable 
extent  ;  he  therefore  holds  his  breath  entirelj'  for  as  long  as  he  can,  generally  presses  a 
hand  o\er  tlie  precordial  region,  and  when  he  is  compelled  to  inspire  again  he  finds  that  he 
gets  checked  before  he  has  breathed  in  as  much  aii  as  he  would  like  ;  he  therefore  contents 
himself  for  a  minute  or  two  with  a  minimum  dejjth  of  breathing,  by  which  time  the  acute 
stitch-like  precordial  pain  passes  off  and  he  is  able  to  breathe  normally  again.  The  attack 
may  be  repeated  after  an  interval  of  minutes  or  hours  ;  there  is  often  no  sense  of  palpitation, 
but  in  some  cases  severe  palpitations  accompany  or  follow  the  pain,  and  the  main  difficulty 
is  to  exclude  organic  heart  disease  which  the  jiatient  fears  his  symptoms  indicate.  When 
the  attacks  are  only  very  occasional,  and  there  is  no  shortness  of  breath,  gastric  disorder 
is  more  probable  than  heart  trouble  ;  when,  however,  the  attacks  are  frequent  and  the 
patient  is  out  of  condition,  it  may  reciuire  very  skilful  judgement  to  decide  that  the  attacks 
of  precordial  colic  are  of  gastric  and  not  cardiac  origin.  Fatty  or  fibroid  or  tobacco  hearts 
are  the  most  dilTicult  to  exclude  ;  the  relief  the  patient  receives  from  carminatives  such  as 
bicarbonate  of  soda,  gentian,  cajaput  oil,  ginger,  rhubarb,  peppermint,  does  not  necessarily 
indicate  that  the  trouble  is  [irimarily  gastric  ;  and  even  when  the  fullest  examinations 
have  been  made,  including  the  use  of  the  clectrocardiograijh.  there  arc  many  instances  in 
which  it  remains  very  much  a  matter  of  opinion  wlulhcr  the  attacks  arc  due  to  myocardial 
chantres  or  to  the  much  less  .serious  heartburn.  Ilnhcii  Fmic/i. 

HEART,   ENLARGEMENT    OF.     (Sec  f;M,Aiic;i-,Mi;Nr  oi-  tmi;  lIi-.AiiT,  p.  -JIKi.) 

HEART  IMPULSE,  DISPLACED.  The  apex  beat,  which  is  th..  low.-sl  and  outer- 
most point  at  which  the  cardiac  impulse  can  be  felt,  is  situated  in  the  normal  adult  chest  in 
the  fifth  left  intercostal  s[)ace,  one-half  to  one  inch  internal  to  the  manunary  liTic.  It  may 
lie  impossible  to  dclinc  the  position  of  the  apex  beat  even  in  health,  on  account  of  increased 
tliickncss  of  the  chest  wall  either  from  iiuiscular  development  or  excess  of  fat  ;  or  in  the 
female  on  a<'Count  of  a  large  mamma.  .\  similar  diflic'ulty  arises  when  the  cardiac  impulse 
is  feeble  :  wlien  the  heart  is  overlapped  by  I  lie  left  lung,  as  in  pulmonary  emphysema  ;  or 
when  ))erieardial  clliision  is  present.  In  children,  the  apex  beat  is  situated  further  to  the 
left  and  a  little  higher  tlian  in  adults.  Speaking  generally,  it  is  oulsidc  Hie  mammary  line 
dm-ing  the  first  three  years  of  life,  in  the  mamillary  line  from  (lie  rourlli  In  lln-  tenth  years, 
anil  it  gradii.illy  nmliis  I  he   adult  position  by  llic  age  oriillccu. 

Till'  (•iiiiiljliiiiis   whirli   priiiliiri-  ilisplaeiiiuiil    iiC  Ihi-  rariliar   iiiipuisi'  are  :  — 

.1.  When    the    Bulk    of    the    Heart    in    in    the    Norniiil    Position. 

1 .   Dincnsrs  iif  tlie  linirl  : 

((I).    Valvuhir;     ih).    My.. -aiili:!!  :     (,  1.    I'lriianlial. 


298  HEART    IMPULSE.     DISPLACED 

2.  Changes  in  the  heart  seconrlarij  to  : 

(a).  Diseases    of    tlie    lunns,    sueli    as       (c).  Aiuemia  and  debilitatiiii;  condilions,  aH(et- 
emphysema,  fibrosis,  etc.  i  iiig  cliiefly  the  right  ventricle 

(rf).  Toxic     conditions     producing     myocanlial 
(6).  Arterial  sclerosis  and  chronic  renal  changes,  as  in  infective  diseases 

disease  (r).  .Muscular  exertion. 

li.  When    the   Whole    Heart    is    Displaced. 

1.  Changes  in  the  kings  : 

(«).  Contraction  of  one  lun'4  or  a  portion  of  it  :     (/>).   Xcw  growth  of  lung. 

2.  Clianges  in  tlic  pleura'  : 

(a).  Pleurisy  with  effusion,  enijiyema,  pneumothorax  ;    (Ij).  Xew  growth   of  pleura. 

3.  Other  tliorctcie  tumours  : — Xew  growth,  aneurysm. 

4.  Deformities  of  the  ehest  7cal!  : — The  result  of  scoliosis. 

5.  Changes  in  the  al)dnmen  : — .\scites  ;   tympanites  ;   abdominal  tumour  :    ])regnaiuy. 
C.  Transposition  of  the  tieart. 

To  distinguish  lietween  the  two  groups  is  usually  not  dilficidt,  for  when  the  bulk  of  the 
heart  is  in  the  luniiuil  jjosition  and  the  ajjex  beat  is  displaced  beyond  the  left  mammary  line, 
the  area  of  cardiac  dullness  is  increased,  not  only  to  the  left,  but  also  to  the  right  of  the 
sternum,  and  U])ward.  If  both  lungs  are  emphysematous  and  the  cardiac  apex  is  displaced 
outwards,  although  the  size  of  the  heart  cannot  be  estimated  by  percussion,  yet  the  bidk  of 
the  heart  may  confidently  be  jjresumed  to  be  in  the  normal  position. 

The  presence  of  a  cardiac  lesion,  arterial  sclerosis,  or  chronic  renal  disease,  helps  to 
confirm  the  view  that  the  abnormal  position  of  the  apex  beat  is  due  to  an  increase  in  the 
bulk  of  the  heart,  and  not  to  a  displacement  of  the  organ  as  a  whole.  The  examination  of 
the  pulse  gives  valuable  information  ;  if  it  be  of  high  tension  and  is  sustained,  or  if  the  pulse 
is  of  the  ■  water-hammer  "  type,  it  indicates  that  the  displaced  apex  beat  is  due  to  enlarge- 
inent  of  the  left  ventricle,  and  that  probably  there  is  no  displacement  of  the  heart.  The 
blood-pressure  is  increased  in  arterial  sclerosis  and  in  renal  disease,  and  must  therefore  be 
estimated,  for  it  gives  additional  evidence  that  the  displaced  a])ex  beat  is  part  of  a  general 
enlargement  of  the  heart.  Examination  of  the  urine  must  never  be  omitted  ;  if  there  be 
polyuria,  with  a  small  trace  of  albumin,  low  specific  gravity,  and  hyaline  and  granular 
casts,  the  presence  of  chronic  interstitial  nephritis  is  ascei-tained,  and  this  will  account  for 
the  enlargement  of  the  heart,  and  any  displacement  of  the  apex  beat  down  and  to  the  left. 

The  presence  of  a  cardiac  bruit  is  of  great  value  in  determining  that  the  displaced  apex 
is  due  to  morbid  changes  in  the  heart  ;  but  the  absence  of  a  bruit  does  not  necessarily  mean 
that  the  displaced  apex  beat  is  unassociated  with  cardiac  disease.  The  enlargement  of  the 
left  ventricle,  due  to  arterial  degeneration  or  chronic  interstitial  nephritis,  may  not  be  accom- 
panied by  any  bruit  imless  dilatation  becomes  so  great  that  mitral  regurgitation  supervenes. 
The  characters  of  any  of  the  cardiac  soimds  are  frequently  altered  in  dilatation  and  hyper- 
trophy of  the  left  ventricle.  Thus,  the  aortic  second  sound  may  be  accentuated  on  account 
of  the  increased  arterial  tension,  and  the  second  sound  over  the  base  of  the  heart  may  be 
reduplicated  on  account  of  the  aortic  and  pidmonary  valves  not  closing  synchronously. 
The  first  soimd  is  frequently  louder  and  more  prolonged  in  hypertrophy  of  the  ventricles, 
due  to  an  increase  in  the  muscular  element  of  the  soimd,  and  the  greater  force  with  which 
the  ainieulo.\ cntrieular  valves  are  closed.  In  simple  dilatation  of  the  ventricles  the  first 
sound  is  olteii  slightly  accentuated,  but  is  usually  sharper  and  shorter. 

In  the  second  class  of  cases,  in  which  the  whole  heart  is  displaced,  the  cause  of  the 
displacement  is  usually  easy  to  ascertain.  The  chest  is  frequently  asymmetrical,  for  there 
will  be  either  bulging  of  the  chest  wall  on  the  side  from  which  the  heart  is  displaced,  or  some 
shrinking  on  the  side  to  which  it  is  drawn.  Percussion  may  show  that  resonance  is  present 
where  normally  there  is  cardiac  didlness  ;  thus,  when  the  right  hmg  is  emphysematous  and 
the  heart  is  pulled  over  to  the  left,  the  resonance  of  the  right  lung  may  be  found  extending 
to  the  left  of  the  sternum.  It  is  not  always  so  easy  to  determine  the  boundaries  of  the  heart 
when  the  displacement  is  due  to  the  presence  of  a  pleural  effusion,  as  there  is  dullness  over 
the  effusion  which  may  be  continuous  with  the  cardiac  dullness.     In  such  a  case,  however, 


HEART    I.MPULSK.     DISPLAC'KI)  299 

the  dullness  over  the  base  of  the  lung  is  not  only  in  I'mnt,  hut  is  likely  to  be  found  behind  as 
well.  There  are  also  signs  of  compression  of  the  lung  by  the  effusion,  such  as  absence 
of  breath  and  voice-sounds,  tubular  breathing,  or  skodaic  resonance  ;  aegophony  may  be 
heard  at  the  uj)per  level  of  the  fluid,  and  it  is  always  very  suggestive  of  pleuritic  effusion. 
When  the  heart  is  drawn  over  to  one  side  by  the  contraction  of  the  lung,  as  in  fibrosis,  there 
is  impaired  resonance  upon  percussion  over  the  fibrosed  lung,  continuous  with  the  cardiac 
dullness.  The  boundaries  of  the  heart  may  be  difficult  to  define  by  percussion,  but  over 
the  fitjrosed  lung,  breath-sounds  are  present,  tubular  in  character,  vocal  fremitus  and  reso- 
nance are  decreased,  and  crackling  riiles  and  other  adventitious  sounds  may  be  heard.  When 
the  heart  is  drawn  over  in  this  manner  by  fibrosis  of  one  lung,  the  resonance  over  the 
healthy  lung  will  be  found  to  extend  across  the  middle  line,  and  thus  invade  the  normal 
jKjsition  of  cardiac  dullness.  Examination  of  the  chest  by  means  of  the  .r-rays  usually 
helps  to  determine  tlie  position  of  the  heart  :  but  large  tumours,  pleuritic  effusions,  etc., 
produce  shadows  which  may  be  continuous  with  that  of  the  heart.  The  pulsations  of  the 
heart  are  generally  well  seen,  especially  in  children,  and  indicate  its  position. 

The  changes  in  the  abdomen  causing  displacement  of  the  heart  upwards  arc  not  likely 
to  be  overlooked,  because  there  must  be  a  considerable  amount  of  abdominal  enlargement 
before  the  heart  can  be  raised  by  it  ;  and  therefore  if  displacements  of  the  apex-beat  are 
due  to  ascites,  tympanites,  abdominal  tumours,  or  pregnancy,  the  causes  are  all  of  such  a 
marked  degree  or  in  such  an  advanced  stage,  that  tliey  are  easily  recognizable.  When  the 
heart  is  displaced  as  the  result  of  marked  changes  in  the  lungs  and  pleurae,  intrathoracic 
tumours,  or  abdominal  enlargements,  the  causes  of  the  displacement  are  usually  found 
first  on  account  of  the  symptoms  and  physical  signs  they  produce  ;  the  alteration  in  the 
position  of  the  a])ex  beat  is  then  a  confirmatory  sign. 

In  the  first  group,  in  which  the  bulk  of  the  heart  is  in  the  normal  jjosition,  the  direction 
in  which  the  apex  beat  is  dis|)laced  is  of  some  diagnostic  value.  It  is  displaced  downwards 
and  to  the  left  in  hi/pertrophij  of  the  heart,  especially  when  it  affects  chiefly  the  left  ventricle. 
In  mitral  regurgitation  the  apex  beat  is  displaced  outwards  and  to  the  left,  whereas  in  lesions 
of  the  aortic  valves  the  displacement  is  to  the  left  and  downwards,  so  that  the  apex  beat  is 
commonly  situated  in  the  sixth  intercostal  space.  In  both  these  conditions  the  left 
ventricle  is  enlarged,  but  with  mitral  regurgitation  the  right  side  of  the  heart  becomes 
enlarged  early  in  the  disease,  and  the  apex  is  displaced  nuieh  more  outwards  than  down- 
wards. When  the  right  ventricle  is  alone  enlarged,  as  in  jnilmonarv  eni|)hysema,  the  dis- 
placement of  the  apex  beat  is  directly  to  the  left,  and  not  downwards  at  all. 

The  varying  enlargement  of  the  two  ventricles  may  be  fairly  gauged  by  watching  the 
position  of  the  apex.  It  is  raised  and  displaced  slightly  to  the  left  by  any  cause  which 
increases  the  height  of  the  diaphragm,  such  as  ascites,  tympanites,  abdominal  tumours, 
and  pregnancy.  The  cardiac  impulse  is  also  raised  by  pericardial  eliiision.  There  are, 
however,  a  considerable  number  of  cases  of  displaced  apex  beat,  with  tlie  bulk  of  the  heart  in 
the  normal  position,  in  which  it  is  dillicult  to  ascertain  the  cause  of  the  displacement.  This 
is  especially  so  in  yotmg  adults,  in  whom  the  apex  beat  may  be  found  to  be  displaced 
slightly  outwards  without  any  apparent  cause.  If  the  subject  be  a  young  and  muscular 
man  who  otherwise  seems  in  good  health,  the  condition  is  prob.ddy  due  to  hypertroi)liy  of 
the  left  ventricle  as  the  result  of  c.ivr.v.v/ir  athletic  e.vcrcisc  or  of  some  arduous  muscular  work. 
The  history  would  eoiilirni  lliis  view.  '  If.  on  the  other  hand,  the  patient  is  not  a  muscular 
individual,  the  displiii  riiiciil  rii:i\  slill  be  due  to  si  lain,  liul  some  other  cause  should  always 
be  looked  for,  and  in  I  lie  aliMiicc  iilaii\  obvious  cardiac  lesion,  pericardial  adhesions  nnist, 
not  be  forgotten  :  IIksc  may  produce  few  sym|)toms  except  slight  enlargement  of  the  heart. 
In  young  girls  the  apex  beat  is  often  situate<l  in  tlu'  mammary  line,  and  this  displace- 
ment is  associated  with  chlorosis  and  other  debilitating  conditions  which  produce  dilatation 
of  the  eonus  arteriosus.  The  apex  beat  is  not  only  displaced  outwards,  but  also  raised. 
The  diagnosis  is  conlirmed  b\'  finding  that  the  cardiac  dullness  is  iuereased  in  an  upward 
direction,  and  by  the  presence  of  a  Innelional  syslnlie  broil  in  IIk'  pnlmoiiiiry  aica  and  a 
brnil  de  diahlc  in  the  neck. 

In  elderly  people,  in  whom  tliere  is  no  vaKular  disi  ase  ,i(  Ihe  heart,  the  apex  ma\  be 
displaeed,  not  oidy  as  Ihe  result  of  hypertrophy  of  the  jell  Ncntricle  sicondary  to  renal 
disease  and  arterial  s<lenisis.  and  as  the  resnil  of  enlargement  of  Ihe  right  ventricle 
secondary   to   pulmonary   empliyserna  :     bnl    aKn   as   I  lie    rcsiilj    of  iniimiinliid  dcgciicndion. 


300 


HEMIANOPSIA 


The  last  condition  may  be  difficult  of  diagnosis,  but  when  there  is  no  evidence  of  valvular 
disease,  emphysema,  chronic  renal  disease,  arterial  sclerosis,  or  anything  causing  displace- 
ment of  the  heart  as  a  whole,  it  must  always  be  suspected.  Symptoms  which  frequently 
accompany  it  are  dyspnoea  upon  exertion,  attacks  of  syncope,  palpitation,  and  oedema  of 
the  legs.  The  pulse  is  often  feeble  and  irregular,  and  in  failing  cases  the  imjiulse  is  feeble, 
a  gallop  rhythm  may  be  present,  and  a  soft  systolic  bruit  at  the  apex. 

Another  form  of  uniform  cardiac  hypertrophy  that  needs  special  mention  is  that  which 
results  from  long-continued  drinking  of  large  quantities  of  Ihiid,  particularly  beer — the 
beer-drinker's  heart.  J.  E.  II.  Sawyer. 

HEART  SOUNDS,  ACCENTUATION  OF.— (See  Accentuation  of  Heart  Sounds, 
1).  1.) 

HEART  SOUNDS,  REDUPLICATION  OF.— (See  Reduplication  of  Heart  Sounds, 
J).  .587.) 

HEMERALOPIA.  -(See  Vision,  Defects  of,  p.  763.) 

HEMIANv€;STHESIA.— (See  Sen.s.vtion,  Abnormalities  of.  p.  610.) 

HEMIANOPSIA — or,  as  it  is  sometimes  called,  hemiopia  or  hemianopia — means 
inability  to  see  objects  in  one  half  of  the  field  of  vision.  It  is  generally,  but  arbitrarily, 
restricted  to  cases  in  which  this  defect  is  due  to  changes  elsewhere  than  in  the  retina  or 


Fii    13S  —A  diagia 
TL  tiu     of  the  optic  r 
(. iini il  I  erves    and  the  o 
ill  iitnesoiUo  to  1  ft  ci 
e^  e     c    reliv  of      1 
suf  euoi     cori-  Ub 
OLCipitil   cortex 
1 1  'ht  half  of  the  fl  I 
pital  tortes    whicl 
lialf  of  the  held  of  \  i^ion 


«<?.139.— A  .h  :ji  nil  -li.i"  III  ■  lii.u   1  tumour 
of  the  pituit  If  >  '  •    I'    u".itirig 

fibres  at  the  ni    i        i         -  i    -  'upulses 

passing  from  rl -  il  h  ill  ni  i  ii  !m  i  ii'tuia  to 

the  correspoiKliiii:  cortcK  or  to  tlip  corredpond- 
inc:  3rd  nucleus.  Hence  bilateral  temporal 
hemianopsia  and  absence  of  pupil  reaction 
to  li^lit  tlirown  on  the  nasal  half  of  either 
retina. 


disc.  It  is  not  a  common  condition,  but  it  sometimes  escapes  recognition  because,  which- 
ever half  of  the  visual  field  has  become  blind,  good  vision  remains  at  the  central  part,  and 
even  the  patient  himself  may  not  always  be  conscious  of  his  defect  until  some  accident, 


HEMIANOPSIA 


'     301 


such  as  running  into  objects  in  broad  daylight,  draws  his  attention  to  it.  To  map  out  the 
blind  area  witli  accuracy  an  instrument  known  as  tlie  perimeter  is  required. 

It  is  possible  to  get  hemianopsia  in  one  eye  only,  but  this  is  very  rare  apart  from 
functional   conditions   or   migraine. 

When  both  eyes  are  affected,  the  blindness  may  affect  :  (1)  Corresponding  halves  of 
the  field  of  vision — bilateral  homonymous  hemianopsia — sjjoken  of  as  right  if  neither  eye  can 
see  objects  in  the  patient's  right-hand  half  of  the  field  of  vision  {Figs.  140  and  1-11),  and  as 
left  if  in  the  left  half  ;  or  (2)  O])posite  halves  of  the  field  of  vision — almost  invariably  the 
temporal  halves,  and  referred  to  as  bilateral  temporal  hemianopsia  {Fig.  139). 

These  are  the  only  two  varieties  that  arc  of  clinical  importance.  They  are  generally 
not  the  only  symptoms  in  the  case,  but  they  sometimes  serve  to  localize  certain  cranial 
lesions  with  accuracy. 

Bilateral  Homonymous  Hemianopsia  has  a  variety  of  causes,  affecting  one  or  other 
of  three  main  sites,  namely  :    (a)  One  optic  tract  ;    (6)  The  posterior  limb  of  one  internal 


Fii/.  111. — A  dill'.,'ram  showiiiir  how   :i   Ir-^inn    nf 
the  left  optic  radiations  or  of  th''  \i  nil  |HTrii':i  .,1 

tlm  left  oceipital  cortex  caiisei   l.lMi.i i    ilir 

right  Imlf  o(  tlie  llelil  of  vision  ■>!  '■■!  l,  n...  Ihji 
docs  not  prevent  the  pupils  fiuiu  hm.  un-  m 
response  to  a  ray  of  li'-rlit  falling'  on  Ihi-  hlind  luilf 
of  eitlier  retina. 

(■iipMilc  :  (ir  (r)  'I'lie  optic  radiations  (ir  cnic  occipital  region  at  or  near  the  cuneus.  In  any 
ol'  Ihcsi-  sills  llic  iiMlhological  lesion  ni;iy  \iv  either  vascular  thrombosis,  lueniorrhage, 
cinhoIiMii.  or  inlirinil  lent  closure  ;  or  a  neoplasm,  such  as  a  gumma,  a  tuberculous  nodule, 
an  inilaniiiiiilory  swelling,  or  a  gliomatous,  carcinomatous,  or  sarcomatous  nodule.  The 
lirst  step  is  to  locate  the  site  of  the  lesion  :  its  nature  will  then  be  detirniincd  more  easily, 
because  in  the  internal  capsule  a  hiemorrhage,  thrombosis,  or  embolism  of  the  middle 
cerebral  artery  is  the  commonest  cause  of  the  symptom  ;  a  neoplasm,  or  an  abscess,  is 
probably   its  eiiiniiionest  cause   in    the  oceipilal   corlcv.    though   an   alisccss,   or   rupture   or 

occlusion  <illhe  posterior  cerebral  artiry  would  also  be  tl glil  of:    in  llie  optic  tract   it   is 

as  often  as  not  guminalous.  or  in  some  ol  licr  way  sypliilili<'. 

Bilateral   Temporal   Hemianopsia.     There   is  onl\-   one   spot    at   wliich  a  single  lesion 
can  produce  this  condjljoii  ;  this  is  at  llic  ecniral  pari  of  the  optic  cliiiisina.  where  the  libres 


302  HEMIANOPSIA 

from  the  nasal  half  of  each  eye  are  decussating.  The  three  commonest  causes  of  this  rare 
lesion  are  :  (o)  Hypertrophy  of  the  pituitary  body,  a  condition  which  also  leads  to 
acromegaly,  so  that  it  is  important  to  test  for  bilateral  temporal  hemianopsia  in  every  case 
of  acromegaly,  and  it  will  be  found  in  a  certain  number  :  (b)  Callus,  resulting  from  a  frac- 
ture of  the  base  of  the  skull  through  the  basi-sphenoid  bone  :  (c)  A  gumma  or  other  tumour 
in  this  region.  The  differential  diagnosis  between  these  three  groups  will  generally  be 
obvious  enough  when  the  variety  of  ha^niianopsia  has  been  established. 

In  order  to  decide  the  locality  of  the  lesion,  it  is  essential  in  the  first  place  to  determine 
whether  a  pencil  of  light  falling  upon  that  part  of  the  retina  which  cannot  see  is  able  to 
evoke  a  reflex  contraction  of  the  pupil.  This  requires  careful  testing  in  a  dark  room,  with 
a  small  pencil  of  light  directed  towards  different  ])ortions  of  the  eye  at  the  observer's  will 
by  a  suitable  mirror  or  lens.  Anatomical  considerations  make  it  obvious  that  if  the  optic 
tract  is  destroyed  there  is  no  path  by  which  the  light  impulses  from  the  non-seeing  portions 
of  retina  can  reach  the  oculomotor  nucleus,  so  that  there  will  be  no  reflex  movement  of  the 
pupil  in  response  to  light  (F/g.  140).  If.  on  the  other  hand,  the  optic  tract  is  intact,  the 
lesion  being  in  the  posterior  limb  of  tlie  internal  caijsule.  or  in  the  optic  radiations  or  the 
cimeus,  the  same  hemianopsia  results,  but  the  pupils  react  to  light  stimuli  falling  U])on  the 
blind  halves  of  the  retinie  (Fig.  141). 

If  the  light  reflex  is  lost  the  lesion  is  at  once  located  to  the  optic  tract,  provided  there 
is  no  obvious  trouble,  such  as  cataract,  or  locomotor  ataxy,  or  iritic  adhesions,  to  prevent 
the  reaction.  If,  on  the  other  hand,  the  light  reflex  remains,  the  lesion  must  be  in  one  of 
the  three  other  places  mentioned,  and  in  determining  this  the  history  may  help  considerably. 
If  there  has  been  an  apoplectic  seizure  in  an  elderly  person,  haemorrhage  in  the  region  of 
the  internal  capsule  is  likely,  and  there  will  often  be  both  hemiparesis  and  hemiparaes- 
thesia  at  the  same  time.  In  a  yoimger  person  suffering  from  heart  disease,  a  somewhat 
similar  history  would  point  to  embolism  involving  the  posterior  limb  of  the  internal  capsule. 
If.  on  the  other  hand,  there  has  been  a  slow  onset,  with  increasing  headache,  vomiting,  and 
giddiness,  then  a  neoplasm  or  gumma  affecting  the  optic  radiations  or  one  occipital  pole 
will  be  not  unlikely. 

If  the  patient  is  unable  to  see  things  in  the  right  halves  of  his  fields  of  vision,  the  lesion 
will  be  in  his  left  optic  tract,  left  internal  capsule,  left  optic  radiations,  or  left  cuneus,  as 
the  case  may  be,  and  vice  versa. 

Hemianopsia  due  to  migraine  or  to  intermittent  closure  of  cerebral  vessels  will  be 
distinguished  from  that  due  to  the  other  causes  by  its  presence  on  some  occasions  and  its 
absence  on  others. 

Irregular  or  partial  forms  of  hemianopsia  residt  from  irregular  or  partial  lesions  in  the 
optic  tract  or  other  regions  mentioned  above.  The  differential  diagnosis  is  then  more 
dillieiilt,  though  it  is  made  upon  the  same  lines  as  those  described  above.  From  a  dia- 
gnostic point  of  view  it  is  fortunate  perhaps  that  hemianopsia,  when  it  occurs  at  all,  is 
generally  definite,  and  either  bilateral  temporal  or  bilateral  homonymous. 

Herbert  French. 

HEMIPLEGIA  signifies  loss  of  motor  power  in  the  limbs  of  one  side  :  the  face, 
especially  its  lower  half,  being  affected  frequently  at  the  same  time.  In  the  great  majority 
of  eases  the  face  is  paretic  on  the  same  side  as  the  atteeted  arm  and  leg,  but  there  is  one 
important  exception,  namely,  when  the  lesion  is  in  one  side  of  the  pons  Varolii,  when  there 
is  paralysis  of  the  face  upon  the  same  side  as  the  lesion,  and  of  the  arm  and  leg  upon  the 
opposite  side — a  condition  known  as  crossed  hemiplegia.  The  lesion  in  most  cases,  how- 
ever, is  in  or  near  the  internal  capsule,  less  often  in  the  motor  cortex,  of  the  opposite  side 
to  that  which  is  hemiplegic.  There  may  or  may  not  be  hemian;esthesia  (p.  610)  ;  and  in 
rare  cases,  when  the  lesion  is  far  back  in  the  internal  capsule,  there  may  also  be  He.mi- 
ANOPSi.v  (p.  aOO).  When  the  cause  lies  in  the  internal  capsule,  the  (laralyzed  muscles  may 
be  either  flaccid  or  spastic,  but  they  do  not  as  a  rule  exhibit  the  athetotic  and  other 
involuntary  movements  that  cortical  lesions  may  give  rise  to  (see  Cgntr.vctions,  p.  131). 
When  a  patient  has  dilliculty  in  speech  associated  with  hemiplegia,  it  is  imjiortant  to 
distinguish  dysarthria  from  aphasia  (.see  Spkech,  Abnor.m.\lities  of.  p.  026).  Lesions 
of  the  internal  capsule  often  produce  dilficulty  in  using  the  tongue,  which  renders  speech 
mechanically  dillicult  (dysarthria) — a  very  different  thing  from  the  aphasia  or  dilficulty 
in  uttering  the  correct  words  when  the  mechanism  for  the  movements  of  the  tongue  is 


HI<:.MIPLEGIA  303 

tinaffectcd.  True  aphasia  associated  with  hemiplegia  suggests  a  lesion  at,  or  close  to, 
Broca"s  area  of  the  cortex  on  the  left  side,  and  is  therefore  far  less  common  with  left-sided 
than  with  right-sided  hemiplegia. 

The  fact  of  hemiplegia  is  generally  not  difficult  to  determine,  though  in  some  cases 
there  may  be  so  slight  a  weakness  that  doubts  arise  as  to  whether  there  is  any  hemiplegia 
at  all.  Routine  examination  of  such  a  patient  will  generally  detect  a  little  inequality  in 
the  degree  to  which  the  eyes  can  be  closed  firmly,  a  slight  difference  in  the  depth  of  the 
two  naso-labial  folds  when  the  ])atient  opens  his  lips  with  his  teeth  clenched,  a  greater 
difference  than  previo\isly  between  the  two  hand-gri])s.  as  measin-ed  by  the  dynamometer, 
slightly  brisker  radial  and  ulnar  wrist-jerks,  or  tricipital  and  bicipital  elbow-jerks  u])on  the 
affected  side,  inequality  of  the  knee-jerks  with  a  tendency  to  exaggeration  ujjon  the  paretic 
side,  with  corresponding  extensor  plantar  reflex  and  increased  Achillis  jerk  or  even  ankle- 
clonus.  All  these  changes  will  be  pronounced  in  cases  where  the  hemiplegia  is  more 
definite,  though  if  the  patient  be  seen  within  a  short  time  of  the  onset  of  hemiplegia  from 
cerebral  haemorrhage,  the  tendon  and  other  reflexes — which  will  presently  be  exaggerated 
.shoultl  the  patient  survive — may  for  the  time  being  be  decreased  or  even  unobtainable 
nj)(iii  the  affected  side. 

Stress  is  often  laid  upon  the  jiresence  or  absence  of  rigidity  in  connection  with  hemi- 
plegia, particularly  according  as  the  rigidity  comes  on  early  or  late  in  the  case.  This  helps 
less,  however,  in  the  diagnosis  than  it  does  in  the  prognosis.  A  few  cases  of  hemiplegia 
arc  flaccid  throughout,  though  this  is  uncommon  if  the  patient  survives  and  the  hemiplegia 
persists  :  in  cases  of  hemiplegia  due  to  ceref)ral  lucmorrhage  early  rigidity  generally 
suggests  a  smaller  ha-morrhage  than  does  early  flaccidity  followed  by  rigidity  ;  so  variable 
is  this,  however,  that  the  point  is  of  less  value  than  has  sometimes  been  supposed. 

It  is  (iillicult  to  classify  the  causes  of  hemiplegia  .satisfactorily,  but  the  following  is  a 
siinuiiMrv  of  those  discussed  : — 

A. — TuE    C'oMMON'Kii    C'.vrsES    OF    Hhmiplegi.v. 

1 .  Hemiplegia    of    Moderately    Rapid    Onset. 

C'lTchnil   IrrniDirlr.iL'c  I        Sy|]lnlitic     cnilartcritis     vt    a     middle 

Thrombosis  (ila  middle  ciTolira!  artery     )  forebrnl  artery. 

•2.  Hemiplegia   of   Sudden   Onset. 

iMnholisin  of  tlie  mid<llc  eerchral  artery,  generally  due  to  mitral  stenosis,  or  to  liiriiiatin" 
endocarditis. 

."i.  Hemiplegia  dating  from  Birth,  or  from  infancy,  and  resulting  from  : — 

Injury  |    Sinus  thrombosis 

Congenital    mall'ormalion  Mcningoeoceal  meninu'ilis. 

-Aente  enecphalitis  | 

li. — Leh.s    U.su.\l    C.vuses    ov    IIe.mii'i.eoia. 

(.(■iieral  paralysis  of  the  insane  1  Stab   or   bullet    wound   injuring   the   spinal 

lionlerlanil   sullieiiney  of  the   cerebral    eir-  I  cord  in  the  cervical  rejjion 

{Illation    in    old    peopli-    (inter  rriiltent  '  Meningitis,   whetber  tn()ereulons,   suppnra- 

elau(Iieation)  j  tive.  posterior-basal,  or  epidemic  eerc- 

(erebral  tumour,   uitli   or  willioiil    liainor-  :  brospinal 

rbage  into   it  Disseniinated  sclerosis 

<  erebral  abscess  I  Caisson  disease 

Ilemieliorea  '  Hysteria. 

(;iaiil'(i  llial  a  palienl  is  surieriiig  deHiiilely  from  lieniiplegia.  the  exact  cause  of 
the  symptom  has  to  l)e  delcriniTu<l.  ()?»■  may  say  at  once  that  the  <liagtiosis  is  easy  in  a 
very  large  proportion  of  cases.  Hemiplegia  of  moderately  rapid  onset  in  a  pali<>iit  o\cr 
fifty  years  of  age  is  almost  certainly  due  \o- circliriil  liiniiorrhtiffr,  particularly  when  it  is 
associatcil  with  coma  (p.  117)  of  rapid  but  not  instantain'ous  onset,  when  there  is  :i  high 
blood-pressure  and  enlargement  <if  the  heart,  with  a  ringing  aortic  second  sound,  wifli  or 
wit  limit  albuminuria  or  other  evidence  of  granular  kidney  or  arlcrioselerosis.  If  the 
hemiplegia  has  been  of  gradual  onset  in  a  young  adult,  particularly  if  one  limb  is  very  nnieh 
more  allected  than  the  rest  ol'  Hint  half  of  the  body,  if  there  bad  been  prcmoniloiy 
syriiplMiiis   I'or  some   hours,   or  e\  en   days,    heforc   I  lie   paresis   heeaim-   liiarkid,   and    if  there 


304  HEMIPLEGIA 

has  been  no  loss  of  consciousness,  the  great  probabiUty  is  that  the  patient  is  suiTering  frornv 
syphilitic  endarteritis  of  the  middle  cerebral  artery,  with  or  without  secondary  thrombosis. 
The  diagnosis  may  be  confirmed  by  a  history  of  syphilis,  by  the  occurrence  of  cutaneous 
ulcers  or  other  syphilitic  lesions,  or  by  a  positive  Wassermann"s  serum  reaction. 

If  the  ])atient  is  young,  if  the  hemiplegia  has  been  of  absolutely  sudden  onset,  generally 
without,  but  sometimes  with,  loss  of  consciousness,  the  probability  of  embolism  of  the 
middle  cerebral  artery,  secondary  to  mitral  stenosis  or  to  [ungating  endocarditis,  will  be  con- 
siderable, and  the  diagnosis  will  generally  be  confirmed  by  physical  examination  of  the 
heart,  and  by  enquiry  into  the  history  as  regards  acute  rheumatism,  chorea,  or  other 
rheumatic  affections.  In  cases  of  fungating  endocarditis  one  would  look  for  the  signs 
described  on  p.  34. 

If  the  patient  has  been  hemiplegic  from  birth  or  from  early  infancy,  the  probability 
is  that  there  has  either  been  an  injury  to  the  opposite  side  of  the  brain  at  birth,  or  congenital 
malformation  of  that  side,  or  acute  inflammation  of  it  after  birth — the  result  perhaps  of 
acute  encephalitis,  sinus  thrombosis,  or  even  meningococcal  meningitis  which  has  recovered. 
It  is  particularly  in  these  infantile  cases  that  hemiathetosis  is  liable  to  be  associated  with 
the  hemiplegia. 

Although  the  above  are  by  far  the  conmionest  causes  of  hemiplegia  at  the  different 
age-periods,  it  is  possible  for  them  to  overlap  as  regards  age  incidence  ;  and  one 
occasionally  sees  fatal  cerebral  haemorrhage,  apjiarently  of  the  senile  type,  in  persons  not 
much  over  twenty  ;  similarly,  syphilitic  thrombosis  of  the  middle  cerebral  artery  may 
not  occur  until  after  fifty  :  fungating  endocarditis,  followed  by  cerebral  embolism  may 
occur  at  any  age,  though  it  is  commonest  in  young  persons  ;  the  same  applies  to  cerebro- 
spinal meningitis.  The  diagnosis  will  be  indicated,  if  at  all,  by  other  symptoms  than  the 
hemiplegia.  In  doubtful  cases  assistance  may  be  derived  from  linnbar  puncture  and 
analyses  of  the  cerebrospinal  fluid  :  the  following  are  some  of  the  main  points  in  which  the 
latter  may  differ  from  the  normal  under  various  pathological  conditions  : — 

Appciiratice. — Cerebrospinal  fluid  is  normally  ([uite  clear  and  free  from  colour,  so 
that  in  a  test-tube  it  may  be  dillicult  to  distinguish  it  from  water  ;  when  there  are  inflam- 
matory changes  in  the  central  nervous  system,  particularly  in  all  the  acute  forms  of 
meningitis,  the  fluid  becomes  opalescent,  turbid,  purulent,  or  ever)  fibrinous  ;  and,  instead 
of  being  colourless,  it  may  develop  a  yellow  or  reddish-brown  colour — when  coagulable 
])roteid  is  also  present  the  combination  has  been  termed  the  xaniho-proleic  reaction. 

Specific  Gravity. — Its  normal  specific  gravity  is  low,  lying,  as  a  ride,  between  1004- 
and  1-007.  It  may  retain  a  normal  specific  gravity  even  in  diseased  conditions,  for  instance, 
in  cases  of  general  paralysis  of  the  insane  ;  but  with  inflammatory  changes,  such  as 
meningitis,  the  specific  gravity  is  liable  to  increase.  ' 

Tension. — Normally  the  fluid  drops  out  through  the  lumbar-puncture  needle  at  the 
rate  of  60  drops  per  minute.  If  it  exudes  at  a  lower  rate  than  this  no  definite  deduction 
can  be  drawn  ;  but  if  the  rate  of  outflow  is  higher  than  one  dro]3  per  second,  it  indicates 
a  condition  of  hypertension  due  to  disease  such  as  meningitis,  cerebral  tumour,  haemor- 
rhage, or  abscess. 

Reaction. — Cerebrospinal  fluid,  normal  or  abnormal,  is  always  alkaline. 

Cryoscopy. — The  normal  freezing  point  of  the  cerebrospinal  fluid  is  -  0-55°  C.  :  in 
disease  it  may  be  either  above  or  below  this  ;  generally  speaking,  the  greater  the  diminution 
in  the  freezing  point  the  more  likely  is  acute  organic  disease  to  be  |)resent  in  the  central 
nervous  system. 

Sugar. — The  amount  of  reducing  substance  in  normal  cerebrospinal  fluid,  estimated 
l)y  the  reduction  of  Fehling"s  solution,  is  approximately  1-.5  jiarts  per  1000  :  in  diabetes 
niellitus  this  is  more  or  less  increased  ;  what  the  figures  are  in  other  conditions  has  not 
yet  been  established  fully,  but  there  is  some  evidence  to  show  that  the  sugar  is  nuiterially 
decreased  in  dementia  prsecox. 

Vrea. — Urea  in  cerebrospinal  fluid  amoimts  ndrnudly  to  015  parts  per  1000  ;  the 
disease  in  which  there  is  any  material  increase  in  this  is  uraemia,  and  the  excess  of  urea  in 
cerebrospinal  fluid  in  this  condition  is  sometimes  an  important  point  in  the  differential 
diagnosis  in  cases  of  coma. 

Proteids. — There  is  little  if  any  coagulable  ))rotcid  in  normal  cerebrospinal  fluid  ; 
careful  analyses  have  shown   that  no   albumin   is  ])resent.   but   that   there  are  traces  of 


HEMIPLEGIA  ;!05 

globulin  ;  in  diseased  conditions,  particularly  those  associated  with  inflammation  within 
the  cranium  or  spinal  canal,  there  are  albumin,  more  globulin  than  normal,  and  often 
some  nucleo-proteid. 

Choline. — Some  stress  was  laid  at  one  time  upon  the  supposed  fact  that  clioline 
platino-chloride  crystals  were  obtainable  from  the  cerebrospinal  fluid  wlicn  acute  nervous 
degeneration  was  taking  place,  and  not  in  health  ;  but  the  tests  employed  were  unreliable, 
and  the  general  opinion  now  is  that  deductions  drawn  from  analyses  for  choline  are 
erroneous,  even  when  the  choline  periodide  crystals  are  tested  for  instead  of  the  ])latino- 
chloridc. 

Ci/lolnaical  Ki'(i)inii(ili(»i.  -The  normal  fluid  is  practically  free  from  cells,  although, 
owing  to  the  impossibility  of  avoiding  slight  injury  to  vessels  by  the  introduction  of  the 
lumbar-puncture  needle,  a  few  red  corpuscles  are  generally  found  in  the  ccntrifugali/ed 
deposit,  and  a  few  leucocytes  corresponding  to  the  niunbers  that  would  be  expected  in  the 
blood  represented  by  the  red  cells.  It  is  probable  that  cerebrospinal  fluid  obtained  quite 
free  from  blood  contamination  would  be  free  from  leucocytes.  Quite  otherwise  is  it  in 
certain  diseases — not  only  in  acute  lesions,  such  as  meningitis,  but  also  in  chronic  degenera- 
tions, such  as  general  paralysis  of  the  insane.  It  is  important  to  examine  the  centrifugalized 
deposit,  not  merely  for  the  presence  or  absence  of  leucocytes,  but  also  for  the  dillercnt 
relative  proportions  of  polymorphonuclear  cells  and  of  lymphocytes.  A  considerable 
number  of  i)olymorphonuclear  cells  generally  indicates  bacterial  infection  of  the  sub- 
arachnoid space  by  some  organism  other  than  the  tubercle  bacillus,  especially  streptococci. 
sta])hylococci.  pneumococci,  and  meningococci.  Some  degree  of  polymorphonuclear 
excess  may,  however.  accom])any  the  characteristic  lymphocytosis  of  a  few  cases  of  tuber- 
culous meningitis.  Mononuclear  ]jroliferation — lymphocytosis — indicates,  as  a  rule,  a 
subacute  or  chronic  inflammatory  or  degenerative  condition  ;  it  almost  invariably  accom- 
panies syphilitic  lesions  of  the  central  nervous  system,  jjarticularly  general  paralysis  and 
tabes  dorsalis  :  it  is  also  to  be  expected  in  tuberculous  meningitis,  and  in  sleeping  sickness. 
It  is  not.  however,  pathogiionmnic-  of  any  of  these,  for  it  has  been  observed  also  in  entirely 
dilTerent  conditions,  such  as  herpes  zoster,  acute  anterior  poliomyelitis,  some  cases  of 
cerebral  tumour,  lymphatic  Icuku'inia,  chloroma.  and  e\cn  mumps.  Although  lympho- 
cytosis generally  indicates  chronic  mischief,  and  polymorphonuclear  leucocytosis  acute 
infection,  in  the  later  stages  even  of  acute  microbial  infections  mononuclear  cells  may  be 
more  numerous  in  the  cerebrospinal  fluid  than  are  the  polymorphonuclears.  In  a  few 
cases  of  new  growth,  especially  sarcoma,  affecting  the  spinal  cord  or  its  meninges  the 
diagnosis  has  been  suggested  by  the  discovery  of  large  atypical  cells  in  the  fluid  obtained 
by    lumbar    puncture. 

lidctviiiilogiciil  K.rdiiiiiiiilion.—'Sormnl  cereljrospinal  llui<l  is  absolutely  sleriic.  In 
pathological  conditions  it  may  be  examined  bacteriologically  in  various  ways,  including 
<lirect  staining  of  films  made  from  the  centrifugali/.ed  deposit,  cultural  methods,  and 
inoculalioti  into  animals.  The  most  important  organisms  that  have  been  found  are  the 
piieumococcus.  si  n|it(icoe(us.  bacillus  tuberculosis,  meningococcus  (Weichselbaum's 
Dijjlo.inriis  iiilidcil/iiliiiin  nirtiiiigiliilis),  ])neumobacillus,  staphylococcus,  bacillus  Isphosus, 
bacillus  infhicn/.a'.  spjroclueta  |)alli(la,  and,  probably  as  a  terminal  iideclion  only,  the 
JidciHtis  ciili  coniniiDiis.  The  cerebros])inal  fluid  may  be  used  for  testing  for  Wassermann's 
reaction  for  syphilis  in  the  same  way  as  is  blood  serum  ;  the  test  is  not  necessarily  positive 
in  the  former  when  it  is  in  the  latter,  but  when  the  cerebrospinal  fluid  itself  gives  a  positive 
reaction,  tlu'rc  is  almost  certainly  active  syphilitic  disease  of  the  nervous  system.  II  is 
important  lo  know  that  a  negati\-e  Wasscrmami  reaction  in  the  blood  does  not  exclude 
syphilis  of  the  nerv<ius  syslem  the  blood  is  negalivc  in  not  a  few  eases  of  labes  dorsalis, 
lor  exampii-.  CNcn  win  ii  no  antisyphilitic  remedies  have  lieiii  crniiloycil.  The  Trci>omiti(i 
//(illitliini  (Sjiinic/iirld  jiiilliild)  has  b;'en  found  in  the  cercl'ii)s|iiti:il  lluid.  bul  II  is  mor<'  likely 
to  be  delected  in  the  local  syphilitic  lesions.  The  oidy  protozoori  at  all  constant  l\  inel  with 
in  the  cerebros|iiiial  lluid  in  dis<-ase  is  the  'l'ii//idiiii.siiiiid  <iti»ihi(iisi-  in  casis  In  wliicli  I  he 
trypanosomiasis  has  naclied   the  stage  of  sleeping  sickness. 

.\mongst  the  less  usual  CiUises  of  hemiplegia  it  is  worlhy  of  particular  mention  that 
liriiiidl  iirirdli/sis  of  llir  iiisnuc  sometimes  attracts  little  or  no  allenlion  until  a  seizure  of 
some  kind  occiirs.  Iliis  scizun-  not  iiirri-ip]cntl\'  liclng  cjillcpt  ll'orm,  and  sdUKllmes  producin;^ 
a    hrrulplcgia    closely    simMiatinu    llial    due    to   ccrelirMl    li;emorrliag<'.      Tlic   diagnosis    may 

u  -JO 


y06  HEMIPLEGIA 

remain  uncertain  until  the  course  of  tlie  case  can  be  followed,  but  \Vassermann"s  serum 
reaction,  and  the  lymphocytosis  in  the  cerebrospinal  fluid,  may  each  serve  to  point  to 
the  true  nature  of  the  case.  Another  feature  is  the  very  rapid  rate  of  temporary  recovery 
exhibited  by  some  patients  :  deeply  comatose  and  liemiplef;ic  when  seen  upon  the  day  of 
seizure,  nearly  all  the  symptoms  may  have  disapjieared  by  the  next  morning  in  a  way  that 
would  be  unusual  were  they  due  to  a  hicmorrhage  of  sullicient  size  to  cause  so  deep  a  coma. 
In  elderly  people,  incomplete  hemiplegia  may  occur  rapidly  but  transiently  over  a 
period  of  years,  in  such  a  way  as  to  suggest  during  the  first  attack  or  two  that  there  has 
been  an  actual  extravasation  of  blood  within  the  brain.  The  rapidity  with  which  the 
hemiplegic  symptoms  may  disappear,  and  the  way  in  which  they  may  recur  and  yet  dis- 
appear again  each  time,  render  it  probable  that  these  (jatients  are  not  suffering  from  the 
effects  of  recurrent  small  ha-morrhages.  but  from  a  condition  of  partial  occlusion  of  their 
cerebral  vessels  by  atheroma  to  such  an  extent  that,  whereas  the  circulation  is  just  suflicient 
for  the  needs  of  the  brain  at  one  time,  it  is  Just  insuflicient  at  other  times  ;  the  result  being 
that  wlien  the  insufficiency  of  cerebral  circidation  is  most  in  evidence,  weakness  of  a  hemi- 
plegic type  ensues,  to  disappear  when  rest  in  bed  restores  the  cerebral  circulation  to  a 
sufficiency  again.  Cases  of  this  kind  have  been  s[)oken  of  as  suffering  from  intermittent 
claudicntion ,  as  though  the  vessels  could  alternately  dilate  and  close  up  spontaneously  : 
but  there  is  evidence  to  .show  that  thei-e  are  no  eflicient  vasomotor  nerves  in  the  cranial 
vessels,  so  that  the  theory  of  l/orderliinil  sufficiency  of  circulation  through  atheromatous 
vessels  is  more  probable  than  that  of  intermittent  claudication. 

Cerebral  tumour  or  cereliral  absces.s  may  produce  hemiplegia  by  infiltrating  either  the 
cerebral  cortex  or  the  pyramidal  tract  directly,  or  by  these  becoming  involved  in  the 
softening  around  the  tumour  or  the  abscess  ;  in  most  cases  there  will  be  a  hi.story  of  weeks 
or  months  of  headache,  giddiness,  and  effortless  vomiting,  with  or  without  signs  of  irritation 
previous  to  the  paralysis  ;  o|)hthalniosco])ic  examination  will  frequently  reveal  optic 
neuritis  of  the  choked  disc  tyi)e  {Plate  .\7.\.  Fig.  A.  |).  41(>),  and  in  the  ab.seess  eases  there 
will  generally  be  a  predisposing  cause.  ])articularly  otitis  media.  It  is  well  known,  however, 
that  either  a  tumour  or  an  abscess  within  the  cranium  may  be  latent  for  months,  and  in 
some  such  ca.ses  symptoms  may  come  on  acutely,  esi)ecially  if  there  has  been  hiemorrhage 
into  a  softening  tumour.  Ordinary  cerebral  luemorrhage  may  be  simulated  in  this  way. 
but  if  well  marked  optic  neuritis  is  found  in  both  eyes,  it  is  probably  not  a  haemorrhage 
only.  The  existence  of  pyrexia  is  not  by  itself  evidence  of  abscess,  for  hsemorrhage  near 
the  internal  cap.sule,  or  in  the  motor  cortex,  often  leads  to  some  rise  of  temperature  for 
the  time  being,  whilst  pontine  hiemorrhage  is  not  infrequently  associated  with  hyper- 
pyrexia, and  in  not  a  few  cases  of  intracranial  abscess  pyrexia  is  conspicuously  absent. 

Injury  to  the  Spinal  Cord  in  the  Cervical  Region  is  a  very  rare  cause  of  paralysis  of  the 
arm  and  leg  U])on  the  same  side  ;  first,  because  trauma  here  is  extremely  liable  to  damage 
more  than  half  the  cord  :  and,  .secondly,  because  the  injury  must  involve  the  lower  part 
of  the  cervical  enlargement  if  the  arm  is  to  be  paralyzed,  and  it  is,  therefore,  very  liable 
indeed  to  interfere  with  the  subsidiary  respiratory  centres,  and  thus  prove  rapidly  fatal. 
Occasionally,  however,  either  a  knife  stab  or  a  bullet  wound  on  one  side  of  the  neck  produces 
hemiplegia  with  evidence  of  unilateral  paralysis  of  the  diaphragm  as  observed  when  the 
patient's  abdominal  respiratory  movements  are  watched  in  a  good  light.  It  has  sometimes 
been  asserted  that  the  patient  will  have  anaesthesia,' not  of  the  same,  but  of  the  opposite 
side  of  the  body  :  in  practice  this  is  not  generally  the  ease,  the  hemiplegia  and  the  hemi- 
ansesthesia  being  on  the  same  side  as  the  lesion  in  at  least  some  instances. 

Children  of  a  rheumatic  tendency,  who  are  subject  to  chorea,  sometimes  present  the 
movements  of  the  latter  upon  one  side  of  the  body  only — hemichorea  :  both  before  the 
actual  movements  appear  and  after  they  have  ceased  there  is  apt  to  be  considerable,  and 
occasionally  extreme,  weakness  of  the  affected  side  ;  so  much  so  that  some  intracranial 
lesion  may  be  su.speeted,  imless  there  has  been  clear  evidence  of  the  existence  of  chorea. 

Occasionally,  weakness  of  a  hemi])legic  nature  may  be  the  first  symptom  ot  meningitis. 
whether  tuberculous,  suppurative,  posterior  basal,  or  epidemic  cerebrospinal  ;  sometimes, 
upon  post-mortem  examination  a  definite  unilateral  softening,  or  a  tuberculous  nodule 
affecting  the  pyramidal  fibres  may  be  found  to  account  for  this  ;  but  more  often  the  appear- 
ances seen  after  death  fail  to  explain  why  there  should  have  been  unilateral  ])aretic 
symi)toms.     In  the  earlier  stages  the  diagnosis  may  be  quite  obscure,  but  sooner  or  later 


HICCOUGH  ;i07 

the  paresis  becomes  bilateral,  and  tlie  course  of  the  disease  indicates  meninjiitis  beyond 
doubt,  especially  if  there  are  convulsions,  vomiting,  and  optic  neuritis.  Choroidal  tubercles 
may  be  detected  in  some  cases  {Plate  XX.  Fig.  if,  p.  418),  and  the  cerebrospinal  fluid 
may  be  examined  cytolo<;ically  and  bacteriolojiically. 

Disseminated  Sclerosis  is  a  very  slowly  progressive  disease,  in  which  during  the  earlier 
stages  the  foci  of  sclerosis  are  few  and  quite  irregularly  distributed,  so  that  whereas  in 
the  later  stages  ataxy,  intention  tremor,  more  or  less  spasticity  with  increased  knee-jerks, 
extensor  plantar  reflexes,  ankle-clonus,  and  either  slurred  or  staccato  speech,  are  to  be 
expected,  these  are  only  jiresent  when,  in  the  course  of  years,  numbers  of  sclerotic  foci 
have  accumulated  in  the  spinal  cord  and  brain  :  long  previous  to  this  there  have  been 
irregular  symptoms,  amf)ngst  which  may  be  hemiplegia  ;  the  diagnosis  at  this  stage  is 
often  a  matter  of  opinion  only,  though  if  the  patient  can  be  watched  over  a  sullicient  length 
of  time  the  nature  of  the  case  ultimately  becomes  obvious. 

The  symptoms  of  eni.isoii  disease  are  due  to  the  liberation  of  air  bubbles  in  the  nervous 
system,  and  what  the  symptoms  will  be  depends  on  where  these  bubbles  are  ;  in  most 
instances  they  are  widely  scattered,  so  that  bilateral  paralyses  are  more  common  than 
imilateral  :  it  is  possible,  however,  for  caisson  disease  to  produce  hemiplegia  if  a  relatively 
large  air  bubble  becomes  liberated  in  or  near  the  internal  capsule.  The  diagnosis  depends 
on  the  history  and  occupation. 

Hysteria  may  be  responsibU'  I'nr  almost  any  form  of  nerve  symijtom.  hemiplegia  being 
not  an  uncommon  variety.  There  is  no  wasting,  except  that  which  may  be  due  to  disuse  ; 
the  knee-jerks  may  be  exaggerated,  but  the  plantar  reflexes  will  remain  flexor,  and  there 
is  no  ankle-clonus  :  the  face,  as  a  rule,  is  unaffected  ;  if  the  patient,  lying  flat  upon  her 
back,  is  asked  to  raise  her  legs  from  the  bed,  she  will  raise  the  sound  leg,  but  not  that  which 
is  paretic  ;  whereas,  in  a  case  in  which  there  is  incomplete  paralysis  of  one  leg  due  to 
organic  lesions  of  the  ujiper  neuron  upon  one  side,  an  attempt  to  raise  the  leg  in  this  way 
often  leads  to  the  iiaretie  leg  being  lifted  as  well  as  the  other.  The  sex  and  age  of  the 
patient,  her  jirevious  history,  and  the  presence  possibly  of  other  functional  nerve  symptoms 
(p.   l-li.j).  would  indicate  the  diagnosis.  Ihrln-rt  French. 

HICCOUGH  is  a  symptom  which  more  often  than  not  has  no  clinical  significance. 
rcsiiltini;,  ;is  it  does  even  in  the  healthiest  people,  from  excessive  laughter,  from  stimulation 
of  certain  reflex  spots,  especially  about  the  chin,  from  tickling,  or  e\en  coming  on  spon- 
taneously  wiihout   any  obvious  cause  at   all. 

Occasionally,  however,  hiccoughing  may  be  so  ])ersistcnt  or  may  reach  so  alarming 
a  degree,  that  it  becomes  of  clinical  ini])ortance.  The  patients  may  be  divided  into  two 
groups,  namely,  those  in  whom  there  is  already  severe  illness,  and  those  who  are  not 
<)b\  iously  ill.  Of  the  former  group  there  are  two  main  types — the  Alcoholic  and  the 
Peritonitic.  No  rlilliculty  of  diagnosis  arises  between  these  two  ;  the  dnmkcn  person's 
hiccough  has  a  eharaclcr  of  its  own.  The  patient  who  has  an  acute  abdominal  condition 
associated  with  hiccough  will  have  presented  gra\e  symptoms  long  before  hiceougli  sets 
in.  the  diagnosis  often  having  been  arrived  at  by  urgent  laparotomy.  Hiccough  in  these 
cases  does  not  serve  to  distinguish  between  acute  peritonitis  due  to  whatever  cavise,  acute 
ha-morrhagic  pancreatitis,  acute  intestinal  obstruction  from  any  cause,  or  acute  post- 
operative dilatation  of  the  storuacli  :'  its  occurrence  and  persistence.  liowe\er.  indicati'  a 
very  grave  i)rognosis. 

When  persistent  or  reciureiit  hiccough  is  a  troublesome  symi)tom  in  a  patient  who 
is  not  obviously  ill  —so  troublesome  that  something  more  than  a  simple  hiccough  has  to 
be  thought  of — three  main  ty]>cs  of  malady  will  suggest  themselves,  namely  : — 

1.  Hysteria  or  neurosis. 

2.  .Mediastinal  irritation  of  vagi  or  phrenic  ncr\-es.  e.g..  by  caseous  glands, 
."i.    Degenerative  changes  in  the  nicilulla  nhlongatii. 

None  of  these  llirce  t\|ics  is  ;i|  all  roniiniin.  and  llicir  diagnosis  during  life  is  often  a 
mat  ter  of  opinion. 

Functional  Hiccouf<h  is  a  rcMiaiUalile  niala(l\  haidl\  to  he  mistaken.  The  patient 
is  gcncrallv  a  girl  hitwceii  1.")  and  2."i  years  of  age.  and  slie  may  hiccough  persistently 
throughout  her  waking  hours  for  weeks,  at  the  rate  of  two  oi-  three  limes  a  minute.  She 
will  sleep  well,  and  the  hiccough  stops  during  sleep.     She  will  lat  w<  II,   liut  may  hiccough 


308  HICCOUGH 

(luriiif;  nuals  in  a  most  (lisd-cssing  way.  Slie  will  have  exaggerated  knee-jerks,  brisk 
flexor  plantar  reflexes,  and  she  will  be  amenable  to  treatment  by  suggestion.  Whether 
treated  or  not,  the  hiccough  will  cease  in  time,  though  it  may  persist  on  and  off  for 
weeks  ;  often  it  will  be  noticed  to  have  come  in  the  ])lace  of  some  other  neurosis 
(p.  4()5).  aiul   when   it  goes  it   may  be  replaced  by  other  functional  nerve  symptoms. 

Irritation  of  a  Vagus  or  Phrenic  Nerve  by  something  in  the  mediastinum  causes 
recurrent  attacks  of  intractal)le  hiccough  only  in  rare  cases.  In  a  child,  the  least  uncom- 
mon cause  is  liihercidoiis  cii.scdiidii  of  hroniliiiil  and  iiicdiaslhiid  <llnnils  ;  these  seldom  obstruct 
a  bronchus  or  in  other  inechaiiical  ways  aliord  e\idence  of  their  jjresence  :  but  they  may 
be  associated  with  periodic  attacks  of  febrile  illness  in  a  patient  who  looks  delicate,  and 
who  has  been  in  the  habit  of  drinking  much  milk  ;  and  there  may  be  evidence  of  chronic 
enlargement  of  the  glands  elsewhere,  particularly  those  in  the  neck  or  in  the  abdomen.  It 
may  be  possible  to  see  the  shadow  of  the  gland  with  the  .c-rays  {Fi<>.  (il.  ]).  149).  AiDicrent 
perirnrdium,  or  any  cause  of  great  erdrirgement  of  the  hetirl.  may  also  produce  hiccough. 
In  an  adidt  the  least  unconmion  causes  are  either  malignaid  or  lympliddenomatous 
deposits  in  the  mediastinum,  or  else  fibrous  mediastinitis.  The  former  may  be  indicated 
hy  reason  of  there  being  symptoms  of  a  primary  growth  in  the  u-sophagus  or  elsewhere, 
or  by  progressive  varicosity  of  the  veins  of  the  chest  wall,  or  signs  of  recent  and  increasing 
obstruction  to  a  bronchus  ;  chronic  mediastinitis  has  generally  been  preceded  by  repeated 
attacks  of  pleurisy  and  pericarditis,  especially  in  those  subject  to  acute  rheumatism. 
Hiccough  is  an  exceptional  symptom  in  these  cases. 

Uraemic  Hiccough  is  rare,  but  it  may  he  persistent  and  of  grave  omen.  A  few  patients 
suHering  from  serious  but  not  urgent  abdominal  disease  develop  distressing  hiccough  in 
some  reflex  way  that  is  not  understood  ;  in  a  few  instances  it  may  be  that  the  diaphragm 
is  being  irritated,  for  example  l)y  secondary  de])osits  of  (•«/*(•<•(■  iit  the  liver,  a  siiinniKi  or  (il)seess 
ill  the  liver,  an  infaret  in  tlie  spleen,  or  a  carcinoma  of  the  stonitieh  ;  but  sometimes  the 
mischief  seems  far  removed  from  the  diaphragm — a  carcinoma  of  the  sigmoid  colon,  for 
instance,  or  cancer  of  the  tvomb,  even  when  there  are  no  secondary  deposits. 

Finally,  if  hiccough  is  due  to  degeneration  or  .softening  of  the  tnedidlari/  eeidres,  it  will 
almost  certainly  be  associated  with  other  syni])toms  of  cerebral  or  sj)inal  mischief  :  in 
a  young  adidt  there  might  be  a  suggestive  history  of  sy]ihilis  or  chronic  alcoholism,  whilst 
in  an  older  jjcrson  there  would  be  thickened  and  tortuous  arteries,  a  high  tension  pulse, 
an  enlarged  heart,  areus  senilis,  possibly  albuminuria  in  an  abundant  urine  of  low  speciflc 
gravity — signs  of  senile  degenerative  changes.  Jlnherl  Firiich. 

HIPPUS. — (See  Pupil,  AnNORMAi.rriKS  of  Tiiii,  p.  551.) 

HUSKINESS. — (See  Speech,  Abnoh.malitii-.s  of,  p.   623'. 

HYPERACUSIS,  or  undue  sensitiveness  to  ordinary  noises  or  sounds,  is  seldom  a 
symptom  jxiinting  to  disease  of  the  ear  itself;  aural  lesions  such  as  otitis  media  nearly 
always  cause  impaired  hearing  or  actual  De.vfness  (p.  163),  and  not  hyperaeusis.  The 
latter  is  complained  of  rather  by  those  whose  brain  centres  are  in  an  imstable,  irritable, 
over-strained,  or  excitable  state  as  the  result  of  either  local  or  general  conditions  which 
inelude  the  following  : — 

1 .  Local  Causes  : — 


Early 

stages 


Gumma  of  the  brain 
.Abscess  of  the  brain 
Tumour  of  the  brain. 


(a).    With  gross  lesions  of  the  bruin  itself. 
'f ubcrcuhtus   mciiinjiitis 
McniiiLiococcal    mcniui»itis 
.Suppurative  mcnlniiitis 
Paeliy  meningitis 

(b).   Without  gross  lesions  of  the  brain   itself,   bid   affeeling  the  latter  re/le.rli/  from   tlic 
severity  of  loeid  pain  : — 
Tic  douloureux  i    .Severe    headaelie     from     any    cause 

Glaucoma  !        (p.   2y8),   especially  siek  headache 

Iritis  I        or  migraine. 

Indamniatory  conditions  of  the  sealp 

((■).  After  iiijuri)  to  the  heail — eonenssion. 


1 


HYl'ERPVK?:xrA 


2.  General  Causes  : — 

(a)  Diiiinij  convalescence  from  any  severe  illness,  especially  fevers. 

(6)    Strycliuint  poi.soiiing  ^    Secondary  syphilis  |    Hysteria 


Tetanvis 
Alalaria 


Hiflh  bloocl-i)rcssiirc  conditions 
Xeurasthenia 


Hypochondriasis 
Graves's  disease. 


The  circumstances  of  the  case  will  nearly  alway.s  indicate  the  nature  of  the  cause. 
Probably  the  most  marked  instances  of  hypcracusis  are  met  with  in  association  with  tic 
<loiilourcux  ;  it  is  not  so  much  perhaps  that  the  patient  hears  more  actuely  than  usual,  as 
that  she  dreads  the  onset  of  a  paroxysm  of  facial  ])ain  which  may  be  brouijht  on  suddenly 
and  acutely  by  almost  anythini;,  and  often  by  hcarinfj  a  door  bani;.  or  somebody  talking 
loudly  ;  she  therefore  com])lains  of  the  least  noise,  and  keeps  herself  shut  up  in  her  room, 
from  which  all  sounds  are  excluded  by  all  kinds  of  special  devices. 

The  neurasthenic  jiatient  who  suffers  from  hyperacusis  is  to  be  pitied  greatly  ;  for 
though  suffering  from  no  serious  organic  disease,  he  dreads  all  sounds  so  nuich  that  he 
becomes  an  almost  useless  member  of  society,  a  misery  to  himself  and  his  friends.  His 
functional  sufferings  may  be  so  bad  as  to  drive  him  to  desperation  and  to  suicide. 

The  desire  for  perfectly  silent  surroundings  during  an  attack  of  sick  headache  or  of 
migraine  are  familiar  to  all.  The  remaining  affections  in  the  list  above  need  not  be  dis- 
cussed in  detail  here,  for  they  will  be  associated  with  other  symptoms  that  will  point  to  the 
<lifferential  diagnosis  -C'oxvrLsioxs  (p.  14.3)  for  exani])le  :  or  Evi;,  Aclte  Ini'i,a:mmation 
OK  (p.  2;il),  or  VoMiTiNC  (p.  7()3).  and  so  on.  One  would  add,  however,  that  before 
diagnosing  a  case  as  purely  functional,  the  blood-pressure  should  be  measured  instrument- 
ally,  and  the  urine  tested  for  albumin,  in  case  the  cause  is  arteriosclerosis  or  chronic 
nephritis  with  hyperpiesis  ;  and  in  not  a  few  cases  it  is  advisable  to  have  the  blood  tested  for 
Wassermann's  reaction,  for  it  is  surprising  how  often  obscure  nerve  sym])toms  that  at  first 
sight  appear  purely  functional  reallj-  have  a  sy|)hilitic  basis.  Herbert  French. 

HYPERIDROSIS.     (See  Swi:atin(;.   .VBNon.MAi.rnr.s  ok,   J).  0.54.) 

HYPERPYREXIA.  -The  point  at  which  pyrexia  becomes  hyperpyrexia  is  arbitrary; 
by  some  it  is  fixed  at  10.5  K..  by  others  at  l()(i  F.  It  may  occur  occasionally  in  many 
different  diseases,  liut  it  is  seklom  itself  of  diagnostic  signihcance.  The  patient  will  nearly 
always  have  exhibited  other  symptoms  or  signs  pointing  to  the  diagnosis  ;  therefore  the 
following  list  of  maladies  in  which  hyperpyrexia  may  occur  needs  little  discussion  : — 


A.  Fevers    of    Microbial,    or    probably    of    Microbial,    Origin: 


I.(>l>ar   pnciunonia 
HroDchopiu-unioiii:! 
Scarialin;i 
I'va-niia 
S(|ificaliii:i 
l-avsipcias 
'I'vphoicl    lever 
Tvpliiis  lever 
■JVI s 


Malit;riaiit  ciidocanlitis 
(Jeiieral  tiilKTeulosis 
Til heri'd lolls    meningitis. 
I'ostcriov    liasa!    nieningit's 
lOpideiiiie  eercl)rospinal   nieniii- 

gilis 
.Suppurative   meningitis 
Malaria 
l{elapsing   fever 


Cholera 
Dvsciiterv 
Yellow    leNcr 
lilieinnalie    l'e\'e{ 
Chorea    insanien^ 
t'raniia  due  to 

nephritis 
I'velitis. 


li.  Lesions    of    the    Central    Nervous    System 

t'erehnd    huiMii'rha;;c,    cspicially    poii- 

tinc,  or  inid  i<nr  opiic  llialaiMiis 
Kraeturcd  skull,  wilh  eontusion  oi'  Ihc 

hr.iin 
Cerehral   Mirieiiirii; 

C.  Affections    tiiat    are    less    easy    to    classify: 


.\n<T  hums  or  M-ald- 
Ileal    stroke   or  suuslrnk. 
Inraiilile    eonxulsioiis 
Deliriuiii    trciuciis 

I).  Hysteria. 


Cerelral   luniour  or  abscess,  especi:! 

lunioiu'  of  llic  pons  Varolii 
I''ractured  spine,  espi-eially  Iti  llie  Un 

ecrvieal  or  upper  dorsal  regions 
Aeide  myelitis  alter  injury. 


III:. I    due    h 


I'ra-inia  olhir   Ih; 

iiephril  is 
Aenle  yellow  alroph>   ol  Ihc  li\c'r. 


There  arc.   howcxcr,  eiiiaiii   small   poirds  aboni    liyperpyrexia   llial    may   be   imporlant 
in  diagnosis. 


310  HYPERPYREXIA 

Acute  rlieumalism  is  often  stated  to  be  a  prominent  cause  of  it  :  as  a  matter  of  fact, 
liyiierpyrexia  is  excessively  rare  in  acute  rheumatism,  so  that  should  it  occur  in  a  case  that 
has  been  regarded  as  rheumatic  fever,  the  diagnosis  should  be  very  carefully  revised,  lest 
it  really  be  sejitica-mia. 

1)1  children  the  ])hysical  signs  alone  may  leave  one  in  doubt  as  to  whether  there  is 
bronchitis  only,  or  bnincho-pniumdnia.  or  even  general  tuberculosis  of  the  lungs  :  the 
occurrence  of  hyperpyrexia  gcniially  inilicates  that  there  is  more  than  bronchitis  ;  if  the 
])atient  is  not  particularly  livid,  bmiichopneumonia  is  more  likely  than  general  tuber- 
culosis ;  the  latter  becomes  the  more  ])robable  the  more  ill  the  patient  is  out  of  proportion 
to  the  physical  signs.  Occasionally  hyperjjyrexia  occurs  in  an  infant  or  child  after  a  fit. 
without  any  definite  cause  being  assignable  either  for  the  con\  ulsion  or  for  the  high  tem- 
perature, and  withovit  any  serious  consequence  resulting. 

In  Uibereiiloiis  nieningitis  hyperpyrexia  is  generally  terminal  :  in  posterior-biisdl 
Diciiiiigitis,  on  the  other  hand,  it  sometimes  occurs  periodically  and  transiently,  producing 
acute  upward  '  spikes  "  upon  a  temperature  curve  that  is  not  otherwise  very  high  ;  these 
pyrexial  'crises'  (Fig.  253,  p.  591),  as  they  have  been  called,  jjoint  to  posterior-basal 
rather  than  to  the  more  serious  tuberculous  meningitis. 

Hyperpyrexia  may  sometimes  serve  as  the  chief  point  in  distinguishing  pontine  Iriinoi- 
rliage  or  liciit-stidlic  from  other  forms  of  coma,  such  as  acute  alcoholism  or  opium  poisoning  : 
in  the  latter,  the  temperature  is  below  normal.  The  circumstances  of  the  case,  such  as 
climatic  conditions  or  occupations,  will  generally  serve  to  distinguish  between  heat-stroke 
and  pontine  ha'morrhage. 

After  an  injury  to  the  back — for  instance,  by  a  fall  in  the  hunting  field — the  occurrence 
of  hyperpyrexia  sometimes  serves  to  exclude  the  diagnosis  of  a  mere  bruising,  and  to  point 
to  the  gravity  of  the  conditions — a  fractured  or  dislocated  spine  near  the  cervical  region, 
or  acute  traumatic  myelitis  or  softening  of  the  upper  i)art  of  the  spinal  cord. 

The  diagnosis  of  the  other  diseases  mentioned  in  the  above  list  is  not  much  assisted 
by  the  occurrence  of  hyperpyrexia. 

It  only  remains  to  add  a  word  or  two  about  lii/nlciiii  and  high  temperatures.  There 
can  be  no  doubt  that,  in  exceptional  eases,  nearly  all  of  which  are  of  the  female  sex.  the 
mercury  in  the  clinical  thermonuter  does  actually  rise  to  a  very  high  figure  without  there 
being  any  corresponding  illness  in  the  ])atient.  Malingerers  have  .sometimes  learned  a  trick, 
such  as  compressing  the  bidb  of  the  thermometer  enough  to  send  the  mercury  up  :  but 
quite  apart  from  malingering,  there  are  females  in  whom,  for  some  reason  that  is  not  yet 
miderstood,  the  mercury  really  does  record  temperatures  that  are  not  those  of  the  internal 
tissues.  Headings  have  been  taken  simultaneously  in  the  mouth.  arni|)its.  and  rectum, 
all  possibility  of  malingering  being  excluded  by  S])ecial  precautions  ;  all  the  thermometers 
registered  hyperpyrexia.  The  diagnosis  is  generally  made  by  the  fact  that  the  readings 
are  so  high  that  they  must  be  mireal  ;  the  following  \vA\e  been  recorded  in  various  cases  : 
'107  ,  108",  111",  113  ;  115-8  =  ,  116-4.",  117",  120-8  =  ,  122  \  127=,  128  ,  and  even  131"  F.  In 
most  of  these  jiatients  the  .symptoms  were  slight,  though  sometimes  there  have  been 
flushings,  headache,  restlessness,  and  various  functional  nerve  symptoms,  or  even  delirium 
and  convulsions.  Unless  it  is  at  once  obvious  that  the  patient  is  not  really  ill.  there  must 
always  be  difliculty.  danger,  and  anxiety  in  arriving  correctly  at  the  diagnosis  of  hysterical 
hyperpyrexia  ;  the  nature  of  the  case  may  remain  in  doul)t  until  the  course  and  result 
have  been  watched.  Herbert  Frencli. 

HYPERTROPHY  OF  THE  HEART.     (.Sec  Knl.vrgkmknt  oi- thf.  Hkaut.  p.  206.) 

HYPOTHERMIA  signifies  a  condition  of  subnormal  temperature,  and  generally  speak- 
ing it  is  assumed  to  refer  to  the  temperatui'es  registered  by  the  thermometer  in  the  mouth. 
Rectal  temijeratures  do  not  always  coincide  with  those  of  the  mouth,  but  the  clinical  sig- 
nificance of  variations  in  rectal  temperatures  is  not  yet  fully  understood.  From  a  dia- 
gnostic point  of  view  hypothermia  is  not  often  a  sym]>tom  of  great  importance,  but  there 
are  at  least  two  points  about  it  that  require  special  mention.  In  the  first  ]>lace,  coma  due 
to  opium  poisoning  may  be  closely  simulated  by  coma  due  to  pontine  luemorrhage  ;  in 
both  there  are  bilateral  loss  of  movement,  pinpoint  pupils,  and  few  other  symptoms  ;  with 
opium    poisoning,    however,    the    temperature    becomes   subnormal,    whilst    with   pontine 


HYPOTHERMIA 


311 


haemorrhage  it  tends  to  rise  to  the  level  of  hyperpyrexia,  so  tiiat  the  thernioineter  may  be 
the  means  of  diagnosing  between  them.  In  the  second,  patients  sufl'ering  from  chronic 
valvular  heart  disease,  with  symptoms  of  imjiending  or  actual  failure  of  compensation,  very 
commonly  sufl'er  from  hypothermia.  This  is  a  point  not  always  emphasized  sufficiently  ; 
not  a  few  cases  of  lieart  disease  having  for  their  normal  temperature  base-line  not  98-4'  F, 
but  97"  F.,  or  even  96  F  (Fig.  142).  It  follows  that  a  i)atient  whose  normal  temperature  is 
96°  F.  really  has  over  two  degrees  of  fever  when  his  tem])erature  reaches  98-4'  F.  ;  he  may 
develop  fungating  endocarditis  on  the  top  of  his  chronic  valve  lesion,  and  yet  his  temperature 
may  not  rise  materially  above  98-4-  F.  The  fact,  therefore,  that  hypothermia  is  a  common 
feature  in  heart  cases  has  great  importance,  for  it  indicates  the  necessity  for  regarding 
even  slight  rises  above  98-4°  F.  with  greater  seriousness  in  them  than  in  other  cases. 

For  the  rest  it  will  suffice  to  indicate  the  chief  causes  of  hypothermia,  which  are  as 
follows  : — 


Chronic    Debilitating    Maladies,    such  as  :- 
C'letinisin 


Chronic     valvular 

lieart   disease 
.Addison's   diseaxc 
Diabetes  niellitiis 


ArteridscliTosIs 
.Mvxu'ilcina 


Coma,  due  to  poisons,   particularly  : — 


Opium 
.Mcoli.il 


Cliloral 
Aiiivsthctics 


Increased    Intracranial    Pressure    in  certain  cases  of  :- 


Cerebral   abscess 
Cerebral   tuiiif)ur 


Cerebellar  abscess 
Cereljfllar  tumour 


Chronic    nephritis,    with   or 

without   uru'inia 
Inanition,      maliuiiant      or 

otherwise   (Fig.   143). 


Carbolic  acid 
Oxalic  acid 


Cerebral   ha'morrhagc. 


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considerably  from  its  value  in  dilTcrcntial  diagnosis  in  these  cases. 

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In  the  morning,  in  cases  of  Intermittent  Pyrexias  ol'  the  septic  or  beeiic  t\pes.  It 
is  important  Ibal  llie  temperature  should  have  been  taUiii  bolb  night  and  morning  before 
the  low  riL;nres  lur  the  morning  arc  assumed  to  indic;Ue  eonliimed  hypothermia  ;    very  low 


S12 


HYPOTllKK.MIA 


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resided  long  in  the  Tro])ics  arc  frequently  found  to  have  ])ersistently  low  normal  mouth 
temperatures  when  they  return  to  England  on  retirement  ;  thus  it  is  quite  common  for 
them  to  have  a  normal  temiierature  as  low  as  00    F.,  or  in  a  few  instances  even  94  '  F. 

Ilfihi-rl  French. 
ICTERUS.      (Sec  .lAiNDiCF..   ]..   321.) 

IMPOTENCE,  strictly  speaking,  includes  any  condition,  whether  in  the  male  or  in 
the  female,  that  ])revents  the  performance  of  coitus  :  by  common  consent  it  has  come  to 
he  restricted  to  inability  on  the  jiart  of  the  male.  It  is  not  synonymous  with  sterility  : 
the  latter,  in  the  male,  implies  absence  of  the  spermatozoa  necessary  to  fecundation  ;  a 
man  may  be  sterile  without  being  impotent,  or  impotent  without  being  sterile,  or  both 
impotent  and  sterile.  There  are  three  main  groups  of  conditions  which  lead  to  impotence, 
namely  : — 

1.  Mechanical  Defect,  such  as  congenital  or  acquired  malformation  of  the  penis. 
ab.sence  of  the  penis,  carcinoma,  elephantiasis,  and  so  on.  These  need  not  detain  us,  for 
their  diagnosis  is  generally  obvious  on  inspection  ;  one  need  only  say  that  even  considerable 
deformities  of  the  genital  organs  are  by  no  means  necessarily  associated  with  impotence. 

2.  Entire  Absence  of   Penile   Erections  :   as  the  resvilt  either  of  some  organic  disease 


INCOXTIXENCE    OF    F.ECES 


of  the  nervous  system,   or  of  some  general   constitutional  eoiKiition 
particularly  the   followinj;  :  — 


)ne  niav   mention 


Tabes  dorsalis 
Ataxic  paraplegia 
(Jciieral  paralysis  of  the  insane 
I'rimary  spastic  ])araplegia 
Disseminated  sclerosis 
Amyotrophic    lateral    sclerosis 
Transverse    softening    of    the 
cord 


I'lmiiljisni 

(.'ompicssion  uT  the  lower  pait 
of  the  cord 

Dementia 

Diahetes  mellitus 

Atrophy  of  the  testicles  from 
injury  or  from  severe  orchitis, 
gonorrlural  or  otherwise 


Senility 

I'ernieious  ananiia 
.Malarial  cachexia 
Sy])hilitic  cachexia 
Cancerous  cachexia 
Phthisical  cachexia 
Exhaustion  from  excesses. 


There  is  little  need  to  discuss  these  further  here.  for.  providin<;  they  are  borne  in  mind, 
they  will  be  diagnosed  readily  as  the  result  of  a  carefid  routine  examination  of  the  nervous 
system,  urine,  lungs,  and  so  on.  One  need  only  add  that  impotence  may  l)c  an  early 
.symptom  in  ataxic  ])araj)legia.  disseminated  sclerosis,  and  ])htliisis,  and  that  the  diagnosis 
ma\'  seem  to  be  neurasthenia  oidy  imtil  the  ease  has  been  watched. 

:i.  Impotence  due  to  Inability  to  obtain  Erections  at  the  right  time. — This  is  a 
\ery  common  form  of  the  symptom  ;  the  i)atients  are  generally  told  they  are  suffering 
from  neurasthenia  ;  and  so  they  are.  of  a  particular  sort.  This  is  ])sychieal  or  nervous 
impotence  :  strong  erections  may  be  jirescnt  at  inopportune  times,  there  may  be  emissions 
during  sleep,  and  yet  at  the  very  moment  when  sexual  intercourse  is  intended  the  erection 
is  lither  quite  absent  or  iin))erfect.  Sometimes,  owing  to  extreme  irritability,  emission 
occurs  on  so  little  excitation  that  it  takes  place  before  insertion  is  complete,  the  rigidity 
of  the  penis  relaxing  almost  at  once,  so  that  com])letion  of  coitus  becomes  impossible. 
Temporary  impotence  of  this  kind  is  not  at  all  inicommon  during  the  first  few  days  or 
weeks  of  married  life,  especially  if  the  wedding  has  been  ])receded  immediately  Ijy  par- 
ticularly liar<i  business  strain  or  mental  overwork  preparatory  to  the  honeymoon.  The 
<liagnosis  is  arrived  at  partly  by  the  history,  partly  by  the  negati\c  result  of  careful  ])hysical 
examination  of  all  the  systems,  especially  the  nervous  and  pulmonary  ;  early  ])hthisis  is 
often  accompanied  by  inability  to  obtain  ]>cnilc  erection  :  but  the  (iiial  criterion  is  the 
elicct  of  time.  Where  there  is  no  organic  cause  for  the  symptom,  normal  coitus  will  occur 
j)reseiitly  if  the  patient   ceases  to  be  over-anxious  about   it.  Ilciltiil  Frciirli. 

IMPULSE,  DISPLACED  CARDIAC.  -(See  Ukaht  Impi  i.sh,  Displacki..  |).  297.) 

INCONTINENCE  OF  F;«CES.  -Evacuation  of  the  contents  (,f  the  rectum  without 
\iiluntary  coutrol  or  initiation  may  occur  under  several  distinct  conditions,  the  iinestiga- 
tioii  of  which  may  yield  results  of  great  diagnostic  im[)ortanc<'. 

In  healthy  persons  the  rellex  relaxation  of  the  sphiiicler  ani  which  is  neccssarx  for 
deliccation  lakes  place  only  at  the  bidding  of  tlu'  will.  Some  bealtli\-  persons  arc  belter 
able  to  resist  an  impcrati\e  call  to  stool  than  olbers,  and  it  happens  occasionally  that  an 
indix  idual  who  is  poorly  endowed  with  the  power  of  itdiibitiug  Ihe  rcllcx  may  sulTcr  from 
an  incontinence  of  fa-ces  when  Ihe  stinuilus  exdUcd  by  irritating  contents  of  the  bowel  is 
ovcrpoweringly  strong.  The  individual  woul<l  be  conscious  of  the  accident,  which  would 
be  of  rare  occurrence,  and  examination  would  reveal  no  abnormality.  Children  often 
suffer  in  Ibis  wa\-.  .Somewhat  similar  "  explosive  diarrlura  "  is  also  a  promineul  feature 
of  certain  eases  of  carcinomatous  stricture  of  the  sigmoid  colon. 

.Mechanical  ineotitincnce  of  licccs  results  from  injuries  or  diseases  of  the  rectum  or 
peiineum,  such  as  carcinoma,  in  which  Ihe  outlet  of  Ihe  bowel  is  no  longei-  guaiiled  by  an 
cnicicnl  s|iliiiict(r.  Local  ins|i(ctioM  and  digital  cxaminalion  (jf  the  parts  will  sulliec  to 
(liscoM'i-  the  cause  of  such  irieoiil  incncc. 

In  conditions  of  coma  or  partial  unconsciousness.  Irom  wbatcxcr  cause  arising,  rellex 
emptying  of  the  bowel  may  occur  at  interxals,  particularly  if  aperients  arc  administircd. 
Digital  cxaminalion  of  the  rectum  in  such  eases  will  rcxcal  a  normal  sphincter  which  closes 
on   the  observer's  linger. 

Injuries  or  discjiscs  id'  Ihe  central  ncrxdus  system  abo\c  1  be  sacral  region  of  the  cord, 
if  they  interfere  with  impulses  passing  from  the  cortex  to  the  lumbo-sacral  eulargcment, 
but  do  not  cause  serious  sensory  <listurbanec  in  the  perineal  area,  lead  to  an  nirslablc  con- 
dition to  which  the  term  '  precipitancy  of  <lcfa-eation  "  is  applie<l.  In  these  cireunistanecs, 
Ihr   patiiiil    is   usuallx    comsI  ipali<l,    but    the  call    to  stool,   when    it    comes,   spnntaucously  or 


314  INCONTINENCE    OF    F.ECES 

as  the  result  of  aijerient  niedieiiie.  is  im|ierati\  e,  aiul  Hnds  the  |)atient  powerless  to  resist 
or  delay  the  aet.  The  examination  of  sueh  a  jjerson  discloses  a  normal  sphincter  but.  in 
all  probability,  some  degree  of  spastic  paraplegia,  with  brisk  tendon  jerks  and  extensor 
plantar  responses,  and  inquiry  will  elicit  the  history  of  precipitate  micturition.  Moreover, 
the  |)atient  will  be  conscious  of  the  acts  of  defaecation  and  micturition.  This  association 
of  signs  and  symptoms  is  common  enough  in  cases  of  partial  injury  to  the  spinal  cord,  in 
cases  of  old  dorsal  myelitis,  of  disseminated  sclerosis,  of  syringomyelia,  etc. 

With  more  serious  disease  of  the  central  nervous  system  above  the  sacral  region,  the 
impulses  conveying  the  need  for  defaecation  do  not  reach  the  brain,  and  the  act  takes  place  in 
a  reflex  manner  without  the  knowledge  of  the  patient.  Under  these  circumstances,  para- 
plegia with  sensory  disturbance  over  the  sacral  segmental  areas  will  help  to  localize  the  site 
of  the  lesion.     The  tone  of  the  sphincter  ani  may  be  little  below  normal  or  quite  unimpaired. 

Disease  or  injury  leading  to  destruction  of  the  sacral  cord  or  of  the  cauda  equina  is 
distinguished  by  the  fact  that  incontinence  of  fa'ces  is  associated  with  an  insensitive  relaxed 
spliinrier  and  with  serious  motor,  sensory,  tro|)liie,  and  rcllex  disturbances  in  the  lower 
extremities.  When  the  fa'ces  are  small  and  fluid  they  esca])e,  more  or  less  continuously, 
through  the  gaping  anal  aperture.  On  the  other  hand,  they  sometimes  tend  to  accumulate 
in  dry  masses  too  large  to  pass  the  portal  without  assistance.  The  ])atient  is  imconscious 
of  the  accumidation,  unconscious  of  soiling,  and  insensitive  to  the  exploring  finger. 

It  will  l)e  imderstood  from  the  above  statements  that  for  the  pur|X)se  of  diagnosis  it 
is  necessary,  in  all  cases  of  ftccal  incontinence,  not  only  to  inquire  into  the  exact  features 
of  the  incontinence,  the  presence  or  absence  of  a  call  to  stool,  the  tendency  to  constipation 
or  precipitancy,  the  ability  to  feel  the  passage  of  motions,  etc.,  but  to  supplement  the  know- 
ledge gained  in  this  way  by  a  local  examination,  especially  of  the  sphincter  ani,  and  an 
investigation  of  the  motor,  sensory,  and  reflex  conditions  in  the  lower  extremities. 

E.  Fiirqiiliiir  JSiizzard. 

INCONTINENCE   OF    URINE.     (Sec  Micrt  hition,  Aunormai.itiks  ok.  p.  893.) 

INCOORDINATION.     (Sec  Ataxy,  p.  55.) 

INDICANURIA.  -Indican  in  the  urine  is  mainly  due  to  the  formation  of  indol  in 
tile  intestine  as  the  result  of  jiutrefactivc  changes  in  the  products  of  tryptie  digestion 
of  proteids.  The  indol  so  formed  is  absorbed  from  the  bowel,  and  converted  in  the  liver 
into  relatively  innocuous  potassium  indoxyl  sulphate,  or  indican.  This  is  tested  for  by 
oxidizing  it  to  indigo,  the  blue  colour  of  which  is  characteristic.  Almost  any  oxidizing 
agent  could  be  utilized  for  the  test,  but  the  dilficidty  is  that  even  slight  excess  of  the  reagent 
destroys  the  indigo.  A  brown  ring  appearing  at  the  junction  of  the  urine  and  the  acid, 
when  testing  for  albumin  with  nitric  acid  that  is  slightly  fuming,  generally  indicates  a 
considerable  degree  of  indicanuria.  To  be  certain  of  this,  .Jaffe's  bleaching-powder  test 
is  usually  employed.  There  arc  several  ways  of  using  it.  Fresh  solution  of  calcium 
hypochlorite  is  essential.  To  about  20  e.c.  of  urine  add  S  c.c.  of  chloroform  and  3  c.e.  of 
hydrochloric  acid  of  medium  strength  ;  the  colourless  chloroform  sinks  to  the  bottom  of 
the  mixture  ;  a  drop  of  the  caleiimi  hyjtochlorite  solution  is  now  added  and  the  test  tube 
deliberately  inverted  once  or  twice  :  a  second  dro|)  is  added,  and  so  on,  the  colour  of  the 
chlorofcniii  being  watched  the  while.  If  indican  is  present,  it  becomes  oxidized  to  indigo, 
which  is  dissolved  out  by  the  chloroform  so  that  the  latter  changes  from  colourless  to  blue, 
and  the  depth  of  indigo-blue  colour  in  the  chloroform  affords  a  rough  measure  of  the  amount 
of  indican  in  the  urine.  The  main  precaution  to  be  taken  is,  not  to  add  the  hypoclilorite 
solution  too  rapidly,  for  excess  of  it  discharges  the  colour. 

Indican  being  an  ethereal  sul|)hate.  it  is  present  in  excess  under  the  same  circum- 
stances as  an  excess  of  ethereal  sulphates.  At  one  time  it  was  thought  that  nuieh  useful 
clinical  information  as  to  the  condition  of  the  intestines  could  be  learned  from  its  occurrence. 
It  is  true  that  any  circumstances  that  are  likely  to  increase  the  ]jutrefactive  changes  in 
the  proteid  in  the  bowel  are  also  likely  to  increase  the  amount  of  indican  in  the  urine 
marked  indicanuria  is  generally  found  in  cases  of  chronic  constipation,  intestinal  obstruc- 
tion, diarrluca.  typhoid  fi'vei-.  dilated  stomacli.  |)eritonitis.  acute  enteritis  or  colitis,  appen 
(Ileitis,  membranous,  tuberculous  or  ulcerative  colitis,  acute  and  chronic  dysentery,  cholera 
intussusception,  and  carcinoma  coli.     It  affords  no  assistance  in  diagnosing  between  oni 


i 


INDIGESTION  315 

and  another  of  these  varions  affections,  however.  Moreover,  it  may  occur  wlien  tlicre  is 
decomposition  of  albumin  elsewhere  in  the  body  than  in  the  bowel  ;  for  instance,  in  gan- 
grene of  the  hint;,  gangrenous  empyema,  ])utrid  bronchitis,  bronchiectasis,  or  advanced 
pulmonary  tuberculosis.  Another  dilJieulty  is  that  a  considerable  number  of  perfectly 
healthy  individuals  pass  (piite  large  quantities  of  indican  in  their  urine.  Tliere  are  some 
who  contend  that  even  these  healthy  persons  are  really  suffering  from  intestinal  putrefactive 
changes  without  knowing  it  ;  this  is  possible,  but  from  the  patient's  point  of  view  it  is 
tantamoimt  to  saying — what  is  indeed  almost  true — that  indieanuria  has  no  real  diagnostic 
or  clinical  significance.  Jlrrherl  French. 

INDIGESTION. — It  is  important  to  remember  that  '  indigestion  '  is  a  symptom, 
and  not  a  disease  :  and  if  a  |)atient  eom|)lains  of  this,  one  should  enquire  more  particularly 
as  to  the  exact  nature  of  the  abnormal  sensations  present,  e.g.,  pain,  fullness,  flatulence, 
vomiting,  etc.  The  diagnostic  indications  furnished  by  each  of  these  symptoms  is  con- 
sidered .separately  (see  Vo-mitino,  p.  763  :  P.\in  in  the  Epig.vstrium.  p.  436  ;  Fullness. 
j».  243  :  Fl.vtilf.nci-..  p.  24-0.  etc.),  but  it  may  be  convenient  here  to  offer  some  general 
guidance  as  to  the  methods  of  arriving  at  a  diagnosis  in  cases  in  which  '  indigestion," 
in  one  or   other  of  its  aspects,  is   the  chief  eom])laint. 

I.  SIMULATION    OF    DYSPEPSIA    BY    OTHER    CONDITIONS. 

.\t  the  outset  one  siiould  ne\er  lorget  that  a  patient  may  descril)C  his  case  as  one  of 
indigestion,  although  he  is  not  really  suftering  from  any  jjriniary  aflection  of  the  stomach 
at  all  ;  anrl  mistakes  can  o?ily  be  avoided  by  subjecting  every  such  case  to  a  thorough 
physical  examination  of  all  the  organs,  and  not  confining  it  to  the  abdomen.  If  tlie  possi- 
bility of  error  is  borne  in  mind,  it  is  not  usually  diliicult  to  avoid  ;  and,  accordingly,  it 
will  be  siiflicient  to  enumerate  briefly  the  chief  conditions  to  be  thought  of.     These  are  : — 

The  Vomiting  of  Pregnancy. —The  jiossibility  of  i)regnaney  should  always  be 
present  to  the  niiiiil  when  om-  is  consulted  by  a  yoiuig  woman  who  complains  of  vomiting 
and  in(lij;<stion.  ami  the  other  sij;ns  and  symptoms  of  pregnancy  (]).  19)  looked  for. 

Cerebral  Vomiting.—  In  children,  particularly,  vomiting  of  cerebral  origin  may  be 
mistaken  for  dyspepsia.  Incipient  meningitis  and  tumour  are  the  commonest  causes  of 
such  vomiting.  The  former,  in  its  earliest  stage,  may  be  very  diliicult  to  diagnose  with 
certainty,  but  the  presence  of  signs  of  cerebral  irritation  (e.g.  photo|)hobia,  squint,  irrita- 
bility, headache.  Kernig"s  sign,  etc.)  should  make  one  suspicious  :  paralyses,  headaelie, 
and  optic  neuritis  point  to  tumour.  Kxaniinatioii  of  the  eeiclirospinal  lluid  ol)laine(l  l)y 
lumbar  puncture  may  be  re(|uire<l  (p.  :'A)\-}. 

Uraemia  may  masquerade  as  •  indigestion."  characterized  by  loss  of  appetite  and 
\<iiiiitiiig  (tira-niic  gastritis).  Tlie  ina-mie  odour"  in  the  breath,  high  arterial  tension, 
and  all)uriiiiHiria  and  albumimirie  retinitis,  should  be  looked  for.  If  nuist  be  remarked, 
however,  that   albimiin  may  !)<■  absent   from  the  urine  in  undoubted  eases  of  ura'mia. 

Phthisis.  In  eases  of  early  phthisis,  indigestion  may  be  the  chief  symptom  of  which 
the  patient  emnpUuns,  nausea  and  vomiting  being  often  presci\t.  This  can  be  excluded 
by  a  earefiil  examination  of  the  chest  and  of  the  sputuiu.  which  should  never  be  omitted, 
especially  in   young  subjects.  ' 

The  Gastric  Crises  of  Tabes  are  apt  to  be  mistaken  lor  dyspepsia.  Paroxysmal 
vomiting  of  great  \  iolenee  is  the  usual  form  they  assume,  and  lliey  ma\-  simulate  gastric 
ulcer  or  other  organic  affections  of  the  stomach.  If  the  knee-jerks  be  absirit  and  the  pupils 
iimnobile  to  light,  the  diagnosis  is  easy,  but  it  nnist  be  remembered  that  gastric  crises  may 
oeeur  earl\  in  a  ease  of  tal)es  Ik  loi-e  tin-  usual  sijiiis  of  disease  of  the  cord  liavc  manifested 
IlieinseUcs.  One  sliiiuld  eri(|iiMc  In  sueli  a  ease  lor  a  history  of  lightning  pains,  and  for 
i  any  trouble  with  the  bladder.  It  is  said  also  that  the  bloodpressure  is  raised  during  a 
gastric  crisis,  whereas  it  is  lowered  in  all  oilier  eases  of  acute  vnniiting.  (See  also  I'.mn 
1  IN    III]:   I,o\m:u    I'^xi  iii;mi  in;s,   p.    UM.) 

Nervous  or  Hysterical  Vomiting  max  also  simulate  dvspepsJM.  The  diagnosis  here 
'  must  be  made  largely  by  the  method  of  exclusion.  'I'lii'  |)atienl  is  usually  a  woman,  and 
there   nia\    be  other  sjyns  of  hysteria    present    (p.     Ki.")). 

In    Chronic    Intestinal    Obstruction    Ihe  aluloiuiiial  paiu^.  ami   the  xdiultiug   which 


316  INDIGESTION 

often  at-C()ni|)aiiy  tlioiii.  may  be  described  by  the  patients  as  '  indigestion."  In  sueli  a 
case  tliere  will  be  distention  of  the  abdomen,  often  with  visible  peristalsis,  and  a  history  of 
gradually  increasing  constipation.  A  tumour  may  be  felt,  or  examination  with  bismvith 
and  the  .r-rays,  or  with  tlie  sigmoidoscope,  may  clear  up  the  case. 

Cholecystitis  is  very  apt  to  be  diagnosed  as  "  indigestion."  In  the  case  of  middle- 
aged  or  clikrly  women,  particularly,  who  coinplain  of  "  wind  '  and  '  spasms,'  the  possi- 
bility of  the  piesence  of  gall-stones  should  always  be  thought  of. 

Chronic  Appendicitis  may  manifest  itself  chiefly  by  symjitonis  which  point  to  the 
stomach  rather  than  to  tlu'  vermiform  appendix  as  the  seat  of  the  disease.  The  pain  in 
such  a  case  may  have  the  character  of  a  typical  '  hunger-pain,"  and  be  relieved  by  alkalis. 
In  children  who  are  brought  to  one  for  "  indigestion,"  with  vague  abdominal  pains,  the 
possibility  of  ajjpendicitis  should  be  specially  remembered. 

Angina  Pectoris  in  one  of  its  forms  may  be  a<'companie(l  by  much  flatulence,  which 
leads  the  patient  to  consult  his  doctor  for  '  indigestion."  The  occurrence  of  the  symptoms 
upon  exertion,  the  characteristic  tendency  of  the  pain  to  spread  into  the  left  arm,  and  the 
frequent  presence  of  a  high  blood-pressure  are  all  of  diagnostic  value.  Abdvnihinl  tinginti. 
in  which  the  pain  is  seated  in  the  large  abdominal  blood-vessels,  may  be  more  dilUcult  to 
<lilTerentiate.  Flatulence  is  again  a  pronounced  feature  ;  but  there  may  also  be  vomiting, 
and  even  ha-matcmesis.  Thickening  of  the  peripheral  blood-vessels  is  usually  present  ; 
and  the  therai)eutic  test  is  of  hel]),  the  pain  being  relieved  by  vasodilators,  and  especially 
by  diuretin. 

A  patient  who  suffers  from  Migraine  may  describe  his  case  as  one  of  '  indigestion.' 
The  chief  diagnostic  ])oint  is  the  occurrence  of  severe  headache  with  or  preceding  the 
gastric  symptoms,  and  the  markeil  periodicity  of  the  attacks. 

Extra-abdominal  causes  of  Pain  are  often  put  down  by  ])aticnts  to  indigestion. 
Exam|iles  of  lliese  are  jileurisy,  sjiinal  caries,  and  aneurysm. 

Eructatio  Nervosa,  due  to  air-swallowing,  is  also  usually  described  as  indigestion. 
For  the  method  of  diagnosing  it,  see  Flatulenck  (p.  24()). 

II.   FUNCTIONAL    VERSUS    ORGANIC    DYSPEPSIA. 

Having  excluded  all  these  possible  causes  of  error  one  may  conclude  that  one  has  to 
deal  with  a  case  of  either  organic  or  functional  disease  in  the  stomach  itself.  If  vomiting, 
loss  of  flesh,  or  severe  pain  be  prominent  symptoms,  the  disease  is  probably  organic  ;  if 
these  be  absent,  and  the  affection  has  persisted  for  some  time,  one  has  most  likely  to  do 
with  a  funclionnl  disorder. 

III.  DIFFERENTIAL    DIAGNOSIS    OF    ORGANIC    DYSPEPSIAS. 

The  chief  organic  di.sca.ses  which  liave  to  be  thought  of  are  :  (1)  Cancer,  (2)  I'Icer, 
(:i)  (Idslritis,  (!•)  Obstriiclive  dilatalioti. 

Cancer.-  -A  malignant  growth  in  the  stomach  may  be  situated  either  at  the  cardiac 
orifice,  in  the  hodi/.  or  at  the  pfjlorus.  In  the  first  of  these  situations  it  will  produce  dilliculty 
in  swallowing.  If  at  the  |)ylorus,  it  will  result  in  dilatation  of  the  stomach  (see  below). 
(;rowths   in   the   body   arc   those  which   are   most   didicult   to   diagnose. 

(a).  .\  history  of  "  indigestion  '  beginning  abruptly  in  a  patient  (oftenest  a  man) 
above  the  age  of  forty,  and  not  yielding  s))eedily  to  simple  treatment,  is  very  suspicious. 
On  the  other  hand,  it  must  be  remembered  that  in  a  considerable  number  of  cases  the  growth 
starts  in  an  old  ulcer,  so  that  a  history  pointing  to  this  may  also  be  in  favour  of  carcinoma. 

{I)).  Steady  loss  of  weight,  and  the  larly  appearance  of  antemia,  point  to  malignant 
growth  ;  but,  on  the  other  hand,  the  absence  of  these  signs,  and  even  a  temporary  gain 
in  weight  under  treatment,  by  no  means  exclude  it. 

(c).  Loss  of  appetite,  and  especially  a  disinclination  for  meat,  are  usually  early 
symptoms.  Nausea  and  vomiting  supervene  later  but  are  rarely  absent  altogetlier.  Pain 
inay  be  present  early,  and  is  often  more  or  less  constant.  (See  Pain  in  Tnii  Epigastuiu.m, 
p.  436). 

(,d).  A  steady  diminution  in  the  amount  of  hydrochloric  acid  in  the  gastric  juice,  with 
the  presence  of  lactic  acid  and  of  0])pler-Boas  bacilli  in  the  gastric  contents,  is  a  combina- 
tion |)ointing  strongly  to  carcinoma. 


INDIGESTION  317 

It  is  therefore  upon  a  combination  of  thfese  symptoms  and  signs  that  the  diagnosis 
must  be  based  in  tlie  early  stage  wlien  it  is  most  important  to  make  it.  Later,  a  tumour 
may  be  felt  below  the  left  costal  margin,  or  in  the  epigastrium  ;  enlarged  glands  may 
appear  above  the  left  clavicle,  although  they  are  exceptional  ;  and  there  may  be  signs 
of  secondary  growths  in  the  liver,  or  at  the  umbilicus.  When  ulceration  has  supervened, 
traces  of  blood  may  be  found  in  the  gastric  contents,  and  occult  blood  in  the  stools  (p.  81). 

In  some  cases  of  carcinoma  of  the  body  of  the  stomach,  pronounced  ana-mia  is  one 
of  the  earliest  and  most  striking  symptoms.  Such  cases  have  to  be  diagnosed  from  per- 
nicious anaemia.  A  blood-count  will  usually  suirice  to  distinguish  them,  for  in  gastric 
carcinoma  the  red  cells  are  rarely  below  2,000,000  per  cubic  mm.,  whereas  in  pernicious 
anaemia  they  go  much  lower  than  that  ;  in  pernicious  aniemia,  also,  the  colour-index  is 
about  1  or  above  it,  in  carcinoma  it  is  less  than  1.  Megaloblasts  arc  found  in  the  film  in 
pernicious  anuinia  (]).  24),  but  not  in  carcinoma.  In  spite  of  all  tliat  has  luin  said  above, 
the  early  diagnosis  of  carcinoma  of  the  stomach  is  a  matter  of  great  dilliculty  ;  and  it  may 
be  justiHable  to  resort  to  an  exploratory  operation  in  a  suspicious  case  which  does  not  clear 
up  after  a  few  weeks'  treatment. 

Ulcer. — The  characteristic  symptom  of  gastric  ulcer  is  pain  which  comes  on  after 
food  and  is  relieved  by  vomiting,  which  is  usually  though  not  invariably  ])resent. 
H;rmatemcsis  is  strongly  confirmatory,  but  is  often  absent.  The  symjitonis  will  be  found 
on  p.  2(i8.  Duodenal  ulcer  is  also  often  associated  with  sym|)toms  that  the  patient  describes 
vaguely  as  ■  indigestion  '  ;    the  symptoms  are  given  on  p.  271. 

The  chief  sign  of  ulcer  is  a  localized  spot  of  tenderness  on  deep  pressure. 

Gastritis. — Chronic  "gastric  catarrh'  is  certainly  diagnosed  oftener  than  it  sliould 
be,  the  majority  of  cases  so  described  being  really  examples  of  functional  dysi)c])sia.  Tlie 
sym])toms  are  loss  of  appetite,  fullness  and  weight  in  the  epigastrimn.  tlcjiciitlin'^  '^ndttij 
Ujwii  the  kind  of  food  taken  ;  pain  is  not  a  feature  of  gastritis  ;  nausea  is  conunon,  and 
vomiting  may  occur,  but  is  not  usually  a  prominent  symptom.  There  is  no  characteristic 
physical  sign,  and  a  diagnosis  cannot  be  made  with  certainty  without  the  use  of  the  stomach' 
tube.  This  shows  :  (a)  Diminished  total  acidity,  or  even  complete  absence  of  gastric  juice  ; 
(h)  I"',xecss  of  mucus  in  tlie  contents,  or  the  presence  of  nuicus  on  washing  out  the  fasting 
stomach.  Ilaxing  determined  the  ])resence  of  gastritis,  one  has  to  settle  whether  it  is 
primary  or  secondary.  Secondary  gastritis  may  occur  :  (a)  Where  there  is  disease  of  the 
heart,  causing  back-j)ressure  ;  (b)  In  cirrhosis  of  the  liver  :  (e)  In  chronic  renal  disease. 
If  all  of  these  can  be  excluded,  primary  gastritis  may  be  diagnosed,  and  the  chief  causes 
of  the  latter  looked  for.  These  are  :  (a)  Defective  or  carious  teeth,  and  oral  se])sis  ; 
(//)  Abuse  of  alcohol,  tea.  or  tobacco,  or  the  taking  of  irritating  articles  of  food. 

Dilatation.  'I'he  /ircfience  of  dilalalion  is  determined  by  :  ('()  Showing  tliat  the  stomach 
is  iiilargcd  ;    and  (h)  I*ro\ing  the  occuricncc  of  stagnation  of  the  t'ontents. 

(a).  I'^nlargcment  of  the  stomach  may  be  inferred  when,  by  percussion,  the  greater 
curvature  is  found  to  reach  below  the  level  of  the  umbilicus,  the  lesser  curvature  being  in 
its  normal  position.  In  order  to  facilitate  percussion  it  may  be  necessary  to  inflate  the 
stomach  by  making  the  patient  swallow  00  gr.  of  tartaric  acid  followed  by  120  gr.  of  bicar- 
bonate of  soda.  i-;xamination  by  tlic  .r-rays  after  ,i  bismuth  meal  is  of  help  in  obscure 
cases  (Fiji,.  111-).  The  presence  of  splashing  is  nol  a  eerlain  sign  of  dilMlalinii,  unless  it 
be  present  s(jme  hours  after  a  meal.   * 

(h).  The  occurrence  of  stagnation  of  contents  is  proved  by  giving  the  [lalient  an  even- 
ing meal,  preferably  containing  some  easily  recognizable  food,  e.g..  cuiranis,  and  washing 
out  next  morning.  If  food  residues  are  present  in  the  washings,  stagnation  may  be  iid'errcd. 
ICxarninalion  with  the  ,i-rays  is  a  still  more  certain  uielliod  of  <liagn(>sing  delay  in  einptving 
of  the  sloioaeh  :  normally  the  bismulli  or  barium  meal  should  ha\c  l<ft  the  stomaeli  iji  six, 
or  at    niosl    eii;lil.   hoins. 

TI(C  raiisr  of  ilihilalion  may  be  eillier:  (</)  Some  obstruction  at  the  pylorus:  or 
(Ij)   Primary  atony  of  the  stomach   wall. 

In  (listingnishing  between  these,  the  history  may  help.  Thus  the  occurrence  in  the 
past  of  symptoms  of  ulcer  points  to  a  cicatrical  stenosis  of  the  pylorus.  If  \isible  peristaltic 
waves  arc  seen,  one  may  be  sure  of  the  existence  of  an  ohsl  ruel  ion.  These  can  sonietinics 
be  elicited  by  massaging  the  stomach,  or  by  llieking  the  surface  of  the  abdomen  gently 
Willi   II    wel    lijwel.      'I'lie   presenee  (i(  aehial   sla'nialidii   of  Hie  (•cinlelils   is  also   slniligK    in 


Dis 


INDIGESTION 


favour  of  ol)stiuction.  as  this  rarely,  if  ever,  occurs  in  cases  of  atonic  dilatation.  Copious 
voniitino  also  points  to  obstruction,  as  it  is  exceptional  to  meet  witl)  this  symptom 
ill  atonv. 

Assuming  that  obstructive  dilatation  has  been  diagnosed,  one  has  next  to  deternune 
its  cause.  Here  one  has  to  distinguish  between  benign  and  maligiiant  obstruction.  A 
history  or  signs  and  symptoms  of  ulcer  (see  above),  i)oint  to  the  former  ;  the  general  sym- 
ptoms of  carcinoma  to  the  latter.  A  tumour  may  be  felt  in  either  case.  p:xaniination  of 
the  stomach  contents  also  helps  in  the  differential  diagnosis.  The  presence  of  abundance 
of  free  HC'I,  with  sarcina?  and  yeasts,  points  to  benign  stenosis  :  diminution  or  absence  of 
IlCl  with  the  presence  of  lactic  acid  and  Oppler-Boas  bacilli,  to  malignancy. 

One  has  further  to  distinguish  dilatation  from  :  (a)  Gastroptosis  ;  and  (6)  Hour-glass 
stomach. 

{(i).  In  gastroptosis,  percussion  (if  necessary  after  inflation)  will  show  that  the  lesser 
curvature  is  displaced  downwards,  as  well  as  the  greater  :  but  the  normal  distance  between 
the  two  curvatures— about  four  inches— is  preserved.  In  most  cases  of  gastroptosis  the 
riglit  kidney  is  more  or  less  freely  movable,  and  this  affords  confirmatory  evidence.  The 
.i-rays  may  also  be  of  help  {Fig.  14-J.). 

(/;).  Ilour-glass  stomach  may  be  diagnosed  by  the  following  signs  : — 

(i).  If  the  stomach  be  washed  out  with  a 
known  quantity  of  fluid,  e.g.  30  oz.,  it  will  be 
found  that  some  has  been  lost,  e.g.  6  oz.,  when 
the  return  fluid  is  measured.  Some  of  the  fluid 
seems  to  disappear,  in  fact,  as  if  it  had  flowed 
through  a  hole. 

(ii).  If  the  stomach  is  washed  clean,  and  the 
tul)e  passed  a  few  minutes  later,  .several  ounces 
of  fermenting  litiuid  may  be  obtained,  which  lia\e 
escajicd  from  the  pyloric  pouch. 

(iii).  If  the  stomach  is  drained  apparently 
(lr\.  a  splash  can  still  be  obtained  over  the 
pyloric  end  ("  paradoxical  dilatation  "). 

(iv).  If  the   stomach  resonance   is  percussed 

out  carefully,  and  the  viscus  is  then  inflated  with 

tartaric  acid  and  soda,  as  described  above,  and 

then    again    percussed,    it    will    hi    found   that    a 

great  increase    in  resonance  has    occurred  at  the 

cardiac  end  only.     If  the  abdomen  is  watched  for 

a  little,  the  ])yloric  ))ouch  may  sometimes  be  seen 

'^'•'■"'    "^u1'.'i"n!"u"'i':     '.  ,     , '     ,     '.  MMhe      to  fill  gradually  and  become  prominent.     Aloud 

veVt'i'c'ai'|."-inMii'    c, 'i''''>'"'i  1.  1^     riusof       aushing  sound  can  also  be  distinguished  on  listen- 

cXm'.';/D%'."'x"  c.'^Cto^  -..eMai      r^_^.    ^^.jj,^    ^jj^.    Stethoscope    over    the    site  of   the 

o|)ening  between  the  two  ])Ouches. 
(v).    r-ray  examination  after  a  bismuth   meal  will  sliow  tlie  division  of  the  stomach 
into  two  i)ouches  {Fig.  128.  p.  268). 

IV.  DIFFERENTIAL    DIAGNOSIS    OF    FUNCTIONAL    DYSPEPSIA. 

Assuming  that  all  the  al)ove  forms  of  organic  disease  can  be  excluded,  one  may  con- 
clude that  the  case  is  one  of  functional  dyspepsia. 

The  next  task  is  to  determine  what  particular  variety  of  functional  disorder  one  has 
to  deal  with.  In  attempting  to  do  this,  one  is  met  at  the  outset  by  the  dilHculty  of  classi- 
fying functional  disorders  of  the  stomach.  Three  forms  of  classification  may  be  adopted  : 
(1)  Physiological,  (2)  Clinical,  (3)  Etiological. 

Physiological  Classification.— In  this  classification,  cases  of  functional  dyspepsia 
are  arranged  according  to  the  particular  function  affected,   thus  : — 


(a).  Affections  of  secretion  : — 

(i)  Excess  =  Hypersecretion  and  hypcic-hlorliydria, 
(ii)  Defect   =  Achylia  ami  liypocliloiliydria. 


IXDKiESTION  319 

(b).  Affections  of  motilili/  : — 
(i)  Excess  =  Pyloric  spasm, 
(ii)  Defect   =  Atony,   or  impaired  motility. 

(f).  .Affections  of  sensation  : — 

Excess  —  Hypencsthesia  or  i;astralj;ia. 

Any  of  these  may  be  present  alone,  or  two  or  more  may  exist  in  conjimction. 

The  diagnosis  of  affections  of  secietion  and  motility  can  be  made  by  tlu-  aid  of  the 
stomach  tube  and  by  bismuth  and  the  ,r-rays. 

For  the  diagnosis  of  liypenrsthesia  (gastralgia'.  sec  Fain  in  the  Epicasiiuum  (j).  43(ij. 

The  above  is  undoubtedly  the  most  scientific  method  of  making  a  differential  diagnosis 
in  cases  of  functional  dyspepsia,  but  it  has  the  iiieon\  enicnce  of  necessitating  the  use  of 
test   meals. 

Clinical  Classification. — t'linically.  cases  of  functional  dyspejisia  may  l)e  classified 
into  certain  rough  groups  according  to  their  symptoms.     Thus  : — 

id).  Hyperstlienic  Ih/spepsiii. — This  is  jirobably  due  to  a  combination  of  hypersecretion 
and  hypencsthesia.  The  patient  is  usually  a  young  man,  otherwise  hcaltliy  :  and  the 
chief  symptom  is  pain  during  the  late  period  of  digestion. 

(h).  Asthenic  Vyspepsifi. — This  is  due  to  impaired  motility  (atony),  with  or  without  some 
disorder  of  secretion.  The  patient  may  be  of  cither  sex.  and  of  any  age.  and  the  chief 
symptoms  are  natulcncc  and  fullness.  It  is  often  present  along  with  gastroptosis, 
especially  in  women  :   and  there  may  be  atonic  dilatation  of  the  stomach. 

(f).  Acid  J'.ijspepsin. — This  is  an  ill-defined  groii))  in  ivhich  the  chief  symptom  is  a 
sensation  of  acidity,  or  the  presence  of  acid  eructations.  Some  cases  are  really  examples 
of  hyperchlorliydria.  with  or  without  the  presence  of  gastritis.  In  others,  the  cause  is 
the  jiroduetion  of  organic  acids  by  fermentation.  Diagnosis  can  only  be  made  by  aid  of 
the  stomach  tube. 

Other  cliiucal  forms  of  d\spcpsia  arc  also  described,  e.g..  •  senile  "  (iys|)epsia 
(essentially  a  hypcjchylia).  "  gouly  "  dyspepsia  (the  same  as  the  "acid"  form).  "  (latulent  ' 
dyspepsia  (usually  due  to  defective  motility),  and  others  :  but  the  use  of  such  terms  is 
inaccurate,  and  should  be  avoided  as  far  as  possible. 

Etiological  Classification. — Instead  of  attempting  to  distinguish  different  forms  of 
luiiclioiial  dyspepsia,  one  can  regard  the  latter  as  an  aggregation  of  symptoms  of  gastric 
disorder  excited  by  dilicri  lit  causes,  and  classify  cases  according  to  the  ))artieular  exciting 
oau.se  at  work.  This  method  is  simple  and  eonxcnient.  and  is  also  useful  for  pur])oses  of 
treatment.      .\do|)ting  it.  one  may  say  that  functional  dys|)epsia  ma\'  be  induced  by  : — 

ill).  Dietetic  raiises.  e.g..  unsuilalile  food,  hasty  meals,  the  abuse  of  alcohol,  tobacco, 
tea.   etc. 

(Ij).  I'/ii/siiiil  canses.  e.g..  inipcrfict  eliexviiiii.  (Ufecli\c  teeth,  oral  sepsis,  over-fatigue, 
d(  lieient   exercise,   etc. 

(e).  Mental  causes,  e.g..  (j\er-work.  a  studious  life,  ilc 

(il).  linwliiiual  causes,  e.g..  shock,  worry,  etc. 

Any  of  the  above  methods  is  useful,  the  essential  |)oinl  hcing  that  a  elassilication  ol 
some  sort  should  be  adopted.  Frobably  a  combination  of  the  llrst  and  third  methods, 
which  t;ikc  into  aeeounl  both  the  particular  disorder  which  is  present  and  the  cause  which 
has  hrought   it  about   will  lead  to  the  best  treatment. 

-Micnioiis   111-    ICxAMiMSi:    iiii;   Skimacii. 

Till-  ruliowiii;.'  is  a  l>ri<l'  accoiir.t  ol  some  sp(<ial  mkIIhkIs  employed  in  examining  the  stomach, 
wliici]  aic  lapable  (if  heiiig  carried  onl   in  ordinary  practice  : 

1.  Dclcrminution  of  Size.  This  is  done  l)y  li;;hl  periiission,  or  l)y  percussion-auscultation, 
witli  or  wilhont  [>re\ioiis  inllatii>n.  The  position  of  llie  lesser  and  ^Teater  curvatures  and  of  tin- 
funilns  nnist  lie  determined.  Inllation  is  performed  either  ;  (ii)  Throu^di  a  stomach  tiihe  eomieeteil 
Willi  a  llicL-inson's  syrinfje  :  or  (/<)  l!v  makin;;  llie  patient  swallow  !I0  yr.  of  tartaric  aeiil  dissolved 
ill  three  onnees  of  water,   followe<l  liy'  1^11  ;;r.  of  l.iearhonate  (d'  soda. 

■J.  Invcsligation  of  tlic  Contents.  .\  lest  meal,  eonsisllng  of  two  slices  of  dry  loasl  and  two 
cups  of  tia  with  a  little  milk,  is  yiven  in  tin-  moriiin;;,  and  the  tube  passed  an  hour  later.  The  tnlie 
should  have  a  solid  end  and  one  lievelled  lateral  eye  close  to  il .  The  sample-  drawn  oil  shmild  he 
investigated   as    regards: 

(«).  (iiKuilitji.  \  ver\  small  result  eontaining  little  lluid  indiiales  diminished  secretion 
(aehylla)  :    an  aiiundaril    aiid  \ery  liipriil  yield   indicates  diminished   rnnlilils'. 


320  INDIGESTION 

(b).  Phi/sical  CharacWrs.-^The  i„osencc  of  large  pieces  of  but  slightly  =*',t"^<i./7;^J"'?;';f'7 
defective  secretion  and  digestion  ;  a  large  amount  of  liquid  with  a  granuar  deposit  shows  hyper- 
secretion. A  very  sour  odour  reveals  the  presence  of  organic  acids.  Viscidity  of  the  contents, 
so  that  they  filter"  slowly,  is  characteristic  of  the  presence  ol  mucus  in  excess. 

(,).  .  <i<  illl.  ^^^^  ^^^^  //CZ.— ConiTo-red  i)aper  is  turned  blue,  methyl-orange  paper  red,  if 
free  H€l  be  present.     The  depth  of  colour  indicates  approximately  the  amount  of  free 

rii)  Total  Acidilii.—  l\n  c.c.  of  the  filtered  contents  are  titrated  with  ^^  caustic 
soda  solution,  two  or  three  .Imps  of  plunolphthalcin  solution  being  used  as  an  indicator 
\  pink  tin..c  appears  as  soon  ns  thv  a.i.lity  has  been  neutral./.e<l.  Fhe  result  is  expressed 
in 'terms  o(  the  amount  of  causlie  so,la  solution  required  to  neutrahze  100  e.c^  of  the 
gastric  contents  :  e.g.,  if  fi  c.c.  ueutiuli/.e  10  of  the  contents,  tlien  the  acidity  is  60.  The 
normal  aeiditv  is  between  4()  and  70.  .  f»i 

(iii)  Or"<n,ic  lci,l.s  need  only  be  tested  for  if  free  HCl  is  absent.  A  sour  odour  of  the 
eonf cuts  indicates  their  presence  :  acetic  acid  and  butyric  acid  can  be  recognized  by  he 
odour  of  vinegar  or  ranei.lit  v  respe.tively  :  iaeti.-  a.id  by  adding  a  few  drops  of  the  contents 
to  some  Uffetmann's  reagent  (equal  parts  of  1-20  carbolic  and  weak  liq.  fern  perehlor.) 
in  a  test  tube  :  a  bright  yellow  colour  is  ,jrr„hue,l  if  the  acid  be  present 
(,/)  Fennmls.^Heimin  can  be  tested  for  by  neutralizing  some  of  the  contents,  and  trying 
whether  the  addition  of  a  few  drops  to  a  little  milk  results  in  coagulation  when  kept  warm  loi 

*'"''lLre'i"m!'couvenicnt  test  for  pepsin,  but  its  absence  may  usually  be  inferred  if  there  is  no 

rennin  Vr^'^!^-^^^-  ci,„rarlers.-V\hns  are  made  from  some  of  the  .Icposit,   and  stained  with 

dilute  '.entiau  violet.     Oppkr-Boas  bacilli,  yeasts,  and  sarcina-  {Fig.  121,  p.  241)  shoi.ld  be  looked 

■IMie  hist  occur  spiciallv  in  cases  of  carcinoma  :   the  two  last  in  benign  stenosis  of  the  pylorus. 

:j    Determination    of   Motility.^Impaircd   motility   is   shown   by   the   presence  of   food   residue 

in   n  V  on  mtil  V  (sav  .1h,h1    f  ounces)  six  and  a  half  hours  after  an  ordinary  dinner.     In  order  to 

ro^c^         Hvsenle  of  >la.„ation,  a  light  meal,  preferably  containing  some  easily  recognized  food 

e"    e.rruts)    shoul.l  be  -iven  in  the  evening,   and  the  stomach  washed  out  next  morning.    It 

food  be    b   nd  in  the  washings,  stagnation  exists.     If  there  be  no  food,  but  it  several  oimces  of 

Ireenish  acid  lluid  arc  obtain'ed,  hypersecretion  is  present;   flakes  of  mucus  ™-y^^^;;--d  in J^hc 

washings  in  gastritis. 

INEQUALITY   OF  THE  PULSES.— (Sec  Pi-i.sks,  I'neqi-.m..  P-  550.) 

INEQUALITY   OF  THE  PUPILS.  -(See  Pn-ii.,  .Vbnoum.m.itiks  of  thk.  p.  551.) 

INSOMNIA  means  inability  to  obtain  the  normal  amount  of  sleep.  It  includes  sleep- 
lessness and  broken  or  restless  sleep,  and  admits  of  no  closer  definition  because  the  normal 
amount  of  sleep  varies  widely  with  age.  habit,  and  idiosyncrasy.  Thus,  out  ot  the  twcnty- 
fb.ir  hours  an  infant  at  one  month  will  sleep  for  twenty-one,  at  six  months  for  eighteen, 
at  twelve  months,  for  fifteen  hours.  A  child  four  years  old  needs  twelve  hours  sleep,  the 
schoolboy  of  twelve  needs  ten,  the  public-school  man  .should  have  nine.  The  average  hours 
of  sleep  in  adult  life  are  said  to  be  eight  for  women,  seven  for  men.  but  idu.syncrasy  may 
cut  down  the  hours  necessary  in  certain  pco,.le  to  no  more  than  three  or  four,  for  long  periods 
an.l  without  any  impairment  of  health  or  the  power  to  work.  Habit  may  tram  neglected 
children  or  overworked  labourers  and  servants  to  get  on  with  short  hours  of  rest  and  inter- 
rupted sleep  that  would  speedily  make  an  ordinary  person  ill.  Insomnia  is  a  symptom 
indicating  that  something  is  amiss,  not  a  disease  per  se.  It  occurs  in  a  great  many  acute 
and  chronic  disorders,  but  in  most  cases  it  .lepcnds  on  functional  disturbances,  faulty  habits 
or  hy<.iene,  an  ill-arranged  regimen,  and  not  up,.ii  organic  disease.  It  is  to  be  diagnosed 
whenever  lack  of  sleep  causes,  or  is  associated  with,  loss  of  health.  Most  patients  habitually 
underestimate  the  amount  of  sleep  they  get.  without  any  intention  to  deceive  ;  and  are  apt 
to  conqjlain  that  they  have  been  awake  all  night  when  in  point  of  fact  they  have  had  many 

hours  of  sleep.  x-  i     •     n..  . 

The  chief  causes  of  insomnia  are  tabulated  below  in  three  mam  groui.s,  etiologicall>  .- 

1.  Insomnia  due  to  Faulty  Habits  or  Hygiene,  such  as— 
Some  sudden  chau-e  in  the  r..Mtine  of  the  day  or  evening 
Exposure  to  undue  excitement  or  bad  atmosphere  before  retiring 
The  use  of  a  noisy,  airless,  or  overheated  bedroom 
The  use  of  too  many  bedclothes,  or  too  few 
Going  to  bed  on  too  full  or  too  empty  a  stomach 
Drinking  strong  tea  or  coffee  too  late  in  the  day 
The  over-use  of  tobacco 


INSOMNIA  321 

2.  Insomnia  due  to  Acute  Disorders,  such  as — 

Pain  due  to  any  cause,  inflammation,  injury,  neuritis,  etc. 
The  early  stages  of  fevers 

Acute  insanity,  meningitis,  delirium  tremens,  acute  mania,  etc. 
Acute  nervous  exhaustion. 

3.  Insomnia  due  to  Chronic  Disorders,  such  as — 

Gastro-intcstinal  disorders,  dyspepsia,  constipation,  etc. 

Chronic  insanity  of  all  sorts,  neurasthenia 

Cerebral  syphilis,   intracranial  tumour 

Disease  of  the  heart,  valvular  or  myocardial 

Disease  of  the  lungs,  emphysema,   bronchitis,   asthma,   etc. 

Disea.ses  of  the  liver  or  kidneys 

Arteriosclerosis  and  high  blood-pressure,  hyperpicsis 

Ana;mia,   primary  or  secondary 

Hysteria  and  malingering. 

The  closer  investigation  of  the  causes  of  insomnia  may  best  be  done  liy  taking  the  age 
of  the  patient  into  consideration. 

Sleeplessness  in  an  Infant  is  most  often  due  to  indigestion,  himgcr,  or  bodily  discomfort; 
in  rare  cases  it  is  c\  idcncc  of  nervous  instability  or  ear  or  brain  disease.  Enquiry  into  the 
methods  and  hours  of  feeding  the  infant  will  often  show  where  the  fault  lies  :  the  food  may 
be  improper,  the  hours  of  feeding  too  frequent,  the  practice  of  giving  the  bottle  or  breast 
whenever  the  infant  cries  may  have  been  followed,  or  the  habit  of  allowing  it  a  dummy  teat 
to  suck  at  all  hours.  The  artificially  fed  infant  is  likely  to  suffer  from  indigestion  and  coHc, 
with  screaming,  drawing  up  of  the  legs,  and  rigid  abdomen  ;  tlie  breast-fed  infant  will  more 
often  fail  t(j  sleep  because  it  is  hungry.  In  many  cases  it  fails  to  sleep  because  it  is  in 
discomfort  from  a  wet  napkin  or  bed,  from  having  too  many  bed-clothes  and  being  over- 
heated, or  from  being  cold  :  the  bedroom  may  be  too  light  or  too  noisy.  In  not  a  few 
instances  it  fails  to  sleep  well  for  want  of  proper  training  ;  especially  if  it  finds  that  it  will 
be  fed  or  rocked  in  tlic  arms  or  cradle  as  often  and  as  long  as  it  sees  fit  to  cry.  When  the 
infant  is  six  months  old  or  more,  rickets  and  the  local  irritation  of  teething  are  common 
additional  causes.  In  a  minority  of  cases  the  sleeplessness  is  due  to  the  onset  or  presence 
of  acute  or  clwonic  disease,  or  to  the  indeterminate  condition  described  as  nervousness  or 
nervous  instability,  or  to  definite  mental  deficiency  ;  carefid  examination  of  the  infant  and 
its  previous  history  should  sulliee  to  clear  up  the  diagnosis  in  these  cases.  As  the  treatment 
of  sleeplessness  in  an  infant  hardly  ever  demands  the  use  of  sedative  drugs,  but  consists 
niaiidy  in  rectifying  errors  of  diet,  hygiene,  or  up-bringing,  it  is  obvious  that  the  medical 
riian  must  be  |)rcpar((l  to  go  deeply  into  these  domestic — rather  tlian  medical — matters. 

Sleeplessness  in  Children  is  due  largely  to  causes  similar  to  those  described  above. 
In  a  great  many  cases  it  is  due  to  indigestion,  with  which  may  be  associated  flatulence, 
teething,  and  the  presence  of  worms  in  the  intcsliiu-  :  tea-drinking  is  a  common  cause  of 
chronic  dyspepsia,  nervous  irritability,  and  disturbed  sleep,  in  children  as  well  as  in  adults. 
Many  children  slce|)  ill  because  they  arc  i)ut  to  bed  within  an  hour  or  so  of  a  late  tea  or  early 
supper  of  loo  solid  a  character  ;  others,  for  want  of  fresh  air  in  the  bedroom,  waking  late 
on  the  following  morning  in  a  headsichy  and  irritable  condition  anri  with  little  appetite  for 
lireakfast.  Not  a  few  ill-fed  or  anaemic  school-cliildreti  sleep  badly  during  term-time 
because  they  arc  o\cr-worked.  or  wc'rricd  about  their  lessons  or  their  jjlacc  in  the  class, 
without  being  actually  overworked  ;  in  such  eases  the  distraction  afforded  by  games  is 
likely  to  be  more  successful  in  cITectiiig  a  cure  than  treatment  by  rest.  It  is  only  in  the 
niinorily  of  instances  llial  the  iiiNonniia  is  due  to  disease,  whether  acute  or  chronic,  .sucli  as 
adenoids,  enlarged  loiisiK.  nv  <irganic  (JiM-asc  of  the  various  viscera.  A  few  special  forms  of 
insomnia  seen  in  chi  Id  III  lod  call  lor  brie  I  incnt  ion.  In  curl//  hiii-tliscimc  sleep  may  be  disturbed 
by  sudden  starling  pains  :  I  lie  child  go<'s  off  to  sleep,  only  to  be  awaUcn<'d  almost  at  (Uice 
l>y  sud(l<ii  siKjiiliiig  pains  in  the  allccte<l  leg  or  hip.  Sleep  is  broken  by  fright  in  iii^lil-tcrmrs 
(see  Xi(,]i  iM  \Fii>.  p.  Il)-J).  in  which  the  child  wakes  up  screaming  and  frightened,  but 
conscious  and  able  In  explain,  so  far  as  excitement  permits,  the  nature  of  the  fright  ;  indis- 
cretions in  diet,  or  the  presence  of  adenoids  or  worms,  often  explain  the  oecmTcnce  of  such 
night-ternus.  In  the  rarer  and  more  serious  form  of  night-terror,  known  as  l'(wtir  nocliirnus, 
the  child  awakes,  screaming  and  frighlencil.  but  not  fnllv  ('(Uiseious.  and  unable  to  recognize 
tlio>-('  aronnil   liini.      'I'liirr   is  no  rccollccliun  uf  the   IViglil    iiexl    ila\.  and    ill  all   pi'oliability 

1)  •_'! 


322  IXSO.MXIA 

the  pavor  is  akin  to  epilepsy,  occurring  mainly  in  children  with  a  bad  family  history  of 
nervous  disease.  It  is  plain  from  what  has  been  said  above  that  the  diagnosis  of  the  cause 
of  sleeplessness  in  a  child  demands  scrutiny  of  the  daily  routine,  diet,  and  sleeping- 
arrangements,  as  well  as  examination  of  tlie  child  itself.  Sedative  drugs  are  practically 
never  required  for  its  treatment,  exce])t  in  tlie  case  of  severe  acute  or  chronic  disease,  and 
even  then  should  be  given  but  rarely. 

Insomnia  in  Adults,  in  tlie  majority  of  cases,  is  due  to  faults  of  habit  or  In/giene  similar 
to  th(>s<'  already  nunlicnicd  in  the  ease  of  children  :  but  it  is  due  to  organic  disease  of  one 
sort  or  another  in  not  a  few  instances,  discussed  later.  The  sleepless  adult  should  devote 
thought  to  the  economy  and  arrangement  of  his  bed  and  bedroom,  and  the  hours  he  keeps. 
The  bed  should  be  comfortable — whether  the  mattress  be  hard  or  soft  is  a  matter  of  taste  ; 
many  people  sleep  better  with  a  high  ])illow  than  with  a  low,  and  if  a  high  pillow  is  not 
agreeable,  the  same  effect  can  often  be  ])roduced  by  putting  blocks  two  or  three  inches  high 
beneath  the  posts  at  the  head  of  the  bed.  The  bedclothes  should  be  light  rather  than  heavy  ; 
they  should  be  warm  enough  to  jirevent  the  occurrence  of  cold  feet,  a  very  common  cause  of 
sleeplessness.  The  bed  should  not  be  jilaced  so  that  the  sleeper  faces  the  light.  A  supply 
of  fresh  air  throughout  the  night  is  essential,  and  is  assured  if  the  room  is  heated  by  an  open 
fire  :  stuffiness  and  overheating  of  the  atmosphere  seem  almost  inseparable  from  heating 
by  .stoves,  hot  air,  hot  water,  or  steam,  and  are  common  causes  of  sleeplessness.  The 
hygiene  of  the  bedroom  having  been  attended  to,  the  habits  of  the  sleepless  patient  should  be 
passed  in  review.  Many  well-to-do  people  sleep  ill  because  they  go  to  bed  too  soon  after 
a  heavy  dinner  :  a  few  because  they  go  to  bed  hungry.  Not  a  few  find  that  they  sleep  badly 
if  they  take  a  cup  of  coffee  after  dinner,  or  even  drink  tea  in  the  afternoon  ;  others  sleep  ill 
if  they  indulge  in  brain-work  after  dinner,  or  attend  exciting  public  meetings,  theatres, 
concerts,  and  so  forth.  It  is  known  that  bodily  and  mental  fatigue  j^romote  sleep,  and  some 
patients  with  insomnia  solicit  sleep  and  aggravate  their  condition  by  pushing  fatigue  to 
the  point  of  exhaustion,  forgetting  that  over-fatigue  often  produces  sleeplessness.  The 
observance  of  fairly  regular  hours  for  work,  food,  and  sleep  is  often  neglected  by  busy  men, 
and  the  neglect  often  results  in  disturbance  of  their  sleep.  Sudden  changes  in  the  mode 
or  routine  of  daily  life,  or  alterations  in  the  altitude  or  locality  inhabited,  may  result  in 
acute  and  persistent  insomnia.  It  is  to  the  investigation  of  these  and  similar  irregularities, 
trifling  as  many  of  them  may  appear,  that  one  must  lo(jk  in  diagnosing  the  cause  of  insomnia 
in  healthy  or  fairly  healthy  patients  ;  its  treatment  will  naturally  turn  mainly  on  their 
correction.  Healthier  habits  of  life  must  be  advised,  and  the  use  of  sedatives  prohibited 
entirely. 

In  the  case  of  adults  suffering  from  the  most  various  acate  disorders,  slight  or  severe, 
the  occurrence  of  insomnia  is  a  commonplace.  It  passes  off  with  the  amelioration  of  the 
disorder,  and  if  the  patient  is  able  to  give  an  account  of  himself  and  his  symptoms,  the 
diagnosis  should  not  be  dilHcult. 

It  is  often  otherwise  with  adults  suifering  from  insomnia  due  to  chronic  disease  ;  the 
sleeplessness  may  be  one  of  the  earliest  symptoms  of  illness,  or  the  other  symptoms  that 
are  present  may  have  escaped  the  patienfs  notice.  For  example,  persistent  inability  to 
sleep  is  often  a  prominent  and  early  feature  of  nervous  or  mental  disease — melancholia, 
mania,  general  paralysis,  hypochondriasis,  neurasthenia,  acute  nervous  exhaustion,  paralysis 
agitans,  and  chronic  alcoholism  may  here  be  mentioned  :  in  old  age,  senile  nocturnal  mania 
may  occur  as  a  very  troublesome  form  of  insomnia.  Inability  to  sleep  may  be  marked 
in  cases  of  cerebral  tumour  or  cerebral  syphilis.  Want  of  sleep  throws  a  great  strain  on 
the  nervous  system  generally,  and  so  is  a  prominent  factor  in  the  production  of  insanity  ; 
the  one  aggravates  tlie  other,  and  a  vicious  circle  is  established.  In  heart  disease,  insomnia 
is  frequently  a  distressing  feature  ;  the  patient  often  has  to  sleep  propped  up  in  bed  because 
of  breathlessness  whenever  the  recumbent  position  is  adopted,  and  when  he  does  get  off  to 
sleep  he  is  often  awakened  by  cardiac  palpitation  or  dyspnoea,  within  a  few  minutes. 
Restless  nights  are  passed  even  while  cardiac  compensation  is  maintained  :  when  com- 
pensation fails  the  condition  is  much  aggravated.  Patients  with  aortic  incompetence  may 
be  kept  awake  by  the  pulsating  shock  and  noise  of  their  own  hearts.  Dyspnoea  is  a  common 
cause  of  sleeplessness  in  many  diseases  of  the  lungs.  Patients  with  bronchitis,  emphysema, 
spasmodic  asthma,  extensive  pulmonaiy  adhesions  or  pulmonary  tuberculosis,  and  other 
kindred  diseases,  often  pass  restless  nights    because  they  are  awakened   by  pulmonary 


IRRITABILITY  32:! 

dyspncea  soon  after  getting  off  to  sleep.  Willi  these  patients,  as  with  those  suffering  from 
heart  disease,  the  sitting  or  semi-recumbent  position  at  night  is  often  imperative,  the  reasons 
being  that  diaphragmatic  breathing  is  easiest,  and  the  amplitude  of  the  diaphragmatic 
movements  greatest  when  the  patient  sits,  less  when  he  lies,  and  least  when  he  is  in  the  erect 
position.  Sleeplessness  is  frequent  in  cirrliosis  of  llie  liver.  I)eing  accompanied  by  nocturnal 
delirium  in  the  severer  cases  ;  it  may  also  occur  in  i-hraiiii-  iciial  disease.  It  is  often  a 
persistent  and  distressing  feature  of  arteriosclerosis  and  high  bloud-pressure,  with  hypertrophy 
of  the  heart.  The  mechanism  whereby  this  sleeplessness  is  produced  is  obscure  ;  but  from 
the  fact  that  any  treatment  that  lowers  the  blood-pressure — massage,  hot  baths,  high- 
frequency  currents  of  electricity — cures  the  insomnia,  it  may  be  assumed  that  the  high 
arterial  pressure  acts  directly,  preventing  the  establishment  of  the  degree  of  cerebral  anamia 
that  is  requisite  for  sleep.  But  it  must  be  noted  that  if  insomnia  results  from  the  supply 
of  too  much  blood  to  the  brain,  it  also  results  from  the  supply  of  too  little  ;  hence  sleepless- 
ness occurs  in  grave  ancernia,  whether  primary  or  secondary. 

In  conclusion,  it  may  be  noted  that  in  hi/sleria,  professions  of  obstinate  insomnia  go 
far  beyond  the  observed  facts  ;  and  that  the  malingerer,  claiming  not  to  have  slept  at  all  for 
days  or  weeks,  may  urge  the  sound  slumber  lie  enjoys  in  hospital  as  an  argument  for  the 
prolongation  of  his  stay.  A.  J.  Jex-Blake. 

INTERSCAPULAR  PAIN.— (See  P.un.  Intkrscapli.ai!.  i).  4G1.) 
IRIDOPLEGIA.— (See  Pupil,  Abnok.mai.itiks  ok  tiif.,  )).  551.) 

IRRITABILITY. — It  is  not  very  often  that  irritability  can  be  regarded  as  a  symptom 
of  diagnostic  importance.  It  is  a  relative  condition,  varying  in  its  significance  with  the 
individual,  and  more  especially  with  his  age.  Children,  for  instance,  display  irritability 
much  more  readily  than  adults  under  similar  intlucnccs,  owing  to  incomplete  education  of 
their  powers  of  control,  and  a  like  distinction  may  be  drawn  between  different  persons  of 
adult  age.  Varying  degrees  of  irritability  may  be  recognized  under  any  condition  of  ill- 
health,  and  as  a  solitary  symptom  it  can  hardly  be  regarded  as  one  of  much  import.  .\n 
exception  may  perhaps  be  made  in  favour  of  the  steadily-increasing  irritability  which  is 
sometimes  observed  as  a  prodrome  of  meningilis.  and  which  may  be  sufficiently  remarkable 
to  instigate  a  careful  look-out  for  other  early  signs  of  that  disease,  such  as  vomiting,  head- 
a<'hc.  strabismus,  and  head-retraction. 

In  adults,  the  personal  disposition  is  longer  established  and  better  recognized,  so  that 
<lefinite  alteralions  in  temperament,  in<lependent  of  obvious  ciiuse,  and  clearly  not  of  fleeting 
charaeti  r.  must  always  receive  attention  from  the  medical  man  to  whose  notice  they  are 
brought.  .Many  chronic  ailments,  especially  those  whieli  entail  mental  or  physical  suffering, 
may  be  associated  with  increased  irritability  without  exciting  special  remark.  On  the 
other  hand  there  are  some  constitutional  or  metabolic  disturbances  which  are  noted  for  the 
irritability  to  which  they  may  give  rise.  Diabetes  mellitiis  and  chronic  nephritis  are  common 
examples  of  this  kind,  and  the  examination  of  the  urine  of  patients  in  whom  friends  have 
()l)s(r\((l,  or  who  may  even  themselves  com]>lain  of,  irritability,  should  never  be  neglected. 
Ill  such  eondilions  as  janndice,  (iraves's  disease,  and  acromegalii.  other  syin|itiiins  and  signs 
are  more  obvious  and  more  conclusive. 

Irritability  often  forms  jiart  of  a  nenrasthcnic  .sipidroine.  but  it  is  well  to  remember  that 
I  111-  same  symptom  may  be  present  in  the  early  stages  of  general  partdi/sis  of  the  insane. 
.\  caicrul  investigation  of  other  mental  changes,  of  the  eondition  of  the  reflexes  and  pupils, 
and.  If  suspicion  is  aroused,  a  Wasscrmann  test,  should  be  carried  ont  before  coming  to  a 
delinite  diagnosis.  It  is  hardly  necessary  to  add  that  irritability  may  be  associated  with 
other  dejiressed  mental  states,  such  as  mcJaiicholia  and  epitejUic  dementia.  Finally,  chronic 
intoxications,  and  especially  chronic  alcoholism  and  plaiidiism.  may  be  rcsponsibte  for  great 
irrilaliility.  ispcci;illy  in  the  earlier  limirs  of  the  day.  A',  /■'iinniliar  Utizzurtl. 

IRRITABILITY  OF  THE  BLADDER.  (S,,  Man  liinoN.  .\iiN oumaiitii.s  oi 
p.  ::!i:!.) 


ITCHING.      (Sec    I'm  urn-,,    p.   5KI.) 


324  JAUNDICE 

JAUNDICE  is  the  term  used  to  indicate  the  yellow  or  greenish  coloration  of  the  skin, 
conjunctiva,  mucous  membranes,  and  other  tissues  and  fluids  of  the  body,  by  bile  pigment. 
The  following  are  its  chief  signs  : — 

The  Skin. — The  colour  varies  from  a  light  sulphur  yellow  to  a  deep  orange,  greenish, 
and,  in  some  cases,  dark  olive  tint.  The  greenish  or  dark  olive  shade  is  only  found  in  severe 
cases  of  long  standing.  Intense  itching  is  often  produced,  especially  if  the  jaundice  is  the 
result  of  obstruction  of  the  bile-duets  ;  and  this  sometimes  leads  to  vigorous  scratching  and 
the  production  of  scratch-marks,  blood-crusts,  and  sore  places. 

In  certain  cases,  after  some  time,  little  yellowish-white  or  light  yellowish-salmon- 
coloured  patches  of  soft  smooth  tissue  slightly  raised  above  the  surface  of  the  surrounding 
skin  may  appear  on  the  upper  eyelids  near  the  inner  canthi.  These  patches  may  spread 
until  the  eye  is  surrounded  entirely  by  this  altered  skin,  xanthelasma  palpebrarum.  A 
similar  condition  may  also  occur  on  the  palmar  surface  of  the  hands  and  Angers,  or  firm 
rounded  nodides  varying  in  size  from  \  in.  to  ^  in.  in  diameter,  more  or  less  raised  above 
the  level  of  the  surrounding  skin,  may  develop  over  the  elbows,  knees,  or  in  other  places — 
xanthelasma  planum  and  xanthelasma  tuberosum. 

The  Eyes. — The  conjunctivae  are  yellow.  Care  must  be  taken  to  distinguish  deposits 
of  sub-conjunctival  fat  from  actual  coloration.  Occasionally,  it  is  said,  patients  suffer  from 
yellow  vision  (xantliopsia). 

The  Urine  may  jjresent  almost  any  shade,  from  a  light  saffron-yellow  to  yellowish- 
brown,  medium  brown,  dark  mahogany  lirown.  greenish-brown,  or  even  almost  black. 
On  looking  across  the  upper  portion  of  the  urine  in  a  specimen  glass  a  distinct  greenish 
tinge  may  be  detected,  and  the  froth  which  forms  at  the  toj)  on  .shaking  possesses  a  distinct 
yellowish  or  greenish  shade.     It  stains  white  blotting-paper  and  linen  a  bright  yellow. 

As  a  general  rule,  when  jaundice  is  developing,  bile  pigment  can  be  detected  in  the  urine 
before  the  conjunctiva;  become  yellow,  and  the  conjunctiva;  become  jaundiced  before  the 
skin.  On  the  other  hand,  when  jaundice  is  leaving  a  patient,  the  bile  pigment  first  disappears 
from  the  urine,  whilst  the  skin  remains  coloured  for  some  time  afterwards.  There  are 
certain  special  cases,  indeed,  in  which  the  skin  and  eonjimctiva?  exhibit  obvious  jaundice, 
yet  there  is  no  bile  pigment  in  the  urine.     This  condition  is  termed  acholuric  jaundice 

(p.  ;wj). 

other  Secretions. — The  sweat  and  milk  of  women  who  arc  nursing  may  be  tinged 
yellow.  Pleuritic,  pericardial  or  peritoneal  effusions  may  be  similarly  coloured.  The 
tears,  saliva,  and  gastro-intestinal  secretions  are  not  affected  in  this  manner,  nor  are  the 
meninges,  brain,  spinal  cord,  or  cerebrospinal  fluid. 

The  Faeces. — In  ea.ses  of  jaundice  due  to  obstruction  of  the  larger  ducts,  the  fseces 
become  greyish-white  or  clay-coloured  from  lack  of  stereobilin,  and  they  may  contain  an 
excess  of  fat  which  by  decomppsition  is  likely  to  give  the  stools  a  very  offensive  smell.  The 
bowels  are  usually  constipated. 

The  Pulse. — It  is  frequently  stated  that  the  jjulse  is  apt  to  become  much  .slower  than 
normal.  es|)ecially  in  cases  of  catarrhal  jaundice  without  pyrexia.  It  is,  however,  very 
rare  to  find  tliese  slow-pulse  cases  clinically  ;  more  often,  although  jjhysiological  experiments 
show  that  the  bile  salts  tend  to  slow  the  heart  remarkably,  the  i)ulse-rate  is  accelerated, 
especially  in  pyrexial  cases. 

Bruising. — There  is  a  marked  tendency  to  capillary  oozing  and  haemorrhage  in  certain 
cases  ;  this  is  important,  not  only  from  the  jioint  of  view  of  operations,  but  also  because  of 
the  ready  bruising  of  the  .skin  which  might  be  mistaken  for  evidence  of  violence. 

Cholaemia. — In  cases  of  severe  or  long-continued  jaundice,  cholaemic  symptoms  may 
supervene,  namely,  stupor,  delirium,  convulsions,  coma,  and  death. 

.laundice  must  not  be  mistaken  for  other  conditions  which  cau.se  yellowness  of  the  skin. 
There  should  be  but  little  possibility  of  this,  provided  a  careful  examination  is  made.  Slight 
jaundice  and  pernicious  ansemia  are  jjerliajjs  the  two  conditions  that  may  most  readily 
be  mistaken  for  each  other  ;  in  the  latter,  however,  the  conjunctivae  are  generally  of  a 
pearly  whiteness,  however  yellow  the  skin  may  be  ;  and  if  the  urine  .should  be  suspiciously 
dark,  its  colour  will  be  found  to  be  due  to  urobilin,  detected  by  its  spectroscopic  band 
between  the  E  and  F  lines  {Fig.  36,  p.  80),  whilst  tests  for  bile  pigments  would  be  negative. 
If  Ihere  is  doubt  as  to  the  presence  of  urobilin  on  direct  spectroscopic  examination  alone, 
further  urobilin  tests  will  be  applied.     One  of  the  best  is  carried  out  as  follows  :   A  quantity 


JAUXDICE 


825 


of  the  urine,  say  an  ounce,  is  poured  into  a  suitable  glass  cylinder  acidulated  with  a  few 
drops  of  acetic  acid  ;  about  half  an  ounce  of  aniyl  alcohol  is  then  added,  and  the  mixture 
is  slowly  shaken  too  and  fro  in  the  cylinder  several  times,  after  which  it  is  allowed  to  stand 
for  some  minutes  whilst  the  amyl  alcohol  separates  to  the  top  ;  the  urobilin  is  now  in  solu- 
tion in  the  amyl  alcohol,  which  may  be  poured  off  into  a  test  tube  ;  on  adding  a  few  drops 
of  a  saturated  solution  of  zinc  acetate  in  ethyl  alcohol  to  it,  a  beautiful  red-green-yellow 
fluorescence  results  if  m-obilin  is  present,  the  appearance  being  similar  to  that  of  a  weak 
solution  of  eosin  {Plate  A'A'A'/('.  Fig.  12,  p.  748)  ;  and  the  absoiption  band  of  urobilin  can 
l)e  seen  readily  through  it  with  the  spectroscope.  In  veiy  rare  cases  of  pernicious  anicmia 
there  may  be  jaundice  also.  Acholuric  jaundice  cases  are  probably  the  most  dillicult  to 
be  sure  of.  and  in  some  of  these  the  diagnosis  becomes  a  matter  of  opinion. 

Having  concluded  that  a  patient  has  jaundice,  the  next  step  is  to  decide  between  the 
cau«es  of  the  symptom.     The  following  are  the  chief  of  them  : — 


CAUSES    OF    JAUNDICE. 

I.  Jaundice    due    to    Obstruction    of     the    larger     Bile-ducts,    especially     of     the 
common    Bile-duct :  - 

.1.   Causes  ivithiii  the  Duet  : — 


Gall  stones 
Inspissated  bile 


j  C  Hydatid  cysts 

f  Parasites  ■'  Distomata 

I  .\sca  rides 

B.  Causes  affecting  the  Wall  of  the  Duct  : — 

Catarrh   iif  the   nmcoils   menihranc   of      (Mtaiili     of     tlic      ijiuktcms     spicading     to 
the  duct  and    involving   the    ampulla    ol'   X'ater 

Catanli   of  the   nmcous   membrane   of  (C'lironie  jiancrcatitis) 

the    diuideinmi    involvhig    and    oh-       Carcinoma  of  the  duct 

struclin!;  the  ampulla  of  Vatcr  Cicatrization  following  idciiatioii  of  the  duct 

Congenital  ohiitcration  of  the  duct 

C.  Causes  compressing  the  Duct  from  nutsirle  or  invading  it  from  outside  : — 


^ Peril oiual   adhesions 

Knlargc(l  portal  lympliaJii-  glands 

(ii)  Seconilary  malignant 

(t>)  Lymphadcnoniatous 

((•)  Tnlierculoiis 

{il)  Lcnka'mic 
Tuuiours  ol'  the   Vwvv 


TiMi: 


)f  tli( 


stomach 
colon 
,,  right  kidney 

,,  ,,         suprarenal  capsule 

, ,  , .         ovaries 

uterus 
omentum 
.\uriM'vsm   of  the   lu'pati<'   aitirv 


(luodcUHi 

II.  Jaundice    without    Obstruction    of    the    larger    Bile-ducts : 

A.   Causes  associateil  7vitli  Diseiise  of  tin'  Liver  :  — 

.\cutc   yellow  alro|iliy 
I'assivc  congestion  from  ( 
.Sluijlc  Syphilis 


CarcinorTiti 
Cin-liosis 


.\hseess 


Multiple  or  pyainic 


lu'ouic  heart  failure 


.\etivc  congestion 


Ii.  .Jaundice  in  .Icute  Fevers  anil  Infections,  such  as  : — 
Tvplnis  I     Hlicuyialic   lexer 

Typhoid    fever  .Syphilis 

Pvainia  Weil's  disease 

Pneumonia  |    Yellow   fever 

C.  Jaundice  due  to  Poisons  : 

Phosphorus  Autimnriiuril  ted    li\droL'<ri 

.\rs(niuri-ll.(l    lixdro-        Midc  Icrn 

(..,■11  Tolllvleucdiairiili,- 

Trinitrol  >ImoI 

D.  .laundicc  due  to  \crvinis  Causes  :    - 

Mental   iinoliou  I         Concussion 


F.  .Iiiundicc  due  to  I'nclassificd  Ciius 

I''aniilial    iauniliei'  Pernicious 

l'',|iideiriie         infeclive         Splenii-    all 

iaMli.lne  l.rllkalnla 


■.V  : 


Kelapsing  fever 
.Malaria 

Ami  some  other    tropieal 
fevers 


Snake   poison 

'I'l'traclilorethane 

Dinitrolien/.ene 

(  hloride  of  Sulphur 


lelerns   tk 
Icterus  v.<- 


JArXDIC'E 


THE    DIAGNOSIS 


When  diagnosing-  the  cause  of  jaundice  in  any  given  case,  it  is  important  to  consider, 
not  only  the  degree  of  jaundice,  but  also  the  age  of  the  patient,  the  history,  and  the  signifi- 
cance of  any  other  symptoms  which  may  be  ))resent. 

Very  intense  jaundice  and  clay-coloured  motions  indicate  some  obstruction  to  the 
common  bile  duct,  of  which  the  commonest  causes  are  catarrh,  gall-stones,  chronic  pancrea- 
titis, or  carcinoma. 

Jaundite  with  rigors  suggests  :  (1)  Infective  or  suppurative  cholangitis,  with  or  without 
suppurating  gall-bladder  from  gall-stones  or  from  carcinoma  :  (2)  Infective  or  suppurative 
pylephlebitis,  especially  after  appendicitis  ;  (3)  Hepatic  abscess  (single  or  pya-niic). 
Almost  all  the  different  causes  of  jaundice  may  also  cause  pyrexia,  so  that  without 
rigors  tlie  existence  of  pyrexia  does  not  assist  greatly  in  the  differential  diagnosis.  That 
cirrhosis  of  the  liver  and  carcinoma  of  the  liver  are  both  \ery  apt  to  cause  evening  rises  of 
temperature  to  as  much  as  100°  F.,  101^  F.,  or  more,  is  a  fact  that  is  sometimes  overlooked 
{Pig.  167,  p.  371,  and  Fig.  145). 

The  absence  of  jjyrexia  in  a  jaundice  case  will  serve  to  exclude  such  conditions  as 
abscess,  pylephlebitis,  cholangitis,  acute  specific  fevers  such  as  typhoid  or  Weirs  disease, 
and  epidemic  infective  jaundice. 


TIME 

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Jaundice  with  enlargement  of  the  liver  may  occur  in  any  condition  of  obstruction  to 
the  common  bile  duct,  and  in  congestion  of  the  li^•er,  cirrhosis,  carcinoma,  syphilis,  abscess, 
phos]jhorus  jioisoning. 

Jaundice  with  a  very  greatly  enlarged  gall-bladder,  especially  persistent  jaundice 
in  a  middle-aged  person,  suggests  carcinoma  of  the  head  of  the  pancreas.  Gall-stones 
seldom  cause  both  jaundice  and  a  large  gall-bladder  at  the  same  time,  perhaps  because 
the  infective  process  that  produces  the  gall-stones  also  causes  peritoneal  adhesions  about 
the  gall-bladder  which  tie  it  down  and  prevent  it  from  expanding. 

The  diagnosis  is  very  often  almost  ob\i()us.  For  instance,  jaundice  appearing  in  an 
infant  two  or  three  days  after  birth,  and  rapidly  disappearing  again,  is  almost  physiological 
(icterus  neonatorum).  Transient  jaundice  in  an  otherwise  healthy  boy  or  girl  will  almost 
certainly  be  catarrhal.  Jaundice  following  an  acute  attack  of  colic  at  once  suggests  a 
gall-stone.  Recurrent  attacks,  extending  over  years,  are  not  likely  to  be  due  to  malignant 
disease,  whereas  persistent  and  deepening  jaundice  without  intense  pain  in  a  person  over 
40  years  of  age,  who  has  been  wasting  and  has  only  been  ill  a  month  or  two.  suggests 
malignant  disease.  It  often  happens  that  the  primary  growth,  in  cases  of  secondary 
malignant  jaundice,  is  not  at  once  obvious,  and  it  is  important  not  to  omit  a  rectal  examin- 
ation, lest  there  be  a  rectal  carcinoma  that  is  itself  causing  no  symptoms. 

A  few  words  may  now  be  said  about  cacli  of  the  main  causes  of  jaundice. 


JAUNDICK  327 

I.  OBSTRUCTION    OF    THE    COMMON    BILE-DUCT. 
A.  Within    tlie    Duct. 

Gall-stoDc.'i  may  give  rise  to  no  symptoms  so  long  as  they  remain  in  the  gall-bladder. 
They  vary  in  si/.e  from  a  grain  of  sand  to  a  hen's  egg,  and  in  a  few  cases  they  may  be  detected 
by  the  .r-nys  (Fig.  14(>).  If  imiricted  in  the  eystie  dnct.  distention  of  the  gall-bladder  may 
follow,  but  there  is  no  jaundie;.'.  When  impacted  in  the  common  duet,  intense  jaundice  is 
produced,  and  some  enlargement  of  the  liver,  but  in  th.^  majority  of  cases  no  distention  of 
the  gall-bladder.  Before  impaction  of  the  eileulus  takes  place  as  it  moves  from  the  gall- 
bladder along  the  ducts,  intense,  agonizing,  colicky  pain  is  produced,  which  is  first  felt  in 
the  epigastrium  and  right  hypochondriimi,  extending  thence  to  the  back  of  the  lowci  part 


/■■iV/.  1  ir..— .skii 


The  Mnlical  Aniiiki'.  I'.lll.) 


of  the  right  chest,  to  the  back  of  the  right  shoulder,  and  it  may  be  so  severe  that  the  patient 
becomes  collapsed.  Vomiting,  pyrexia,  and  rigors  are  other  symptoms  which  are  fre- 
quently associated  with  these  attacks  of  i)ain.  The  latter  lasts  a  varying  time  according 
to  what  happens  to  the  calculus.  If  expelled  into  the  duodenum  the  severe  pain  ceases, 
and  the  gall-stone  may  be  found  in  the  fa-ces.  If  found,  it  should  be  examined  carefully, 
for  if  its  surface  is  faceted  it  indicates  that  other  gall-stones  are  ))resent,  and  points  to  the 
likclihocMl  (if  liiilhcr  allai-ks  dC  (•dlic  aiid  jaundice  occurring. 


32«  JAUNDICE 

Jaundiof  depen.ient  on  the  passage  of  gall-stones  usually  comes  on  about  twelve  hours 
after  the  conimencemcnt  of  the  attack  of  colic,  and  persists  for  a  varying  period  according 
to  the  length  of  time  the  calculus  remains  in  the  duct.  Occasionally  jaundice  occurs  without 
any  previous  colic.  Recurring  attacks  of  jaundice  in  a  middle-aged  woman,  with  or  without 
attacks  of  colic  are  almost  pathognomic  of  gall-stones  ;  only  one  other  disease  produces 
precisely  similar  symptoms,  namely,  chronic  pancreatitis.  In  the  latter,  however,  the 
jaundice  is  apt  to  persist  longer,  and  it  may  never  go  completely  away,  lessening  between 
the  attacks,  to  deepen  again  with  each  recurrence  of  the  acute  pancreatic  pain.  It  is  often 
very  difficult  without  laparotomy  to  distinguish  gall-stones  from  chronic  ])ancreatitis.  The 
absence  of  gall-stones  in  the  ftcces,  and  the  presence  of  a  positive  pancreatic  reaction  in  the 
urine  (see  Cammidgk's  Pancreatic  Reaction,  p.  100),  would  point  to  chronic  pancreatitis 
rather  than  to  gall-stones  ;  the  former  is  distinguished  from  neo))lasm  l)y  the  greater  amount 
of  pain  it  causes  and  the  longer  the  case  lasts. 

There  are  several  methods  of  detecting  ]>ancreatic  disease,  most  of  wliich  depend  upon 
the  non-entry  of  the  pancreatic  juice  into  the  intestine.  The  percentage  of  fat  in  the  stools 
when  ordinary  quantities  are  given  by  the  mouth  is  very  much  greater  when  the  pancreatic 
juice  fails  than  when  the  bile  alone  fails,  so  that  extremely  fatty  iridescent  stools  favour 
a  diagnosis  of  pancreatitis  or  pancreatic  neoplasm.  The  same  indication  is  afforded  when 
the  ffEces  contain  a  large  number  of  undigested  muscle  fibres  ;  also  when  keratin-coated 
capsules  are  passed  undigested,  or  when  such  capsules  containing  methylene  blue  are  given 
without  the  urine  sub.sequently  turning  blue.  Other  tests  concern  the  tryptic  activity  of 
the  motions,  and  so  forth,  and  their  value  is  still  sub  judice. 

If  a  stone  remains  imi)aeted  in  the  common  duct,  the  jaundice  is  intense  ;  but  if  it  soon 
passes  into  the  duodenum,  the  jaundice  is  slighter  and  transient. 

Inspissated  Bile  is  always  mentioned  as  a  cause  of  jaundice,  but  there  are  no 
distinguishing  signs  of  this  condition,  and  it  would  require  considerable  boldness  on  the 
part  of  the  physician  to  make  this  the  sole  diagnosis.  Thickening  of  the  bile  may  occur 
in  acute  fevers,  poisonings,  and  so  forth,  and  this  is  jiossibly  the  cause  of  the  jaundice  in 
many  of  the  cases  where  there  is  no  obstruction  to  the  large  bile-ducts  ;  but  a  diagnosis 
of  '  inspissated  bile  "  by  itself  would  clearly  be  ineom])lete  and  inadequate. 

Parnsiles. — A  In/dalid  ei/sl  of  the  liver  may  happen  to  be  in  such  a  position  as  to  stcnose 
the  common  bile-duet,  or  it  might  open  into  the  gall-bladder,  cystic,  hepatic,  or  common 
bile-ducts.  It  is,  however,  an  exceptionally  rare  cause  of  jaundice,  and  it  eoulil  seldom 
be  diagnosed  unless  by  laparotomj-. 

Distoma  hepaiieum . — The  normal  habitation  of  this  parasite  is  the  bile-duets  of  the 
sheej)  ;  it  is  sometimes  found  occupying  a  similar  i)osition  in  man,  though  in  England  this 
is  of  extreme  rarity.  The  chief  symptoms  are  jaundice,  ascites,  enlargement  of  the  liver, 
vomiting,  pyrexia,  diarrhcea,  and  jjain  in  the  right  hypochondrium.  If  circumstances 
"should  suggest  this  infection,  the  vomit  and  the  stools  should  be  examined  for  ilukes,  and 
the  stools  for  ova,  which  are  large,  brown,  and  operculated,  measuring  0-13  by  '08  mm 

Ascaris  liDiihrieoidcs  (round  worm).— This  parasite  inhabits  the  upper  part  of  the 
small  intestine  and  measures  from  ]  5  to  45  cm.  in  length.  It  seems  to  have  a  special  tendency 
to  force  itself  into  small  orifices,  and  it  has  been  recorded  as  becoming  impacted  in  the 
common  bile-duct,  with  jaundice  as  the  result.  The  worms  themselves  seldom  ]>roduce 
symptoms,  and  unless  they  are  actually  found  in  the  duct  they  could  never  be  diagnosed 
with  certainty  as  the  cause  of  jaundice.  Even  if  the  worms  or  their  ova  were  found  in  the 
patient's  faeces,  it  would  be  a  bold  thing  to  diagnose  that  an  ascaris  impacted  in  the  bile- 
duct  was  the  cause  of  the  jaundice. 

B.  Causes    affecting    the    Wall    of    the    Duct. 

Calarrh  of  I  lie  MiiriiKs  Mcwhmiic  of  tlie  Bile-duct  (catanluil  jaundice).  -This  is  a  common 
cause  of  jaundice — in  young  peojjlc  the  most  eonunon  of  all.  It  is  due  U)  the  obstruction 
caused  by  the  swelling  of  the  mucous  membrane,  and  it  is  almost  im])ossil)le  to  distinguish 
clinically  between  eases  in  which  the  catarrh  is  confined  to  the  bile-ducts,  and  those  in 
which  it  began  in  the  duodenum  and  thence  extended  to  the  biliary  papilla.  It  is  usually 
preceded  by  gastro-intestinal  disturbances,  especially  epigastric  discomfort  and  dyspepsia. 
The  jaundice  develops  almost  suddenly  in  many  eases,  and  it  may  become  intense,  the 
stools  being  clay-coloured  and  the  mine  dark  with  bile  pigment.     There  may  be  a  slight 


JAUNDICK  329 

rise  of  temperature  at  first,  the  pulse  may  be  less  accelerated  than  would  be  proportionate 
to  the  temperature,  and  in  quite  rare  cases  it  is  absolutely  slowed  down  to  40,  or  even  30  ; 
the  liver  and  spleen  may  be  enlarged  slightly,  the  tongue  furred  and  the  breath  foul  :  loss 
of  appetite,  nausea,  constipation,  a  feeling  of  weight  and  discomfort  in  the  right  hypo- 
chondriac region  may  also  be  prominent  symj)toms.  In  mild  cases  the  jaundice  is  slight 
and  disappears  at  the  end  of  one.  two,  or  three  weeks  ;  sometimes  it  lasts  as  long  as  eight 
weeks,  or  even  more.  In  considering  the  diagnosis,  it  should  be  remembered  that  jaundice 
in  a  child  or  a  yoimg  adult  is  most  likely  to  be  due  to  catarrh.  The  slightness  of  the  pain 
helps  to  exclude  gall-stones  and  chronic  pancreatitis,  and  malignant  disease  is  rendered 
improbable  if  the  jaimdice  presently  clears  up,  and  if  the  patie/it  does  not  emaciate.  There 
is  a  growing  belief  that  so-called  catarrhal  jaundice  is  really  a  specific  infectious  fever  allied 
to  the  exanthemata,  and  many  instances  of  its  affecting  several  members  of  a  family  or 
school  or  village  within  a  short  period  of  one  another  are  on  rfcord. 

Catarrh  of  the  I'ancrentic  Ducts,  extending  to  the  ampulla  of  Vater  and  so  to  the  bile- 
ducts,  has  already  been  discussed  under  cliroiiic  pancreatitis  above.  It  differs  from  catarrh 
starting  in  the  duodenum  or  in  the  bile-duct  by  being  associated  with  periodic  attacks  of 
colicky  epigastric  jiain  resembling  gall-stone  colic. 

Cicatrization  follnzcing  Ulceration  of  the  Duet. — Simple  fibrous  stricture  of  the  bile-diicts 
is  a  pos.sible  but  rare  result  of  ulceration  due  to  gall-stones.  If  the  cystic  duct  is  thus 
stenosed,  distention  of  the  gall-bladder  without  jaundice  follows  ;  if  the  hepatic  duct, 
jaundice  and  enlargement  of  the  liver  without  distention  of  the  gall-bladder  ;  and  if  the 
common  duct,  intense  jaundice,  enlargement  of  the  liver,  and  possibly,  but  not  necessarily, 
distention  of  the  gall-bladder.  It  is  practically  impossible  to  diagnose  between  this 
condition  and  impacted  gall-stones  dining  life.  exce|)t  by  lajiarotomy. 

Congenital  Ohiilcralion  of  the  liilc-duets.  .laundicc  in  infants  is  almost  always  transient, 
icterus  neonatorum  (leveloi)ing  about  the  third  day  and  ])assing  off  in  a  week  or  less.  If  an 
infant  should  remain  jiersistently  jaundiced,  a  grave  condition  is  almost  certainly  present, 
though  only  a  ])ost-mortem  examination,  as  a  rule,  can  decide  whether  it  is  due  to  congenital 
syphilis  with  or  without  cirrhosis  and  pervious  duets,  to  congenital  obliteration  of  the  I)ile- 
ducts,  or  to  ■  icterus  gravis."  the  last  term  being  used  when  the  child  dies  and  no  obvious 
cause  for  the  jaiuidiee  can  be  found  post  mortem.  As  regards  congenital  obliteration  of  the 
bile-duets,  boys  are  affected  more  frequently  than  girls.  .Jaundice  may  be  present  at  birth 
or  appear  on  the  .second  day.  or  even  as  late  as  the  fourteenth  day.  At  first  it  is  slight,  but 
.soon  becomes  intense.  Constipation,  jjale  motions,  bile  in  the  urine,  and  spontaneous 
hicmorrhages— especially  fron\  the  umbilicus — are  the  most  prominent  symptoms.  Death 
jnay  take  place  in  two  or  three  weeks  when  haemorrhage  occurs,  but  if  there  is  no  bleeding 
life  may  be  |)?()l(inged  for  six  or  seven  months.  Increasing  jaundice,  colourless  motions, 
bile-stained  urine,  and  spontaneous  luemorrliages  would  point  to  some  eondilion  more 
serious  than  icterus  iiconaldrinn. 

C.  Causes    Compressing    the    Duct    from    Outside    or    Invading    it    from    Outside. 

When  compression  of  the  eonuiion  bilc-dnel  is  spoken  of,  (lie  term  invasion  of  it  would 
oltcM  be  more  correct,  especially  when  the  so-called  com|)ression  is  due  to  seeon<lary 
deposits  of  malignant  disease  in  the  lyniphalic  glands  in  tlie  portal  fissure.  In  almost  all 
cases  of  the  kind  jaundice  is  pcrsisleiil .  and  it  is  often  pn>gressi\ c.  altliough  tlicrc  may  be 
slight  variations  in  its  <lepth. 

Kniarfieil  (Hands  in  llic  J'ortal  /''issuri'.  a.  Sixondakv  .Malignant  (Ji.ands. — The 
l\iMphatic  glaiKis  in  llic  poilal  fissure  are  xcry  liable  to  become  enlarged  from  deposits  of 
secondary  growth  in  eases  of  abdominal  malignant  disease.  .laundiee  with  or  withovit 
ascites  is  a  prominent  iiidiealion  of  sucli  a  coiKlition.  and  when  Ixilh  jaundici-  and  ascites 
are  present  in  a  ease  of  nialigiiant  disease  of  llie  stoniai'h  or  intestine,  whether  the  li\er  is 
enlarged  or  not.  it  is  probable  llial  there  are  enlarged  malignant  glands  in  the  j)orlal 
fissure.  The  dillieully  of  diagnosis  arises  in  cases  in  which  no  primary  growth  can  be 
fniind.      Ill  a  fair  muiiber  of  these  it  is  either  in  the  rectum,  colon,  or  i)ancreas. 

''.  I,^  \iriiAi)i;N()M A  loi  s  (;i,\mis.  The  portal  glands  occasionally  become  enlarged 
in  ciises  of  lyinphadeTionia  (Ilorlgkin's  disease),  or  lynipliosarcoma,  with  a  similar  result. 
The  preseiiee  ol  eMlarg<(l  superficial  lymph  glands  and  enlargement  of  the  spleen  and 
li\(r.  t(ii;etliir  willi  ;i  simple  ana'inia  without  leueoeylosis.  would  suggest  this  diagnosis. 
In  iiiiist  eases  of  I yniphadenoma  in  which  jamidiee  occurs  it  is  a  late  symploiii,  arising 
long  alter  llie  eorreel   diagnosis  has  already  been   made. 


330  JAUNDICE 

c.  Tuberculous  Glands. — Although  the  glands  in  tlic  portal  fissure  frequently 
become  caseous  in  cases  of  tuberculous  peritonitis,  they  rarely  coni])ress  the  bile-duct 
and    cause    jaundice. 

d.  Lymphatic  Leuk.emic  Glands. — The  visceral  glands  may  become  enormously 
enlarged  in  some  cases  of  lymphatic  leukaemia,  and  in  rare  instances  those  in  the  portal 
fissure  have  led  to  jaundice.  The  diagnosis  is  easy,  even  if  the  spleen  and  superficial 
lymphatic  glands  are  not  enlarged,  for  a  blood-count  would  show  that  the  total  number 
of  leucocytes  per  c.mm.  of  blood  was  raised  to  anything  between  50,000  and  2,000,000, 
wliilst  the  differential  leucocyte  count  would  show  a  great  preponderance  of  lymphocytes. 

Tintioiirs  of  tlie  Liver. — Any  disease  which  causes  a  local  enlargement  of  the  liver,  e.g., 
carcinoma,  sarcoma,  abscess,  gumma,  or  hydatid,  in  the  immediate  neiglibourhood  of  the 
])ortal  lissure,  may  compress  the  common  bile-duct  and  lead  to  jaundice.  On  account  of  the 
close  relationship  between  the  bile-duct  and  the  portal  vein,  ascites  is  equally  liable  to  be 
))roducc(l.  The  association,  therefore,  of  jaundice  and  ascites  with  a  local  enlargement 
of  the  liver  would  point  to  this  last-mentioned  condition  being  the  cause  of  the  two  former. 
In  many  such  cases,  however,  the  jaundice  is  really  due  to  deposits  in  the  portal  lymphatic 
glands  ;  for  if  the  latter  escape  there  may  be  munbcrs  of  malignant  deposits  in  the  liver 
without  any  jaundice  at  all. 

Tiinioiirs  of  the  Pancreas — A  timiour  of  the  head  of  the  pancreas  generally  causes  jaundice 
by  invading  the  orifice  of  the  common  bile-duct.  In  some  cases,  situated  far  back  in  the 
abdomen,  a  mass  can  be  felt  which,  on  account  of  its  close  proximity  to  the  aorta,  may 
present  distinct  transmitted  pulsation.  It  may  prove  didicult.  without  artificially  inflating 
the  stomach,  to  distinguish  it  from  a  tumour  of  the  latter  or  of  the  liver.  A  pancreatic 
tumour  is  situated  behind  the  stomach,  and  does  not,  as  a  rule,  move  on  respiration,  though 
if  attached  to  the  jiortal  fissure  it  moves  with  the  liver.  Glycosuria  and  fatty  stools  would 
be  strong  evidence  in  favour  of  a  pancreatic  tumour,  even  if  no  tumour  were  palpable. 
The  tests  mentioned  on  page  101  could  be  employed  here  too.  The  gall-bladder  is  apt  to 
become  greatly  distended  ;  indeed,  persistent  and  increasing  jaundice  and  decided  enlarge- 
ment of  the  gall-bladder  in  a  person  of  the  cancer  age  are  probably  the  most  characteristic 
symptoms  of  carcinoma  of  the  head  of  the  pancreas. 

Tumours  of  the  Duodenum. — Primary  carcinoma  of  the  duodenum  is  very  rare,  but 
when  it  does  occur  it  usually  arises  in  the  immediate  neighbourhood  of  the  biliary  papilla, 
and  by  obstructing  the  common  bile-duet  causes  persistent  jaundice,  with  progressive 
emaciation. 

Tumours  of  the  Stomach. — A  carcinomatous  tumour  of  the  pyloric  end  of  the  stomach 
may  become  adherent  to  the  portal  fissure  and  cause  jaundice  by  compressing  the  conmion 
bile-duct.  If,  liowe\-er,  the  existence  of  a  gastric  carcinoma  were  known  in  a  patient  who 
developed  jaundice,  the  chances  would  be  strongly  in  favour  of  the  latter  being  due  to 
obstruction,  not  by  the  ])rimary  growth,  but  by  secondary  de])osits  in  the  portal  lymph- 
glands.  It  should  also  be  borne  in  mind,  however,  that  even  when  carcinoma  exists,  a 
microbial  catarrh  of  the  duodenum  may  cause  transient  non-malignant  jaundice. 

Tumours  of  the  Colon. — Carcinoma  of  the  hepatic  flexure  or  transverse  colon  may 
become  adherent  to  the  liver  and  cause  jaundice  by  compressing  the  common  bile-duct. 
It  may  be  dillicult  to  distinguish  such  a  tumour  from  a  local  enlargement  of  the  liver  ;  but 
constipation,  vomiting,  tympanitic  distention  of  the  intestine,  and  the  passage  of  blood 
per  rectum  would  jjoint  to  a  growth  in  the  colon.  In  most  of  such  cases,  however,  the 
obstruction  to  the  bile-ducts  is  not  by  the  primary  growth,  but  by  secondary  deposits  in 
the  portal  glands.  The  importance  of  rectal  examination  has  already  been  insisted  on. 
whilst  much  help  in  diagnosis  may  also  be  afforded  by  serial  a-ray  examination  of  the 
alimentary  canal  after  a  bismuth  or  barium  meal. 

Tumours  of  tlw  liight  Kidney. — Large  tumours  of  the  right  kidney,  especially  malignant 
growths,  may  com])ress  the  bile-duct  and  cause  jaundice.  If  the  tumour  becomes  adherent 
to  the  liver  it  is  dillicult  to  distinguish  it  from  an  enlargement  of  that  organ,  as  the  liver  and 
tlie  enlarged  kidney  would  move  together  during  respiration.  If  the  abdomen  is  palpated 
l)imanually,  however,  the  loin  may  be  felt  to  be  filled  out  behind  ;  and,  in  front,  the  edge 
of  the  liver  may  be  distinguislu-il  lying  over  the  front  of  the  tumour,  and  it  may  he  possible 
to  detect  a  vertical  band  of  colonic  resonance  over  the  otherwise  dull  mass.  IIa;maturia, 
albuminuria,  or  pyuria  woidd  be  additional  evidence  of  renal  disease. 


JAUNDICE  331 

Transitory  attacks  of  slight  jaundice  are  not  uncommon  in  association  with  movable 
kidney.  This  is  possibly  due  to  compression  of  the  coimnon  bile-duct  by  the  kidney,  but 
it  may  also  result  from  the  associated  enteroptosis  causing  a  drag  on  the  duodenum,  and 
a  kinking  of  the  common  bile-duct.  The  diagnosis  of  movable  kidney  is  not  difficult,  the 
position  and  the  mobility  of  the  tumour,  and  the  curious  sickening  sensation  experienced 
by  the  patient  when  it  is  compressed,  being  sufficiently  characteristic. 

Tumours  of  the  Rigid  Suprarenal  Capsule. — Malignant  growth  of  the  right  suprarenal 
capsule  is  very  rare,  but  it  may  give  rise  to  an  enormous  tumour  which  is  difficult  to 
distinguish  from  a  renal,  or  even  in  some  cases  a  hepatic,  enlargement.  Malignant  disease 
of  one  capsule  causes  no  symptoms  of  Addison's  disease  if  the  other  remains  healthy. 
In  children,  hypernephroma  may  be  suggested  by  the  ])rcniature  development  of  pubic 
hair  (see  p.  408). 

Ovarian  Tumours. — A  large  ovarian  cyst  may  extend  upwards  to  the  portal  fissure, 
compress  the  common  bile-duct,  and  cause  jaundice,  but  such  a  complication  is  rare  ;  indeed, 
when  jaundice  is  associated  with  ovarian  tumour  the  suspicion  will  naturally  be  that  the 
latter  is  malignant  and  that  there  are  secondary  deposits  in  the  glands  in  the  portal  fissure 
obstructing  the  large  bile-duets.  Ascites  is  very  apt  to  be  present  at  the  same  time,  so  that 
unless  the  existence  of  an  ovarian  tumour  is  already  known,  or  unless  its  existence  can  be 
determined  by  abdominal,  vaginal,  or  rectal  examination,  there  may  be  much  difficulty 
in  determining  the  precise  cause  of  the  jaundice,  though  if  cirrhosis  of  the  liver  can  be 
excluded,  some  form  of  malignant  disease  will  ])r(>l)ably  be  suspected. 

Tumours  of  the  Uterus. — A  large  tumoiu'  of  the  uterus  may  cause  jaundice  in  a  similar 
manner  to  an  ovarian  tumour,  but  even  more  rarely. 

Tumours  of  the  Omentum. — A  large  omental  tumour  may  compress  the  bile-duct  and 
thus  cause  jaundice,  but  it  is  an  exceedingly  rare  result  of  such  a  condition.  Whether 
malignant  or  tuberculous,  it  usually  lies  across  the  U])per  part  of  the  abdomen,  is  superlieial. 
and  moves  slightly  with  respiration.  If  it  has  become  adherent  to  the  liver  it  may  be 
didicult  to  distinguish  it  from  a  local  enlargement  of  the  latter.  In  any  case,  the  jaundice 
will  probably  be  diagnosed  as  due  to  deposits — tuberculous  or  malignant — in  the  portal 
glands,  rather  than  to  the  omental  mass  itself. 

Aneuri/sm  of  the  Hepatic  Arteri/,  Ccelic  Axis,  or  .Ihdojuinal  .Inrta. — An  aneurysm  of  the 
hepatic  artery  is  decidedly  rare,  but  it  is  by  no  means  milieard  of  in  eases  of  fungating 
endocarditis  with  embolism.  .Jaundice  is  intense,  on  account  of  the  close  proximity  of 
the  hepatic  artery  to  the  common  bile-duct.  A  correct  diagnosis  would  be  almost  impossible 
during  life,  especially  in  view  of  the  fact  that  jaundice  may  occur  in  fungating  endocarditis 
cases  simply  from  the  inspissation  of  the  bile  that  results  from  the  toxaemia  and  fever. 

Aneurysm  of  the  eo'liae  axis  or  u))])er  part  of  the  abdominal  aorta  is  also  a  very  rare 
cause  of  jaundice.  An  abdominal  tumour  with  marked  expansile  ])ulsation,  a  systolic  bruit, 
and  alxlominal  pain,  are  (lie  most  important  diagnostic  signs,  especially  if  they  occur  in 
a  |)erson  who  is  known  to  ha\c  had  syphilis. 

II.  JAUNDICE    WITHOUT    OBSTRUCTION    OF    THE    LARGER    BILE-DUCTS. 

.1.  Causes   associated    with    Disease   of    the    Liver. 

(iireinoma  of  the  l.iivr. — Jaundice  occurs  in  more  than  'M  per  cent  (if  the  eases  of 
malignant  disease  of  the  liver,  whether  secondary  or  primary  ;  il  is  seldom,  however,  that 
the  masses  in  the  liver  itself  cause  the  jaundice,  but  rather  the  associated  deposits  in  the 
portal  glands.  .\  liver  may  contain  hundreds  of  nodules  of  new  growth  without  there  being 
either  jaundice  or  ascites  if  the  portal  glands  escaj)e.  Jaundice  brought  about  in  this 
niamier  is  permanent,  and  when  the  conunon  duct  is  involved  is  intense.  The  skin,  which 
at  first  is  a  deep  orange,  becomes  greenish,  and  linally  the  dark  oli\e-green  tint  which  is 
alriMist  |)athognomonic  of  jaundice  due  to  maligMMut  disease.  Increasing  jaundice  in  a 
patient  oscr  K)  years  cif  age.  who  has  been  ill  less  than  six  months,  who  lias  progressively 
wasted  and  liiidinc  wcnUci.  and  whose  lixcr  is  enormously  enlarged,  hard,  and  nodular. 
))oints  wilhoiil  much  douhl  lo  iiialignant  disease,  though  caielul  search  may  be  recpiircd 
beOire  the  primary  source  is  round.  Tlie  nodules  may  even  be  felt  to  be  imibilicated. 
Primary  eareiiKima  of  llie  lixcr  should  no!  be  diagnosed  until  a  very  cjireful  physical 
examination  has  fai!<'(l  to  furnish  evidence  of  the  primary  growth  in  some  other  organ. 


3B2  JAUNDICE 

Cirrhosis. — In  many  cases  of  cirrliosis  of  the  liver  the  late  or  multilobular  stage  of  the 
disease  may  be  reached  without  there  having  been  any  jaimdice  at  all.  If  it  occurs  late 
in  the  disease,  when  ascites  is  already  present,  the  jaundice  is  usually  slight.  Ascites  is  the 
most  constant  and  characteristic  feature  at  this  late  stage  of  cirrhosis,  but  when  slight 
jaundice  and  ascites  are  associated  in  a  patient  who  gives  a  definite  history  of  alcoholism, 
and  also  has  symptoms  and  shows  signs  of  this  condition  (]).  720),  and  has  a  hard  liver  with 
a  well-defined  and  beaded  edge,  the  diagnosis  of  cirrhosis  of  the  liver  is  not  diflicult.  Some- 
times, however,  jaundice  is  a  marked  feature  of  the  case  at  an  early  stage,  when  the  organ 
is  still  large  and  the  fibrosis  unilobular,  and  at  this  time  ascites  is  consjjicuous  by  its  absence. 
In  most  of  these  cases  there  is  an  evening  rise  of  temperature  to  about  100°  F.  (Fig.  167.  p. 
371).  The  liver  is  considerably  enlarged,  its  surface  is  smooth,  firm  perhaps,  and  tender, 
and  its  edge  is  even  and  well-defined,  reaching  to  the  level  of  the  umbilicus  or  even  below  it. 
The  jaundice  may  pass  off,  and  the  patient  survive  many  years  before  the  multilobular 
ascitic  stage  of  his  malady  is  reached  ;  on  the  other  hand,  if  the  jaundice  persists  and 
deepens,  the  prognosis  is  grave  ;  chola?mia  sets  in,  drowsiness  and  muttering  delirium 
passing  on  to  coma  and  death. 

There  is  a  peculiar  form  of  cirrhosis  of  the  liver  (Ilanofs)  which  affects  several  members 
of  the  same  family,  and  whose  first  symijtom  in  each  patient  is  jaundice.  The  disease 
appears  not  to  be  caused  by  alcohol,  .syphilis,  or  malaria.  It  is  possible  for  the  patient  to 
live  many  years  with  more  or  less  jaundice  all  tlie  time.  The  icteric  tinge  of  the  skin  is 
often  imacconipanied  by  bile  pigment  in  the  urine  in  these  chronic  eases — a  variety  of 
acholuric  jaundice.  The  liver  is  enlarged  and  hard,  and  the  spleen  is  also  moderately 
increased  in  size.     The  diagnosis  is  arrived  at  by  enquiring  into  the  family  history. 

There  is  another  malady,  known  as  ffiDtilial  (ichoturic  jaundice  (Pliitc  XJ'III).  wliich 
simulates  Hanofs  cirrhosis  very  closely  during  life,  but  is  found  at  operation  or  post 
mortem  to  present  no  hepatic  cirrhosis.  Several  members  of  the  same  family  are 
affected,  the  spleen  is  enlarged  considerably,  the  symptoms  develo))  either  soon  after  birth 
or  during  the  first  ten  years  of  life,  progress  slowly,  with  periods  of  remission,  and  during 
exacerbations  there  is  considerable  chlorotic  ana;mia.  associated  with  fragility  of  the  red 
corpuscles  as  tested  with  varying  strengths  of  salt  solution,  and  a  consequent  tendency 
to  hjemorrhages  of  all  kinds — hicmatemesis,  haemoptysis,  epistaxis  and  purjiura  in  particular. 
The  pathology  of  this  condition  is  still  obscure  ;  some  of  the  cases  give  a  positive 
Wassermann  test  and  appear  to  be  due  to  congenital  syphilis  ;  these  are  differentiated 
by  some  observers  from  what  they  term  true  familial  acholuric  jaundice,  in  which  the 
AVassermann  test  is  negative.     Excision  of  the  spleen  has  cured  not  a  few  of  these  cases. 

There  is  yet  another  particular  variety  of  cirrhosis  of  the  liver  which  occurs  in  children 
and  young  people,  and  is  characterized  by  enormous  enlargement  of  the  spleen,  slight 
enlargement  of  the  liver,  ana-mia  without  leucocytosis,  hfematemesis,  clubbing  of  the  fingers, 
jaundice,  and  stunted  growth.  It  differs  from  Hanoi's  cirrhosis  in  that  the  liver  is  smaller 
and  the  spleen  larger,  and  from  the  latter  featiue  of  the  case  it  is  termed  splenomegalic 
cirrliosis. 

Single  or  Tropical  Abscess. — In  cases  of  single  or  tropical  abscess  of  the  liver  intense 
jaundice  is  rare,  and  it  is  only  likely  to  occur  when  the  abscess  bulges  in  the  region  of  the 
l)ortal  fissure.  The  general  appearance  of  a  patient  who  is  suffering  from  hepatic  abscess 
may,  however,  be  mistaken  for  jaundice,  because  the  complexion  is  sallow,  and  the  conjunc- 
tivae may  even  have  a  slightly  icteroid  tinge.  The  urine,  however,  seldom  contains  bile 
pigment.  The  disease  mostly  aflects  people  who  have  resided  in  the  tropics,  particularly 
those  who  have  had  dysentery.  The  diagnosis  is  discussed  on  ]>.  3(i!)).  Should  the  abscess 
open  into  the  lung,  the  dull  reddish  pus  expectorated  would  jjoint  to  its  origin  in  the  liver 
even  though  no  Amwbce  dysentericc  be  found  in  the  ]]us. 

Mnltiple  Abscesses  in  the  Liver  might  theoretically  arise  by  infection  through  any  one 
of  four  different  channels,  namely,  the  portal  vein,  the  bile-ducts,  the  hepatic  artery,  and 
the  lymphatics.  In  practice  only  the  first  two  are  important,  giving  rise  to  suppurative 
pylepldebitis  on  the  one  hand,  and  suppurative  cholangitis  on  the  other.  There  are  really 
no  sharp  lines  of  demarcation  between  non-suppurative  and  suppui'ative  inflammations  of 
these  channels  ;  there  are  all  intermediate  stages  between  simjile  catarrh  of  the  duets  and 
acute  suppurative  cholangitis  ;  and  there  are  similar  degrees  of  inflammation  in  the  case  of 
the  portal  venules.     Jaundice  is  almost  constantly  a  symptom  of  cholangitis,  and  the 


PLATE     XV  III 


FAMILIAL      ACHOLURIC      JAUNDICE 


A  case  of  (iiTiili:il  aclioluric  juun.li™  willi  niil.iraf.l  In 
I'lit  Imd  licen  piTsisleiit  since  infniic-y.  N'ote  tli;it  Ihc  K' 
oljvlous  bile  ill  tlie  urine. 


IMIKX     or      [MAIlXdSI?  -r<)   jttCC   IK    332 


JAUNDICE 


333 


Fig.  117. — Lcucin  crystals,  ! 


iider  tlie  }.}n.  ol»je( 


diagnosis  is  arrived  at  when  a  cause  for  cholangitis  exists,  such  as  gall-stones,  carcinoma 

of  the  gall-bladder,  empyema  of  the  gall-bladder  after  typhoid  fever,  and  when  the  patient's 

liver  enlarges  and  becomes  tender,  especially  if  rigors  also  occur  from  time  to  time.    Suppura- 
tive pylephlebitis  is  diagnosed  less  easily, 

and  indeed  it   is   often  overlooked   as   a 

cause     for     an     obscure     febrile     illness 

accompanied  by  rigors.     About  half  the 

patients  who  have  it   develop   jaundice, 

and   one   very   impoi'tant   point  is   that, 

in  over   half  the  cases,  the  cause  of  the 

infection  of  the   portal  vein  is  a  i-ecent 

mild  attack   of  appendicitis.      If.  there- 
fore,   a    patient    who    has   recently    had 

pains    or   discomfort    in    the    right    iliac 

fossa    presently    begins     to     do     badly, 

developing   pyrexia   and   rigors    without 

apparent   cause,   and    if    that  patient  in 

the  course  of  a  week  or   so   develojjs    a 

tinge  of  jaundice  and  a  slightly  enlarged 

liver,    the   grave    diagnosis   of   infective 

pylephlebitis  should  suggest  itself. 

In  Acute  Yellow  yltrophij  of  ilie  Liver 

jaundice  is  one  of  the  earliest  symptoms. 

In  the  early  stages  bile  pigment  may  be 

found  in  the  urine,  but  towards  tlie  end, 

when   the  skin  becomes  green,    Gmelin's 

reaction  cannot  be  obtained,  or  only  a  trace  of  pigment  can  be  detected  (acholuric  jaundice). 
The  disease  is  rare.     It  affects  females  under  30  years  of  age  more  frequently  than  males, 

and  ill  a  go(»l  inany  cases  has  l)ccn  preceded  by  fright,  fir  severe  mental  emotion,  or  child- 

birth.     It  usually  commences  in  the 

same  manner  as  an  attack  of  catar- 
rhal jaundice,  with  nausea,  vomiting, 
loss  of  appetite,  constipation,  and 
pain  in  the  right  hypochondrium. 
.At  the  end  of  two  or  three  weeks 
a  sudden  change  occurs,  which  com- 
mences with  severe  vomiting,  head- 
ache, restlessness,  followed  by  deli- 
rium, convulsions,  and  coma.  The 
temperature  rises  to  101°  V.  or  102° 
F.,  and  the  pulse  Ijccomes  rapid. 
The  tongue  is  dry  and  brown.  There 
is  a  tendency  to  liaMuorrhage  from 
various  parts,  e.g.,  epistaxis,  ha-ma- 
temesis,  nietena,  and  metrorrhagia. 
The  most  important  diagnostic  signs 
arc  the  remarkable  dimiiuition  of 
urea  and  uric  acid,  and  the  presence 
(if  lcucin  (Fifi.  1  17)  and  tyrosin  {Fig. 
I  IH)  in  (III-  uiiric  ;  also  he  rapid 
(liminulidii  in  llic  cxhiil  oC  Hie 
hepatic  dulliKss  uliicli  lakes  place 
alter  the  (lc\<'lo|)riicnl  of  Ilic  aliove- 
mcntiiincd  nervous  syiiiplonis.  The 
iliii'Mliiiii  i>r  llic  malady,  in  the 
■    (inic  dl'    llic   sudden  clianuc    in    llie 


/■'■J.    IIS.     Tyiosi,,    ,Tj-ti.is, 
muTdsroJ'e  ;  slitMived  ol  coIour]eri^ 
of  plicnj'I-gliicosuzoiio  (Fig.  127, 


lo  hcc-ji  u.i.lu-  the  liiKl.-l.cmiT 
needles,  coarser  and  sliurter  tin 
p.  262J,  which  arc  yellow. 


majority  of  cases,   is  under-   fmirlccn    (hi 
type  of  tilt-  jaundici-. 

'llic    slriUiiiM    rt-scmlilaTicc   bet  wet  n 


lii.'il     pnidiii-ihU-    by   p 


834  JAUNDICE 

suggests  that  in  it  there  is  toxa?mic  catarrh  of  the  bile-ducts — that  is,  a  catarrh  produced 
by  the  excretion  through  the  bile  of  injurious  products  which  cause  extensive  degenerative 
changes  in  the  liver  cells.  A  condition  which  resembles  acute  yellow  atrophy  very  closely 
in  its  clinical  features  has  affected  not  a  few  persons  engaged  in  the  varnishing  of  the  wings 
of  aeroplanes,  or  occupied  upon  the  premises  in  which  this  work  is  being  carried  on.  The 
^■a^nish  used  is  a  very  special  one,  comiiosed  of  acetate  of  cellulose  dissolved  in  a  mixture 
of  spirit,  acetone,  benzol  and  tetrachlorethane.  It  is  the  vapour  of  the  latter  which  is  the 
cause  of  the  toxic  symptoms  ;  in  milder  cases  recovery  occurs  when  the  patient  is  removed 
from  the  works  on  account  of  continued  ill-health  with  more  or  less  severe  gastro-intestinpl 
symptoms — sspecially  flatulent  dyspepsia,  vomiting,  epigastric  pains  and  loss  of  appetite  ; 
those  who  remain  exposed  to  the  vapour  for  weeks  or  months  develop  jaundice  in  addition — 
at  first  exactly  like  a  simple  catarrhal  jaundice,  but  soon  passing  on  to  a  serious  and  gener- 
ally fatal  stage  precisely  similar  to  that  of  acute  yellow  atrophy  of  the  liver,  though  generally 
without  leucin  and  tyrosin  in  the  urine  A  somewhat  similar  condition  has  resulted 
from  the  effects  of  diuitrobeiizoic.  used  in  the  manufacture  of  high  explosives  such  as  roburite 
and  bellite  ;  from  irinitrotohuil.  and  from  the  use  oi  chloride  of  suJphw  by  rubber  workers. 
The  diagnosis  is  suggested  by  the  circimistances  of  the  occupation.  Post  mortem  the  liver 
in  these  cases  is  shrunken  and  discoloured,  just  as  it  is  in  acute  yellow  atrophy. 

Passive  Congestion  (nutmeg  li^'e^). — Jaundice  occurs  in  severe  cases  of  passive  conges- 
tion, especially  as  the  result  of  long-standing  mitral  stenosis,  or  of  fibrosis  of  the  lung  with 
ultimate  failure  of  the  right  side  of  the  heart.  It  is  usually  but  an  icteric  tinge,  but  when 
severe  its  association  with  cyanosis  gives  a  curious  dusky-green  tint  to  the  skin,  especially 
that  of  the  face.  Qidema  of  the  legs  and  ascites  are  also  present  as  a  rule.  The  liver  is 
considerably  enlarged,  its  edge  is  sharj)  and  well  defined,  its  surface  smooth,  firm,  tender, 
and  possibly  pulsating.  Jaimdice  from  this  cause  should  not  be  difficult  to  diagnose.  If 
in  a  chronic  heart  case  there  are  both  pyrexia  and  jaundice,  fungating  endocarditis  is 
probable. 

Syphilis. — Congenital  sj'jjhilis  may  cause  jaundice  in  infants  or  young  children  as  the 
result  of  intralobular  fibrosis,  but  it  is  possible  for  the  latter  to  be  extensive  without  there 
being  any  jaundice,  and  even  where  the  latter  is  present  it  is  usually  slight.  If  associated 
with  uniform  enlargement  of  the  liver,  wasting,  and  other  signs  of  congenital  syphilis,  tlie 
diagnosis  is  not  difficult. 

In  an  adult  it  is  possible  for  gummata  to  cause  jaundice  by  compressing  the  ducts,  but 
this  is  distinctly  rare.  The  local  enlargement  of  the  liver  and  pjTexia  may  lead  to  a  diagnosis 
of  abscess  or  of  secondary  carcinoma.  A  carefid  examination  must  be  made  for  signs  of 
.syphilis  ;  in  some  cases  it  is  not  until  antisyphilitic  remedies  have  been  administered  and 
the  effect  watched  that  a  correct  diagnosis  can  be  made.  If  there  are  any  active  lesions  of 
the  skin  or  mucous  membranes,  it  may  be  possible  to  detect  the  Spirochcvia  pallida  micro- 
scopically (see  Plate  A'A'f  III,  Fig.  J.  p.  61-t)  :  or  the  patient's  serum  may  be  examined  in 
the  laboratory  for  Wassermann's  reaction. 

ti-  Probably  the  commonest  period  at  which  sj-philis  may  be  directly  responsible  for 
jaimdice  is  the  secondary  stage,  when  it  is  apt  to  cause  catarrh  of  many  different  glandular 
ducts,  including  those  of  the  liver.  The  symptoms  will  be  very  like  those  of  simple 
catarrhal  jaimdice,  together  with  the  roseola,  the  sore  throat,  the  pyrexia,  the  albuminuria, 
and  other  signs  of  secondary  syphilis. 

Active  Congestion. — Active  congestion  of  the  liver  is  a  diagnosis  that  some  observers 
woidd  not  hold  with,  whilst  others  are  convinced  that  it  is  not  an  imcommon  result  of  many 
of  the  acute  fe\'ers,  such  as  malaria,  and  that  it  may  arise  from  insufficient  exercise  associated 
with  alcoholism  and  over-eating,  particularly  in  Europeans  who  live  in  the  tropics.  The 
liver  is  slightly  enlarged  and  tender.  The  chief  symptoms  are  slight  jaundice,  pain,  and 
a  feeling  of  fullness,  weight,  and  oppression  in  the  right  hypochondrium,  which  sensations 
are  much  increased  by  pressure  ;  also  pain  in  the  right  shoulder,  a  bitter  taste  in  the  mouth, 
nausea,  sickness,  a  furred  tongue  with  indented  edges,  constipation,  and  scanty  high- 
coloured  urine.  There  may  be  a  temperature  of  102°  F..  and  then  care  must  be  taken  to 
distinguish  it  from  hepatic  abscess.  An  absence  of  leucocytosis  would  be  in  favour  of 
congestion  and  against  suppuration.  If  due  to  malaria,  an  examination  of  stained  blood- 
films  should  demonstrate  the  presence  of  malaria  parasites.  It  is  clearly  impossible  to 
distinguish  clinically  between  active  congestion  of  the  liver  and  catarrh  of  the  bile-ducts. 


JAUNDICE 


B.  Jaundice    in    Acute    Fevers. 


Malaria. — Slight  jaundice  may  occur  in  long-continued  tertian  and  acstivo-autuninal 
infections,  arid  on  account  of  the  associated  irregular  pyrexia  it  may  lead  to  a  mistaken 
diagnosis  of  hepatic  abscess.  iMicroscopic  examination  of  stained  blood-films,  and  the 
discovery  of  the  characteristic  parasites  in  the  red  blood-corpuscles  (Plate  XXl'III.  p. 
614),  are  the  most  conclusive  evidence  of  malaria.  Jaundice  may  also  occur  as  a  result  of 
malarial  cirrhosis.  It  should  be  borne  in  mind  that  the  parasites  disappear  rapidly  from 
the  l)lood  in  cases  in  which  quinine  has  been  administered  recently.  It  is  important,  there- 
fore, to  examine  blood-films  before  quinine  is  given,  and  if  possible  at  the  very  start  of  an 
ague  fit,  at  which  time  they  are  at  their  most  typical  stage  of  development.  If  quinine 
has  been  given  already,  however,  there  will  still  be  presumptive  evidence  of  malaria  if 
there  is  no  leucocj-tosis,  and  if  the  differential  leucocj'te  count  shows  a  decided  increase 
in  the  proportion  of  large  hyaline  lymphocytes — up  to  15  per  cent  or  more. 

Typhus  Fever. — Jaundice  may  occur  occasionally  in  this  disease,  which,  fortunately, 
is  now  extremely  rare  in  Great  Britain,  but  it  may  reappear  in  any  country  during  times  ol 
famine  or  distress  ;  or  during  war,  as  in  Servia  and  other  regions  during  the  European  War. 
It  is  a  disease  of  poverty,  famine,  dirt  and  squalor,  and  is  spread  by  lice.  The  onset  is 
more  sudden,  and  the  prostration  occurs  earlier  and  is  more  marked,  than  in  typhoid  fever. 
There  is  often  a  slight  leucocytosis.  The  rash  apjjears  from  the  third  to  the  fifth  day, 
and  consists  of  a  dusky  red  mottling — the  mulberry  rash — rose-coloured  papules  which 
appear  on  the  abdomen  and  chest,  together  with  a  certain  number  of  ])etechi;c — the  latter 
not  being  found  in  tj-phoid  cases.  The  fever  tends  to  terminate  by  crisis  rather  than 
by  lysis.     Widal's  reaction  is  negative. 

Typhoid  Fever. — Jaundice  is  rare  in  this  disease  ;  it  occurred  in  only  three  out  of  Osier's 
series  of  829  cases.  It  is  due  to  an  inflannuation  of  the  bile  passages  by  typhoid  bacilli. 
The  gall-bladder  may  become  enlarged  and  tender,  and  give  rise  to  a  tviiical  palpable 
tumour,  though  this  may  also  occur  in  typhoid  fever  without  any  jaundice  at  all.  It 
arises  occasionally  as  a  complication  in  the  course  of  the  disease,  or  it  may  be  a  sequela,  or 
again  it  may  be  an  early  and  prominent  symptom  for  which  the  patient  seeks  advice.  Cases 
have  been  recorded  of  primary  typlioid  infection  of  the  gall-bladder  and  bile-ducts  without 
any  accompanying  ulceration  of  the  intestine.  The  low  pulse  ratio  when  compared  with 
the  temperature,  e.g..  a  pulse  of  itO  with  a  temperature  of  lOl  F.,  the  ])rescnce  of  typical 
rose-red  s])ots  on  the  abdomen,  enlargement  of  the  spleen,  Icucopenia,  and  a  positive  Widal's 
reaction,  are  the  most  important  signs  which  would  point  to  a  diagnosis  of  typhoid  fever, 

PyiFtnia  and  Seplicwmia. — .laundice  is  frequently'  a  late  symptom  of  pya'inia,  and  may 
or  may  not  be  associated  with  the  presence  of  multiple  abscesses  in  the  liver.  It  is  more 
likely  to  occur  in  cases  of  portal  than  arterial  pyaemia.  Rigors,  high  irregular  temperature, 
rajjid  pulse,  profuse  sweating,  rapid  emaciation,  and  progressive  loss  of  strength,  are 
sym])toms  which,  if  developing  after  parturition,  wounds,  or  operations,  would  jioint  withoul 
nuicli  doubt  to  a  diagnosis  of  pya'nua.  In  some  instances  of  acute  scpticu'mi.a  due  In 
streptococci,  staiihylococci,  and  perhaps  other  micro-organisms,  there  has  been  intense 
jaundice  of  the  skin  and  conjunctiva-  of  a  peculiar  nuistard-yellow  tint,  without  the  urine 
giving  a  positive  (Jmeliirs  lest.  The  urine  may  or  may  not  be  discoloured — in  some  instances 
it  looks  merely  cotieentratcd,  in  others  it  looks  almost  like  porter,  and  yet  il  gi\es  no  play 
of  colour  to  the  nitric  acid  test  ;  the  cause  of  this  would  seem  to  be  the  oxidation  of  the 
pigment  before  it  reaches  the  urine.  This  occurrence  of  acholuric  jaundice  in  septic  cases 
is  very  remarkable,  and  it  may  be  a  confusing  factor  in  the  case, 

J'liciunonia. — .Jaimdice  occurs  occasionally  as  a  complication  of  pneumonia.  It  varies 
very  much  in  its  fre<|nene.y  in  different  ei)i(Iemies  of  the  disease.  It  is  noticed  soon  after 
the  initial  rigor,  but  is  rarely  intense.  It  is  |)robably  due  to  engorgement  of  the  liver  and 
catarrh  of  the  bile-ducts.  Its  more  frc(|ueut  association  with  right  basal  |inemnonia  is 
suggestive.  The  sudden  onset  with  a  rigor,  the  high  temperature,  the  ra|)id  respiration-rate, 
which  is  above  the  ordinary  temperature  and  respiration  ratio,  and  the  comparatively  slow 
pulse  (e.g.,  T.  1(U°  F.,  li.  10,  P.  100),  the  characteristic  tenacious,  russcl-brown  sputum,  the 
sliort  catchy  cough,  the  pain  in  the  side,  the  plcurilic  rub,  and  the  signs  of  consoli<iali()n 
of  the  lung,  the  hoi  dry  skin,  the  delicicncy  of  chlorides  in  the  urine,  and  the  oecurrenic 
of  herpes  facialis,  are  the  accompanying  indications  which  in  the  majority  of  cases  woulil 
jmint  to  a  diagnosis  of  i)ncumonia. 


336  JAUNDICE 

Infeciioits  or  Epidemic  Jaundice  (Weil's  Disease)  is  characterized  by  a  sudden  onset 
witli  pyrexia,  severe  pain  in  tlie  bacli  and  limbs,  lieadaclie,  and  giddiness,  followed  in  a  day 
or  two  by  jaundice,  enlargement  of  the  liver  and  spleen,  and  nephritis.  The  jaundice 
becomes  intense  within  twenty-four  hours,  the  temperature  rises  to  103°  F.  to  10i°  F.,  and 
the  pulse  becomes  rapid.  Nephritis,  next  to  jaundice,  is  one  of  the  most  constant  features 
of  this  disease.  Males  between  15  and  30  are  most  affected,  and  it  is  connected  with 
insanitary  surroimdings.  Butchers  appear  to  be  particularly  susceptible.  It  is  practically 
unknown  in  England. 

Yellozv  Fever  in  some  respects  resembles  acute  yellow  atrophy  of  the  liver,  but  the 
liver  does  not  atrophy,  neither  does  the  spleen  enlarge,  and  crystals  of  leucin  and  tyrosin 
are  not  found  in  the  urine.  It  is  essentially  a  tropical  or  sub-tropical  disease,  prevalent  in 
the  West  Indies  and  Central  and  South  America.  The  incubation  period  is  from  three  to 
four  days,  and  the  onset  sudden,  with  rigors,  headache,  pain  in  the  back  and  limbs,  and 
constipation.  Jaundice  is  an  early  symptom,  and  one  of  the  most  characteristic,  but  it 
varies  in  intensity,  being  much  more  severe  in  fatal  than  in  mild  cases.  The  temperature 
rises  to  102°  F.  or  103°  F.  ;  the  pulse  is  rapid  at  first,  but  may  fall  as  the  temperature  rises, 
and  this  is  regarded  as  a  very  typical  sign  of  the  disease.  Albuminuria,  black  vomit, 
haemorrhage  from  the  gimis  and  beneath  the  skin,  are  other  important  symptoms.  A 
sporadic  case  occurring  in  this  country  would  probably  be  looked  upon  as  acute  yellow 
atrophy  of  the  liver  imless  a  definite  history  of  exposure  to  infection  was  obtainable.  It  may 
be  dilHcult  to  distinguish  it  from  dengue  (p.  466)  and  pernicious  malaria.  From  the  latter 
it  can  be  diagnosed  if  crescents  are  discovered  in  the  blood  (Plate  XXVIII.  Fig.  E.  p.  614). 

Relapsing  Fever. — Jaundice  is  a  common  symptom  of  this  contagious  fever,  which  is 
prevalent  in  India,  and  is  liable  to  arise  in  other  countries  in  times  of  famine.  It  is  spread 
by  bed-bugs.  Considerable  cnhngement  of  the  liver  and  spleen,  and  a  good  deal  of  abdo- 
minal pain  and  tenderness,  are  present  in  most  cases  ;  also  epistaxis  and  haemateniesis.  The 
most  characteristic  feature  of  the  disease  is  the  temperature,  which  rises  abruptly  to  104' 
or  105°,  and  even  to  108°  F.,  remains  high  for  five  or  six  days,  and  then  suddenly  falls  to 
normal  when,  after  an  interval  of  about  a  week,  it  again  rises  and  remains  high  for  three  or 
four  days  (Fig.  5,  p.  27).  During  the  periods  of  pyrexia  the  Spirochcela  obermeieri  (Plalr 
XXVIII,  Fig.  I.  p.  614)  may  be  found  on  examining  blood-films  prepared  and  stained 
in  the  same  manner  as  for  the  detection  of  malaria  parasites.  The  blood  examination 
serves  to  distinguish  it  from  malaria. 

C.  Jaundice   due   to   Poisons. 

Phosphorus. — Jaimdice,  though  by  no  means  constant,  is  one  of  the  most  characteristic 
svmi)toms  of  |)hosphorus  poisoning.  It  is  slight  at  first,  appearing  on  the  second  or  third 
day  in  se\ere  cases,  but  in  mild  ones  not  until  the  end  of  the  first  week,  or  even  later.  This 
form  of  poisoning  is  rare  in  this  country  since  the  stringent  law  regulating  the  manufacture 
of  matches  from  the  non-poisonous  form  of  the  drug  has  been  in  force.  In  the  cases  which 
do  occur,  the  phosphorus  has  been  taken  in  the  form  of  match-heads  or  rat  paste,  with  suicidal 
intent.  At  first  the  .signs  are  those  of  acute  irritant  poisoning,  coming  on  soon  after  the 
phosphorus  has  been  swallowed,  viz.  :  nausea,  vomiting,  severe  burning  pains  in  the  epigas- 
trium, collapse,  extreme  thirst,  rapid  feeble  pulse,  rapid  respiration,  and  tenderness  in 
the  epigastrium  and  right  hypochondriac  regions.  In  many  cases  that  receive  treatment 
earlv  these  acute  irritant  symptoms  subside  in  a  day  or  two.  and  recovery  residts.  If  they 
do  not  thus  subside,  however,  after  from  two  to  five  days  the  symptoms  change,  the  vomit 
becomes  black  or  brownish  from  the  presence  of  blood,  jaundice  appears  and  rapidly  deepens, 
the  liver  enlarges,  and  headache,  drowsiness,  delirium,  convidsions.  and  coma  super\enc. 
followed  shortly  by  death.  If  hepatic  enlargement  cannot  be  ascertained  it  may  be  dillicult 
to  distinguish  phosphorus  poisoning  from  acute  yellow  atrophy  of  the  liver.  Ilicmorrhages. 
although  common,  are  not  as  frequent  as  in  acute  yellow  atrophy.  The  urine  is  concentrated 
and  strongly  acid  :  the  total  nitrogen  is  first  reduced,  as  in  cases  of  starvation,  to  about 
one-fourth  the  usual,  and  then,  in  s])ite  of  the  fact  tliat  the  patient  can  retain  no  food,  it 
rises  to  the  usual  amount.  Urea  forms  the  greater  part  of  the  total  nitrogen,  but  towards 
the  end  the  total  amount  of  ammonia  is  increased.  Ueucin  and  tyrosin  arc  not  usually 
found,  and  the  chlorides  are  diminished.  The  condition  of  the  urine,  therefore,  forms  a 
contrast  to  the  clianges  which  are  found  in  cases  of  acute  yellow  atrophy.      The    chief 


JOINTS,     AFFECTIONS    OF    THE  337 

indications  of  the  disease  that  are  found  post  mortem  are  jaundice,  multiple  punetiform 
haemorrhages,  fatty  degeneration  of  tlie  hver,  kidneys  and  heart,  and  enlargement  of  the 
spleen. 

Arseniuretted  Hydrogen  causes  Jaundice  in  a  similar  manner  to  toluylenediainine, 
through  blood  destruction  and  extreme  concentration  of  the  bile  ;  the  increase  of  bile 
pigment  may  be  to  three  and  a  half  times  more  than  its  normal  amount.  The  bile  acids 
arc  diminished. 

Toluyletiediamine  has  been  used  for  experimental  purposes,  and  its  action  has  helped 
to  prove  that  so-called  haematogenous  jaundice  is  really  due  to  obstruction  of  the  smaller 
ducts  through  increased  viscidity  of  the  bile.  When  injected  into  dogs  it  soon  produces 
intense  jaundice  ;  it  causes  destruction  of  blood,  and  the  ha-moglobin  thus  liberated  increases 
the  viscidity  of  the  bile,  so  that  temporary  obstruction  of  the  smaller  duets,  followed  by 
jaundice,  results. 

Tetrachlorellifiiic  DiiiHrobenzene.  and  Chloride  of  Sulphur  are  discussed  above. 

Snake  Poison. — .Jaundice  is  a  common  result  of  snake-bite,  and  is  produced  in  a  similar 
manner  to  the  last  three  forms  described,  viz.  :  as  a  result  of  concentration  and  increased 
viscidity  of  the  bile  leading  to  obstruction  of  the  smaller  bile-duets.  The  diagnosis  depends 
upon  the  history.  The  symptoms  vary  with  the  kind  of  snake  that  has  bitten  the  patient. 
In  England  the  only  poisonous  variety  is  the  adder  or  viper,  whose  bite  is  followed  almost 
at  once  by  a  burning  local  pain,  (piickly  succeeded  by  acute  ascending  oedema  and  darkening 
discolouration  of  the  limb.  The  patient  is  nauseated  and  presently  vomits,  he  turns  giddy 
and  faint,  has  to  lie  down,  and  in  from  one  to  three  hours  is  completely  prostrated,  often 
comatose,  and  covered  with  clammy  perspiration.  The  temperature  falls  below  normal, 
the  pulse  may  be  almost  imperceptible,  and  death  may  result  at  this  stage.  More  often 
the  severe  constitutional  sym])toms  pass  off  gradually,  improvement  beginning  within 
twenty-four  hours  ;  but  the  swelling  and  discoloration  of  the  bitten  limb  remain  extreme, 
and  there  may  be  generalized  ccdema  all  over  the  body.  Su|)puration  or  even  gangrene 
is  common,  and  recovery  is  apt  to  be  very  slow,  even  when  appropriate  surgical  measures 
are  em])loyed  at  once.  It  is  during  the  period  between  the  passing  off  of  the  initial  coma 
and  the  beginning  of  convalescence  that  jatmdice  is  prt)ne  to  develop. 

D.  Jaundice    due    to    Nervous    Causes. 

Iclerus  Seniiso — Mentid  Kniolion. — Cases  are  on  record  of  jamidice  following  almost 
immediately  after  some  violent  mental  emotion,  but  they  arc  of  extreme  rarity.  The 
jaundice  has  been  explained  as  being  the  result  of  a  sudden  spasm  of  the  bile-ducts. 
In  another  class  of  these  cases  icterus  does  not  appear  until  twelve  or  fourteen  hours 
after,  and  it  is  then  probably  due  to  catarrh  of  the  bile-duets,  associated  with  gastric 
and  duodenal  catarrh,  for  it  is  well  enough  known  that  severe  mental  emotion,  grief, 
or  anxiety  may  give  rise  lo  aciilc  (lysp(])sia.  .Jaundice  may  occur  similarly  after 
concussion   of   the    brain.  Herbert   French. 

JAW,  SWELLING  OF  THE.     (See  SwKi.i.rM:  ok  Till-.  .Iaw.  1).  (i.s:j.) 

JERK,   ACHILLES.     (See  Anki.k-C'i.onis,  p.  :!!).) 

JERK,   KNEE.     (Sec  KM;l.-.I^,l!l^.  .\iiv()iimai.iiii;s  of  xni;.  j).  :i.)7.) 

JOINTS,    AFFECTIONS    OF    THE.      II    will    he   well    lo   place    lliese   ill    Iw.i   ur .s 

(1)  .tente  :   (2)  Chronic. 

1.  Acute  Joint  Affections.- -,  I. ///////v  diir  lo  lilicnnndir  Fever  is  I  lie  iiiosi  lrei|iic-iil 
of  these.  The  patient  has  ollcii  had  the  discMsc  Ik  roic.  or  olhcr  iiiciiibiis  u(  llie  raniily  may 
have  had  it  :  there  may  be  iiianilestal  ions  of  past  rheumalie  alTeelioii  of  otlier  parts  of  tlie 
body  :  thus  the  presence  of  oiy.uiie  iiiilral  disease  is  of  great  help  in  the  diagnosis  of  a 
(loiii)tful  case.  A  liisldiy  ,,[  piisl  elimca.  several  attacks  of  tonsillitis,  pericarditis,  or 
iheiimatic  crytheiiia  or  iiuilulcs  will  help.  The  distinguishing  features  of  the  arthritis  are 
that  it  is  acute,  and  alTeels  (iist  and  ehiclly  the  larger  joints,  altlioiigli  in  a  very  severe  ease 
even  the  joints  of  the  hand  and  fingers  may  be  iinplieated  :  it  does  not  occur  in  all  the 
affected  joints  siiiiiillaneoiisjy,  but  appears  in  one.  a  lew  hours  after  in  another,  and  so  on. 
As  the  arthritis  iifhii  lasts  a  lew  (la\  s  ill  aiiv  one  joint,  in  some  it  may  have  passed  away 


338  JOINTS,     AFFECTIONS    OF    THE 

while  others  are  being  affected.  The  pain  is  very  severe  and  is  greatly  increased  by  any 
jar  of  the  bed  ;  it  is  more  fleeting  than  the  arthritis,  but  like  it,  flits  from  joint  to  joint, 
hardly  ever  returning  to  the  same  joint  in  the  same  attack.  The  swelling  of  the  joint  is 
usually  only  slight  or  moderate  ;  it  is  due  to  synovial  effusion,  never  suppurates,  generally 
subsides  in  a  few  days,  and  usually  in  at  most  a  fortnight  the  joint  returns  completely  to 
its  normal  condition.  Permanent  distortion  or  stiffness  of  the  joints  after  rheumatic  fever 
occurs,  but  it  is  highly  exceptional.  Often  there  is  a  faint  red  blush  over  the  joint  when 
first  affected. 


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Fi//.  149.— Temperatu 


showing  rapid  fall  ot  temperature 


The  most  important  diagnostic  characteristics  of  this  arthritis  are  :  (1)  The  fact  that 
it  flits  from  joint  to  joint.  Never  diagnose  rheumatic  fever  so  long  as  only  one  joint  is 
affected.  I  have  known  failure  to  remember  this  lead  to  a  diagnosis  of  rheumatic  fever  in 
traumatic  arthritis,  tuberculous  arthritis,  arthritis  due  to  acute  necrosis  of  a  bone  near  a 
joint,  and  acute  suppurative  arthritis  ;  in  eacli  of  the  last  two.  the  mistake  has  cost  the 
patient  his  life.  (2)  The  arthritis  in  turn  quickly  leaves  joints.  Failure  to  remember  this 
has  often  caused  septic,  gonococcal  and  various  forms  of  infective  arthritis  to  be  called 
rheuinatic   arthritis,  a  mistake  which   has   also  cost  lives.     The  drenching,  sour-smelling 


T-g.  1.50. — ^Temperature  chart  in  a  case  of  gonococcal  artliritis  of  ordinary  severity,  to  show  the  absence  of 
effect  of  salicylates  upon  the  pyrexia.    The  case  was  mistaken  at  first  for  acute  rheumatic  fever. 


sweat.^,  and  the  relief  of  the  ])aiu  by  salicylates,  are  very  characteristic  of  rheumatic  fever, 
but  septiciemia  also  causes  sweating.  The  sweating  of  rheumatic  fe\er  is  particularly 
liable  to  be  accompanied  by  minute  glassy  vesicles — sudamina.  Finally,  the  arthritis  of 
rheumatic  fever  being  transient,  is  not  accompanied  by  much  arthritic  muscular  atrophy. 
Rheumatic  nodules  are  rare,  but  when  present  are  almost  diagnostic  ;  they  are  most  often 
seen  in  young  boys  affected  with  rheumatic  fever  and  heart  disease  ;  but  very  rarely  they 
are  met  with  in  osteo-arthritis,  and  once  I  have    seen   them  with   gonorrlioeal   arthritis. 


JOINTS,     AFFECTIONS    OF    THE 


339 


(3)  The  joint  pains  and  the  p\Texia  are  generally  {Fig.  149),  though  not  absolutely  invariably 
relieved  by  salicylates  within  forty-eight  hours,  whereas  gonococcal  arthritis  (Fig.  150), 
acute  rheumatoid  arthritis  (Fig.  152,  p.  341),  gout  (Fig.  151),  and  other  acute  joint  affec- 
tions, are  not  quickly  influenced  by  salicylates  in  the  same  way. 

Septic  Arthritis  is  constantly  being  thought  to  be  rheumatic  fever  :  a  bad  mistake 
especially  for  the  ])atient.  In  septic  arthritis,  it  is  true,  several  joints  may  be  affected  ; 
but  it  may  be  one  only,  which  it  never  is  in  rheumatic  fever  ;  further,  in  septic  arthritis 
the  trouble  does  not  clear  up  in  one  joint  and  then  pass  to  another  ;  a  joint  once  affected 
remains  affected  till  the  source  of  infection  is  removed  ;  the  soft  tissues  around  are  thickened 
and  brawny,  quite  unlike  rheumatic  fever,  and  if  the  colour  is  altered — which  is  not  often 
the  case — it  is  dusky,  and  not  the  bright  red  of  rheumatic  fever.  Suppuration  often  occurs  : 
in  rheumatic  fever,  never.  Whether  or  not  suppuration  takes  place,  the  joint  often  becomes 
fixed,  which  is  excessively  rare  in  rheumatic  fever.     Then,  if  proper  search  is  made,  the 


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J-'i<l.  l-'ji. —Four-hourly  tfimperature  cliflrt  in  a  case  of  acute  ffout.    Woman,  age  40,  had  had  several  previous  attacks 
of  typical  gout ;  recovered  completely  for  the  time  being.     Salicylates  iiad  no  effect  upon  the  pyrexia,  j 


source  of  Infection  can  usually  be  found  ;  conunon  places  that  are  overlooked  arc  the  sockets 
of  the  teeth,  and  the  vagina  and  uterus,  but  the  source  may  be  anywhere,  e.g.,  septic  arthritis 
may  follow  dilated  biorichial  tubes,  cystitis,  prostatic  abscess,  a  l)oil  on  the  skin,  otorrlKca, 
inllarnmation  of  the  nasal  caxilies,  and  perhaps  ulceration  of  the  intestine.  .Sometimes  the 
most  careful  seeking  fails  to  find  tlie  source,  but  the  searcli  must  not  be  given  up  readily. 
The  irregular  temperature,  usually  hectic,  the  leuciicytosis,  sweats,  and  ntlicf  signs  of 
septiea-niia  are  often  a  help. 

I'liiiniKiciiccal  iirllirilis  is  rare  in  adults,  .iiid  nearly  always  exists  as  a  complic.ition 
ora<Mile  pneumonia.  It  may.  lii)we\er,  be  found  without  evidence  of  pneumococcal  disease 
in  any  other  part  of  the  boily.  Pneumococcal  otitis  media  should  not  be  forgotten  as  its 
possible  source.  (Jencrally  only  one  joint  is  affected,  usually  the  knee,  less  often  some 
other  large  joint,  such  as  the  shoulder  or  elbow.  Often  there  is  a  history  of  recent  injury 
to  the  ))art.  The  patient  suddenly  feels  a  pain  in  the  joint  ;  within  a  IVnv  hours  of  this 
the  temperature  is  raised  :  the  joint  swells  rapidly,  is  very  painful  and  cxcpiisilely  tender  ; 
yellowish-green  pus  (piickly  forms.  'I'lie  diagnosis  is  obviously  easy  if  the  patient  has 
pneumonia.  l)ut  may  be  dillieult  if  he  lias  not  :  it  is  important  to  come  to  a  diagnosis 
early,  for  it  is  a  serious  disease,  and  if  allowed  to  go  far  without  incision  and  drainage  the 


:!40  JOINTS,    AFFECTIONS    OF    THE 

patient  may  succumb  to  a  general  septicsemia.  Pneumococcal  arthritis  is  the  commonosl. 
form  of  infective  arthritis  in  eliiklren  under  five  years  old.  As  in  adults,  it  is  confined 
generally  to  one  large  joint.  The  swelling  may  be  very  great,  and  extend  to  the  soft  tissues 
beyond  the  joint.  The  pain  is  less  than  iii  adults,  and  redness  is  not  common.  Its  possible 
presence  must  be  remembered,  for  as  in  adults,  so  in  children,  it  is  necessary  to  drain  the 
joint  early.     The  child  has  a  raised  temperature,  and  looks  ill. 

Typhoid  Arthritis. — There  are  two  varieties,  both  very  rare  :  (1)  That  which  precedes 
the  typhoid  fever  ;  this  is  a  multijile  arthritis,  not  of  severe  degree,  which  subsides  just 
before  definite  symptoms  of  typhoid  show  themselves.  It  is  impossible  to  diagnose  it 
until  the  appearance  of  the  typhoid  fever.  (2)  This  occurs  during  the  typhoid  fever  : 
one  or  many  joints  may  be  affected  ;  the  arthritis  is  of  varying  severity  :  it  may  subside 
completely,  or  require  incision  and  drainage.  In  a  few  cases  even  when  there  has  been  no 
arthritis  during  or  before  the  attack  of  typhoid  fever  some  chronic  arthritis  may  appear 
later  ;  most  often  the  joints  and  ligaments  of  the  spine  are  affected,  and  during  the  conva- 
lescence from  his  fever  the  patient  complains  of  much  pain  and  stiffness  of  his  back  ;  he 
is  then  said  to  have  a  typhoid  spine.  In  a  similar  way  the  hip  may  become  stiff,  and  very 
rarely  there  is  chronic  osteitis  of  the  head  and  neck  of  the  fenuir. 

Scarlatin(d  arthritis  affects  many  joints,  is  not  severe,  soon  subsides,  and  is  easily 
diagnosed  when  there  has  been  recent  scarlet  fever.  It  is  commonly  known  as  scarlatinal 
rheumatism,  a  bad  name  which  quite  gratuitously  assumes  a  connection  between  this 
arthritis  and  rheumatic  fever,  for  the  existence  of  which  there  is  no  evidence. 

Arthritis  occurs  commonly  in  association  with  meningococcic  meningitis  and  Malta 
fever,  less  conmionly  with  dysentery,  rarely  in  association  with  influenza,  glanders,  sntall- 
poi\  measles,  and  diphtheria.  In  all  these  cases  the  presence  of  the  principal  disease 
determines  the  diagnosis. 

Gonorrhaal  Arthritis-is  often  called  gonorrhoeal  rheumatism,  but  this  phrase  should  be 
discarded,  for  there  is  no  association  between  gonorrhcea  and  rheumatic  fever.  Gonorrhtt»aI 
arthritis  is  frequently  overlooked.  I  have  repeatedly  demonstrated  its  presence  when  the 
family  physician  has  believed  its  existence  impossible.  It  is  particularly  likely  to  be 
missed  in  women.  I  have  met  with  it  in  married  women  of  fifty  ;  it  is  probable  in  these 
cases  that  they  are  infected  by  their  husbands.  It  may  follow  gonorrhoeal  ojjhthalmia 
and  even  ophthalmia  neonatorimi.  The  diagnosis  may  be  very  easy,  as  when  a  patient 
is  seized  with  an  acute  arthritis,  either  of  a  single  joint  or  of  several  joints,  while  he  or 
she  is  suffering  from  gonorrhcea.  If  it  is  possible  to  withdraw  a  little  fluid  from  the  cavity 
of  the  swollen  joint,  the  discovery  of  the  gonococcus  makes  the  diagnosis  certain,  but  this 
is  usually  quite  imnecessary,  and  unless  done  very  carefully  may.  by  introducing  micro- 
organisms from  without,  greatly  increase  the  damage  to  the  joint.  Often  a  urethral 
discharge  may  be  found,  though  sometimes  in  long-standing  eases  of  gleet  it  is  very  slight  : 
if  the  gonococcus  cannot  be  found  in  the  discharge,  it  may  be  detected  in  a  swab  taken 
from  the  posterior  urethra  or  vagina.  If  in  women  it  is  thought  undesirable  to  excite 
suspicion  by  taking  a  vaginal  swab,  tlie  natiu-e  of  a  doubtful  arthritis  may  be  determined 
by  the  wide  variations  of  the  opsonic  index  to  the  gonococcus. 

It  is  difficult  fronr  the  clinical  character  of  gonorrhceal  arthritis  to  tell  it  certainly 
from  other  forms  of  arthritis.  Mistakes  happen  least  often  to  those  who  constantly  think 
of  the  possibility.  It  is  of  varying  degrees  of  acuteness  ;  in  the  chronic  cases  of  gleet  the 
corresponding  arthritis  is  chronic,  but  in  the  acute  cases  of  gonorrhoea  it  may  be  so  acute 
that  I  have  more  than  once  known  the  disease  called  rheumatic  fever.  Gonorrhoeal  arthritis 
may  be  limited  to  one  joint,  and  then  most  often  to  a  large  one,  especially  the  knee  ;  but 
it  may  be  multiple,  and  very  many  joints,  even  those  of  the  wrists,  hands,  and  fingers, 
may  be  implicated  ;  there  is  often  much  swelling  of  the  soft  tissues  around,  and  this  is 
more  responsible  for  the  swelling  than  is  the  effusion  in  the  joint.  Gonorrhoeal  arthritis 
is  usually  very  painful.  The  sheaths  of  tendons  are  often  infiamed  and  tender,  and  so  are 
some  fascife,  especially  the  plantar  fascia.  The  patient  often  comphuus  of  pain  at  the  back 
of  the  sole  of  the  foot,  and  in  a  chronic  case  he  has  flat-foot.  There  is  no  variety  of 
arthritis  in  which  muscular  atrophy  is  more  striking.  I  have  known  a  severe  case  of 
gonorrhoeal  arthritis  of  the  hand  called  progressive  muscular  atrophy.  When  gonorrhoeal 
arthritis  is  chronic  throughout  the  whole  of  its  course,  and  is  limited  to  one  joint,  the  cause 
of  the  trouble  is  often  erroneously  set  down  to  tubercle.     Suppuration  is  very  rare.     Some 


JOIXTS,     AFFECTIONS    OF    THE 


341 


cases  are  extremely  chronic,  and  may  lead  to  fibrous  ankylosis  with  deformities, 
but  with  our  modern  means  of  diagnosis  and  treatment  this  has  become  exceptional. 
Salicylates  have  no  decided  effect  either  upon  the  joint  pains  or  upon  the  co-existent 
pyrexia  (Fig.  150). 

All  the  acute  affections  hitherto  mentioned,  except  rheumatic  fever,  are  often  included 
imder  the  phrase  "  infective  arthritis,''  because  they  are  known  to  be  due  to  infection  by 
a  micro-organism  ;  but  this  is  a  loose  term  that  ought  only  to  be  used  in  a  general  sense, 
for  a  diagnosis  of  the  precise  cause  of  the  infection  is  nearly  always  possible  if  care  be  taken. 
Sometimes  in  an  infective  arthritis  there  is  more  than  one  micro-organism  at  work  to 
cause  it  ;  thus,  in  the  late  stages  of  gleet  various  micro-organisms  flourish  in  the  diseased 
urethra,  and  the  arthritis  may  be  due  to  a  mixed  infection  in  which  the  gonococcus  is  not 
the  preponderating  micro-organism  ;  under  such  conditions  i)us  may  form  in  the  joints. 
Indeed,  I  have  known  a  mixed  infection  of  gonococci  and  streptococci  from  the  genitals 
of  a  woman  cause  in  her  a  very  severe  acute  arthritis  with  a  temperatui'c  of  105"  F.  In 
exhausting  diseases,  e.g.,  typhoid  fever,  the  patient  may  suffer  from  a  secondary  strepto- 
coccal infection  which  may  cause  arthritis. 

ylciite  Secondary  Arthritis. — By  this  is  meant  arthritis  due  to  spread  of  disease  from 
the  bone  in  the  neighbourhood  of  the  joint.  It  is  limited  to  one  joint  :  the  most  acute 
and  dangerous  form  is  that  which  follows  acute  osteomyelitis.  More  than  once  I  have 
known  this  called  rheumatic  fever,  because  the  onset  has  been  sudden  and  the  temperature 


ri'j.  l.ii.— Phart  sl.owin-,'  tlie  p\ 


r:iisc(l.  It  is  a  most  imrorl  imiilc  mistake,  t'or  patients  suflVring  from  this  form  ofarlliritis 
are  liable  to  die  (piiekly  from  general  septicaemia,  to  prevent  which  the  joint  ought  to  be 
opened  and  drained  at  once.  The  mistake  may  usually  be  avoided  by  remembering  that 
rlu'iunatic  fever  does  not  affect  one  joint  only.  The  more  dillietilt  cases  arc  those  in  which 
more  than  one  joint  is  acutely  diseawd.  as  a  result  of  disease  of  the  ends  of  the  bones.  To 
M\(iifl  this  mistake,  disease  of  the  bones  themselves  nmst  be  carefully  sought.  Fortunately 
l(ir  iliagnosis.  this  disease  of  several  joints  is  most  frecpieni  in  infants,  and  in  them  severe 
ai  tliritis  due  to  rheumatic  fever  is  unknown.  It  is  ealliMl  acute  (irtlirilis  of  infants.  Disease 
III  joints  may  be  secondary  to  an  abscess  in  the  bnnc  or  to  tuberculous  disease  of  the  bone. 
'I'licse  varieties  are  diagnosed  by  discovering  the  iinilirlying  disease  of  the  bones  ;  a'-rays 
are  often  of  iiiuch  use. 

Hheninatiiiil  .Irthrilis.  Thv  first  attack  is  often  acute:  therefore  the  disease  is  best 
considered  here.  The  name  is  bad  and  has  led  to  confusion  :  it  owes  its  origin  to  the  fact 
thai  I  lie  disease  in  some  resiiects  resembles  rhcuiiial  ii-  Uvcr  :  hence  the  name  implies  an 
artliiilis  resendding  that  of  rheumatic  fe\(i-.  It  uiiuld  priilial>l\  had  to  worse  confusion 
III  invcid  a  new  name,  so  the  present  had  better  stand  until  the  micro-organism  <'ausing 
the  disease  has  been  discovered.  The  lirst  attack  is  ushered  in  with  fever  :  the  temperature 
is  rarely  higher  than  100  or  101  l<'.  in  the  evening  and  !MI  or  100  1''.  in  the  morning. 
This  feMT  lasts  friini  three  to  six  weeks,  slowlv  subsiding  towards  the  end  (/•'/;.'.  I.">-').      The 


342  JOINTS,    AFFECTIONS    OF    THE 

jjiilse  is  generally  rapid,  out  of  proportion  to  the  fever,  the  hands  and  feet  sweat  profusely, 
patches  of  freckle-Mke  pigment  are  prone  to  appear  on  the  body.     Most  of  the  patients 


Fi,i.  10:i,— Auiite  rlieuiiKUoi.i  artliritis  :  sliov 
ioHlts  hetweea  tike  fTl-st  i^nd  second  plialangei, 
the  wrist  and  metacarpo-phalangeal   oints. 


are  young  women.     The  pyrexia  is  less  severe  and  longer  lasting  than  that  of  rheumatic 
fever,  the  pulse  is,  considering  the  temperature,  faster,  the  sweating  is  almost  confined  to 


JOINTS,     AFFECTIONS    OF    THE 


34;; 


liands  and  feet,  pigment  is  fretiuent.  Xor  are  the  difleienees  with  regard  to  the  arthritis 
less  striking,  for  in  rheumatoid  arthritis  the  characteristic  joints  to  be  affected  are  those 
between  the  first  and  second  ])hahinges,  and  as  it  is  an  affection  of  the  synovial  membranes, 
and  also  considerably  of  the  soft  tissues  around  the  joints,  quite  early  in  the  disease  we 
get  a  spindle-shaped  swelling  of  these  joints  (Fig.  153)  ;  but  soon  many  other  joints  are 
affected,  and  before  long  almost  every  joint  in  the  body  is  implicated,  so  that  we  have 
the  sinuiltaneous  affection  of  a  great  many  joints.  The  temporo-maxillary  joint  is  often 
involved  :  so  is  the  spine.  It  will  be  noticed  that  in  every  resi)cct  the  arthritis  is  clinically 
•litferent  from  that  of  rheumatic  fever.  The  joints  never  suppurate,  but  the  epitrochlear 
gland  may  be  found  enlarged.  Slowly  the  attack  subsides  :  as  it  does  so,  passive  move- 
ments and  massage  should  be  undertaken,  for  if  not,  the  thickening  of  the  tissues  around 
the  joints  leads  to  their  fixation.  That  this  may  be  prevented  is  shown  by  the  fact  that  the 
jaw  rarely  becomes  fixed,  presumably  because  of  its  frequent  movement.  There  is  never 
any  endocarditis.  The  arthritic  muscular  atrophy  is  often  as  extreme  as  in  any  variety 
of  arthritis.  In  a  few  months  a  second  attack  comes  on,  but  both  the  general  symptoms 
and  the  arthritis  are  less  severe  than  in  the  first  ;  then  a  few  months  later  another,  less 
severe  than  the  second,  and  so  on,  until  after  four,  five,  or  six  attacks  the  disease  wears 
itself  out.  In  the  later  stages,  if  the 
joints  have  been  allowed  to  become 
stiff,  the  disease  is  often  confused 
with  osteo-arthritis  ;  but  rheumatoid 
arthritis  occurs  in  younger  subjects, 
and  there  are  no  bony  outgrowths 
(Fig.  1.54),  except  in  a  few  cases  in 
which  chronically  thickened  fringes  of 
synovial  membrane  have,  by  friction 
during  movements  of  the  joints,  worn 
away  a  little  patch  of  cartilage,  exposed 
and  irritated  the  bone,  and  led  to  a 
slight  outgrowth.  In  such  a  case  the 
erosion  of  the  cartilage  may  lead  to 
bony  grating,  but  in  even  a  \<r\- 
chronic  and  extreme  case  of  rhcunialoiil 
arthritis,  in  whieli  the  joints  have  not 
been  trcateil,  grating  and  hoiiy  out- 
growths are  quite  inconsiderable,  and 
arc  not  a  leading  feature  as  in  osteo- 
arthritis. Heberdcn"s  nodes  (Fig.  155) 
arc  not  seen  in  rheumatoid  arthritis. 
The  spindle-shaped  swelling  of  the 
phalangeal  joints  of  this  disease  is  not 
seen  in  osteo-arthritis.  The  joints 
principally  affected  arc  different  in  the 

two  diseases,  as  will  be  seen  on  reference  to  osteo-arthritis,  and  the  history  is  entirely 
different.  Formerly  some  importance  was  attached  to  the  transparency  of  th<'  bones  to 
the  ,i'-rays  in  the  ncighbourliood  of  the  alTected  joints  which  may  be  seen  in  rlu'umaloid 
arthritis  (Fig.  15(>),  but  this  is  now  known  to  be  visible  in  other  forms  of  arthritis.  The 
iC-rays  arc,  however,  of  use  as  showing  the  bony  outgrowths  of  osteo-arthritis.  In  chronic 
cases  of  both  rheumatoid  arthritis  and  osteo-arthritis  ulnar  dcllcet  ions  maybe  seen  (Fig.  154). 
JfciiDch'.i  I'ldjiiirn.  'l'\us  disease  is  confined  to  children  between  inraiiev  and  lifleen 
years  old.  and  curly  in  its  course  pain  and  slight  swelling  of  some  of  the  large  joints,  with 
a  little  elevation  of  temperature,  are  often  present.  .Vs  in  children  the  pyrexia  and  aitliritis 
of  rheumatic  fever  are  inconspicuous,  mistakes  have  occurred  between  it  and  Ilcnocirs 
purpura,  but  tlu-  |)ain  in  the  latter  is  trivial.  The  attacks  of  abdominal  pain,  with  perhaps 
vomiting  and  diarrho'a,  are  eharaetcristic,  and  so  is  the  purpura  (Fig.  157),  logethcr,  in 
many  eases,  with  bleeding  from  some  internal  organ — ha-maturia,  h;ematcmcsis,  or  mehcna. 
The  purpina  should  not  gi\e  rise  to  aiiv  (Hfliculty  :  rlieUTii.'ilic  pinpura  is  unknown  under 
till-    :igr   ,,r   (iflirn. 


ri</.  lOJ. — llcberdcri's  notiositici  .situiLtcJ  on  tlic  Icniiiiuil  plial:inf:i': 
of  the  index  and  middle  lingers.  (Kroni  .IrthrUU  Drfonnaiis,  bj 
Llewellyn  Jones  I^lcwellyn.) 


344  JOINTS.    AFFECTIONS    OF    THE 

Gout. — Tliis  is  often  said  to  be  present  when  it  is  not.  Tlie  most  certain  points  in 
tlie  diagnosis  of  gout  are,  first,  the  detection  of  nrate  of  sodium,  usually  as  white  hard 
masses  in  connection  with  a  joint  (Fig.  158),  in  a  bursa,  or  as  a  deposit  in  the  cartilage 
of  the  edge  of  the  ear  ;  here  it  is  frequently  not  easy  to  be  sure  if  a  white  nodule  is  urate  of 
soda  or  a  projection  of  cartilage  with  the  skin  stretched  tightly  over  it.  If  it  is  possible 
to  remove  a  minute  fragment  with  a  needle,  crystals  of  urate  of  sodium  may  be  seen  under 
the  microscope.  Secondly,  there  may  be  a  Jiistory  of  repeated  characteristic  attacks. 
The  gouty  arthritis  that  we  see  now-a-days  is  generally  strongly  inherited,  but  not  often 
by  women,  and  therefore  the  family  history  is  of  importance  ;  it  rarely  shows  itself  before 
the  age  of  twenty,  though  I  have  seen  it  in  a  boy  fifteen  years  old.     Most  of  the  sufferers 


Fiy.  156. — Rheumatoid  arthritis 


iig  the  transparency  of  the  ends  of  bone 


from  gout  now  alive  get  their  attacks  ijuite  independently  of  any  errors  in  diet  ;  many 
of  them  are  most  abstemious.  The  diagnosis  is  not  difficult  when  the  patient  has  one  or 
more  attacks  of  arthritis  in  the  characteristic  joint — that  of  tlie  ball  of  the  great  toe,  more 
often  the  right  than  the  left  ;  the  attack  usually  begins  at  night  with  excruciating  pain, 
which  subsides  towards  the  early  morning  ;  the  patient,  exhausted  with  iiain.  drops  asleep, 
to  wake  later  and  find  his  joint  swollen  and  tense.  There  is  some  fever  (Fig.  151,  p.  339). 
Probably  during  the  day  his  toe  does  not  cause  pain  unless  he  walks  on  it  ;  but  he  has 
another  attack  the  next  night,  not  so  severe  as  that  on  the  first,  and  on  each  successi\e 
night  the  attacks  arc  less.  He  may  have  another  bout  at  any  ])eriod  of  his  life,  and  he  may 
have  many  bouts,  and  other  joints  may  become  affected  subsequently.     The  real  difficulty 


JOINTS,     AFFECTIONS    OF    THE 


345 


Firj.  157.— llfn 


in  the  acute  cases  comes  when  it  is  suggested  that  an  acute  arthritis  with  pyrexia,  and  swell- 
ing and  redness  of  a  joint  other  than  that  of  the  great  toe,  is  caused  by  gout.     I  have  recently 

seen  the  difficulty  in  one  patient  in  the  wrist,  in  another  in  the  knee.     Such  cases,  if  they  are 

not  gout,   are   some  bacterial  arthritis.      If  more 

than  one  joint  is  affected  with  acute  arthritis  at 

the  same  time,  the  probability  is  against  gout. 

and  the  greater  the  number  of  joints  affected  the 

less  likely  is  the  case  to   he  one  of  gout.     The 

liistory  and  presence  of  urate  of  sodium  are  often 

conclusive  in  favour  of  gout.      If  pus  forms,  the 

case  is  almost  certainly  not  gout,  for  gouty  joints 

very  rarely  suppurate  except  late  in  the  chronic 

disease.     On  the  other  hand,  the  imi)heation  of 

tendon  sheaths  and  pain  in  the  back  of  the  soles 

of  the  feet  are  in  favour  of  gout,  though  it  must 

be  remembered  that  both  these  occur  in  gonor- 

rha-al  cases.     The  presence  of  a  source  of  infec- 
tion is  of  course  against  gout.     The  didieulty  is 

especially  great   in  eases   in  which    the    general 

symptoms  antl  arthritis,  although  gouty,  arc  con- 
tinuous  rather    than    paroxysmal  ;    but    on    the 

whole,  continuously  increasing  severity  of  general 

symptoms  is  against     gout.  The  goutily-inflamcd 

joint  looks  especially  shiny,  is  extiuisitcly  tender 

on  the  surface,  and  is  more  painful  at  night  than 

during  the  d.iv.     Cases  of  extreme  difficulty  have 

been  recorded  in  which  the  first  joint  affected  by 

])yieinia  chanced  to  be  Hiat  of  the  great  toe. 

Probably  most  examples  of  acute  arthritis  said  to  lie  gouty  are  so.  but  mistakes  are 

<'onmion   about   chronic  gout.     Many   patients   witli   chvonic   arthritis   arc   (piite   wrongly 

said   to  have  gout  ;    nsu:ill\    lli(\-   have  osteo-arthritis.     The  presence  of  visible  urate  of 

sodium  in  places  already  mentioned 
{Fig.  158),  the  history  of  jirevious 
acute  attacks,  the  history  of  gout  in 
ancestors,  the  age  and  sex,  will  all 
help.  The  presence  of  bony  out- 
griiwlhs  is  strongly  against  gout, 
tliough  it  is  not  conchisixc,  for  such 
may  oecin-  in  true  gout,  cither  more 
or  hss  all  round  the  joint,  or  in  the 
Idrni  (il  liltle  nodules;  but  they  never 
allain  the  considerable  size  conunon 
in  osteo-arthritis.  If  no  urate  of 
soda  is  visible  anywhere,  the  dia- 
gnosis may  be  very  didlcult  :  the 
reader  should  consult  the  principal 
points  mentioned  imdcr  the  heading 
i<\  osli-o-avlhrilis.  Any  jninis  in  tin- 
l)(i(l\  ina\  be  affected  b\-  gout,  but 
it  is  very  rare  in  the  joints  of  the 
trunk,  the  shoulder,  or  the  hip.  The 
spine,  shoulder,  and  hip  are  com- 
MHinly  af'fVcled  in  osteo-arthritis. 
s  liulit  spots  in  ,i-ra\  prints  {Fi!<.  15i»). 
pass  on  to  consider  llic'  diagnosis  of 
•lironie,  but  it  must  be  remembered 
uiy   of  those   mentioned  as  acute    become  chronic,   and    their   diagnosis   has   been 


I  rate  ot  siKJiiini  may  lie  seen  in  and  ilea 
•_'.  Chronic     Joint     Affections.     \\'( 

v;iri(lics  (,r  artlnilis   which   arc   for  the 


tlial    III 
describe 


III.- joints 

will    now 

most    part 


346  JOINTS,    AFFECTIONS    OF    THE 

Osleo-arlliritis  is  a  chronic  disease  frequently  confused  with  rheumatoid  arthritis, 
from  which  it  is  completely  distinct,  both  clinically,  and  from  the  point  of  view  of  morbid 
anatomy.  Rheumatoid  arthritis  (p.  341)  is  primarily  a  disease  of  the  synovial  membrane 
and  soft  tissues  of  the  joints.  Osteo-arthritis  is  primarily  a  disease  of  the  cartilage  and 
bones,  leading  to  the  destruction  of  the  cartilage,  eburnation  of  bony  surfaces,  and'the 
production  of  much  new  bone  at  the  edges  of  the  joint  ;  hence  bony  outgrowths  (osteo- 
phytes), grating  of  the  joint,  and  locking  of  it  so  that  movement  is  diflicult,  are  common. 
Thickening  of  the  synovial  membrane  occurs,  but  is  less  important  :  the  ligaments  become 
implicated  and  may  soften  ;  if  so,  the  joint  becomes  flail-like  ;  there  may  be  some  thicken- 
ing of  the  tissues  around  the  joint  and  some  increase  of  synovial  fluid,  and  then  the  joint 
becomes  enlarged.  It  is  easy  to  distinguish  in  most  cases  between  osteo-arthritis  and 
rheumatoid  arthritis  by  the  appearance  of  the  affected  joint.  In  the  former  we  have  an 
irregularly  enlarged  joint,  with  palpable  bone  excrescences  and  much  grating  ;  often  the 
joint  is  fixed  by  these  bony  excrescences,  rarely  it  is  flail-like  from  destruction  of  ligaments  ; 
often  all  the  causes  just  mentioned  combine  to  make  it  very  large.  This  is  altogether 
diflerent  from  the  spindle-shaped  swelling  of  rheumatoid  arthritis  (p.  341).  Then  osteo- 
arthritis is  often  confined  to  one  joint,  and  that  a  large  one,  e.g..  the  knee  ;    rheumatoid 


Fi(j.  150. — Chronic  gout :  skiagram  of  tlm  hands,  showing  sodium  urate  deposits  about  ttie  ends  of  many  of  the  phalang 


arthritis  affects  many  joints,  and  is  most  characteristically  seen  in  small  joints,  e.g.,  those 
between  the  first  and  second  phalanges  ;  but  when  osteo-arthritis  does  show  itself  in  small 
joints,  those  most  often  affected  are  the  terminal  joints  of  the  phalanges,  where  the  bony 
excrescences  form  Heberden's  nodes.  Rheumatoid  arthritis  is  far  more  commonly  seen 
in  young  women  ;  osteo-arthritis  in  women  at  the  menopause.  Rheumatoid  arthritis 
nearly  always  begins  with  fever,  although  often  slight  :  osteo-arthritis  is  almost  always 
afebrile.  The  pulse  is  often  rapid  in  those  who  have  active  rheumatoid  arthritis  ;  it  is 
not  particularly  affected  in  those  who  have  osteo-arthritis.  The  spine  is  more  often  affected 
by  osteo-arthritis  than  rheumatoid  arthritis,  and  it  is  quite  common  in  the  dissecting- 
room  to  find  that  elderly  subjects  have  osteo-arthritis  of  the  spine.  Muscular  atrophy  is 
far  greater  with  rheumatoid  arthritis  than  with  osteo-arthritis.  Osteo-arthritis  is  especi- 
ally liable  to  attack  the  hi|) — usually  only  one — and  this  form  is  conmionest  in  elderly  men. 
It  was  formerly  called  morbus  coxce  senilis.  Great  cifte  must  be  taken  to  distinguish  the 
pain  due  to  this  from  that  of  sciatica.  The  chief  point  of  distinction  is  that  in  the  latter 
the  nerve  itself  is  tender  to  pressure  ;  but  it  must  not  be  forgotten  that  in  very  rare  cases 
osteo-arthritic   outgrowths  from    the  hip  may  implicate  the  sciatic  nerve  and  so   cause 


JOINTS,     AFFECTIONS    OF    THE 


347 


genviine  sciatica.  Although  osteo-arthritis  of  the  hip  usually  causes  lameness,  so  many 
other  conditions  do  this,  e.g.,  sacro-iliac  disease,  that  the  symptom  is  of  little  value.  The 
knee  is  the  joint  most  often  affected  by  osteo-arthritis — usually  both,  but  sometimes  only 
one  is  implicated.  This  disease  of  the  knee  is  very  common  in  women  of  ages  between 
forty-five  and  fifty-flve.  They  complain  of  pain  and  stiffness.  Often  the  pain  and  tender- 
ness, if  present,  are  confined  to  one  spot.  There  is  usually  considerable  enlargement  of  the 
joint,  bony  irregularities  may  be  felt,  and  grating  and  crackling  on  movement  are  very 
conuiion  ;  these  are  due  to  bony  out-growths,  erosion  of  cartilage,  and  thickening  of  syno- 
vial membrane,  which  also  gives  a  feeling  to  the  observer's  hand  placed  over  the  joint  when 
it  is  moved  as  though  he  were  feeling  the  movement  of  wet  sand  in  a  bag.  The  grating  may 
be  heard  very  loudly  through  the  stethoscope.  Other  joints  often  implicated  in  osteo- 
arthritis are  the  shoulder,  elbow,  ankle,  wrist,  and  temporo-maxillary  joint  ;  but  what  has 
been  said  about  the  disease  in  general,  and  that  of  the  knee  in  particular,  applies  to  them. 
The  disease  may  be  considerably  advanced  and  yet  confined  to  one  joint,  or  any  mmiber 
may  be  affected.  The  points  which  have  been  especially  mentioned  as  helping  to  distin- 
guish osteo-arthritis  from  rheumatoid  arthritis  will  aid  in  the  distinction  of  it  from  other 
forms  of  arthritis.     Pads  (Figs.  160.  161)  on  the  dorsal  aspect  of  the  joints  between  the  first 

and  second  phalanges  are  not  rare.  They 
vary  in  size  from  a  split  pea  to  a  hazel-nut. 
The  joints  are  not  diseased,  but  these  pads, 
which  are  due  to  a  great  growth  of  fibrous 
t  issue  underneath  the  corium,  have  been  con- 
fused with  osteo-arthritis.  They  are  often 
associated  with  Dupuytren's  contracture  (Fig. 
5!),  p.  11-2).     Ulnar  deflection  (Fig.  154,  p.  34.2) 


/'if/.  I"!".  -Pads  oil  tlie  Joraal  aspect  of  joiiit.^ ; 
not  to  be  confuHcil  with  osteo-arthritic- ctiaiiges.  (liy 
pennKsioii  from  T/ie  Quarterly  Journal  of  Medicine 
vol.  i.) 


Fi,j.  l(;;.--SI<iai;ramsliowii,-  Miat,  tin;  paiN 
Jepu-t4?d  in  Fiff,  HW)  alTect  the  soft  parts  and  not 
the  urulcflvhis  joints.  (Tiy  permission  from 
The  Qimrlerh/  Journal  of  Medicine,  vol.  i.) 


Is  seen  iti  oslco-arthritis,  but  is  also  present  in  so  many  o(hcr  alTections  of  the  fingers  and 
wrist  thai   l)y  itself  it  is  of  no  value  in  diagnosis. 

Tiihcrciiliins  Disnisc  of  .foints.— Thin  is  most  ((iiiirniiii  in  cliildnii  ol  between  three  and 
five  years,  and  becomes  rarer  as  age  advances,  .\boul  K)  pii'  itiil  ol  the  cases  are  in  the 
spine,  40  i)er  cent  in  the  hip,  10  per  cent  in  the  knee,  and  the  other  joints  which  are  alfeeted 
not  uncommonly  are  the  ankle,  shoulder,  elbow,  and  wrist.  The  disease  is  essentially 
slow,  so  that  the  early  stages  are  often  overlooked.  II  is  stateil  that  tuberculous  arthritis 
is  so  insidious  in  its  onset  that  for  one  Ciise  in  which  the  affection  is  (Ictccled  and  a(lei|iiately 
treated  in  tlie  lirst  month  of  its  existence,  there  are  twenty  in  which  it  is  allowed  to  drift  on 
for  three  or  lour  months,  or  even  longer,  before  it  is  recognized.  For  some  time  there  may 
beonly  sliglil  transient  impairment  of  movement,  or  an  occasional  twinge  of  pain  ;  gradually 
impaired  movement,  showing  itself  as  slight  lameness  in  the  lower  extremity,  becomes 
evident,  but  it  nmst  not  be  concluded  that  there  is  no  tuberculous  disease  of  a  joint  because 
there  is  no  impairment  of  mo\cmcnt.  In  the  sanie  way,  although  pain,  often  worse  at 
night,  and  causing  screaming,  is  an  important  sign,  ycl  pain  niiiy  be  absent  lor  a  long  while, 
or  altogether.     In  all  the  joints  except  the  shoulder  and   the   hip     which  are  so  deeply 


348  JOINTS,     AFFECTIONS    OP    THE 

■covered  by  soft  parts  that  unless  it  is  considerable  it  cannot  be  detected — swelling  is  a  very 
iniportant  symptom,  for  it  is  almost  invariably  present,  even  in  the  earliest  stage.  It  may 
be  very  slight.  Although  there  may  be  no  defect  of  movement  in  the  early  stages,  sooner 
or  later,  and  often  quite  early,  this  symptom  develops  and  is  of  great  value.  Tuberculous 
arthritis  is  usually  accompanied  by  wasting  of  muscles  moving  the  joint.  It  must  never  be 
forgotten  that  a  tuberculous  arthritis  is  so  slow  in  its  development  that  often  it  is  not 
ascribed  to  its  correct  cause  ;  also  that  for  a  time  the  symptoms  are  so  slight  that  no  atten- 
tion may  be  ])aid  to  them.  Mistakes  are  very  serious,  and  tuberculous  arthritis  ought 
iihvays  to  be  present  in  our  minds  when  examining  a  diseased  joint.  It  is  very  rare  for 
more  than  one.  or  perhaps  two,  joints  to  be  affected  in  the  same  person  ;  tuberculous  disease 
elsewhere,  e.g..  phthisis,  is  not  common  :  lardaceous  disease,  formerly  so  frequent  a  compli- 
cation, is  now  seldom  seen  ;  and  general  symptoms,  e.g.,  pyrexia,  are  often  absent  and 
rarely  extreme  ;  on  the  other  hand,  those  affected  are  often  pale.  Bony  outgrowths  are 
not  to  be  detected  :  the  joint  is  swollen  and  feels  thick  :  hence  the  phrase  '  pulpy  knee." 
There  is  often  a  history  of  injury  to  a  joint  which  later  becomes  tuberculous,  and  then  the 
transition  from  a  traumatic  to  a  tuberculous  arthritis  is  often  overlooked.  Tuberculous 
disease  of  the  .sacro-iliac  joint  is  particularly  difficult  to  diagnose.  Tuberculosis  of  the  hip 
is  often  overlooked  because  the  pain  is  referred  to  the  knee,  and  the  sliglit  wasting  of  the  hip 
nuiscles  is  not  detected. 

Aciiuired  Syphilitic  ArtlirHis. — This  is  most  easily  recognized  by  those  who  constantly 
bear  in  mind  the  possibility  of  its  existence.  If  the  characteristic  pains  of  syphilis,  which 
arc  usually  worse  at  night,  happen  to  occur  near  a  joint,  they  may  be  ascribed  carelessly  to 
gout  or  osteo-arthritis.  In  the  secondary  stage  of  syphilis,  and  more  particularly  early  in 
it,  a  syphilitic  synovitis  of  any  joint  may  occur.  It  is  subacute,  slow,  is  attended  with 
stiffness,  swelling,  and  occasionally  tenderness,  and  usually  is  confined  to  one  joint.  Pain, 
too,  may  be  present,  but  commonly  neither  pain  nor  tenderness  is  a  prominent  symptom. 
There  is  some,  but  not  much,  enlargement  of  the  joint  from  distention  with  synovial  fluid  : 
in  a  few  cases  the  size  of  the  joint  varies  considerably  in  a  short  time.  These  cases  are 
often  mistaken  for  tuberculous  arthritis.  l)ut  the  error  can  usually  be  avoided  if  the  patient 
is  examined  carefidly  and  questioned  for  other  evidence  of  syphilis  ;  and  in  this,  and  all 
other  forms  of  arthritis  in  which  there  is  any  possibility  of  syphilis,  a  Wassermann  test 
should  be  done.  .Sypliilitic  arthritis  in  the  tertiary  stage  is  rare  :  there  are  two  varieties  of 
it.  both  of  which  produce  considerable  swelling  and  disorganization  of  the  joint  ;  in  one 
there  is  a  de])osit  of  gummatous  material  in  the  subsynovial  tissue,  in  the  other  in  the  ends 
of  the  bone.  Both  varieties  are  usually  confined  to  a  single  joint,  neither  is  painful,  and 
•  both  are  liable  to  recur.  Great  effusion  of  synovial  fluid  is  iiot  common.  Init  when  the 
disease  is  in  the  subsynovial  tissues  the  joint  is  enlarged  and  the  thickening  of  the  synovial 
membrane  can  be  felt. 

Congenital  Syphilitic  Arlhiilis. — In  children  and  young  adults  congenital  syphilis  may 
cause  an  arthritis  which  is  very  like  that  caused  by  tubercle.  The  knees  are  affected  most 
often,  and  the  disease  is  often  symmetrical.  If  there  is  nuich  synovial  exudation,  fluctua- 
tion is  detected  easily  :  if  there  is  nuich  gummatous  deposit  in  the  subsynovial  tissue,  the 
svnovial  membrane  feels  thickened  and  irregular.  There  is  no  pain,  and  very  little  impair- 
ment of  movement.  The  existence  of  this  disease  must  always  be  remembered  ;  the  history 
and  examination  for  other  signs  of  syphilis,  especially  nerve  deafness  or  interstitial  keratitis 
nuist  be  thorough,  and  the  Wassermann  reaction  must  be  tested. 

In  infants  congenital  syphilis  may  cause  osteochondritis  in  the  sub-epiphyseal  plate 
of  cartilage  and  adjacent  bone  ;  the  cpipliysis  becomes  separateil  from  the  shaft,  so  that 
there  is  motility  and  dull  grating,  as  if  a  fracture  had  occurred.  At  the  same  time  there  is 
considerable  swelling  of  the  soft  parts  around,  from  the  inflanmiation  having  spread  to 
them,  so  that  there  is  much  swelling  about  the  joint,  although  the  joint  itself  is  usually 
not  implicated.  Separation  of  the  epiphysis  from  the  shaft  makes  tlie  limb  paralyzed  : 
hence  the  phrase  si/jiliililir  //.sciiilo-jxinili/sis  api)lics  to  this  condition.  .Su|)puration  is  very 
rare,  and  the  impro\emeut  with  mercury  is  rapid.  This  condition  may  be  noticed  at  any 
period  from  one  month  after  birth  till  the  age  of  two  or  three  years,  but  it  is  most  often  seen 
when  the  child  is  two  or  three  months  old.  It  is  usually  multiple,  and  there  is  some  tender- 
ness and  slight  pain.  Other  signs  of  congenital  syphilis  are  generally  present,  but  if  not. 
the  condition  is  so  characteristic  that  the  child  must  at  once  be  given  mercurv. 


JOINTS.     AFFECTIONS    OF    THE 


;!49 


htlermiltint  Ilyilinrtliiosis. — This  rare  disease  should  be  diagnosed  easily.  It  is  com- 
monest in  women.  Cases  have  been  recorded  between  the  ages  of  eight  and  fifty,  but  the 
patients  are  most  often  between  twenty  and  thirty  years  old.  Fluid  is  poured  out  rapidly 
in  the  joint,  so  that  it  is  distinctly  swollen  in  a  few  hours  ;  the  distention  attains  its  maxi- 
mum in  one  or  two  days  ;  it  then  recedes,  and  has  disappeared  by  the  fourth  or  fifth  day. 
The  effusion  leads  to  stiffness  of  the  joint,  and  generally  there  is  some  pain,  but  usually 
very  little  tenderness,  and  the  joint  is  neither  red  nor  hot.  The  knee  is  affected  most 
often  ;  it  may  be  one  or  both  knees  ;  if  not  the  knee  it  is  almost  always  a  large  joint  that 
is  the  seat  of  the  effusion.  It  is  rare  for  more  than  two  joints  to  be  affected  at  once.  The 
remarkable  part  of  the  affection  is  that  the  effusion  is  periodic,  and  often  the  interval  of 
time  between  the  attacks  in  the  same  patient  is  on  each  occasion  exactly  the  same  :  thu.s 
in  one  patient  the  effusion  always  began  on  the  ninth  day  from  the  beginning  of  the 
previous  effusion  ;  the  interval  has  been  known  to  be  less  than  this,  and  it  is  often  more. 
It  may  be  that  for  a  period  the  intervals  are  of  a  certain  length,  and  then  for  a  period  they 
are  of  a  different  but  uniform  length.  In 
other  cases  there  is  no  ])eriodicity.  In  eacli 
attack  the  same  joint  or  joints  are  affected  in 
the  same  patient,  .\fter  three  or  four  years 
the  attacks  cease  in  most  cases,  but  occasion- 
ally there  are  recurrences. 

ChnrcoVs  Disease  {Fig.  I(i2). — This  is  the 
arthritis  met  with  in  tabes  dorsalis,  and  if 
any  patient,  of  such  an  age  that  he  could  be 
sulTcring  from  taljes,  has  chronic  arthritis  of 
a  single  joint,  we  ought  always  to  examine 
him  for  signs  of  tabes.  Because  this  is  not 
done  many  cases  are  overlooked,  for  tlie 
arthritis  may  exist  even  when  the  patient  is 
iniawarc  that  he  lias  any  signs  of  tabes. 
There  is  nothing  characteristic  of  tabetic 
arthritis,  and  many  joints  affected  with  il 
might,  for  all  the  clinical  symptoms  of  tlic 
arthritis,  or  from  the  appearances  after  <leath. 
be  equally  well  affected  by  osteo-arthritis  : 
t)Ut  the  following  points  will  often  make  one 
suspicious.  The  effusion  is  frequent ly  very 
great  —some  of  the  biggest  joints  seen  are 
those  affected  by  tabetic  arthritis  ;  the  liga- 
ments may  be  much  softened,  so  that  flu- 
joint  becomes  flail-like,  but  the  groxvlli  of 
new  bone  at  the  eilgcs  of  the  joint  is  oricii 
(|uile  slight,  and  there  is  eonsidciablc  alropliy 
of  bone:  thus  I  have  seen  the  floor  of  the 
acclabulum  as  thin  as  paper,  aiifl  bcaause  il 
was  so  thin,  the  pressure  from  the  neck  of  the 

femur  had  expanded  the  lloor  of  the  aectal>uluni  so  jai-  into  the  pcKis  thai  il  fonncd 
a  large-  projection  into  the  pelvic  cavity.  Tabetic  arthritis  is  usually  chronic  and  never 
acute,  but  it  may  be  ra|)id  ;  thus  there  may  be  advanced  destruction  of  the  joints 
in  a  IV'w  weeks  (Fif!.  Ki.'i)  ;  it  is  almost  always  painless  ;  generally  large  joints  e.g.,  knee, 
hip  are  affected  :  usually  only  one  joint,  but  I  have  seen  two.  The  rareliution  of  the 
bones  makes  them  liable  to  fracture.  \\'hen  tabetic  arthritis  occurs  in  the  bones  of  the  hand 
or  foot  the  considerable  swelling  may  cause  il  In  lie  uiislakcri  for  tuberculous  disease.  In 
75  per  cent  of  cases  of  tabetic  arthritis  the  joints  aUcclcil  arc  I  hose  of  the  lower  cxtreinily. 

Aillnilis  ill  Si/riiifiiiini/iliii. —  In  7.>  per  cetil  of  llie  patients  affected  with  this  form  of 
arthritis  the  joinls  alfceled  are  those  of  the  upper  extremity.  There  is  nothing  absolutely 
disliiieti\c  of  tliis  \ariety  ;  it  resembles  closely  that  due  to  lalxs  ;  perhaps,  on  the  whole, 
some  of  the  cases  more  nearly  resemble  osteo-arthritis.  Owing  lo  the  loss  of  i)ain-sensati<in 
in  syringomyelia,  woun<ls  are  common  ;    hence  the  joints  may  become  .septic.     .Mistakes 


Fiij.  102.— CI 
assocmtioii  witli 
also  displuccMiiciil  of 


disease  of  the  riglit  knee-joint  iii 
ibes  dorsalis  :    sllowing  distention,  and 


350 


JOINTS,     AFFECTIONTS    OF    THE 


n  diagnosis  can  only  be  avoided  by  always  having  in  mind  the  possibility  of  tlie  occurrence 
of  syringomyelia,  and  examining  the  patient  for  it.  Happily  it  is  rare,  and  often  the 
symptoms  of  syringomyelia  (p.  608)  ire  evident  before  the  arthritis  shows  itself.  In  about 
half  the  cases  of  syringomyelia  there  is  scoliosis  of  the  spine. 

Arthritis  in  HtemopliiUa. — In 'this  disease  blood  may  be  poured  out  into  either  the 
synovial  membrane  or  the  cavity  of  the  joint.  This  is  probably  always  the  result  of  a 
blow,  often  so  slight  as  to  pass  unnoticed.  It  is  most  common  in  the  knee  and  ankle.  If 
the  bleeding  is  at  all  considerable  the  joint  swells,  the  rate  of  swelling  depending  upon  the 
rate  of  effusion  of  blood.  The  joint  is  puffy  ;  there  may  be  fluctuation,  pain  on  movement, 
and  tenderness.  The  whole  trouble  often  subsides,  but  sometimes  more  or  less  swelling 
persists  for  a  time,  and  even  if  a  joint  gets  well,  relapse  is  likely.  In  other  cases,  either 
the  impaired  blood-supply  resulting  from  damaged  vessels  or  the  friction  of  the  clots  leads 

to  erosion  of  the  cartilage,  and  per- 
manent disease  of  the  joint  results. 
Forgetfulness  of  the  fact  that  disease 
of  the  joints  occurs  in  h<emophilia 
has  led  to  the  .serious  mistake  of 
incising  one  into  which  bleeding  has 
occurred.  The  condition  is  to  be 
diagnosed  by  observing  the  other 
signs  of  hiemophilia. 

Maligiiaiit  find  Ilydritid  Disease 
of  Joints. — Both  these  are  very  rare, 
and  in  eacli  case  the  disease  almost 
always  begins  in  the  adjacent  bone, 
and  therefore  pro])erly  belongs  to 
diseases  of  bones.  Both  are  very 
serious  ;  hydatid  disease  of  a  joint 
is  very  liable  to  lead  to  suppuration 
in  it. 

Displueement  of  a  Semiluniir 
Curtilage  may  cause  much  synovitis, 
and  the  cause  of  the  latter  is  very 
apt  to  be  overlooked.  There  is 
often  a  history  of  a  wrench,  or  the 
patient  comi)lains  that  he  feels 
something  in  the  joint  slip  or  catch  ; 
tliis  may  cause  considerable  pain, 
and  there  is  often  tenderness  over 
the  internal  semilunar  cartilage. 
SdiiK'tinus  similar  symptoms  are 
produced  by  a  thickened  fringe  of 
synovial  membrane  becoming  nip- 
ped. This  may  occur  in  osteo- 
arthritis. Tlie  thickened  fringe  may 
become  detached,  and  then  it  forms 
a  loose  body  inside  the  joint. 

Nervous  JMimicry,  Neiiromim^sis. 
or  Hysterical  Joints. — In  these  cases 
some  of  the  symptoms  of  arthritis  are  imitated  without  there  being  any  actual  disease  of 
the  joint.  It  is  important  to  remember  that  hysteria  is  a  disease  and  is  not  mere  malinger- 
ing. The  malingerer  can  volimtarily  get  rid  of  his  sujaposed  disease  if  he  wishes  ;  the 
hysterical  girl  cannot,  as  she  has  not  sufficient  jjower  of  will.  There  are  three  main 
varieties  :  (1)  The  joint  is  kept  constantly  in  an  abnormal  position,  e.g.,  the  knee  may 
be  considerably  flexed  ;  (2)  The  joint  cannot,  be  moved,  e.g.,  the  hand  may  hang  down 
from  the  wrist,  as  in  extensor  paralysis,  and  it  cannot  be  raised  ;  (3)  Tliere  may  be 
acute  pain  in  the  joint.  In  all  these  cases  careful  examination  will  usually  show  that 
there  are  no  real    symjitoms    of   arthritis  :   there   is  no  swelling,  no  heat,  no  grating,  no 


Fig.  H;;^, — Skiagram  of  Charcot's  disease  of  the  hip.-,ioint.  The 
ppearaiii.-es  are  typical  and  diagnostic  ;  they  show  extensive  destruc- 
ioii  of  norm.il  bone  and  large  masses  of  abnormal  new  bone  throu-n 
ut  arouTid  it. 

(.fl.imjmm  hi,  Dr.  C.   Thur.itan  IloUuml.) 


JOINTS,    AFFECTIONS    OF    THE 


bony  outgrowtli.  the  imnioviihly 
the  other  hand  the  pain,  if 
j)resent,  is  far  in  excess  (if  any 
l)ain  due  to  arthritis,  and  the 
tenderness  may  be  so  great 
that  the  patient  will  not  let 
tlie  joint  be  touched.  Both 
])ain  and  tenderness  disappear 
if  the  patient's  attention  is 
diverted,  and  neither  keep  the 
patient  awake  nor  affect  the 
general  health.  The  pain  may 
radiate  far  beyond  the  joint  ; 
very  rarely  in  hysteria  there 
is  trivial  swelling,  but  it  is 
not  such  as  would  be  ])ro- 
duced  by  the  distention  of  the 
synovial  ca\  ity  :  it  is  often 
more  in  the  neighbourhood  of 
the  joint  than  over  it  :  but 
nearly  always  there  is  no  swel- 
ling about  a  hysterical  joint. 
rsiiiilly  llic  joint    siipiicscd    to 


•  fixed  joint  can  be  moved  freely  under  an  an;i^llM  ti 


liseased  is  cold  ;  very  rarely  it  is  hot  and  perhaps  a 
little  red  ;  but  this  phenomenon,  when 
present,  is  only  a  local  blush  due  to  the 
fact  that  the  i)aticnt"s  attention  is 
directed  to  the  joint,  and  it  passes  away 
quickly.  The  stiffness  of  a  hysterical 
joint  can  be  made  out  to  be  due  to  con- 
traction of  nmscles  and  not  to  alteration 
of  the  joint  itself:  occasionally  it  is 
variable,  and  it  is  often  extreme,  out  of 
all  proportion  to  any  possible  joint 
disease;  and  often,  too,  the  attitude  of 
the  joint  is  not  tliat  usually  seen  in 
aitlirilis.  It  has  been  pointed  out  re- 
peatedly that  muscles  which  move  a  joint 
usuall>  atrophy,  often  rapidly,  wlun  that 
joint  is  diseased,  (piite  apart  from  disuse. 
In  hysterical  affections  of  joints  the 
muscles  waste  only  slowly  in  proportion 
to  the  disuse  of  the  joint. 

Mitxiiihir  Pdidli/nis. —  Often,  e.g.,  in 
pcriplieral  lU'uritis.  the  muscles  which 
undergo  rapid  wasting  as  a  result  of 
disease  of  the  lower  motor  neuron  soon 
li(;.;iii  Id  conli-.-icI,  and  this  leads  to  con- 
^idiralilc  ,illir:il  ion  in  the  usual  position 
lit  joints.  'I'luis,  llic  knee  and  tlie  elbow 
liecomc  strongly  (lexeil.  and  ul  (irst  il  may 
l)e  thought  that  these  uiuisual  positions 
are  the  result  of  disease  of  the  joint,  for 
long-coTitinued  <'lironic  disease  of  a  joint 
will  lead  to  unusual  permanent  positions 
from  conlraclurc  of  ligaments,  from  the 
pull  of  muscles  on  a  weakened  joint,  and 
from  contracture  of  nmscles  wasted  from 
arthritic  atrophy  ;    but  a  little  estimation 


3r,2  JOINTS.     AFFECTIONS    OF    THE 

of  the  history,  the  eondition  ot  the  joints,  the  symptoms  of  nerve  disease  and  tlie  electrical 
reactions  ot  the  muscles  will  soon  lead  to  a  correct  diagnosis.  There  is  no  reaction  ot 
decreneration  in  muscles  that  have  atrophied  secondarily  to  arthritis. 

Hypertrophic  Pulmonary  Osteo-arthropathy  is  rare  and  not  really  a  disease  of  joints  at 
all.  for  the  change  consists  in  an  enlargement  of  the  ends  of  the  bones,  and  hence  the  joints 
appear  large  and  the  patient  cannot  bend  them  properly.  Often  this  is  all  that  is  the 
matter  with  them,  but  in  advanced  cases  there  is  some  thickening  of  the  synovial  membrane 
and  some  erosion  of  cartilage.  The  upper  extremity  is  affected  more  often  than  the  lower, 
and  the  joints  usually  deformed  are  the  wrist,  and  the  carpal  and  interphalangeal  joints 
(Pigs.  104  and  165)  ;  when  the  condition  exists  in  the  lower  extremity  the  corresponding 
joints  are  implicated.  In  extreme  cases  the  enlargement  extends  up  the  shafts  of  the 
affected  bones.  The  condition  is  distinguished  easily,  for  it  is  almost  always  accompanied 
by  clubbing  of  the  fingers,  and  in  80  per  cent  of  the  cases  it  is  associated  with  chronic 
pulmonary  disease,  especially  fibrosis,  bronchiectasis,  or  chronic  empyema,  of  which  there 
are  generally  ample  physical  signs.  The  remaining  20  per  cent  of  the  cases  are 
associated  with  such  diverse  conditions  that  text-books  must  be  consulted  ;  the  most 
interesting  is  aneurysm  of  the  subclavian  artery.  Hypertrophic  osteo-arthropathy  used 
to  be  confused  with  acromegaly  ;  not  only  ought  the  clubbing  of  the  fingers  and  the 
associated  conditions  to  prevent  such  a  mistake,  but  also  in  acromegaly  there  is  consider- 
able enlargement  of  the  head  and  characteristic  changes  in  the  face  (see  Fig.  116,  p.  237). 

W.   Hale  White. 

KIDNEY,  ENLARGEMENT  OF.— .\  renal  swelling  may  be  so  slight  that  it  is  only 
found  upon  clinical  examination,  or  it  may  be  large  enough  to  attract  the  patienfs 
attention  to  it.  A  number  of  pathological  changes  in  the  kidney  may  give  rise  to  a  timiour 
of  that  organ,  such  as  hydronephrosis,  pyonephrosis,  renal  tuberculosis  or  abscess,  new 
growths,  and  various  forms  of  cysts  in  the  kidney  ;  it  is  necessary  to  be  able  to  diagnose 
any  one,  not  only  from  any  other,  but  also  from  other  tumours  simulating  a  renal 
swelling. 

The  chief  characteristic  points  of  a  renal  tiuiKiiu'  are  : — 

1.  The  large  intestine  is  in  front  of  the  tumour.  When  either  kidney  is  merely  slightly 
enlarged,  both  large  and  small  intestine  will  be  in  front  of  it  ;  but  when  the  organ  is  so 
enlarged  as  to  reach  the  anterior  abdominal  wall  the  coils  of  small  intestine  are  pushed 
aside.  The  anatomical  relation  of  the  large  intestine  to  the  kidney,  and  the  absence  of 
a  mesentery,  do  not  allow  of  the  same  mobility  of  the  colon,  wliich  retains  its  position  in 
front  of  the  kidney.  Hence  an  area  of  resonance  can  usually  be  obtained  in  front  of  a 
renal  swelling  :  if  the  colon  be  empty,  it  can  sometimes  be  felt  in  a  thin  subject  and  rolled 
t)\'  the  fingers  on  the  surface  of  the  tumoiu'.  Bowel  is  never  placed  in  front  of  a  splenic 
timiour,  and  only  rarely  in  front  of  a  hepatic  tumour. 

2.  The  area  of  dullness  to  pereussion  is  continuous  from  the  lateral  aspect  of  the  swelling 
to  the  mid-line  posteriorly — that  is,  there  is  no  area  of  resonance  between  the  mass  and 
the  vertebral  spines,  as  in  a  splenic  or  ovarian  tumour. 

3.  .\  renal  tinnour  usually  retains  Die  siuipe  of  the  kidney  ;  it  is  rounded  at  its  borders 
and  poles,  and  does  not  possess  any  edge  or  sharp  margin,  as  in  splenic  or  hepatic  swellings. 

4.  A  renal  tumour  in  the  process  of  enlargement  projects  foncards  and  doicnicard.s. 
It  may  fill  up  the  natural  hollow  of  the  loin,  but  very  seldom  causes  any  prominence 
posteriorly.  A  perinejjhric  abscess,  which  often  simulates  a  renal  swelling,  may  cause 
a  distinct  prominence  in  the  loin. 

5.  .\  renal  tmnour  does  not  descend  so  freely  upon  deep  inspiration  as  a  splenic  or  hepatic 
tumour.  A  renal  tumour  may  be  movable  downwards  or  inwards,  or  may  be  fixed  ia 
the  loin  by  ])receding  inflammation.  An  enlarged  kidney  can  be  felt  with  ease  bimanually, 
and  if  grasped  between  the  two  hands  can  be  pushed  into  the  loin. 

6.  AVhen  a  renal  tumour  is  large  enough  to  reach  the  anterior  abdominal  wall,  it 
commonly  comes  in  contact  with  the  latter  at  the  level  t>f  the  umbilicus,  at  the  same  time 
bulging  out  the  ilio-costal  space.  There  i.s  usually  a  line  of  resonance  between  the  upper 
margin  of  the  tumour  and  the  hepatic  dullness 

7.  A  varicocele  may  be  developed  on  the  same  side  as  the  renal  tumour. 

8.  With  a  renal  tumour  there  may  be  changes  in  the  urine  pointing  to  renal  disease  : 
but  on  the  other  hand,  the  urine  at  any  one  time  may  be  normal,  free  from  blood  or  pus. 


KIDNEY.     EXLAR(iE.MENT    OF  353 

from  the  fact  that  the  ureter  of  tlie  diseased  side  is  liloeked,  or  tliat  the  disease  does  not 
involve  the  renal  pelvis. 

i).  In  exeei^tional  eases,  a  tiniiour  of  the  right  kidney  niay  extend  upwards  into  the 
dome  of  the  dia])hragni.  rotating  the  liver  so  that  the  anterior  margin  descends  below  the 
costal  margin,  and  jirevents  satisfactory  palpation  in  the  renal  area. 

Although,  from  the  above  physical  characters,  it  would  seem  that  a  renal  tumour 
should  present  little  didleulty  in  diagnosis,  yet  it  is  by  no  means  infrequent  to  find  that  a 
tumour  possessing  several  of  these  characters  may  give  rise  to  considerable  doubt  in  the 
determination  of  the  organ  from  which  it  arises.  The  following  points  will  assist  in  the 
diagnosis  of  renal  swellings  from  other  tumours  with  which  they  are  likely  to  be  confused  : — 

1.  Tumours  of  the  gall-bladder  (p.  2.52)  are  jilaeed  immediately  below  the  costal  margin, 
so  that  no  interval  exists  between  the  tumour  and  the  lower  margin  of  the  liver.  They 
are  usually  oval  in  outline,  with  the  long  axis  in  the  line  between  the  ninth  costal  cartilage 
of  the  right  side  and  the  umbilicus  ;  are  freely  movable  with  the  respiratory  movements, 
and  movable  from  side  to  side  about  an  axis  at  the  costal  margin.  There  is  dullness  on 
percussion  over  them,  and  they  cannotbe  felt  in  the  loin  or  be  grasped  bimanually.  With 
a  tumour  of  the  gall-bhulder  there  may  be  attacks  of  colic,  with  or  without  jaundice. 

2.  Enlargements  of  the  liver  (p.  366)  pass  downwards  from  beneath  the  costal  margin 
so  that  there  is  no  line  of  resonance,  or  area  in  which  the  hand  can  be  depressed,  between 
the  tumour  and  the  costal  margin.  Hei)atic  tumours  do  not  impair  the  normal  resonance 
in  the  loin  in  the  .same  manner  as  a  renal  tumour.  .\  tongue-shaped  lobe  of  the  liver 
(Uieder.s  lobe)  may  cau.se  dilHculty  in  diagnosis  :  but  here  the  lower  margin  is  seldom  so 
rounded  as  in  a  renal  tumour,  nor  will  the  mass  be  felt  in  the  loin  on  bimanual  examination. 
A  tumour  or  cyst  in  the  concave  aspect,  or  of  the  left  lobe,  of  the  liver  is  especially  liable 
to  cause  error  in  diagnosis,  whereas,  on  the  other  hand,  a  tumour  of  the  right  kidney  which 
projects  u])\vards  behind  the  liv'cr  may  so  rotate  the  latter  that  its  anterior  margin  descends 
below  the  costal  margin  and  completely  obscures  the  kidney.  In  a  case  of  a  large  carcinoma 
of  the  right  kidney,  the  liver  was  in  this  way  so  depressed  as  to  render  palpation  of  the 
kidney  impossible. 

3.  Enlargements  of  the  spleen  (j).  628)  descend  from  beneath  the  left  costal  margin, 
and  have  no  bowel  in  front  of  them.  The  edge  of  a  s])lenie  tumour  is  usually  well-de(ined 
aiul  often  nolehed.  ami  there  is  resonance  between  the  posterior  as])ect  of  the  tmnour  and 
the  spinal  column.  .\  splenic  tumour  is  more  movable  than  a  renal  tumour.  ,V  blood- 
count  may  heli>  in  splenic  enlargements. 

4.  Perinephric  effusions,  whether  of  blood,  pus.  or  urine,  may  form  a  tumour  in 
the  loin  which  upon  physical  examination  may  be  mistaken  for  a  renal  swelling.  .V  peri- 
nephritic  elTusion  ma\  arise  from  some  suppurative  condition  of  the  ki<lney,  so  that  the 
previous  history  and  examination  of  the  urine  will  not  assist  in  dirCerentiation  ;  or  it  may 
be  line  to  conditions  entirely  distinct  from  renal  disease.  .\n  elfusion  of  blood  around 
thi-  kidney  is,  in  nearly  all  eases,  caused  by  an  injury  to  the  loin,  and  will  be  aceoni])anied 
by  other  signs  of  injury.  .\  perinephric  abscess  forms  a  nuich  more  ill-dehncd  tumour 
than  that  caused  by  a  r<Mial  swelling,  is  more  acute  in  its  general  symptoms,  such  as  pain 
and  temperature,  and  fills  up  the  ilio-costal  s|)ace.  The  skin  oxer  it  may  be  thickened  or 
(cdemalipus,  and  llueluation  may  be  felt  to  be  more  superficial  than  in  a  renal  swelling. 
A  |)erinc|)hric  abscess  is  most  likely  t(f  resull  from  suppuration  about  a  carcinoma  of  the 
large  bowel,  fniin  :i|p|i(THliciil  iiillaniinalion.  or  from  su|ipurMl  i(]n  in  a  |iciincphrie  liaMuatoma 
due  to  injury. 

.5.  Tumours  arising  from  the  pelvic  organs,  troni  Ihe  o\ary  or  uterus,  may  in 
.some  cases  sirnuNilr  rrn;il  tinnours.  An  o\:iriiiii  e\sl  willi  a  long  pedicle  occupying  the 
loin  has  lri(|U(nlly  been  mistaken  lor  an  enlarged  oi'  movable  kidney,  and  any  sudden 
att.aeks  of  pain  occurring  from  torsion  of  the  pedicle  may  be  looked  upon  as  due  to  renal 
colic.  The  usual  ovarian  cyst  or  uterine  fibroid  will  seldom  be  confused  with  a  renal 
.swelling,  for  it  is  placed  in  Ihe  middle  line  of  the  body,  can  be  felt  to  come  up  from 
the  pelvis,  and  can  be  felt  readily  upon  bimanual  vaginal  examination  to  be  attached  to 
the  uterus  or  its  appendages.  These  tumours  also  give  rise  to  dullness  anteriorly,  and  do 
not  alter  the  normal  resouMnee  in  the  loin.  In  cases  of  malignant  o\arian  tumours 
associated  willi  aseil<s,  the  lumbar  resonance  may  be  lost,  but  on  lurning  the  patient  over 
upon  one  side.   Ilic   pnxiousiy   dull   note   hceornes   i(|>lae<'d   by   resoniiwc   in   Ihe   uppermost 

»  23 


354  KIDXKV.     ENLARGEMENT     OF 

loin.  In  the  case  of  an  ovarian  cyst  with  a  long  pedicle,  or  of  a  uterine  fibroid  of 
pedunculated,  subserous  form,  the  position  in  the  loin  may  sometimes  suggest  a  renal 
tumour  ;  it  will  be  found,  however,  to  occupy  a  more  anterior  position  in  the  abdomen 
than  a  renal  tumour,  and  to  possess  a  much  greater  range  of  movement,  and  it  does  not 
slip  back  into  the  loin  imder  the  costal  margin  in  the  same  manner  as  an  enlarged  kidney 
does  ;  there  is  resonance  posteriorly,  the  kidney  may  be  actually  palpated  as  well  as  the 
abdominal  timiour,  whilst  a  distinct  connection  with  the  pelvic  organs  can  sometimes  be 
traced  from  the  tumoiu'  when  the  latter  is  drawn  up. 

In  contradistinction  to  the  ab<ne.  a  very  large  cystic  renal  swelling  may  be  mistaken 
for  an  ovarian  cyst.  In  may  occupy  the  greater  part  of  the  abdomen,  and  even  be  felt 
per  ^•aginam  to  be  encroaching  upon  the  pelvis  ;  but  on  careful  examination  in  a  renal 
tumour  of  this  form  there  will  be  no  line  of  resonance  between  the  mass  and  the  vertebral 
column  jjosteriorly.  the  natural  hollow  of  the  loin  will  be  filled  up.  and  there  is  frequently 
a  distinct  bulging  in  the  lower  thoracic  wall,  together  with  an  increased  length  of  the  ilio- 
costal sjjace  on  the  affected  side.  Some  assistance  may  be  obtained  from  the  history, 
when  a  hydronephrosis  may  luue  been  first  noticed  as  a  tumour  commencing  under  the 
costal  margin,  and  gradually  increasing  downwards  towards  the  iliac  fossa  and  inwards 
across  the  median  line,  whereas  an  ovarian  tumour  may  have  been  noticed  to  increase 
iijjwards  from  the  jjclvis. 

0.  Suprarenal  tumours  may  occasionally  be  of  sufficient  size  to  form  an  abdominal 
tuniiiur.  ))rescnting  a  rounded,  movable  swelling  in  the  hypochondrium.  It  is  practically 
imixissible  to  distinguish  them  from  renal  tumours  without  laparotomy. 

7.  Faecal  accumulations  in  the  colon,  caecum,  or  sigmoid  flexure  may  give  rise 
to  a  tumour  and  j)aiu  of  a  colicky  nature  in  tlie  loin.  They  will  be  distinguished  from 
renal  swellings  by  the  general  intestinal  symptoms,  flatvilence,  and  the  changes  in  form 
consequent  on  the  administration  of  large  enemata.  It  must  be  remembered  that  a 
patient  with  a  collection  of  fa-ces  in  the  colon  may  not  complain  of  constipation,  but  may 
in  fact  have  a  small  daily  evacuation  from  the  overloaded  bowel. 

H.  Inflammatory  thickenings  about  the  appendix  will  be  diagnosed  from  renal 
tumours  by  the  situation  of  the  pain  and  by  the  swelling  being  in  the  iliac  fossa  rather 
than  in  the  loin.  In  some  cases,  however,  the  pain  may  be  referred  to  the  lumbar  region, 
or  an  appendical  inflammatory  thickening  may  spread  upwards.  The  onset  of  the  trouble, 
the  acute  sj'mptoms,  and  the  febrile  disturbance  will  usually  distinguish  these  cases  from 
renal  lesions. 

0.  Malignant  growths  of  the  large  intestine,  especially  of  the  ascending  or 
descending  colon,  may  form  a  tumour  in  the  loin  which  closely  resembles  a  renal  swelling. 
The  mass  formed  by  the  growth  may  be  grasped  bimanually,  is  movable  in  the  same  direc- 
tions as  a  renal  tiunour,  and  comes  forward  under  the  costal  margin.  The  percussion 
note  over  the  front  of  the  lunij)  is  resonant,  and  there  is  usually  an  aching  pain  in  the  loin. 
If  the  growth  has  infiltrated  through  the  wall  of  the  bowel  uncovered  by  peritoneum,  the 
perirenal  tissues  may  be  thickened,  or  albuminuria  may  be  produced  by  direct  invasion 
of  the  kidney,  when  the  ease  will  even  more  resemble  a  renal  lesion.  Cancer  of  the  large 
.  intestine  should  be  suspected  if  there  is  any  irregularity  in  the  action  of  the  bowels,  mucus 
or  blood  in  the  motions,  or  any  symptom  of  conunencing  obstruction  in  the  intestine.  The 
tumour  may  be  irregular  and  nodular,  whereas  a  renal  tumour  presents  roimded  margins. 
The  occurrence  of  a  tumour  in  either  side,  associated  with  discomfort  or  palpable  distention 
of  the  cajcum  from  the  accumulation  of  faeces,  would  render  a  growth  in  the  colon  the  more 
siis]iicious.  The  appearances  seen  with  the  ,r-rays  at  a  suitable  interval  after  a  bariunr 
or  bisnuith  meal  may  assist  the  diagnosis  by  showing  organic  intestinal  stenosis. 

10.  Tumours  of  the  omentum,  mesentery,  or  pancreas,  cither  cystic  or  malignant, 
are  more  median  in  position,  do  not  project  into  the  loin,  and  seldom  resemble  a  renal 

tlUUOlU'. 

In  many  cases  in  which  difficulty  arises  in  the  diagnosis  of  a  swelling  in  the  loin,  great 
help  may  be  obtained  by  jjyelography — that  is,  the  injection  into  the  renal  peh-is  by  means 
of  a  ureteric  catheter  of  some  substance  such  as  collargol  in  a  7  per  cent  solution,  followed 
immediately  by  radiography.  By  this'  means  the  renal  pelvis  may  be  definitely  outlined 
in  its  normal  ])osition,  and  any  change  in  position  or  shape  may  indicate  that  the  swelling 
is  of  renal  origin. 


KIDXEV.     EXLAR(;K^1ENT    of  355 

A  kidney  may  be  enlaroed  but  yet  not  palpable,  from  the  lact  that  it  is  either  wholly 
above  the  costal  margin  or  obscurerl  by  the  liver  or  the  thick  abdominal  walls  of  the 
patient.  On  the  other  hand,  a  kidney  may  be  so  diseased  as  to  be  functionless  and 
shrunken,  when  it  cannot  be  felt  :  but  the  remainino-  organ  may  be  enlarged  in  a  com- 
pensatory degree  and  may  be  distinctly  palpable.  One  must  remember  the  danger  of 
regarding  an  enlarged  kidney  as  the  diseased  organ  when  it  is  in  reality  the  only  function- 
ating one.  Aching  pain  may  be  present  on  the  functional  side,  as  a  reno-reflex  pain  from 
the  disease  on  the  other  side.  The  kidney  of  normal  size  and  position  is  not  palpable 
from  the  abdomen,  or  on  bimanual  examination  with  one  hand  on  the  loin  :  but,  in  a  thin 
subject,  the  lower  pole  may  be  felt  to  descend  between  the  hands  on  the  patient  taking 
a  full  inspiration  ;  if,  therefore,  a  kidney  can  be  felt  easily  on  bimanual  examination,  it 
is  either  unduly  mobile  or  enlarged.  It  is  often  difficult  to  say  if  a  kidney  that  is  movable 
is  also  enlarged  to  a  slight  decree  :  and  a  kidney  which  was  thought  clinically  to  be  enlarged 
has  often  been  found  to  be  of  normal  size  when  exposed  :  this  is  in  part  due  to  the  thick 
coverings  of  the  abdominal  wall,  or  to  the  amount  of  fatty  tissue  surrounding  the  organ. 

If  the  kidney  is  definitely  enlarged,  it  remains  to  determine  the  nature  of  the  enlarge- 
ment :  in  this  one  is  guided,  not  only  by  the  physical  characters  of  the  tumour  present, 
but  also  by  other  symptoms  that  are  associated  with  it,  more  especially,  perhaps,  by  the 
altered  characters  of  the  urine.  The  kidney  may  be  enlarged  only  slightly,  as  in  tubercu- 
losis, pyelonei)hritis,  commencing  hydronephrosis,  or  carcinoma  :  or  may  be  enlarged  to 
a  considerable  degree  in  polycystic  disease,  hydro-  or  pyonephrosis,  and  in  some  forms  of 
malignant  growth.  From  the  physical  examination  of  the  enlarged  organ  it  is  often 
possible  to  say  that  the  swelling  is  .fluid  or  solid  in  nature,  but  it  is  seldom  that  a  true 
diagnosis  of  the  lesion  can  be  made  from  palpation  of  the  kidney  alone.  In  the  following 
diseases  in  which  renal  enlargement  is  usually  jiresent.  the  diagnosis  must  be  arrived  at 
by  the  consideration  of  associated  symptoms. 

In  renal  tiihcrrulnsis  the  disease  occurs  in  a  miliary  or  in  a  caseous  form.  Miliary 
tuberculosis  occurs  as  a  part  of  a  general  tuberculosis,  usually  in  children,  is  bilateral,  and 
causes  no  tumour.  The  caseous  variety  occms  as  a  ])rimary  disease  in  one  kidney,  in  which 
one  or  several  foci  may  be  present.  These  enlarge  and  soften  to  form  a  tuberculous  absce.ss, 
which  invades  the  medullary  tissues,  to  open  eventually  and  discharge  its  contents  into 
the  renal  ijclvis.  'i'he  kidney  is  enlarged  and  tender,  and  there  are  persistent  i)yuria  and 
lia-maturia  in  small  amount.  The  lining  membrane  of  the  ureter  is  (|uickly  in\aded  by 
the  tuberculous  process,  becoming  thic^kened  and  infiltrated,  and  at  the  same  time  shortened 
in  length,  so  that  cystoscopically  it  is  .seen  to  be  drawn  upwards  {Plate  AT,  Fig.  D,  p. 
■i82).  .\n  early  symptom  of  renal  tuberculosis  is  increased  frequency  of  micturition,  even 
before  the  bladder  has  become  infected  in  the  downward  progress  of  the  disease.  The  ureter 
may  be  felt  to  be  thickened  per  rectum  or  per  vaginam,  or  other  tuberculous  foci  niay  be 
found  in  the  pro'-tatc.  vcsicuhc  seminalcs,  or  testes  in  the  male.  .\  thorough  search  should 
be  made  for  tubercle  Ijaeilli  in  the  urine. 

In  jiijriiiiiciihiili.s  the  kidney  may  be  slightly  enlarged,  togctiur  wilh  renal  pain, 
pyuria,  and  general  malaise.  I'velonephritis  is  usually  bilateral,  and  due  to  some  infective 
or  obstructive  lesion  in  the  lower  urinary  trael,  symptoms  of  which  are  usually  obvious 
(see  I'vi  i!i.\,  |).  .574), 

MalifitianI  tiimi/ars  nf  llir  l.idiii//  gi\c  li^c  cilliii'  to  an  irreguhir  nodular  i-nlargrnient 
of  till-  kidney,  or  to  a  general,  uniform,  solid  tumour.  There  is  usually  aching  pain  in 
the  loin,  wilh  intermittent  attiicks  of  profuse  luematuria,  the  latter  occurring  as  soon  as 
the  growth  has  infiltrated  the  renal  pel\is.  'I'lie  bleeding  may  be  so  |)rofuse  that  clots  are 
formed  in  the  renal  ealiccs.  pyramidal  in  sli:i|ic.  wliieli  in  their  passage  down  the  ureter 
give  rise  to  typical  renal  colic.  'I'lic  iii.ilit;iiaMl  liiriioiirs  round  in  the  kidney  are  of  several 
varieties,  and  their  origin  ami  exact  pallioiogical  nature  lia\c  gi\cn  rise  to  nnich  discussion 
in  recent  years.  The  true  carcinoma  and  sarcoma  exist,  but  are  very  rare,  forming  but 
a  small  percentage  of  the  maliunanl  renal  tumours.  They  give  rise  to  renal  enlargement 
and  intermittent  huinalnria,  iirc  usually  e\lniMil\  Mialii;nanl .  and  are  accompanied  by 
early  metastases.  The  UMjre  connnon  l>pe  of  iinal  lunionr  in  the  cortical  portion  of  the 
kidney  the  hypernephroma  was  formerly  supposed  to  arise  in  small  aberrant  areas  of 
suprarenal  tissue  which  are  fre(|uently  found  in  this  situation.  Uecent  observers  maintain 
that    these    tumours   arise    from    the    renal   elements.       The    tumours    conunonlv   arise     in 


3r)6 


KIUNEV,    ENLARGKMEXT    OF 


the  iijjper  pole  of  the  kidney,  are  of  yellow  or  brown  colour,  and  are  usually  fairly  well 
defined  from  the  renal  tissues.  Microscopically,  their  structure  is  similar  to  that  of  the 
sii])rarcnal  gland,  and  their  metastases  are  of  the  same  nature.  They  were  formerly 
classified  as  angiosarcoma,  alveolar  sarcoma,  endothelioma,  or  carcinoma,  but  are  now 
classified  luider  the  term  h\']iernephroma.  They  form  a  comparatively  slowly-growing 
tumour  of  the  kidney,  and  give  rise  to  less  severe  symptoms  than  the  true  sarcoma  or 
carcinoma.  There  is  aching  in  the  loin,  and  enlargement  of  the  kidney  may  be  found  on 
examination,  but  at  first  the  symptoms  are  slight.  Ilaematuria  occurs  without  any  ajij^arent 
exciting  cause,  and  there  may  be  renal  colic  from  the  passage  of  clots  down  the  ureter  ; 
the  tumour  may  be  of  fair  size  before  any  hematuria  is  noticed. 

.\notlicr  form  of  malignant  tumour  that  occurs  in  the  kidney  is  that  which  is  supposed 
to  arise  from  embryonic  tissues,  and  to  which  the  name  of  embryoma  has  been  applied. 
These  tunmurs  are  formed  of  striated  muscle  (rhabdomyoma)  or  of  mixed  tissues,  such 
as  striated  and  non-striated  muscle,  cartilage  or  bone,  and  epithelial  structures  in  tabular 
or  glandular  Icniii.     Tluy  grow  in  the  renal  tissues,  expanding  the  latter  to  form  a  spurious 

caspide.     They   occur   most   frequently  in 
children,  and  ha-maturia  is  infrequent. 

Thus,  the  occurrence  of  a  renal 
tumour,  accompanied  by  intermittent 
attacks  of  hiematuria,  especially  if  profuse, 
should  always  give  suspicion  of  renal 
growth  in  an  adult.  Renal  tuberculosis 
and  calculus  both  may  give  rise  to  renal 
enlargement,  but  the  ha'maturia  is  seldom 
profuse  ;  with  calculus,  the  hematuria  is 
often  brought  on  or  increased  by  exertion, 
whereas  with  growth  it  may  come  on  at 
any  time,  even  during  rest.  At  the  same 
time,  it  should  be  remembered  that  both 
profuse  ha^naturia  and  renal  enlargement 
may  arise  from  a  vesical  tumour  which 
obstructs  the  normal  flow  of  urine  from 
the  lu'cteric  orifice  ;  in  all  cases  therefore 
a  cystoscopic  examination  should  be  made 
before  any  operative  measure  is  carried 
out.  The  rapid  development  of  a  viirico- 
cete,  especially  on  the  right  side,  is  a  point 
significant  of  renal  growth. 

iri/droneplirosis  and  pijoneplirosis  form 
definite  enlargements  of  the  kidney,  which 
may  attain  a  large  size.  The  tumour  is 
oval  or  rounded,  smooth,  and  gives  a  sense 
of  tenseness  or  elasticity,  whilst  occasion- 
ally distinct  fluctuation  may  be  obtained. 
Pyelography  assists  the  diagnosis  in  dilli- 
cidt  cases  {Fig.  166).  A  hydronephrosis 
occurs  when  there  is  a  partial  obstruction  to  the  meter,  or  in  cases  of  lepeated  attacks  o( 
temporarily  complete  ureteric  obstruction.  Hilatei'al  hydronephrosis  may  also  arise  fiom 
the  back-pressure  due  to  any  obstruction  of  the  normal  passage  of  mine  from  the  bladder. 
Hydronephrosis  is  usually  unaccompanied  by  pain  or  ha-matiu-ia  ;  but  the  timiour  may 
show  marked  changes  in  size,  from  the  varying  character  of  the  lesion  producing  the 
obstruction;  thus,  if  the  ureter  be  wholly  blocked,  the  tiunour  will  increase  in  size  and 
become  more  tense  ;  whilst  if  the  obstruction  be  partially  relieved,  the  tumour  will 
diminish,  synchronously  with  the  passags  of  a  larger  quantity  of  urine  of  low  specific 
gravity.  The  presence  of  any  obstruction  to  the  normal  How  of  urine  from  the  kidney 
predisposes  to  the  onset  of  infection  of  the  kidney  by  micro-organisms,  so  that  a  hydro- 
nephrosis may  become  converted  into  a  pyonephrosis,  or  the  latter  may  arise  from  the 
obstruction  to  the  ureter  of  a  kidney  already  the  seat  of  pyelitis.     The  physical  examination 


sided      In.llc.lM  l.linr-l-.     rhr     rr-llll      i.l      ■■:i|,'l||.,(|,     ,|l..i':r-l-.       TwO 

Stones  hud  been  removed  from  this  Icidiiey  ;i  year  previously, 
at  wliicli  time  tlie  pyelograpliic  appearances  were  practically 
tlie  same.  {SMaffram  hij  Dr.  V.  Tliurstan  Holland.) 


KNEE-JERK.     ABNORMALITIES    OF    THE  357 

of  a  kidney  distended  with  urine  or  witli  pus  shows  practically  no  difference  between  them, 
but  with  pyonephrosis  other  indications  are  usually  present  to  assist  the  diagnosis. 
Examination  of  the  urine  will  reveal  the  presence  of  pus  at  some  time,  although,  if  the 
ureter  is  wholly  obstructed  at  the  time  of  examination,  pus  may  be  absent  if  the  other 
kidney  and  the  bladder  are  normal.  If,  however,  the  ureter  is  blocked  only  partially,  pus 
will  be  found  in  the  urine  ;  in  the  intermittent  form,  pus  may  be  present  in  large 
quantities  at  intervals  coinciding  with  the  decrease  in  the  size  of  the  renal  timiour.  With 
])yonephrosis,  also,  there  will  be  the  general  evidence  of  suppuration,  namely,  raised 
temperature,  sweating,  pallor,  and  often  diarrhoea.  The  most  frequent  causation  of 
pyonephrosis  is  renal  calculus,  so  that  a  careful  enquiry  into  the  history  of  the  case  for 
symptoms  of  calculus  may  give  important  indications,  and  x-my  examination  may  be  of 
service  (Fig.  133,  p.  279)  unless  the  stone  has  been  passed.  Very  occasionally  palpation 
of  a  kidney  enlarged  from  calculous  disease  will  give  rise  to  distinct  crepitation  from  the 
I'rictiiin  of  one  stone  u|)on  another. 

yi  srroiia  or  hijdalid  cyst  of  the  kidney  may  give  rise  to  a  tumour  in  the  loin  exactly 
resembling  a  hydronephrosis,  and  would  usually  be  diagnosed  as  such.  The  discovery  of 
booklets  (Fig.  18,  p.  49)  or  hydatid  elements  in  the  urine,  or  in  the  fluid  aspirated  from  a 
renal  cyst,  will  ])oint  to  the  nature  of  the  disease. 

I'oli/ci/stic  disease  of  the  kidney  may  occur  in  children  or  in  adults,  and  forms  a  tumour 
which  is  eonnnonly  bilateral,  though  that  of  one  side  may  be  larger  than  the  other.  In 
adults  the  disease  causes  practically  no  trouble,  except  the  presence  of  the  tumour,  in 
the  early  stages  ;  but  later,  symptoms  of  renal  inelliciency  develop.  The  tumour  gives 
the  usual  physical  signs  of  a  renal  enlargement,  and  may  attain  a  great  size  on  both  sides. 
There  may  be  aching  pain  in  the  loins  and,  occasionally,  marked  ha?maturia.  The  urine 
is  of  low  specilic  gravity,  is  increased  in  amount,  and  in  the  absence  of  blood  often  contains 
a  small  amount  of  albumin.  The  disease  is  usuidly  accompauieil  by  arteriosclerosis.  The 
<'haracter  of  the  mine  and  the  bilateral  renal  tumour  arr  usually  sullicient  data  upon  which 
to  form  a  diagnosis  ;  but  with  unilateral  tumour,  as  occasionally  occurs,  the  diagnosis  is 
very  dilTicult.  .\  hydronephrotic  or  pyoncphrotic  kidney  may  give  evidence  of  fluctuation 
which  will  not  be  obtaineil  with  a  ])olycystic  kidney.  H.  II.  .loceli/n  Szciiii. 

KNEE-JERK,  ABNORMALITIES  OF  THE.-Hefore  discussing  the  abnormalities 
1)1  Ihc  kncc-jirk.  11  is  desirable  to  say  a  few  words  about  the  methods  used  for  eliciting 
Ihis  \alnablc  physical  sign,  and  what  may  be  considered  to  be  its  normal  variations. 

II  is  essential,  if  mistakes  are  to  be  avoided,  lo  lesl  the  knee-jerk  with  a  suitable 
iiistruriienl.  The  fingers,  or  the  edge  of  a  hand  (jv  oI  a  book,  are  imsatisfactory.  Sexeral 
pereussoi-s  are  miule  for  the  |)urpose,  the  best  being  a  wooden  stethoscope  with  a  moder- 
ately hea\y  ear-piece  surrounded  by  a  thick  iudi.irubber  ring.  Tlie  j)atieut  should  be 
either  sitting  or  lying  down.  If  seated  in  a,  chair,  he  nia\-  l>e  directed  to  cross  one  knee 
over  the  oilier,  or.  l)etter  still,  place  l)otii  feel  on  tlie  lloor  as  Car  away  lioin  liiin 
as  is  possible,  sii  liaig  as  the  whole  sole  of  eaeli  is  ill  eolilael  with  the  ground.  Ill  eillier 
position  a  tap  on  the  patellar  lendon  will  pro\<ike  a  coiil  ract  ion  of  the  (|uaihi((  ps  extensor 
iiiiisele.  which  will  extend  the  leg  on  the  thigh,  and  may  be  seen  or  felt  e\(U  if  il  tails  to 
actually  iiio\c  the  leg.  If  the  ])atient  is  in  bed.  lie  should  lie  Hat  on  his  back,  an<l  be  told 
to  allow  Ihc  observer  to  move  his  legs  without  resislanec.  The  latter  then  Ilexes  the  knee 
by  grasping  tlie  thigh  above  the  .joint  and  raising  it  until  an  obtuse  angle  is  formed  by  the 
poplileal  space,  the  foot  resting  on  the  bed.  The  position  of  the  manipulator's  hand  will 
enable  liiin  to  detect  whether  the  (piadriceps  and  hamstring  nmscles  are  sulHciently  relaxed 
III  tlie  case  of  small  children  or  infants,  it  is  advisable  to  stand  at  I  he  cud  of  the  bed  and 
to  giasp  llie  ankle  with  the  left  hand.  The  knee  can  then  be  Hexed  easily  by  pusliing 
I  lie  Idol  towards  the  patient,  and,  al  the  moiiieiil  when  llie  limb  feels  relaxed,  a  lap  on 
llie  patellar  tciidiiii  lie  given  willi  llie  iiisl  niiiieiil   ill  the  right  hand.      Ifdidicully  is  t'oimd 

i akiiig   Hie   palieiil    relax    his   niiib   in   aii\    of   lluse   positions,   his  allenlion  should   be 

din'cled  lo  eariying  lail  some  other  volimlary  movemenl,  such  as  pulling  apart  his  grasped 
bands  while  lie  looks  al  Hie  ceiling.     This  is  known  as  •  rcinforcenu'nt ." 

The  Normal  Knee-jerk. — It  is  impossible  to  delinc  a  normal  knee-.jerk.  because 
the  extent  of  the  reaction  varies  much  in  individuals  and  much  in  Ihc  same  person  al 
dillercnt  times.     .Vbscnce  of  the  knee-jerk  indicates  an  abnormality,  and  nuist  be  regarded 


:i.-,s  IvXKK-.IKKIv.     ,\  UNOH.M  ALITIES    OF    THE 

iis  ]);itliol(ii,ncaI.  Iiu'ijiuility  (if  the  jcik  (in  tlif  two  sides  must  also  be  ref;arfled  as  very 
stroiii;  evidence  of  some  organie  morbid  eoiidition. 

Abnormalities. — Tbe  knee-jerk  may  l)e  exanfjerated.  diminislied.  or  lost. 

Tlie  knee-jerk  is  exaggerated  wlicn  the  reflex  are  wliich  governs  the  tone  of  the  (jiiadri- 
ceps  muscle  is  insulficiently  inhibited  or  controlled  by  the  higher  nervous  centres.  This 
occurs  imder  two  chief  conditions,  one  of  which  constitutes  a  functional,  the  other  an 
organic,   loss  of  control. 

Functional  loss  of  control  occurs  wheneNcr  the  general  health  or  nervous  tone  of  the 
patient  is  below  jjar.  l'",xaggeration  of  the  knee-jerk  may  therefore  be  met  with  in  almost 
any  eoiistitiitionril  ailment,  and  is  nearly  always  to  be  observed  when  a  person  is  seriously 
out  of  health.  For  instance,  a  i)htliisieal  patient,  a  ease  of  chronic  renal  disease,  a  conva- 
lescent from  enteric  fever,  or  a  neurasthenic,  may  present  very  brisk  jerks,  and  their 
presence  may  only  be  looked  upon  as  an  indication  of  a  general  loss  of  nervous  tone.  This 
fact  emphasizes  the  necessity  for  never  being  satisfied  with  an  examination  of  tlie  knee- 
jerk  alone  in  attempting  to  diagnose  the  condition  of  the  nervous  system.  The  examina- 
tion of  the  knee-jerk  must  at  least  be  sup|)lemented  by  that  of  certain  other  reflexes,  the 
most  important  of  which  are  the  abdominal  and  plantar.  If  exaggerated  knee-jerks  are 
associated  with  normal  abdominal  reilexes  and  with  the  flexor  Xype  of  plantar  response, 
and  if  the  knee-jerks  are  approximately  equal  on  the  two  sides,  it  may  be  assumed  with 
some  exceptions  that  the  exaggeration  is  due  to  a  functional  loss  of  control  over  the  reflex 
arc.  If.  on  the  other  hand,  the  abdominal  reflex  is  absent  and  the  plantar  response  is  of 
the  extensor  type,  the  exaggeration  of  the  knee-jerk  is  due  to  some  organic  change  in  the 
cells  of  the  motor  area  of  the  brain  or  in  the  pyramidal  tracts  which  arc  made  up  of  the 
axonal  processes  of  those  cells.  Exaggeration  of  the  knee-jerk  due  to  organic  disease  is 
always,  or  nearly  always,  associated  with  other  reflex  changes,  and  particidarly  with  the 
extensor  type  of  plantar  response.  Frc(|uently.  but  not  invariably,  these  two  signs  are 
supi)lemcnted  by  the  presence  of  ankle-clonus,  by  a  spastic  condition  of  the  lower  extremi- 
ties, and  by  a  loss  of  voluntary  control  over  the  vesical  and  rectal  sphincters. 

When  the  pyramidal  tract  is  affected  ecpially  on  both  sides,  the  jerks  will  also  be 
exaggerated  equally  :  but  if,  as  in  hemiplegia,  one  pyramidal  tract  is  more  diseased  than 
the  other,  there  is  a  corresponding  difference  in  the  knee-jerk  on  the  two  sides,  that  of 
the  paralyzed  leg  being  brisker  than  that  of  the  sound  limb.  Inequality  of  the  knee-jerk 
is  also  observed  in  certain  eases  of  general  j)arahjsis  of  the  insane  for  the  same  reason. 

\  very  brisk  knee-jerk  is  sometimes  associated  with  a  phenomenon  wliieh  g(3es  by 
llie  name  of  patellar  clonus.  With  the  limb  resting  relaxed  and  fully  extended  on  the  bed, 
the  patella  is  sharply  pressed  towards  the  foot,  with  the  result  that  clonic  contractions 
of  the  quadriceps  are  provoked  and  continue  as  long  as  the  pressure  is  sustained.  The 
l)resencc  of  well-sustained  ])atellar  clonus   is  generally  indicative  of  organic  disease. 

Tlie  knee-jerk  may  be  diminished  as  the  result  of  some  pathological  processes  similar 
to  those  which  abolisli  the  jerk.  On  the  other  hand,  owing  to  the  natural  variations  in 
the  activity  of  the  reflex,  it  is  often  dillicult  to  be  sure  that  the  sluggish  character  of  a 
knee-jerk  is  of  pathological  origin  imless  there  is  evidence  to  show  that  it  had  been  obtained 
prexiously  with  greater  facility.  Most  infants  suffering  from  acute  febrile  or  debilitating 
disorders  present  very  diminished  knee-jerks  :  often  the  latter  cannot  be  obtained  at  all. 
at  the  height  of  bronchopneumonia  or  epidemic  diarrhtra  for  instance,  though  they  return 
to  normal  as  convalescence  progresses. 

The  knee-jerk  is  lost  only  in  organic  disease,  and  the  absence  of  that  reflex,  tlurefore. 
is  evidence  of  some  pathological  process.  The  conditions  under  which  the  knee-jerk  is 
lost  may  be  classified  in  the  following  manner  : — 

1.  Affections  of  the  quadriceps  extensor  muscle,  as  in  the  myopathies. 

2.  Affections  of  the  afferent  path  of  the  reflex  arc.  as  in  cases  of  tabes  in  which  the 
lumbar  region  of  the  spinal  cord  is  involved. 

;5.  Affections  of  the  anterior  Iwrn  cells,  such  as  occur  when  myelitis  involves  the  third 
and  fourth  lumbar  segments  of  the  cord. 

4.  .Affections  of  the  efferent  fibres  in  the  anterior  crural  nerve  innervating  the  <|uadri- 
eeps  muscle,  as  in  some  forms  of  perii)heral  neuritis. 

5.  In  complete  transverse  lesions  of  the  spinal  cord  above  the  lumbar  enlargement. 
This  is  usually  the  result  of  a  dorsal  myelitis,  or  of  a  fracture-dislocation  of  the  vertebral 
column  with  severe  injury  to  the  cord. 


LECCOCYTOSIS  .).-,!? 

6.  When  Ihc  iiitracianial  ])icssuic  is  ivrcatly  incifasicl.  particularly  in  fasts  of  intra- 
cranial tumour,  aud  more  especially  wlu  ii  the  tumour  oeciii)ies  the  posterior  fossa  of  the 
skull. 

It  should  be  noted  carefully  that  the  absence  of  the  knee-jerk  in  most  cases  affords 
evidence  of  some  lesion  of  the  structures  which  constitute  the  rcHcx  arc,  on  the  intcfrrity 
of  which  it  depends.  It  is  a  localizing'  sijrn.  not  necessarily  a  sijjn  of  some  particular  disease. 
For  instance,  it  is  quite  possible  for  patients  suffering;  from  talies  to  retain  their  knee-jerks 
so  long  as  the  morbid  process  has  not  insolvcd  the  lumbar  region  of  the  spinal  cord,  or 
one  knee-jerk  may  disappear  before  the  other.  For  the  same  reason  the  jerk  may  be 
present  in  certain  cases  of  acute  poliomyelitis,  or  one  may  remain  when  the  other  has 
been   lost. 

It  is  also  desirable  to  l)oint  out  that  the  abolition  of  llie  knee-jerk  may  be  the  o;;/// 
indication  of  any  affection  of  the  nervous  mechanism.  For  example,  the  knee-jerk  is 
often  lost  after  an  attack  of  diphtheria,  even  when  there  is  no  evidence  of  paralysis  of  the 
leg  muscles  or  of  any  sensory  loss  in  the  lower  extremities.  Another  instance  of  the  same 
kind  is  afforded  by  many  cases  of  lobar  pneumonia,  especially  in  children,  in  which  the 
pneumo-toxin  is  sufliciently  poisonous  to  interfere  with  the  sensitive  |)atellar  reflex  without 
producing  other  signs  of  disturbance  of  the  nervous  system.  In  diaheles  melliliis  the  knee- 
jerks  may  be  absent   without  any  further  signs  of  peripheral  neuritis  developing. 

Attention  has  been  drawn  to  the  occasional  absence  of  knee-jerk  in  cases  of  intracranial 
tumour.  The  explanation  of  this  is  not  very  clear,  but  reference  may  be  made  to  the 
great  variability  of  this  phenomenon  from  time  to  time.  At  one  examination  the  knee- 
jerk  is  obtained  :  at  another,  a  few  hours  later  it  is  lost,  jjcrhaps  to  return  on  the  following 
day.  This  ebb  and  flow  of  the  knee-jerk  is  highly  characteristic  of  increased  intracranial 
pressure,  and  is  rarely  found  imdcr  other  conditions. 

Two  other  forms  of  abnormal  knee-jerk  deserve  brief  reference.  One  of  them  is  what 
is  sometimes  called  the  choreic  knee-jerk.  In  many  eases  of  chorea,  when  the  l<g  is 
extended  on  the  thigh  as  the  result  of  tapping  the  patellar  tendon,  it  is  held  in  that  position 
for  an  appreciable  length  of  time  before  relaxation  takes  place  and  the  foot  falls  to  its 
former  position.  In  nii/a^lhenia  arm-is  it  is  sometimes,  but  only  rarely,  possible  to  tire 
out  the  knee-jerk.  A  ready  response  is  obtained  at  lirst.  but  rapid  repetition  of  the  test 
leads  to  abolilion  ni  [\w  reflex  excitability,  which  (piiekly  recovers  itself  after  a  short  rest. 

/','.  FiiKiiilifir  liiivjird. 

KRAUROSIS,    VULVAE.      (See   Index   at    end.) 

KYPHOSIS.     (See  CiKVATruK,   Si-iNAr,,   p.   1,5:5.) 

LEG,  ULCERATION  OF  THE.     (S<.c  fLCKUATroN  of  nii-,  l,i.:(i.  p.  -:{(;.) 

LEGS,   PAIN    IN    THE.  -(See  under  I'ain,  p.    VM.) 

LEGS,  SWOLLEN.     (Se-  (Kdkma,  p.    HI.) 

LEUCOCYTOSIS  is  a  word  which  has  been  usc.l  to  denote  two  .lilfcrciil  cnnclil  ]..iis. 
namely  :  (1)  .\u  absolute  increase  above  the  normal  of  the  munber  of  leucocytes  per  c.mm. 
of  blood,  without  distinction  as  to  which  particular  variety  of  leucocyte  is  mainly  it\crease(l  : 
and  {■!)  .\n  absolute  increase  in  the  total  mimbcrs  of  polymorphonuclear  cells  per  c.mm. 
of  blood.  If  if  is  used  in  the  latter  restricted  sense,  then  there  is  no  clinical  term  fo  express 
an  .ilisolufc  increase  of  all  the  leucocytes  in  the  bloo<l,  whatever  their  kin<l,  aud  it  seems 
preferable  to  use  the  term  leucoeytosis  in  the  broader  sensc\  as  being  an  absolute  incri'asc' 
in  the  total  munber  of  white  corpuscles  per  c.nun.  of  blood,  indicating  the  kind  of  leuco- 
eytosis by  means  of  a  differential  leucocyte  count.      It  is  used  in  this  sense  here. 

The  point  at  which  an  increase  in  the  total  mimbcT  of  leucocytes  per  c.nun.  of  lifooil 
can  be  called  leucoeytosis  is  arbitrary,  for  whereas  -)()()(»  per  e.nim.  is  regariled  as  I  In 
average  in  health,  there  are  considerable  variations  during  the  day,  either  in  relation  lo 
digestion,  exercise,  or  what  not.  and  the  same  person  who  at  one  lime  of  the  da>  ma\  have 
.")(><>(),  may  at  another  have  even  as  many  as  1  ^OIK)  per  c.mm.  If  the  dilfcrcnlial  leucocyte 
count  remains  normal,  no  total  leucocyte  count  less  than  ir>.()0()  per  c.nun.  <au  be  regarded 
as  abnormal,  and  it  is  not  until  the  figure  reaches  aO.OdO  or  more  tliat  mncli  stress   can  be 


360  LEUC'OC'VTOSIS 

laid  ui)on  it.  Tlie  numbers  tend  to  be  liifjlier  in  ehildren  und  in  pregnant  women  than  in 
other  healtliy  individuals. 

From  a  clinical  point  of  view  there  are  only  two  main  groups  of  conditions  in  whicli 
the  existence  of  leucocytosis  is  really  of  diagnostic  importance,  namely  :  (1)  In  cases  of 
splenomedullary,  lymphatic,  or  mixed  leuka-mia,  the  differential  diagnosis  of  which  is 
discussed  under  Anaemia  (]>.  24)  ;  and  (2)  In  connection  with  infective  processes,  particu- 
larly those  associated  with  suppuration.  - — 

There  are  many  maladies  in  wliich  moderate  leucocytosis  may  occur,  but  in  which 
the  behaviour  of  the  leucocytes  themselves  is  of  little  diagnostic  significance.  Thus, 
whether  there  is  or  is  not  any  leucocytosis  makes  little  or  no  difference  in  the  diagnosis 
of  the  following  conditions,  in  all  of  which  the  number  may  be  anything  from  5000  to 
20,000  per  c.mm.  :  acute  rheumatism,  scarlet  fever,  myxoedema,  intestinal  obstruction, 
diplithcria,  cholera,  iVrtid  bronchitis,  bronchiectasis,  urethritis,  acute  follicular  tonsillitis, 
whooping-cough,  carcinoma,  sarcoma,  rabies.  In  all  of  these,  and  probably  in  many 
others,  whereas  many  cases  show  no  leucocytic  change  at  all,  a  certain  proportion  exhibit 
leucocytosis.  If  there  were  a  universal  rule,  either  that  there  was  leucocytosis  or  was  not, 
the  fact  might  be  used  in  differential  diagnosis  :  for  instance,  the  occurrence  of  leucocytosis 
in  scarlet  fever  might  be  used  as  a  point  in  distinguishing  it  from  measles,  in  which  such 
leucocytosis  is  rare  :  but  it  is  just  possible  that  there  may  be  a  leucocytosis  in  a  case  of 
measles,  and  it  is  more  than  possible  that  scarlet  fever  may  present  no  leucocj'tosis,  so 
that  whereas  the  general  rule  is  to  the  contrary,  it  is  not  so  constant  as  to  be  a  safe  ground 
upon  which  to  make  a  differential  diagnosis.  It  can  only  be  said,  broadly  speaking,  that 
whereas  leucocytosis  is  not  imcommon  in  the  conditions  already  enumerated,  it  is  upon 
the  whole  not  common  in  measles,  malaria,  typhoid  fever,  typhus  fever,  influenza,  small- 
pox, mumps,  and  tuberculosis  other  than  caseous  bronchopneumonia,  secondary  infected 
phthisical  cavities,  or  tuberculous  meningitis. 

It  is  stated  that  certain  drugs  may  produce  leucocytosis.  though  careful  experiments 
with  some  of  them  have  by  no  means  always  confirmed  this.  Succinic  acid,  protargol, 
and  essential  oils  such  as  turpentine,  peppermint,  or  cinnamon,  are  examples  of  those  said 
to  produce  slight  leucocytosis.  After  severe  loss  of  blood,  such  as  may  result  from  excessive 
h:ematcmesis,  venesection,  post-partum  hicmorrhage,  and  the  like,  the  leucocj^tes  may 
rise  in  a  comparatively  short  time  to  over  15,000,  and  perhaps  to  over  20,000  per   c.mm. 

It  is  clear,  therefore,  that  when  so  many  conditions  may  lead  to  leucocytosis,  its 
importance  is  much  diminished  as  a  means  of  differential  diagnosis.  One  may  say,  how- 
ever, that  unless  there  are  other  clinical  indications  to  the  contrary,  a  definite  leucocytosis 
of  20,000  or  more,  the  figure  sometimes  reaching  even  50,000  or  60,000,  together  with  a 
relative  increase  in  the  ])olyniorphonuck'ar  cells  from  their  normal  65  per  cent  to  80,  85, 
or  even  90  per  cent  of  all  the  leucocytes  present  in  the  blood,  is  considerable  evidence  of 
there  being  suppuration  somewhere.  It  is  worthy  of  notice,  that  in  a  suppuration  which 
|)roduces  leucocytosis  with  a  relative  increase  in  the  polymorphonuclear  cells,  the  pus 
requires  to  be  confined  under  pressure,  for  in.stance  in  an  ai)pendiculav  abscess,  an  abscess 
of  the  liver,  empyema  of  the  gall-bladder,  suppurative  itykplikbitis.  infective  cholangitis, 
perineal  abscess,  pyosalpinx,  suppurating  ovarian  cyst,  thoracic  empyema,  abscess  of  the 
lung,  cerebral  abscess,  subcutaneous  or  pya^mic  abscess,  an  unopened  whitlow,  an  infected 
thrombosed  vein,  or  sujjpiu-ating  lymphatic  glands.  When  an  abscess  which  has  hitherto 
been  associated  with  leucocytosis  is  opened,  the  number  of  leucocytes  in  the  blood  falls 
quickly  to  normal  :  there  is  little  or  no  leucocytosis  in  conditions  in  which  pus  is  not  under 
pressure,  for  instance  in  cases  of  impetigo  and  other  forms  of  pyodermia,  superficial 
gangrene  of  the  skin,  sujipuration  connected  with  opened  hip-joint  disease  or  psoas  abscess, 
and  so  forth.  It  is  probably  on  this  account  that  fungating  endocarditis  often  produces 
a  slight,  but  hardly  ever  any  considerable,  leucocytosis  ;  the  same  applying  to  pyelitis, 
pyonephrosis,  and  pyelonephritis,  in  all  of  which,  if  there  is  free  drainage  through  the 
ureter,  leucocytosis  is  absent,  whilst  if  there  are  abscesses  in  the  kidney  substance  tlu 
leucocytosis  may  be  considerable.  Gangrene  of  the  lung  is  .mother  instance  of  the  .same 
kind,  for  there  may  be  extensive  gangrene  without  leucocytosis  if  there  is  free  expectoration  : 
whilst  if  the  gangrenous  tissue  is  prevented  from  escaping,  leucocytosis  may  result. 
Erysipelas  is  an  exception  to  the  rule  that  superficial  suppuration  does  not  produce  leuco- 
cytosis, for  here  consiilcrable  increase  in  the  leucocytes  is  common. 


LEUCOPENIA  361 

Anioiifrst  diseases  in  wliieh.  though  they  are  not  in  the  ordinary  sense  suppurative, 
kueoevtosis  is  the  rule,  arc  acute  meningitis  and  pneiiinoriia.  I'nfortunately,  all  forms  of 
acute  meningitis,  whether  tuberculous,  suppurative,  or  meningococcal,  lead  to  more  or 
less  leucocytosis,  so  that  this  ])oint  cannot  be  made  much  use  of  in  the  differential  diagnosis 
between  them  ;  but  upon  the  whole  the  greatest  leucocytosis,  up  to  40,000  or  more,  is 
to  be  expected  in  the  acute  cerebrospinal  form.  The  fact  that  pneumonia,  whether  of 
the  lobar  or  lobular  type,  produces  leucocji:osis  with  a  relative  increase  in  the  polymorpho- 
nuclear cells,  more  often  than  not  makes  it  impossible  to  rely  upon  this  point  in  determining 
whether  or  not  an  empyema  is  developing  after  the  lung  inflammation,  unless  it  is  known 
that  up  to  the  time  of  the  crisis  there  was  only  a  moderate  leucocytosis,  and  that  after  a 
continuance  of  the  fever,  or  a  recurrence  of  it  after  the  crisis,  there  is  a  greater  leucocytosis, 
with  a  still  further  rise  in  the  relative  percentage  of  polymorphonuclear  cells.  When 
there  lias  been  no  pneumonia,  and  when  the  physical  signs  are  such  as  to  suggest  fluid  in 
the  chest,  it  is  to  some  extent  helpful  to  know  that  acute  pleurisy,  with  effusion  of  the  type 
sometimes  spoken  of  as  "simple,"  shows  little  leucocytosis,  whereas  empyema  nearly 
always  produces  a  considerable  leucotytosis  of  the  polymorphonuclear  type. 

The  value  of  the  knowledge  that  there  is  leucocytosis,  when  a  given  case  has  been 
hitherto  regarded  as  one  of  some  disease  not  associated  with  leucoc\'tosis  is  obvious  (see 
Leixopenia  below)  :  thus,  tv-phoid  fever  may  have  been  diagnosed  in  a  case  of  obscure 
pjTcxia,  in  which  the  existence  of  ]}olymori)honiiclear  leucocytosis  indicates  that  the 
diagnosis  of  ty])hoid  fever  is  wTong,  and  that  there  is  really  deep-seated  suppuration,  such 
as  an  appendicular  abscess  or  a  pyosalpinx.  Another  similar  example  of  the  possible 
value  of  this  in  differential  diagnosis  is  in  distinguishing  malaria,  in  which  there  should  be 
no  leucocv-tosis,  from  hepatic  abscess,  in  which  leucocytosis  is  the  rule.  Herbert  Frencli. 

LEUCOPENIA  denotes  the  jjrescnce  of  a  smaller  iiuinhcr  of  leucocytes  ])er  c.nmi. 
nl  hliKid  thiui  normal.  When  there  are  less  than  .I. ()()()  leucocytes  per  c.mni.  one  may 
(•;'ll  the  condition  leucopenia.  There  are  a  large  number  of  affections  in  which  this  occurs, 
in  most  of  which  the  fact  is  of  little,  if  any,  diagnostic  importance.  It  may  result  from 
simple  stdrvdiinn.  cither  voluntary,  or  due  to  stenosis  of  the  (rsophagus  or  other  similar 
lesion.  It  is  the  rule  in  most  elirnnic  intoxications.  ])articularly  those  which  result  from 
pliiiiihism  or  jxiisoning  by  merciiri/.  arsenic,  ether,  alcoliol.  or  iiKnphiii.  It  is  to  1)C  found 
in  certain  of  the  scTcrc  ana'rnias.  more  particularly  pernicious  ana'tnia.  aplastic  anainia, 
and  some  cases  of  lipnplunieuonia.  jtarticularly  in  the  later  stages.  .Iciitc  niiliarij  tiitjercit- 
losis  is  often  associated  with  leucopenia.  and  so  also  is  tiil/ercahiis  peritonitis  in  more 
cases  than  not . 

The  ehicl'  dtagnnstie  iriiporlanec  oT  leucopenia  is  in  comicction  with  two  diseases  in 
particular,  namely.  Ii/plioiil  fcicr  and  malaria.  In  the  former  there  is  leucopenia  almost 
from  the  beginning,  and  eases  arc  not  few  in  which,  during  the  earlier  days  of  the  illness, 
before  \Vi<lars  reaction  could  be  positi\e,  typhoid  fe\cr  has  seemed  probable  until  the 
discovery  of  leucocytosis  instead  of  leucopenia  has  suggested  suppuration  rather  than 
t>-phoid,  the  ])us  being  discovered  subse(|ucntly  perhaps  in  the  pelvis  in  connection  with 
a  pyosalpinx.  or  in  an  appendicular  abscess  or  the  like.  The  dilTerential  leucoevte  count 
may  also  assist  in  the  same  direction,  for  the  leucopenia  of  typhoid  fever  is  associated  with 
a  relative  increase  of  the  smaller  lym|)hocytes  and  diminution  of  the  polymorphonuclear 
cells,  whilst  with  suppuration  the  reverse  is  the  ease.  l,cueoi)cnia  will  not  serve  to  <listin- 
guish  between  typhoid  fever  on  the  one  hand,  and  either  general  tuberculosis,  inllueu/.a, 
or  malaria  iipmi  the  other:  hut  granted  that  there  is  a  pyrexial  illness  suggestive  of 
lyplioici  li\(i.  the  (Mciirrciice  of  leucopenia  with  a  relative  increase  in  the  small  lymphocytes 
helps  consideralily  in  conlirming  the  diagnosis  days  before  the  Widal's  reai-lioii  would  he 
positiM-.  The  leucopenia  |)ersisls  unless  perforation  or  olhcr  ciiniplicatidn  leading  to 
pus  formation  supervenes. 

.Malaria  is  generally  associated  with  a  reihiction  of  the  total  riuinhrr  of  leueoeytcs 
p<  1  c.nuu.  down  to  perhaps  :«H)0,  2000.  <ir  e\<ii  less,  .\ssoeialcil  willi  this  Icueopenlii 
then-  is  relati\c  increase,  not  in  the  small  lymphocytes  as  in  ty|>hoid  fever,  but  iii  the  large 
hyaline  lymphocytes;  the  association  of  these  two  things  together,  in  a  jjatient  whose 
hislorx  points  to  the  possibility  of  malaria,  assists  considerably  in  eliiicliing  the  diagnosis, 
and   it    in:i\    lie  i\\  paiiicMJai-  \aliic  in  casis  in   which  i|uininc  has  been  adniinistered  so  that 


m->  LEUCOPENIA 

the  most  eoiiclusivc  proof  of  the  nature  of  the  eoni])liUiit.  namely,  the  discovery  of  the 
malarial  parasites  in  blood  films,  is  not  for  the  moment  possible.  One  difficulty,  which  is 
not  at  all  imcommon  in  the  tro])ics,  is  to  decide  between  malaria  on  the  one  hand  and 
abscess  of  the  liver  iijion  the  other.  Leiicopenia  and  a  relative  increase  in  the  large 
lymphocytes  strongly  favours  malaria,  whereas  an  abscess  would  cause  leucocytosis  and 
a  relative  increase  in  the  polymorphonuclear  cells.  Herbert  French. 

LEUCORRHflEA.— (See  Disch.vrge.  Vaginal,  p.  185.) 

LIMPING.     (See  Gait,  Abnormalities  of,  p.  251.) 

LIMPING  IN  CHILDREN.  (See  also  Gait,  Abnorjl\lities  of,  p.  251.) — Limping 
in  a  cliild  may  be  present  from  the  time  it  first  begins  to  walk,  or  it  may  develop  in  one 
who  has  previously  walked  normally.  In  either  case  it  may  be  due  to  pain,  to  defor- 
mity, to  some  form  of  paralysis,  or  to  any  two  or  to  all  three  of  these.  Apart  from 
absolutely  acute  affections,  such  as  suppurative  osteomyelitis  of  the  tibia,  the  one  condition 
that  it  is  most  important  to  diagnose  or  exclude  as  the  cause  is  tuberculous  disease  of  the 
hip-joint,  for  limping  may  be  the  earliest  and  only  sign  of  this  malady,  in  its  most  curable 
stage  if  ])roper  treatment  by  complete  and  prolonged  rest  is  adopted  forthwith.  The  next 
most  important  causes,  generally  recognized  with  greater  ease,  are  tuberculous  disease  of 
the  knee,  the  ankle,  or  the  tarsus.  Most  other  lesions  need  little  discussion,  for  their  nature 
is  generally  obvious  fi'oin  the  history  or  upon  careful  examination  of  the  leg  and  foot. 

Any  ])ainful  or  deforming  affection  of  the  lower  limb,  from  toes  to  spine,  may  lead  to 
limping,  and  one  may  emimerate  the  following  : — 


1 .  Causes  affecting  tbe  Foot  or  Ankle,  and  associated  with  Pain  in  tlie  Foot  :- 


lll-fittiufj    ))oot 

are  too  short 
Chilblains 
Corns 

Whitlow  of  ii  toi' 
Blister 

Abrasion  of  the  skin 
Injury    by    a    crush 

fracture,  etc. 
Foreign  body,  such 
Rubbed  heel 


csj)ecin 


those    whieli 


m  any  part  of  the  foot 
blow,    kick,    sprain, 


IS  a  thorn  or  a  needle 


Inthuumation    of    the    bursa    beneath   the 

tendo-.\chillis 
Tuberculous  dactylitis 
Tuberculous  disease  of  the  tarsus 
Tuberculous  disease  of  the  ankle 
Hheuniatic  '  growing  pains  ' 
.Still's  disease  (p.  378) 

.Suppurative  arthritis  in  the  ankle  or  foot 
I'eliosi>:  rheuniatica    i   with  ha-morrhage  into 
Henoch's  i)ur])ura       i       tlic  ankle 
Ilaniopliilia. 


Causes  affecting  tlie  Foot  or  Ankle,  and  associated  with  Deformity  rather  than 
with  Pain  : — 


Talipes  varus 
Talipes  valgus 
Talipes  equinus 


Talipes  calcaneus 
Talipes  equinovarus 
Talipes  ealcaneo-valgus 


Hammer  toe 
Flat  foot. 


3.  Causes  affecting  the  Calf : — 

Bruising 

Infantile    paralysis,   with   atrophy    of   the 

calf  muscles 
Peripheral  neuritis  (e.g.,  post-diphtheritic) 
Muscular     dystrophy,     especially     Tooth's 

peroneal  t,ype  (p.  60) 
Chronic   periostitis   of   the  tibia   or  fibula  : 

(a)  traumatic,   [b)  tuberculous,  (c)  svph- 

ilitic 


(Jreenstick  fracture  of  tibia  or  fibii 

Sarcoma  of  the  tibia 

Sarcoma  of  the  fibula 

Osteomyelitis  of  the  tibia  or  libula 

Epiphysitis  of  the  tibia  or  libula 

Ervthema  nodosum 

Rickets 

Phlebitis  and  thrombosis  of  veins. 


4.  Causes  affecting  the  Knee-joint : — 

Traumatic  syno\  itis 
T>oose  cartilage 
Tuberculous  knee-joint 

t'ongenital   syphilitic  disease   of  the   knee- 
joint 
Rheiuiiatic  fever 


Still's  disease  (p.  378). 

Foreign  body,  such  as  a  needle,  pin,  or  thorn 

Suppurative  arthritis  in  patellar  region 

Peliosis  rheuniatica 

Henoch's  ]>ur]Hira   i   with  luemorrhage  into 

Hsemophilia  i       the  joint. 


LI.Ml'IXG     IN  .  CHILDREN  3( 

5.  Causes  affecting  the  Thigh  : — 

Bruising  Osteomyelitis  of  the' femur 

Infantile  paralysis  Epiphysitis  of  the  femur 

Chronic  periostitis  of  the  femur  :  (n)  trau-  Rickets 

matic,  (b)  tuberculous,  (c)  syphilitic  Tuberculous  disease  of  the  bursa  beneath 
Greenstick  fracture  of  the  femur  the  tendon  of  the  gluteus  niaximus. 

Sarcoma  of  the  fenuir 

6.  Causes  affecting  the  Hip-joint  Region  or  Groin  : — 

Tuberculous  disease  of  the  hip-joint  Inguinal  hernia 

Traumatic  synovitis  of  the  hip-joint  I      Femora!  hernia 

Congenital  sv-philitic  disease  of  the  hip- 
joint 

Dislocation  of  the  hip  :  (a)  congenital, 
(h)  from  injury 

Inflamed  glands  in  the  groin 


Hftaiiicd  testicle 

I'snas  abscess 

I'clidsis  I'lieumatica 

Henoch's  purpiira   I   with   ha;niorrhagc  into 

Hfemophilia  )       Hie  joint. 


7.  Causes  affecting  the  Pelvis  or  the  Lower  Part  of  the  Spine : — 

Injury  :       Sacro-iliac  joint  disease 

Tuberculous  caries  |       Acute  osteomyelitis  of  the  ilium. 

Many  of  the  above  conditions  need  no  detailed  discussion  :  the  diagnosis  may  be  clear 
from  the  locality  of  the  pain,  the  transient  nature  of  the  limj),  or  the  existence  of  visible 
inflammation  or  swelling.  Doubts  are  likely  to  exist  in  connection  with  the  earlier  stages 
of  tuberculous  disease  of  the  digits,  tarsus,  ankle,  or  knee,  and  it  may  not  be  until  persist- 
ence of  the  painful  limping  points  to  the  lesion  Ijeing  other  than  simple,  that  the  real  nature 
of  the  ea.se  forces  itself  upon  one"s  mind.  Examination  with  the  .r-rays  niay  help  materi- 
ally, and  the  same  applies  to  other  affections  of  the  bones — periostitis,  greenstick  fracture, 
new  growth.  Treatment  by  rest  will  be  enjoined  pending  diagnosis  ;  the  latter  may  not 
become  clear  until  the  ca.se  has  been  watched  and  the  course  of  the  .symptoms  followed. 
Growing  pains  may  be  relieved  by  salicylates  ;  they  are  nearly  always  to  be  regarded  as 
acute  rheumatic,  and  a  careful  watch  will  be  ke])t  upon  the  heart  lest  the  child  be  allowed 
to  be  up  and  about  with  acute  endocarditis  alter  the  pains  have  been  relieved  by  the 
.salicylates. 

It  is  in  connection  with  the  hip  region  that  the  diagnosis  of  the  cause  of  the  pain  that 
leads  to  limping  is  so  (lillicult.  especially  when  the  child  complains  that  it  is  the  knee  which 
hurts,  though  the  disease  is  really  in  the  hip — an  example  of  referred  pain  due  to  the 
obturator  nerve  which  supplies  the  hi]),  sending  a  small  geniculate  branch  to  the  knee. 
The  hip-joint  is  embedded  so  dec|)ly  in  muscles  that  it  is  often  dillicult  to  make  out  any 
local  swelling,  such  as  is  generally  distinctive  of  similar  [julpy  disease  of  the  knee  or  ankle. 
Kvcn  ,r-ray  examination  may  fail  to  give  clear  evidence  of  disease  when  the  latter  is  in  an 
early  stage.  Ihougli  skilled  radiologists  may  detect  rardaction  of  the  Irabecula'  in  the  head 
of  the  femur  on  comparison  of  th<-  two  sides,  long  before  there  is  bony  destruction  to  cause 
any  dill'ercncc  in  contour.  When,  however,  the  patient  complains  of  ijcrsistent  pain  in 
the  hip-joint  region,  less  severe  some  days  than  others  perhaps,  yet  not  disappearing  as  the 
days  go  by  :  when  this  pain  makes  him  walk  with  a  limj).  or  wake  with  a  start  and  cry  out 
at  night  :  if  there  are  no  jjains  elsewhere  in  the  body,  and  if  there  is  sonu-  irregular  though 
|)ossil)ly  only  slight  pyrexia  :  tuberculous  disease  of  the  hip-joint  would  be  suspected  even 
if  the  child  looked  well,  and  still  more  so  if  he  looked  delicate  and  had  not  a  robust  ap])etite. 
The  suspicion  would  be  rendered  almost  a  certainty  if,  on  getting  the  child  to  stand 
stripped,  in  a  good  light,  one  found  dclinite  asymmetry  of  the  buttocks,  that  of  the  painful 
side  being  flabbier  or  obviously  stnaller  than  the  other  :  the  natal  fold  beneath  it  running 
at  the  same  linu'  obli(|uely  downwards  and  oulwards.  instead  of  nearly  horizontally,  as  it 
should  noriiiall\  :  it  is  always  the  nius<les  inunedialely  above  an  alfeetcd  joint  that  waste 
lirsl  the  Ihigli  muscles  when  the  kiu-c-joinl  is  diseased,  the  glutei  in  the  case  of  the  hip- 
jciiiil,  .'iiid  so  on.  II  may  also  be  noticed  lh:d  llic  patient  holds  the  whole  limb  on  the 
paiiilul  side  in  an  abiiormal  attitude  -  sliglill\  abdncled  an<l  outwardly  rotated  in  the  very 
earliest  stages,  so  thai  Ihcrc  is  apparent  (but  not  actual)  lengthening:  adducled  and 
inwardly  rotated  in  most   cases,  with  apparcMl   sliDrlcning.      Mensuration  is  of  little  assist- 


864  LBIPING     IN     CHILDREN 

aiicc  ill  arrivino-  at  a  diagnosis,  because  it  is  only  at  a  much  later  stage  after  considerable 
bony  destruction  has  taken  place,  that  there  is  real  shortenin"-.  and  tlic  diiionosis  will  have 
been  made  long  before  this  has  occurred.  On  attempting  to  move  tlie  various  joints  of  the 
legs  when  the  patient  is  lying  flat  upon  his  back,  those  of  the  sound  limb  will  show  no 
limitation  of  movement  ;  on  the  affected  side  the  child  will  allow  one  to  move  the  ankle 
and  the  knee  freely  if  care  is  taken  not  to  jar  the  hip,  but  when  one  tries  to  move  the  hip 
itself,  muscular  contractions  will  resist  attempts  at  passive  flexion,  extension,  or  rotation, 
or  the  child  will  cry  out  so  that  one  desists  from  trying.  If  one  flexes  both  thighs  slightly 
on  the  trunk,  so  as  to  allow  the  spine  and  pelvis  to  lie  flat  along  a  firm  mattress,  one  finds 
that  the  sound  limb  can  be  extended  until  it  also  lies  flat  along  the  bed  without  altering 
the  position  of  the  pelvis  or  spine  :  but  if  one  now  presses  the  affected  limb  gently  down 
to  straighten  it  similarly  on  the  bed,  a  hand  held  beneath  the  child's  lumbar  vertebrie 
detects  the  fact  that  as  the  thigh  of  the  affected  side  gets  straighter  the  lumbar  vertebrre 
begin  to  arch  ;  this  is  owing  to  muscular  rigidity  preventing  free  play  at  the  acetabulum, 
so  that  instead  of  tlic  head  of  the  femur  rotating  as  it  should,  without  moving  the  pelvis, 
the  pelvis  moves  with  the  thigh,  and  arching  of  the  back  results.  If  attention  is  paid  to  all 
these  points,  it  is  generally  possible  to  detect  tuberculous  hip-joint  disease  at  a  compara- 
ti\ely  early  date,  though  in  some  eases  one  may  fear  it  without  being  able  to  diagnose  or 
exclude  it  definitely, 

Sacro-iliac  joint  disensc  may  simulate  hip-joint  disease  at  first  sight,  but  on  careful 
examination  it  will  be  foimd  that  all  movements  at  the  hi]i-joint  can  be  made  painlessly 
if  the  sacro-iliac  joint  is  not  jarred  ;  whereas  the  least  jarring  to  the  sides  of  the  pelvis  may 
be  acutely  painful.  It  is  generally  possible  to  locate  l)oth  pain  and  tenderness  clearly  to 
the  sacro-iliac  joint  region  posteriorly,  and  thus  arrive  at  the  diagnosis. 

Psoas  abscess  secondary  to  tuberculous  caries  of  the  spine  may  also  simulate  hip- 
joint  disease  closely,  for  owing  to  the  extension  of  the  caseous  abscess  in  the  jjsoas  muscle 
downwards  over  the  front  of  the  hip-joint,  in  the  direction  of  the  lesser  trochanter  of  the 
femur,  movements  at  the  hip-joint  may  be  very  i)ainful — especially  those  of  extension, 
'riie  patient  is  apt  to  keep  the  thigh  flexed,  and  inwardly  or  outwardly  rotated  according 
to  the  direction  in  which  the  psoas  abscess  is  burrowing.  One  would  look  for  fullness  of 
the  deeper  structures  of  the  groin,  or  a  definite  swelling  here  ;  actual  fluctuation  obtain- 
able from  above  to  below  Pouparfs  ligament  is  to  be  expected  theoretically,  but  in  practice 
it  is  very  seldom  obtainable.  The  main  thing  to  look  for  in  verifying  the  diagnosis  is 
evidence  of  disease  of  the  dorsal  or  hmibar  vertebra-.  If  there  is  Potfs  angular  curvature 
of  the  spine,  the  diagnosis  is  obvious  :  often,  however,  the  disease  is  confined  to  the  anterior 
aspects  of  the  bodies  of  the  vertebrae,  and  no  bony  deformity  is  visible  in  the  back  ;  one 
would  then  look  specially  for  rigidity  of  the  back,  local  pain  or  tenderness  on  gentle  percus- 
sion of  successive  spines,  or  deficient  mobility  of  the  dorso-lumbar  region  of  the  vertebral 
column  when  the  patient  atteni])ts  to  bend  forward,  or  turns  from  side  to  side.  The  .r-rays 
are  sometimes  valuable  in  detecting  the  disease  (Fig.  195,  ]).  460)  ;  Ijut  on  the  other  hand, 
absence  of  .r-ray  evidence  of  caries  does  not  exclude  it. 

liichcts  sometimes  gives  rise  to  considerable  difficulty  on  account  of  the  ill-delined 
but  often  severe  pains  in  the  bones  the  patient  suffers.  The  child  is  generally  quite  young 
— two  or  three  years  old — when  these  rickety  pains  are  worst,  and  therefore  cannot  give 
a  personal  aecoimt  of  where  they  are.  The  bones  may  be  variously  deformed,  the  patient 
may  be  unable  to  walk  properly,  and  one  may  have  grave  doubts  as  to  whether  there  is 
not  tuberculous  disease  of  the  spine,  sacro-iliac  joint,  hip-joint,  knee,  or  ankle,  as  well  as 
rickets.  Repeated  examinations  will  be  made,  and  yet  the  doubts  may  remain.  One 
would,  however,  adopt  treatment  by  reeimibent  rest  and  good  hygiene  in  matters  of 
food,  air,  and  cleanliness  in  either  case,  and  it  is  better  to  ])rolong  the  period  of  rest 
lest  there  is  tuberculous  mischief,  than  to  curtail  it  on  tlie  presimiption  that  the  lesion  is 
rickets  only. 

When  pain  causing  limping  in  a  child  is  confined  to  a  single  joint,  such  as  the  hip  or 
knee,  it  is  a  safe  rule  to  say  that  it  is  never  rheumatic  ;  neglect  of  this  rule  has  led  to  the 
ruin  of  many  a  joint. 

I.,ong  though  the  list  above  is,  the  remaining  conditions  given  in  it  do  not  call  for 
<lctailed  discussion.  Tiiey  will  be  diagnosed  from  other  symptoms  presented  by  the  case 
besides  limping.  Herbert  French. 


LIPS.     AFFFA'TIONS    OK    THE    RED    PART    OF    THE  365 

LINEj^}  ALBICANTES,  sometimes  termed  liiieie  ati()|)hic;e,  consist  of  areas  of  skin 
many  times  longer  tlian  broad,  somewhat  shiny,  and  bhiisli-white,  produced  by  atrophy 
of  portions  of  the  true  corium. 

There  is  no  disease  that  really  resembles  them,  and  indeed  no  other  condition  of  the 
skin  with  which  they  can  be  confounded  when  once  they  have  been  pointed  out.  Morphoea 
and  leucodermia  are  the  only  possible  exceptions,  and  these  only  under  the  rarest 
circumstances,  for  the  patches  of  these  affections  are  not  linear,  do  not  shine,  and  do  not 
show  those  small  cross  wrinkles  of  epidermis  at  right  angles  to  the  axis  of  a  linea  so  charac- 
teristic of  linea?  albicantes  :  these  wrinkles  can  be  smoothed  away  by  stretching  the  skin 
in  a  direction  parallel  to  the  linea,  but  they  retinn  at  once  on  relaxing  the  tension. 

The  usual  meaning  of  these  lineic  is  that  the  skin  has  been  unduly  stretched  over 
some  fairly  long  period  of  time  ;  but  they  give  not  the  slightest  indication  as  to  the  cause 
of  the  stretching  ;  this  caution  is  very  necessary,  because  when  these  lineae  are  foimd  on  a 
woman's  abdomen  or  breasts,  it  is  connnonly  assumed  that  they  constitute  evidence  oT 
a  i)ast  pregnancy  :  it  is  perfectly  true  that  this  is  the  conunonest  origin  :  but  anv  other 
cause  of  swelling,  such  as  tumour,  ascites,  and  even  fat  and  (vdema.  etc..  will  produce  them 
by  stretching  the  skin. 

They  are  also  apt  to  ai)]>ear  over  the  shoulders  or  in  front  of  the  knees,  or  on  the  flanks, 
thighs,  or  buttocks,  without  it  being  ])ossible  to  draw  any  conclusion  as  to  their  causation 
or  signiflcance.  Preil.  J.  .S»u7/(. 

LIPS,  AFFECTIONS  OF  THE  RED  PART  OF  THE.— The  simplest  affection 
to  which  the  vtrniiliiiii  ol  tlie  lips  is  liable  is  tliat  known  as  •  chapping,"  a  condition 
frecjuently  due  to  exposure  to  keen  winds,  and  sometimes  aggravated  by  the  habit  of 
'  picking.'  In  some  cases  the  Assuring  is  sufliciently  deep  to  cause  appreciable  pain 
and  great  disfigurement. 

Tlie  xcrmilion  of  the  lips  may  be  involved  also  in  a  number  of  cutaneous  diseases, 
among  them  liiptis  vulgaris,  lupus  erythematosus,  lichen  planus,  herpes  febriiis  and  zoster, 
tinea  cireinata,  urticaria,  psoriasis,  and  some  forms  of  syphilis.  The  lesions  of  the 
epitheliinn  of  the  lips,  as  of  mucous  membranes  in  general,  are  seldom  characteristic 
enough  to  warrant  a  confident  diagnosis  ;  in  none  of  the  above  affections  is  the  red  of  the 
li])s  alone  alfeeted,  and  guidance  as  to  the  diagnosis  will  be  found  in  the  more  distinctive 
lesions  of  the  skin. 

Ordinary  eczema  is  sometimes  limited  to  the  lips  and  immediately  adjacent  parts. 
Associated  with  a  slightly  seborrhciMc  condition  of  the  scalp,  there  is  sometimes  a  ])ersistent 
and  repeated  exfoliation  of  the  vermilion  of  the  lips  (cheilitis  exfoliativa).  In  a  somewhat 
similar  yet  not  identical  case,  the  lijjs  as  a  whole  were  covered  with  a  thick  accunuilation 
of  scales,  which  caused  them  to  protrude.  \Vhen  the  scales  were  removed  the  lips  were 
blue  instead  of  red.  The  jjaticnt  complained  of  some  burning  pain,  but  ehielly  of  a  feeling 
of  <Iea(ltiess  in  the  lips.  The  condition  Iwid  i)crsisted  for  elexcii  years,  and  appeared  to 
li;i\c  hccii  set  up  by  a  lKil)il  of  biting  the  lips  :mi(I  Icaring  off  the  skin.  The  subjects  of 
(■iHJIilis  cxfoiiMliNa  arc  usually  neurotic,  and  in  lliis  case  Ihiic  was  some  tendency  to  that 
((in<liti()n,  but  there  was  no  associated  seborrhua.  In  cheilitis  gluudularis  there  may  be 
TKilhcr  seborrho'a  nor  neurosis:  the  chronic  inllanMnalion  of  the  lower  li]),  with  swelling 
of  Ihe  mucous  glands,  a|)pcars  to  originate  in  catarrh  of  flu-  mouth  and  pharynx.  It  is 
chiclly  the  vermilion  that  is  affected,  but  the  inllammation  spreads  to  the  inside  ot  the 
lip,  and  sometimes  also  to  thc>  neighbouring  skin,  which  presents  an  erythematous  aspect. 
Tlie  conditions  here  described  arc  idl  rare,  and  arc  not  likely  I"  he  confMscd  wilh  more 
ordinary  affections  of  the  labial  epitheliiini. 

In  syjihilis  the  red  of  the  lips  is  somelinies  tlu'  seal  of  the  primary  sore  (see  /•'/;,',  -j;!. 
p.  T;!).  and  in  the  secondary  stage  condylomata  may  occur  in  tliis  situation.  The  clianere 
ni:iy  be  llallisli  and  eo\cred  witli  :i  false  membrane,  or  it  may  present  itself  as  a.  craleriforni 
iiilillraleil    Ml<'rr. 

In  </iilhilii,uiii  Ihe  lip  M-,nally  Ihe  lower  one  is  frc(|ninlly  I  li<-  poinl  of  alt:ick,  llie 
growth  iH'ginning  as  a  slight  abrasion,  eraeU.  or  papule,  :in(l  iimniiiL;  I  lie  usual  course. 
(See  under  Ti  \ioi  us  oi'    iii!;   Skin.  p.  TliO.) 

l-'ardycr's  iliscasc  speciallx'  alhu'ks  the  red  (jf  Ihe  lips  ^ind  Ihe  oial  iriue(jns  membrane, 
the    lesions    eonsislinir    i,r    small    uliili-.li    o|-    \ill(.\\lsli     niiliiMM-like    bodies,    wliieli    in;i\     be 


:J66  LIPS.     AFFECTIONS    OF    THE    RED     PART    OF    THE 

discrete  or  coalescent,  profuse  or  scanty.  Inside  the  mouth  the  miUum-hke  bodies  are 
whiter  than  those  on  the  lip,  and  are  also  more  projecting.  If  subjective  symptoms  are 
present,  they  take  the  form  of  slight  burning  and  itching,  with  a  feeling  of  stiffness.  The 
signs  can  hardly  be  confoinided  with  those  of  any  otiier  affection.  When  the  lesions  are 
very  abundant,  they  may  simulate  a  solid  patch  ;  Init  if  the  tissues  are  stretched,  the 
milium-like  bodies  can  be  distinguished. 

Perleche  is  a  contagious  affection  almost  peculiar  to  children,  and  due  probably  to 
streptococci.  It  usually  starts  at  both  angles  of  the  lips,  as  a  whitening  and  maceration 
of  the  epithelium,  which  is  easily  detached  ;  it  extends  along  the  epithelium  towards  the 
middle  line,  involving  also  the  surrounding  skin  and  the  mucosa  of  the  inside  of  the  lips. 
There  are  usually  some  hyperirmia  and  inflammation,  and  the  feeling  of  heat  and  discomfort 
prompts  the  child  constantly  to  lick  its  lips — hence  perleche.  The  affection  often  appears 
in  association  with  impetigo  contagiosa,  or  impetiginous  stomatitis,  or  vesicular  erythema. 
In  some  cases  it  can  only  be  discriminated  from  the  mucous  patches  of  syphilis  by  the 
absence  of  other  secondary  signs.  From  herpes  it  can  be  diagnosed  by  its  symmetry  and 
its  not  beginning  as  a  vesicular  eruption.  Malcolm   Morris. 

LIPURIA.     (See  Chyi.uria.  \).  108.) 

LIVER  DULLNESS,  DEFICIENT.— The  most  common  cause  for  diminution  of  the 
iiepatic  dulhuss  is  tniphysiTua.  The  chest  is  barrel-shaped,  the  lower  ribs  are  everted, 
and  tlie  diminution  of  the  dullness  is  at  its  upper  part.  The  dullness  is  diniinislied  from 
above  df)vvnwards  in  cases  of  tight  lacing,  which  forces  the  liver  down,  and  in  eases  of  liepato- 
ptosis.  but  in  tiiese  two  instances  the  hepatic  dullness  descends  lower  than  is  normal,  so 
that  the  total  liver  dullness  is  often  natural.  The  hepatic  dullness  is  diminished  very  con- 
siderably and  rapidly  in  acute  yelloxv  atrophij  :  the  signs  of  this  disease  are  so  striking  that 
tlie  diagnosis  is  not  as  a  rule  difficult  (p.  333).  It  slowly  diminishes  when  the  liver  shrinks 
in  the  terminal  stage  of  cirrhosis.  It  is  often  said  that  in  perforative  peritonitis  the  presence 
of  free  gas  in  the  peritoneal  cavity  leads  to  a  diminution  of  the  hepatic  dullness  ;  this  is 
undoubtedly  true  sometimes,  but  the  sign  is  so  often  absent  that,  considering  there  are 
other  causes  of  diminution  of  hepatic  dullness,  it  is  unwise  to  lay  much  stress  on  its  presence 
or  absence  in  coming  to  a  diagnosis  of  perforative  peritonitis.  Considerable  gaseous  disteii- 
tion  of  the  boivels  will  also  cause  diminution  of  the  hepatic  didlness,  and  so  will  a  pneumo- 
thora.r  on  the  right  side.  W.  Hale  White. 

LIVER,  ENLARGEMENTS  OF  THE.— In  adults  the  liver  is  about  .l,  but  at  birth 
it  is  ,Jj  to  -jL  of  the  weight  of  the  whole  body  :  therefore  in  infants  and  young  children  it.  is 
relatively  larger  than  in  adtdts.  I'uless  this  is  remeudjered  the  liver  may  in  such  patients 
be  thought  enlarged  when  really  it  is  of  normal  size.  On  deep  inspiration,  in  thin  people 
whose  abdominal  muscles  are  lax,  the  lower  edge  of  the  normal  liver  can,  in  the  supine 
position,  be  felt  to  descend  to  touch  the  fingers  if  they  are  thrust  up  imder  the  ribs  outside 
the  right  rectus.  In  tlie  upright  position  it  may  descend  half  an  incli  lower  than  this.  In 
the  epigastric  angle  a  small  portion  of  the  anterior  surface  of  tlie  left  lobe  is  in  contact  with 
the  anterior  abdominal  wall,  but  often  this  cannot  be  felt  owing  to  rigidity  of  tlie  recti 
abdominales  muscles. 

The  hepatic  dullness  to  the  left  of  the  sternum  cannot  be  distinguished  from  that  due 
to  the  heart  :  on  the  right,  it  begins  at  the  middle  of  the  eiisiform  process  of  the  sternum, 
in  the  right  nipple  line  it  reaches  the  upper  part  of  the  fifth  intercostal  space,  in  the  mid- 
axillary  line  the  seventh,  in  the  line  of  the  angle  of  the  scapula  the  ninth.  In  health  the  edge 
of  the  liver  is  firm  and  uniform,  and  the  surface  feels  smooth.  In  excessively  rare  instances 
the  whole  organ  is  lobulated.  This  is  probably  not,  as  has  been  sujiposed,  a  developmental 
abnormality,  but  represents  past  disease,  possibly  intra-uterine.  If  the  liver  is  transposed, 
the  right  lobe  is  small  and  the  left  large.  Occasionally  either  lobe  is  dwarfed  by  disease, 
e.g.,  alcohol  or  syphilis.  A  tongue-like  projection  of  the  right  lobe  may  protrude  from  its 
lower  right-hand  part.  This  projection,  known  as  Riedel's  lobe,  is  often  associated  with 
disease  of  the  gall-bladder  such  as  gall-stones,  or  with  tight  lacing,  and  is  commoner  in 
women  than  in  men,  but  as  it  may  be  found  in  quite  young  children  it  must  be  regarded  as 
sometimes  an  anatomical  abnormality.     A  Riedel's  lobe  may  give  rise  to  great  difficulties 


LIVER.     ENLARGEMENTS    OF    THE  367 

of  diagnosis  :  if  the  connection  between  it  and  the  liver  is  only  peritoneum,  it  may  be  mis- 
taken for  a  floating  kidney,  especially  as  in  such  a  case  there  may  be  a  band  of  resonance 
between  it  and  the  liver  :  or  the  lobe  may  be  confused  with  any  tumour  that  may  be  found 
on  the  right  side  of  the  abdomen.  When  palpating  the  abdomen  it  is  often  very  difficult  to 
tell  the  right-hand  lower  i)art  of  the  liver  from  the  kidney,  even  when  there  is  no  projection 
which  can  be  called  a  Riedel's  lobe. 

Many  conditions  quite  unconnected  with  the  liver  cause  an  apparent  alteration  in  its 
size.  Thus,  a  general  weakness  of  the  tissues  may  lead  to  its  dropping  downwards  in  the 
erect  posture  from  laxness  of  its  supports,  which  are  chieHy  its  ligaments,  and  t(3  a  less 
extent  the  abdominal  walls.  I  have  known  this  occur  in  wasting  diseases,  the  fact  that  the 
liver  was  not  enlarged  ha\ing  been  e\ident  on  post-mortem  examination  ;  indeed,  in  such 
a  case  I  have  known  the  dropped  liver  to  be  regarded  as  enlarged  from  cancer,  which  was 
believed  to  be  the  cause  of  the  wasting,  when  in  reality  the  patient  was  wasted  because  he 
had  dialietes.  Again,  if  the  liver  is  somewhat  enlarged  from  disease,  its  extra  weight  may 
cause  it  to  drop,  and  hence  it  apjjcars  larger  than  it  really  is.  Thus  it  is  not  uncommon  for 
a  nutmeg  liver  to  appear  during  life  lari>er  than  it  is  :  but  that  it  is  not  may  be  proved  by 
noticing  that  percussion  shows  the  upper  line  (jf  he])atic  dullness  to  have  descended. 

.\lterations  in  the  chest  may  lead  to  depression  of  the  liver,  which  may  then  be  thought 
erroneously  to  be  enlarged.  Thus,  in  an  extreme  case  of  fibrosis  of  the  lungs  with  adherent 
pleura  I  have  seen  the  sui'king  in  of  the  ribs  on  inspiration  lead  to  depression  of  the  liver 
down  to  the  umbilicus  :  the  right  lobe  may  be  depressed  into  the  right  loin  by  compression 
of  the  chest  due  to  tight  lacing,  this  being  often  associated  with  a  movable  right  kidney. 
Deformities  of  the  chest  due  to  rickets  or  curvature  of  the  spine  may  lead  to  great  depression 
of  the  liver.  It  may  be  depressed  by  large  collections  of  fluid  in  the  right  side  of  the  chest, 
but  they  must  be  quite  large,  for  the  fluid  will  more  easily  compress  the  lungs  and  push  the 
heart  to  the  left  than  depress  the  diaphragm.  It  may  also  be  depressed  by  a  right-sided 
])ncumothorax.  If  in  diaphragmatic  pleurisy  the  diaphragm  is  not  working,  and  is  in  a 
more  or  less  constant  (xisitiou  of  inspiration,  the  liver  is  also  constantly  in  this  position, 
and  hence  seems  to  be  a  little  depressed.  Extreme  pericardial  effusion  is  said  to  depress 
the  liver,  but  this  must  be  very  rare.  It  is  often  stated  that  a  subdiaphragmatic  abscess 
will  dejircss  the  liver  considerably  ;  but  this  also  is  very  rare,  for  the  niunerous  adhesions 
in  conned  ion  with  such  an  abscess  generally  prevent  depression  of  the  liver. 

Tight  lacing  may  cause  a  deep  furrow  on  the  liver  palpable  during  life.  I  have  known 
NO  deep  a  furrow  caused  by  a  man's  belt  that  the  part  of  the  liver  below  the  furrow  felt 
almost  separated  from  the  rest  of  the  organ  ;  in  such  a  case  there  may  be  a  false  impression 
of  enlargement.  The  <  Ifeet  of  corsets  or  other  artificial  pressure  is  often  such  as  to  give  an 
incorrect  impression  of  enlargement,  because  the  organ  is  pressed  down  ;  most  commonly 
the  liver  is  forced  down.  Ilattened,  and  elongated  from  above  downwards.  Such  a  pressure 
often  leads  to  a  transverse  depression  across  the  right-hand  lower  part  of  the  right  lobe,  so 
that  a  more  or  less  detached  portion  of  it  lies  in  the  position  of  a  Riedt  Ts  lobe. 

It  is  ((uite  rare  lor  enlargement  of  the  liver  to  lead  to  any  uj)war(l  extension  of  tiie 
hepatic  dullness.  This  is  what  might  be  expected,  for  the  mere  weight  of  the  enlarged  liver 
will  lead  to  its  falling,  and  the  resistance  of  the  ititestines  and  abdominal  walls  being  nuicli 
less  than  that  of  the  diaphragm,  it  will  therefore  grow  in  the  direction  of  least  resistance, 
that  is,  downwards.  Uaising  of  the  ypper  limit  of  hepatic  didlness  is  best  observed  when 
some  local  disease  of  the  liver  directly  im])lieates  the  diajihragTu  :  thus,  a  tropical  abscess 
of  the  li\(r  growing  from  its  upper  surface  will  soften  the  diaphragm  and  cstcnd  upwards  ; 
a  hy(lati<l  will  do  the  same.  So,  when  there  is  an  extension  upwards  of  llic  upper  hepatic 
dullness,  it  is  a,  local  extension  forming  a  dome-shaped  addition  lo  the  hepatic  dullness. 
\(i y  large  collections  of  ascitic  fluid  or  very  large  abdominal  tuinouis  in:iv  push  the  liver 
up.  hut  this  is  cxecssi\-cly  rare,  for  such  conditions  will  mori'  readily  compress  the  intestines 
and  bulge  the  abdominal  walls.  .\  suhdiaphrauinal  ic  absciss,  by  its  extension  of  dullness 
up  into  the  chest,  may  appear  to  e.\tend  the  li\(r  (luliiiess  upwards. 

There  are  three  moderately  common  tumours  in  I  he  alxlomen  which  may  give  a  false 
impression  of  increase  in  the  size  of  the  li\er.  They  ar<'  :  .(  stitiiimh  rijfcclcil  tcilli  iniiliffiidiit 
(lisvaac.  especially  when  the  growth  infiltrates  much  of  the  greater  curvature  ;  iiiiilifiiiiiiil 
<//.S(Y/.sr  ((/'or  hiiiinrtion  oj  [tvcrs  in  the  Irtinnrrrsr  cdIoii  :  and  the  great  omentum  thickened 
and  puckered  tip  towMrds  the  transNcrsc  ciilon  by  scitiic  form  itf  i-liroiiii-  iiriilonilis.      Any  ot 


368  LIVER,     ENLARGEMENTS     OF    THE 

these  tiimoiiis  may  move  up  and  down  with  respiration,  for  they  are  all  directly  or  indirectly 
attached  to  the  liver  ;  but  the  movement  is  not  usually  so  extensive  as  that  of  the  liver 
should  be,  and  a  band  of  resonance  may  sometimes  be  detected  between  the  li\'er  and  tlie 
tumour,  or  the  ed<;e  of  the  liver  may  be  felt  above  it.  Enlargements  of  the  pylorus,  and 
thickening  in  connection  with  a  gastric  or  duodenal  ulcer,  may  all  be  difficult  to  distinguish 
from  an  enlarged  gall-bladder.  The  hepatic  dullness  may  be  altered  by  gas,  and  it  may  be 
almost  obliterated  by  the  descent  of  an  emphysematous  lung  ;  slight  lowering  of  the  upper 
margin  of  the  hepatic  dullness  from  this  cause  is  quite  common.  In  emphysema,  too,  the 
lower  ribs  stand  so  far  forward  that  it  may  be  impossible  to  feel  the  lower  edge  of  the  liver. 
AVhen,  as  in  perforative  peritonitis,  there  is  free  gas  in  the  peritoneal  cavity,  the  gas  getting 
in  front  of  the  liver  may  diminish  the  hepatic  dullness,  but  this  sign  is  so  often  absent  that 
its  absence  must  not  be  used  as  an  argument  against  the  existence  of  ])erforative  peritonitis. 
On  the  other  hand,  ])artial  obliteration  of  the  hepatic  dullness  may  be  due  to  the  fact  that 
some  of  the  intestine  is  between  the  liver  and  the  anterior  abdominal  wall,  or  that  there  is 
much  gaseous  distention  of  the  colon  behind  the  liver.  A  large  collection  of  ascitic  fluid 
often  renders  it  difficult  to  estimate  the  size  of  the  liver. 

Ilepatopfosis,  and  wandering  liver,  are  terms  applied  to  a  liver  which,  being  imdidy 
displaceable,  leaves  its  normal  position.  It  is  rare,  but  nnist  be  borne  in  mind,  for  if  not  a 
liver  which  is  only  displaced  may  erroneously  be  thought  to  be  enlarged.  Extreme  degrees 
are  met  with  in  cases  of  general  visceroptosis.  It  is  commoner  in  women  than  men,  and 
mostly  after  forty.  The  abdominal  walls  are  usually  pendulous,  and  as  the  abdominal 
muscles  are  powerfid  agents  for  keeping  the  abdominal  viscera  in  place,  this  weakness, 
combined  with  a  laxity  of  the  hepatic  ligaments,  is  probably  the  cause  of  the  hepatoptosis. 
Tight  lacing  leads  to  weakness  of  the  abdominal  muscles,  as  well  as  jircssing  the  liver  down  : 
it  is  fl.ittened.  (iftcn  extending  to  the  umbilicus  with  its  greatest  |)roininence  near  its  lower 
part  and  on  the  right.  It  may  form  a  protrusion  of  the  abdominal  walls  ;  it  is  easily  pal]i- 
able,  moves  up  and  down  with  respiration,  and  can  usually  be  ])ushed  back  into  its  normal 
position  when  the  patient  lies  down  ;  indeed,  when  the  patient  is  in  the  supine  position  it 
sometimes  goes  back  of  its  own  accord,  only  to  fall  again  when  she  stands  up.  It  is  movable 
laterally,  and  can  be  rotated  with  the  hands  about  a  horizontal  axis  passing  through  the 
attachment  of  the  organ  to  the  inferior  vena  cava.  There  is  considerable  diminution  in,  or 
even  absence  of,  the  hejiatic  dullness  in  the  chest  ;  in  an  extreme  case  the  hand  may  be 
passed  up  between  the  liver  and  the  ribs,  and  at  the  up])cr  right-hand  part  of  the  abdomen 
there  is  a  de|3ression  between  the  \\\ev  and  the  ribs.  There  may  be  no  symptoms,  but  the 
l)atient  usually  com])lains  of  a  dragging  pain  and  a  heaviness  in  the  he])atic  region.  These 
are  nuich  worse  in  the  erect  posture,  so  that  she  may  have  always  to  lie  down.  Often, 
sudden  attacks  of  pain  oceiu'  in  tlie  right  of  the  abdomen  :  these  may  be  due  to  gall-stones 
or  to  a  movable  kidney,  both  often  present  with  hepatoptosis,  or  to  kinking  of  the  bile-duct 
which  may  lead  to  jaundice.  The  patients  are  usually  neurotic,  dyspeptic  valetudinarians. 
As  the  abdominal  muscles  are  weak,  the  blood  stagnates  in  the  abdominal  vessels  in  the 
erect  posture  :  hence  faintness,  palpitation,  exhaustion,  and  dyspmea  on  exertion  are 
common,  these  symptoms  passing  away  when  the  patient  lies  down. 

Wc  shall  now  consider  each  of  the  itathological  enlargements  of  the  liver,  and  indicate 
the  chief  |)oiTits  to  l)e  utilized  in  the  diagnosis  of  eaeli. 

Venous  Congestion  of  the  Liver,  or  Nutmeg  Liver. — There  nuist  be  heart  disease, 
usually  of  the  mitral  valve,  or  perhaps  incompetence  of  it  secondary  to  severe  aortic  disease, 
or  disease  of  the  valves  on  the  right  side,  or  severe  disease  of  the  myocardium,  or  chronic 
pulmonary  disease,  usually  bronchitis,  or  arteriosclerosis  or  chronic  nephritis  with  high 
blood-pressure  and  secondary  heart  failure.  The  enlargement  of  the  liver  is  uniform,  its 
edge  is  firm,  its  surface  smooth.  It  may  reacli  to  the  umbilicus,  and  as  the  abdominal 
nniscles  are  often  weak  in  these  cases,  especially  in  women,  and  the  liver  is  very  heavy  from 
the  extra  amount  of  blood  in  it,  the  organ  is  often  a  little  dropped.  Pain  and  tenderness 
over  it  are  common  :  due  in  some  cases  to  stretching  of  the  hepatic  capsule,  in  others  to 
local  ])atclus  of  perihepatitis.  The  skin  over  the  liver  may  be  tender.  In  severe  cases 
there  is  often  slight  jaundice.  Dyspeptic  symptoms  are  frequent.  Ascites  may  be  ])resent  : 
if  so,  it  is  associated  with  the  oedema  due  to  the  heart  disease. 

In  a  severe  degree  of  nutmeg  liver  the  organ  may  pulsate.  If  so,  the  tricuspid  oi'ifice 
must  be  incompetent  and  the  right  ventricle  nmst  be  beating  strongly  :    then  a  pulse-wave 


LIVER.     ENLARGEMENTS    OP    THE  ;!69 

travels  l)ack  in  the  inferior  vena  eava  and  hepatie  veins  to  reaeh  the  hver,  and  makes  the 
whole  organ  expand  synchronously  with  each  contraction  of  the  right  ventricle.  .Such 
incompetence  of  the  tricus]iid  orifice  is  nearly  always  secondary  to  mitral  disease.  Great 
care  must  be  taken  not  to  mistake  a  thrust  downwards  of  the  liver  by  the  contraction  of  a 
hypertrophied  heart,  or  the  thrust  forwards  by  a  pulsating  aorta,  for  hepatic  pulsation. 
The  distinguishing  feature  of  this  is,  that  when  one  hand  is  placed  on  the  front  and  the 
other  on  the  back  of  the  abdomen  over  the  enlarged,  congested  liver,  the  two  hands  can  be 
felt  to  be  separated  by  the  expansile  ])ulsation.  This  is  not  the  case  when  the  pulsation  is 
transmitted.  Pulsation  of  the  ^•eins  of  the  neck  is  generally  pronounced  in  cases  in  which 
the  liver  can  be  felt  to  i)ulsate. 

General  Congestion  of  the  Liver. — This  is  frequently  said  to  be  present  in  those 
who  suffer  from  dyspepsia,  but  if  this  be  so  it  does  not  give  rise  to  a  demonstrable  enlarge- 
ment. When,  however,  a  European  lives  for  many  years  in  a  tropical  country  he  is  liable 
to  suffer  from  attacks  of  congestion  of  the  liver,  and  these,  when  frequently  repeated,  lead 
to  an  enlargement  called  tropical  liver.  The  organ  is  imiformly  enlarged,  smooth,  some- 
what hard,  and  has  a  uniform  edge.  Pain  and  tenderness  are  not  such  prominent  features 
as  they  are  in  a  nutmeg  liver.  The  condition  is  often  associated  with  indigestion,  errors 
of  diet — especially  the  taking  of  too  nuieh  alcohol — and  attacks  of  pyrexia.  When  these 
are  present  the  liver  becomes  tender,  painful,  and  more  enlarged,  and  I  have  known  such  a 
condition  mistaken  for  hepatic  abscess.  The  sufferer  complains  of  a  sensation  of  weight  in 
the  hepatic  region  :  he  is  constipated,  and  the  urine  is  full  of  lithates.  In  an  extreme  and 
chronic  case  the  organ  may  extend  four  inches  below  the  ribs  ;  the  patient  is  depressed, 
irritable,  and  of  a  sallow  complexion.     The  spleen  may  be  enlarged. 

Obstruction  to  the  Common  Bile,  whatever  the  cause,  is  often  associated  with 
uniform  cnlargeiuent  of  the  liver  owing  to  the  fact  that  the  biie  is  dammed  back  into  it 
and  so  swells  it  u])  :  even  simple  catarrh  may  do  this  :  jaundice  will  always  be  present  at 
the  same  time,  and  the  differential  diagnosis  will  be  found  discussed  under  that  heading 
(sec  .Jainukk.  p.  827). 

Suppuration  within  the  Liver. — Multiple  pya?mic  abscesses  within  the  liver,  which 
constitute  part  of  the  condition  known  as  portal  pya-mia,  generally  do  not  cause  enlarge- 
ment of  the  liver,  nor,  as  a  rule,  do  multiple  abscesses  connected  with  the  bile-ducts — • 
si'ppuralivc  cliohiiif^ilis — unless  there  is  sullicient  obstruction  to  cause  jaundice  (]).  :{2(i)  at  the 
same  time.  Rigors  (j).  .5!M),  pyrexia,  and  tenderness  of  the  liver  will  be  prominent  features 
of  most  such  cases.  Enlargement  of  the  liver  is  more  often  present  with  a  large  single 
ahseets.  There  is  usually  a  history  of  dysentery,  for  amoebic  dysentery  is  by  far  the  com- 
monest cause  of  a  large  single  abscess  :  therefore  it  usually  occurs  in  the  tropics,  and  is  then 
commonly  called  a  tro|)ieal  abscess.  \'ery  rarely  it  is  secondary  to  other  specific  fevers,  it 
may  be  due  to  suppuration  niund  a  gall-stone,  or  may  sjtread  from  some  neighbouring 
suppnration.  e.g..  a  pcrincphritic  abscess.  Or  again,  it  may  be  caused  by  suppuration  of  a 
hydatid  or  by  injury.  The  i)resen<e  of  any  of  these  causes  may  help  the  diagnosis  :  but 
imetimes,  even  when  the  abscess  is  due  to  the  dysenteric  anurba,  it  may  be  dillicult  to 
obtain  a  history  of  dysentery  :  and  indeed,  the  dysenteric  ulcers  of  the  intestine  may  have 
healed  years  before  the  symptoms  of  hepatic  abscess  show  themselves.  Very  rarely  it 
iijjpcars  to  follow  intestinal  uleeriilion^whieh.  as  far  as  wc  know,  is  not  dysenteric  :  this  is 
so  in  some  of  the  examples  of  single  large  abscesses  in  which  the  patient  has  never  left  this 
luntry.  Indeed,  sometimes  a  single  large  hepatic  abscess  is  found  in  the  tro[)ics  when 
the  most  careful  search  fiiils  to  find  any  am(i-b;e  in  the  pus  of  the  abscess,  or  to  obtain  any 
history  of  dysenlery,  or  only  a  history  of  liacillary  dysentery.  Tropical  abscess  is  most 
common  in  men  between  the  ages  of  twenty-live  and  forty-five.  It  is  much  commoner  in 
Kiiro|)eans  than  natives.  iMghly  per  ceni  arc  in  the  right  lobe,  usually  in  its  up|)cr  part. 
The  colour  of  the  pns  depends  upon  the  amount  of  l)roken-down  Ik  palie  tissue  present  : 
if  tlicri'  is  mneh.  it  is  the  colour  of  anchovy  paste  :  if  llure  is  none,  it  is  yellow,  but  the 
anchovy-paste-likc  pus  is  characteristic.  .\in(cb:e  may  !»■  found  in  it  (see  Fig.  -!i.  p.  77). 
or  more  often  in  the  granulation  tissue  forming  llie  wall  of  the  abscess.  Bacteria  may  be 
present,  but  if  the  abs<-css  has  existed  some  time  the  pus  is  often  sterile.  The  symplonis 
and  physical  signs  to  which  attention  milsl  be  directed  are  as  follow  :  — 

(leiieral. — Tlie  niosl  iniporlani  is  |)yrexia  :  often  this  is  the  initial  symptom.  At  liist 
the  rise  of  tempi  niluic  is  sIIl'IiI    ;inrl   incgular  :    graduall\    it    bccunies  hcctie.   with  a   wiilc 

I)  21 


H70  LIVER,     ENLARGEMENTS    OF    THE 

daily  excursion,  say  from  99°  F.  in  the  niorninji  to  10.3°  F.  or  10i°  F.  in  the  eveninu;.  Often 
the  patient  is  thought  to  have  malaria,  but  an  examination  of  the  blood  will  show  that  no 
malarial  organisms  are  present,  and  generally  there  is  leucocytosis.  whereas  in  malaria  the 
tendency  is  towards  leucopenia.  There  are  s(jmetimes  considerable  intermissions  during 
which  the  temperature  is  normal  for  weeks  or  months,  and  then  there  is  a  week  or  so  of 
pyrexia.  When  such  a  case  occurs  in  this  country  mistakes  in  diagnosis  are  very  likely.  I 
know  of  a  man  afflicted  with  tropical  abscess  whose  attacks  of  pyrexia  were  separated  by 
such  long  interxals  of  normal  tem])erature  that  he  was  thought  by  many  physicians  to  have 
recurrent  influenza,  and  this  although  it  was  well  known  that  he  had  been  in  the  tropics. 
Kigors  are  striking  and  severe,  and  in  cases  of  doubtful  diagnosis  are  very  suggestive  of 
hejiatic  abscess,  though  they  also  make  this  disease  resemble  malaria.  In  mild  cases  the 
rigor  is  reduced  to  a  mere  feeling  of  chilliness.  Often  there  are  profuse  sweats.  The  pulse 
is  rapid  in  proportion  to  the  temperature.  .Jaundice  may  be  present,  but  generally  is  not. 
In  bad  cases  the  patient  is  excessively  ill  and  weak,  ana-mic.  and  wasted  to  a  mere  skeleton. 
In  this  country  we  see  such  cases  on  their  arrival  from  India,  the  disease  haxing  made  rapid 
progress  on  board  ship.  On  the  other  hand,  if  there  are  long  intervals  of  apyrexia  the 
patient  hardly  suffers  in  his  general  health  ;  in  such  cases  the  abscess  usually  has  thick  walls. 
The  blood  may  show  a  great  increase  of  polymorphonuclear  cells,  but  this  leucocytosis  is 
often  absent,  especially  if  the  pus  is  sterile  or  the  abscess  has  thick  walls.  During  the  fever 
the  patient  has  a  dry  tongue,  anorexia,  and  is  thirsty  :  the  urine  is  scanty  and  high-coloured, 
and  may  contain  albumin. 

Local. — The  abscess  is  most  often  at  the  uijjjer  jjart  of  the  right  lobe,  grows  upwards 
l)elween  the  layers  of  the  coronary  ligament,  and  thus  forms  an  extraperitoneal  subphrenic 
abscess  which  softens  the  diaphragm  and  pushes  it  up,  giving  a  dome-shajsed  area  of  dullness 
\ aiying  in  size  from  one  to  several  inches  across,  added  to  the  top  of  the  normal  line  of  the 
he])atic  dullness,  and  best  seen  by  ma])piiig  out  the  dullness  with  a  blue  ])eneil.  It  is  usually 
posterior  to  the  mid-axillary  line.  Somctinies  tlie  abscess  is  in  such  a  place  that  a  rounded 
swelling  may  be  felt,  or  even  seen,  on  the  liver  when  the  patient  draws  a  deep  breath.  The 
measurement  round  the  lower  part  of  the  chest  may  be  longer  on  the  affected  side,  the  inter- 
costal spaces  may  be  obliterated,  and  if  the  abscess  be  very  large,  the  lower  ribs  may  bulge. 
Not  uncommonly  the  abscess  is  of  such  size  and  position  that  the  greatest  care  is  necessary 
before  it  can  be  detected.  The  whole  of  the  he])atic  area  should  be  jjressed  carefully  by  one 
finger,  for  local  tenderness  is  often  a  great  aid  in  the  diagnosis.  If  the  abscess  presents  in 
the  abdomen  the  rectus  muscle  over  it  may  be  rigid.  Pain  is  very  variable  :  it  may  be 
absent,  it  may  be  severe  ;  often  coughing,  drawing  a  deep  breath,  or  shaking  the  patient, 
will  cause  pain.  In  about  one-sixth  of  the  cases  there  is  pain  in  the  right  shoulder  ;  if  the 
al)scess  is  in  the  left  lobe,  there  may  be  pain  in  the  left  shoulder.  If  the  abscess  comes  close 
to  the  skin,  there  may  be  oedema  and  redness  over  it.  and  in  excessively  rare  cases,  (luctua- 
tion.  Often  the  liver  is  enlarged  generally  as  well  as  locally.  If  the  abscess  is  large,  it  may 
be  seen  with  the  .r-rays.  for  pus  casts  a  very  dark  shadow.  If  it  implicates  the  diaiihragm. 
mfection  may  spread  through  it  and  cause  bronchitis,  pleurisy,  empyema,  pneumonia,  or 
gangrene  of  the  hmg,  but  this  is  not  nearly  so  common  as  with  other  subjihrenic  abscesses  : 
hepatic  pus  may  be  coughed  U])  from  the  lung  when  the  abscess  has  ruptured  into  it,  may 
be  vomited  when  it  has  ruptured  into  the  stomach,  or  may  be  passed  by  the  bowel  when  it 
has  rujjtured  into  the  intestine.  Lastly.  I  would  again  remind  the  reader  that  in  some  of 
the  chronic  cases  seen  in  this  country,  both  the  local  and  general  signs  may  be  so  slight  that 
great  skill  is  necessary  to  detect  the  abscess. 

Cirrhosis  of  the  Liver. — Nearly  always  in  this  country  the  patient  has  taken  more 
alcohol  llian  lie  should,  but  cirrhosis  of  the  liver,  indistinguishable  from  alcoholic  cirrhosis, 
occurs  in  children  and  others  who  have  not  taken  alcohol,  especially  m  Egypt.  Here  we 
have  to  consider  only  the  stage  in  which  the  liver  is  enlarged.  It  has  been  known  to  weigh 
200  oz.,  but  anything  over  100  oz.  is  exce])tional.  In  the  early  stages  the  liver  is  not  altered 
in  shape,  and  the  surface  and  edge  are  smooth  ;  later  on,  as  the  fibrous  tissue  contracts  and 
tlie  lat  is  absorbed  from  the  cells  which  have  imdergone  degeneration,  the  surface  Ijeconies 
finely  uneven  ;  this  uneveimess  increases,  the  liver  becomes  hard  and  more  uneven  until  the 
irregularities  on  it  are  like  liolmails.  and  can  be  felt  through  the  alxioniinal  wall.  .\t  this 
stage  the  edge  of  the  liver  is  irregular  and  very  firm.  .\s  the  irregularity  increases,  the 
diagnosis  from  cancer  becomes  more  dillicult.  but  no  irregularitv  from  cirrhosis  ever  exceeds 


LIVER.     ENLARGEMENTS    OF    THE 


371 


the  size  of  a  small  cherry,  nor  is  it  ever  uinbilicated,  nor  does  it  ever  enlarge  suddenly  ; 
whereas  a  cancerous  nodule  may  be  umbilicated  and  may  enlarge  suddenly  from  ha;mor- 
rha^e  into  it.  Usually  a  cirrhotic  liver  is  not  painful  :  if  it  be,  the  pain  is  due  to  some  local 
perihepatitis.  Other  symptoms  to  be  looked  for  in  cirrhosis,  and  to  be  borne  in  mind  when 
makinf;;  a  diagnosis,  are  that  in  cirrhosis  the  spleen  is  often  enlarged,  and  sometimes  much 
so  ;  the  increased  fibrous  tissue  in  the  liver  constricting  its  small  portal  veins  leads  to 
engorgement  of  the  veins  of  the  stomach,  and  hence  haematemesis,  which  may  be  accom- 
jjanicd  by  mela-na,  is  common  at  some  jieriod  in  the  case  ;  and  occasionally  we  see  dilata- 
tion of  the  veins  round  the  umbilicus.  There  are  often  symptoms  of  chronic  gastritis  and 
enteritis.  Cirrhosis  is  commoner  in  men  than  women  in  the  proportion  of  three  to  one  : 
the  ])atients  are  usually  over  thirty  ;  there  is  a  more  frequent  association  of  alcoholic  excess 
in  the  lower  classes  than  among  those  who  are  socialh'  above  them.  Dyspepsia  and  morn- 
ing sickness  are  common  :  there  are  much  impairment  of  strength,  wasting,  a  sallow  look, 
dilated  venules  on  the  cheek,  red  nose,  a  furred  tongue  which  is  often  tremulous,  and  a  dry, 
hai'sli  skin.  The  ])ulse  becomes  weaker,  and  when  the  disease  is  fatal  its  end  is  usually  by 
cardiac  failure.  In  about  one-third  of  the  cases  that  are  ill  enough  to  come  into  the  hospital, 
the  temperature  is  raised  a  little  every  evening  (Fig.  107).  .Jaiuidice  is  or  has  been  present 
in  about  one-third  of  the  cases  :  it  rarely  if  ever  becomes  as  deep  as  that  seen  in  cancer  of 
the  liver.  Ascites  occurs  in  50  per  cent  of  all  cases  of  cirrhosis,  but  generally  in  the  latest 
stages  only  :    if  it  is  abundant  the  enlarged  liver  can  be  felt  only  by  dipping,  which  means 


8*  34-  90  86  84-  I 


24;[24-,24v24.;24., 20^20^ 
24-!2*S6  !24-]2«)-[22  |2A 


76  84-84-  84-76  SOlBO 

sa^se'sa  84-  8o'68'80 

26T24^'20"26' 


>^o 


22.20I24-22  20  22   26 


80^  88 '  84-  88  72   84-  104-  96  96  80  84-  92  80  84- 
90  92'96'92'ee  88  100  84-'88  84  76  72 '90  96 


24-,2O:2O|20|24-|20,24-  24-|20|20  20,24-,24-,2fl. 


l^i^-^itr  -*^ 


24-124-126  26120I2O  20I24-I26I20 


.-■lOMipe 


111,'  iiiul  pvetiiii'.;)  from  a  cj 
sli'^'lit  pyrexia,  especially 


pressing  the  hand  down  suddenly  on  the  liver,  and  so,  by  dispersing  the  fluid  whicli  is  over  it, 
coming  down  on  it.  Tymi)anites  is  not  un<'ommon  in  severe  cases  of  cirrhosis,  and  it  too  may 
make  it  didicult  to  I'eel  the  liver.  The  urine  is  usually  scanty,  of  high  specific  gravity, 
\(  IV  acid,  high-coloured,  and  full  of  urates  :  it  generally  contains  urobilin  and  sometin\es 
bile.  Naturally  suff<'rers  from  cirrhosis  may  have  delirium  tremens,  but  apart  from  this, 
cirrhosis  towanis  the  end  is  often  accompanied  by  nervous  symptoms,  especially  coma, 
and  this  may  be  so  even  in  those  who  have  not  recently  taken  alcohol  and  who  are  not 
jsiimdiced.  In  severe  cases  the  ankles  swell,  excii  when  there  is  no  disease  of  the  heart, 
luiiu-..  (M-  kiiliicy-.  or  pressure  on  the  \(m;i  cmn:!.  to  accounl    for  it.      Lastly,  it  should  be 

riiMirniK  i-cil  that  (  iirhosis  nuiy  exist  will I  aii\  sMiiploiiis  :    in  between  a  third  and  a  half 

III  all  cases  of  cirrhosis  found  in  the  posl-inorlciii  rouin  the  patient  has  died  of  something 
else,  ami  in  many  of  these  cases,  althoiigli  he  lias  hiiii  imdci-  iil>sir\at  ion  in  the  wards,  no 
symptoMis  of  cirrhosis  ha\('  been  obscrNcl. 

The  (imiciilties  of  diagnosis  fall  iril^i  (nic  nl  luii  classes  :  liu-  eaiiM-  ol  Ascttks  ()).  15), 
and  I  he  cause  of  enlargement  of  the  liver.  It  we  lia\e  iiiaileoul  thai  the  liver  is  undoubtedly 
enlarged,  il  is  urieii  a  mailer  oT  gre:il  ilillieulls  In  lell  whether  this  is  due  to  cancer  or  to 
cirrhosis  :  this  will  he  releiieil  In  in  speaking  nl  cancer.  Sometimes  cancer  and  cirrhosis 
are  present  in  the  same  lixcr.  Iiul  this  is  rare.  .Syphilis  of  th<-  liver  does  not  cause  much 
(lilliiiilty.  for  it  is  uneomninn  at  liie  bedside  :  \\\v  irregularities  of  I  lie  liver  are  much  larger 
tlian  tlie  hobnails  of  einhosis  :  the  patient  who  has  a  syphilitic  liver  is  rarely  jaundiced, 
ami  haiillx-  e\(r  lias  aseiles.  The  syniiiloms  of  a  syphilitic  liver  are  nearly  always  entirel\ 
local  :    s\phililie  disease  of  the  li\(  r  rarely  produces  general  symiitoms.     Obstruction  of 


372  LIVER.     ENLARGKMENTS     OF    THE 

the  coniiiion  bile-duct  leads  to  a  large  smooth  liver  ;  when  this  is  due  to  a  gall-stone  there 
is  usually  dee])cr  jaiuidiee  than  in  cirrhosis,  but  no  ascites  ;  the  stools  are  quite  pallid, 
which  is  very  luiusual  in  cirrhosis,  and  there  is  commonly  a  history  of  gall-stones.  There 
is  no  real  diihculty  of  diagnosis  between  the  enlargement  of  malaria  and  ordinary  cirrhosis, 
for  so-called  malarial  cirrhosis  occurs  only  in  those  who  have  drunk  to  excess,  and  is  then 
to  be  ascribed  to  alcoliol. 

Hanoi's  Cirrhosis — often  called  hyjjertrophic  biliary  cirrhosis,  an  extremely  bad 
name — is  a  ^■ery  rare  disease,  of  which  the  distinguishing  features  are  :  Most  of  the  sufferers 
are  children  ;  few  reach  the  age  of  thirty  ;  it  is  commoner  in  males  than  females  :  it  lasts 
many  years  ;  the  liver  is  firm,  enlarged,  and  smooth  :  long-standing  jaundice  is  present  ; 
the  spleen  is  very  much  enlarged.  The  patients  are  usually  children  of  stunted  growth, 
and  therefore  the  liver  appears  very  large,  but  the  spleen  is  proportionately  more  enlarged. 
The  liver  usually  remains  smooth  throughout,  and  even  when  towards  the  end  of  a  long 
ease  it  becomes  a  little  granular,  it  never  ])roceeds  to  anything  like  the  irregularity  of  ordi- 
nary cirrhosis.  Jaundice  is  an  early  sym))tom  and  lasts  till  the  end.  so  it  may  be  jiresent 
many  years  ;  very,  very  slowly  it  becomes  darker.  From  time  to  time  the  patient  has 
periods  during  which  he  feels  ill  and  his  temperature  is  raised  ;  but  it  is  strange  that  in 
spite  of  their  jaundice  the  children  afflicted  with  this  disease  do  not  for  years  appear  ill  : 
they  may  be  seen  runniiig  about  enjoying  life,  with  a  clean  tongue  and  a  good  appetite. 
Ascites  is  rare,  and  if  present  means  that  the  end  is  near.  In  many  cases  the  fingers  become 
clubbed  ;  the  clubbing  is  exactly  like  that  seen  in  chronic  fibrosis  of  the  lung.  As  growth 
is  stunted — for  example,  whereas  the  average  height  at  13  years  is  4  ft.  9  in.,  a  patient  with 
this  disease  was  only  4  ft.  1  in. — the  size  of  the  liver  and  spleen  makes  the  abdomen  very 
prominent.     At  the  later  stages  there  may  be  purpura  and  other  haemorrhages. 

Splenic  Anaemia. — This  is  a  disease  in  which  there  are  progressive  enlargement  of  the 
spleen,  secondary  anicmia.  leucopenia.  a  marked  tendency  to  hsemorrhage.  especially  from 
the  stomach,  and  in  many  cases  a  terminal  stage  of  cirrhosis  of  the  liver,  jaundice,  and 
ascites.  The  disease  is  often  called  splenomegalic  cirrhosis,  and  its  terminal  stage  of  cirrhosis 
of  the  liver  is  frequently  designated  Banti's  disease.  When  in  this  terminal  stage  the  liver 
is  enlarged  from  cirrhosis,  it  may  be  almost  impossible  to  distinguish  the  condition  from 
ordinary  cirrhosis  of  the  liver  unless  we  know  from  the  medical  history  of  the  case  that  the 
spleen  has  been  enlarged  for  some  time.  Other  points  that  may  help  are  :  on  the  average 
the  spleen  is  much  larger  in  splenic  ana>mia  than  in  ordinary  cirrhosis,  so  that  an  exces- 
sively large  spleen  is  somewhat  in  favour  of  splenic  anaemia  :  haematemesis  is  an  early 
symptom,  usually  present  long  before  the  stage  of  cirrhosis  of  the  liver.  The  disease  is 
very  slow,  but  the  patient  may  die  before  the  supervention  of  either  ascites  or  jaundice  ; 
he  does  not  often  do  this  in  ordinary  cirrhosis.  Ana-mia  is  present  in  both  conditions,  but 
is.  on  the  whole,  severer  in  splenic  anremia. 

Bronzed  Diabetes. — In  this  disorder,  which  is  very  seldom  seen,  the  liver  is  enlarged, 
hard,  and  cirrhotic,  exactly  like  that  of  an  ordinary  cirrhosis  :  the  pigmentation  of  tlie  skin, 
which  is  like  the  discoloration  due  to  arsenic,  the  absence  of  jaundice,  and  the  presence  of 
sugar  in  tlie  urine,  sufficiently  distinguish  the  disease. 

Syphilis  of  the  Liver. — Sj-philis  when  it  affects  the  liver  produces  gummata  in  it. 
and  leads  to  increased  growth  of  fibrous  tissue.  Much  of  this  is  in  the  form  of  hard  bands 
traversing  the  liver  irregularly  and  leaving  large  areas  of  healthy  liver  substance,  so  that 
what  with  the  presence  of  recent  gummata,  gummata  that  have  begun  to  shrink,  bands  of 
fibrous  tissue  that  liave  begun  to  contract,  and  pieces  of  normal  liver,  a  syphilitic  liver  is 
very  lumpy  and  irregular.  It  may  be  enlarged,  and  even  during  life  this  lumpiness  may  be 
felt,  but  the  syphilitic  liver  does  not  become  so  large  as  a  large  cirrhotic  liver,  unless  larda- 
ceous  disease  be  present  ;  it  is  much  more  irregular,  and  indeed  usually  resembles  a  cancerous 
more  than  a  cirrhotic  liver,  but  it  seldom  produces  any  clinical  symptoms  :  if  detected 
during  life  the  discovery  is  generally  accidental  :  it  occurs  at  a  younger  age  than  cancer  ; 
there  are  none  of  the  other  signs  of  cancer,  but  there  may  be  some  of  syphilis,  and  the 
Wassermann  reaction  will  be  positive  ;  ascites  and  jaundice  do  not  occur  as  signs  of 
this  disease  unless  an  enlarged  gland  presses  on  the  [jortal  vein,  which  is  so  rarely  the  case 
as  to  be  negligible  ;  and  the  liver  is  at  most  a  little  enlarged,  never  huge  as  in  cancer. 

In  children,  congenital  syphilis  may  produce  in  the  liver  precisely  the  same  effects  as 
the  acquired  di.sease  does  in  adults.  Lardaceous  disease  may  be  due  to  syphilis  ;  it  will  be 
discussed  presently. 


LIVER,     ENLARGEMENTS     OF    THE  378 

Universal  Chronic  Perihepatitis  may  make  the  liver  appear  lariie.  for  the  |>critoneal 
coating  of  the  whole  organ  is  much  thickened  ;  but  as  the  liver  itself  is  of  normal  size  the 
apparent  increase  is  not  great,  rarely  exceeding  an  extra  finger's  breadth  below  the  ribs. 
Such  of  the  liver  as  can  be  felt  is  smooth  :  the  edge  is  uniform  and  thick.  Usually,  however, 
no  ap]iarent  enlargenunt  can  be  detected  in  universal  chronic  perihepatitis,  and  often  the 
organ  and  its  thickened  capsule  weigh  the  same  as  a  normal  liver,  from  which  we  may 
conclude  that  the  liver  itself  is  a  little  atrophied  :  in  a  few  cases  it  appears  actually  smaller 
than  natural,  for  the  thin  anterior  edge  is  folded  upwards  under  the  thick  peritoneal  coat. 
There  are  no  he])atic  symptoms,  e.g.,  jaundice,  and  the  universal  perihepatitis  is  only  part 
of  a  general  chronic  i)critonitis,  symptoms  of  which,  e.g.,  ascites  and  thickening  of  other 
parts  of  the  peritoiiemn.  may  be  detected  on  palpation. 

Secondary  Cancer  of  the  Liver. — This  is  the  commonest  tumour  of  the  liver.  Gener- 
ally there  will  be  symptoms  of  the  primary  malignant  disease,  which  in  about  90  per  cent  of 
the  cases  is  in  the  periphery  of  the  portal  area,  but  not  infrequently  none  are  present,  and 
the  patient  does  not  know  that  he  has  anything  serious  the  matter  with  him  until  he  has 
symptoms  of  hepatic  carcinoma.  On  the  other  hand,  in  about  half  the  cases  of  hepatic 
carcinoma  no  symptoms  of  it  are  present,  and  it  is  not  known  to  exist  until  a  post-mortem 
examination  is  performed,  for  the  primary  disease  kills  while  the  hepatic  disease  is  still  in 
its  early  stages.  Seventy-five  per  cent  of  all  the  patients  are  between  40  and  70  years  old, 
and  hepatic  carcinoma  is  all  but  unknown  under  the  age  of  20.  If  the  disease  gives 
rise  to  clinical  symptoms  the  liver  can  usually  be  made  out  to  be  enlarged  both  by  jjercussion 
and  jialpation.  There  is  no  other  disease  in  which  such  a  huge  liver  may  be  found.  I  have 
known  a  cancerous  liver  to  weigh  19  lb.,  and  I  have  read  of  one  which  weighed  33J  lb.  ; 
weights  of  6  or  7  lb.  are  quite  common.  In  rare  cases  the  increase  in  the  weiglit  of  the  liver 
may  be  so  great  that  the  patient  actually  gains  a  little  weight  in  spite  of  the  general  wasting 
caused  by  the  cancer.  The  organ  may  be  felt  well  below  the  ribs,  even  far  below  the  umbi- 
Jicus.  Often  it  is  so  big  that  it  can  be  seen  to  go  up  and  down  with  each  breath.  I'pward 
increase  of  the  hepatic  dullness  is  rare,  and  when  present,  slight.  The  edge  of  the  enlarged 
organ  can  be  felt  to  move  up  and  down  willi  r(s[)iration,  unless  it  is  fixed  by  adhesions, 
which  is  unusual.  The  edge  is  liard,  and  often  irregular  ;  when  the  secondary  nodules  are 
numerous  the  whole  organ  feels  uneven,  knobby,  and  hard,  and  sometimes  the  lumps  on  it 
feel  umbilieated  ;  this  is  absolutely  diagnostic  of  cancer.  If  much  softening  has  occurred 
a  faint  sense  of  (luctuation  may  be  detected  ;  in  a  few  instances  local  peritonitis  causes  a 
rub.  Sometimes  the  nodules  can  be  appreciated  by  the  hand  only  when  the  patient  takes 
a  deep  breath,  for  then  those  imder  the  ribs  come  far  enough  down  to  be  felt.  Occasionally 
the  cancer  grows  so  fast  that  the  liver  obviously  increases  in  size  in  a  week  ;  very  rarely  a 
nodule  may  enlarge  suddenly  from  hirniorrhage  into  it.  Either  or  both  these  points  are 
almost  proof  that  the  enlargement  is  due  to  carcinoma.  It  must  not  be  forgotten  that  not 
all  livers  enlarged  frotn  malignant  disease  have  jjalpable  nodules,  for  they  may  be  in  such  a 
sitiialion  that  tluy  cannot  be  felt,  tli<v  may  be  too  small  to  be  felt,  or  the  growth  may  be 
(liHiiscil  through  the  whole  liver.  About  liall'  llii'  patients  liaxc  pahi  ill  the  heiiatie  region, 
and  may  have  it  near  the  right  shoulder  and  down  the  right  arm.  If  the  liver  is  very  large 
there  is  a  sense  of  dragging  and  fullness  in  the  right  hypoehondrium.  .Miout  half  the  patients 
are  jaundiced.  It  is  extremely  imporfant  to  remember  that  by  far  the  most  frctpient  cause 
of  long-standing  jaundice  is  cancer  of  the  liver,  which  jiroduecs  a  deeper  yellow  of  the  skin 
than  any  other  disease  :  as  time  goes  on  this  yellow  changes  to  deep  olive-green.  The 
wasting  becomes  extreme,  the  skin  dry  and  shrivelled,  the  patient  becomes  weaker  and 
weaker,  his  jiulse  feebler,  his  respiration  shallow,  and  finally  he  dies  comatose.  The  usual 
syiiijitoms  of  .Iaindick  (p.  :V2\-)  are  present.  .\st  itf.s  (p.  Ui)  is  rather  less  lrc(|iient  than 
jamidice,  and  the  jiatient  generally  dies  before  tapping  is  necessary,  for  ascites  is  a  late 
symptom.  The  urine  usually  contains  much  bile  and  lithates.  Rapidly  growing  carcinoma 
of  the  liver  is  often  assoeiateii  with  an  evening  rise  of  temperature  to  99'  !•".  or  1(11  !•'. 
{Fin.   It."),  p.   .•!-J(i).      I   ha\c  kiioHti  it  tobelO'J     !•'.  every  evening  lor  weeks. 

The  chief  dilliculty  of  diagnosis  is  from  cirrhosis.  The  large  cirrhotic,  liver  is  uniformly 
large,  and  the  palpable  nodules  are  small  :  if  they  feel  bigger  than  small  cherries  the  case 
cannot  be  one  of  cirrhosis,  for  hobnails  are  ne\cr  bigger  than  this  ;  hobnails  are  never 
imihilieated,  and  never  increase  rajiidly  in  size  :  it  juiindiic  is  present  and  the  patient  has  a 
large  cirrhotic  liver,  the  jaundice  is  ii<\(i-  vciy  (hip.  and  leinains  yellow  ;    it  never  becomes 


374  LIVER.     ENLARGEMENTS    OF    THE 

the  dark  olive-green  seen  in  eancer.  In  cirrhosis  we  do  not  get  clay-coloured  motions  ncir 
dilatation  of  the  gall-bladder,  but  we  often  find  a  large  spleen.  Extreme  wasting  and  dryness 
of  the  skin  are  more  common  in  cancer.  A  moderate  leucocytosis  is  often  found  in  both 
diseases  in  the  late  stages.  The  discovery  of  cancer  elsewhere  is  of  course  conclusive,  and 
the  history  is  of  great  help.  Syphilis  of  the  liver  has  already  been  described  sufficiently  to 
indicate  the  jjoints  of  difference.  Cases  in  which,  owing  to  non-malignant  obstruction  of 
the  bile-duet,  usually  by  a  gall-stone,  there  are  enlargement  of  the  liver  and  jaundice,  may 
give  rise  to  dillieulty  of  diagnosis  :  but  these  patients  rarely  have  the  extreme  wasted  look, 
with  dry  shrivelled  skin,  so  frequently  seen  in  cancer  ;  the  hepatic  enlargement  is  imiform 
and  never  so  great  as  it  may  be  in  cancer  ;  the  jaundice  does  not  become  green  :  if  it  disap- 
pears for  a  time,  it  means  that  the  gall-stone  has  shifted  :  that  the  jaundice  due  to  cancer 
should  disappear  is  almost  unknown.  Rigors  arc  common  in  cases  of  gall-stones.  The  age, 
history,  and  detection  of  growths  elsewhere  will  be  of  help.  As  far  as  my  experience  goes, 
when  we  are  in  considerable  doubt  as  to  whether  a  patient  has  an  impacted  gall-stone  or  a 
malignant  growth,  exploration,  if  done,  almost  always  reveals  a  growth.  Hydatid  tumours 
of  the  liver  are  seldom  confused  with  cancer,  for  almost  always  these  are  only  one  or  two  in 
number,  the  liver  is  smooth  and  regidar,  and  is  not  tender  :  the  hydatid  tumour  causes 
neither  pain,  jaundice,  ascites,  nor  general  emaciation,  and  it  may  give  a  thrill.  There  is 
no  onliiiarv  Uueocytosis.  but  tlie  patient  may  have  eosinophilia. 

Primary  Carcinoma  of  tlie  Liver. — This  is  very  rare  ;  the  liver  has  the  same 
character  as  in  the  secondary  form,  but  there  are  no  symptoms  of  a  primary  growth  else- 
where. It  is  almost  always  a  disease  of  adult  life.  It  is  usually  more  rapid  than  secondary 
cancer  :  most  of  the  patients  are  dead  within  three  months  from  the  onset  of  symptoms, 
and  therefore  the  jaundice  has  not  time  to  become  dark  green.  Wasting,  and  other  general 
signs,  including  slight  pyrexia,  are  present.  During  life,  primary  can  hardly  ever  be  dia- 
gnosed from  secondary  cancer  of  the  liver,  for  even  when  the  liver  apjjears  clinically  to  be 
the  only  organ  affected,  it  often  turns  out  that  there  has  been  primary  disease  elsewhere, 
giving  no  syni])t()ms.  and  not  detected  till  after  death. 

Secondary  Sarcoma  and  Embryomata  of  the  Liver. — These  do  not  produce  enlarge- 
ment enovigh  to  be  detected  during  life — exeept  perhajjs  in  the  case  of  melanotic  sarcoma 
secondary  to  a  tumour  of  the  eye.  when  the  liver  may  enlarge  very  rapidly  and  to  an 
extreme  degree. — f'of  the  primary  disease  and  the  numerous  secondary  deposits  elsewhere 
than  in  the  liver  soon  kill  the  patient.  If  melanotic  growth  is  suspected,  the  urine  should 
be  tested  for  melanin  (p.  74.5). 

Primary  Sarcoma  of  tlie  Liver  is  very  rare,  and  during  life  cannot  be  distinguished 
from  ])rimarv  careiudiiia. 

Adenomata  of  tlie  Liver  arc  also  very  rare  :  they  are  hardly  ever  of  sufficient  size 
to  be  detected  during  life.  Tliey  are  single,  and  I  know  of  an  instance  in  which  a  large  one 
was  operated  on  under  the  impression  that  it  was  a  hydatid. 

Lymphadenomata  of  tlie  Liver. — New  formations  consisting  of  lymphoid  tissue, 
generally  diffused  through  the  whole  liver  but  sometimes  occurring  in  nodules,  may  be  seen 
in  those  dying  from  lIodgkin"s  disease  or  from  lymphatic  leuka-mia.  The  nodules  cannot 
be  detected  during  life,  but  in  a  few  cases  the  diffuse  variety  makes  the  liver  uniforndy 
enlarge<l  ;  it  is  smooth,  its  surface  and  edge  are  firm,  it  is  painless,  not  tender,  never  of  great 
size,  and  there  is  no  jaundice,      Leukaemic  cases  will  be  detected  by  the  blood-count  (p.  24). 

Angiomata. — It  is  not  uncommon  to  find  small  angiomata  in  the  liver  in  the  post- 
inortem  room.  l)ut  they  cannot  be  detected  during  life  unless  they  are  large  enough  to  give 
symptoms  which  result  from  their  size,  and  this  is  very  rare.  Sometimes  when  a  large 
tumour  of  the  liver  has  been  thought  to  be  a  carcinoma,  and  yet  the  patient  has  seemed 
well  enough  to  be  suitable  for  operation,  the  growth  has  turned  out  to  be  a  cavernous 
angioma,  and  these  tumours  have  been  excised.  About  fifteen  of  such  cases  are  on  record, 
and  the  patient  was  usually  under  fifty  years  of  age. 

Fatty  Liver. — This  is  very  common,  but  the  enlargement  of  a  fatty  liver  is  usually 
not  sudicicnt  to  be  detected  during  life,  sometimes  because  the  [jatients  are  so  obese  that 
palpation  of  the  liver  is  dilfieult.  A  fatty  liver,  if  increased  in  size,  is  uniformly  enlarged, 
has  a  rounded  edge,  feels  a  little  softer  than  natural,  with  a  smooth  surface  ;  there  is  neither 
pain  nor  tenderness.  The  causes  are  so  numerous  that  often  they  hardly  help  the  diagnosis. 
The  largest  fatty  livers  are  met  with  in  phosphorus  poisoning  ;    they  then  may  weigh  10  or 


LIVER.     ENLARGEMENTS    OP    THE  375 

12  lb.  Severe  anipiiiia.  wastiuj;  disease,  especially  tubercle,  and  alcoholic  excess,  are 
perhaps  the  coiimionest  causes.  There  is  neither  jaundice  nor  any  other  symptom  that  can 
be  attributed  to  the  disease  of  the  liver. 

Lardaceous  Liver. — The  liver  is  imiformly  enlarged  ;  the  increase  in  size  may  be 
considerable  :  indeed,  next  to  cancer,  lardaceous  disease  causes  the  largest  livers  with  which 
we  meet.  .\  lardaceous  liver  has  been  known  to  weigh  14  lb.  It  is  so  smooth  that  even 
through  tlic  skin  it  feels  strikingly  so  :  it  is  firm,  and  the  edge  is  sharp  and  hard  ;  it  causes 
no  ])ain,  and  is  not  tender.  The  diagnosis  of  this  disease  is  much  facilitated  by  finding 
lardaceous  disease  of  other  organs  :  thus  the  spleen  may  be  enlarged  considerably  and 
uniformly,  there  may  be  albuminuria  from  lardaceous  disease  of  the  kidneys,  or  diarrhoea 
from  lardaceous  disease  of  the  intestine.  Only  two  causes  for  lardaceous  disease  are  known, 
viz.,  long-continued  sujtpuration,  e.g.,  psoas  abscess,  bronchiectasis,  chronic  phthisis  with 
cavitation,  chronic  hi])-joint  disease  :  and  long-standing  syphilis,  even  if  this  has  not  caused 
any  suppuration.  I  have  known  it  occur  in  a  small  child  as  a  result  of  congenital  syphilis. 
In  a  very  few  instances  no  cause  for  lardaceous  disease  can  be  discovered,  but  this  is  so 
exceptional  that  we  should  be  very  cautious  of  diagnosing  lardaceous  disease  in  the  absence 
of  syphilis  or  sui)puration. 

Tuberculosis  of  the  Liver. — It  is  excessively  rare  for  a  tuberculous  deposit  in  the 
liver  to  form  a  mass  sudiciently  large  to  be  detected  clinically  :  indeed,  so  rare  is  it  that  the 
diagnosis  could  not  be  made  before  exploration  unless  it  were  known  that  the  patient  had 
tuberculous  disease  at  the  periphery  of  the  portal  vein.  Judging  by  morbid  anatomy,  a 
tuberculous  tumour  of  the  liver  would,  if  discovered  during  life,  be  a  solitary  tiunour  of  the 
liver.  At  an  exploratory  ojjcration  an  irregular  shaggy  abscess  cavity  would  be  found, 
the  pus  of  which  would  contain  tubercle  bacilli.  There  may  be  some  uniform  enlargement 
of  the  liver  in  a  child  suffering  from  general  tuberculosis. 

Actinomycosis,  or.  as  it  is  sometimes  called,  streptotrichosis  of  the  liver,  could  hardly 
be  diagnosed  without  laparotomy  unless  the  patient  were  known  to  have  actinomycosis 
elsewhere.  It  is  very  rare,  and  has  seldom  been  recognized  in  the  liver  until  after  the 
I)atient's  death.  If  detected  during  life,  there  would  be  a  local  enlargement  of  the  liver. 
The  pus  in  it  would  be  in  an  irregular  cavity  with  shaggy  walls  and  trabecuhc,  and  the 
characteristic  little  sulphur-coloured  granules  would  be  seen  in  it  with  the  naked  eye,  and 
the  ray  fimgus  on  e.xainination  with  the  microscope  (Plate  XXf'IJI,  Fig.  S.  p.  61-t). 

Hydatid  Disease  of  the  Liver  can  hardly  be  recognized  unless  the  cyst  causes  a 
discoverable  iMiiHiiir  ol  the  li\ir.  'I'his  may  be  huge.  Hydatid  cysts  of  the  liver  may 
contain  thirty  |)ints  or  more.  If  the  tumour  can  be  felt,  It  is  rounded,  smooth,  localized, 
and  regular,  and  thus  is  distinguished  by  its  feel  from  cancci'ous  or  syphilitic  livers,  for  in 
these  the  tumours  are  Irregular  and  rough,  and  often  there  are  one  or  more  In  different  parts 
the  ll\er.  A  hydatid  tumour  Is  neither  tender  nor  painful,  and  thus  differs  from  an 
<((ss.  II  the  tumour  |)n)jeets  from  the  lower  part  of  the  liver  it  may  resemble  a  gall- 
bladiler.  .\  large  liyilatid  cyst  of  the  lower  part  of  the  right  lobe  of  the  liver  causes  con- 
siderable intra-abdominal  enlargement  of  that  lobe  :  on  the  other  hand,  if.  as  Is  fre(|uently 
the  ease.  It  grows  upwards  between  the  layers  of  the  coronary  ligament,  it  pushes  up  the 
llaphragm.  forming  a  rduiideil  projection  which  may  be  percussed  out  In  llic  cli 'sl  as  au 
ad<litlon  to  the  top  ol  llic  uorinal  hepat<c  dullness  :  in  exceptional  cases  the  luiiioiii'  may  be 
io  huge  that  the  dome  shape  of  the  dullness  is  lost,  and  the  ease  is  apt  to  be  regarded  as  one 
if  pleuritic  cHuslon.  If  a  hydatid  tumour  is  deep  In  the  Ihcr.  the  swelling  feels  hard  ;  if  it 
■onies  to  the  surlMcc.  the  liiiiiour  Iccis  tense  so  tense  that  lluetualliin  is  very  rare.  The 
so-called  li\ilal  id  III  ill  I  |iiic(  pi  ililc  In  II  ic  lliM^cr  lying  on  the  Imnonr  when  It  Is  struck  by  a 
linger  ul  llic  oilier  liand.  is  not  iiricn  Irll  :  il  may  be  obliilned  o\cr  any  tense  collection  of 
lluld.  but  if  it  bi-  prcsiiil  il  is  dl  idnsideialile  diagnostic  value,  for  other  tense  cysts  are 
very  unusu:il  in  the  lixcr.  ( tecasinniilly  two  or  e\cn  three  hydatid  cysts  are  present  In  the 
ame  liver;  each  tlien  has  the  eharaetcrlstics  of  a  single  cyst,  but  the  diagnosis  of  these 
cases  may  give  much  dlllleulty.  It  is  excessively  rar<'  for  hydatids  to  cause  pressure  sym- 
ptoms :  jaundice  Is  hardly  e\cr  seen  :  If  present.  Il  Is  probably  caused  by  rupture  of  the 
•yst  Inio  Ihc  bill- -passiiLics.  A  huge  cyst  may  displace  the  heart.  1'',()sin<)1'iiij.i  v  (p.  21K), 
L'vcn  III  :i  innsidiralilr  degree.  Is  snnullnies  found  when  the  parasitic  eysl  is  living  and 
active,  lull  mil  whin  il  is  i|iii(sciiil  iir  nhsulile.  1  lia\c  seen  10  percent  iif  ciisiiuiphilcs, 
md  even   "ill  per  cciil    li:i\c  been  i  riindril.      A  more  niiiiliral  e  Ineiciisi-  is  siiiniiiines  seen  Ml 


:J76  LIVER.     EXLARdEMENTS    OF    THE 

cancer.  I'siially  eosinophilia  is  absent  in  hydatid  disease,  hut  when  ])resent  it  is  a  consider- 
able help  in  diagnosis.  It  decreases  greatly  after  the  cyst  is  drained.  If  the  hydatid  fluid 
becomes  absorbed  tlie  patient  may  have  urticaria.  When  the  blood-serum  of  a  patient 
witli  liydatid  disease  is  mixed  with  some  hydatid  fkiid.  a  precipitate  may  be  formed  after 
about  twenty  hours  :  this  reaction  is  not  constant,  but  it  does  not  occur  when  hydatid  fluid 
is  mixed  with  the  serum  of  a  patient  who  has  not  got  hydatid  disease.  Hydatid  fluid  does 
not  give  an  albuminous  precipitate  when  heated,  whereas  the  fluid  of  an  ordinary  pleuritic 
effusion  docs  ;  on  the  other  hand,  hydatid  fluid  gives  an  abundant  white  precipitate  of 
silver  chloride  when. silver  nitrate  is  added  to  it.  Hooklets  (see  Fi<>.  18.  p.  49)  may  often  be 
found  in  hydatid  fliiid,  es])eeially  after  it  is  centrifugalized.  Hydatid  cysts  sometimes 
suppurate,  and  then  they  can  hardly  be  distinguished  from  other  forms  of  single  solitary 
abscehS.  Alveolar  echinococciis  disease  is  very  rare.  No  case  has  been  recorded  in  Englanii. 
The  Ijver  is  enlarged,  and  there  is  jaimdice,  gradually  deepening  during  the  two  or  three 
years  the  patient  lives.  Pyrexia  and  gastro-intestinal  symptoms  are  often  present,  and  the 
patient  dies  from  exhaustion. 

Other  cysts  of  the  liver  are  very  rare  and  very  difficult  to  diagnose.  Special  text- 
books dealing  with  the  liver  should  be  consulted  about  them.  H'.  Hale  While. 

LIVIDITY.-(See  Cyanosis,   p.   156.) 

LOCK   JAW.- (See  Thismus.   J).  7-29.) 

LORDOSIS. -(See  tritVATrRE.  Spinal,  p.  153.) 

LUNG,  HEMORRHAGE  FROM.— (See  Ha-moptysis.  p.  2K5.) 

LYMPHATIC    GLAND    ENLARGEMENT. 

A.  GENERALIZED    ENLARGEMENT. 

There  are  certain  diseases  in  which  there  is  a  tendency  for  all  or  nearly  all  the  lymphatic 
glands  in  the  body  to  be  enlarged — generalized  glandular  enlargement,  as  distinct  from 
enlargement  of  local  groups  of  glands  only.  The  distinction  is  not  absolute,  however,  for 
in  some  jsatients  suffering  from  a  malady  which  usually  causes  general  lymphatic  glandular 
enlargement  the  changes  may  be  confined  to  local  groups  instead  of  being  as  widespread 
as  usual.  It  may  be  said,  however,  that  if  there  is  generalized  enlargement  of  the  lymphatic 
glands,  the  patient  is  probably  suffering  from  one  or  otiier  of  the  following  diseases  : — 


Lym])hatic  leukaemia       Lymphosarcoma 
Hodgkin's  disease  Secondary  syphilis 

Lynii)liadenonia  German  measles 


Plague 

Tubercle,  rare  type. 


Lymphoma  StiU's   disease 

It  is  of  course  important  to  be  quite  sure  that  the  glands  are  really  enlarged,  and  not 
merely  palpable  with  greater  ease  than  usual  ;  experience  alone  will  decide  this  question. 
There  are  many  conditions  in  which  wasting  affects  the  subcutaneous  fat  and  not  the 
lymphatic  glands,  so  that  the  latter  are  felt  with  considerable  ease,  especially  in  the  groins. 
General  glandular  enlargement  usually  implies  affection  of  the  cervical,  axiflary,  and 
inguinal  glands  at  the  same  time  :  those  in  the  popliteal  space  or  above  the  internal  condylcj 
of  the  humerus  are  less  often  affected  ;  the  various  groujjs  within  the  abdomen  can  seldon 
be  palpated,  unless  perhaps  in  the  iliac  region  or  jjclvis,  whilst  enlargement  of  thd 
mediastinal  and  bronchial  groups  can  only  be  surmised  when  there  is  evidence  of  obstructioD 
to  one  or  other  bronchus,  or  when  they  can  be  demonstrated  by  the  j'-rays  (Fia.  01.  p.  149)1 

AVhen  a  case  of  generalized  lym])hatic  glandular  enlargement  jiresents  itself,  it  is' 
inqxirtant  to  make  a  blood-count  :  the  blood-changes  will  either  indicate  It/mphatic 
leuku'iiiia  (see  An.emia,  p.  25).  or  else,  if  the  characteristic  leucocyte  counts  of  the  latter 
are  not  found,  lymphatic  leuksemia  will  be  excluded.  None  of  the  other  conditions  exhibit 
pathognomonic  blood-changes,  although  there  will  very  often  be  a  considerable  degree  of 
anaemia  of  the  chlorotic  ty[)e. 

Ilodgkin's  disease  nearly  always  starts  witli  much  swelling  of  one  group  of  glands 
before  the  rest.  es])ecially  those  in  the  neck  ;  there  is  usually  moderate  enlargement  of  the 
spleen  at  the  same  time,  and  in  the  course  of  weeks  or  months,  generalized  swelling  of  the 


LYMPHATIC    GLAND    ENLARGEMENT 


37 


iibly 


Ions  the 
s  in  t!ie 
tlie  left 


lyiiiijliiitic  i;iiui(is  occurs,  especially  those  in  the  axillae  and  within  the  thorax,  the  resultant 
masses  sf)riietinics  beintj  of  considerable  size  (Fig.  108).  though  the  individual  glands  remain 
distinct  from  one  another,  do  not  tend 
to  break  downi  and  suppurate,  and  tlo 
not  become  fixed  either  to  the  skin  or  to 
the  deeper  parts,  as  they  would  do  if 
they  were  tuberculous  or  due  to  second- 
ary dejiosits  of  malignant  disease.  The 
blood-changes  in  Hodgkin's  disease  are 
lor  the  most  p:irt  negative  (see  An-Emia. 
p.  20).  thiiugh  in  blood-fjlnis  the  occur- 
rence of  an  occasional  basophile  cor- 
])usele  or  myelocyte  may  help  to  clinch 
the  diagnosis. 

Li/tiipliadeiioma  differs  from  Hong- 
kin's  disease  so  little  that  some  authori- 
ties use  the  two  names  as  though  they 
were  synonymous ;  others  reserve  the 
term  lymphadenoma  for  those  cases  in 
which  splenic  enlargement  is  not  appar- 
ent whilst  the  affection  of  the  lymphatic 
glands  is  \cry  ])rofoimd  in  one  group 
and  nttle  marked  elsewhere.  Li/mpli- 
iiiiia  is  a  term  that  has  sometimes  been 
used  in  the  same  sense. 

Where  hniiphosarcoma  ends  and  Hodgkin's  disea.se,  lymphadenoma,  or  lymiilionui 
begins,  it  is  dillii  iilt  to  say.  If  there  is  generalized  enlargement  of  the  lymphatic  glands 
without    mncli    aflcclinn   of   the   s[)lcen.    without   any   i)athognomonie   blood-changes,   and 

with  a  rapidly  fatal  ending,  the  condition  is 
spoken  of  as  lymphosarcoma,  but  it  might 
(•i|ually  well  be  termed  acute  lymphadenoma. 
Si/pliililicglniitls  seldom  reach  any  great 
size,  only  swelling,  roughly  s|)eaking.  to  two 
or  tliree  times  the  normal  :  tlic  first  to  be 
involved  are  those  in  the  neigldxjurhood  of 
the  chancre,  and  therefore  most  often  those 
in  the  groin,  spreading  later  to  all  the  glands 
in  the  body,  including  those  in  the  occipital 
I'cgion,  which  are  not  as  a  rule  affected 
except  by  syphilis,  jiedieulosis  capitis  with 
sores,  and  (Jcrman  measles.  Syphilitic 
glands  are  almond-shaped  aiul  llrm.  pain- 
less, or  at  most  slightly  tender,  and  they  do 
not  become  a<lherent  to  the  skin  or  to  the 
deeper  parts.  Tlu'V  may  remain  palpable 
tor  y<'ars  after  all  the  signs  of  seconilary 
syphilis  ha\c  disappeared.  'I'lie  dillieulty  in 
their  jliagnosis  does  not  arise  when  chancre 
or  roseola  is  present  :  but  later  their  nature 
may  not  be  obvious  unless  then'  is  a  clear 
liistorv  of  syphilis  or  \\'assermaim's  scnim 
test  is  posit  i\c. 

(Ivruuni  imitslis  causes  generalized  cn- 

largenu'iit   of    I  lie    iyniphatie    glands    very 

similar  to  that    of  secondary   syphilis,  l)ut 

(he  diagnosis  is  generally  obvious  from  the 

The    oeeurrenee    of   enlarged    oceipilal    and    oilier    glands 

rash  serves  to  distinguisli    (iiiriiaii    iiiiash  s    riniii   orilinarv 


ilitLTiiliiilangcal  joi 


nature  of  the  skin  eruption, 
assoeiateil  with  a  measles-like 
measles,  and  also  from  scarlet  fever  and  other  erythcmata. 


378  LYMPHATIC     GLAND     ENLARGEMENT 

Still's  fliscfisc  attracts  attention  jiriniarily  on  account  of  the  affection  of  the  joints, 
and  the  enlarfiement  of  tlie  lyni])hatic  glands  is  a  symptom  of  secondary  importance.  It 
is  an  affection  of  children  (Fig.  169)  precisely  corresponding  to  acute  rheumatoid  arthritis 
of  adults  :  no  joint  in  the  body  is  exempt,  and  it  is  probable  that  the  lymphatic  glandular 
enlargement  is  secondary  to  absorption  of  micro-organisms  from  the  infected  joints.  The 
patient  becomes  aniemic,  with  a  tendency  to  pigmentation,  and  the  spleen  is  enlarged  as 
well  as  the  lymphatic  glands.  The  disease  is  unmistakeable.  Similar  lymphatic  glandular 
enlargement  occurs  in  the  acute  rheumatoid  arthritis  or  infective  synovitis  or  peri-arthritis 
of  older  persons,  especially  in  that  form  which  is  characterized  by  spindle-shaped  swelling 
of  the  first  interphalangeal  joints  of  the  hands  (Fig.  1.53.  p.  342)  :  but  as  a  rule  the  enlarge- 
ment is  confined  to  those  glands  which  are  closest  to  the  affected  joints — epitrochlear  glands, 
for  instance,  in  the  case  of  tlie  fingers  and  hands,  and  so  forth  :  and  the  glandular  enlarge- 
ment disappears  when  the  malady  is  in  its  quiescent  phases,  although  the  joint  deformity 
remains. 

Plague  may  be  associated  with  very  acute  glandular  enlargement  all  over  the  body  : 
the  diagnosis  depends  largely  on  the  history,  and  partieidarly  upon  the  patient  having  been 
exposed  to  the  risk  of  contracting  plague  in  some  infected  town  or  ])ort.  The  diagnosis  may 
be  confirmed  bacteriologically. 

Tuberculosis  of  glands  is  much  more  often  local  than  general :  occasionally,  however, 
one  meets  with  a  case  in  which  the  inguinal  and  axillary  as  well  as  the  cervical  and 
internal  glands  are  all  enlarged  as  the  result  of  tuberculous  infection;  the  case  then  simu- 
lates lymphadenoma  very  closely,  and  it  may  be  necessary  to  excise  one  or  more  of  the 
affected  glands  and  examine  them  histologically  before  one  can  be  sure  of  the  diagnosis. 

B.   LOCALIZED    LYMPHATIC    GLANDULAR    ENLARGEMENT. 

In  all  those  diseases  in  which  enlargement  of  the  lymphatic  glands  may  be  general,  it 
may  sometimes  be  local,  or  may  begin  locally  before  it  becomes  general,  so  that  in  every 
case  in  which  there  is  an  affection  of  a  local  group  of  lymphatic  glands,  it  is  important  to 
remember  the  possibility  of  the  case  being  due  to  one  of  the  diseases  already  discussed 
under  heading  A. 

The  following  additional  causes,  however,  have  also  to  be  considered,  namely  : — 

Septic    absorption,  from  sores,  etc..  on   the  skin  or  mucous  membranes  from 

which  the  lymphatics  drain  into  the  i)articular  glands  that  are  involved 
Tuberculous  disease 
Secondary  malignant  disease. 

Whenever  there  is  any  doubt,  a  blood-count  should  be  made  in  order  either  to  diagnose 
or  exclude  lymphatic  leukaimia.  When  this  can  be  excluded,  the  nature  of  the  local 
glandular  enlargement  will  generally  be  suggested  by  the  age  of  the  patient,  by  the 
characters  of  the  glands  themselves,  and  by  their  locality.  We  will  here  deal  witli  the 
subject  from  the  point  of  view  of  the  particular  group  of  glands  involved. 

Occipital  Glands. — These  seldom,  if  ever,  become  enlarged  as  the  result  of  leukicmia, 
Hodgkin's  disease,  lymphadenoma,  German  measles,  syphilis,  or  tuberculosis,  unless  there 
is  obvious  enlargement  of  other  glands  at  the  same  time.  When  there  is  enlargement  oi  the 
occipital  glands  and  no  others,  by  far  the  most  likely  cause  is  septic  absorption  from  the 
posterior  region  of  the  scalp,  particularly  from  impetigo,  seborrha'ic  dermrititis.  or  most  likely 
of  all,  pediculosis  capitis.  Nits  should  always  be  looked  for  in  the  hair  with  care,  and  they 
may  sometimes  be  found  even  in  ladies  in  whom  the  mode  of  infection  may  be  quite  inexplic- 
able. The  patients  generally  have  much  irritation  of  the  skin  at  the  back  of  the  neck  at 
the  same  time,  and  it  may  be  attributed  to  the  rubbing  of  a  collar  or  the  neck  of  a  dress. 
There  is  generally  considerable  annsmia,  the  patient  looks  unwell,  and  often  has  some  even- 
ing |)yrexia. 

Pre-auricular  Glands. — The  most  common  causes  for  enlargement  of  the  pre-aurieular 
glands  are  :  Septic  infection  of  the  skin  of  the  cheek,  eyelid,  ear,  or  temporal  region  of  the 
scalp,  or  epitliclioma  of  these  regions.  The  occurrence  of  enlargement  of  this  gland  in 
association  with  an  ulcer  vyhich  may  be  rodent  on  the  one  hand,  and  an  epithelioma  on  the 
other,  does  not  necessarily  indicate  the  latter,  for  without  there  being  secondary  dejjosits, 
the  gland  may  become  enlarged  from  absorption  of  bacteria  and  their  products  from  the 


I.V.Ml'HATIC    (iLAND     ENLAR(;E.MEXT  379 

pus  of  rodent  ulcer.  In  those  very  rare  eases  of  chfincre  of  an  ei/elid  or  other  neighbouring 
part,  enlargement  of  the  pre-auricular  gland  may  precede  the  generalized  enlargement  of 
the  glands  to  which  syphilis  gives  ri.se.  The  gland  may  also  be  the  site  of  melunotic  sarcoma 
in  very  rare  cases,  the  primary  growth  being  in  the  eye  or  a  pigmented  mole. 

Submaxillary  Glands. — The  commonest  cause  for  enlargement  of  these  is  septic 
absorption  from  the  mouth  ;  tonsillitis  and  inflammation  of  the  fauces  are  responsible  for 
the  great  majority  of  cases  in  which  a  firm  gland  becomes  palpable  just  beneath  and  behind 
the  angle  of  the  jaw  :  generally  the  enlargement  is  greater  upon  one  side  than  upon  the 
other,  and  it  may  persist  for  days  or  even  weeks  after  the  causal  inflammation  in  the  tonsil 
has  subsided.  The  glands  are  painful  in  the  acute  stages,  and  in  a  few  cases  the  infection 
is  so  severe  that  the  tissues  break  down,  and  suppurative  adenitis  with  an  abscess  results. 
All  kinds  of  inflammation  of  the  throat  may  cause  this  glandular  enlargement — -ordinary 
simple  tonsillitis,  hospital  sore  throat,  rheumatic  tonsillitis,  quinsy,  diphtheria,  scarlet  fever, 
acute  |)hlegmonous  tonsillitis.  The  precise  nature  of  tlje  infecting  organism  is  to  be  ascer- 
tained by  taking  swabbings  from  the  tonsils  or  fauces  for  bacteriological  cultivation. 
Vincent's  angina  less  frequently  produces  glandular  enlargement  than  do  other  severe  forms 
of  sore  throat. 

Inflammatory-  changes  in  glands  further  forward  beneath  the  jaw  are  often  secondary 
to  caries  of  a  tooth  or  to  some  variety  of  stomatitis,  the  diagnosis  being  ascertained  by 
inspection  of  the  mouth.  I>ess  acute  enlargement,  going  on  to  much  greater  size  than  is 
the  rule  with  inflammatory  adenitis,  may  result  from  secondary  deposits  of  malignant 
(liscasc  in  the  submaxillary  glands  when  there  is  squamous-celled  carcinoma  (epithelioma) 
of  the  tongue,  lip,  gum,  cheek,  nose,  palate,  fauces,  tonsil,  pharynx,  or  larynx.  The 
diagnosis  in  these  cases  depends  upon  the  presence  of  an  obvious  primary  epithelioma  ; 
if  there  is  any  doubt  as  to  this,  a  small  portion  of  the  ulcerating  mass  may  be  excised  for 
microscopical  examination.  AVhcn  a  gummatous  ulcer  simulates  epithelioma,  the  effect 
of  iodide  of  potassium  and  mercury  may  point  to  the  former,  or  Wass?rmann"s  serimi  test 
may  be  ])ositivc.     .\  gumma  of  the  tongue  is  likely  to  be  median,  an  epithelioma  lateral. 

Cervical  Glands. — Kniargement  of  the  glands  in  the  neck  generally  may  be  either 
unilateral  or  bilateral.  If  unilateral,  if  only  a  few  glands  are  involved,  and  if  the  history  is 
a  short  one,  the  changes  are  probably  inflammatort/.  i)articularly  if  there  has  been  any  sore 
place  on  the  skin  of  the  neck,  the  buccal  mucosa,  or  throat,  or  if  there  is  evidence  that  the 
patient  has  been  exposed  recently  to  scarlet  fever,  or  if  there  is  otitis  media.  Acute  cervical 
adenitis  with  sore  throat  is  one  of  the  chief  features  of  a  new  e|)i(lemie  malady,  described  by 
Kirkland.  and  referred  to  in  detail  on  p.  (il(i.  Pediculosis  capitis  is  a  common  cause  of 
enlargexl  cervical  glands  in  children  of  the  poorer  classes.  It  is  sometimes  diflicult,  however, 
to  decide  when  tUr  enlargement  is  merely  inflammatory  and  when  it  is  due  to  some  more 
serious  lesion,  particularly  tiilivrrnlosis  on  the  one  hand  and  li/niplnidcnoma  or  Iffmphosarroma 
upon  the  other.  'I'he  longer  the  glandular  swellings  persist,  the  less  likely  is  it  that  they, 
are  jjurely  iriflaimiiatory.  The  yoimger  the  patient,  and  the  more  unsterili/.cd  cow's  milk 
he  has  been  drinking,  the  more  likely  are  they  to  be  tuberculous.  If  they  are  present  on 
both  sides  of  the  neck  :  if  tliey  show  a  tendency  to  become  adherent  to  one  another  and  to 
the  skin  ;  if  they  are  tender  notwithstanding  their  having  been  ])resent  for  some  time,  they 
are  probably  tuberculous,  and  the  diagjiosis  will  be  settled  by  surgical  measures,  the  affected 
glands  being  excised  and  examined  microscopically.  Spontaneous  breaking  down  of  the 
glands,  with  a  red  indolent  condition  of  the  skin  arounil  a  diseliargiiig  tistula.  and  very  slow 
healing,  are  to  be  forestalled  whenever  possible  :  but  if  they  ha\e  oecuned.  the  condition 
is  almost  certainly  tuberculous  in  cases  in  which  there  is  no  (piestion  of  a  late  stage  of  malig- 
nant disease.  There  may  be  eonflrmatory  eviflence  in  the  shape  of  tuberculous  lesions 
elsewhere,  especially  in  a  joint,  the  spine,  or  the  periloneimi.  It  is  noteworthy  that  eases 
of  tuberculosis  of  the  glands  are  even  less  likely  than  other  individiiiils  to  develop  ordinary 
phthisis,  so  that  the  absence  of  lung  signs  is  [lo  indication  that  the  glantls  are  not  tuber- 
culous. Lymphadenoma  is  sometimes  so  restricted  in  its  earlier  lesions  as  to  alfeel  the 
cervical  lymphatic  glands  to  a  great  extent,  and  long  before  any  other  groups  are  involved  : 
in  such  eases,  j)revious  to  operation  and  microscopical  {•xamination.  the  nature  of  the 
glandular  enlargement  may  be  open  to  great  doubt  :  and  e\cii  after  an  operation  lliere 
may  be  dilTerences  of  opinion,  lor  IImic  are  some  who  hold  that  the  larije-eilled  liy[)erplasia 
exliibitid  niicroseopi<:illv  li>    llodfiUiirs-cliMiiM-  glamis  is  an  in.licMt  ion  llial  they  are  only  a 


380  LYMPHATIC    GLAND    ENLARGEMENT 

chronic  variety  of  tuberculosis.  Clinically,  the  two  are  distinguished  by  the  fact  that 
tuberculous  glands  become  matted  together,  while  Hodgkin's-disease  glands  remain  separate 
from  one  another,  and  do  not  soften  or  break  down  even  when  they  have  become  of  such 
great  size  that  had  they  been  tuberculous  they  almost  certainly  would  have  done  so  ;  conse- 
quently, they  do  not  become  adherent  to  the  skin,  to  one  another,  or  to  the  deeper  parts, 
and  they  do  not  cause  a  fistulous  discharge.  Enlargement  of  the  spleen  as  well  as  of  the 
lymphatic  glands  in  the  neck  would  indicate  Hodgkin"s  disease  rather  than  tubercle. 

Si'cninhirfi  carcinoma  of  the  glands  in  the  neck  is  easy  to  diagnose  when  a  primary 
growth  is  already  known  to  exist  ;  it  is  generally  either  a  squamous-cclled  carcinoma  of  the 
buccal  cavity,  especially  of  the  tongue,  lip,  or  palate,  or  else  of  the  pharynx,  larynx,  or 
oesophagus.  The  cases  which  give  rise  to  the  greatest  doubt  are  those  in  which  an  oesopha- 
geal growth  has  not  caused  stenosis,  so  that  the  occurrence  of  secondary  deposits  in  the 
glands  may  be  the  first  indication  of  anything  being  wrong.  The  patient's  age  will  generally 
suffice  to  make  tuberculosis  unlikely,  tor  tuberculous  glands  are  far  commoner  in  children 
than  in  adults,  whilst  carcinoma  is  a  disease  of  the  middle  and  later  periods  of  life  ;  if  there 
is  any  doubt  to  start  with,  the  rapid  enlargement  of  the  glands,  their  extreme  hardness,  the 
way  they  become  fixed  to  the  deeper  structures  and  ultimately  to  the  skin,  through 
which  they  finally  ulcerate,  will  leave  little  or  no  doubt  as  to  their  character. 

Sarcomatous  glands  in  the  neck  are  much  rarer,  the  chief  variety  to  be  met  with  ijeing 
that  which  has  already  been  referred  to  above  as  acute  lymphadenoma  which,  on  account 
of  its  acuteness.  is  sometimes  termed  lymphosarcoma. 

Supraclavicular  Glands. — When  the  glands  immediately  above  the  clavicle,  especially 
those  (in  the  kit  side  in  the  region  of  the  attachment  of  the  sternomastoid  muscle,  are  en- 
larged, without  affection  of  any  other  lymphatic  glands  in  the  neck,  it  is  highly  suggestive 
of  there  being  a  primary  new-groivth  in  the  abdomen,  with  secondary  deposits  ascending  along 
the  course  of  the  thoracic  duct.  a,nd  exhibiting  themselves  in  the  glands  close  to  where  the 
thoracic  duct  enters  the  junction  of  the  left  jugular  and  left  subclavian  veins.  There  are, 
of  course,  many  cases  of  abdominal  malignant  disease  in  which  these  glands  do  not  become 
affected  at  all ;  but  the  value  of  the  sign  when  it  does  occur  can  scarcely  be  exaggerated 
(Fig.  17,  p.  49).  No  one  variety  of  intra-abdominal  carcinoma  is  more  liable  than  another 
to  produce  secondary  deposits  here  ;  the  primary  seat  may  be  the  stomach,  gall-bladder, 
pancreas,  duodenum,  colon,  rectum,  an  ovary,  or  even  a  testicle  or  kidney ;  in  not  a  few 
cases,  excision  and  microscopical  examination  of  the  left  supraclavicular  gland  has  indi- 
cated the  exact  site  of  the  primary  growth.  The  right  supraclavicular  gland  may  be 
enlarged  in  a  similar  way,  but  far  less  often  ;  and  generally  not  as  the  result  of  intra- 
abdominal but  of  intra-thoracic  new-growth,  particularly  squamous-celled  carcinoma  of  the 
oesophagus.  When  the  supraclavicular  glands  are  affected  at  the  same  time  as  the  axillary 
glands,  in  cases  of  cancer  of  the  breast,  the  condition  is  very  important  as  indicating  that  the 
disease  has  extended  beyond  the  limits  within  which  operative  cure  is  likely  to  be  possible. 

Axillary  Glands. — The  three  main  causes  for  enlargement  of  the  glands  in  one  axilla 
without  enlargement  of  the  glands  elsewhere  are  :  Septic  absorption  from  sore  places  upon 
the  fingers,  arm,  breast,  shoulder,  or  upper  part  of  the  back  ;  secondary  deposits  of  carci- 
noma from  the  breast  ;  and  lymphadenoma.  Tuberculous  axillary  glands  without  obvious 
affection  of  those  in  the  neck  have  been  recorded,  but  they  are  by  no  means  common.  It 
is  important  to  examine  carefully  for  any  possible  source  of  septic  absorption,  for  some- 
times it  is  by  no  means  obvious  ;  it  may  be  no  more  than  inflammation  around  a  ragnail. 
Inflammatory  glands  are  generally  very  painful,  and  they  are  associated  with  more  or  less 
pyrexia. 

Lymphatic  leukiBmia  will  be  excluded  by  the  absence  of  pathognomonic  blood-changes  ; 
secondary  malignant  glands  should  be  diagnosed  when  primary  growth  is  found  on  careful 
palpation  of  the  breast  :  Hodgkin's  disease  will  only  suggest  itself  if  inflammatory  absorp- 
tion, secondary  growth,  tubercle,  and  malignant  disease  can  be  excluded  ;  and  it  is  prob- 
able that  if  the  case  is  watched,  if  it  is  one  of  Hodgkin's  disease  other  lymphatic  glands  will 
presently  become  enlarged  also  (see  Fig.  168,  p.  377),  particularly  those  in  the  neck  of  the 
same  or  opposite  side,  and  those  in  the  other  axilla.  Enlargement  of  the  spleen  at  the  same 
time  would  be  an  argument  in  favour  of  Hodgkin's  disease. 

Epitrochlear  Glands. — The  only  im])ortant  cause  of  enlargement  of  the  epitrochlear 
gland    is    microbi(d   absorption   from    the  fingers,  hand,  or   forearm  :    the  site  of  ])rimary 


LYMPHATIC    GLAND    ENLARGEMENT  881 

infection  may  be  in  the  skin — a  whitlow,  for  example,  or  a  post-mortem  wound,  or  a  dis- 
secting-room sore  :  or  it  may  be  more  deep-seated,  as  in  cases  of  infective  synovitis, 
arthritis,  or  peri-arthritis.  It  is  important  not  to  mistake  for  a  simple  whitlow  such  a 
lesion  as  a  digital  chancre,  which  may  also  cause  enlargement  of  the  epitroehlear  gland 
before  infection  becomes  general  ;  if  the  history  and  the  local  appearance  of  the  chancre 
do  not  suggest  the  diagnosis,  its  course  and  the  associated  secondary  symptoms  will 
indicate  the  nature  of  the  case.     Wassermann's  serum  reaction  should  be  tried. 

Mediastinal  and  Bronchial  Glands. — These  can  never  be  palpated,  and  their  enlarge- 
ment can  only  be  surmised  wlun  there  are  signs  of  something  within  the  thorax  obstructing 
one  or  other  bronchus,  or  leading  to  laryngeal  paralysis,  or  stenosis  either  of  the  innominate 
vein  or  of  the  superior  or  inferior  vena  cava.  The  diagnosis  will  be  between  aortic  aneurysm^ 
chronic  tnediastinitis.  and  mediastinal  neiv  growth.  The  j'-rays  may  be  of  considerable 
value  in  confirming  the  diagnosis,  and  in  distinguishing  enlarged  malignant  glands  from 
aneurysm  of  the  aorta  {Fig.  100,  p.  20!)).  Inflammatory  or  caseous  bronchial  or  mediastinal 
glands  seldom  if  ever  obstruct  a  bronchus  in  the  way  that  malignant  glands  do,  possibly 
because,  before  they  have  reached  a  sufficient  size,  they  have  softened,  and  perhaps  discharged 
their  contents  into  tlie  bronchial  tube.  When,  as  happens  in  rare  cases,  a  caseous  gland 
does  obstruct  a  bronchus,  it  is  imjiortant  to  remember  that  j)ost-mortem  evidence  shows 
that  it  is  very  much  less  uncommon  for  a  right  bronchial  gland  to  do  this  than  a  left. 

Mesenteric  Glands. — It  is  seldom  possible  to  palpate  enlarged  mesenteric  glands, 
although  the  diagnosis  that  they  are  swollen  may  often  be  made  upon  circumstantial 
evidence.  Any  injlainmatori/  condition  of  the  bowel  may  lead  to  their  being  enlarged, 
l)articularly  if  there  is  any  breach  of  tlie  mucous  membrane,  as  in  cases  of  ulcerative  colitis, 
(li/scntcrij.  tiiliercalo.sis  of  the  lionrl,  or  typhoid  fever.  They  are  greatly  involved  in  most  cases 
of  lidtcrriiloKn  peritonitis  :  the  masses  tliat  arc  felt  in  the  abdomen,  however,  are  hardly  ever 
the  glands  themselves,  but  rather  extensive  inHammatory  and  caseous  foci  of  which  glands 
may  form  the  nucleus.  Malignant  new  groivth,  such  as  primary  carcinoma  of  the  stomach 
or  colon,  pelvic  organs,  or  testes,  may  cause  extensive  secondary  deposits  in  the  mesenteric 
and  retroijcritoncal  lymphatic  glands,  usually  most  marked  in  the  immediate  neighbour- 
hood of  tlic  primary  new  growth,  but  extending  thence  in  the  direction  of  the  liver  until 
the  portal  glands  arc  invoI\ed  :  however,  without  opening  the  abdomen,  it  is  almost  impos- 
sible to  determine  wlutlur  the  masses  felt  in  cases  of  this  kind  are  really  enlarged  lymphatic 
glands. 

Iliac  and  Pelvic  Glands. — What  has  been  said  above  in  connection  with  mesenteric 
glands  applies  here  also  ;  but  it  is  more  often  possible  to  determine  by  palpation  whether 
or  not  the  pelvic  lynipliatic  glands  are  affected.  In  cases  of  suspected  malignant  disease, 
charaeleristie  nodules  of  secondary  deposits  in  lymphatic  glands  may  be  felt  sometimes  on 
careful  |)al|)ation  of  the  iliac  fossa  or  upon  making  a  rectal  examination. 

Inguinal  and  Femoral  Lymphatic  Glands. — The  commonest  cause  by  far  of  enlarge- 
ment of  the  inguinal  lymphatic  glands  and  not  of  those  elsewhere,  is  .septic  ab.iorption  from 
microbial  foci  in  the  regions  whose  lymphatic  vessels  drain  into  these  glands  ;  sore  places 
should  be  looked  for  upon  the  toes,  and  between  them,  ujjon  the  feet,  legs,  thighs,  buttocks, 
lower  part  of  the  back,  scrotiun.  penis,  ])erineal  and  vulval  regions  (see  Sonr.s,  Penili;, 
r.Ti  ..  |).  ()17):  and  a  urethral  discharge,  gonorrhd-al  or  otherwise,  should  also  be  sought  for. 
Must  of  those  eases  will  be  assnciattil  with  constitutional  symptoms,  especially  pyrexia  and 
loss  of  appetite,  and  witli  local  pain  and  |)erhai)S  reddening  of  the  skin  (>\<r  the  inllaim-d 
lands.     Tlic  lallcr  ina\    l)riak  down   iiilo  abscesses     buboes. 

.\nother.  but  far  less  common,  cause  fur  localized  enlargement  of  the  inguinal  glands, 
is  secondari/  carcinoma-  secondary  to  s(|uamous-celIcd  carcinoma  of  the  scrotum,  prepuce, 
penis,  perineal  region,  amis,  clitoris,  labium  majus,  vagina,  leg,  or  fool.  In  such  cases  the 
diagnosis  will  become  obvious  when  the  primary  growth  is  found,  and  if  doubt  exists  as  to 
the  nature  of  any  such  idcerating  sore,  the  result  of  microscopical  examination  of  a  small 
|)ortion  (•xcised  will  clinch  the  diagnosis. 

Melanotic  .sarcoma  is  another  rare  but  very  important  cause  of  (■idar^cinciil  cil  liie 
inguinal  lymphatic  glands;  sometimes,  when  the  primary  growth  is  hardly  largir  than  a 
pea,  arising  in  connection  with  the  skin  of  one  of  the  toes,  or  perhaps  a  mole,  the  inguinal 
glands  nuiy  be  as  big  as  pigeon's  eggs,  rapidly  growing  and  comparal  ively  pairdcss.  The 
nature  of  this  cidargement  m;iy  be  (inilc  obscure  uidess  the  d:irk  tinge  of  the  growth  can  be 


382  LYMPHATIC     (iLAND    ENLARliE.MENT 

seen  through  the  skin,  or  there  is  melanuria  (Plate  XXXII',  Fig.  10,  p.  748),  or  a  careful 
examination  reveals  a  small  primary  new  growth  of  the  skin,  or  unless  surgical  measures 
are  adojjterl  for  their  removal. 

Popliteal  Glands  are  seldom  felt,  and  when  jjaljiable  they  are  discovered  as  a  rule 
rather  because  there  are  enlarged  lymphatic  glands  elsewliere  than  from  any  symptoms 
which  attract  notice  to  the  popliteal  space  itself.  Almost  tlie  only  cause  for  their  enlarge- 
ment is  septic  absorption  either  from  joints  or  from  the  skin  of  the  toes,  feet,  or  legs,  com- 
parable to  the  conditions  wliicli  produce  enlargement  of  the  cpitrochlear  glands  of  the  arm. 

Lymphatism  or  Status  Lymphaticus. — >Iuch  attention  has  recently  been  attracted 
to  the  fact  that  in  young  persons  under  puberty  who  have  died  as  the  result  of  poisoning  by 
anajsthetics,  or  of  what  under  ordinary  circimistanees  would  be  regarded  as  inadequate 
causes,  such  as  operation  for  the  removal  of  tonsils,  circumcision,  and  so  forth,  the  internal 
lymphatic  glands  and  tissues,  particularly  the  tonsils,  thymus  gland,  bronchial  and  mesen- 
teric glands,  Peyer"s  patches,  and  the  solitary  follicles  of  the  intestines,  are  considerably 
larger  than  is  usually  the  case  in  post-mortem  examinations  upon  patients  of  similar  ages 
who  have  died  of  other  diseases.  It  is  generally  stated  that  the  condition  referred  to  is 
pathological,  and  it  has  been  described  as  the  status  lymiihaticus  or  lymphatism.  It  is 
doubtful,  however,  whether  this  is  not  really  the  normal  condition  of  tlie  lymphatic  tissues 
at  this  age,  for  very  similar  appearances  are  to  be  found  in  the  bodies  of  children  killed,  not 
slowly  by  disease,  but  suddenly  by  accidents.  In  any  case,  it  is  almost  impossible  to 
diagnose  the  so-called  status  lymphaticus  during  life,  for  if  it  is  an  affection  at  all,  it  is  one 
of  the  internal  lymphatic  tissues  and  not  of  the  peripheral  and  easily  palpable  lymphatic 
glands.  It  is  doubtful,  however,  if  it  is  really  a  pathological  state,  though  deaths  produced 
by  an;cstheti(s  are  being  accredited  to  it.  Herbert  Freiieli. 

MACROGLOSSIA.— (See  Swelling  of  tue  Tongue,  p.  <i98.) 

MACULES  arc  circumscribed  discolorations  or  decolorizations  of  the  skin,  without 
noticeable  elevation  or  depression.  They  may  be  due  :  (1)  To  the  passage  of  blood,  or  of 
the  colouring  matter  of  the  blood,  into  limited  areas  of  the  skin,  as  in  purpura  :  (2)  To 
hypersemia,  either  arterial  or  venous,  as  in  erythema  ;  (3)  To  dilatation  of  the  vessels  of 
the  skin,  or  the  formation  of  new  vessels,  as  in  capillary  nievus  and  telangiectases  ;  (4)  To 
changes  in  the  pigmentation  of  the  skin,  whether  of  the  rete  or  of  the  corium — on  the  side 
of  excess  as  in  chloasma,  or  on  that  of  deficiency  as  in  leucodermia  ;  and  such  changes  may 
result  from  the  administration  of  drugs  sudi  as  arsenic  and  chloral,  or  may  be  an  expression 
of  trophoneurosis,  as  in  glossy  skin. 

Macules  of  the  second  and  third  grou])s  arc  effaced  temporarily  by  pressure  ;  those  of 
the  iirst  and  fourth  remain  unaltered. 

Macules  may  be  inflammatory  as  in  the  rose  spots  of  enteric  fever,  or  non-inflammatory 
as  in  purjnn'a  ;  congenital  as  in  moles,  or  acquired  as  in  the  exanthemata  ;  temporary  as 
in  drug  rashes,  or  permanent  as  in  leucodermia  :  scanty  as  sometimes  in  leucodermia,  or 
abundant  as  in  roseola.  They  may  be  attended  by  subjective  symptoms  (e.g.,  itching) 
as  in  drug  rashes  ;  but  generally  there  are  no  such  accompanying  symptoms.  I'sually 
round  or  roundish,  they  may  be  oval,  or  irregiUar  ;  they  also  vary  greatly  in  definition.  In 
colour  they  may  be  red,  brown,  or  yellow,  in  various  shades.  In  size  they  vary  from  a  mere 
speck  to,  say,  the  area  of  a  man's  hand  ;  if  very  widely  diffused,  as  in  malaria,  the  pigmenta- 
tion is  usually  styled  a  discoloration.  Most  frequently  a  primary  lesion,  as  in  lentigo,  the 
macule  may  also  be  secondary  to  burns,  blisters,  excoriations,  and  eruptions  of  various 
kinds,  erythematous,  vesicular,  bullous,  papular,  pustular,  and  cezematous.  The  brown 
spots  which  follow  traumatic  or  purpuric  ecchymoses,  haemorrhagic  urticaria,  varicose 
eczema,  etc.,  form  a  special  group  of  macules  in  which  the  pigment  is  hiemosiderin.  If  a 
macule  takes  on  a  slight  degree  of  elevation  it  is  sometimes  styled  a  maculo-papule. 

The  differential  diagnosis  of  the  erythemas,  of  which  the  lesions  are  for  the  most  part 
too  diffuse  to  be  regarded  as  macules,  is  set  out  in  the  articles  on  Krvthema  (p.  222)  and 
NoDiLES  (p.  402)  ;  that  of  the  purpuras  in  the  article  on  Plkplra  (p.  552)  :  that  of  leuco- 
<iermia,  sclerodermia,  morphoca,  the  various  forms  of  chloasma,  and  the  discolorations  due 
to  the  use  of  drugs,  in  the  article  on  Pigment.vtion  of  the  Skin  (p.  527).  Nor  need  the 
most  familiar  macule,  that  which  occurs  in  lentigo  (freckles),  be  described  here,  for  the  only 


MACULES 


3So 


affection  with  which  it  can  be  confuse*!  is  xeroderma  pigmentosum,  the  diagnosis  from 
which  is  given  under  Timouhs  of  the  Skin  (p.  730),  where  also  will  be  found  the  differential 
diagnosis  of  another  macular  affection,  xanthoma  in  its  various  forms.  Tinea  versicolor 
has  been  dealt  with  imder  Fungous  Affections  of  the  Skin  (p.  2.50)  ;  pityriasis  rosea 
under  Scales  (p.  601):  lichen  planus  and  herpes,  in  both  of  which  macules  appear  as 
secondary'  lesions,  respectively  under  Papules  (p.  487)  and  Vesicles  (p.  753).  Of  na:vi 
and  of  telangiectases  the  identification  is  self-evident,  and  it  only  remains  to  speak  of  the 
macules  of  !c|)n)sy  and  syphilis. 

In  leproay,  following  the  i^rodromal  symptoms  and  the  period  of  invasion,  erythematous 
spots  appear  on  the  face,  limbs,  or  trunk,  varying  in  colour  according  to  the  natural  pig- 
mentation of  the  skin,  but  usually  in  white  races  of  a  light  red.  The  colour  is  brightest  at 
the  edge  ;  the  centre  may  become  wliitc  :',nd  atropliic.  In  size  the  macules  ^■arv  from  a 
pin"s  head  to  the  palm  of  the  hand, 
or  larger  :  they  are  smooth  and 
shining,  with  a  well-defined  outline. 
.Some  infiltration  is  usually  present. 
Fresh  crops  continue  to  come  out 
at  irregular  intervals,  and  each  out- 
burst is  accompanied  by  an  exacer- 
biition  of  the  constitutional  sym- 
ptoms. .\fter  a  time  the  macules 
and  the  neighbouring  areas  of  ap- 
parently normal  skin  become  more 
or  less  ana'sthetic.  The  macular 
.stage  of  leprosy  may  possibly  be 
confused  with  erythema  simplex,  but 
the  macular  areas  are  usually  larger 
than  in  erythema,  in  which  also 
there  is  little  or  no  constitutional 
disturbance.  ,As  soon  as  ana?sthesia 
arises  the  diagnosis  is  settled.  This 
is  indeed  the  crucial  test  in  all  cases 
of  doubt  as  between  leprosy  and 
any  other  affection,  for  in  leprosy  it 
is  almost  invariably  present,  if  not 
in  tlie  lesions  themselves,  then  in 
some  neighbouring  area  of  the  skin. 
Its  cninmoncst  sites  are  towards 
the  centre  of  the  macule,  in  tin- 
pale  ])atchcs  left  by  macules  thai 
have  disappeared,  and  in  tin- 
hands  and  feet,  .\nollur  dislinc- 
fivc  feature  of  leprous  spots  is  that 
they  rarely  perspire.  In  si/ri)if>ii- 
mi/tliii  the  sensory  and  Iropliic 
lesions  may  suggest  Icjirosy.  but  the 
macules  will  be  absent,  nor  is  the 
friMiks.  (l-'or  the  diaunnsis  ol  i 
)).  !()J.)  WlKiii-vcr  doubl  cxisls.  II 
nasal  discharge. 

The  iniiciiliir  siijiliiliilr  is  n\\v  ii\  the  most  characteristic  lesions  of  secondary  syphilis. 
The  eruption  (/''/!,'•  17(1).  cryllicnialous  in  character  and  styled  syphilitic  roseola,  begins  as 
a  niaciihir  niullling,  resembling  measles  but  nilliir  more  itiisky.  dislrilinh'd  over  the  chest 
and  alid<pTncn.  II  is  extremely  evanescent.  <illcn  (lis;i|i|)(  ai  irig  in  a  lew  liunrs  and  coming 
out  au'ain  :is  suddenly.  The  mucous  membrane  ol  llic  thrnal  is  the  sial  ol  a  similar  erup- 
tion, and  siiperrK-ial  ulcers  may  forrn  on  the  tonsils,  (iciurally  al>i)nl  a  loi'lniglit  from  its 
appearance  the  rash  begins  to  laile.  giving  phirr  In  a  papular  or  lojlicnlar  eruption  on  the 
liiuik.  lindis.  face,  and  neck.      Ilyperaniia  nf  the  |pa|iilke  here  anrl  Ihcre  gives  rise  on  the 


cniarorini 

liilar   Irprc 

Irpra  h; 

>r  III 


I  ol  lyiMplialic  glands  or  thickening  of  ner\e- 
S'  liiirn  lupus  xulgai'is.  sec  inidei'  Xoix  i,i;s, 
ilhis  slidulcl  he  siinyhl   in  llie  l(si,,ns  or  in  the 


384  MACULES 

chest  and  abdomen,  and  often  on  the  flexor  aspects  of  the  Hmbs.  to  red  patches  which  may- 
persist  for  a  longer  or  shorter  time  as  isolated  blotches,  varyin<i  in  colour  from  a  delicate 
rose  to  a  pale  violet  or  dusky-bluish  or  even  brownish-red.  Scattered  about  among  these 
macular  syphilides  may  often  be  seen  papules  (maeulo-papular  syphilides).  which  leave 
.stains  of  varying  depth. 

From  the,  macular  syphilide  both  tinea  versicolor  ami  linen  cireinain  may  be  dis- 
tinguished by  'the  fungous  parasites  present  in  the  lesions  of  those  affections,  and.  in 
the  case  of  tinea  versicolor,  by  the  ease  with  which  the  scaly  patches  can  be  detached 
by  the  finger-nail  ;  the  erythematous  drug  rashes,  such  as  those  produced  by  copaiba,  etc. 
(p.  222),  b\'  their  more  vivid  redness  and  the  presence  of  itching  and  burning  :  seborrhicd 
eorporis  by  its  nioie  limited  distribution  ;  measles  by  the  creseentic  character  of  the  eru])tioTi. 
the  eoryza,  cough,  and  the  different  distribution.  .\  peculiarity  of  this  .syphilide.  which 
should  always  be  watched  for  in  doul)tful  cases,  is  that  it  varies  in  colour  with  the  temper- 
ature :  a  cool  atmosphere  will  bring  it  out  in  vivid  colours,  even  when  almo.st  completely 
f:"lt''l-  Malcolm   Morris. 

MAIN-EN-GRIFFE.-(See  Ci..\w-H.\nd.  p.  109.) 

MARASMUS  literally  means  "  wasting.'  and  therefore  signifies  much  the  same  as 
loss  of  weiglit.  By  conmion  consent,  however,  when  speaking  simply  of  marasmus,  one 
generally  has  in  mind  an  infant  or  young  child,  so  that  lesions  which  cause  loss  of  weight 
in  tender  years  will  be  considered  under  the  present  heading,  whilst  wasting  in  older  patients 
is  discussed  under  the  heading  Weight,  Loss  of,  p.  768. 

The  bodies  of  infants  and  young  children  consist  .so  largely  of  water  that  great  vari- 
ations may  occur  within  a  comparatively  short  time,  particularly  in  association  with  a 
disease  which  causes  loss  of  fluid.  The  most  rapid  loss  of  weight  occurs  as  the  result  of 
ncule  diarrlaea,  with  or  without  vomiting  ;  in  the  summer  zymotic  diarrhoea  of  infants 
the  subcutaneous  tissues  may  be  seen  to  shrivel  in  twenty-four  hours  or  less,  the  eyes  become 
sunken,  the  fontanelle  depressed,  and  the  patient  loses  weight  rapidly.  There  are  probably 
various  micro-organisms  producing  these  acute  symptoms,  of  which  the  best  known  are 
the  Bacillus  enteritidis  of  Gaertner  and  Morgan's  bacillus  I..  l)ut  the  exact  bacteriological 
diagnosis  of  the  symptoms  can  only  be  arrived  at  by  investigation  of  the  stools  and  perhaps 
of  the  patient's  serum  in  special  laboratories.  Acute  vomiting  without  diarrhoea  generally 
causes  loss  of  weight,  but  less  markedly  than  does  severe  diarrhoea  ;  it  sometimes  does  so 
to  a  considerable  extent,  nevertheless,  particularly  in  that  periodic  type  of  the  malady 
known  as  cifclical  vomiting  of  infants.  Without  apparent  eau.se,  a  child  of  tender  years 
who  is  subject  to  this  complaint  is  seized,  without  any  preceding  irregularity  in  diet  ami 
apparently  without  anything  definite  to  account  for  the  mischief,  with  most  severe  and 
recurrent  vomiting,  lasting  for  twenty-four,  thirty-six,  or  forty-eight  hours,  or  even  longer, 
nothing  whp.tever  being  kept  down,  and  the  urine  at  the  same  time  abounding  as  a  rule 
with  diacetic  acid  and  acetone,  the  evidence  of  acidosis  (p.  3).  Severe  though  the  loss 
of  weight  may  temporarily  be,  the  symptoms  generally  subside  as  rapidly  as  they  come 
on,  and  the  ])atient  remains  in  apparently  normal  health  until  the  next  period  of  similar 
vomiting  with  acidosis  comes  on.  Besides  cyclical  vomiting,  severe  attacks  of  vomiting 
may  be  caused  by  errors  of  diet  of  various  kinds,  though  it  is  remarkable  how  ehiklreu 
escape  the  disorders  of  injudicious  feeding  if  only  virulent  organisms  are  not  administered 
in  the  food  at  the  same  time.  Congenital  ht/pertropliic  stenosis  of  the  pylorus  is  nowadays 
spoken  of  as  though  it  were  itself  a  disease  ;  it  is  associated  with  jiersistent  vomiting  of  all 
foodstuffs,  the  symptoms  coming  on  either  immediately  after  birth  or  within  a  few  days 
or  weeks,  and  in  not  a  few  instances  resulting  in  death  from  sheer  inanition.  .-Vt  the  post- 
mortem examination  in  such  cases  there  is  undoubtedly  both  more  muscle  than  there  should 
be  in  the  pylorus,  and  undue  tightness  of  its  constriction,  but  it  is  very  doubtful  whether 
this  is  really  a  condition  of  congenital  malformation,  and  not  the  result  of  spasm  of  the 
pylorus  produced  by  injudicious  feeding,  especially  the  giving  of  food  before  the  mother 
has  milk  in  lier  breasts  ;  the  pyloric  hypertrophy  being,  not  congenital,  but  the  result  of 
the  muscular  contractions  so  induced. 

.Simple  starvation  owing  to  inability  of  the  parents  to  ]>rovide  food  will  naturally  cause 
acute  wasting,  though  the  nature  of  the  case  may  not  be  obvious  to  the  doctor  unless  the 
conditions  of  home  life  are  known. 


MENORRHAGIA  SHJ 

Defective  feeding  is  one  of  the  commonest  causes  of  lack  of  progress  and  of  actual 
marasmus  amoni;st  the  children  of  tlie  lower  classes.  The  amount  of  dirt  that  reaches 
the  child's  mouth  from  its  own  linoers.  from  its  mother's  breasts,  and  from  the  utensils 
in  which  the  food  is  given,  is  by  itself  enough  very  often  to  upset  the  digestion,  even  if  the 
right  food  were  given  in  the  proper  amounts  and  at  the  right  intervals  :  when,  in  addition 
to  the  dirt,  the  food  supply  is  of  the  wrong  kind  and  the  intervals  are  irregular,  it  is  not  at 
all  surprising  that  the  child  does  not  thrive. 

Rickets  is  not  so  much  a  cause  of  marasmus  as  a  concomitant  effect  of  the  injudicious 
feeding — many  rickety  children  being,  indeed,  unduly  fat  and  heavy. 

Congenital  sjjpliilis,  on  the  otiier  hand,  is  a  very  potent  cause  for  marasnuis.  The 
diagnosis  may  sometimes  be  guessed  at  ;  it  may  sometimes  be  obvious  from  the  snuffles, 
skin  lesions.  Parrot's  nodes,  condylomata,  and  so  forth  ;  it  may  be  known  of  in  the  parents  ; 
and  it  may  be  confirmed  by  Wasscrniann's  serum  test.  Many  congenital  syphilitic  children, 
without  developing  any  of  the  better  known  evidences  of  syphilis,  fail  from  simple  inability 
to  thrive,  and,  althougli  born  fine,  healthy-looking  infants,  presently  waste  and  pine,  and 
they  may  be  said  rather  to  cease  to  live  than  in  the  ordinary  sense  to  die  of  a  disease. 

Tuberculosis  is  a  very  important  and  conmion  cause  for  loss  of  weight  in  infants, 
though  it  is  generally  very  dillicult  indeed  to  be  certain  that  a  tuberculous  lesion  is  present. 
No  obvious  foci  s\ich  as  tuberculous  glands  in  the  neck,  kyphosis  from  spinal  caries,  ascites 
or  abdominal  hnnjis  from  tubcrcidous  peritonitis  or  tabes  mesenterica,  tuberculous  joints 
sudi  as  the  hiji  or  knee,  tuberculous  dactylitis,  and  so  forth,  may  be  jircscnt,  anfl  yet  there 
may  be  some  deep-seated  lesion,  of  which  the  conunoncst  by  far  is  caseation  of  tlic  l>n)nchial 
glands.  Phthisis  pulmonalis  is  almost  imknown  in  infancy  and  childliood  ;  in  ])lithisical 
Ijaticnts  there  is  jiractieally  never  caseation  of  the  bronchial  glands  ;  in  infants  and  yoimg 
children  caseous  bronchial  glands  are  very  common,  and  they  occur  almost  entirely  in  those 
who  have  drunk  any  large  (piantity  of  milk.  The  <langer  in  such  cases  is  that  the  bacilli 
will  not  remain  localized  to  the  bronchial  glands  :  many  a  child  is  quite  Tmsus])cctcd  of 
having  such  a  lesion  until  some  intercurrent  malady  such  as  measles  causes  the  mischief 
to  light  up  and  become  generalized  in  the  form  of  general  tuberculosis  and  meningitis, 
and  at  the  post-mortem  examination  caseous  bronchial  glands,  obviously  of  long  standing, 
are  found.  l\Iany  children  recover  completely,  and  the  nature  of  the  case  at  the  time  when 
there  were  loss  of  weight  and  general  ill-health  may  never  be  determined.  The  child  out- 
grows its  delicacy.  It  is  always  possible,  or  even  ])robable,  when  obscure  wasting  occurs 
in  a  child  who  objectively  itrescnts  no  particular  abnormality  exec))!  ill-hcallh.  that  llie 
lesion  is  tuberculous  al)sor[)tion  from  infected  milk,  with  accumulation  of  the  bacilli  in 
the  mesenteric  and  bronchial  glands.  The  f'a'ccs  may  be  examined  for  the  bacilli  after 
aiilitormin  treatment  in  the  laboratory.  It  may  often  Ik1|)  the  diagnosis  to  eliminate  milk 
from  the  dictarv.  and.  if  need  be,  butter  also,  and  watch  the  effects  of  giving  the  patient 
such  foods  as  arc  known  to  contain  no  tubercle  bacilli.  N'on  Pinpiet's  skin  reaction  might 
also  be  tried,  though  its  rcsidts  are  by  no  means  pathognomonic  (p.  7<i8),  especially  if  the 
tuberculin  used  is  not  pre|)arcd  exactly  as  it  was  in  \dn  Piiquet's  original  method. 

Herbert  French. 

MELJEtiX. —  This  term  is  correctly  ai)pNc(l  to  black  motions  containing  altered  blood. 
The  colour  is  due  to  the  action  of  the 'digestive  juices  upon  ha'inoglobin,  and  the  condition 
is  usually  associateil  with  some  ulcerative  lesion  of  the  stomacli  or  duodcmim.  It  may  be 
simulated  by  the  ])resence  of  sul|)hiile  of  iron  or  of  bisnuith  in  the  stools  of  patieiils  taking 
either  of  these  metals.  The  shitcy-l)lack  colour  of  tlicse  sulphides  ilocs  not  very  closely 
resemble  the  tarry  motions  of  hemorrhage.  Tlie  motions  may  also  be  black  aflir  coii- 
sumplion  of  cliarcoai,  in  the  i'orm  of  biscuits  or  otherwise,  or  of  bilbcnics.  In  ease  of  doubt. 
the  microsco|)e  may  ))(■  used  to  rc\cal  bloo(i-<-orpiiscles,  or  llie  chemical  Icsis  tor  blood 
may  be  employed.     (Se<'   Hi.ood   pm.h   Amm,   p.  7."i.)  If.    Cnil   HiianiKiuet. 

MELANURIA.      (See   IKim:.   AiiNuiiM  \i,  (  oi.oiiMioN   OK.   p.  7  !.'>.) 

MEMORY,    LOSS    OF.      (.See    .\mm.sm,    p.    l!l.) 

MENORRHAGIA. — Uy  this  symptom  is  rnemt  an  excessive  amoMiit  of  the  menstrual 
flow,  or  an  imdue  prolongation  of  the  lime  during  which  it  takes  place.  It  is  important 
to  remember  that  in  this  eondilioii   tin;  patient  is  free  from  bleeding  during  the  inter- 


386 


MENORRHAGIA 


menstrual  periods,  the  term  Metrorrhagia  (p.  390)  being  reserved  for  bleeding  which 
occurs  between  the  periods.  The  careful  distinction  between  these  symptoms  often  serves 
to  distinguish  very  important  conditions,  and  they  should  on  no  account  be  confounded 
with  one  another  or  considered  as  the  same  entity.  Pure  menorrhagia  is  an  important 
symptom  of  many  well-defined  conditions  which  do  not,  as  a  rule,  give  rise  to  irregular 
bleeding.  Both  these  terms  must  be  limited  carefully  to  patients  who  menstruate,  and 
must  not  be  used  for  bleeding  after  the  menopause.  The  term  Metrostaxis  (p.  392)  is 
the  best  for  bleeding  occurring  after  menstrual  life  has  passed. 

Causes  of   Menorrhagia. 


Geserative  System 


Circulatory  System 


3.    Nervous  Syste 


Uterine  congestion 

Endometritis 

Retroversion  and  flexion 

Fibroniyoma 

Salpingo-oophoritis 

Sub-involution 


Uncompensated     valvular 

disease  of  the  heart 
Cirrhosis  of  the  liver 
Emphysema  of  the  lungs 

The  Circulalion 

Passive    hypera^nia    from  : 


Excessive  coitus 
Prevention  of  conception 

■4  Single  Excessive  Period 
Fright 

Violent  emotion 
Sudden      changes      of 


Acute  Infectious  Diseases 

Consti])ation 

temperature 

Influenza 

Tight-lacing 

Cold  bath 

Enteric 

Sewing  machine 

Dancing 

Cholera 

Gvmnasties 

Scarlatina 

The  Blood  Itself 

Bicycling,  etc. 

Variola 

Deficient  coagulabilitv 

Hhcunuitism 

Scorbutus 

Malaria 

Purpura 

Diplitlieria 

Ha;mophiIia 

.Measles 

High  Blood-pressure 
Arteriosclerosis 
Disturbance      of     internal 
secretions 

Perusal  of  the  above  table  will  make  it  clear  that  the  causes  of  pure  menorrhagia 
can  be  grouped  under  the  three  headings  of  diseases  of  the  generative  organs,  circulatory 
organs,  and  the  nervous  system.  In  attempting  to  differentiate  these  causes  from  one 
another,  the  first  point  to  ascertain  is  whether  there  is  any  disease  of  the  generative  system, 
and  failing  this,  to  make  such  systematic  examinations  as  will  place  the  cause  under  one 
of  the  other  two  headings. 

In  considering  the  Generative  System,  it  is  clear  that  some  diseases  will  be  easy  to 
discover,  others  will  require  some  special  method  of  examination. 

For  instance,  of  all  the  causes  of  pure  menorrhagia,  fibromyoma  of  the  uterus  stands 
out  by  itself  as  the  only  important  growth  associated  with  this  symptom,  and  a  simple 
bimanual  examination,  as  a  rule,  sullices  to  show  that  such  a  tumour  exists,  the  chief  char- 
acteristics of  a  fibromyoma  of  the  uterus  being  these  :  the  uterus  itself  is  enlarged,  and  in 
almost  every  instance  the  enlargement  is  asymmetrical,  the  typical  shape  of  the  organ 
being  altered  ;  as  there  may  be  more  than  one  tumour  in  the  uterus,  its  shape  may  be 
exceedingly  irregular  ;  the  consistence  of  the  tumour  is  hard  and  unyielding  as  a  rule, 
but  pathological  changes  in  these  tumours  are  common,  some  of  them  leading  to  softening, 
others  to  cystic  cluinges  which  may  give  a  fluid  thrill.  The  tumour  and  cervix  always 
move  together  if  the  organ  can  be  moved  at  all.  The  only  dilliculty  in  diagnosis,  as  a  rule, 
lies  in  distinguishing  a  fibromyoma  of  the  uterus  from  an  ovarian  cyst,  and  sometimes  this 
is  exceedingly  difficult,  for  it  is  not  always  possible  to  say  that  a  given  tumour  is  actually 
the  enlarged  uterus.  It  must  be  remembered,  however,  that  the  symptom  which  has  led 
to  this  difficulty  is  menorrhagia,  and  ovarian  tumours  almost  never  give  rise  to  it.  Ovarian 
tumours  usually  cause  no  disturbance  of  menstruation  at  all,  unless  they  arc  double  and 
destroy  completely  both  ovaries,  in  which  case  they  cause  amenorrhani.  If  the  tumour 
cannot  be  diagnosed  by  simple  examination,  there  still  remains  examination  by  the  uterine 
sound.  If  no  possibility  of  ])regnancy  exists — and  with  pure  menorrhagia  jjregnancy  is 
impossible — the  sound  may  be  passed  into  the  uterus  with  every  precaution  against  sepsis. 


MENORRHAGIA  387 

In  all  cases  of  fibromyoma,  the  sound  passes  beyond  the  normal  2!,  inches,  and  it  may  [jass 
as  much  as  6  inches,  or  even  more.  In  cases  of  subperitoneal  fibroids,  the  uterus  may 
not  be  much  enlarged,  but  in  such  cases  menorrhagia  is  not  usually  present.  In  ovarian 
tumours  the  length  of  the  uterine  cavity  is  not  increased  unless  a  condition  of  endometritis 
co-exists,  which  is  very  uncommon  ;  and  if  it  did  not  exist,  the  amount  of  elongation  of 
the  uterine  cavity  would  be  small.  In  general,  however,  it  is  quite  unnecessary  to  use 
the  sound  for  the  diagnosis  of  a  fibromyoma. 

Uterine  Congestion  and  Endometritis. — These  lesions  can  only  be  inferred  in  cases  of 
pure  menorrhagia  when  the  uterus  is  not  enlarged  to  any  appreciable  extent,  and  when, 
in  addition,  there  are  leucorrhtra  and  backache.  These  three  cardinal  symptoms,  Pozzi's 
syndrome,  point  always  to  endometritis,  whatever  other  lesion  of  the  generative  system 
may  be  present.  As  a  rule  the  subjects  of  these  are  married  and  have  had  pregnancies  or 
abortions,  but  endometritis  may  occur  in  a  virgin,  the  result  of  infection,  without  any 
pregnancy  having  taken  place.  The  presence  of  endometritis  cannot  be  proved  without 
the  removal  of  the  endometrium  and  microscopical  examination  of  sections  of  the  material 
removed  by  curettage. 

Retroversion  and  flexion  of  tlie  uterus  and  salpingo-oophoritis  are  very  definite  and 
obvious  lesions  which  arc  associated  with  menorrhagia,  but  the  actual  prime  cause  is  again 
endometritis  and  uterine  congestion. 

So  also  with  sub-involution,  which  necessarily  can  only  follow  labour  or  abortion  ; 
though  a  relaxed  uterine  muscle  and  a  dilated  uterine  cavity  are  present,  endometritis 
and  congestion  are  present,  too,  and  are  the  real  causes  of  menorrhagia. 

EocanthematH. — The  various  exanthems  are  liable  to  cause  menorrhagia  exccjit  in 
those  instances  where  they  give  rise  to  anaemia.  It  has  been  shown  baeteriologically  that 
an  acute  endometritis  may  be  set  up  by  various  zymotic  diseases,  and  therefore  it  is  not 
sur|)rising  that  in  some  instances  this  condition  becomes  chronic  and  causes  a  lasting 
menorrhagia. 

Circulatory  System. — Under  this  heading  there  can  be  no  doubt  that  definite  causes 
of  menorrhagia  exist,  but  in  the  absence  of  well-defined  lesions  of  heart,  liver,  or  lungs  it 
may  be  a  matter  of  considerable  dilliculty  to  make  a  differential  diagnosis.  Any  lesion  of  the 
heart,  liver,  or  lungs  which  leads  to  back-pressure  in  the  venous  system  may  cause  hyper- 
a-mia  of  the  pelvic  organs  and  consequent  excessive  menstrual  losses.  It  does  not  follow, 
however,  that  this  will  be  the  case,  because  the  sufferers  from  these  diseases  are  sometimes 
ana-niic  as  far  as  the  (luality  of  the  blood  goes,  and  consequently  may  lack  the  stimulus 
to  menstruate  at  all.  However,  it  hajipens  not  uncommonly  that  menorrhagia  is  caused 
by  uiicoiiipensated  valvular  lesions  of  the  heart,  cirrhosis  of  the  liver,  or  em|)hvsema  of 
the  lungs.  Passive  lii/j>er(fnii(i  of  the  pelvic  organs  may  result  from  constipation,  tight 
lacing,  or  certain  occupations  such  as  the  working  of  a  treadle  sewing-machine  :  l)ut  endo- 
metritis may  also  be  present  and  be  the  real  underlying  cause  of  excessive  flow. 

.■l/(«'»/(V(.--That  the  quality  of  the  blood  itself  may  be  a  cause  of  menorrhagia  is 
undoubted,  and  particularly  if  it  be  deficient  in  calcium  salts,  leading  to  retardation  of 
the  coagulation-time.  Modern  methods  of  estimating  coagulation-time  enable  us  to  dis- 
tinguish these  cases  with  some  certainty,  and  thus  itoint  out  a  line  of  treatment,  t'ul'or- 
tunately  there  is  no  simple  clinical  method.  Doubt  also  has  recently  been  thrown  on  the 
view  that  the  caleiuiii  salts  have  any  effect  on  eoagulation-tiiiie.  Tlie  well-known  signs  of 
scorljutus  in  its  iiiirKir  degrees,  j)urpura.  and  iKfiuopliiliu  may  ilruw  at  tint  ion  lo  cases  of 
this   class. 

Menorrhagia  in  young  girls  al  the  lime  oC  piilinly  :inil  I'diiiiiiiiiccnicnl  ni  mciisl  iiial  ion 
<l(|Mii(ls  upon  e.ri-essive  oviiriiin  tulijil//,  and  we  must  couclude,  Iheril'ore,  a  disturbance  of 
the  balance  between  llie  iiilernal  secretions.  It  is  often  associated,  too,  with  retardation 
oi  llie  coagulatioM-tiiiie  ni  the  blood,  especially  in  the  subjects  of  chilblains,  cold  hands 
and  feet,  "  dead  lingers,"  etc.  It  must  not  be  forgotten  that  young  girls  may  have  a 
inalignaiil  growth  of  the  uterus,  such  as  sarcoma,  but  this  is  more  likely  to  cause  irregular 
bleeding  iis  well  as  menorrhagia. 

Kinally.  Iiigh  liloiid-jiressure  n\ust  be  reckoned  with  as  a  cause  of  menorrhagia  at  any 
period  of  life,  but  particularly  when  nearing  the  onset  of  the  mcno|)atise.  Menopause 
menorrhagia  much  more  often  depends  upon  one  of  the  well-defined  lesions  of  the  uterus 
described  above  than  on  high  blood-pressure,  but  cases  occur  in  which  the  blood-pressure 


388  MENORRHAGIA 

is  alone  responsible.  The  arteriosclerosis  which  is  likely  to  affect  the  uterine  vessels  about 
this  period  of  life  may  contribute  to  the  causation  of  menorrhag:ia.  The  high  blood- 
pressure,  and  possibly  the  arteriosclerosis  also,  may  eventually  prove  to  be  connected  with 
the  internal  secretions  of  the  ductless  glands.  Though  still  mainly  a  matter  of  theory, 
normal  menstruation  depends  in  part  at  least  on  the  normal  balance  being  preserved 
between  the  various  internal  secretions,  the  ovarian  and  thjToid  on  the  one  hand  being 
balanced  by  the  suprarenal  and  pituitary  on  the  other,  and  any  disturbance  of  this 
balance  may  result  in  amenorrhoea  (as  in  myxcedema),  or  in  menorrhagia,  as  sometimes 
occurs  in  exoplithalrnic  goitre  and  at  the  menopause.  It  is  very  fascinating  to  believe  that 
high  blood-]3ressure  may  be  due  to  the  imbalanced  action  of  the  sujjrarenal  and  pituitary 
secretions,  and  to  suggest  a  remedy  in  consetpience.  In  the  absence,  however,  of  collateral 
signs  of  definite  lesions  of  ductless  glands,  we  have  at  present  no  icady  means  of  telling 
which  gland  is  at  fault. 

The  Nervous  System  alone  is  never  likely  to  be  a  cause  of  lasting  menorrhagia,  but 
that  a  single  profuse  period  may  result  from  such  disturbance  of  the  nerve  mechanism  of 
menstruation  has  long  been  believed.  There  certainly  are  cases  in  which  no  other  causation 
can  lie  recognized,  and  in  which  the  excessive  How  is  not  repeated.  The  effect  of  sexual 
intercourse  upon  the  menstrual  How  is  difticult  to  determine,  but  cases  do  occur  in  which 
excessive  menstruation  lias  been  cured  by  abstention,  and  we  cannot  but  believe  that 
excesses  in  this  direction  must  therefore  have  been  the  cause.  Such  cases  occur  chiefly 
in  the  newly  married.  The  part  played  by  incomplete  coitus,  coitus  interruptus,  or  pre- 
vention of  conception  by  other  means,  is  still  diflicult  to  determine,  but  we  have  no  rea{ 
evidence  to  hand  which  proves  that  any  menstrual  disturbances  arise  on  these  accounts. 
In  any  case,  liowever,  we  are  not  justified  in  assuming  that  the  nervous  system  is  to  blame 
for  a  menorrhagia  until,  by  careful  examination,  we  have  eliminated  the  other  more 
important   causes.  T.   G.   Stevens. 

MENSTRUATION,  ABNORMALITIES  OF.— (See  .\.MExuiuuia.:A.  ji.  IT  :  .AIenor- 
RU.\t;iA,  p.  385  ;    and  METKOiiiiiiAGi.\,  p.  390.) 

MERYCISM  is  equivalent  to  cud-chewing  or  rumination  ;  it  is  very  rare  in  man  ;  even 
when  it  does  occur  it  is  no  evidence  of  disease.  It  has  to  be  distinguished  from  pyrosis 
and  from  tlatulence  ;  in  typical  cases  there  is  no  dilFiculty,  for  with  merycism  the  act  may 
be  voluntary  to  some  extent  :  actual  food  returns  to  the  mouth  instead  of  merely  acrid 
fluid  as  in  pyrosis,  and  there  is  none  of  the  belching  of  flatulence.  It  sometimes  develops 
in  several  members  of  the  same  family  ;  this  may  be  a  question  of  imitation,  but  it  is  due 
quite  as  likely  to  congenital  peculiarity.  The  diagnosis  depends  mainly  upon  the  patient's 
own  account  of  what  he  feels  taking  place  inside  him,  upon  the  history  of  a  similar  condition 
affecting  other  members  of  the  family,  and  upon  the  absence  of  objective  evidence  of  gastric, 
intestinal.  Intracranial,  or  renal  disease.  Herbert  Frencli. 

METEORISM,  or  tyni])anites,  is  the  term  used  to  denote  enormous  distention  of  the 
abdomen  with  gas,  the  latter  generally  being  within  the  alimentary  canal,  though  it  may 
be  free  in  the  peritoneal  cavity.  It  is  seldom  a  symptom  in  itself  of  diagnostic  importance, 
the  nature  of  the  case  being  determined  usually  on  other  grounds.  It  is  apt  to  be  very 
troublesome  in  cases  of  general  peritonitis  ;  the  diagnosis  will  depend  upon  the  history, 
which  may  suggest  a  cause  for  peritonitis,  such  as  gastric  or  duodenal  ulcer,  appendicitis, 
typhoid  fever  ;  and  upon  the  persistent  vomiting,  the  dry  furred  tongue,  the  motionless 
rigid  abdomen,  the  rising  rapidity  of  pulse,  the  facies  Hippocratica,  the  impairment  of  note 
in  the  flanks,  the  rub  over  the  liver  or  spleen,  and  the  absence  of  borborygmi. 

Intestinal  obstruction,  whether  acute,  subacute,  or  chronic,  and  whether  due  to  stran- 
gulated hernia,  peritoneal  band,  volvulus,  new  growth,  intussusception,  or  other  cause, 
often  leads  to  extreme  meteorism,  with  visible  peristalsis,  the  passage  of  neither  fjeces  nor 
flatus,  and  persistent  vomiting  which  will  become  fjeculent  if  the  case  is  not  operated  upon. 
Peritonitis  ultimately  supervenes  ;  but  previous  to  this,  intestinal  obstruction  is  differ- 
entiated from  general  peritonitis  by  the  absence  of  rigidity  of  the  abdominal  wall,  by  the 
presence  of  borborygmi  and  visible  peristalsis,  the  absolute  constipation  in  spite  of  enemata, 
the  slower  pulse,  and  the  relatively  better  condition  of  the  patient. 


METEORISM 


389 


Acute  paticrcdlitis.  whether  hseinorrhagic  or  not,  niay  cause  acute  nieteorism.  The 
symptoms  are  variable,  but  they  nearly  always  suggest  an  acute  abdominal  condition 
requiring  immediate  laparotomy,  the  diagnosis  being  then  suggested  directly  the  areas  of 
fat  necrosis  are  seen  in  the  omental  fat.  Previous  to  laparotomy,  the  sym])toms  are  rather 
those  of  acute  intestinal  obstruction  than  of  general  peritonitis  ;  the  usual  history  of  acute 
])ain  in  the  epigastrium  may  at  first  suggest  perforated  gastric  ulcer,  but  the  abdomen 
remains  supple  as  in  obstruction  more  often  than  it  becomes  rigid  as  in  peritonitis. 

Meteorism  in  cases  of  typhoid  fever,  dysentery,  detisiie,  and  other  severe  illnesses  in 
which  the  bowel  is  affected,  is  chietly  of  importance  in  that  it  may  lead  to  a  sus])icion  of 
perforation  and  general  peritonitis.  The  diagnosis  is  often  very  didieult,  and  there  may 
be  grave  anxiety  and  doubt  as  to  whether  the  abdomen  should  be  o])encd  or  not.  One 
important  point  in  typhoid  fever  is  that  perforation  is  generally  accompanied  by  a  sudden 
drop  in  the  temperature  and  an  equally  sudden  rise  in  the  pulse-rate,  whereas  meteorism 
by  itself  would  not  cause  this. 

\Vhen  the  vessels  in  the  mesentery  are  affected  by  thrombosis  or  oiiholisiii.  acute 
meteorism  results,  with  all  the  signs  of  intestinal  obstruction,  rajjidly  followed  by  jjcritonitis. 
The  nature  of  the  case  may  be  (juite  obscure  imtil  laparotomy  is  pcrfornuil.  imless  the 
existence  of  a  cause  is  known,  such  as  fungating  endocarditis. 

Interference  with  the  sular  and  mesenteric  plexuses  of  nerves  has  sometimes  led  to  severe 


Fifj.    171. — Hiischsprung's  disease;    or  idiopathic  dilatation  of  the  colon.    Xote  the 
distended  coils  of  intestine.    (From  Professor  llutherford  Morlson's  Introduction  to  ^nnjerij.) 


niilcorisiii  in  cases  of  t(tl>is  incscntericu.  or  inliltrating  intra-abdominal  nerv  growtli.  The 
syniplom  oicors  laic,  and  the  diagnosis  will  generally  have  been  made  on  other  groimds. 
.\rf(cti(]iis  of  tlie  spiniil  cord  may  lead  to  paralysis  of  the  bowel  and  tymi)anites.  This 
iii:ty  rcsiill  from  transverse  "  myelitis,'  whether  due  to  ])rimary  softening  of  the  cord  from 
syphilitic  or  oilier  spinal  arterial  thrombosis,  from  compression  by  spinal  caries,  new  growth, 
aneurvsm.  or  from  dcstruelion  of  the  <lorsal  region  of  Ihe  cord  bv  a  slab,  a  eiiisliing,  or  a 


There  will  ; 
lit  en 


■nerally  be  1'aiiaim.i: 

indiralcs   il- 


:i\  (p.  510)  to  indicate  the  nature 


the 


or  li 
Mete 


inipi'iii 
i-orisin. 


Mg   tcrMiinatiiin   in   coma  by   Ihe   onset  of 
The  diagnosis  will  be  known  already  on 


iKo  coiMiiioii   in   the  late  stages  of  cirrhosis  of 


bidlet  woi 
case. 

Diiil/elcs  imlliliis 
al)(l<iMiiiial   pains,   with   nii 
aeeoiiiil    ol    the   ;;lvcoMni:i 
///(■   lirrr. 

I'artirMJ.ir  mention  may  lie  niiiilc  of  llirsehspruiifl's  disciisc  idiopathic  enormous 
dislrrition  of  the  sigmoid  colon  in  ehildien  and  young  people  (/'V^'.  171).  Careful  exam- 
ination indicates  I  hat  tin-  (iioiiiions  gaseous  distent  ion  ol  I  lie  abdomen  is  not  due  to  general 
tympanites,  but  to  ballooning  of  what  may  seem  at  lii-.l  to  be  stomach,  but  which  is  proveil 
not  to  be  this  by  Ihe  absence  of  immediate  effect  on  the  gas-containing  cavity  when  (luid 
or  gas  is  given  by  the  mouth,  by  tin'  swelling  ajjpcaring  to  arise  from  the  left  iliac  fossa. 


390 


METEORISM 


and  if  need  be  by  the  .r-ray  shadows  after  a  bismuth  meal.  Obstinate  constipation,  or 
symptoms  of  recurrent  intestinal  obstruction,  are  usual  in  these  cases,  and  the  diagnosis 
is  confirmed  by  the  laparotomy  that  is  generally  required,  in  the  end,  to  relieve  the  patient. 
Hysteria,  or  rather  functional  derangement  of  the  nervous  system,  can  lead  to  almost 
any  symjitom  (p.  4(i5),  inchiding  meteorism.  Two  difficulties  arise  in  the  diagnosis  : 
namely,  to  be  sure  :  (1)  That  the  condition  is  meteorism  at  all,  and  not  pregnancy,  ascites, 
ovarian  cyst  or  other  tumour — phantom  tumours  are  diiflcult  to  diagnose  without  exam- 
ination imder  an  anaesthetic,  and  even  laparotomy  may  be  luidertaken  before  the  absence 
of  a  tumour  is  established  certainly  ;  and  (2)  That  the  meteorism  has  no  organic  basis — 
tlie  circumstances  may  sometimes  suggest  this  at  once,  but  in  some  cases  the  exclusion 
of  an  organic  cause  for  the  tympanites  may  take  much  time,  carefvil  enquiry  into  symptoms 
and  physical  signs,  and  considerable  anxiety  meanwhile.  Herbert  Freiuti. 

METHvI'.MOGLOBINURIA.  -(See  H.KMOGLOBiNtRiA,  p.  284.) 


METRORRHAGIA  means  loss  of  blood  from  the  uterus  in  the  intermenstrual  periods, 
and  the  term  should  be  a])plied  only  to  irregular  haemorrhages  during  menstrual  life.  It 
is  not  correct  to  apply  it  to  ha'morrhages  connected  with  pregnancy,  for  menstruation  is 
then  in  abeyance.  It  may.  however,  be  used  with  propriety  in  those  cases  remotely  con- 
nected with  pregnancy  in  which  menstruation  has  been  re-established.  The  term  may 
be  used  for  losses  of  actual  blood,  or  for  blood-stained  discharges  in  which  mucus  is  mixed 
with  the  blood. 

Causes    of   Metrorrhagia. 


1.    Ges^rative  System 

2.      CIRCULATORV    SYSTEM 

3.    NERVOUS  System 

Malignant  Grozeths  : 

High  blood- pressure  dtie  to  : 

Sexual  excess  • 

Carcinoma 

Internal  secretions 

Squamous  epithelioma 

Arteriosclerosis 

Sarcoma 

C'horion-epitlielioma 

At  the  iiienofxntse 

Undue  congestion  due  to  : 

Benign  Growtlis  : 

luteriui!   secretions 

Sul)ni  neons  lihroiii 

Deficiency   of  calcium   at 

Fil)roi(l   i)0ly|)us 

the  onset 

Mucous   ])olypus 

Blood  Changes  : 

Iiiflammalory  Lesions  . 

Piirpura 

Erosion  of  cervix 

Scorbutus 

Endometritis 

Hiemophilia 

Tuberculosis  of  the 

iterus 

Leuksemia 

The  Lesions  of  the  Generative  Organs  which  give  rise  to  metrorrhagia  are  well  defined 
as  a  rule,  and  in  the  case  of  growths  of  the  cervix  uteri  a.re  often  self-evident.  Wliere 
growths  of  the  body  of  the  uterus  are  present,  differential  diagnosis  is  often  a  matter  of 
great  difficulty,  and  in  many  instances  cannot  be  made  without  a  preliminary  curettage 
and  microscopical  examination  of  the  material  removed.  In  fact,  with  the  exception  of 
obvious  mucous  polypi,  fibroid  polypi,  and  advanced  growths  of  the  cervix,  all  the  growths 
of  the  uterus  require  a  preliminary  histological  examination  for  their  exact  diagnosis  unless 
the  symptoms  demand  a  radical  operation.  In  such  cases  it  is  sufficient  to  diagnose  the 
actual  nature  of  the  growth  after  removal.  It  is  not  out  of  place  here  to  suggest  the 
best  way  to  make  histological  preparations  from  curetted  material,  a  matter  of  great 
importance  to  the  patient,  becau.se  it  is  often  difficult  to  distinguish  between  cancer  and 
endometritis  unless  the  very  best  microscope  sections  can  be  secured.  The  curetted 
material  must  be  obtained  after  dilatation,  with  a  sharp  curette,  and  the  larger  the  frag- 
ments removed  the  more  easy  will  the  histologisfs  work  be.  Anaesthesia  is  always  essential 
except  in  the  case  of  cervical  growths.  In  doubtful  cervical  growths  a  wedge  should  be 
cut  out,  including  some  normal  tissue  if  possible.  Curetted  fragments  should  be  washed 
free  from  blood  for  a  minute  or  two,  but  should  not  be  left  to  soak  in  water.  They  should 
then  be  placed  immediately  in  an  efficient  fixing  fluid,  and  the  best  all-round  fluid  for  this 


METRORRHAGIA  391 

purpose  is  formalin  10  c.c,  0'75  per  cent  salt  solution  90  c.c.  Twenty-four  hours  in  this 
fluid  lead  to  good  fixation,  after  which  the  tissues  can  be  dehydrated  in  successive  strengths 
of  alcohol,  cleared  in  xylol,  and  finally  embedded  and  infiltrated  with  paraffin  wax.  Sections 
cut  from  these  paraffin  blocks  are  the  best  obtainable,  far  superior  to  any  freezing  method 
or  celloidin  infiltration.  If  the  stained  sections  are  submitted  to  a  histologist  who  has 
experience  of  uterine  growths,  there  should  not  be  two  per  cent  of  doubtful  specimens.  If. 
however,  the  tissues  are  fixed  improperly,  thick  sections  are  cut,  and  stained  badly,  then 
the  most  skilled  histologist  will  be  unable  to  give  a  definite  and  reliable  diagnosis. 

Cancer  of  the  body  of  the  uterus,  cancer  of  the  cervical  canal,  early  cancer  of  the  cervix, 
sarcoma  of  tlie  uterus,  chorion-epithelioma,  some  sloughing  libmids.  tvihercle.  and  endo- 
metritis can  be  distinguished  from  one  another  only  by  investigations  carried  out  on  these 
lines.  The  fact  that  all  these  lesions  produce  metrorrhagia,  and  may  give  rise  to  hsemor- 
rhage  on  coitus,  walking,  straining  at  stool,  and  bimanual  manipulation  of  the  uterus, 
makes  it  imperative  that  we  should  have  histological  confirmation  of  the  nature  ol  the 
lesion  before  making  an  exact  diagnosis. 

The  relation  oi  fibromyoma  to  metrorrhagia  as  opposed  to  pure  menorrhagia,  which  is 
the  rule  with  these  tumours,  is  interesting.  Fibroids  only  produce  irregular  bleeding  when 
they  are  submucous  and  in  process  of  extrusion,  when  they  are  infected  and  sloughing, 
or  when  they  are  actually  polypoid.  The  reason  for  this  is  that  in  these  conditions  the 
tumours  are  always  partly  strangulated  by  uterine  contractions,  and  therefore  in  a  state 
of  gross  venous  Cf)ng(stion  :  hence  they  bleed  more  or  less  constantly,  without  provocation. 
The  occurrence  of  irregular  Ijleeding  in  a  person  who  is  known  to  liavc  fibroids  almost  always 
means  oije  of  these  conditions,  and,  commonly,  extrusion  of  the  tmnour  from  tlie  uterus. 
On  the  other  hand,  it  must  not  be  overlooked  that  carcinoma  may  develop  in  the  endo- 
metrium with  a  fibroid  also  present,  or  that  a  fibroid  may  become  sarcomatous,  or  that  a 
sarcoma  may  arise  de  novo  in  the  uterus  and  attack  a  pre-existing  fibroid.  Rapid  enlarge- 
ment of  a  uterus,  with  irregular  ha-morrhage,  is  very  suspicious  of  a  sarcoma,  but  as  it  is 
not  uncommon  for  several  fibroids  to  be  present  in  the  same  uterus,  it  is  also  common  for 
rapid  enlargement  to  occur  as  a  result  of  cystic  changes  in  one  of  them,  wliilst  luemorrhage 
may  take  place  due  to  extrusion  of  another. 

Pure  rnrcinoma  of  the  body  of  llir  uterus  rarely  ])roduccs  much  enlargement  of  the  organ, 
and  any  increase  in  size  is  not  very  rapid. 

('Iiiirii)ii-rj)itlir!ii)>iia  follows  hydatidilorm  mole  in  about  .50  per  cent  of  the  recorded 
cases,  and  if  always  follows  pregnancy,  never  having  l)een  seen  in  the  uterus  in  a  case  where 
pregnancy  could  be  excluded.  It  is  associated  especially  with  profuse  bleeding  and  the 
rapid  development  of  a  ftrtid  discharge  due  to  decomposition  of  blood  and  necrosing 
tissues  in  ulero.  Carcinoma  of  the  body  of  the  uterus  rarely  produces  foul  discharges 
until  the  condition  is  very  advanced  and  has  become  exposed  to  the  air. 

The  diircrcntial  diagnosis  of  bleeding  due  to  cancer,  erosion,  and  tnl)crrle  of  Die  eervir 
is  often  difiiiult  in  the  early  stages.  In  advanced  can<'er  the  friable  hardness  of  the  growth 
distinguishes  it  at  once  froui  the  tough  leathery  hardness  present  in  erosions.  In  the  former, 
the  growth  can  lie  broken  down  with  the  (iiiger  ;  in  the  latter,  the  soft  velvety  erosion  can 
be  scra|)cd  oft  the  tough  leathery  and  fibrous  cervix  beneath.  Nothing,  however,  but 
.sections  made  from  wedges  removed  from  the  cervix  enable  us  to  distinguish  cancer  or 
erosion  from  tuhcrcle  in  the  early  stages.  Tubercle  of  the  cervix  is  usually  niislaUcn  for 
cancer.  l)ut  the  dilfcriticc  is  clear  enough  in  microscope  sections. 

Mucous  Jiolyj)!  and  Jihroiil  polypi  arc  common  causes  of  interuienstrual  bleeding,  and 
arc  usually  (juile  definite  growths.  The  mucous  polyjnis  is  soft,  strawberry-red  in  colour, 
ofl(  n  pediuiculalcd,  and  contains  cystic  spaces  filled  with  glairy  nmcus.  It  almost  never 
gives  rise  to  a  malignant  growth.  The  fibroid  ))olypus  is  hard,  and  shows  the  glistening 
whorled  appearance  so  well  knf>wn  in  fibromyomata  (m  section.  These  growths  arc  liable 
to  infcclion  and  sloughing,  and  arc  then  apt  to  !)e  mistaken  for  cancer  or  sarcoma.  The 
microscope  alone  will  enable  the  dirfcrcncc  to  be  uiadc  out. 

Kndoniclrilis  rarely  causes  se\cn-  incl  rorrhagia.  but   is  often  associalcd  wilh  a  bl 1- 

stained  watery  discharge.  In  a  doiibHiil  case  llicrc  is  absolulely  no  way  of  disl  iiiguishing 
it  except  wilh   the  microsc<ipc. 

The  Circulatory  System  is  sometimes  responsible  for  metrorrhagia,  just  as  it  is  for 
-Mknouiiiiacia  (p.  :!.s."i).  and  the  actual  causes  are  nuich  the  same.     It  is,  however,  especially 


392  METRORRHAGIA 

at  the  onset  and  the  decline  of  menstruation  that  irregular  bleeding  is  likely  to  occur  from 
this  cause.  The  same  disturbance  of  the  internal  secretions  which  may  cause  menorrhagia 
at  these  periods  sometimes  acts  similarly  in  causing  irregular  bleeding.  It  is  fairly 
common  to  find  yoinig  girls  at  the  onset  of  menstruation  liaving  menorrhagia  and  metror- 
rhagia, and  it  is  often  very  dilliciilt  to  be  certain  of  a  cause.  It  depends,  however,  very 
largely  on  two  definite  factors,  namely  :  (1)  Unusual  uterine  congestion,  the  result  of  an 
excess  of  the  biochemical  stinmUis  (internal  secretions)  of  menstruation,  and  (2)  deficient 
coagulation  power,  possibly  due  to  a  want  of  calcium  in  the  blood.  The  former  cannot 
be  diagnosed  by  any  defined  investigation,  but  the  latter  is  determined  by  estimating  the 
coagulation-time.  Purpura,  scorbutus,  and  ha?mophilia  are  diagnosed  readily  when  they 
act  as  causal  agents.  Leukainia  is  sometimes  responsible  for  irregular  uterine  bleeding, 
and  is  diagnosed  readily  by  making  a  total  and  differential  leucocyte  count  (p.  24). 

The  Nervous  System  seldom  causes  metrorrhagia,  but  there  is  no  doubt  that  sexual 
excess,  often  seen  in  the  iirst  months  of  married  life,  is  a  reflex  cause  of  uterine  congestion, 
and  may  cause  metrorrhagia  as  well  as  menorrhagia.  T.  G.  Stevens. 

METROSTAXIS  is  the  term  aiiplied  to  uterine  ha>morrhage  at  any  period  of  life, 
unconnected  with  menstruation,  or  at  times  when  menstruation  is  in  abeyance.  It  is 
convenient  to  keep  this  form  of  luemorrhage  separate  from  the  other  varieties,  because 
in  this  way  all  the  pregnancy  haemorrhages  can  be  differentiated  carefully.  Its  cause  may 
be  classified  according  to  whether  the  uterus  is  pregnant  or  not.  The  bleeding  which 
occurs  from  the  vagina  occasionally  in  new-born  infants  is  usually  thought  to  depend  upon 
uterine  congestion  subsequent  to  the  cessation  of  the  placental  circulation.  It  is  usually 
trivial,  but  a  fatal  case  has  been  reported. 

Causks    of    ?.Ij;ti!0.staxi.s. 


UrERUS  Non-Pregnant 


rTEKV?     PREf.NANT 


Uterine   bleeding  in   the  now-born                               Threatened   ahortion 

Malignant  growtlis  j             Antc-partum  hu'niorrliagc 

Polypi  I            Extra-uterine  gestation 

Senile  endometritis  Malignant  growths  of  cervix  or  vagina 

Senile  granular  vaginitis  Erosions 

Pyometra  Polypi. 

Secondary  post-])artnm  hsemorrhage 

Sub-involution  j 

The  differentiation  of  maHgrinnt  growths,  polypi,  and  senile  endometritis  can  only  be 
established  in  the  same  manner  as  in  cases  occurring  dm-ing  menstrual  life  (p.  391).  Senile 
adhesive  vaginitis  nnist  not  be  overlooked  as  a  possible  cause  ;  the  vaginal  walls  at  the 
fornices  become  inflamed  and  form  granulation  tissue  which  may  bleed  if  the  surfaces  rub 
together.  On  examining  such  cases  the  surfaces  may  be  partly  adherent,  and  the  separation 
brought  about  by  the  finger  may  cause  bleeding.  In  any  doidjtful  case,  the  routine 
dilatation  and  curettage  of  the  uterus  must  never  be  omitted.  An  unsuspected  pi/omelra. 
or  distention  of  the  uterus  with  pus,  may  cause  hsemorrhage,  along  with  a  foul  dischargi'. 
and  although  it  is  almost  always  accompanied  by  a  malignant  growth,  may  be  only  the 
result  of  infection  and  granidation-tissue  formation. 

In  relation  to  a  recent  pregnancy,  luemorrhage  may  result  from  simple  sub- 
involution, from  retained  products  of  conception,  and  from  chorion-c])itheli(jina.  The 
differentiation  of  these  conditions  can  be  established  only  by  exploration  of  the  uterine 
cavity,  with,  if  necessary,  the  assistance  of  the  microscope.  Such  conditions  may  be 
termed  secondary  post-partum  hfemorrhage  in  cases  occurring  within  a  few  days  of  delivery. 

Haemorrhage  from  the  pregnant  uterus  almost  always  means  separation  of  tin- 
placenta  or  of  the  embryo  from  its  attachments,  but  malignant  growths  of  the  cervix, 
erosions,  and  polypi  may  have  to  be  considered.  HaMnorrhage  from  a  pregnant  uterus  Is 
never  due  to  malignant  growths  of  the  body  of  the  organ,  because  jjregnancy  is  |)raetieally 
impossible  with  such  lesions.  There  are,  however,  two  great  difficulties  in  connection 
with  pregnancy  haemorrhages:  these  are  to  differentiate  (1)  the  uterine  haemorrhage 
which  occurs  along  with  e.rtra-iiterine  gestation  from  that  due  to  threatened  abortion  ;    and 


MICTURITION.     ABNORMALITIES    OF  393 

(2)  the  bleeding  of  placenta  prcevia  from  that  due  to  tlic  separation  of  a  nonnalli/  situated 
placenta. 

In  tlie  first  case,  arising  very  early  in  pregnancy,  the  haimorrhage  occurs  when  the 
extra-uterine  gestation  is  separated  from  its  tubal  or  other  attachments  and  is  converted 
into  a  tubal  mole,  when  it  becomes  extruded  from  the  fmibriated  extremity  of  the  tube, 
or  when  the  tube  ruptures.  Therefore,  there  may  be  history  of  acute  abdominal  pain, 
faintness,  and  possibly  collapse  from  internal  luemorrhage.  Along  with  this,  the  uterus 
will  not  be  found  obviously  enlarged,  whilst  there  is  some  sort  of  swelling  in  one  or  the 
other  [jostenor  quarter  of  the  pelvis.  Haemorrhage  due  to  threatened  abortion  cannot 
be  diagnosed  unless  the  presence  of  an  intra-uterine  pregnancy  can  be  established.  There- 
fore, in  this  case  we  must  look  for  the  definite  signs  of  a  normal  pregnancy,  which  in  the 
early  months  will  be  :  amenorrhcea,  morning  sickness,  breast  changes,  enlargement  of 
the  uterus,  llegar's  sign,  and  Braun"s  sign.  The  former  consists  in  the  extreme  softening 
of  the  upper  part  of  the  cervix  and  lower  part  of  the  uterine  body,  combined  with  the  as 
yet  misoftened  vaginal  portion  and  globular  tense  fundus  ;  it  is  found  from  the  sixth  to 
tlie  eighth  week.  The  latter  consists  in  the  irregular  shape  of  the  uterus  from  the  eighth 
to  the  twelfth  week.  One  side  is  larger  tlian  the  oHur,  and  an  ill-defined  groove  is  found 
hetween   them. 

In  the  second  ease,  occurring  generally  after  the  sixth  month  of  pregnancy,  it  is  of 
the  greatest  importance  to  be  able  to  diagnose  placenta  prwvia.  The  only  definite  sign  is 
the  feeling  of  the  ])lacenta  through  the  cervix  when  it  will  admit  of  this  method  of  investi- 
gation. The  suggestive  signs  are  those  due  to  the  filling  up  of  the  lower  uterine  segnaent 
by  the  jdacenta.  The  presenting  jiart  remains  high  up  and  movable,  not  engaged  in  the 
brim,  and  there  is  a  sensation  of  great  increase  of  thickness  between  the  vaginal  fornices 
and  the  j)resentiiig  i)art.  In  any  case  of  severe  luemorrhage,  however,  the  cervix  must 
be  dilated  so  as  to  admit  a  finger,  as  treatment  depends  ujion  diagnosis,  and  no  patient 
with  a  placeiila  pra'via  is  safe  until  she  is  delivered  and  bleeding  has  ceased. 

T.  G.  Stevens. 

MICROPSIA.      (See   \isiON.    Dki-kcts   ok,    p.   7(i3.) 

MICTURITION,  ABNORMALITIES  OF.— .\  persi.n  iu  health  micturates  about 
five  times  during  the  twenty-four  hours,  the  total  amoimt  of  urine  ])assed  being  about 
150()  c.e.,  or  .50  ounces.  This  \aries  according  to  the  amount  of  llidd  taken,  the  amount 
lost  by  perspiration,  and  so  forth.  The  act  of  micturition  is  controlled  by  a  nervous 
mechanism,  a  stinndus  from  the  vesical  nmeons  mendirane  starting  an  imi)ulse  which 
causes  contraction  of  the  detrusor  muscle,  and  at  the  same  time  relaxation  of  the  sphincter 
at  the  urethral  oriliee.  'J'lic  s])eeial  centres  eontrolling  the  iiiolDr  functions  of  the  bladder 
are  in  the  spinal  cord  at  the  level  of  the  third  sacral  ner\c.  wliilst  the  brain  controls  these 
centres  in  response  to  sensory  impulses  received.  The  abiinnii.ililiis  of  micturition  which 
.•ire  nut  with  in  practice  depend  partly  upon  jc^iims  of  mhiic  portion  of  the  minary 
apparatus,  and  partly  upon  some  change  in  the  nervous  mechanism  controlling  the  ael, 
and  will  he  discussed  from  these  j)oiiils  (jf  \  irw.  ;i.iid  under  I^'^MUKsis  (p.  218). 

1.  Increased  Frequency  of  Micturition.  A  large  number  of  diseases  of  the  geiiilo- 
urinary  trad  are  accompanied  by  ifiereased  frecpieiiey  of  micturition,  and  it  is  necessary 
to  ascertain  if  the  increased  freipiency  of  micturition  depends  upon  an  increased  amount 
of  urine  to  be  passed.  Thus  in  diabetes  or  cliionie  interstiti(d  nephritis,  the  increased  amount 
of  urine  will  cause  an  increased  frcfpicncy  of  desire  to  micturate,  provided  the  capacity  of 
the  iilad<ler  is  unaltered.  If  the  total  amomit  of  urine  remains  normal,  any  iiiereaseil 
fre(piency  of  niielurition  may  be  due  to  some  lesion  of  the  genilo-uriuary  apparatus,  and 
eonsideral  ion  of  the  other  sym|)toms  of  a  ease  will  often  point  to  a  dclinilc  diagnosis.  II 
iiiusi  he  riiniriilK  red.  however,  that  increased  frecpicney  iloes  not  neeessaril\  imply  Ihal 
llie  l>ladiler  is  llie  seal  of  the  disease,  as  the  symptom  is  present  with  any  form  of  renal 
pyelitis      eoituiioniy  <aleui<ius  or  tubercidous    -or  with   prostatic  eidargemeul. 

It  is  important  to  ascertain  the  relationship  between  mi<-tnrilion  during  llie  day  and 
during  llu-  night.  Xormally,  a  healthy  person  should  not  wake  during  the  nigid  to  pass 
urine,  nidess  an  excess  of  fluid  has  been  taken  ;  but  if  any  irdlainmalory  condit  ion  is  present 
ill  llie  bladder,  micturition  will  he  present  during  the  night,  as  well  as  inereascrl  in  frei|uencv 
diuiMg   the  day.      .\ny    form   of  ei/\lilis  or  aeiile   iiillaniinatory   eoridilions   of   llie   prostate 


394  MICTURITION.     ABNORMALITIES    OF 

or  neighbouring  organs,  will  cause  increased  fre(|uency  both  day  and  niglit.  In  jjatients 
with  chronic  nephritis  who  are  passing  normal  quantities  of  urine  during  the  day,  frequent 
micturition  at  night  is  common. 

With  vesical  calculus  there  is  increased  frequency  during  the  day,  but  often  no 
urination  is  necessary  during  the  night.  The  frequency  during  the  day  is  increased  with 
activity  or  exercise,  or  by  the  jolting  movements  of  travelling,  but  is  absent  during  a 
period  of  rest.  If  the  presence  of  a  calculus  has  excited  cystitis,  increased  frequency  of 
micturition  will  be  present  both  day  and  night. 

With  prostatic  eiilargenieiit.  whether  simple  or  carcinomatous,  the  increased  frequency 
is  most  marked  at  night,  and  is  commonly  the  first  symptom  of  the  disease  noticed  by  the 
patient,  generally  a  man  of  about  sixty.  The  bladder  is  not  emptied  completely,  so  that 
the  addition  of  a  relatively  small  amount  of  urine  from  the  kidneys  soon  fills  up  the  in- 
completely emptied  viscus  and  sets  up  afresli  the  desire  to  micturate. 

In  vesical  carcinoma,  increased  frequency  of  micturition  is  present  during  both  the 
day  and  night,  as  the  infiltration  of  the  vesical  wall  prevents  the  bladder  from  being  dis- 
tended without  pain,  and  it  is  frequently  associated  with  cystitis. 

In  renal  colic  caused  by  calculus  or  blood-clot,  or  torsion  of  a  movable  kidney,  there 
may  be  increased  desire  to  micturate,  and  the  symptom  may  be  present  in  inflammatory 
diseases  in  the  pelvis,  such  as  salpingitis.  pi/()S(d])inT.  or  a  low-placed  appendicitis,  or  in 
the  secondary  infiltration  of  the  bladder  in  carcinoma  of  the  uteras  or  rectum. 

Increased  frequency  of  micturition  may  be  produced  by  mechanical  obstruction  to 
the  normal  vesical  distention  by  a  tumour  occupying  the  pelvis,  and  is  seen  commonly 
with  ovarian  ri/st,  uterine  fibroid,  or  a  retroverted gravid  uterus  ;  these  tumours  will  be  found 
upon  vaginal  examination. 

In  children,  increased  frequency  of  micturition  may  be  due  to  phimosis,  balanitis, 
a  small  urinary  meatus,  worms,  penile  calculus  (p.  4(i!t).  oxaluria  (p.  42;i).  coli  bacilluria 
(p.  09),  or  to  hyperacidity  of  the  urine. 

2.  Changes  in  the  Stream  of  Urine. — .\n  abziormality  of  the  stream  of  urine  may 
be  due  to  a  congenital  deliciency  of  the  terminal  urethra,  as  in  hypospadias  or  epispadias. 
or  to  some  lesion  mechanically  obstructing  the  stream.  Most  commonly  this  is  due  to  a 
stricture  of  the  urethra.  If  the  stricture  be  situated  in  the  penile  portion,  the  stream  of 
urine  is  of  small  calibre  but  of  fair  force,  whilst  if  the  stricture  is  in  the  bulbous  urethra, 
the  mechanical  effect  upon  the  stream  of  urine  passing  through  the  stricture  into  the 
urethra  of  wider  calibre  beyond  the  stricture  is  that  the  force  is  diminished,  whilst  the 
actual  stream  as  it  leaves  the  meatus  is  not  thinned.  .\  stricture  at  or  near  the  urethral 
meatus  forms  a  thin  but  forcible  stream  ;  but  no  reliance  can  be  placed  upon  the  com- 
plaint of  a  '  twisted  stream.' 

The  obstruction  to  micturition  by  an  enlarged  prostate  causes  the  stream  of  urine  to 
be  slow  and  forceless,  so  that  it  may  fall  vertically  from  the  meatus  instead  of  in  the  usual 
arched  manner.  This  same  dribbling  of  urine  will  be  seen  when  a  urethral  stricture 
becomes  much  narrowed,  or  again  when  the  bladder  musculature  has  lost  its  contractile 
jjower,  or  in  disease  of  the  nervous  system  affecting  the  motor  paths  to  the  bladder. 

In  any  case  presenting  an  abnormality  in  the  stream  of  urine,  careful  inquiry  should 
be  made  to  ascertain  if  the  stream  has  become  gradually  and  jjrogressively  narrowed,  as 
in  stricture,  or  if  the  alteration  in  the  force  of  the  stream  is  accompanied  by  increased 
frequency  of  urination,  as  in  prostatic  hypertrophy  in  an  elderly  patient,  or  by  urethral 
discharge  in  a  case  suggestive  of  acute  prostatitis.  A  strictiu'c  may  be  diagnosed  with 
certainty  by  careful  endoscopic  examination  under  air-distention,  or,  failing  this,  by  the 
obstruction  offered  to  the  passage  of  a  catheter  or  bougie.  Prostatic  enlargement  or  inflam- 
mation will  be  suggested  by  the  history  of  the  case,  and  confirmed  by  a  digital  examination 
of  the  gland  per  rectum  ;  in  the  absence  of  a  mechanical  obstruction  in  the  urethra,  exam- 
ination should  be  conducted  for  any  disease  of  the  spinal  cord  by  testing  the  knee-jerk 
and   other   reflexes. 

Sudden  stoppage  of  the  floio  of  urine  during  mictiu-ition  may  be  caused  by  a  small, 
movable  vesical  calculus,  if  the  latter  happens  to  engage  in  the  internal  urethral  orifice  or 
becomes  impacted  in  the  urethra.  The  same  sudden  cessation  of  the  flow  is  caused  occa- 
sionally by  a  tuft  of  a  vesical  villous  tumour  blocking  the  urethral  opening  during  mic- 
turition.    Usually  the  flow  will  be  resumed  after  a  few  seconds,  unless  the  calculus  has 


MICTURITION'.     ABXORMALITIES    OF  395 

passed  into  the  urethra,  when  it  may  be  passed  naturally  or  require  to  be  removed  by 
surgical  means.  If  the  symptom  recurs,  a  cystoscopic  examination  of  the  bladder  will 
distinguish  readily  between  the  two  conditions. 

The  same  sudden  cessation  of  the  stream  may  occur  without  any  intravesical  lesion 
as  the  result  of  spasmodic  coniraclion  of  the  vesical  sphincter.  Patients  subject  to  this  trouble 
(so-called  stammering  bladder)  can  at  times  pass  urine  quite  normally,  but  at  others  the 
stream  is  interrupted  frequently,  or  they  may  be  unable  to  pass  urine  at  all,  especially  in 
the  presence  of  a  second  person. 

:i.  Difficulty  In  Micturition. — Frequently  associated  with  some  change  in  the  character 
of  the  stream  of  urine,  a  patient  may  complain  of  difBculty  in  micturition,  either  as  a 
hesitation  in  coinmenciug  the  How  or  a  need  to  strain  to  maintain  it.  This,  again,  is  most 
common  with  iiretliral  stricture  or  prostatic  enlargement,  or  may  be  due  to  the  impaction  of 
a  calculus  in  the  urethra  or  to  the  formation  of  blood-clot  in  the  bladder.  A  calculus  may 
be  passed  into  the  urethra  and  become  arrested  in  the  canal,  but  not  so  that  it  wholly 
obstructs  the  passage  of  urine.  It  is  not  uncommon  for  a  calculus  to  occupy  the  dilated 
portion  of  the  virethra  behind  a  stricture,  or  occasionally  a  prostatic  calculus  ])roJects  from 
the  gland  into  the  lumen  of  the  posterior  urethra.  A  calculus  so  placed  may  increase  in 
size  by  the  further  deposition  of  urinary  salts  whilst  in  the  urethra,  and  cause  difficulty 
in  micturition  ;  it  may  be  felt  in  the  canal  from  the  outside,  upon  recta!  examination,  or 
upon  passing  a  soft  bougie  into  the  urethra.  Even  if  placed  behind  a  stricture  it  may 
be  felt  by  a  fine  guide  or  bougie  passed  to  dilate  the  stricture.  Difficulty  in  micturition 
may  also  arise  from  jjrostatie  inflammation  or  from  tuberculous  disease  of  the  prostate. 

Dilficulty  in  micturition  due  to  the  presence  of  blood-clot  in  the  bladder  will  usually 
be  indicated  by  the  jirevious  passage  of  blood-stained  urine  and  by  the  constant  efforts 
to  micturate. 

Dilliculty  in  micturition  in  the  female  may  be  caused  by  a  pelvic  tumour  by  the  drag 
or  direct  pressure  on  the  virethra  or  vesical  neck.  This  may  occur  with  a  uterine  fibroid 
or  a  pregnant  rctrovertcd  uterus.  Occasionally,  difficulty  is  produced  by  the  direct  infll- 
I  nil  ion  of  the  urethra  by  a  carcinoma  of  the  vaginal  wall  or  vulva. 

IJilficulty  in  micturition  is  not  uncommon  in  disease  of  the  nervous  system,  causing 
paralysis  or  paresis  of  the  detrusor  muscle  of  the  bladder.  This  may  be  due  to  trauma 
and  pressure  on  the  spinal  cord  by  blood-clot,  or  to  myelitis  or  tabes.  It  must  be  remem- 
bered that  it  is  not  uncommon  for  the  early  cord-changes  of  tabes  to  affect  the  urinary 
organs,  and  that  dilliculty  in  passing  urine  may  be  complained  of  when  the  urethra  and 
bladder  are  normal. 

.It'tny  of  the  hlintder  icfdl  without  any  affection  of  the  nervous  niechauisni.  Inim  recur- 
ring over-distcrition  of  the  bladder,*  may  cause  dilliculty  in  micturition. 

I.  Retention  of  Urine — by  which  is  implied  the  gradual  aecumidation  of  urine  in 
tlic  lihuldcr.  wilh  inability  to  pass  any  [jer  urethram — may  arise  from  ntcclianiral  causes 
obstructing  the  un-thra.  or  from  derangement  of  the  nervous  system.  Ketention  of  urine 
nnist  be  distinguished  from  Am  iti.\  (p.  :j!)).  or  failure  of  the  kidneys  to  secrete  in'ine,  for 
in  retention  the  ki<liieys  are  still  furu'tioning,  and  the  urine  is  collecting  in  the  distended 
hl:iilder.  Retention  of  urine  occurring  suddenly  produces  very  severe  ])ain  and  strangury, 
IjuI  in  cases  of  old-standing  obstruction  the  bladder  may  be  distended  enormously  before 
pain  becomes  se\(rc.  If  the  retention  remains  unrelieved,  urine  may  conl  iiuially  dribble 
iiway  per  urethram,  when  a  condition  resembling  incontincnri-  iif  urine  is  produced  :  but 
it  is  most  important  to  distinguish  the  condition  from  tr}ie  incontinence  ol  urine  due  to 
injury  or  p;'r;!lysis  of  the  vesical  sphincter  muscle.  In  true  ineoni  ineru  c  the  bladder 
remains  eiiijily.  urine  Hows  away  as  soon  as  it  (nisses  down  into  the  bladder,  and  there  is 
no  iihsl  riielicjii  In  I  hi'  iiiclhia  ;  \vhcr(:is.  in  I  he  eoiidilion  of  involunlary  passage  of  urine 
from  an  liMiclieMcl  ilislencU  il  lihiddei'  inr(nitinrncc  frinii  (rtcrjlinc.  or  false  incontinence — 
the  bladder  may  be  fell  distended  in  the  su|)rapill)ic  region,  and  there  exists  some 
meelianieHJ  obstruction  in  the  urethra,  or  at   the  internal  urethral  oriliee. 

The  common  causes  of  retention  of  urine  are  urethral  stricture  and  prostatic  enlarge- 
UKiil.  In  stricture,  it  does  not  necessarily  follow  that  the  urethra  is  entirely  occluded  by 
llu'  fibrosis,  but  rather  that  sonu'  spasm  or  congestion  is  present  al  the  stricture,  from 
exposure  to  cold  or  indulgence  in  alcohol,  when  a  snndl  catheter  may  be  passed.  In 
elderly  men  with  prosttilic  hypertrophy .  aeulc  retentioti  may  occur  early  in  the  disease  from 


396  MICTURITION.     ABNORMALITIES    OF 

a  congested  condition  of  the  enlarged  gland,  or  in  the  later  stages  be  due  to  actual  obstruc- 
tion of  the  urethra  by  a  localized  enlargement  from  either  lateral  lobe  or  the  so-called  third 
lobe  which  acts  as  a  ball-valve  to  the  internal  urethral  orifice  in  such  a  manner  that  each 
forced  attempt  at  urination  closes  the  orifice  more  securely.  A  large  coude  catheter  can 
usually  be  passed  readily  :  but  in  cases  of  acute  retention,  especially  in  those  of  old- 
standing  obstruction  in  which  the  kidneys  are  probably  affected  by  the  backward  pressure, 
///(■  Hiiiw  niiixl  be  drincii  (iff  it;//  slowly,  otherwise  fatal  aniu'ia  may  be  induced. 

A  case  of  acute  retention  of  urine  from  stricture  of  the  iirellira  will  generally  be  that 
of  a  comparatively  young  patient,  who  will  give  a  history  of  former  gonorrhoea,  gradually 
increasing  difficulty  in  micturition,  narrowing  of  the  stream,  and  inability  to  finish  the 
flow  completely  without  some  dribbling  of  urine.  Examination  of  the  urethra  by  an 
endoscope,  or  by  the  passage  of  olivary-pointed  flexible  bougies,  will  reveal  the  presence 
of  a  stricture. 

In  prostatic  enlargement  the  patient  is  usually  above  the  age  of  flfty-flve  years,  has 
been  troubled  with  increasing  frequency  in  micturition,  especially  at  night,  with  .straining 
and  loss  of  force  in  the  stream  of  urine.  Per  rectum,  the  prostate  may  be  found  to  be 
enlarged  both  from  above  downwards  and  laterally  ;  it  may  be  smooth,  elastic,  and 
movable  in  the  pelvic  space  in  the  case  of  adenomatous  enlargement,  or  nodular,  hard, 
irregular,  and  fixed  in  tlie  case  of  carcinoma  :  the  subjective  symptoms  of  both  are  very 
similar.  In  some  cases  the  prostate  may  not  appear  to  be  much  enlarged  upon  rectal 
examination,  though  it  is  causing  an  intravesical  tumour  which  obstructs  urination,  or  a 
firm  fibrous  collar  around  the  internal  urethral  orifice  which  gives  rise  to  marked  prostatic 
symptoms.  In  prostatic  cases,  even  a  large  catheter  of  coude  form  can  usually  be  passed 
into  the  bladder  readily.  Retention  of  urine  may  also  be  present  in  cases  of  acute  pro- 
statitis or  of  ])rostatic  abscess. 

.\eute  retention  of  urine  may  be  produced  by  other  causes  than  the  above.  A  small 
calculus  may  be  passed  into  the  urethra  and  totally  obstruct  the  passage  of  urine.  This 
may  occur  at  any  age,  and  the  calculus  become  arrested  at  some  narrow  portion  of  the 
canal — usually  at  the  meatus  or  at  the  membranous  urethra.  The  uretlira  may  lodge  a 
calculus  for  some  time  with  comparatively  little  pain  ;  but  more  often  the  stone  passes 
into  the  canal  during  micturition,  causing  a  sudden  pain,  with  cessation  of  the  flow  of  urine 
and  dribbling  of  a  few  drops  of  blood.  Tlie  calculus  may  be  jjalpated  if  it  lies  in  the  penile 
urethra  or  in  the  j)erineum.  or  will  be  felt  on  passing  a  metal  instrument  into  the  urethra. 

Retention  may  be  caused  by  the  blockage  of  the  internal  urethral  orifice  by  the  free 
poi'tion  of  a  pedunculated  vesical  tumour.  On  any  atteni])!  at  micturition  the  growth  is 
forced  into  the  orifice  and  obstructs  it.  Tliese  cases  are  rare,  but  in  one  under  the  care 
of  the  writer,  a  man,  owing  to  his  inability  to  pass  any  uriue,  had  been  condemned  to 
catheter  life  on  the  assumption  that  he  had  prostatic  enlargement.  No  enlargement  could 
be  felt  jier  rectmn.  but  ui)on  cystoscopic  examination  a  jjapilloma  was  found  in  the 
bladder,  attached  by  its  pedicle  just  above  the  urethral  orifice  and  obstructing  the  flow 
of  mine. 

Retention  of  urine  may  also  occur  with  parali/sis  of  the  motor  nerves  of  the  detrusor 
nniscle  of  the  bladder,  or  interference  with  the  spinal  centres  by  compression  j)ara])legia, 
tabes  dorsalis,  or  myelitis,  each  being  diagnosed  on  examination  of  the  nervous  system  ; 
or  as  a  reflex  spasm  of  the  vesical  sphincter  after  operations  upon  the  rectum  or  neighbour- 
ing organs. 

In  fither  cases,  retention  of  urine  is  present  in  association  with  other  syni])toms  of 
lif/sleria  :  but  care  must  be  taken  not  to  give  a  diagnosis  of  liysteria  until  all  other  causes 
of  retention  are  excluded.     These  cases  usually  occur  in  children  or  in  young  women. 

Retention  of  urine  occurring  after  operations  about  tlie  anal  or  rectal  areas  or  for 
hernia,  etc.,  will  be  diagnosed  readily. 

5.  Pain  during  Micturition. — Pain  may  be  present  duriug  or  immcdiatelii  after  mic- 
turition, and  it  is  iniportiint  to  ascertain  not  only  the  period  at  whieli  it  is  ])resent,  but 
also  the  actual  location  of  the  pain.  If  pain  is  present  in  the  urethra  during  micturition, 
it  usually  indicates  that  a  stricture  or  some  inflammatory  process  is  present,  the  latter 
being  evidenced  by  a  urethral  discharge  (see  Disch.\rge.  Uretuk.^l,  p.  181).  If  pain  is 
experienced  immediately  after  micturition,  and  felt  as  a  tingling  or  pricking  sensation  in 
the  glans  penis,  there  is  some  inflammatory  or  irritant  process  at  the  trigonal  region  of 


.MICTURITION.     .\BXORM.\LITIES    OF  397 

the  l)lad(ler.  Formerly  this  syniptoni  was  looked  ii])Oii  as  diagnostic  of  vesical  calculus, 
and  though  it  is  almost  a  constant  symptom  of  the  latter,  provided  the  calculus  is  not 
trapped  in  a  post-prostatic  pouch,  it  is  also  present  in  cystitis,  tuberculous  or  otherwise, 
in  vesical  carcinoma  which  is  infiltrating  the  bladder  base,  and  in  acute  or  subacute  pros- 
tatic infections.  Prostatic  infection  can  be  diagnosed  by  the  history  of  the  case,  usually 
following  an  acute  urethritis,  and  by  a  rectal  examination.  Tuberculous  cystitis  usually 
occurs  in  young  adults,  and  frequently  other  tuberculous  lesions  are  present  in  the  genito- 
urinary organs,  such  as  the  epididymis,  vas  deferens,  seminal  vesicles,  or  prostate,  whilst 
the  urine  contains  not  only  blood  and  pus,  but  tubercle  bacilli.  Cystitis  from  other  causes, 
and  vesical  growth  or  calculus,  can  be  ascertained  upon  eystoscopic  examination. 

Pain  may  be  felt  in  the  perineum,  during  and  after  micturition  in  cases  of  prostatic 
disease,  especially  if  much  straining  occurs  during  micturition,  or  may  be  felt  in  both  the 
perineum  and  the  anal  area  in  vesical  carcinoma. 

In  the  female,  pain  is  felt  at  the  uretlu'al  orifice  and  in  the  vulva  after  n^icturition  in 
eases  of  cystitis  or  vesical  carcinoma. 

It  should  be  noted  that  in  either  sex,  severe  pain  may  be  present  at  the  termination 
of  the  urethra  after  micturition  when  a  calculus  is  impacted  in  the  vesical  cud  of  a  ureter. 
{Fig.  192,  p.  -tao),  especially  if  the  latter  is  partially  prolapsed  into  the  bladder.  In  one 
such  ease  the  patient  would  hold  her  urine  for  hours  rather  than  pass  it,  owing  to  the  pain 
that  followed  micturition. 

<i.  Micturition  through  Fistulae. — Urine  may  pass,  either  wholly  or  in  part,  through 
a  listulous  track  communicating  with  the  urinary  organs,  such  opening  being  the  result 
of  preceding  disease  or  injury.  Occasionally,  owing  to  congenital  malformation  of  the 
urethra  or  bladder,  urine  jjasses  by  an  opening  in  the  perineum,  pubes,  or  into  the  vagina  ; 
but  these  cannot  be  regarded  as  flstuhc. 

Irinary  listiilic  in  connection  with  the  urethra  are  most  ((inuiion  as  the  residt  of  peri- 
urethral abscess,  stricture,  or  some  operation  ;  and  in  a  case  in  which  a  ]jeiiile  fistula  is 
present,  it  is  necessary  to  ascertain  if  the  calibre  of  the  urethra  is  in  any  way  narrowed  by 
cicatricial  inllanmiation.  .\  fistula  may  open  in  the  perineum  as  the  result  of  inflamma- 
tion and  extravasation  behind  a  stricture,  following  an  operation  upon  the  lower  urinary 
organs,  or  in  the  female  into  the  vagina  from  damage  during  parturition  or  some  vagina! 
operi',tion.  In  cases  in  wliieh  a  fistula  opens  into  the  vaginal  fornix,  the  urine  may  leak 
from  the  blailder  or  from  the  lower  enrl  of  the  ureter.  The  oi)ening  is  usually  small  and 
embedded  in  an  area  of  eicatiiciiil  tissue,  so  that  it  is  very  dillieidt  to  jiass  a  probe  along 
tlic  tn'ck.  In  IIksc  eivscs.  cvidcuct'  of  llic  nalurc  of  the  fistula  may  be  obtained  by  filling 
lln-  bladilcr  with  sonic  sterile  eoioured  solution,  sueli  as  weak  methylene  blue  ;  if  the  open- 
ing is  in  corurnuniciilion  with  tli<'  bladder,  coloured  solution  will  api)ear  in  the  vagina,  but 
if  the  uritic  comes  finm  the  ureter,  no  stain  will  be  found.  I'Aidenee  may  also  Ije  obtained 
by  means  of  the  cystoscupe,  when  a  cicatricial  area  may  be  found  in  the  bladder  surround- 
ing a  retracted  fistulous  opening,  or  the  ureteric  orifice  of  one  side  may  lie  found  displaced 
from  its  normal  situjition  by  the  scar  contraction  when  the  ureter  is  at  fault.  In  these 
cases  it  may  be  impossible  to  pass  a  bougie  into  the  ureter  more  than  a  very  short  distance, 
the  ti{)  being  arrested  by  the  scar  tissue. 

A  urinary  fistula  may  be  |)rcsent  in  I  he  suprapubic  area  in  comiccl  ion  wit  h  the  bladder. 
or  hi  the  lumbar  area  comrnuni<-aling  with  flic  kidney,  as  the  result  of  operalions  on  these 
two  organs.  .\  fislula  lias  been  seen  in  the  iliac  fossa  as  Ihe  result  of  an  (>|)eraliou  on  the 
ureter,  and  after  the  opening  of  an  abscess  formed  around  Ihe  incler  from  Ihe  uiceialion 
caused  by  a  urelciic  calculus. 

7.  Disorders  of  Micturition  f.-om  Diseases  of  the  Nervous  S.vsteni. —  In  most 
of  the  foregoing  par:igi:iplis  It  will  lie  noliciil  lli:il  syniploius  ri  reiablc  (o  Die  urinary  organs 
have  been  slaleil  lo  be  due  in  soine  ciiMs  lo  disease  of  Ihc  uerxous  system,  such  as  myelitis, 
tabes  dorsalis,  or  hemiplegia  :  In  spile  of  repetition  it  is  advisable  lo  gather  these  imdcr 
one  heading.  The  control  of  Ihc  ;i<l  of  micturition  depends  upon  the  integrity  of  the 
nervous  system  ;  for  allliough  special  centres  exist  in  Ihe  lower  segnu'iits  of  the  spinal 
area  presiding  (;vcr  the  motor  functions  of  the  bladilcr,  Ihc  impidsc  calling  for  action  of 
these  centres  is  supplied  by  the  brain  aflcr  a  stinujlus  has  been  conveycil  to  the  latter 
by  the  sensory  nerve  libres  from  Ihc  blailder.  There  are  two  centres  in  Ihe  lower  spinal 
segment,  by  one  of  which  Ihe  detrusor  nmsele  of  Ihe  bladflcr  is  brought  into  action,  and 


398  MUCUS     IN    THE    STOOLS 

by  the  otl;cr  tlie  si)hinctcr  nniscic  siirroundinir  the  vesical  outlet  is  maintained  in  tonic 
contraction  until  inhibited  by  the  same  stimulus  which  produces  contraction  of  the 
detrusor.  The  two  vesical  muscles  are  thus  antagonistic  in  their  action,  the  detrusor 
contracting  and  the  sphincter  relaxing  in  answer  to  the  stimulus  to  micturition.  In  the 
diagnosis  of  all  neuroses  of  the  bladder  it  is  most  important  to  exclude  all  lesions  of  the 
urinary  apparatus,  and  not  to  overlook  the  fact  that  vesical  symptoms  are  often  produced 
by  some  lesion  in  the  kidney  when  the  bladder  on  careful  examination  appears  quite 
normal. 

(n).  Irritability  of  the  Sensory  Newes  of  the  Bladder. — Sonae  patients  experience  an 
urgent  and  frequent  desire  to  pass  urine,  often  every  half-hour,  though  no  objective 
symjitoms  of  disease  can  be  found,  and  all  inflammatory  lesions  can  be  excluded  ;  there 
is  no  pain  and  no  increased  frequency  of  micturition  during  the  night.  The  cases  have 
received  the  name  of  cystalgia.  hi/periesthesia  vesiece.  and  irritable  bladder,  and  they  must 
be  distinguished  carefully  from  those  in  which  there  is  some  lesion  of  the  urinary  organs, 
the  rectum,  and  of  the  female  jielvic  organs. 

(b).  Irrilaltititi/  of  the  JMotor  Xerves  of  the  Bladder. — In  this  condition  there  is  a  spas- 
modic contraction  of  the  s])hincter  muscle  of  the  bladder,  with  resulting  retention  of  urine 
or  great  difficulty  in  micturition.  There  is  no  stricture  or  urethral  obstruction,  as  shown 
by  the  ease  with  which  a  catheter  is  passed,  nor  is  there  any  prostatic  enlargement.  The 
neurosis  is  not  confined  to  the  male  sex,  and  is  seen  in  hysteria  as  well  as  in  those  nervous 
affections  which  affect  the  sjjinal  centres,  such  as  myelitis,  lateral  sclerosis,  and  tabes 
dorsalis. 

(r).  Paralysis  of  the  Motor  Xerves  of  the  Bladder  may  affect  the  peripheral  nerves  or 
spinal  elements,  but  the  results  as  regards  the  bladder  are  the  same.  If  the  nerves  supply- 
ing the  detrusor  muscle  or  its  spinal  centre  be  paralyzed,  retention  of  urine  occurs,  and 
the  patient  can  expel  urine  only  by  the  force  of  the  abdominal  wall.  If  the  sphincter  muscle 
is  affected,  it  bccoujes  relaxed,  and  urine  dribbles  away.  In  many  cases  only  ])art  of  the 
motor  tract  is  affected,  so  that  the  ])ower  of  the  bladder  is  not  abolished  but  diminished, 
and  a  portion  of  the  urine  is  retained  in  the  bladder  after  micturition.  The  bladder  may 
be  affected  thus  in  compression  of  the  spinal  cord  by  fracture,  or  lucmorrhage  into  the 
membranes,  in  myelitis,  paraplegia,  and  tabes. 

(rf).  Destruction  of  the  Spinal  Centres  for  Micturition,  by  injury,  softening,  or  com- 
pression, gives  rise  to  incontinence  without  distention  of  the  bladder.  The  urine  dribbles 
from  the  urethra  as  fast  as  it  enters  the  bladder.  l{.  //.  Jocelyn  Sivan. 

MOUTH,   PIGMENTATION    IN.— (See  PKiMENTATiox  i\  tue  iMorxu,  p.  526.) 

MUCUS  IN  THE  STOOLS.-— This  occurs  in  such  a  variety  of  conditions  that  it  is 
impossible  to  give  a  complete  differential  diagnosis  of  them  here.  Its  presence  always 
indicates  organic  disease,  usually  of  the  large  bowel,  for  if  it  comes  from  the  small  bowel 
it  will,  imless  the  motions  are  very  fluid,  be  so  incorporated  with  them  that  it  cannot  be 
seen.      It  occurs  in  malignant  disease  of  the  colon  as  a  clear  glairy  mucus,  often  blood-stained. 


and  it  has  the  same  characters  in  intussusception,  for  the  obstruction  in  both  these  cases 
accoimts  for  the  absence  of  ftecal  colouring.  It  is  often  seen  in  constipated  motions,  the 
hard  fa;ces  ha^'ing  led  to  irritation  of  the  large  bowel,  with  consetiuent  excessive  secretion 
of  mucus  ;  if  this  has  lain  some  time  in  the  bowel  it  has  become  coagulated  into  white 
shreds,  which  can  be  seen  attached  to  the  motions  and  look  like  parasitic  worms.    In  severe 


NAILS.     AFFECTIONS    OF    THE  399 

cases  a  motion  may  consist  almost  entirely  of  these  shreds  :  there  may  be  little  faecal 
matter.  If  the  mucus  has  not  lain  so  lonij  in  the  bowel,  it  appears  like  a  jelly  outside  the 
motion.  .Sometimes,  especially  in  adult  women  who  are  constipated,  complete  easts  of 
the  bowel  formed  of  coagulated  mucus  are  passed  :  they  may  be  a  foot  or  more  in  length 
{Fig.  172).  Often,  however,  by  the  time  they  are  passed,  they  have  become  broken  into 
fragments  which  the  patient  describes  as  skins,  and  which  look  not  unlike  segments  of 
tape-worm.  Patients  passing  this  variety  of  mucus  are  said  to  have  membranous  colitis. 
In  the  more  acute  varieties  of  inllammation  of  the  bowel  the  mucus  passed  is  jelly-like 
and  semi-fluid,  of  varying  colour  according  to  the  amount  of  ficcal  staining.  In  severe 
cases  of  enteritis  the  motions  consist  of  nothing  but  mucus  and  blood.  It  is  impossible 
to  attempt  to  differentiate  here  between  all  the  numerous  varieties  of  enteritis. 

ir.  Hale  While. 

MUCUS  IN  THE  URINE  is  generally  of  little  clinical  significance.  Many  normal 
u^ine•^.  jiart  icularly  tlmsi'  cjf  women,  develop  a  faint  or  even  a  more  definite  deposit  of 
mucus,  whicli  may  remain  in  suspension  or  may  accumulate  as  a  light  floccular  deposit  at 
the  bottom  of  the  specimen-glass.  Such  mucus  is  a  normal  product  of  the  epithelial  cells 
of  the  urinary  passages.  It  is  not  possible  by  merely  looking  to  say  whether  it  is  in  excess 
or  not.  It  may  indicate  catarrh  of  the  mucous  membranes  ;  but  such  catarrh  will  be 
shown  more  decisively  by  the  occurrence  of  epithelial  cells  or  actual  pus  corpuscles,  or  by 
a  cause  for  catarrh  such  as  Ox.yluria  (p.  423)  ;  diagnosis  depending  not  upon  the  mucus 
but  u])on  the  other  substances  present  with  it.  It  is  important  not  to  mistake  elongated 
strands  of  mucus  for  tube-casts  ;  the  error  is  particularly  apt  to  occur  if  the  cover-glass. 
on  being  pressed  down  on  a  specimen  stained  with  methylene  blue,  slips  slightly  and  draws 
out  the  mucus  into  long  narrow  strands.  When  large  numbers  of  these  are  seen  all  jjarallel 
with  one  another,  they  are  not  likely  to  be  mistaken  for  casts.  Mucus  stains  readily  either 
with  methylene  blue  or  with  eosin,  but  exhibits  no  structure  beyond  granular  particles, 
or  cells  that  may  have  become  entangled  in  its  meshes. 

If  a  male  jjatient  has  formerly  suffered  from  gonorrhnca,  a  residual  catarrh  of  the 
glands  in  the  prostate  often  persists  long  after  the  cure  may  have  seemed  to  be  complete. 
Urine  from  such  a  case,  looked  at  in  a  tall  glass  vessel,  often  exhibits  numerous  filaments 
or  '  prostatic  threads.'  consisting  for  the  most  part  of  mucus  coming  in  the  form  of  casts 
from    Ihe   prostatic   tubules.  Ilerljerl  French. 

MUSC^    VOLITANTES.     (.See  IJi.ack  Si-ixks  befoke  thk  Evi:s,  j).  71.) 

MUSCULAR    ATROPHY. -(Sec  .Vtuoimiv,  Mtscri..M!,  i).  59.) 

MYDRIASIS.— (See  Ft  I'll.,  .ViiNoitMAi.niKs  or  tui..  p.  .5.">1.) 

MYOSIS.     (Sic  I'li'ii,.  AnN()i!MAi.rrii:s  or  iin:,  p.  .551.) 

NAILS,  AFFECTIONS  OF  THE.  \uriims  pigmentary  and  degenerative  changes 
may  occur  in  the  nails  as  Ihc  rcsuil.of  oi  ciipal  inn.  as  in  dyers,  washerwomen,  jewellers. 
<-onfcctioiurs,  and  others:  or  the  condition  known  as  j>terii!liiini  may  arise,  the  fold  of 
skin  at  the  proximal  end  ol  the  nail  adhering  and  giowing  oxer  the  nail,  like  a  "wing." 
The  nails  are  liable  to  attack  also  in  such  cutaneous  alTeeticjns  as  ringworm,  favus,  ec/.cma, 
psoriasis,  and  epidermolysis  bidlosa.  The  differences  between  the  onychomycosis  due  to 
ringn-orm  and  that  due  lit  fai'iis  are  described  in  the  article  on  Fi'Noofs  Aitections  of 
THE  Skin'  (p.  2K1).  In  eczeina.  usually  the  first  sign  of  invohcment  of  the  nails  is  pitting, 
whicli  gives  tluin  an  appearance  somewhat  resendding  orange-rind.  Tlicy  become  dis- 
coloured anil  thinned,  transverse  and  longitudinal  splitting  follows,  and  finally  exfoliation 
may  occur.  In  long-standing  cases  they  may  be  thickcneil  to  the  extent  of  deformity. 
In  ])S(irinsis.  if  the  matrix  of  the  niiils  is  attacked,  they  become  furrowed  Iransversely, 
and  dull  in  colour  ;  later  the  nails  split  and  may  be  shed,  but  not  permanently.  In  otlier 
cases,  instead  of  the  matrix  being  alTecled,  the  nails  are^discoloured  about  the  free  l)order, 
and  they  become  thickened  as  the  discoloration  extends  downwards  to  the  root.  In 
epirlermnli/si.s  linllosn  there  may  be  repeated  bleb-forniation  at  the  finger-ends,  causing 
atrophy  of  the  skin  and    loss   of  nails.     The   signs   of   nail    involvement    in   these   three 


400  NAILS.     AFFECTIONS    OF    THE 

conditions  are  sufficiently  distinctive  to  obviate  confusion  between  tliem  :    and  tlie  lesions 
elsewhere  will  aid  the  diagnosis. 

Trophic  changes  in  the  nails  may  also  be  conseijuent  on  aciile  illness  or  senile  decay,  or 
they  may  occur  without  any  apparent  cause  :  the  longituilinal  striie  may  be  exaggerated, 
transverse  furrows  may  appear,  or  white  spots  may  de\elop,  and  a  large  [lart  or  the  whole 
of  the  nail  may  become  white  (lenconychin).  With  this  condition  sponn-nails  may  be 
associated  ;  the  nail  becomes  thin  and  hollowed,  either  from  side  to  side  or  antero-posteriorly. 
Shedding  of  the  nails  may  occur  not  only  in  distinctively  cutaneous  affections,  but  also  in 
diabetes  mellitus  and  syphilis,  in  locomotor  ataxy  and  other  nervous  disorders.  Either 
without  definite  etiology,  or  in  connection  with  inHannnation  of  the  finger-tips,  the  nail 
may  be  separated  from  its  bed  without  being  actually  shed.  Onychia,  or  inflammation 
of  the  nail,  is  in  some  instances  due  to  syphilitic  or  tuberculous  infection  ;  in  the  latter 
case  associated  scrofulous  lesions  will  often  be  found  in  the  eyelid  and  elsewhere.  Onychia, 
however,  may  also  be  due  to  trauma,  or  to  contact  with  irritants  used  in  industries,  or 
may  be  idiopathic.  Whatever  the  cause,  the  condition  cannot  be  mistaken.  If  the 
process  is  acute  there  is  great  pain,  with  redness  ;  sup])ur;i.ti(in  takes  place  beneath  the 
nail,  which  becomes  thickened  and  discoloured,  and  is  ultimately  shed,  leaving  an  un- 
healthy sore.  If  this  shoidd  fail  to  heal,  the  lymphatics  may  be  involved,  and  the  case 
becomes  one  of  paronychia,  or  whitlow.  This  condition  is  sometimes  caused  by  the 
pressure  of  tightly-fitting  boots,  or  by  irritation  set  up  by  the  edge  of  a  badly-cut  nail — 
usually  that  of  the  big  toe.  Onychorrhc.ris.  brittleness  of  nails,  may  be  either  congenital 
or  acquired.  It  is  sometinies  present  in  chciropompholyx,  and  in  other  cases  is  associated 
with  nervous  affections  and  anomalies  of  development.  In  onychaaxis,  hypertrophy  of 
the  nail,  there  may  be  overgrowth  in  one  or  in  all  directions,  accompanied  by  distortion 
or  discoloration,  and  sometimes  by  inflammation.  In  some  cases  the  free  end  may  grow 
to  a  great  length,  and  may  become  twisted  like  a  ram's  horn  (onychogryphosis).  This 
curious  distortion  is  often  found  in  connection  with  congenital  ichthyosis.  A  rarer  con- 
dition of  modified  nutrition  is  that  known  as  cgii-shrll  nail,  whicli  is  intimately  associated 
with  hyperidrosis  ;  it  has  been  met  witli  in  debilitated  young  women  :  the  nail  tends  to 
grow  upwards  rather  than  forwards  ;  its  connection  with  the  distal  portion  of  the  bed  is 
enfeebled  ;  and  in  typical  cases  the  colour  is  precisely  that  of  the  inner  face  of  the  shell 
of  a  hen's  egg — a  delicate  comljination  of  white  and  i)urple.  It  has  been  suggested  that, 
owing  to  the  maceration  of  the  distal  ])ortion  of  the  nail-bed  due  to  hyjieridrosis,  there  is 
interference  with  the  normal  cornification  of  the  nail-plate.  Whatever  the  process,  the 
diagnosis  is  clear.  Transverse  ridging  of  the  nails  due  to  previous  illness  (Fig.  306,  p.  769) 
is  desciibcd  on  p.  769.     (See  also  Finger.  Soue,  p.  239.)  Malcolm  Morris. 

NAPKIN-REGION  ERUPTIONS.— Infantile  eruptions  in  this  region,  when  they 
ai'C  a  niauitestation  of  ciingenilal  sypliilis.  are  usually  erythematous  or  papular,  but  they 
may  also  be  j)ustular,  bullous,  sipiamous,  or  polymorphic  ;  in  all  cases  alike  they  are 
distributed  svnunetrieally  on  the  buttocks.  Frequently,  around  the  anus  and  the  genital 
organs  the  papules  are  moist  and  coalescent,  and  form  flatfish  condylomata.  Similar 
lesions  are  also  found  on  the  soles,  palms,  forehead,  and  around  the  mouth,  and  in  these 
regions  also  the  distribution  is  symmetrical.  The  eruption  is  as  a  rule  transitory.  The 
other  symptoms  of  hereditary  syphilis  are  so  characteristic  that  the  lesions  here  described 
are  seldom  liable  to  misinterpretation.  The  skin  eruption  is  usually  preceded  by  a  chronic 
coryza  ("  snuffles ')  and  laryngitis.  Often  the  nails  are  severely  affected  coincidently 
with  the  skin.  The  colour  of  the  lesions,  approximating  to  the  characteristic  raw-ham 
tint,  the  loose,  dry,  cafc-aii-lait  skin,  the  senile  aspect  of  the  face,  and  the  accompanying 
cachexia,  form  a  distinctive  clinical  picture. 

A  napkin-area  eruption  which  was  often  mistaken  for  congenital  syphilis  is  the 
infantile  erythema  of  Jaequet.  It  is  a  process  which  manifests  itself  in  :  (1)  Simple  erythe- 
matous, (2)  Erythemato-vesicular,  (3)  Papular,  (4.)  Ulcerating  forms.  These  may  develop 
consecutively  or  coincidently.  The  most  common  are  the  erythematous  and  the  papular. 
All  alike  are  probably  due  in  part  to  the  irritation  set  up  by  moist  or  soiled  najjkins,  but 
vasomotor  irregularities  and  gastro-intestinal  toxaemia  may  also  be  concerned  in  the 
etiology.  The  preference  sites  of  all  four  forms  of  the  eruption  are  the  convex  surfaces  of 
the  buttocks,  of  the  thighs,  and  of  the  scrotum  or  vulva.     In  the  simi^le  er>d:hemas,  of 


NAPKIN  REGION     ERUmO^S  401 

wliich  tlic  iisuiil  subjects  are  quite  young  infants,  the  rash  may  be  hmited  in  mild  eases 
to  the  genitaUa,  the  inner  sides  of  the  thighs,  and  the  perineum,  while  in  severer  cases  it 
may  extend  to  the  hmibar  region,  the  lower  abdomen,  and  the  calves  and  heels.  In  the 
erythemato-vesicular  form  there  appear  on  the  convex  surfaces  towards  the  centre  of  the 
erythematous  areas  small  bright-red  erosions  which,  forming  groups  of  from  two  or  three 
to  a  dozen  or  more,  may  become  eonlluent  ;  the  erosions  are  preceded  by  vesicles,  which 
may  usually  be  found  near  the  borders  of  the  reddened  area.  The  erythemato-])aiJular 
form  of  the  eruption  is  met  with  when  the  erosions  just  described  have  thrown  ii]i  flattened 
granulations,  which  give  to  the  lesions  tlie  appearance  of  flat,  reddish  pa])ules.  In  this 
stage  the  lieels  and  the  lower  abdomen  may  be  involved  in  the  erythema.  In  the  fourth 
form  of  the  eruption  the  erosions,  failing  to  g'ranidate,  develop  into  ulcers,  with  sharply 
defined  borders  or  coalescing  into  vermicular  lesions.  They  are  confined  to  the  convex 
surfaces,  the  folds  always  escaping.  Attention  to  the  appearance  and  distribution  of  the 
lesions,  and  the  course  they  run,  together  with  the  absence  of  the  more  familiar  signs  and 
symptoms  of  congenital  syphilis,  will  prevent  confusion  with  that  disease,  or  with  the 
condition  which  Colcott  Fox  has  styled  vacciniform  erythema  of  infants. 

I'cinphigus  neonatorum  consists  of  an  eruption  of  bidlw  on  the  thighs  and  buttocks 
in  new-born  infants.  It  is  not,  however,  confined  to  this  region,  but  attacks  other  parts, 
including  the  face,  and  this  is  true  also  of  the  bullous  impetigo  of  older  babies,  which 
.\damsou  believes  to  be,  like  pemphigus  neonatorum,  a  form  of  the  impetigo  contagiosa 
of  Tilbury  Fox.     The  diagnosis  of  these  affections  has  been  given  imder  BtLL.F,,  p.  96). 

The  ■  seborrhceie  eczema  of  infants  "  has  been  styled  "  seborrhn?ic  dermatitis  of 
infancy  "  by  Adamson,  who  was  the  first  to  lay  stress  upon  its  special  incidence  u])on  the 
napkin  region,  antl  who  does  not  regard  it  as  a  form  of  eczema.  The  whole  napkin  region 
is  occupied  by  a  uniform  bright-red  rash,  for  the  most  part  covcreil  with  moist  or  greasy 
yellowish  scales,  though  in  prominent  jiarts  the  surface  may  be  smooth  and  polished.  The 
margins  of  the  area  are  sharply  defined.  The  rash  often  extends  downwards  to  the  thighs 
and  eahes,  and  upwards  to  the  imibilicus,  while  beyond  this  area  there  are  smaller  patches 
and  many  pin-heail,  red,  scaly  papules.  Other  parts  that  arc  atta<-ked  frequently  are  the 
bends  of  the  knees,  the  flexm-es  of  the  elbows,  the  axilla^,  the  side  of  the  neck,  the  naso- 
labial fissure,  and  behind  the  ear.  On  the  scalp  will  always  be  found  a  red,  squamous 
or  crusty  eruption.  The  diagnosis  rests  upon  the  distribution  and  the  sharply  dehned 
margins,  with  the  patches  and  crusted  papules.  It  is  assisted  by  the  readiness  with  which 
the  eruption  yields  to  mild  local  parasilicidal  api)lications.  In  cases  of  congenital  syphilis 
which  mimic  this  condition,  the  presence  of  the  concomitant  specific  signs,  as  enumerated 
above,  will  |)revent  confusion  between  that  disease  and  '  seborrhceie  eczema.' 

In  adults  the  same  region,  known  as  the  bathing-drawers  area,  is  liable  to  attack  in 
a  number  of  alfeelions.  In  rrzema  niiirgiiitilion  (tinea  marginata,  as  I  prefer  to  term  it), 
dhobie'n  ilrli.  and  cii/lliidsmti  the  eruption  occurs  exclusively,  or  almost  exclusively,  in  this 
region  ;  of  these  affections  tlie  dilierenlial  diagnosis  has  been  given  under  HiNc.woim 
(p.  247).  In  prdiciilosis  /iiihia  the  pubes  may  alone  be  arteeted,  or  I  he  parasile  may  wander 
to  the  abdomen,  the  thorax,  the  axilla',  and  max-  even  reach  Ihe  beanl,  whiskers,  and  eye- 
lashes. 'i"hc  diagnosis  of  this  condition  can  prcscnl  no  diHieulty.  In  sriihir.s  Ihe  lesions 
may  be  very  slight  on  the  hands  and>  wrists,  and  llic  liiuiit  of  the  attack  may  lie  boriie  by 
the  penis  and  scrolum.  the  lower  part  of  Ihe  abdomen,  and  the  thighs.  In  iixoridnis  the 
eruption  is  sometimes  very  severe  in  the  bathing-drawers  area,  of  which  the  surface  is  an 
almost  uniform  deep  red,  and  is  the  seat  of  profuse  des(}uamalion,  while  on  the  special 
sites  of  election — the  knees  and  elbows  the  lesions  may  be  (juite  insignilieant.  In  eczema 
intertrigo  and  cri/tliema  intertrigo  the  folds  in  the  area  under  consideration  are  oidy  liable 
to  attack  in  common  with  folds  in  other  parts.  The  diagnosis  of  these  affections  has  been 
gi\cn  elsewhere  :  but  it  may  here  be  mentioned  that  in  diabetes,  eczema  may  begin 
on  the  penis  or  flic  vulva,  and  may  spread  thence  to  other  regions.  Other  conditions 
which  may  affect  this  area  specially  are  :  acute  traumatic  erysipelas,  pruritus  iuii, 
sniall-pox  in  the  prodromal  stages,  and  the  various  forms  of  syphilis.  In  syphilis 
Ihe  eommouesl  site  Inr  the  moist  papule  is  around  tlic  anus  and  genitalia  (see  P.\l'ULES, 
l>-    "•<»)•  Mtilrolm   Morris. 

NEURITIS,    OPTIC.     (Sec  OeirrnuMosr c   .\i>n;Aii.\NCi;s.   Notks  on,   p.   U5.) 

IJ  20 


40J  NIGHTMARES 

NIGHTMARES  may  oocur  at  any  age,  but  they  are  particularly  comnioii  in  children 
between  four  and  eight,  when  they  may  be  so  bad  and  persistent  as  to  merit  the  term  night- 
terrors.  The  commonest  cause  for  a  nightmare  in  an  adult  is  some  indiscretion  in  diet, 
the  last  meal  having  been  taken  too  late  in  the  evening,  or  else  having  contained  some 
injudicious  article.  The  symptom  is  not  otherwise  of  diagnostic  import,  though  some 
individuals,  particularly  those  of  nervous  inheritance,  are  more  liable  to  nightmare  than 
(itliers.  and  tlic  tendency  is  certainly  increased  by  svich  excitement  as  the  reading  of 
thrilling  novels  or  participating  in  unusual  events.  Children  are  particularly  prone  to 
night-terrors  during  term-time,  when  they  are  working  at  high  pressure  ;  during  the 
liolidays  the  symptom  often  disappears.  Those  who  are  keenest  upon  their  school  work 
are  ajit  to  suffer  most,  and  similar  evidence  of  excitability  of  the  nervous  system  is 
exhibited  ijarticularly  by  those  who  have  a  tendency  to  acute  rheumatism  in  the  form  of 
chorea.  Night-terrors  may  occur  in  these  patients  without  any  other  cause  than  over- 
jiressure,  i)articularly  if  they  lie  upon  the  back  rather  than  upon  one  side  during  slec])  : 
but  the  tendency  is  much  increased  by  errors  of  diet,  such  as  the  eating  of  imripe  fruit  and 
so  forth,  by  the  presence  of  intestinal  worni'^.  and  by  the  existence  of  adenoids,  with  or 
without  enlarged  tonsils.  Herbert  Freinii. 

NIPPLE,  DISCHARGE  FROM. -(See  DiscirAR.iE  i-kom  the  Nipple,  p.  181.) 

NODULES  in  ordinary  dermatological  usage  are  solid  elevations  larger  than  a  papule 
and  smaller  than  a  tumour:  the  definition,  however,  makes  no  pretence  to  scientific 
exactitude.  Nodules  differ  from  papules  not  only  in  size  but  also  in  their  greater  ten- 
dency to  downward  growth  :  the  substantial  difference  between  a  nodule  and  one  of 
the  larger  papules  is  that  the  one  is  a  solid  lesion  extending  upwards,  while  the  other  is 
a  solid  lesion  projecting  both  upwards  and  downwards.  They  may  be  neojilastic,  or 
hypertrophic  and  inflammatory. 

Little  need  be  said  here  of  the  nodules  met  with  in  some  malignant  diseases,  for  the 
differential  diagnosis  of  carcinoma  and  of  .sarcoma  will  be  found  under  Tumours  of  the 
Skin  (p.  730).  Fibroma,  myoma,  and  cysts  are  also  dealt  with  under  this  heading,  and 
glanders  in  the  articles  on  Pu.stules  (p.  559). 

The  nodules  of  lupus  vulgaris,  arising  in  either  the  su])erUcial  or  the  deep  part  of  the 
corium,  are  soft,  brownish-red,  and  translucent,  resembling  apple  jelly.  At  first  buried 
in  the  skin,  they  presently  appear  as  discrete  papules  the  size  of  a  pin's  head,  arranged  in 
groups  or  in  irregular  circles,  dull  red  at  the  outset,  but  afterwards  pale.  Gradually  the 
papules  develop  into  nodules,  the  intervening  .skin  meanwhile  becoming  thickened  by 
cellular  infiltration,  reddened  by  intlanunatory  stasis,  and  raised  into  a  ])atch  which  is 
covered  with  fine  branny  scales.  Around  the  edge  of  the  patch  new  nodules  spring  up. 
and  thus  a  large  area  of  skin  may  be  invaded.  The  disease  usually  starts  from  a  single 
focus,  but  others  may  arise  and,  spreading  separately,  may  in\olve  large  areas  of  cutaneous 
surface.  The  patch  may  undergo  slow  involution  and  be  followed  by  scarring  ;  but  much 
more  often  ulceration  occurs,  the  sore  being  covered  with  a  greenish-black  crust,  around 
the  ragged  edges  of  which  will  be  seen  apple-jelly  nodules  in  various  stages  of  develop- 
ment. In  parts  like  the  nose  there  may  be  necrosis  of  cartilage,  but  there  is  never  erosion 
of  bone.  The  apple-jelly  nodule  is  the  chief  diagnostic  feature  of  lupus  vulgaris.  In 
typical  cases  the  patch  described  above,  with  its  infiltrated,  raised  surface,  its  well-defined 
edge  studded  with  the  nodules,  and  its  covering  of  fine  scales,  can  hardly  admit  of  mis- 
interpretation. Less  typical  cases  may  require  to  be  differentiated  from  lupus  erythe- 
matosus, rodent  ulcer,  epithelioma,  scrofulodermia,  and  syphilis.  Lupus  erythematosus 
begins  as  minute  red  points,  not  as  dull-red  papules,  and  the  lesions  never  develop  into 
apple-jelly  nodules,  nor  do  they  ever  ulcerate  or  extend  to  the  deeper  parts  and  erode 
cartilage.  They  are  symmetrical  in  distribution,  as  lupus  vulgaris  scarcely  ever  is,  and 
the  affection  seldom  appears  before  puberty,  a-s  lupus  vulgaris  almost  invariably  does.  It 
is  only  when  the  lesions  peculiar  to  lupus  vulgaris  are  masked  by  oedematous  swelling  that 
the  two  affections  can  be  confused  ;  but  if  the  skin  at  the  spreading  edge  be  stretched, 
small  amber-coloured  nodules  can  usually  be  seen. 

In  rodent  ulcer  there  is  usually  but  one  lesion,  which  runs  a  much  more  sluggish  coui-se 
than  the  nodules  of  lupus  vulgaris  :    the  ulcer  has  an  indurated  border  and  a  firm  base, 


XODULP]S  403 

an<i  penetrates  deeply  into  the  tissues  :  and  the  disease  is  essentially  one  uf  later  life  (see 
Ulceration'  of  ruv.  Face  (p.  735).  Epithelioma,  again,  is  a  disease  of  later  life.  The 
hard,  everted  edge  of  the  growth,  the  fold  base,  frequently  roughened  with  warty  forma- 
tions or  sprouting  with  eauliflower-like  excrescences,  the  implication  of  neighbouring  glands 
(which  very  occasionally,  however,  occurs  in  lupus),  and  the  secondary  deposits,  form 
((uite  a  diffei-ent  clinical  ])icturc  from  that  of  lupus  vulgaris. 

In  one  form  of  scrofulodermia  nodvdes  develop  under  the  skin,  and  an  ulcer  is  formed 
which  is  bordered  by  dark  bluish,  thin,  undermined  skin  that  has  too  little  vitality  to  allow 
of  repair  ;  there  is  no  infiltration  as  in  lupus  vulgaris,  the  nodules  do  not  present  the  apple- 
jelly  aspect,  and  other  e\i<lences  of  the  disease  will  be  found  on  the  neck  or  elsewhere,  in 
the  form  of  enlarged  glands  or  sears.  .Vs,  however,  the  two  conditions  frequently  co-exist, 
and  the  treatment  is  virtually  the  same,  diagnosis  between  the  two  is  of  little  practical 
importance. 

In  the  diagnosis  from  '  lupoid'  tcrliinii  si/pliilis.  again,  the  apple-jelly  nodule  of  lupus 
vulgaris  plays  the  chief  part.  The  sy|)hilitic  process,  further,  is  much  more  rapid,  nor  is 
acquired  syphilis  generally  a  disease  of  early  life.  The  nodules  and  ulcers  of  late  syphilis — 
neoplasms  that  grow  by  infiltration  of  the  surrounding  parts  and  often  break  down  into 
ulcers  which  are  prone  to  become  serpiginous,  and  show  little  or  no  tendency  to  spontaneous 
cure — have  in  turn  to  be  differentiated  from  other  conditions.  They  may  be  mistaken 
for  abscess,  but  if  opened  they  give  issue  not  to  pus  but  to  a  gummy  li(|uid.  If  the  ulcer 
into  which  the  gunnna  breaks  down  be  on  the  leg,  it  may  resemble  callous  idcer,  but  its 
olxliuacv  to  ordinary  treatment  and  its  response  to  the  iodides  will  reveal  its  true  nature. 
AVassermamrs  serum  test  will  probably  be  positive.  From  syphilitic  ulcer  rodent  ulcer 
differs  in  its  hard  edge,  and  red,  shining,  dry  floor,  as  well  as  in  its  favourite  situations  ; 
from  epithelioma,  in  that  a  process  of  new  growth  has  preceded  the  ulceration  ;  from 
scrofulodermia,  in  the  undermined  border  of  the  ulcers  and  the  slow  rate  of  the  process. 

In  ymvs,  as  in  syphilis,  the  nodule  is  the  most  characteristic  lesion  of  the  tertiary  stage. 
It  arises  in  the  subcutaneous  tissue,  and  generally  leads  to  the  formation  of  superficial 
ulcers  which  spread  serpiginously,  like  the  ulcers  of  tertiary  syphilis.  New  nodules  fre- 
quently appear  in  the  neighbourhood  of  the  older  ones,  and  masses  resembling  syphilitic 
gummata  may  form  and  break  down  into  ulcers.  These  late  ulcers  mostly  appear  on  the 
lower  part  of  the  leg,  especially  around  the  ankle,  but  they  arc  not  uncommon  about  the 
lips,  and  indeed  may  occur  in  any  i)art  of  the  body.  The  clavicle,  sternum,  ulna,  tibia, 
and  the  metacarpal  and  metatarsal  bones,  arc  often  tlic  sites  of  nodules  which  may 
occasion  permanent  thickening,  or  break  down  and  cause  ulcers.  Between  yaws  and 
,syphilis  there  are  obvious  resemblances  in  the  tertiary  stage,  but  there  are  marked  differ- 
ences in  the  jirimarv  and  secondary  stages.  In  yaws  the  inoculation  lesion  is  not  indurated, 
there  is  seldom  distinct  glandular  eidargemcnt,  the  nnieous  membrane  lesions  of  syphilis 
arc  absent,  and  the  most  characterisl  ic  lesion,  which  a))pcars  in  the  secondary  period,  is 
the  frambd'sial  gramilomatous  excrescence  known  as  the  yaw  (sec  Scahs,  ]),  (iOl).  In 
yaws,  the  exantlicm.  the  alopecia,  the  iritis,  the  afreetion  of  the  permanent  teeth,  the  bone 
lesions,  the  i)olymorphism,  the  nerve  lesions,  and  the  gummata  of  .syphilis  are  wanting. 
Yaws  is  never  hereditary  nor  congenital  ;.  yaws  and  syphilis  confer  no  immvmity  against 
each  other,  and  yaws  may  die  out  ill  a  community  while  syphilis  remains,  or  it  may  be 
universal  in  a  eommimity  where  syphilis  is  unknown.  The  iiiiiujtc  hisldlogy  of  the  lesions 
III    the  two  diseases  also   lurnishes   iinporlant   diricrcnees. 

From  liiiivrciilosis  y.xws  diU'crs  (aparl  fnim  the  tubercle  bacillus)  in  the  absence  of 
till-  characteristic  tuberculous  architecture  with  its  giant-cells  and  daughter  plasma-cells, 
iiKiic  marked  disintegration  of  the  librous  stroma,  and  eom))lete  disaj)pcarancc  of  the  blood- 
vessels. 

In  hiniisii  the  niidulc  U'i'^.  I7:i)  marks  one  ol  llic  llnce  lyp<'S  nf  thai  allcct  iiiii,  I  he 
others  being  iiir\c  or  anasthelic  leprosy,  and  mixed  or  eonqilele  leprosy.  In  nodular 
(or  tubercular)  lejirosy  the  macules,  which  arc  always  the  primary  lesion,  are  transformed 
into  nodules  by  sudden  increase  of  inflammatory  inliltration.  \Vhcn  fully  developed  they 
\ary  in  size  from  a  small  shot  to  a  lill)crt,  or  larger,  are  round  or  oval,  but  raised  eonsi<ler- 
abl\  above  the  level  of  the  skin.  They  may  mimic  lupous  nodules,  syphilitic  papules, 
rosacea,  ervlhenia  iiodosuni,  or  sycosis.  Sometimes  telangicelascs  may  be  observed  on 
their   surface.      TIicn    -.uv   clastic   to    llic    touch,   aic   at    lirsl    sometimes   li\  pcr.cslhct  ic.    but 


404 


NODULES 


later  very  frequently  become  temporarily  or  permanently  anwsthetic.  Nodules  on  the 
mucous  membranes  are  red  or  grey,  and  may  resemble  syphilitic  lesions.  Both  on  skin 
and  on  mucous  membrane  they  tend  to  break  down,  but  in  exceptional  cases  they  either 
undergo  cicatricial  shrinking  or  reach  the  ulceration  stage  by  way  of  suppuration.  The 
differential  diagnosis  of  leprosy  in  the  macular  stage  is  given  under  JMactles  (p.  38:5). 
In  the  later  stages  the  identification  of  the  disease  seldom  presents  difficulty.  The  nodules 
of  leprosy  may  resemole  those  of  lupus  vulgaris  and  the  tubercular  syphilide,  but  the 
lupous  and  syphilitic  eruptions  are  both  of  limited  extent,  and  there  is  no  anaesthesia.  The 
syphilide  also  is  serpiginous,  or  uecurs  in  crescentic  groups.  Wassermann's  serum  test 
may  be  positive  in  leprosy  without  syphilis,  and  therefore  cannot  be  relied  on  in  differ- 
entiating the  two.  In  the  early  stages  of  noflular  leprosy  the  lesions  may  strongly 
resemble  those  of  erythetna  nodosum,  and,  as  in  that  affection,  there  may  be  i)ains  about 
the  joints  ;    but  if  the  case  be  one  of  erythema  nodosum  the  nodules  will  disappear  within 

a  fortnight,  though  successive  crops 
may  arise  for  three  or  four  weeks 
longer.  Preceded  and  accompanied 
by  pains  about  the  joints,  by  py- 
rexia and  other  symptoms  of  con- 
stitutional disturbance,  oval  nodules, 
ranging  in  size  from  a  walnut  to  a 
hen"s  egg,  appear  on  the  legs  and 
feet  and,  less  frequently,  elsewhere. 
They  are  most  common  between  the 
knees  and  ankles,  next  between  the 
wrists  and  elbows.  In  colour  they 
are  at  first  bright  red,  but  soon 
become  bluish  in  the  centre  and 
purple  at  the  periphery,  exhibiting 
as  they  subside  the.  changes  of  tint 
]3resented  by  a  bruise.  Erythema 
nodosum  is  an  affection  of  adol- 
escence, and  girls  are  attacked  by 
it  twice  as  often  as  boys.  There  is 
nearly  always  considerable  pyrexia, 
and  acute  osteomyelitis  of  the  tiljia 
may  be  suspected  if  it  is  not  remem- 
bered that  erythema  nodosimi  is 
nearly  always  bilateral,  which  osteo- 
myelitis seldom  is.  There  is  never 
ulceration,  and  this,  with  the  pains 
and  swellings  about  the  joints,  dis- 
tinguishes it  from  syphilitic  nodules. 
The  same  features  distingviish  it  also 
from  an  eri/lhcnui  of  the  legs,  the 
result  apparently  of  excessive  stand- 
ing, to  which  young  girls  are  some- 
times subject,  and  from  the  node-like  swellings  which  sometimes  occur  in  the  legs  of 
women  suffering  from  varicose  I'eins. 

The  absence  of  ulceration  and  the  presence  of  joint-pains  are  points  which  differen- 
tiate erythema  nodosum  from  erythema  induratum  scrofiilosoriim  (Bazin"s  disease).  Here 
the  nodules,  which  occur  chiefly  on  the  legs,  are  at  first  subcutaneous,  and  can  only  be 
felt,  not  seen.  They  are  generally  discrete,  but  may  become  fused  together  into  a  solid, 
infiltrated  mass,  and  are  apt  to  break  down  into  irregular  ulcers.  They  differ  from  the 
nodules  of  erythema  nodosum  not  only  in  the  features  already  noted,  but  also  in  colour, 
being  violet  instead  of  bright  red,  and  not  undergoing  successive  bruise-like  changes  of 
tint.  From  gummata  they  differ  in  being  less  painful  and  in  running  a  less  rapid  course, 
as  well  as  in  being  more  numerous,  and  in  attacking  both  legs.  The  only  effect  of  anti-  : 
syphilitic  treatment  is  to   aggravate  the  condition.     The   nodules  of  erythema  keratodes 


NOISES    IX    THE    HEAD  405 

differ  from  those  both  of  erythema  nodosum  and  of  erythema  induratum  scrofulosorum 
in  that  they  appear  only  on  the  bacli  of  tlie  finger-joints,  while  on  the  palms  and  soles  there 
is  overgrowth  of  the  horny  tissue,  aeeompanied  by  oedema  and  tenderness. 

The  condition  which  Boeck  designated  multiple  benign  sarcoid,  or  miliary  benign  lupoid, 
presents  some  resemblance  to  lupus  and  sarcoma.  The  nodules,  at  first  rose-coloured, 
afterwards  become  livid,  then  brownish.  In  size  they  vary  from  a  millet  seed  to  a  large 
bean.  The  favourite  sites  of  tlie  eruption,  which  is  always  symmetrical,  are  the  face, 
shoulders,  wrists,  and  the  extensor  surfaces  of  the  upper  limbs  ;  but  exceptionally  the 
scalp,  the  back,  and  the  lower  limbs  are  attacked.  Occasionally  the  lymphatic  glands 
are  enlarged.  The  nodules  never  break  down,  but  after  a  period,  it  may  be  of  several 
years,  shrink  and  disappear,  leaving  a  slight  atrophic  scar.  The  affection,  which  often 
accompanies  visceral  tuberculosis,  is  distinguishable  both  from  sarcoma  and  from  lupus 
vulgaris  by  histological  examination,  as  well  as  by  the  course  it  runs.  From  the  latter 
affection  it  is  distinguished  also  by  the  negative  reaction  in  inoculation  experiments. 

The  subcutaneous  nodules  of  acute  rheumatism  generally  occur  over  the  sheaths  of 
tendons  and  the  fascia  covering  bony  prominences,  around  joints,  and  on  the  scalp.  They 
may  be  as  small  as  a  pin's  head  or  as  large  as  a  bean.  Within  limits  they  can  be  made 
to  glide  on  the  underlying  tendon-sheath  or  fascia.  They  are  sometimes  met  with  in  advilts 
whose  hearts  have  not  been  damaged  by  the  tox;eniia.  but  much  more  frequently  in  chil- 
dren with  distinct  \alvular  lesions,  and  according  to  some  authorities  they  are  analogous 
to,  if  not  identical  with,  the  nodules  that  have  been  found  post  mortem  on  the  borders  of 
the  mitral  curtain  and  in  the  myocardium.  The  coincidence  of  nodules  such  as  these  with 
rheumatic  fever  can  leave  no  doubt  as  to  their  true  nature.  Heberdcn's  nodes  {Fig.  1.55, 
p.  3i3).  the  little  knobs  on  the  finger-joints  which  are  caused  by  osteophytic  outgrowths 
from  the  bases  of  the  distal  phalanges  in  certain  elderly  persons,  are  immistakeable,  and 
tlie  same  applies  to  the  nodular  pads  which  sometimes  develop  on  the  backs  of  the  knuckles 
(Fig.  100,  p.  ;i47).  Multiple  subcutaneous  ci/sticerci  are  a  rarity  the  diagnosis  of  which 
may  be  suggested  by  the  eosinophilia,  but  can  only  be  clinched  by  excision  and  micro- 
scopical examination  of  one  of  the  nodules.  Malcolm  Morri'. 

NOISES   IN   THE   EARS.-(Sce  Tinnitus    p.  722.) 

NOISES  IN  THE  HEAD  are  comi)lained  of  by  two  cntinly  different  classes  of 
patient:   luuiK-ly.  (1)  The  insane,  and  (2)  The  sane. 

1.  The  Insane. — In  these  cases  the  noises  may  be  of  indistinct  or  indeterminate 
nature,  but  more  often,  in  addition  to  mere  noises,  buzzings.  singings,  roarings,  hootings, 
there  are  more  dclniitc  subjective  auditory  sensations,  which  as  a  rule  take  the  form  of 
voices.  Tliev  then  constitute  a  variety  of  either  hallucination  or  (Uhision  the  former 
if  there  is  some  organic  mischief  at  the  bottom  of  sounds  which  are  misinler|)r('tcd, 
the  latter  if  the  voices  are  pure  fancy.  In  either  case  the  hearing  of  the  voices  needs 
to  be  persistent  to  constitute  evidence  of  insanity,  for  most  normal  persons  have 
transitory  subjeetixc  sensations  of  having  been  sjioken  to  when  they  are  (luite  alone. 
If.  however,  the  patient  |)ersistcntly  hears  voices  when  there  are  none,  other  evidence  of 
insanity  should  be  looked  for.  though  it  often  takes  an  expert  psychologist  to  detect  the 
nature  of  the  mental  malady.  The  voices  may  appear  to  the  |)atienl  to  be  definitely  within 
his  own  head  :  on  the  other  hand,  they  often  a|)f)ear  to  be  external  voices,  sometimes 
strange  to  the  patient,  sometimes  familiar  ;  attril)Uted  [jcrhaps  to  a  non-living  person, 
a  dead  wife,  or  (iod,  or  Christ  ;  perhaps  to  a  living  |)erson  who  is  far  away — a  straying 
daughter,  an  old  friend,  a  loving  mot  her.  The  voices  may  say  different  things  at  different 
times,  or  they  may  coiistaiitiy  r<it<  rale  the  same  senteiu'e  ;  in  tlie  worst  eases  tliey  urge 
the  jiaticnt  to  tliis  or  thiil  particular  action,  especially  suicide  or  liomiciile.  When 
they  have  icaclicc!  Iliis  dcgicc  llurc  can  be  little  doubt  as  to  I  heir  iiidiealing  insanity. 
They  do  not.  Iiowcscr.  belong  to  any  one  ty|)e  of  insanity  in  parlieular  :  they  may  occur  in 
nielaneliolia,  accusing  the  patient  of  having  committed  the  unpardonable  sin  and  urging 
liiin  to  suicide  ;  or  In  mania,  urging  to  homicide  for  some  supposed  wrong  :  or  in  general 
paralysis  of  the  insane  ;  or  in  either  the  melaneholic  or  maniacal  phase  ni  folic  circulaire. 
Tlie  chief  dilliculty  in  diagnosis  arises  in  the  early  stages,  or  when  a  patient  hears  diffused 
sounds  of  subjective  origin,   due   perhaps  to  organic  causes,   but  feared    by    the    patieiiL 


406  NOISES     IN     THE     HEAD 

liimself  to  be  a  sign  that  he  is  going  mad.  In  siicli  cases  inueli  discretion  may  be  required 
in  deeidini;  the  i)sychological  import  of  the  noises  complained  of. 

2.  The  Sane. — Perfectly  sane  persons,  however,  may  be  botlicred  tremendously  by 
subjective  noises  in  the  head — sensations  resembling  the  blowing  off  of  steam  by  railway 
engines :  crackings  and  groanings  ;  hissing  or  buzzing  noises  :  rhythmical  pulsating  noises  ; 
clatterings  and  dins  like  hundreds  of  drums  beating  at  one  time  ;  roarings  ;  hammerings, 
and  so  on.  As  a  rule  it  is  po.ssibIe,  on  careful  inquiry  from  the  patients,  to  differentiate 
these  into  two  main  types  — namely,  (1)  Those  in  which  the  noises  rapidly  wax  and  wane, 
though  they  are  never  absent,  the  variations  having  a  more  or  less  rhythmical  character 
related  to  the  pulse  I'ate  ;  and  (2)  Those  in  which  there  is  no  such  rhythm  in  the  subjective 
noises  lieard.  The  former  group  com))riscs  cases  in  which  the  fault  lies  either  in  the  l)lood 
itself  or  in  the  cerebral  vessels  tlinmuli  wliicli  it  Hows  :  in  tlie  latter  group  the  cause 
usually  lies  in  the  ear  itself — external,  middle,  or  internal — or  in  the  hearing  centre  in 
the  temporo-sphenoidal  lobe  of  the  brain.  In  either  case  tlie  patient  may  live  for  years,  and 
get  used  to  the  troublesome  noises  ;  general  hearing  may  be  quite  good  in  spite  of  them  : 
and  it  is  often  very  difficult  to  be  quite  certain  of  their  cause  because  there  is  so  little 
post-mortem  evidence  to  base  their  ])athology  on.  The  ])atients  do  not  die  in  hospitals, 
and  in  general  practice  ])ost-mortem  research  into  the  causation  of  the  noises  is  rare. 

The  h;emic  and  vascular  conditions  to  think  of  in  connection  with  the  first  group  are 
the  following  : — 

Arteriosclerosis  :    Granular    Kidney. — Evidenced    by    hi^h    blood-pressure    readings    with 

the   sphygmomanometer  and    by   albuminuria. 
Aortic   Regurgitation. — Evidenced  by  the  aortic  diastolic   bruit  and  the   highly  pulsatile 

arteries  generally. 
Atheroma  of  the  Cerebral  Arteries. — Guessed  at  on  account  of  the  age  of  the  patient  and 

the  eondition  of  the   thickened   radials   and  the  tortuous  temporal  arteries  ;   there 

need  be  no  increased  systemic  blood-i)ressurc. 
Severe  Anrpniia  (see  .\n.emi.\,  p.  20). — .Vny  eondition  of  severe  aniemia  may  cause  noises 

in  the  head,  but  it  is  most  marked  in  cases  of  pernicious  ana?mia  (p.   24),  severe 

ehliirosis,  and  anaemia  due  to  any  sudden  blood  loss, — due  for  instance  to  post-partum 

hiiinorrhage,  bleeding  of  a  duodenal  ulcer,  hiematemesis.  or  hanioptysis. 
Graves's  Disease  (p.  229). — In  which  all  the  arteries  may  be  ])ulsating  very  violently. 
Purclij  Functional  Conditions,    with  or    tcithoul  Ilijsleria. — Es])ceially  when    there   is   also 

(uidue  pulsation   of  the   abdominal    aorta   (p.    543)  and    great    exaggeration    of  the 

knee-jerks,  often   \isceniptosis.  and  mobility  of  the  right  kidney. 
7'o.)/r  (V)/»/i7/o/(.v. —l'',s|H<ially  intestinal  toxiemia  from  any  form  of  chronic  constipation: 

or  ficini  aleoliolisni.  acute'  and  clirouie  ;  or  from  the  effects  of  certain  drugs,  especially 

salicylates,  aspirin,  quinine,  arsenic,  iodide  of  potassium,  plunibism. 

When  these  causes  can  be  excluded,  and  there  is  reason  to  suppose  that  there  is  or 
has  been  trouble  in  the  ears  themselves,  the  various  conditions  that  need  to  be  considered 
are  : — 

^Vax   in    the  ear. 

Inllarnniaiion  of  the  external  auditory  meatus. 

lilows  npon  the  ear. 

The  effects  of  work  carried  on  amid  exceptional  circumstances  of  noise,  e.g.,  boiler- 
makers,  rivetters  ;  or  under  exceptional  conditions  of  external  pressure,  e.g..  luider 
high  pressures  :  divers,  caisson  workers,  workers  in  very  deep  pits  ;  or  under  low 
jircssures  :  nioiuitaincers,  those  who  live  at  high  altitudes,  balloonists,  airmen  who 
ascend  to  great  lu-ights. 

The  elieets  of  of  chronic  otitis  media  (otosclerosis),  generally  preceded  by  Otorrhcea 
(p.  421). 

Chronic  thickening  of  the  bones  containing  the  ears ;  for  instance,  as  part  of  osteo- 
porosis, osteitis  deformans  (p.  155),  acromegaly  (p.  237),  chronic  syphilis  of  the  bones, 
leontiasis  ossea. 

Chronic  thickening  of  the  meninges  in  relation  to  the  petrous  bone  ;  secondary  to  otitis 
media  ;    due  to  injury,  age,  or  syphilitic  pachymeningitis. 

Timionr,  abscess,  or  inflammatory  changes  affecting  one  temporo-sijhenoidal  lobe. 

When  the  noises  in  the  head  are  due  to  ear  trouble,  they  are  likely  to  be  much  more 
marked  upon  one  side  of  the  head  than  the  other  ;  when  due  to  vascular  or  hicmic  states, 
they  are  more  likely  to  be  symmetrical  ;  this  general  rule,  however,  is  liable  to  exceptions 
either  way,  and  in  all  cases  a  full  examination  of  the  ears  is  necessary,  especially  by  means 
of  the  aural  speculum  and  by  the  tests  for  hearing  described  under  De.vfness  (p.  164). 


NYSTAGMUS  407 

Any  of  tlic  conditions  mentioned  in  eitlier  of  the  main  groups  above  may  be  associated 
with  vertigo,  so  that  the  latter  is  not  so  useful  a  symptom  in  the  differential  diagnosis  as 
might  be  supposed.  Upon  the  whole,  however,  it  is  true  that  vertigo  is  to  be  expected 
more  with  either  local  ear  conditions  or  with  arteriosclerosis  than  with  any  of  the  others^ 
so  that  in  a  case  in  which  vertigo  is  prominent  but  the  blood-pressure  is  not  raised,  the 
probability  of  some  local  affection  of  the  outer,  middle,  or  internal  ear,  especially  perhaps 
of  tlie  semi-auricular  canals,  will  be  considerable. 

The  Wassermann  reaction  should  be  tested  in  all  cases  in  which  there  is  any  hesitation 
in  the  diagnosis  ;  if  it  is  positive  a  syphilitic  cause  will  be  likely,  and  it  is  surprising  how 
many  nerve  symptoms  of  obscure  origin  are  really  syphilitic.  Incidentally,  in  regard  to 
this,  though  it  has  no  connection  with  the  present  subject,  it  is  noteworthy  that  quite  a 
considerable  proportion  of  cases  of  apparently  simple  sciatica  have  been  shown  to  be  due 
to  sypliilis  in  this  way. 

The  great  majority  of  patients  who  complain  of  noises  in  the  head  are  adults,  aofl 
most  of  them  are  past  middle  age.     The  symptom  is  quite  uncommon  in  children. 

llcrbcii  Flinch. 

NOSE,  BLEEDING  FROM. -(See  Epistaxis,  p.  220.) 

NOSE,  DISCHARGE  FROM.  -(See  Discii.mioe,  X.\.s.\l.  ]..  178.) 

NOSE,  REGURGITATION    OF  FOOD  THROUGH.     (See  Reoi  rgit.vtion  of  Food 

TiiRorcii  ■nil;  .Xosi:.  p.   .'i.S.s.) 

NUMBNESS  OF  THE  FINGERS.  -(See  .Sf.nsatiox,  Abnormai.itiics  of.  p.  (iOl.) 

NYCTALOPIA.— (Sec  \'isiox,  Dkff.ct.s  of.  p.  7():5.) 

NYSTAGMUS. — Several  varieties  of  associated  tremor  of  the  two  eyes  are  comprised 
unilir  tlic  Icriii  nystagmus.  These  are  :  (1)  Searching  movements  ;  (2)  Pseudo-nystagmus; 
and  (:i)  Xystagmus  pro|)er. 

1.  Wide  imrposclul  and  slow  movements  of  the  eyes  in  all  directions  are  usually  seen 
in  peo|)lc  who  arc  born  blind  or  have  lost  the  power  of  fixation  as  the  result  of  some  obstruc- 
tion of  the  retina  or  choroid  at  the  yellow  spot.  The  eyes  appear  to  be  seeking  for  some- 
thing but  never  rest  on  any  definite  object. 

2.  Pscuflo-nystagmus.  which  is  commonly  confu.sed  with  true  nystagmus,  is  the  term 
a|>plicd  to  rapid  jerking  movements  of  the  eyes  when  they  are  carried  to  the  extremity  of 
an  excursion  in  any  direction.  The  eyes,  instead  of  remaining  fixed  on  the  object,  rapidly 
reccrle  from  tlicji-  position  and  return  to  it  at  the  rate  of  four  or  five  oscillations  a  second. 
This  condition  is  a  cliaractcristic  symptom  in  Friedreich's  or  heredilari/  (il<iJ'ij.  and  is  also  met 
with  in  K)  or  50  per  cent  of  cases  of  (lissetiiiixiied  sclerosis  and  in  many  cases  of  ccrehellrir 
tumour.     l'"or  the  differential  diagnosis  of  these  conditions  sec  Pauapi.kcia.  p.  "iio. 

:i.  Nystagmus  ])roper  is  the  term  applied  to  the  condition  in  which  the  eyes  make 
rapid  regular  oscillations  about  a  fixed  point,  not  only  at  the  extremity  of  an  excursion, 
but  wlicn  the  eyes  are  otherwise  at  rest,  and  looking  directly  forward.  The  o.scillations 
iMM\  be  in  I  lie  vertical  or  the  horizontal  meridian,  or  may  in  some  cases  exhibit  a  rotatory 
lonn.  The  condition  is  usually  bilateral,  though  it  is  occasionally  met  with  affecting  one 
eye  only,  anil  in  some  rare  ca.ses  the  chara<-l<r  of  the  nystagnms  may  dilTir  in  llie  two  eyes. 

True  nystagmus  is  caused  by  : — 

('/).  Conditions  causing  defcctiv<>  vision  in  the  early  months  of  lile.  .\s  a  result  of  such 
affections,  the  macular  region  is  not  dillcrentiated  from  the  surrounding  portions  of  the 
retina  as  is  tlie  usual  course  in  the  early  nionlhs  of  infant  life,  and  power  of  fixation  is  never 
ucquircd.  (  onilitions  wliich  m:i\  thus  <ause  nystagnms  arc  opht  lialniiii  of  llic  new-born, 
congenital  caLiract.  (Miloiir  blimlncss.  albinism,  and  certain  cases  in  uliirli  lluie  is  an 
unusual  ilislribiilion  ol  the  rctiniU  pigment.  The  diagnosis  of  llicsc  vaiious  conditions 
depenils  on  an  a<cuiatc  cxaniiniition  of  the  eve. 

(I)}.  (  oiiditions  developing  in  later  life  due  to  constant  strain  fr peculiar  occupa- 
tions, as  Tor  (Sample  miners'  iii/slriiiiniis.  in  which  it  is  i)robably  caused  by  continued  work 
in  a   iliin   liglil,    where   the  central   vision   necessary   for  steady  fixation  is  comparatively 


408 


OBESITY 


ineffective,  and  in  whicli  it  is  associated  witli  other  symptoms  of  failure  of  tlie  central 
nervous  system.     As  a  rule  it  improves  on  the  cessation  of  the  occupation  which  causes  it. 

(r).  Aural  irritation,  in  which  it  is  usually  associated  with  vertigo. 

((I).  Nystagmus  may  also  occur  in  about  1 2  per  cent  of  all  cases  of  disseminated  sclerosis. 

(e).  In  certain  cases  of  cerebellar  tumours  it  is  a  marked  symptom  ;  and  it  may  occur, 

(/■).  In  various  rare  conditions,  after  traumatism  or  poisoning,  and  possibly  syringo- 
myelia. //.  /,.  Ea^on. 


OBESITY  implies  an  excessive  accumulation  of  fatty  tissue  in  the  body.  It  is  not 
necessarily  pathological,  but  even  in  otherwise  healthy  persons  obesity  ultimately  incom- 
modes them,  and  is  very  liable  to  lead  to  cardiac  symptoms  due  to  fatty  changes  in  and 
around  the  heart.     The  following  are  some  of  the  chief  causes  : — 


Ilcrodity 

(iintimicd  over-eating 

C'diilimicd  drinking  of  malt   liqiiors 

Too  little  exercise 

A  i>re-glycosiiric  state 

t'lironic  parenchymatous   neijhritis 

Testicular  atrophy  or  excision 


Ovarian'  insullieienev 
Ilypotliyniiilism 
Ily|]ii|)itiiitarisni 
C'creljcilar   tumour 
Hyiiernephroma 
Adiposis  dolorosa    or  i 
Diffuse  lipomatosis      i 


Dercum's    disease. 


The  majority  of  the  above  need  little  discussion.  Families  in  which  all  the  members 
tend  to  run  to  fat  are  familiar  enough  ;  the  individuals  may-  weigh  anything  from  16  to 
30  stone,  without  necessarily  being  ill.  Over-eating,  over-drinking,  and  under-exercising 
are  generally  obvious  if  the  patient's  mode  of  living ^is  known.  The  prc-glijcosiiric  state 
is  particularly  important  from  the  point  of  view  of  life  insurance  :  when  a  young  man  or 
woman  imder  thirty-five  begins  to  run  to  fat  without  apparent 
cause,  it  is  clear  that  there  is  an  error  in  his  metabolism  : 
there  may  be  no  glycosuria  at  this  time,  but  in  quite  a 
number  of  these  cases  the  error  of  metabolism  develops  as 
time  goes  on.  until  presently  there  is  glycosuria,  and  finally 
tyi)ical  diabetes  niellitus. 


/'(>7.  174.— AgU'l,  aged  G 
fro  n  secondary  deposits  in 
de/elopment  of  pubic  hair. 


s.ifTeriiia 
the  lung 
nliich  in 


from  li.Tpernepliro;ua,  which  proved  fatal 
:  tlie  pliotograph  shows  the  premature 
this  oa^e  appeared  at  the  age  of  eighteen 


Chronic  parenchymaloiis  nephritis  sometimes  gives  rise  to 
a  large,  pale  person,  who  looks,  and  is,  fat  and  flabby.  Part 
of  the  apparent  fatness  may  be  due  to  excess  of  fluid  in  the 
tissues,  but  there  need  be  no  obvious  oedema  with  pitting  on 
pressure.  There  may  or  may  not  be  a  history  of  previous 
acute  nephritis — some  of  these  cases  arise  insidiously  :  the 
diagnosis  is  not  dillicidt.  however,  where  renal  tube  casts  and 
an  abundance  of  albumin  are  foimd  in  the  urine,  ])articularly 
if  there  is  a  big  heart,  a  jirolonged  first  sound  at  the  impidse, 
a  ringing  aortic  second  soimd,  a  high  blood-pressure,  and 
perhaps  albimiinuric  retinitis. 


Fij.  175.— Thesamecaseasi?!<7  171 
after  removal  of  the  pubic  hair  :  sliow- 
ing  the  hypertrophy  of  the  external 
genitalia,  without  development  of  the 


Testicular   atrophy  or  enision  as  a  cause  for  undue   fatness  is  best   exemiilified   bv 


OBESITV 


409 


eunuchs  :  similar  fat  accumulation  sometimes  occurs  in  less  degree  as  the  result  of  atrophy 
after  bilateral  <j;onococcal  orchitis  or  epididymitis  ;  it  does  not  follow  tuberculous  destruc- 
tion, for  the  patient  then  wastes  instead.  Palpation  of  the  scrotum  may  indicate  the 
diagnosis. 

Ovarian  insufficiency  is  probably  a  potent  cause  for  undue  stoutness  in  certain  women, 
but  it  is  difficult  to  prove  this,  because  many  of  the  patients  suffer  from  hypothyroidism 
at  the  same  time  :  there  is  a  close  inter-relationshiii  between  the  thyroid  gland  and  the 
ovaries.  Only  a  small  proportion  of  those  cases  in  which  both  ovaries  have  been  excised 
become  obese  ;  but  when  the  normal  ovarian  activities  are  beginning  to  abate,  especially 
at  and  immediately  after  the  menopause,  it  is  common  for  women  to  become  very  stout. 
They  develop  at  the  .same  time  peculiar  nervous  symptoms,  and  it  is  remarkable  how  easily 
both  the  latter  and  the 
obesity  may  be  relieved  by 
relatively  small  doses  of 
thyroid  extract  :  such  cases 
may  be  termed  sufferers 
from  hypothyroidism,  even 
thougli  they  may  not  have 
the  typical  signs  of  complete 
my  xoedema — increasing 
stoutness,  loss  of  strength, 
broad  features,  increasing 
slowness  of  the  intellect, 
broadening  and  thickening 
of  the  fingers  and  hands, 
malar  flush,  and  falling  out 
of  hair  and  eyebrows.  The 
best  test  of  the  diagnosis  is 
the  effect  of  administering 
earefully  graduated  doses  of 
thyroid  extract. 

'I'licre  are  certain  boys 
and  girls-  -especially  boys 
who  tend  to  become  enor- 
mously fat  long  before  they 
reach  the  age  of  puberty. 
Tlie  |)apers  were  full  of  a 
tyijical  exam|)li'  of  this 
malady  a  while  ago  the 
Fat  Hoy  of  IVckhaiii.  This 
abnormal  development  of 
fat  and  si/.e  is  in  some  eases 
associated  with  an  affect  ion 
of  a  suprarenal  capsule  or 
kidney  li  y  jic  r  iiijili  roniii . 
The  latter  docs  not  always 
ca\ise  this  overgrowth,  how- 
ever, for  in  another  type  of  patient  the  tumour  leads  merely  to  (irematurc  development 
of  tfie  pubic  hair  and  external  genitalia.  J-'iilx.  17  1  and  175  arc  from  a  girl,  aged  seven, 
who  had  had  thick  |)ubi(!  hair  since  she  was  eighteen  months  old.  The  clitoris  was 
enlarged,  but  there  had  been  no  menstruation.  The  diagnosis  was  confirmed  i)ost  mortem, 
the  congenital  suprarenal  tumour  having  i)rodMeed  secondary  deposits  in  the  lungs  after 
sevc'U  years. 

Ueeent  observations  seems  to  show  that  obesity  ma>  be  due  to  (iffcctiuns  of  llic  jiiliiitary 
body  as  well  as  to  those  of  the  suprarenal.  We  are  told  that  when  there  is  over-activity 
of  the  anterior  lobe  of  tlic  pituitary,  a<Tomcgaly  results  (p.  •>:i~)  :  and  that  when  there  is 
deficiency  in  cither  the  anterior  or  the  po.sterior  lobe,  the  resultant  error  of  metabolism 
affects  not  so  nmch  the  bones  as  the  soft  i)arts  ;    Fii;.  17(>  indicates  the  kind  of  patient  that 


ndiposocieiut.ilis. 


410  OBESITV 

results.  The  diagnosis  is  suggested  when,  along  with  the  rapidly  increasing  and  clearly 
pathological  fatness,  there  is  persistence  of  the  infantile  type  of  intellect,  voice,  and  genital 
organs,  a  voracious  appetite,  abundant  stools,  and  a  proneness  to  unusually  long  hours 
of  sleep.  It  is  not  necessary  that  the  intracranial  lesion  should  be  primarily  in  the 
pituitary  body  itself  ;  a  tumour  at  a  distance  from  the  latter  can  sometimes  so  interfere 
with  it  indirectly  that  the  same  kind  of  symptoms  may  result  as  if  tlie  pituitary  gland 
was  the  cliief  focus  of  disease  ;  this  is  probably  the  explanation  of  the  fatness  that  is 
so  often  observed  in  cases  of  cerebellar  or  cerebral  tumour. 

Adiposis  dolorosa,  diffuse  lipomatosis,  and  Dercum's  disease  all  seem  to  be  closely 
related.  There  are  two  types — the  alcoholic  and  the  congenital  syphilitic  ;  the  former 
is  tlie  commoner,  and  occurs  in  older  patients  than  does  the  other.  Extreme  fatness 
develops,  but  not  quite  universally  ;  the  abdominal  wall,  especially  on  either  side  of  the 
umbilicus,  the  neck,  shoulders,  arms,  forearms,  thighs,  and  legs  may  become  enormous, 
but  the  hands,  feet,  scalp,  ears,  nose,  and  forehead  escape.  The  patient's  muscular  power, 
as  tested  by  the  dynamometer,  is  very  small,  sometimes  not  a  tenth  of  the  normal  ;  and 
when  any  of  the  fat  parts  are  taken  hold  of  firmly,  without  any  pinching  or  other  pro- 
cedure that  would  be  unpleasant  to  an  ordinary  patient,  some  of  these  cases  experience 
acute  pain — the  name  adiposis  dolorosa  describing  the  two  main  symptoms  of  the 
malady.  There  are  often  mental  symptoms  at  the  same  time  ;  a  patient  of  thirty  may 
periodically  imagine  she  is  only  eight,  and  behave  and  speak  as  though  for  the  time 
being  she  were  a  child  again  ;  and  so  on  in  other  cases,  the  types  of  mental  symptoms 
being  protean.  Superficially  these  cases  may  simulate  myxoedema,  but  a  moment's 
observation  will  show  that  there  is  no  affection  of  the  hands  and  feet,  which  are  just  the 
parts  to  be  first  broadened  and  thickened  by  myxoedema,  besides  which  thyroid  treatment 
does   not    bring   about   material   improvement.  Herbert  French. 

OBSTIPATION.— (See  Constipation,  p.  121.) 

OBSTRUCTON,  INTESTINAL.— (See  Vo.mitini:.  ]>.  TOT  :  and  Constipation,  ]). 
12],  iiiid  consult  Index  at  end.) 

(EDEMA,  ASYMMETRICAL.— (Edema  of  one  leg  or  arm.  or  of  some  local  part  of 
the  head,  face,  neck,  or  trunk,  may  be  due  to  any  of  the  following  causes  :— 

Cowenital  ■ Blockage  of  lymphatics,  e.g.,  in  celUilitis, 

,,''....',  •  i-     1       J  or  other  local  inflammation;   filariasis 

tonstnction  by  amniotic  bands  a  ^c  •  i    k     i-     * 

,.  ,.■         I    i  1.     ■  J      •  Artificial,   bv  ligature 

C  ommunications  between  arteries  and  veins    ;   „  j  i  ^i  ,„„.]  k.. 

Drug  ocdenias,  siicli  as  tliose  caused  by — 

Acquired: —  I  Aspirin 

Blockage  of  veins  :  I  Antitoxic  sera 

1.  From  within — non-infective  thrombus,    !  Iodides 

varicose   veins,    infective   thrombus,  Bromides 

e.g.,  white  leg  Mercurials  :  and  any  which  cause  urti- 

2.  By  pressure  from  without — by  glands,  carial  lesions   (p.   T71) 

tumours,   aneurysms,   etc.  Angioneurotic  oedema. 

Congenital  Causes  are  rare,  but  as  a  rule  they  are  identified  easily. 

Acquired  Causes. — Tlie  diagnosis  may  be  obvious  :  For  instance,  there  may  be  tooth- 
ache with  unilateral  rcdema  of  the  face,  or  a  scalp  wound  with  boggy  swelling  all  round 
it,  or  a  well-marked  cellulitis,  with  red  streaks  extending  up  the  limb  showing  the  course 
of  acutely  inflamed  lymphatics.  It  is  only  rarely  that  a  celkilitis  presents  any  difficulty 
in  recognition  ;  namely,  when  the  inflammation  is  not  very  acute,  and  when  there  is  no 
obvious  source  of  infection,  such  as  an  abraded  toe  or  a  suppurating  wound  of  a  finger. 
Cellulitis  may  then  be  confounded  with  gout  :  but  the  history,  the  presence  of  leucocytosis, 
and  the  absence  of  other  gouty  manifestations  will  indicate  tlie  real  complaint.  There 
may  be  considerable  pyrexia  in  acute  gout  (Fig.  151,  p.  339),  so  that  the  temperature  chart 
does  not  serve  to  distinguish  it  from  cellulitis. 

Varicose  veins  are  a  frequent  cause  of  asymmetrical  oedema,  especially  in  the  leg,  and 
if  there  is  thrombosis  as  well,  very  marked  swelling  results.  The  thrombus,  however, 
does  not  always  lie  in  a  superficial  vein,  and  if  it  is  in  a  deep  one  such  as  the  popliteal. 


CEDEMA.     ASr.MiMETRR'AL 


411 


femoral,  or  iliac,  the  case  may  not  be  so  clear.  The  thrombus  in  these  cases  is  often  due 
to  septic  infection,  and  the  common  source  is  sepsis  in  connection  with  the  uterus  following; 
parturition — white  leg  ;  or  it  may  arise  in  the  course  of  a  prolonged  febrile  illness  such 
as  tj7)hoid  fever,  or  in  a  case  of  cachexia  resulting  from  malignant  disease  or  other  )irolonged 
and  debihtating  malady,  or  from  one  of  the  blood  diseases  such  as  leukiemia. 

\Vhen  none  of  these  causes  is  present  it  is  necessary  to  examine  carefully  to  ascertain 
whether  there  is  any  swelling  pressing  on  and  obstructing  the  veins,  such  as  an  aneurysm 
in  the  popliteal  space  or  a  mass  of  malignant  glands  :  and  not  only  must  the  wliole  limb 
be  examined,  but  also  the  rectum,  vagina,  and  lower  part  of  the  abdomen,  and  the  neck 
and  upper  thon'.x  in  the  case  of  the  leg  and  arm  respectively.  For  instance,  there  may 
be  a  tiunour  sjjringing  from  some  structure  in  the  ])ehis  causing  pressure  on  the  iliac  veins  ; 
and  swelling  of  the  arm  miolit  be  caused  by  an  aneurysm,  subclavian  or  thoracic,  or  by 
a  mediastinal  new  growth,  in  which  case  a'-ray  examination  may  be  of  material  assistance 
in  verifying  tlie  cause.  The  oedema  due  to  venous  obstruction  jiits  rearlily  on  pressure, 
but  where  the  lymphatics  are  blocked  tlie 
oedema  is  much  more  solid  :  this  may  be  an 
important  diagnostic  ])()int. 

lihphanlidnis  due  to  blockage  of  lymphatics 
by  the  parasite  filaria  sanguinis  Iwminis  is  not 
common  in  England,  though  a  pseudo-elephan- 
tiasis, due  to  long-standing  lymphatic  obstruc- 
tion with  resulting  roughening,  thickening,  and 
fibrotic  changes  in  the  skin  and  underlying 
tissues,  is  not  uncommon,  and  may  result  from 
long  continuance  of  a  tumour,  or  be  associated 
with  a  badly-united  fracture,  or  follow  some 
operation  in  which  the  lymphatics  have  been 
removed,  e.a.  after  am|)iitation  of  the  breast 
an<l  axillary  contents  for  carcinoma.  Prol)al)ly 
the  most  (lillicult  group  of  all  cases  to  diagnose 
is  that  in  which  there  is  a  thrombus  of  one  of 
the  (icep  veins  of  the  leg  without  any  obvious 
disease,  and  in  this  event  the  diagnosis  can 
only  be  arrived  at  by  a  ])rocess  of  exclusion. 
Milniy's  Disease  (Fig.  177)  is  diagnosed  I'rnin 
tin-  family  history  (sec  p.   U  t). 

Li'flaliirc. — It  sometimes  happens  thai  a 
patictit.  generally  a  female.  |)resents  herself 
with  an  (I'dema  of  a  limb  for  which  no  explaii- 
alioii  can  l)e  offered.  It  has  to  be  borne  in 
mind  that  there  are  some  neurotic  individuals 
who  will  tie  a  ligature  round  their  limbs  in 
(iidrr  li]  simulate  disease  or  to  excited  sympathy, 
and  uliri  have  even  gone  so  far  as  to  suffer 
amputation.  It  is  often  extremely  dillicult  to 
detect  the  Irau.l  :  hut  if  the  pc>ssil)ility  he 
suspected,  the  nurse  in  charge  must  be  instructed  to  keep  watch,  and  at  unexpected 
times  to  search  the  patient,  when  a  handkerchief  or  a  piece  of  string  may  In-  found  con- 
stricting the  lind).  The  lad  that  the  upper  limit  of  the  (edema  is  sharply  deliiied  should 
awaken  suspicion.  It  iii:i\  In-  dillicult  to  diirercnliale  this  from  (Uiuioneiirolie  viteina 
{Qiiinel:r's  iliserixcj.  lint  llic  lallci-  condition  is.  as  a  rule.  Iransilory.  and  alTccIs  dilferenl 
Jiarls  of  the  Ixxls'.  e.g.  the  tongue,  lips,  eyelid,  hands,  etc..  at  diirercnl  limes  (Fig.  17S. 
1>.  H2)  :  the  laet  that  the  patient  has  had  picvions  at  tacks  gencially  points  to  the  <liagnosi-,. 
and   the  mala<ly  ulteii  occurs  spontanecjusly   in  se\(ial   members  of  the  same  family. 

(ieorge  li.  (lash. 

(EDEMA,  SYMMETRICAL.  Owing  to  accidcnls  of  posture  such,  lor  instance,  as 
the  p;ili<iit  sitting  with  one  leg  In  the  gKiUiid  .uid  the  iilliir  supported  upon  a  chair,  or 
l\  in;;  in  lied  turned  well  oxer  to  niie  side,  ami  rcriiainin^i  in  this  asymmetrical  |)osition  for 


-Milroy' 


.  abruptly  nt  tli 


i  or  Jteiiie's  UUense ;  A  case  of 
trnphrfdema  of  tlit!  k';^,  Tlie 
"'I  -iioritaneously  in  a  girl  who 
I:  r-l  iiiii,  and  wlio  sullered  little 
i.  .ilr.tion.  tJlio  was  21  wlieii 
.io  n.  ,ind  liad  had  the  swelling 

u  t-rdargenient  of  her  ri;.'liti 

)  groin. 


41-j 


CEDEMA.     SYMMETRICAL 


a  long  time — it  is  possible  for  oedema  which  would  really  be  symmetrical  to  appear  asym- 
metrical. Allowing  for  this  source  of  fallacy,  liowever,  the  causes  of  symmetrical  oedema 
are  different  from  those  of  asymmetrical  oedema  (see  above).  One  may  subdivide  cases 
into  three  main  groups,  namely  :  (1)  Those  in  ivhich  the  oedema  is  universal ;  (2)  Those  cases 
of  a'dema  in  Kiiich  the  swelling  involves  the  face,  neck,  and  arms,  but  not  the  legs  or  the  lower 
half  of  the  triinl:  ;  (3)  Those  in  which  the  oedema  affects  the  legs,  or  the  legs  and  loioer  half  of 
the  triinli.  bid  not  the  arms,  neck,  or  face. 

ffidema  of  the  legs  is  by  far  the  commonest  type,  and  by  far  the  most  important  point 
in  the  diagnosis  is  to  decide  as  soon  as  possible  whether  this  oedema  is  due  to  Bright's  disease, 
heart  failure,  or  to  some  other  cause.  The  broad  distinction  into  these  groups  is  seldom 
<liUicult.  The  urine  should  be  tested  at  once  :  if  albumin  be  present,  microscopic  examina- 
tion for  renal  tube-casts  is  essential,  their  presence  indicating  renal  mischief,  their  absence 
probably  excluding  it,  unless  the  renal  lesion  is  very  acute,  in  which  case  there  will  be  renal 
epithelial  cells  even  if  there  are  no  tube-casts  ;  if  there  be  no  albumin  in  the  urine,  renal 
inllammation  as  a  primary  cause  of  oedema  of  the  legs  is  unlikely. 

It  will  be  easy  as  a  rule  to  decide  whether  there  is  failure  of  cardiac  compensation  or 

not  :  if  there  is,  the  differentiation  between  the 
four  main  groups  of  causes  of  heart  failure, 
namely,  primary  valvular,  primary  muscular, 
])rimary  limg  affections,  and  primary  arterial  or 
renal  conditions,  will  be  made  upon  the  lines 
indicated  upon  p.  14. 

Other  causes  for  oedema  of  the  legs  will  be 
suggested  by  other  symptoms  in  the  case  or  by 
the  history,  but  they  cannot  be  diagnosed  with 
certainty  until  both  renal  inflammation  and 
heart  faihu'e  have  been  excluded.  It  seems 
worth  wliile.  however,  to  discuss  in  rather 
greater  detail  each  of  the  main  groups  indicated 
above. 

Cases  in  which  the  (Edema  is  Universal. — 
AVhen  a  patient  has  a  tendency  to  universal 
symmetrical  cedema.  the  great  probability  is 
that  he  is  suffering  from  either  primari/  acute 
nephritis  or  acute  nephritis  superposed  upon 
chronic  nejihritis  ;  the  diagnosis  is  indicated  by 
the  occurrence  of  albimiin  with  tube-casts.  The 
degree  of  oedema  exhibited  in  different  regions 
varies  partly  by  reason  of  the  looseness  of  the 
subcutaneous  tissues  in  different  places,  and 
partly  by  means  of  the  effects  of  gravity. 
Other  things  being  equal,  the  oedema  shows  most  in  the  legs,  lumbar  region  (lumbar 
cushion),  penis,  scrotimi,  labia,  eyelids,  and  face,  though  careful  examination  may  show 
that  there  is  some  degree  of  oedema  in  every  tissue  from  scalp  to  toes  ;  it  is  due  to  the 
inlluence  of  gravity  that  when  the  patient  is  up  and  about  the  oedema  is  most  marked  in 
tlie  legs  ;  is  very  marked  in  the  lumbar  cushion  and  the  genital  organs  when  the  patient 
sits  propped  up  in  bed  :  and  is  most  prominent  in  the  eyelids  when  the  patient  has  been 
lying  horizontally,  as  during  sleep. 

Other  causes  for  universal  oedema  are  rare,  but  it  may  sometimes  be  due  to  a  universal 
condition  of  angioneurotic  cedema  (Fig.  178).  though  this  is  much  more  often  asymmetrical  : 
or  to  overloading  of  the  tissues  with  fluid — for  instance,  as  the  result  of  excessive  trans- 
fusion or  infusion,  or  in  patients  who  have  been  swilling  beer  day  after  day  until  their  bodies 
lia\e  become  sodden.  Such  cases  present  an  appearance  highly  suggestive  of  acute 
nephritis,  but  the  absence  of  albumin  from  the  mine,  the  history  of  excessive  drinking  over 
long  periods,  and  the  complete  recovery  when  the  drinking  is  stopped,  point  to  the  dia- 
gnosis. Generalized  oedema,  usually  not  of  extreme  degree,  is  apt  to  be  complained  of  by 
some  anaemic  girls,  generally  between  15  and  20  years  of  age,  often  in  association  with 
gastric  .symptoms,  especially  persistent  vomiting  after  food,  and  with  constipation.     These 


-FW.  17 


— Angioneurotic  oedema  of  the 
simulating  acute  nepluitis. 


(EDEMA.     S'VMMETRICAL  413 

cases  have  no  name  :  they  are  ehiefly  of  importance  in  that  they  are  very  apt  to  be  dia- 
gnosed as  nephritis,  altliouwh  there  is  no  albuminuria  as  a  rule,  and  they  get  well  by  them- 
selves. The  oedema  is  doubtless  toxic,  but  whether  the  causal  toxin  is  intestinal,  or  derived 
from  some  other  source,  no  one  knows.  The  same  applies  to  certain  cases  of  acute  universal 
oedema  in  infancy  or  childhood,  simulating  acute  nephritis,  but  differing  from  the  latter  in 
that  there  is  no  albuminuria  and  spontaneous  recovery  occurs.  Both  types  differ  from 
true  angioneurotic  oedema  in  that  the  condition  is  not  familial  like  the  latter  (p.  411). 
Similar  universal  oedema,  perhaps  toxic  in  origin,  but  unaccompanied  by  any  evidence  of 
nephritis,  follows  severe  gastrD-ciiieritis  in  children,  even  when  no  saline  infusion  has  been 
resorted  to. 

Certain  poisons  may  produce  universal  oedema,  though  rarely  ;  iodide  iij  potassium 
has  been  known  to  do  so  to  a  mild  degree  :  one  of  the  effects  of  snake-bite  also  is  to  produce 
universal  oedema  with  or  without  albuminuria,  though  as  a  rule  the  part  originally  bitten 
is  very  much  more  swollen  than  are  the  other  portions  of  the  body. 

Aspirin  affects  certain  individuals  in  a  curious  way,  producing  urticarial  wheals  and 
universal  swelling,  transient  as  a  rule,  or  lasting  little  more  than  twenty-four  hours  ;  though 
sometimes  so  severe  that  the  whole  face  is  swelled  up  and  bloated  to  such  an  extent  that 
the  patient  is  for  the  time  being  unrecognizable.  The  symptoms  appear  to  depend  here 
upon  personal  idiosyncrasy  to  the  drug. 

Only  in  very  rare  cases  does  lieart  failure  produce  oedema  of  the  hands  and  arms  as 
well  as  of  the  legs,  and  when  it  does  so  the  patient  usually  has  been  ill  some  time,  the  dia- 
gnosis has  already  been  made,  and  the  end  is  not  far  off. 

(Edema  of  the  Face,  Neck,  and  Arms,  but  not  of  the  Legs  or  Lower  Half  of 
the  Trunk,  is  nearly  always  due  to  obstruction  to  the  superior  vena  cava  or  to  the  main 
branches  which  go  to  form  this,  and  the  commonest  cause  of  this  obstruction  are  thoracic 
aneuri/sm,  mediastined  nnv  groziths.  or  gumma,  chronic  mediastinal  fibrosis,  and  thromtiosis 
spreading  to  the  main  trunk  from,  for  instance,  an  axillary  vein  infected  from  a  whitlow 
or  from  other  sources  of  phlebitis.  When  the  swelling  comes  on  acutely,  as  it  may  in  any 
of  the  above  conditions,  acute  Bright's  disease  may  be  simulated  on  account  of  the  extreme 
pulTiness  of  the  eyes  :  but  further  examination  will  show  a  remarkable  limitation  of  the 
(rdcma  to  the  head  and  upper  limbs,  whilst  the  urine  will  probably  not  contain  albumin. 
If  the  obstruction  to  the  su])crior  vena  cava  ])ersist,  there  will  be  evidence  of  collateral 
circulation  in  the  form  of  varicose  veins  upon  the  chest  wall  (see  Vkins,  \akicosk 
TuoRACic,  p.  7.50). 

It  only  remains  to  add  that,  instead  of  being  asymmetrical,  inllanunatorv  lesions  may 
-sometimes  i)roducc  almost  symmetrical  a-dema  of  the  face  or  neck,  in  which  connection 
one  may  mention  eri/sipclas.  cellulitis,  anthrax,  angini  Ludoviei,  the  differential  diagnosis 
which  is  based  upon  the  history,  tlic  constitutional  symptoms,  the  local  apjicarances 
nf  the   inllainmatioii.   and   the   results  of  baclcrioliigicMl   cxaininatioii. 

Similar  symmetrical  swelling  may  be  produced  in  the  hands  or  arms  eitlur  by  angio- 
neurotic ccdema  (Fig.  178),  or  by  allied  vasomotor  neuroses,  such  as  Haijnaud's  disease. 
Swelling  of  the  eyes  and  face  suggestive  of  oedema  may  sometimes  be  due  to  bouts  of  crying. 
prolonged  attacks  of  coughing,  as  fcfr  instance  in  whoo))ing-cough.  or  as  (he  result  of  catarrh 
due  to  a  common  cold,  measles,  or  to  the  cllcct  of  such  remedies  as  [lotassiiim  iodide  or 
arsenir. 

(Edema  of  the  Legs  and  Lower  Part  of  the  Trunk,  without  any  of  the  Neck  or 
Face,  is  suggcstisc  of  hcarl  laihnc  or  of  nephritis,  and  I  he  main  |)oints  thai  arise  in  the 
dilTcrential  diagnosis  have  been  discussed  above.  If  both  these  main  groups  of  causes 
can  be  excluded,  however,  it  is  important  to  remember  how  often  the' legs  may  swell  as 
Ihc  result  of  poverty  of  the  blood  in  any  condilion  of  aniemia.  This  is  perhaps  seen  best 
1)1'  all  in  cases  of  chlorosis,  for  palienis  suH(ring  from  the  severer  types  of  ana-mia,  such 
as  pernicious  anivmia.  li/mphidic  or  splenomeilullarij  leukivmia.  Ilodghin's  ftiseasc.  splenic 
anwmia.  pseudo-leuka-mia  infantum,  are  less  continuously  u\>  and  about  than  are  many 
eases  of  chlorosis.  The  same  applies  to  the  severe  aiHvmia  xvhich  follows  loss  of  blood  from 
lia-moptysis.  hu'tnatemesis,  posl-parlum  and  other  ha>morrhages  ;  or  to  the  less  at  iitr 
amemias  that  result  from  parusilic  infections  such  as  Ilothrioeephalus  lalus  or  Ankiilostomuni 
duotlenalc.  or  the  cliects  of  <Mrlain  drugs  :  or  to  cachectic  conilitions  such  as  result  I'roni 
careiiKinia.   sarcoma,   sypliilis.    I  uhcrculosis.   slarxalioii.   malaria  and    \ari(ius  other   tropical 


-114 


(EDEMA.     SYMMETRICAL 


infections.  The  differential  diagnosis  of  these  conditions  will  seldom  depend  upon  the 
presence  of  oedema  alone,  and  eacli  of  the  maladies  will  be  found  discussed  under  the 
heading  of  some  other  symptom. 

Obstruction  to  the  inferior  vena  cava  may  lead  to  extreme  oedema  of  the  legs  ;  if  due 
to  phlebitis,  the  clotting  of  the  inferior  vena  cava  itself  is  nearly  always  preceded  by  that 
of  the  veins  of  one  leg,  so  that  even  when  the  final  result  is  symmetrical,  the  history  nearly 
always  points  to  it  having  begun  asymmetrically.  When  the  inferior  vena  cava  is  obstructed 
by  new  growth  or  by  the  pressure  of  ascitic  fluid,  the  diagnosis  will  depend  upon  the 
discovery  of  some  abnormal  mass,  or  upon  the  interpretation  of  the  cause  of  the  Ascites 
(p.   1-8).     Much  difficulty  sometimes  arises,  as  in  a  case  mentioned  on  p.  7. 

The  influence  of  the  vasomotor  nerves  in  controlling  the  balance  of  lymph  production 
and  lymph  absorption  in  the  legs  is  sometimes  interfered  with.  One  sees  a  good  example 
of  this  in  the  ucdcma  wliich  develops  in  the  lower  extremities  in  convalescent  patients 
when,  having  been  long  in  the  horizontal  position  from  any  cause,  they  first  begin  to 
walk  about  ;  it  is  probable  that  a  perfectly  normal  person  kept  at  rest  in  bed  for  three 
months  would  suffer  from  oedema  of  the  legs  in  varying  degree  for  some  days  or  weeks 
after  first  beginning  to  use  his  limbs,  and  the  tendency  is  still  more  marked  in  those  who 
have  been  laid  up  by  gastric  or  duodenal  ulcers,  typhoid  fever,  fractured  femur,  and  so 

on.  It  may  at  first  arouse  a  suspicion  of  some  kidney 
lesion,  though  the  absence  of  albumin,  and  the  way  in 
which  the  cedema  disappears  spontaneously  in  time, 
especially  under  the  influence  of  massage,  indicate  the 
diagnosis  when  the  history  of  long  confinement  to  a 
horizontal  position  is  known.  Diseased  conditions  of 
the  \asomotor  system  may  produce  even  more  markeil 
I  edema,  as  seen  in  elderly  people,  in  some  cases  of 
Kaynaud's  disease  :  in  angioneurotic  oedema  :  in  associa- 
tion with  peripheral  neuritis,  especially  in  the  tropical 
variety  called  beri-beri.  an  epidemic  febrile  illness 
generally  seen  in  this  country  only  in  seaport  towns  as 
the  result  of  an  outbreak  amongst  seamen  on  board 
ships  in  which  the  diet  has  consisted  largely  of  decorti- 
cated rice. 

There  is  a  peculiar  hereditary  disease  in  which 
oedema  of  the  lower  extremities,  occurring  in  many 
members  of  a  family  {Fig.  179),  may  be  a  prominent 
fiaturo  ;  in  the  early  stages  this  (rdema  is  asym- 
metrical, affecting  one  leg  before  the  other,  but  sooner 
or  later  both  legs  may  become  involved,  until,  if  the 
family  and  personal  history  were  not  known,  the 
oedema  of  Brighfs  disease  might  be  suspected.  The 
affection  is  known  as  Milroy's  disease.  Meige's  disease. 
or  Iwreditary  trophwdema.  The  sudden  demarcation 
between  the  swollen  and  the  non-swollen  parts  at  the 
level  of  a  joint — ankle,  knee,  or  hip — is  characteristic.  There  is  sometimes  a  history  of 
periodic  acute  attacks  of  pyrexia  and  of  gastric  disorder  associated  with  an  increase  in 
the  swelling,  not  altogether  imlike  those  occurring  in  angioneurotic  oedema.  The  swelling 
may  cease  at  the  ankles  in  the  early  stages  ;  when  a  subsequent  spread  occurs,  it  may 
reach  almost  suddenly  up  to  the  knees,  ceasing  there  for  a  variable  mnnber  of  years,  until 
ultimately  it  spreads  to  the  groins,  above  which  it  seldom  extends.  The  diagnosis  is  easy 
when  the  family  history  is  obtainable. 

My.radema  is  a  condition  in  which  the  swelling  of  the  legs  may  simulate  actual  cedema 
very  closely,  and  indeed  in  not  a  few  cases  the  subcutaneous  tissues  of  the  feet  and  legs  do 
pit  to  a  certain  extent  on  pressure.  When  there  is  actual  cedema  as  well  as  myxoedema, 
considerable  doubt  as  to  whether  there  may  not  be  a  cardiac  or  other  factor,  as  well  as 
thyroid  insufliciency,  will  arise.  The  urine  often  contains  albumin,  moreover,  though 
generally  without  tube  casts  :  the  patient  is  nearly  always  a  woman  of  middle  age  (Fig.  104, 
p.  234),  who  has  recently  begun  to  get  much  stouter,  and  at  the  same  time  less  active  both 


of  the  legs  in  :i  -■  ■         - 1        ■ :   ■  .    - 

of  the  faniilv  1"  

also.       She     li.ld      :,     ..   I       I n      .«n      ■■<     J    i,L-|,llnl 

There  was  no  aiinoiinrdity  aliove  I'oupart'^ 
lisaraent.  Milroy's  or  Meige's  disease.  fFor  a 
full  account  see  Hope  and  French,  Quart.  Jour, 
of  Med.,  Tol.  i,  Xo.  3.  p.  312.) 


OPHTHALMOSCOPIC     APPEARANCES 


41: 


mentally  and  physically.  The  diagnosis  of  niyxcEdema  will  be  confirmed  if  the  untoward 
symptoms  and  the  abnormal  state  of  the  subcutaneous  tissues  disappear  under  the 
influence  of  thyroid  medication. 

It  is  not  easy  to  include  all   the  possible  causes  of  nedenia  in  a  classified  list,  but  the 
followini;  include  those  which  ha\e  been  discussed  above  : — 


1.  Universal   (Edema. 

Primary  acute  nephritis 

Acute  nephritis  as  an  exacerbation  of   chronic 

nephritis 
.Angioneurosis 
Excessive  transfusion  or  infusion 


.Soddeninii  from  beer  drinking 

Toxins  {?   intestinal)  in  girls  and  children 

Iodide  of  potassium 

Snake-bite 

Heart  failure. 


•2.  (Edema  of   Face,  Neck,   and    Arms,  but   not   of   Legs. 


Obstruction  to  the  superior 
vena  cava   hy  : 
Tlioracic  aneurysm 
Mediastinal   new  growth 
Mediastinal  gumma 
Mediastinal  fibrosis 
Tiinimhosis 


Ervsipehis 

Cellulitis 

Anthrax 

.Angina  Ludnviei 

Raynaud's    disease 

Angioneurosis 

C'rvinu' 


Cougliing 
ileasles 
Common  cold 
Ptomaine  poisoning,  shell- 
fish variety 
Arsenic 
Aspirin 


(Edema   of  the  Legs,  without  any  of  the  Neck  or   Face. 


Heart  failure  secondary  to  : 
Valvular  disease 
Myocardial  affections 
Chronic  lung  affections 
Renal  or  arterial  affections 

Bright's   disease 

Chlorosis 

Pernicious    ana-mia 

Lymphatic  leukamia 

.Spienomeilidlary  leuka-mia 

Hodgkin"s  disease 

Splenic   an;emia 

Pseudo-leuk;rmia  infant vun 


.\na"mia     following     excessive 

blood  loss 
Parasitic  affections,  especially 

Bothrioeephalus   latus 

Ankylostomum  duodenale 
Cachectic   states   due   to  : 

Carcinoma 

Sarcoma 

Syphilis 

Tuberculosis 

Starvation 

Malaria 

Tropical  affections 


OLIGOCYTHyEMlA.— (Sec  Av.km.a.  p.  -.'(i.) 

OLIGURIA. -(Sec   Am  HIA.    i).   .-W.) 


Inferior  vena  cava  obstruction 
by  : 

Thrombosis 
Xew  growths 
.-\seites 
Convalescence 
Old  age 

Raynaud's  disease 
Angioneurosis 
Beri-beri 
-Milroy's     disease     (hereditary 

tropha><lema) 
Myxo-ilenia 

Ihrhert  French. 


OPHTHALMOPLEGIA.    (See 

Tin;,   p.  .";.■) I  :     and    Dii'i.oi'i  \.   p.    17 


STH  ABISMtS. 

I.) 


p.     (i4!)  :        1*(  IMI..     AitvouMAi.iiiKS 


OPHTHALMOSCOPIC  APPEARANCES,  NOTES  ON.— {/'/«/,  s  A /A  and  AA.) 

Fi!>.  II.  A  Physiological  Cup  nuiy  vary  in  size,  but  usually  occu])ies  the  centre  of 
tlic  disc.  The  retinal  \csscls  dip  over  the  edge,  which  is  usually  steeper  on  the  nasal  side, 
the  temporal  slope  being  more  gradual.  At  the  bottom  of  the  cup  is  seen  the  lamina 
cribrosa.  which  is  mottled  by  the  opi'nings  througli  which  the  retinal  nerve  fibres  pass. 

A  physiological  cup  is  distinguished  from  that  caused  by  glaucoma  (Fig.  :)  bv  tl\e 
fact  that   it  occupies  only  tlic  centre  and  not   the  whole  of  the  disc. 

Fig.  h.  Congenital  Crescents  arc  common,  and  usually  situated  at  the  lower  part 
of  the  disc,  in  coidrast  to  myopic  crescents  (Figs.  Ii  and  i).  which  are  seen  on  the  outer 
side.  They  arc  i)robably  diu'  to  an  uneven  distribution  of  connective  tissue  in  the  lamina 
cribrosa.  and  arc  ciften  associated   with   hypcrnutnipia. 

Fig.  r.  Pigmented  Crescent  in  Disc  Margin.  The  disc  margin  is  always  more 
or  less  pigmented,  the  amouid  var\  ioL'  from  a  snuiil  crescent  to  a  c(im|)lcte  ring.  The 
])igment  has  no  pathological  signilicanec. 

Fig.  il.  -Coloboma  of  the  Choroid  is  a  congenital  deficiency,  and  it  may  be 
recognized  by  its  situation  below  the  disc,  the  snuill  amouid  of  pigment  at  the  edge  of  tlu' 
white  area,  and  the  presence  of  healthy  retinal  vessels  on  its  surface.  II  may  be  associated 
with  other  congenital  abnormalities,  such  as  coloboma  of  the  iris,  optic  disc,  or  lens. 


416  OPHTHALMOSCOPIC     APPEARANCES 

Figs.  e.  f. — Opaque  Nerve  Fibres  exist  normally  in  the  retina-  of  some  mammals, 
e.g.,  the  rabbit.  The  condition  is  due  to  the  persistence  of  the  medullary  nerve  sheath  of 
the  retinal  fibres,  the  sheath  being  lost  usually  at  the  passage  of  the  nerve  fibre  through 
the  lamina  cribrosa.  The  condition  may  be  recognized  by  the  brilliant  white  colour  of 
the  nerve  fibres,  the  striated  appearance  of  the  white  patch,  and  the  fact  that  the  retinal 
vessels  arc  more  or  less  embedded  among  the  nerve  fibres. 

Fig.  g. — Advanced  Syphilitic  Choroiditis. — In  advanced  choroiditis  the  inflamma- 
tory process  has  ended  in  the  total  destruction  of  the  choroid  in  patches,  which  in  some 
places  have  joined  to  disclose  large  bare  areas  of  sclerotic.  There  are  large  masses  of 
pigment,  usually  surrounding  the  white  areas,  the  pigment  being  chiefly  derived  from  the 
choroid.  The  retinal  ]jigment  is  also  increased  in  the  great  majority  of  cases,  and  vision 
is  rendered  extremely  defective.  Macular  choroiditis  is  degenerative  in  origin,  and  does 
not  usually  appear  till  middle  life.  It  probably  commences  in  the  form  of  macular  ha-mor- 
rhages,  which  lead  to  destruction  and  fibrosis  of  the  retina. 

Figs.  It.  i. — The  Myopic  Crescent  is  usually  foimd  on  the  outer  side  of  the  disc,  and 
may  vary  in  size  and  extent  from  a  thin  crescent  to  a  large  atrophic  area  surrounding  the 
whole  disc  (posterior  sta])hyloma).  Usually,  the  size  of  the  crescent  varies  with  the  amount 
of  the  myopia  and  increases  with  age. 

Figs,  k,  I. — Recent  Optic  Neuritis  is  characterized  by  the  swelling  of  the  disc  and 
the  blurring  of  its  outline  by  retinal  oedema.  The  relina  is  greyish  and  striated  in  appear- 
ance, owing  to  a-denia  between  the  retinal  nerve  fibres,  and  the  veins  are  extremely  dilated 
and  tortuous.  Flame-shaped  h<eniorrhages  are  also  seen  on  the  disc  and  in  the  surrounding 
retina,  and  numerous  small  retinal  vessels  on  the  disc,  usually  invisible,  become  dilated 
and  apparent.  In  the  later  stages  of  the  neuritis  the  ha-morrhages  may  disappear,  and 
the  whole  disc  become  greyer  and  paler,  the  condition  >iltimately  terminating  in  post- 
neuritic atrophy  {Fig.  I).  The  outline  of  the  disc  is  entirely  lost,  and  in  severe  cases 
the  disc  may  be  so  swollen  as  to  resemble  a  small  mushroom  in  shape.  Radiating  lines 
of  white  patches  may  also  be  seen  in  the  macular  region,  resembling  albuminuric  retinitis 
(Figs,  p,  q.  r.). 

Figs.  m.  n. — Primary  Optic  Atrophy  {Fig.  n)  is  characterized  by  the  pallor  of  the 
disc,  white  or  bluish-white,  sharply  defined  lamina  cribrosa,  well-mai'ked  edge,  and  retinal 
vessels  of  normal  size.  In  post-neuritic  atrophy  (Fig.  m)  the  disc  is  covered  with  fibrous 
tissue,  which  fills  up  the  physiological  cup  ;  the  colour  is  greyish-white,  the  retinal  vessels 
are  thin  and  tortuoiis.  and  the  edge  of  the  disc  is  irregular.  In  .some  cases  of  old  post- 
neuritic atrophy  or  fibrosis,  following  slight  optic  neuritis,  it  may  be  impossible  to  distinguish 
the  condition  from  iirimary  atrophy. 

Fig.  o. — Thrombosis  of  the  Central  Retinal  Vein. — In  thrombosis  of  the  central 
retinal  vein  the  disc  is  extremely  swollen  and  adematous.  the  edge  being  indistinct  and 
blurred.  .All  the  retinal  veins  are  enormously  dilated  and  tortuous,  and  the  fundus  is 
covered  with  flame-shaped  and  petechial  haemorrhages.  The  (cdema  of  the  retina  from 
the  obstruction  of  the  venous  circulation  may  be  so  great  that  the  vein  may  occasionally 
be  hidden  entirely. 

Figs,  p,  q.  r. — Albuminuric  Retinitis  is  characterized  by  the  presence  of  flame- 
shaped  hremorrhages  in  the  nerve-libre  layer  of  the  retina,  and  white  jjatches.  The  white 
patches  are  of  two  kinds.  Those  seen  in  the  early  stages  of  the  disease  are  ill  defined  and 
woolly,  scattered  about  the  macular  region  in  an  irregular  manner.  These  are  due  to 
exudate  in  the  nerve-fibre  layer  of  the  retina.  In  the  later  stages,  smaller  white  patches 
may  be  seen  usually  arranged  in  radiating  lines  from  the  maeida,  which  are  well  defined, 
and  glistening  or  chalky  white. 

Fig.  s. — Embolism  of  the  Central  Retinal  Artery. — In  embolism  of  the  central 
retinal  artery  the  retina  is  generally  ]>ale  grey  or  white,  owing  to  the  aniemia  consequent 
on  the  obstruction  of  the  artery.  The  macula  itself  being  adherent  to  the  choroid  does 
not  share  in  the  general  pallor,  and  appears  as  a  bright  cherry-red  spot  in  contrast.  The 
retinal  arteries  are  extremely  small,  being  only  fine  white  threads  in  places,  and  the  veins 
may  be  nearly  em])ty.     The  oi)tic  disc  is  white,  blurred,  and  indistinct. 

Fig.  t. — Detachment  of  the  Retina. — The  detached  i)ortion  t)f  the  retina  is  silvery- 
grey  in  colour,  and  raised  above  the  surrounding  fundus.  In  cases  due  to  serous  exudate, 
the  detached  part  of  the  retina  is  transparent,  arranged  in  billowy  folds,  ami  may  float 


PLATE     XIX 

OPHTHALMOSCOPIC      APPEARANCES 


.1.    ir.  //,„,/,  M. 


INHKX   Of   I1I.U.N0S1S— 7V.  /kit  ;i.    110 


OPISTHOTONOS  417 

about  on  movement  of  the  eye.     ^VIlen  the  detachment  is  due  to  growth,  the  retina  is 
usually  smooth  and  opaque.     The  retinal  vessels  are  small,  very  tortuous,  and  dark  in  eolour. 

Fig.  i\ — Glaucomatous  Discs. — The  excavation  of  the  optic  disc  may  be  distinguished 
from  the  physiological  cup  by  the  fact  that  it  affects  the  whole  of  the  disc,  the  edge  often 
being  surrounded  by  an  atrophic  ring.  The  retinal  vessels  bend  sharply  over  the  edge, 
ui(i  may  disappear  from  view  behind  the  overhanging  margin  of  the  disc,  reappearing  on 
the  l)ottom  of  the  cup.  The  lamina  cribrosa  is  well  marked,  and  the  disc  is  white  and 
atrojihic. 

Fig.  jt'. — Tubercles  in  the  Choroid  are  seen  as  ill-defined  circular  masses  varying 
in  size  from  a  pin"s  head  to  masses  nearly  the  size  of  the  optic  disc.  They  are  usually 
issociated  with  miliary  tuberculosis,  grow  rapidly,  but  rarely  attain  any  great  size  owing 
to  the  death  of  the  patient.  It  is  stated  that  they  occur  most  commonly  in  the  neigh- 
l)f)urhood  of  the  disc,  but  this  is  due  to  tlie  fact  that  only  the  posterior  portion  of  the  fundus 
is  visible  with  the  oijhthalmoseoiie.      Post  mortem  they  are  found  all  over  the  choroid. 

Fig.  .r. — Hypermetropic    Astigmatism. — In    hypermetropic    astigmatism   the    disc    is 
ften  oval  and  ill  defined.     The  ))liysiological  cup  is  absent,  the  disc  red,  and  the  margin 
1  deliiKil.     Tlie  vessels  may   l)e   tortuous  though  not  dilated,   and   unless  the  error  of 
refraction  is  observed,  the  condition  may  be  mistaken  for  optic  neuritis. 

Herbert  L.  Easnii. 

OPISTHOTONOS  is  a  rare  but  characteristic  condition,  in  which  the  muscles  of  the 
neck,  back,  and  legs  are  contracted  rigidly  in  such  a  way  that  the  body  is  over-extended 
in  the  form  of  an  arch,  supported  by  the  occiput  above  and  by  the  heels  below.  This 
position  may  be  maintained  ;  more  often  it  is  assumed  periodically,  with  partial  or  complete 
relaxations  between  the  tetanic  seizures.  Its  chief  cause  is  tetanus,  but  it  may  also  be  due 
to  strycliuine  poisoning,  spinal  meningitis,  urcemia,  and  hysteria. 

Tetanus. — The  history  will  often  point  to  the  correct  diagnosis.  If  there  has  been  a 
punctured  wound  recently,  and  if  stiffness  of  the  neck  muscles  and  of  the  lower  jaw  (lock- 
jaw or  trismus)  (p.  729).  has  set  in.  to  be  followed  within  a  day  or  so  by  generalized  rigidity, 
with  severe  paroxysmal  exacerbations,  the  opisthotonos  is  almost  certainly  due  to  tetanus. 
The  fixed  smile — risus  sardonicus — is  common  to  tetanus  and  to  strychnine  poisoning.  An 
attempt  will  be  made  to  obtain  the  drumstick  bacilli  {Plate  XXIJII,  Fig.  T.  p.  614)  from 
the  suspected  wound,  very  often  without  success.  In  some  cases  there  will  be  no  obvious 
wound  or  contusion,  but  although  the  source  of  contagion  will  then  be  obscure,  the  early 
lockjaw  and  the  course  of  the  disease  will  point  to  tetanus. 

Stri/rhnine  poisoning  does  not  give  rise  to  lockjaw,  and  the  paroxysms  of  opisthotonos 
are  separated  by  intervals  of  more  complete  relaxation  than  is  the  case  in  tetanus  ;  there 
may  be  evidence  of  the  source  of  the  poisoning,  either  accidental,  suicidal,  or  homicidal, 
in  the  form  of  a  bottle,  a  hypodermic  .syringe  and  needle,  a  packet  of  vermin-destroyer,  or 
something  of  that  kind.  In  some  cases  the  diagnosis  can  only  be  arrived  at  by  analysis, 
either  of  the  gastro-intestinal  coiiteiits,  or  of  the  \isccra  post  morli'm. 

Spinal  meningitis  seldom  causes  dillieulty  in  the  diagnosis,  for  it  is  generally  part  of 
acute  cerebrospinal  meningitis,  of  which  the  general  symptoms  and  pyrexia  will  have 
existed  some  days,  if  not  a  week  or  more,  before  opisthotonos  is  likely  to  occur.  Optic 
niMiritis  may  be  found,  and  in  some  cases  the  bacteriological  and  cytologic^al  results  of 
lumbar  puncture,  especially  the  discovery  of  the  meningococcus,  may  clinch  the  diagnosis. 

rripmie  convulsions  are  associated  with  eom])lcte  coma,  whereas  in  tetanus  and  in 
strychnine  poisoning  con.sciousncss  is  retained  perfectly  ;  the  convulsions  are  epileptiform 
rather  than  tetanic  ;  there  is  no  7)ersistent  lockjaw  :  and  tlu-  mine  will  nearly  always 
contain  albumin  and  renal  tube-casts. 

Ui/sleria  soinetimcs  takes  a  form  that  may  for  the  imomkiiI  be  dillicult  to  distinguish 
from  tetanus  or  from  strychnine  poisoning.  Cnlike  malingering,  liyslerieal  conlraelions 
that  arc  even  violent  enough  to  cause  opisthotonos  do  not  always  make  the  patient  perspire, 
nor  <lo  they  lead  to  fatigue  in  the  way  that  similar  voluntary  el'lorls  certainly  would.  The 
diagnosis  of  hysteria  is  generally  arrived  at  by  watching  the  case.  Persistent  lockjaw  may 
be  present,  as  in  tetanus  ;  but  whereas  in  strychnine  poisoning  and  in  tetanus  there  is  a 
great  similarity  l)etwccn  one  exacerbation  and  the  next,  hysterical  convulsions  are  apt  to 
be  polymorphous  ;  the  more  the  writhing  and  the  chatige  of  attitude  and  |)osition,  the 
less  likely  is  the  attack  to  be  organic.     The  mind  remains  perfectly  clear  in  tetanus  and 


41.S 


ORTHOPNCEA 


strychnine  poisoning,  tliougli  its  outward  expression  may  be  prevented  by  tlie  muscula 
paroxysms  ;  in  hysteria,  tlie  mental  attitude  is  in  one  way  or  another  abnormal  for  thi 
time  being.  In  arriving  at  a  diagnosis  it  may  be  of  great  assistance  to  know  full  detail: 
of  the  patient's  previous  history,  for  there  may  have  been  similar  hysterical  outbursts  oi 
former  occasions.  Herbert  French 

OPTIC   ATROPHY. — (See  OpmiiALMOscopic  .\ppearanci;s.  Notes  on,  p.  415.) 

OPTIC   NEURITIS. — (See  t)pirriiALMOscopic  Appearances,  Notes  on,  p.  415.) 


ORTHOPNCEA,   or  the  inability  to    breathe    unless   propped   above  the    horizonta 
position,  may  be  due  to  many  causes,  which  may  be  grouped  as  follows  : — 

Failure  of  the  Right  Side  of  the    Heart : — 

Secondary  to  valvular  disease  of  the  left  side  of  the  heart  : 

Mitral  stenosis  I   Aortic  disease  with  secondary  mitral  regur- 

Alitral   regurgitation  gitation 

Mitral  stenosis  and  regurgitation  | 


Some  cases  of  pericarditis 
Primary  alcoholic  heart 


Secondary  to  affections  of  the  heart  muscle  : 

Fatty  heart 
Fibroid  heart 
Adherent  pericardium 

Secondary  to  high  systemic  blood-pressure  : 
Arteriosclerosis  |   Granular  kidney. 

Secondary  to  lung  affections  : 
Empliysema  I   Fibroid  lung 


Chronic  bronchitis 


Pneumothorax. 


Secondary  to  the  effects  of  chronic  poisoning 
Especially  from  tobacco  smoking. 


Obstruction   to  the  Larynx  or  Trachea  :^ 


Acute   oedema  of  the   larynx 

Acute   abductor  paralysis 

Post-pharyngeal  abscess 

Laryngeal  diplitheria 

Laryngismus    strididus 

Catarrlial    laryngitis,    especially    at    tlie 

onset  of  certain  cases  of  measles 
Acute     pneumococcal     or     streptococcal 

laryngitis 
ffidcma  due  to  potassium  iodide 


Laryngeal  crises  of  tabes  dorsalis 

Foreign  body 

Enlarged   thyroid  gland 

Enlarged  thymus   gland 

Aortic  aneurysm 

Mediastinal  new  growth 

Malignant  glands  in  the  neck 

Lymphadenomatous  glands  in  neck 

Irruption  of  a  caseous  gland  into  the  trachea 

Oesophageal  tumour. 


Acute  Obstruction  of  the  Bronchi  and  Bronchioles  :■ — 

.■\cute  l>ronchitis  ;  Asthma 

Acute  capillary  bronchitis  j  Whooping-cough. 

Some  cases  of  acute   bronchopneumonia    1 

Mediastinal  Masses  : — 

Aneurysm  1    New  growth 

Huge  heart  :    Hvdrothorax. 


Enormous  Distention  of  the  Abdomen  by 

Ascites 
Tymi)anites 


Neurosis  or  hysteria 
Solid  or  cvstie  tumours. 


By  far  the  commonest  cause  of  orthojina'a  is  heart  failure  of  some  kind  or  another 
and  the  differential  diagnosis  of  the  variety  of  heart  failure,  and  whether  it  is  due  t( 
valvular  disease,  to  myocardial  degeneration,  to  arteriosclerosis,  to  granular  kidney, 
to  the  effect  of  difficulties  in  the  pulmonary  circulation  from  bronchitis  and  emphysema  o 
fibroid  lung,  has  to  be  decided  upon  the  various  grounds  that  are  discussed  on  p.  14. 


PLATE     XX 


OPHTHALMOSCOPIC      APPEARANCES 


I.    II.  Ihml.  ,M 


ORTHOPN(EA 


When  orthopnoea  is  due  to  obstruction  to  the  larynx  or  trachea,  the  fact  is  "enerallv 
ivious  on  account  of  other  symptoms,  such  as  stridor,  up-and-down  movements  of  the 
rynx  itself,  sucking  in  above  and  below  the  clavicles  and  of  the  lower  intercostal  spaces, 
e  main  difficulty  in  some  of  these  patients  being  to  decide  whether  the  obstruction  is 
Hiciently  near  the  larynx  to  be  relieved  by  tracheotomy,  or  whether  it  is  due  to  mischief 
rtfer  down  in  the  trachea,  bronchi,  or  bronchioles.  The  nearer  the  obstruction  is  to  the 
ynx  the  greater  will  be  the  spasmodic  up-and-down  movements  of  the  thyroid  cartilane, 
d  the  stridor.  If  the  evidence  is  that  the  obstruction  is  in  the  larynx  itself,  and  if  tlie 
thopntra  and  difficulty  with  respiration  are  extreme,  the  probability  is  that  tracheotomy 
II  be  resorted  to  as  an  urgency  measure,  the  precise  diagnosis  being  determined  later, 
le  history,  or  a  local  examination,  would  serve  to  diagnose  or  exclude  acute  abductor 
raiysis.  post-pharyngeal  abscess,  foreign  body,  enlarged  thyroid  gland,  malignant  glands  in 
-  neck,  lymphadennmatous  glands  in  the  neck.  Enlargement  of  the  thymus  gland  can 
dom  be  more  than    conjectured,    or 

ignosed    by    a    process  of  exclusion,      ] ^ 

less  there  is  definite  dullness  behind      ! 

upper   part    of   the   sternum    in    a 
Id  under  ten   years  of  age,  together 
rhaps  with   an  j'-ray  shadow   of  the 
nd   (Fig.    180).     .\ortie  aneurysm  or 
diastinal  nezv  grozvth   obstructing  the 
chea  will  generally  have  given   rise 
other  characteristic  symptoms  at  the 
ne  time  ;     particularly  in  the  case  of 
diastinal  new  growth  to  obstruction 
the  innominate  veins  or  the  superior 
la  cava,  with  varicose  distention   in 
superficial  thoracic  veins  by  way  of 
ateral  circulation  {Fig.  S)!),   p.  208). 
;  ir-rays  may  be  useful  in  eontinning 
diagnosis  {Fig.  100,  p.  209). 
In  a  great  many  cases,  particularly 
children,  none   of  the   above  will  be 
least  likely,  and  if  foreign  body  and 
t-pharyngeal  abscess  have  been  ex- 
led  by  digital  examination,  the  first 
)icion    will    be    that    the   patient  is 
ering     from     laryngeal     diphtheria. 
i  may  be  conlirmed  by  the  presence 
a  small   quantity  of  membrane   on 
pharynx,  the  uvula,   or  elsewhere. 
i  igh  (piite  commonly  when  laryngeal 
li '""lia     Is     extensive     there     is    no 
I  xudate  upon  any  of  the  visible 
I    the  back  of  the  mouth.     The 
'    of  cases  of  diphtheria  in  the 
"luse  or    in    the    neighbourhood   may   point   to    the   diagnosis;    but   in    every  case 
I'lriiis  should   be  obtained   from   as   far  back   in   the  throat   as   possible,   and  examined 
I  l\li  lJ^-l,(K■f^l,■l■  bacilli,  bcth   in  <lireel   lilms  and  by   culture.      I'ntil  laryngeal  diphtheria 
'"   Included  by  the  absence  of  Klebs-l.oelUer  bacilli     and  a  single  negative  result  does 
-sarily  exclude  the  disease     the  nature  of  the  ease  will  probably  remain  in  doubt. 
"/(■;««  of  the  larynx  is  nearly  always  due  to  some  microbial  inle('tion.  and  therefore 
'  use    It    includes   acute    pneumococcal    or   streptococcal   laryngitis,  the  diagnosis  of 
!|  depends  upon  bacteriological  cultivations  from  .swabbings  from  the  throat.     (K<lenia 
'■    iIm,  be  due   to   similar  infection   of  ulcerated   places   in    the    lliniat   developifii;    in   the 
'  -'<>r   tuhercitlous.    sy/ihilitic.    maligiiinil.  lii/mid.  Iraumuli,-.  ur  /insl-lyiihaidal  luryngcid 
'  'iliini.     The  previous  history,  with  the  results  of  examination  of  the  lungs,  larynx,  and 
P;uin,  will  iiidicalc  Ihc  diagnosis  of  these  various  conditions. 


Fig.  180.— .Skiagram  showin?  iiii  cnlaraeii  tliymus  shiiul.  No 
thoracic  symptoms.  The  larso  thymus  was  discovered  in  tlio 
f  oiirse  of  a  routine  j'-ray  cxauuiiatiou  Oil  account  of  dysocpsia  in 
a  female,  aged  48. 

T.  .Shadow  of  the  large  thymus.  H,  i-hadow  of  the  heart. 
D.   Shadow  of   the  diaphragm. 

iskiwimm  hii  I),.  V.   TImrslan  llnllnml.) 


ORTHOPNEA 


Tlie  laryngeal  crises  of  tabes  dnrsalis  are  exceedingly  rare :    they  might  be  suggests 

if  the  patient  were  known  to  have  no  knee-jerks  and  Argyll  Robertson  pupils,  but  evf 

then  there  might  be  doubt  as  to  whether  they  were  really  crises  and  not  the  result 

svphilitie  ulceration,  or  due  to  the  administration  of  potassium  iodide  in  these  cases.     Acut 

oedema  of  the  larvnx  is  sometimes  spoken  of  as  one  of  the  complications  of  acute  Bright 

disease    but  it   is"  very  rare   in  this  malady,   rarer  than  acute  oedema  of  the  lungs  :  i 

is  usually  a  terminal  "factor,  the  diagnosis  of  nephritis  having  been  made  previously  o 

accoimt  of  general  oedema  and  albuminuria  with  tube  casts.     Laryngismus  stridulus  is 

dangerous  diagnosis  to  make,  for  many  cases  thought  to  be  this  are  really  examples 

diphtheria  :   if  laryngismus  stridulus  docs  occur,  it  is  to  be  expected  in  rickety  childr 

who  show  a  tendency  to  spasmodic  muscular  contractions  in  other  parts  besides  the  laryr 

such  for  instance  as  convulsions  from  slight  causes,  or  the  carpo-pedal  contractions 

infantile  tetany  (-spasmophilia').     It  is  supposed  that  similar  spasmodic  contractions 

the  muscles  of  "the  larynx  produce  paroxysms  of  laryngeal  obstruction  with  acute  dyspnoc 

orthopncea  and  cyanosis  ;   but  no  such  cases  should  be  diagnosed  as  simply  neuro-muscut 

until  every  precaution  has  been  taken  to  exclude  all  other  causes  of  laryngeal  obstructio 

csiiwially'diphtheria.     Now  andthen  one  meets  with  a  case  in  which  an  apparently  healtt 

child  is  sei/e<l  suddenly  with  acute  dyspnoea,  cyanosis,  orthopncea  and  general  respirato 

■listress    without  any  signs  of  laryngeal  obstruction,  the  result  of  irruption  of  a    caseo 

bronchial  or  mediastincd  gland  into  the  lower  part  of  the  trachea  or  a  mam  bronchus.     T 

symptoms  are  precisely  such  as  one  would  expect  if  the  patient  had  suddenly  inhaled 

"foreign  body  of  some  size,  and  if  one  can  be  quite  sure  that  no  such  foreign  body  has  be 

inliafed    the  correct  diagnosis  may  sometimes  be  guessed  at.     It  would  be  confirmed  it, 

occasionally  happens,  a  sudden  effort  of  coughing  leads  to  the  caseous  or  cretaceous  nii 

being  expectorated.  ■     ^  r  t. 

The  difficulty  of  being  certain  whether,  in  a  given  case  of  severe  respiratory  distr. 

with  evidence  of" obstruction,  the  mischief  lies  in  the  larynx  or  in  the  lungs,  is  sometin 

considerable  ;    in  either  case  there  may  be  marked  cyanosis,  orthopncea.  dyspnoea,  sucki 

in  above  and  below  the  clavicles  and  of  the  lower  intercostal  spaces  :    the  most  import; 

point  to  note  is  whether  the  larvnx  itself  remains  stationary  as  when  the  mischiet  is 

'he  lunas    or  whether  it  moves  up  an.l  down  with  the  respiratory  movements  as  it  d 

when  the  trouble  is  in  the  larvnx.     Very  often  both  the  lungs  and  the  lar>nx  arc  unolv 

and  it  may  then  be  very  difficult  to  decide  which  is  the  more  so.  and  consT.piently  whet 

tracheotomy  is  indicated  or  not.     The  chief  point  on  which  to  lay  stress,  besides  the  mo 

ments  of  the  larynx,  is  the  result  of  a  physical  examination  of  the  chest  for  evidence 

acute  bronchitis  or  of  bronchopneumonia.  .       »      u-  i  a 

True   asthma  is  a  spasmodic  variety  of  dyspnoea,   the  diagnosis  of  which    and 

difficulty    of   distinguishing   between   asthma   complicated   by    bronchitis   and    bronct 

simulating  asthma,  are  discussed  elsewhere  (p.  535).  ,         ,,  .■     ^   i,;„n 

^YIlooping-cough  is  seldom  difficult   to   diagnose,   for  even  when  the  patient   hini 

does  not  exhibit  the  typical  whoop,  he  will  be  affected  by  a  severe  paroxysmal  coi 

possibly  leading  to  vomiting,  and  at  the  same  time  relatives  or  friends  may  be  affectec 

cough  "which  gives  rise  to  the  typical  whoop.  „     ,     j     m    .,..  , 

Mediastinal  masses,  such  as  aneurysm,  a  huge  heart,  new  growth,  hydrothorax 
marked  displacement  of  the  heart,  and  enormous  distention  of  the  abdomen  by  asc 
tympanites,  or  by  large  tumours,  will  generally  have  been  diagnosed  before  they  p 
t'he  stage  of  producing  orthopncea.  The  chief  reason  why  a  very  large  heart  or  a  tho 
aneurysm  may  produce  orthopncea,  even  when  there  are  no  signs  of  failure  of  the  ca, 
compensation"is  that  when  a  patient  sits  up  there  is  a  greater  distance  between  the  star 
and 'he  yertebn.  than  when  he  lies  back.  The  cause  for  the  -*•-!----*  ^-"^;^,;"^^ 
the  patient  sitting  up  to  allow  a  bigger  space  for  the  accommodation  of  the  abno 
mass^  hence  in  some'  of  these  cases  he  may  be  able  to  walk  about  and  see  to  hi  bu 
without  distress  during  the  daytime,  and  yet  be  unable  to  he  down  at  mght  rhe  cau 
the  orthopncea  associated  in  this  way  with  a  huge  heart  is  unite  different  from  th. 
which  there  is  failure  of  the  right  side,  the  former  being  a  mechanical  means  of  g.v- 
big  mass  more  room,  whilst  the  latter  is  due  to  the  need  of  maximum  assistance  fron 
respiratory  blood-pump. 


OTORRIICEA  421 

OTORRH(EA.-Discliarcje  from  tlie  ear  may  result  from  a  ^•arietv  of  causes  some 
r,v,al.  otlurs  ser,.,us.  The  skin  of  the  normal  external  auditory  meatus  eontains  numero"  s 
erummous  and  sebaeeous  glands,  the  secretion  of  which,  known  as  cerun.en  or  "  x  mav 
.ad  to  trouble  by  formmg  a  hard  solid  plug  which  gives  rise  to  deafness  tinn  U^s"  1 
VerUgo.  hough  not  usually  included  under  the  heading  of  •  discharge.-  in  Z  c""c  ru 
lien  may  be  the  cause  of  a  purulent  discharge  from  the  ear  iipdctcrt  ciru 

When  a  patient  complains  of  an  aural  discharge,  the  colour,  amount,  and  character 
hou  ,1  be  ascertamed.  Any  offensive  odour  should  also  be  noted.  The  discharge  mav  be 
urulent.  muco-puruent  or  .serous,  but  occasionally  it  consists  of  blood.  eithefaZ;  or 
uxed  with  one  „f  the  above-mentioned  varieties 

f  .um!T%u    ?'r  '"";  ^'^"^ '■eternal  auditory  meatus  (olorr.a.la)  n,av  be  the  result 
I  an  injuiij.      llic  tollowmg  lesions  mav  cause  this  symptom  -^ 

Fraclnre  of  Ike  Oase  of  the  shulL     \Vhen  the  line  of  fracture' crosses  the  middle  fossa  it 

r[;m;:ni':r;;r ""  "■  "^ "---' '-  -^  ---  *-  *>■--"'«  --y,  ":;^n^ 

Inj,n>to  the  ca-lernal  mulilon,  nu-at„s.  usually  at  the  junction  of  the  eartilaainous  and 

z::a:^;:':^:  '"=' • "-  *"^  -"••  ^"^  --  ^--  transmitted  tackw.:::^ 

Ihq>t,ncnflhetympu,uc  mnnhrane.  which  may  occur  as  the  result  of  the  introduction 
foreign  body  through  the  external  auditory  nu-atus.  „r  after  a  fall  or  blow  on  the  head 
ithout  any  mjury  to  the  base  of  the  skull. 

IJIeeding  from  the  ear  is  by  no  means  diagnostic  of  fracture  of  the  middle  fossa  •  in 
■OS  cases  the  skull  .s  not  injured.  Care  must  be  taken  to  make  sure  that  tie  blood'hls 
>t  tncklcl  mto  the  meatus  from  some  small  woun,l  of  the  scalp  or  externa  ear  If  Jh 
vternal  auditory  uK-atus  has  been  injured,  the  source  of  the  Lemorrhage  mav  be  d.V 
.  ercd  1^-  m,,,,ung  t.^  blood  away  with  plugs  of  cotton-wool  and  examii^ln;^"^.  a  Z- 
■lum.  .V  „ar  in  the  tympanic  membrane  may  be  visible  if  the  luemorrhaae  comes  from 
.e  tympanum.      If  the  skull  is  fractured,  the  luemorrhage  is  usuallv  profuse    while  i    the 

V  V-  t       r  '.'•",';""■'■''■  '."■'•"■>-  "f  *''«■  «"rfitory  nerve  is  an  occasional  complication. 

.\  van.  t>  „l  acute  inllammat.ou  of  the  mid.Ile  ear  known  as  on,,,  Invmorrha^'ic  otitis  is 
ara..,er,.ed   by  a  discharge  of  blood.     This  trouble  is  usualh-  associat.-d  with  inllu ei  .- 

.  bi'in;  ^ :::::  y;  r""""""""  "'""■"*^-  '^'"'-  "-"-•■■'-^^  -  •--- <->  '.>•  ..ai.,.  =:::,:; 

.         a  1   ikcdl>   hypera.mie.  or  may  show  petechial  spots.     A  ha-n-orrhage  or  blood- 

b    i  1         "h"'"  ""■'"■■■'";  '"  ""■  """■"■  "'•^■'-"i'-  -PPurative  otitic  media  will 

iu       li     h  *;  '"■"'■'""'  '"  """"''  '"■  "'■  """''"'  "f  granulation..     A  similar  l.lood- 

iin  d  discharge  may  be  present  in  nmli!.,>ant  ,li,rosc  of  the  external  or  mi.ldle  car 

Jiu!^!^^u^  '!™''J''''''  """"">  <■"'■""-''  -•'-•>•  may  lead  to  a  seveiv  latal  hemorrhage 
-m     he  external  auditory  meatus.     The  artery  in  its  course  through  the  carotid  ..analls 

;  b e'd.^:';:',  ■  t'"vi '" ""■  '•"""""■  '■^^•'*>' ''>■  -"'>•  ^  • "'"  •"=■"•  •"■  ""-•  -i'icb 

tie  w,  i        T"        ';""!'■  ^"'f''""'"'""-  t'"'^  portion  of  bone  mav  be  destroyed 

tl     «  dis  .,    the  artery  weakened,  so  tjial  it  may  give  way  sud.lenlv.  lea.ling  to  a  ouicklv 

a    I   enhn.  In,m     he  .ir.  nose,  and  mouth.     .V  similar  severe  or  lalal  lM.,n;,nl,ai  nu  v 

'Ult  lioMi  co^-ion  of  tlir  lateral  sinus  from  a  similar  cause 

Cerel,ros,inal  fluid  may  escape  from  the  external  auditory  meatus  after  a  frart.re  of 

>    y  {::z'\:    r  '"■""■:""■  ""•  '"•  '''•"'"•■''■''  ^'^  -'"^ ''■■  ■"■ "-  "'i---  ■'•'.<•  now 

TU        is        ::•  ;""     '"'■'"'   ''"'    '"■■  ^"""-  ■'^'>-      '-"I"'"-   '"'"■"-   -V   —.p.-  when   the 
V  s      ,1  ■'  '   ='''•"■"'•=""•'•   "    ■-•■"Mes  ..erehrospinal   llui.l.    but    (he   amount    is 

>   small.      In  chrome  suppurativ  otitis  media   the  .liscliarge  n.av   !..•  s.n.us    ami   bear 
.^  resemblane..   to  cerebrospinal    Moid,    from   which    it    may   have   to   be  distinguished   in 

;\''  ''',''"'■ ^  ■■':  ""■  ;■'-""  '"^'  ''-"'  i".i"--.v.     Apart  from  examination  of  ,l,e  ,„..„,- 

K  In     i  ;'.7":'""""'   "".^  '■■■' ■  '■'•'•'■'•'-'  ''.V  -Meeting  some  of  the  tluid  and   testin, 

^^Ibumin.  which  IS  present  in  considerable  ..uantily  m  II,..  (Inid  tVnm  th,    labyrinth        \ 
ir^Tial'..       "■'""■"''  "''"  *'""»"'"^  "".<'h  albumin,   wlnl,-  ..nbrospmal  Ihn.l   has  only   the 

Tesl  M        """•"■";""''"'•   "■■   -n>-pnn,l,.„t.      Su,.|,    a    .liM-harg..    mav   arise^rom 

lesion    ol    tl„-    .xt.n.al   aud,t„ry    m.atus.    fn„„    ,|,.,,,.,   „,■    ,,„•    mi.l.ll,.  ear.   or    from 


422  OTORRHtEA 

suppuration    in   some   adjacent   structure,   the  pus   making  its  way  into  the  external  o, 
middle  ear.  and  so  draining  from  the  external  auditory  meatus. 

The  following  lesions  of  the  external  auditory  meatus  gives  rise  to  such  a  discharge  :- 

Eczema.  The  discharge  in  this  case  may  be  serous.  The  trouble  may  be  caused  b> 
the  irritation  of  a  plug  of  impacted  cerumen,  or  it  may  be  associated  with  eczema  of  th( 
auricle  or  of  some  other  region  of  the  body.  It  must  be  remembered  that  eczema  of  th. 
external  auditory  meatus  and  of  the  external  ear  may  be  caused  by  a  discharge  of  pus  fron 
the  middle  ear,  "and  hence,  when  the  external  auditory  meatus  is  eczematous.  every  car. 
must  be  taken  to  make  sure  that  chronic  middle-ear  suppuration  is  not  also  present. 

The  presence  oi  n  foreign  body,  such  as  a  plug  of  cotton-wool  which  has  been  inserte. 
and  forcrotten,  or  of  such  foreign  bodies  as  children  occasionally  insert,  may  produce  , 
dermatitis  of  the  meatus  leading  to  a  discharge  of  pus.  This  condition  is  recognized  easil; 
on  examination  with  the  speculum.  .  „..^„ir„ 

Funmclosis.^This  not  uncommon  trouble  gives  rise  to  very  acute  pain  and  sxNclhn, 
of  the  meatus,  followed  bv  a  discharge  of  thick  pus.  A  furuncle  may  usually  be  seen  o. 
otoscopic  examination,  and  the  trouble  may  be  diagnosed  from  the  extreme  tendernes 
and  swelling  of  the  meatus,  and  the  presence  of  an  opening  from  which  the  pus  escapes^ 

Secondary  Syphitis.-^ln  this  disease  condylomata  may  occur  in  the  external  meatus 
The  discharge  is  usually  serous,  and  may  have  a  very  foul  odour.  The  diagnosis  wi. 
depend  upon  the  presence  of  other  secondary  troubles  or  the  history  of  the  primary  sore 
Tertiary  syphilitic  ulceration  may  also  occur  at  the  orifice  of  the  meatus.  Wassermann 
reaction  should  be  tested. 

Supmrmtws  Sebaceous  Cys/.-The  cutaneous  lining  of  the  external  auditory  meatu 
is  well  supplied  with  sebaceous  glands,  which  may  give  rise  to  cysts  ;  these  may  inflam 
and  suppurate.     The  signs,  symptoms,  and  appearances  closely  resemble  those  of  furur 

'"'°fl/»//(//rn7/f  Inflammation  of  the  ear  is  rare,  but  the  nature  of  the  abundant  swellin 
and  muco-purulent  discharge  to  which  it  gives  rise  may  be  overlooked  entirely  unless  th 
Klebs-LciflUr  bacillus  (Plate  XXVIII.  Fig.  L,  p.  614)  is  looked  for  by  cultural  methods. 

Knilhclioma  may  occlude  the  external  auditory  meatus.  The  appearance  is  otten  s 
characteristic  that  the  diagnosis  presents  no  difliculty  ;  but  it  may  be  simulated  by  c/^ron, 
inflammation  with  granulation  tissue,  by  lupm  of  the  ear.  or  by  rodent  ulcer  ;  the  durat.o 
of  the  disease  may  assist  in  the  diagnosis,  but  histological  examination  of  a  portion  ot  tl, 
affected  tissue  should  be  resorted  to  in  cases  of  doubt. 

Carie.^  or  necrosis  of  the  bonv  external  auditory  meatus  will  give  rise  to  a  proluf 
purulent  discharge,  associated  with  the  presence  of  polypi  or  of  masses  of  granulations. 

The  diagnosis  of  the  above  causes  of  an  aural  discharge  may  be  easy,  but  on  the  oth. 
hand  it  may  be  a  difficult  matter  to  make  sure  that  there  is  no  disease  of  the  middle  ear  ; 
the  same  time,  for  there  is  likelv  to  be  so  much  swelling,  and  probably  tenderness  of  tl 
meatus,  that  it  is  impossible  to  get  a  view  of  tlic  membrane.  It  must  also  be  borne  i 
mind  that  when  there  is  a  discharge  of  pus  from  the  middle  ear  the  lining  membrane  ot  tl 
canal  is  frequently  swollen,  inflamed,  and  eczematous.  ,.        ,-, 

The  most  frequent  cause  of  a  purulent  discharge  from  the  ear  is  suppurative  otit 
media  either  acute  or  chronic.  In  the  former  case,  the  discharge  is  preceded  by  acu 
pain  usually  paroxysmal,  with  pyrexia  and  more  or  less  severe  constitutional  symptom 
Tlie  discharge  usually  consists  of  thick  pus.  and  there  may  be  much  swelling  of  the  meati 
preventing  a  satisfactory  view  of  the  membrane.  When  this  can  be  seen  it  has  a  chara 
teristic  hypera-mic  and' swollen  appearance,  and  tlie  perforation  through  which  the  p. 
escapes  can  be  made  out.  ■-,       ,,     ,„ut  , 

A  bacteriological  examination  of  the  diseliarge  will  often  throw  considerable  light  < 
the  cause  and  also  help  considerably  in  prognosis.  The  most  serious  forms  are  associat. 
with  diplococci  and  the  streptococcus  pyogenes.  The  former  include  the  memngo-coec 
(Weichselbaum),  the  gonococcus,  micrococcus  catarrhalis,  and  the  gram-positive  pneum 
coccus.  Staphylococcus  pyogenes  albus  and  aureus  are  much  less  virulent  than  the  othei 
and  are  found  in  connection  with  funmeuli  as  well  as  with  middle-ear  disease.  The  tuberc 
bacillus  is  often  found  to  be  the  cause  of  otitis  media  and  otorrhoea  in  children.  Ueatne 
and  tinnitus  are  also  present,  but  there  is  usually  no  pyrexia,  and  pain  is  remarkably  abser 
Examination  shows  a  swollen  dull  red  or  pink  membrane,  while  a  perforation,  often  in  t 


OXALURIA  423 

anterior  region,  may  be  made  out  after  cleansing  the  meatus.  In  this  disease,  rapid  destruc- 
tion of  the  bone  may  also  occur  without  pain. 

In  chronic  suppurative  middle-ear  disease  the  character  and  quantity  of  the  discharge 
vary  enormously,  from  only  a  slight  serous  discharge  to  a  profuse  flow  of  foul  pus,  Fre- 
quently the  amount  and  character  vary  from  time  to  time,  and  occasionally  the  flow  is 
intermittent.  The  presence  of  other  symptoms,  such  as  deafness,  tinnitus,  pain,  and 
vertigo,  must  always  be  inquired  for.  Tlie  membrane  must  be  examined  after  syringing 
out  and  drying  the  meatus.  In  practically  every  case  a  perforation  will  be  found,  though 
occasionally  the  pus  may  make  its  way  along  some  bony  track  which  opens  into  the  ex- 
ternal auditory  meatus.  The  position  of  the  perforation  should  be  ascertained,  whether  it 
is  in  the  membrana  propria  or  in  Shrapnell's  membrane.  In  the  latter  case  the  suppura- 
tion occurs  chiefly  in  the  attic,  and  the  ossicles  are  likely  to  be  carious.  Generally  speak- 
ing, perforations  in  the  anterior  portion  of  the  membrana  propria  are  of  less  serious  nature 
than  those  in  the  posterior  portion.  The  presence  of  jjolypi  or  granulations  must  be  noted, 
and  if  possible  the  site  from  which  they  spring  determined. 

In  addition  to  the  above  causes  of  an  aural  discharge,  abscesses  in  adjacent  structures 
may  occasionally  burst  into,  and  lead  to  a  copious  discharge  of  pus  through,  the  external 
auditory  meatus.  An  acute  mastoid  abscess  may  discharge  in  this  way  through  a  sinus 
which  opens  on  the  posterior  aspect  of  the  meatus.  In  chronic  mastoid  suppuration  pus 
may  make  its  way  from  the  mastoid  air-cells  in  a  similar  manner.  Rarely  a  cerebral  abscess 
in  the  temporo-sphenoidal  lobe  may  bvirst  into  the  tympanum  and  discharge  through  the 
external  auditory  meatus.  Occasionally,  an  abscess  in  the  parotid  gland  may  extend  back- 
wards and  discharge  through  the  anterior  wall  of  the  meatus.  A  similar  result  may  happen 
with  an  abscess  which  originates  in  disease  of  the  teniporo-mandibiilar  joint,  or  even  in  the 
neighbouring  lymphatic  glands.  Philip  Turner. 

OXALURIA. — This  term  is  generally  used  to  include  any  condition  under  which 
crystals  of  calciinn  oxalate  are  to  be  found  on  microscopical  examination  of  the  urine. 
They  occur  in  two  forms,  of  which  by  far  the  most  characteristic  and  conmion  is  familiarly 
described  as  the  "  envelope  '  crystal — really  a  regular  octahedron  :  when  crystallization 
has  occurred  imperfectly,  a  spheroidal  form  with  a  central  constriction  like  that  of  a  "  dumb- 
bell '  may  be  seen  occasionally  (Fig.  181 ).  Either  form  is  transijarent,  highly  refractile, 
and  usually  quite  colourless.  If  the  precipitate  is  suflieiently  abundant  to  be  visible  to  the 
naked  eye,  it  is  generally  pure  white  ;  it  often  comes  down  after  more  or  less  mucus  has 
already  gone  to  the  bottom  of  the  specimen  glass,  so 
that  a  dense  white  layer  is  seen  lying  on  the  top  of  a 
less  white  flocculent  mass  :  this  ai)pearanee  has  been 
described  as  that  of  the  "  powdered  wig." 

The  crystals  are  soluble   in  any   mineral  acid,   but 

they  are    insoluble    in   water    or   ordinary    acetic    acid 

solution.     They  may  be   found   in  any  urine,   whether 

acid  or  alkaline,  but   are   commonest    in    acid    urines. 

They   may  be  in   the   urine  when   it   is  voided  ;    more 

often    they    form  as  the   urine   stands  in  the   specimen 

glass,  and  it    is  important  to  rcineinber   that  if  a  slide 

is  prepared   from  the  centrilujiali/.ed  deposit   of  a  urine  ,     „    .  ,  ,     ,     ,  . 

'       '  r^  I  _  ^.j^^_  i^i_ — Varieties  of  orvslaW  of  calcium 

and  allowed  to  stand  for  a  while  before  it  is  examined  oxnintt!  ci"'gi>  power), 

under  the  microscope,  numbers  of  very  minute  calcium 

oxalate  crystals  may  appear  e\-en  when  none  are  to  be  found  in  a  similar  specimen 
examin<'d  at  once. 

The  deposition  of  calcium  oxalate  is  by  no  means  necessarily  pathological  :  indeed. 
ui)wards  of  -JO  milligrams  are  excreted  in  the  urine  daily,  even  :J.">  milligrams  not  being 
beyond  the  normal  limit.  So  long  as  the  oxalic  acid  is  combined  to  form  soluble  salts  suc!i 
as  those  of  sodium  or  potassium,  no  envelope  crystals  apiu-ar,  but  it  is  common  for  the 
proportion  of  oxalic  to  other  acids  on  the  one  hand,  and  of  calcium  to  other  basw  upon 
the  other,  to  be  such  that  the  insoluble  oxalate  of  lime  is  formed  and  precipitated,  either  in 
the  urinary  passages  or  alter  the  speeiiiRii  has  been  voided. 

Certain  patients  presenting  symptoms  of  gastric  or  intestinal  indigestion  have  a  curious 


^.^^  OXALURIA 


tendency  to  snffer  fvon.  alternating  oxaluria  and  phosphaturia  ;    in  their  dietetic  efforts  to 
obtan  comfort  thev  cause  marked  variations  in  the  reaction  of  their  urine  -at  one  time  , 
is  m  "rkedlv  acid,  and  oxalates  are  precipitated,  at  another  it  is  alkaline  and  an  abundant 
deposit  of  phosphates  forms.     No  special  signifrcanee  attaches  to  this  alternation^ 

t'  rcumstances  which  cause  an  absolute  increase  in  the  amount  of  oxahc  ac.d  excreted 
will  na  u  ."llv  increase  the  tendenev  to  visible  oxaluria.  The  best-known  exogenous  sources 
r  oxa  c  ac  d  are  certain  vegetable  products,  of  which  the  followmg  m  particular  may 
be  n^en  ionel  tea.  cocoa,  rhubarb,  spinach,  gooseberries,  figs,  coffee,  chicory,  chocolate, 
peas  beln"  Letroot,  artichokes,  tomatoes,  and  beer.  It  is  probable,  however  hat  there 
TaL  an  Endogenous  source  for  oxalate  of  lime  for  -en  a  starving  pe..on^t.ll«eret^ 
oxalates  in  his  urine.  The  source  of  these  is  stdl  obscure,  but  it  is  held  bj  man>  that  i^r^ 
acid,  creatinin.  and  possibly  other  allied  substances,  may  be  a  source  f  .o.^''^^  ^; ^.J'^^.ff^f^ 
^hat  uric  acid  crystals  and  those  of  oxalate  of  lime  are  to  be  seen  not  infrequently,  either 
oc^it  er  or  alternating  with  one  another  on  different  days,  would  seem  to  favour  this  v.e. 
Ind  loutv  persons  ar^e  perhaps  more  liable  than  others  to  oxaluria.  Calcium  oxalate 
crystals  mav  be  found  in  the  urine  at  any  age,  however,  from  infancy  onwards. 

'  In  ore^t  part,  oxaluria  is  physiological  and  dietetic  :  nevertheless  there  is  a  decided 
tended;  noV-a-days  to  revert  to  the  older  view  that  when  a  patient's  metabohsm  i  ueh 
as  to  cause  a  constant  deposition  of  calcium  oxalate  crystals  in  the  urine,  it  is  also  apt  to 
lead  to  a  'roup  of  symptoms  of  which  nervous  dyspepsia,  neurasthenia    and  even  h>T.o- 

'"^'^ ?'cZ:r;:'pat^nts  who  present  symptoms  that  may  be  due  to  renal  or  vesical  c^ 
cuius  Microscopical  examination  of  the  centrifugalized  urinary  deposits  in  such  a  ea  e 
iv  y  ;erye  to  detict  not  only  pus  cells  and  red  blood-discs,  but  also  calcium  oxalate  crystals 
h^  instead  of  be  n'all  sepLte  from  one  another,  as  is  the  rule  in  a  dietetic  or  neuras- 
^c^::^^be  obviouily  agglomerated  into  minute  calculi  :  J/ there  -  chmca  sym 
ptoms  of  stone,  the  discovery  of  microscopic  aggregations  of  crystals  is  h.ghU  suggests  e 
ihere  beincr  a  larger  calculus  present  somewhere  in  the  urinary  system 

.If  oxalate  crystals  are  deposited  in  numbers  in  the  urine  whdst  it  >«/*>»  '"th 
bladdEr  irritability  of  the  latter  is  apt  to  follow,  with  a  tendency  to  undue  frequency  ol 
liu^lurmrsuef oxaluria  is  not  altogether  infrequent  as  the  cause  for  persistent  nocturna 

^""T^n^il:  rl' tli:;  is  one  of  the  most  important  features  of  oxaluria.     The  s^, 

irrit Jliol:  by  oxaluna  that  may  produce  the  nocturnal  enuresis  i"  g- J -^;^Jo>-  ^^ 

Xn  the  urine  of  adults  containing  a  considerable  excess  of  nucleo-proteid.  and.  >" J'^  ™»'^ 

■nbers  of  spermatozoa.     There  may  be  no  symptoms  whatever,  and  in  that  case  the  onl; 

ortwe  of    1  e  condition  lies  in  ihe  fact  that  the  nucleo-proteid  may  be  mistaken  fo 

dr^^iJ  th/boiling  test  is  applied  to  a  specimen  -'"Gaining  m.cleo-^oeidm^xe. 

cloud  of  phosphates  may  come  down,  and  then  when  acetic  acid  is  added  to  dissohe  u 

h     c  ou^     residual  haze-may  remain  behind  because  the  acetic  acid,  at  the  same    in  e    ha 

tMissolves  the  phosphates,  precipitates  some  of  the  nucleo-proteid.     Ihis  source  of  fa  lac 

mavTe  rv  ated  in  either  of  two  ways  :   the  haze  of  nucleo-proteid  will  clear  up  on  addit.o 

of  a  drop  on  trie  acid,  whereas  a  similar  haze,  due  to  albumin,  will  remaua  :   or   to  mal 

quL  certain    three  test-tubes  may  be  used:    into  the  iirst    put  plain  -'-  ^l^ ^^^^^^^ 

lin.r.    into  the  second,  urine  plus  acetic  acid  without  boiling  :    and  '"tothe  third   xm 

lis   ^c'et  c   acid    the   mixture  being   thoroughly  boiled.     If  the  haze  is  due  to  a  nucle 

roteid  only     t  will  be  equally  marked  in  the  second  and  third  tubes,  whereas  if  the, 

a  bunl  a    well,  the  haze  in  tube  three  will  be  denser  than  that  in  tube  two. 

J  iTtas  oxaluria  may  lead  to  nocturnal  enuresis  in  adolescents,  so  in  a  few  adult  mal 
it  has  been  re^Ld  as  a  factor  in  the  causation  of  excessive  nocturnal  en-sio^s  or^^^^^^^^^^ 
torrho^a. 

PAIN,  ABDOMINAL  (General).-Most  abdominal  pain  is  local,  f-S;-  t'lf  "^""J^ 
renal  or  biliary  stone  or  ,o  appeiuUcular  colic.     The  most  serious  cause  of  general  abdomir 


PAIN.     ABDOMINAL  425 

pain  is  acute  general  peritonitis.  If  this  be  perforative,  at  first  the  jiain  is  local  at  the 
seat  of  perforation,  and  the  abdomen  is  retracted  :  but  soon,  whether  the  peritonitis  is  or 
is  not  perforative,  the  abdomen  becomes  distended  from  paralysis  of  the  bowel,  and  the 
pain  becomes  general.  Increase  in  the  rate  of  the  pulse,  rigidity,  and  immobility  of  the 
abdominal  wall  on  breathing  are  most  important  signs  for  diagnosis.  Quickly  the  pulse 
becomes  more  rapid  and  wiry,  the  patient  looks  ill,  the  temperature  is  raised  a  little,  the 
bowels  are  constipated,  and  there  is  some  nausea,  perhaps  vomiting.  In  cases  of  doubt  it 
is  a  good  plan  to  count  the  pulse-rate  at  intervals  of  ten  minutes  :  a  progressive  rise  in  the 
successive  pulse-rates  often  points  to  the  need  for  urgent  laparotomy.  There  may  be  a 
rapidly  progressive  leucocytosis.  It  is  often  said  that  the  drawing  up  of  the  knees  on  to  the 
abdomen  is  of  importance  :  sometimes  it  is  very  striking,  but  in  many  patients  with  acute 
gfencral  peritonitis  the  legs  are  not  drawn  up,  and  they  may  be  drawn  up  in  other  condi- 
tions. The  early  diagnosis  of  acute  general  peritonitis  is  of  the  utmost  importance.  It ' 
has  been  estimated  that  in  many  cases  each  hour's  delay  in  opening  the  abdomen  means 
that  the  chances  of  death  are  increased  5  per  cent.  Morphia  should  never  be  given  when 
it  is  thought  there  is  even  a  remote  possibihty  that  any  illness  is  acute  general  peritonitis, 
for  it  makes  the  subsequent  diagnosis  so  difficult.  The  onset  of  pneumonia  is  sometimes 
announced  by  an  abdominal  pain  so  acute  that  the  patient  is  thought  to  have  acute  general 
peritonitis  :  the  relatively  rapid  respiration  rate  may  point  to  the  lesion  being  in  the 
chest,  but  in  some  of  these  cases  it  is  only  by  anxious  watching  that  one  can  decide  whether 
the  disease  is  primarily  thoracic  or  abdominal.  Sometimes  it  is  both — for  instance,  in 
pneumococcal  scptica-mia. 

Chronic  General  Peritonitis. — This  usually  causes  a  dull  feeling  of  heaviness  rather  than 
a  general  acute  pain.  The  chief  points  to  be  observed  in  arriving  at  a  diagnosis  are  the 
chronicity  of  the  trouble,  the  presence  of  fluid  in  the  peritoneal  cavity,  and  the  fact  that 
masses  of  thickened  peritoneum  can  often  be  felt.  The  most  usual  is  the  puckered,  thick- 
ened omentum,  forming  a  tumour  lying  transversely  at  the  middle  of  the  abdomen  :  some- 
times other  lumps  can  also  be  felt.  It  must  not  be  forgotten  that  an  infiltration  of  the 
stomach  with  new  growth  will  give  rise  to  a  tumour  lying  transversely  across  the  abdomen, 
and  so  may  a  diseased  colon.  The  presence  of  these  peritoneal  thickenings  often  gives 
the  abdomen  a  dough-like  feel.  The  commonest  cause  of  chronic  peritonitis  is  tubercle. 
Often  there  is  no  discoverable  tubercle  elsewhere  to  help  us  to  a  diagnosis,  but  the  hectic, 
irregular  teniperalure  may  be  a  guide.  .\s  the  fluid  increases,  the  umbilicus  becomes 
flattened  out  (see  .\scitf.s,  p.  V.i).  and  in  tuberculous  peritonitis  sometimes  red. 

Intestinal  Colic.  This  is  due  to  many  causes  which  lead  to  painful  contraction'^of 
the  intestinal  nni.sclcs.  The  pain  is  always  paroxysmal  and  usually  recurrent,  so  that  a 
severe  attack  consists  of  frequently  recurring  paroxysms.  There  are  all  degrees,  from 
quite  a  slight  pain  to  one  that  causes  the  patient  to  shriek  and  break  oirt  into  a  cold  sweat. 
The  Icinpcrature  is  usually  normal,  but  is  occasionally  slightly  raise<l.  The  pulse  is  usually 
of  normal  rate  unless  the  temperature  be  raised.  The  abdomen  is  generally  distended, 
and  in  a  barl  case  peristaltic  mo\ements  of  the  coils  of  intestine  may  be  seen.  Often  the 
abdominal  nuiseles  are  rellexly  contracted  and  rigid.  The  pain  may  come  on  witliout 
warning,  or  may  be  accompanied  by  nausea,  eructations,  and  borborygmi.  It  is  usually 
felt  at  the  umbilicus,  from  which  region  in  a  severe  ease  it  sjjrcads  over  the  whole  abdomen. 
The  patient  losses  about  in  the  severity  of  it.  and  linally  selects  a  position  in  which  he  can 
hrin;;  pressure  to  bear  on  the  abdominal  wall  :  in  peritonitis  this,  so  far  from  relieving  the 
abdominal  pain,  increases  it.  Intestinal  colic  is  usually  brought  on  by  eating  some 
indigestible  article  of  food,  so  the  history  will  help  us  ;  but  it  may  be  due  to  obstruction. 
In  ehildren.  intestinal  colic  is  recognized  bv  their  cries,  restlessness,  and  the  drawini'  up 
of  the   legs 

./(■((/(■  (ir  skIkkhIc  hilrslinal  Olistrarlioii  is  a  eommdri  cause  of  general  alMlninina!  pain. 
and  re(iuires  most   careful   diagnosis  (see   \'()\irnN(;.  p.  7(i7). 

Lead  Colic.  This  is  diagnosed  by  the  symptoms  of  colic,  as  given  .iIhinc.  I>\  llie 
history  and  occupation,  and  by  the  presence  of  other  signs  of  lead  poisoning  (p.  .•(1).  of 
which  the  most  characteristic  is  a  blue  line  on  the  gums. 

(iaslric  Crises  inav  cause  general  abdominal  pain,  but  tliev  will  be  rccogiii/i-d  by  the 
absence  of  kiiec-Jerks  and  oilier  signs  of  tabes  dorsalis. 

Aliiliiniinal  .\iiini/:jiiis.      I'liis  phrase  is  afiplied  to  severe  abdominal  pains  unassnciated 


426 


PAIX.     ABDOMINAL 


with  any  organic  disease.  The  greatest  caution  must  be  exercised,  and  a  diagnosis  of 
abdominal  neuralgia  must  be  looked  upon  with  great  suspicion,  for  there  is  no  doubt  that 
such  a  diagnosis  is  often  wrong,  the  patient  really  having  organic  disease.  The  pain  may 
be  local,  e.g.,  those  neuralgias  of  the  kidney  which  resemble  renal  calculus,  or  it  may  be 
general.     Disease  of  the   spine   nuist  be  excluded   carefully.     Often  these  patients   have 

neuralgia  elsewhere.  The  cases  last  a  long 
while  ;  they  are  commoner  in  women  than 
men.  In  a  few,  opening  the  abdomen  has 
shown  that  the  small  intestine  or  colon  is 
sjiasmodically  contracted  (enterospasm),  and 
indeed,  it  may  be  felt  through  the  abdominal 
wall  as  a  swelling  like  a  thick  cord.  These 
patients  are  often  given  morphia,  but  this 
should  not  be  done.  It  is  not  infrequent  to 
find  that  severe  abdominal  pain  is  appar- 
ently due  to  the  administration  of  mor- 
phia, for  the  pain  ceases  when  the  drug  is 
wUhlield.  I  have  seen  two  such  cases 
recently. 

General  Visceroptosis  often  causes  a 
general  dull,  dragging  abdominal  pain.  It 
can  easily  be  diagnosed  by  feeling  the  dis- 
placed liver  or  kidney,  by  looking  at  the 
abdfiminal  outline  seen  from  the  side  when 
tlie  patient   stands  up  (see  Fig.  .56,  p.  127: 


Fig.  182. — Skiagram  to  show  the  normal  appearance  of  tlie 

rectum,  colon,  and  ciecum  after  injection  of  the  bowel  with  a 

bismuth  enema.      Note  that  food  has  passed  the  ileociecal 

valve  and  entered  the  small  bowel.     Male,  ase  14.  "1 

(Sk-iayram  bi/  Lr.  C.  Thurstun  Holland.)  " 


see  also  Constipation,  p.  121),  and  by 
observing  the  displaced  stomach  or  intes- 
tines by  the  a'-rays  after  the  administration 
of  bismuth.  (Compare  Fig.  182  with  Fig. 
183.)  ir.  UaU  ]yiiile. 

PAIN,  BEARING-DOWN.— This  form 
of  pain  is  very  frequent  in  diseases  of 
women,  and  is  an  associate  of  many  pelvic 
conditions.  It  is  impossible  in  many  in- 
stances to  dissociate  it  from  chronic  aching 
pain ;  but  it  is  not  every  chronic  pain 
which  has  the  bearing-down  character.  It 
is  usually  the  result  of  impaction  of  some 
pelvic  structure,  and  owes  its  character 
more  particularly  to  pressure  on  the  rectum, 
and  sometimes  on  the  bladder.  Displace- 
ment of  pelvic  organs,  or  even  simple  con- 
gestion of  them,  will  sometimes  produce  it. 

Its  source  is  not  always  strictly  gjna^cological,  as  it  may  be  the  result  of  rectal  disease, 
such  as  cancer,  ulcer,  or  ha-morrhoids.  It  is  thus  closely  associated  with  rectal  tenesmus. 
The  commonest  cause  is,  perhajis,  backward  displacement  of  the  uterus,  and  it  is  most  • 


Fig.  183. — Skiagram  after  a  bismuth  meal,  showing  ptosis 
of  the  ascending  and  transverse  colon.  Twenty-five  hours 
after  the  meal.    Female.,  a^e  10.     Erect  posture. 

(.stmyram  bi/  Dr.  C.  rhiir.iliin  Hollaml.) 


PAIX     IN     THE     BACK  427 

marked  in  retroversion  of  the  pregnant  uterus,  especially  if  impaction  of  the  organ  occurs. 
Imiiaction  of  a  pelvic  tumour  may  produce  it,  uterine  fibroids,  ovarian  tumours,  and  pelvic 
hieniatocele  being  the  chief  swellings  which  give  rise  to  it.  These  produce  pain  of  a 
different  character  in  addition,  due  to  pressure  on  nerves  ;  but  the  bearing-down  character 
is  more  particularly  referred  to  the  rectum,  hence  it  is  commonlj'  believed  to  have  some 
relation  to  pressure  on  the  rectum.  A  pelvic  abscess  of  peritoneal  origin  is  an  unusual 
impacted  swelling,  which  gives  rise  to  very  severe  bearing-down  pain  :  impacted,  because 
it  is  bound  down  by  peritoneal  adhesions,  and  exercising  pressure  because  of  the  tension 
in  it.  The  bearing-down  character  becomes  most  marked  if  the  abscess  involves  the 
rectal  wall,  as  it  so  frequently  does,  causing  a  flow  of  nuicus  and  much  irritation  of  the 
rectum. 

The  differential  diagnosis  of  the  causes  of  this  type  of  pain  can  be  made  only  after  a 
complete  ])elvic  examination  by  abdominal  palpation,  and  bimanual  examination  by  the 
vaginal  and  by  the  rectal  touch.  Further,  it  may  be  necessarj'  to  examine  the  bladder 
by  the  cystoscope,  or  the  rectum  by  the  hnger  or  sigmoidoscope.  The  differential  diagnosis 
of  the  pelvic  disorders  mentioned  is  discussed  under  Swellixg.  Pelvic  (p.  688). 

7'.  ^f'.  .Stevens. 

PAIN   IN   THE   ANKLE.— (See  .Joints,  Affections  ok  the.  p.  337.) 

PAIN  IN   THE   ARM. — (See  P.\in  in  the  Extremity,  Upper,  p.  442  .) 

PAIN  IN  THE  BACK. — From  occiput  to  anus,  a  pain  referred  to  the  spinal  axis  is 
a  frequent  cornplaiiil.  and  the  diagnosis  of  its  cause  is  very  often  a  most  troublesome 
problem.  W'e  start  with  the  broad  generalization  that  a  pain  in  any  area  must  be  due 
to  irritation,  either  of  the  trunk  or  the  terminals  of  the  sensory  nerves  supplying  the  spot, 
or,  it  may  be,  of  a  nerve  which  is  in  immediate  anastomosis  with  that  to  the  painful  area. 
Pain  referred  tf)  any  one  spot  and  due  to  central  (cerebral)  irritation  is  so  rare  as  not  to 
re(|uirc  mention  here  (except  that  arising  from  gross  cerebral  trouble,  which  will  be  referred 
to  by  the  ])atient  as  He.\d.\che.  p.  293)  ;  and  applying  this  principle  to  the  spinal  axis,  we 
find  that  the  sensory  divisions  of  the  spinal  nerves,  from  the  first  cervical  to  the  coccygeal, 
all  divide  into  branches  for  (a)  the  skin,  (h)  the  bones  and  meninges  of  the  s])inal  canal, 
((•)  the  nuisclcs  lying  on  the  vertebral  column,  and  (il)  the  viscera  contained  in  the  craniuni, 
neck,  thorax,  abdomen,  and  pelvis.  Conscciuently.  to  interpret  rightly  the  meaning  of  a 
pain  in  the  back,  we  must  look  not  only  to  general  conditions  affecting  the  blood  (fevers  of  all 
sorts  are  often  associated  with  a  general  backache  as  a  prominent  feature),  but  to  the 
condition  of  the  organs  contained  in  that  spinal  segment  (or  the  one  immediately  above 
or  below  it)  in  which  the  pain  is  complained  of. 

Another  very  useful  generalization  is  this.  We  may  draw  a  distinetion  between  a 
pain  complained  of  spontaneously  in  a  spot  not  associated  with  tenderness  on  lirm  pressure, 
and  one  in  which  such  tenderness  is  present.  In  the  latter  ease,  the  tender  spot  is  located 
in  all  probability  at  or  near  the  seat  of  the  trouble  ;  in  the  former  case  it  is  probable  that 
the  pain  is  one  referred  by  the  brain  to  the  spot,  but  not  really  arising  there — a  "  referred 
pain,'  as  il  is  termed  ;  and  this  is  the  more  likely  if  we  fin<l  that  tlie  skin  over  the  area 
is  very  sensitive  to  light  stimulus,  but  not  more  sensitive  perlia|)S  even  less  so — to  a 
stimulus  which  is  rather  rougher,  a  |)ressure  rather  lirmcr  than  a  light  touch.  Carrying 
this  to  its  extreme,  we  have  the  paradoxical  phenomenon  of  severe  pain  being  complained 
of  in  an  area  the  skin  over  which  is  absolutely  ana-stlietic  ;  this  indicates  a  complete 
lesion  of  the  trunk  of  the  nerve  concerned. 

Coming  now  to  the  practical  diagnosis  of  a  pain  in  Ihi-  hack,  we  can  prclly  easily  and 
aceuralcly  eliminate  those  cases  owning  a  pyrcxial  origin  by  observing  that  the  patient 
not  onl\-  complains  of  a  pain  in  the  back  but  looks  acutely  ill  :  if  he  does  so.  take  his 
temi)eralure.  and  if  this  be  founil  to  be  raiseil  above  100  F..  we  may  be  sure  that  wc  have 
to  <leal  with  a  zymotic  dihcase  at  its  onset,  or  peiliaps  il  may  be  with  a  meningitis  or  a 
myelitis  or  even  acute  rheumatism,  and  in  all  nl  lliesc  the  pain  in  the  back  is  only  an 
obtrusive  symptom,  to  wlii<li  will  very  soon  be  added  some  of  the  signs  distinctive  of  the 
disease. 

Often,  however,  we  liavi-  lo  deal  with  .'ases  in  which  Ihc  palienl.  e\(<i)l  for  the  pain 
in   IIh'  back,   is  conipaial  i\  ily  well,  and   he  is  coiKcrncd  lo  know  what   il   means.      Two  or 


4  2H  PAIN    IX    THE    BACK 

three  questions  immediately  arise  in  such  a  case,  the  answers  to  which  will  throw  light  on 
the  nature  of  the  trouble.  The  first  thing  is  to  ask  him  to  locate  the  pain  ;  the  next  to 
enquire  how  did  it  arise,  i.e.,  did  it  come  suddenly  after  a  blow  ?  after  some  unusual 
exertion  "?  after  some  imintentioTial  movement,  say  of  the  head  and  neck,  or  a  slip  off  a 
pavement  ?  And  then  again,  how  long  has  he  had  it,  and  has  he  ever  had  a  similar  pain 
before  ?  Again  we  proceed  to  ask.  is  it  constant  or  intermittent  ?  If  the  latter,  what 
action  on  the  patient's  part  will  cause  it  to  return,  or  what  position  will  ease  it  when  it  is 
present  ? 

It  is  but  seldom  that  we  have  not  by  these  questions  arrived  at  a  jjrovisional 
diagnosis  in  our  own  minds,  but  we  must  never  omit  to  make  a  careful  physical  examina- 
tion for  points  which  will  corroborate  or  correct  this  diagnosis. 

Inspection  may  reveal  skin  conditions,  such  as  a  patch  of  herpes,  which  may  be 
eillier  the  real  cause  or  an  outward  manifestation  of  a  cord  or  bone  lesion ;  swellings  or 
redness  may  be  ap]5arent,  or  undue  jirominence  of  a  spinal  process  ;  bruises  or  purpura 
may  be  seen,  or  a  pulsating  tumour  proving  aneurysm  ;  glands  may  be  visible  in  the 
posterior  triangle  of  the  neck.  It  will  also  reveal  any  trace  of  lateral  tur\ature,  a  frequent 
source  of  backache  in  young  people. 

Palpation  may  reveal  great  tenderness  on  ])ressure.  eitlier  of  muscles  or  bone  ;  it 
may  show  fluetuation  (remember  that  this  fluctuation  must  be  vertical,  not  lateral,  to 
be  reliable)  ;  it  may  prove  the  absence  of  tenderness,  and  may  also  show  hypera-sthesia 
of  the  skin,  suggestive  of  pain  referred  from  a  viscus.  A  very  useful  hint  is  frequently 
derived  from  the  observation  of  the  results  of  palpation  ;  sometimes  these  can  better  be 
seen  when  a  special  stinmlus  sucli  as  an  electric  current  or  persistent  rubbing  is  applied 
to  the  skin  :  thus  it  may  be  limnd  that  over  one  small  area  a  blush  is  raised  more  easily, 
or  is  more  persistent,  than  elscwliere  ;  this  is  strong  evidence  pointing  to  visceral  disease 
as  the  cause  of  the  pain  ;  it  is  due  to,  and  proves  disorganization  of,  the  sympathetic 
nerve  distributed  to  the  viscus.  This  method  will  also  revea.1  hypersesthesia  or  anaesthesia 
if  testing  be  conducted  with  a  light  touch  and  a  pin. 

The  ne>t  step  is  to  apply  tests  for  disease  of  the  bony  walls  of  the  canal  :  ta]>  each 
spinal  ])rocess  in  turn  with  a  percussion  hammer,  and  note  whether  pain  is  elicited  at  any 
spot  ;  jar  the  heels  alterne.tely  with  the  leg  held  rigid  from  the  hip  ;  letting  the  patient 
come  down  on  the  heels  himself  is  more  risky  and  less  satisfactory  ;  also  test  for  pain  on 
resisted  movements  of  the  limbs  or  trunk. 

We  may  then  find  if  pain  is  aroused  by  movements  of  ;iny  kimi — flexion,  extension, 
and  rotation. 

Lastly,  with  the  ])atient  lying  on  his  back,  a  careful  examination  must  be  made  from 
the  fi-ont  in  the  ordinary  way  for  evidence  of  any  visceral  disease,  or  of  growth  of  any  kind. 

If  the  cause  of  the  trouble  should  still  remain  obscure,  or  perhaps  in  any  case  for 
future  reference,  two  or  three  .r-ray  photogra])hs  of  the  painful  area  will  be  taken. 

We  may  now  consider  the  reverse  order  of  procedtue,  and  ask  what  are  the  local 
diseases  associated  with  pain  in  the  back,  and  what  are  their  distinguishing  points.  We 
may  enumerate  these  according  to  the  structures  involved,  thus  : 

Sliiii. — Ulcers,  herpes,  etc.  :    obvious  on  inspection. 

Muscles. — Abscesses,  trauma,   acute   inflammations  ;    so-called    rheumatism,  stiff 

neck,  lumbago,  etc.  ;    simple  debility  ;    overwork. 
Joints. — Rheumatism  :    implication  in  caries  or  in  rheumatoid  arthritis,  etc. 
Bones. — Caries,  aneurysm,  growths  eroding  ;    trauma. 
Meninges. — Inflammations  ;    growths. 
Cord  itself. — Timiours  ;    inflanimation  ;    trauma. 
Viscera  in  front. — Aneurysm  ;   gastric  or  duodenal  ulcer  :    dyspepsia  :  gall  stones  : 

uterine    or    ovarian    trouble  :     a])pendix  :     reetimi  ;     bladder    and    vesieuhe 

seminales  ;    kidneys. 

It  would  be  impossible  within  the  limits  of  this  article  to  give  a  complete  differential 
diagnosis  of  all  the  above,  but  the  procedures  of  investigation  which  we  have  already 
noticed  will  almost  certainly  enable  us  to  come  to  some  conclusion,  and  it  remains  here 
only  to  indicate  a  few  of  the  more  special  points  in  differential  indications,  and  a  few  of 
the  commoner  mistakes. 


PAIN    IN    THE     BREAST  429 

Lumbago  v.  Tumours. — If  a  patient  complains  of  '  lumbago  '  of  some  standing,  it  is 
essential  to  test  tlie  nervous  system,  the  knee-jerks  and  other  leg  reflexes,  and  to  contrast 
them  on  the  two  sides  ;  to  look  for  wasting  of  muscles,  especially  on  one  side,  to  investigate 
the  power  of  the  muscles  in  walking  and  in  simpler  movements  :  to  examine  the  pelvic 
organs  and  the  abdomen  for  growths  of  any  kind.  Only  when  all  these  points  yield  nega- 
tive results  can  we  permit  ourselves  to  think  that  it  is  simple  lumbago.  Lumbago  is 
almost  always  on  both  sides  :  a  tumour  most  frequently  gives  one-sided  symptoms  first, 
though  they  may  spread  to  the  other  side  later.  Rectal  examination  should  never  be 
omitted,  and  in  suitable  cases  vaginal  examination  shoidd  be  made  also. 

Aneurysm  in  Thorax  v.  Indigestion,  ete. —  It  c'annot  be  said  that  this  is  a  common 
mistake,  but  it  is  a  very  serious  one.  The  difficulty  is  that  an  aneurysm  is  extremely  hard 
to  recognize  when  it  arises  from  the  descending  arch  ;  bruits  are  usually  absent,  and  it  is 
perhaps  only  when  a  pulsating  tumour  in  the  back  appears  that  the  diagnosis  is  made. 
The  severity,  the  dull,  aching  character,  and  the  persistence  of  the  pain  are  the  main 
features  that  may  fielp  to  suggest  such  a  serious  cause.  The  patient  should  be  investigate<l 
f>y  the  .r-rays. 

Occipital  Headaches  v.  Caries  of  Spine. — Owing  to  tfie  frequency  with  which  delicate 
patients,  particularly  women  and  young  subjects,  complain  of  pain  in  the  neck,  it  is  well 
to  draw  special  attention  to  this  locality,  though  diagnosis  is  fairly  easy.  The  occipital 
headache  due  to  a  tumour  is  unmistakable  by  its  severity,  and  the  almost  invariable 
association  of  vomiting  and  optic  neuritis.  The  dull,  constant,  wearing  pain  of  caries, 
worse  on  any  slight  jar,  and  the  fixed  [josition  in  which  the  patient  holds  the  head,  are 
sufficient  to  arouse  suspicion  ;  the  .r-rays  will  almost  certainly  clear  up  the  diagnosis.  A 
simple  stiff  neck  is  acute  in  its  onset,  and  generally  preceded  by  a  delinite  history  of  sitting 
in  a  draught.  A  '  crick  in  the  neck,'  possibly  the  equivalent  for  the  rupture  of  a  few 
ligamentous  or  miiseidar  libres,  can  be  recognized  fjy  its  sudden  occurrence  in  the  midst 
of  health  with  no  history  of  previous  pain. 

Debility  in  Youth,  or  Lateral  Curvature  v.  Caries. — The  shapes  of  the  curves  are  usuallv 
sufficient  ;  but  care  must  be  taken  to  examine  the  integrity  of  the  bones  by  the  tests 
giv'cn  above,  and  one  nnist  not  be  satisfied  until  all  the  bone  tests  have  been  tried  and 
found  negative.  Local  rigidity  over  the  painful  area,  best  tested  by  making  the  patient 
stoop  and  rise  again,  whilst  the  physician  feels  the  spine  with  the  flat  of  the  hand,  is  strong 
evidence,  if  persistent,  of  caries. 

Pelvic  Organ  Trouble  v.  Lumbago. — This  mi.stake  is  of  course  more  frequent  in  women 
than  in  men.  The  only  rule  to  be  laid  down  is  always  to  think  of  these  organs  when  a 
woman  complains  of  'lumljago'  or  'backache,'  and  to  en(|uire  carefully  into  the  history 
of  confinements  and  menstruation,  and  to  make  a  thorough  examination.  More  mistakes 
are  made  in  the  diagnosis  of  a  pain  in  the  back  froni  want  of  thought  and  from  careless- 
ness in  examination,  than  from  any  inherent  difficulties  in  the  diagnosis,  at  any  rate  in 
so  far  as  the  more  serious  causes  are  conecrncil.  Fred  ./.  Siiiilh. 

PAIN  IN  THE  BREAST.— When  pain  in  one  breast  is  the  chief  synq)loni  that  a 
patient  complains  of.  the  first  and  most  inq)ortant  stc])  in  arriving  at  a  diagnosis  is  to  make 
a  most  tho 'ough  examination  of  both  breasts  by  inspection  and  palpation,  with  i  \  iew  to 
delecting  any  abiK)rmality  at  all  which  might  suggest  an  early  carcinoma.  The  methods 
of  such  examinations  are  described  on  page  (iS.j.  Unfortunately  ])'iin  is  not  by  any  means 
an  early  sign,  however,  in  cases  of  carcinoma  of  the  breast,  and  generally  by  (lii^  time  it  is 
piDniiunccii  (licrc  is  an  obvic^iis  sl<.)ny  liiird  tuiiinur  already  infiltrating  the  skin. 

()tli(  r  causes  of  pain  in  the  lircast  liiaf  will  generally  be  obvious  upon  inspeclion  oi' 
palpaliori  are  :    - 

(  r;Hki(l  ni|>|ili'  Siiliiniinimary  abscess  Isiiilliclioiiiii  iirilic  iii|i|)li- 

liilhiniiiiatiiiri      (if  llic  Maslitis,    acute,    subacute,  iir        'I'liljcrciiloijs  diMMsr  i.l  t  lie 

rii|)|ile  clirouie  lircMst, 

Cyst  of  the  l)rc:isl  (;;il:ict<)cele 

The  diagnosis  between    these   various   conditions   is    discussed    under   the   heading  of 

SUHI.I.INC.    M\MM\in',    p.    (iH'i. 

Pains    in    the    breast   due    to    inlra-uterine   or    to    ectopic   pregnancy  will  ge:ieiall\   be 


430  PAIN    IX    THE    BREAST 

bilateral  and  associated  with  the  other  siwus  of  pregnancy  ;  in  unexpected  cases  suspicion 
may  be  aroused  by  the  dark  brown  colour  of  nipples  which  should  be  pink,  and  by  the  broad 
secondary  areola  and  swollen  Montgomery's  glands  developing  around  it. 

The  jjains  in  the  breast  that  are  associated  sometimes  with  menstruation  are  also 
bilateral,  and  their  cause  may  be  indicated  either  by  their  development  synchronously  witli 
the  first  menstruation  or  by  their  periodic  recurrence  at  each  menstrual  period  in  an  older 
person. 

The  chief  difficulty  in  the  diagnosis  occurs  in  patients  whose  breasts  may  be  irritated 
perhaps  by  a  hard  upper  border  to  their  stays,  or  who  may  have  had  a  breast  pain  caused 
by  some  forgotten  injury,  but  who,  perhaps  from  the  occurrence  of  other  cases  in  their  own 
family  or  amongst  their  friends,  become  terrified  by  the  thought  that  the  sensation  which 
they  have  is  an  indication  of  incipient  cancer  of  the  breast.  Once  this  fear  has  started 
the  pain  may  assume  larger  and  larger  proi)ortions  without  any  existing  cause  at  all  ; 
whether  to  label  such  a  pain  in  the  breast  hysterical  or  a  neuralgia  or  something  else  is 
difficult  to  decide,  but  the  function  of  the  physician  or  surgeon  will  be  to  examine  the  breast 
with  extreme  care,  not  only  once  but  at  intervals,  in  order  to  convince  himself,  and  sub- 
sequently the  patient,  that  no  tumour  at  all  is  forming  there.  He  may  very  likely  be  in 
some  doubt  himself  for  a  while,  but  in  the  absence  of  any  trace  of  even  a  minute  nodule 
he  will  be  justified  in  waiting  for  a  re-examination  at  short  intervals  of  say  a  week  ;  should 
the  slightest  nodule  become  palpable  he  will  generally  be  justified  in  advising  its  removal 
for  microscopical  examination,  even  though  he  has  little  doubt  that  it  is  non-cancerous, 
but  if  week  by  week  nothing  whatever  can  be  found  abnormal  in  the  breast,  the  diagnosis 
of  functional  breast  pain  will  be  established  ;  and  when  the  patient's  mind  is  set  at  ease 
by  the  absence  of  any  further  developments,  the  ])ain.  previously  to  her  mind  severe,  will 
generally  disajipear.  Herbert  Freneh. 

PAIN  IN  THE  CHEST  is  common  in  all  sorts  of  disorders.  Except  in  the  case  of 
highly  intelligent  persons,  or  of  patients  who  have  had  large  experience  of  chest-pains 
due  to  various  causes,  no  great  help  in  diagnosing  the  cause  of  such  pains  can  be  obtained 
by  enquiring  into  their  individual  characters.  More  assistance  is  furnished  by  investi- 
gating the  circumstances  in  which  the  pain  is  chiefly  felt,  and  the  conditions  that  ease  or 
aggravate  it.  Thus  chest-pains  due  to  disease  of  the  heart  will  be  increased  by  anything 
that  makes  the  heart  beat  more  rapidly  ;  those  due  to  lung-disease  by  anything  causing 
the  patient  to  breathe  faster  or  cough  ;  those  caused  by  disorders  of  the  stomach  will 
generally  be  aggravated  by  or  soon  after  taking  food.  P'or  pains  in  the  back  wall  of  the 
chest,  see  P.\ix  in  tue  B.\ck  (p.  427)  and  Pain,  Interscapular  (p.  461).  For  clinical  pur- 
poses, pains  in  the  chest  are  best  classified  according  to  their  pathology,  and  the  nature 
and  situation  of  the  disorders  to  which  they  are  due. 

1.  Pains  due  to  Diseases  of  tlie  Tissues  composing  the  Thoracic  Walls:  the  pain  is 
in  most  eases  a  direct  pain  : — 

Inflammation  of  the  skin  and  subcutaneous  ,  Neuralgia  :     mastodynia 

tissues  ;     mastitis  |  Herpes  zoster 

Adiposis    dolorosa  ;     neurofihromatosis  j  Pressure  on  nerves 

Myalgia  :  pleurodynia:  stitch  '  Disease  of  the  bones  of  the  chest. 

2.  Diseases  of  the  Thoracic  or  Abdominal  Viscera ;  the  pain  is  in  most  cases 
a  referred  pain  : — 

Pleurisy  :   empyema  i    Pericarditis 


Pneumothorax 
Pneumonia 
Pulmonary  embolism 

Heart   disease — Valvular   disease,    aortitis  : 
angina  ])ectoris,  true  and  false 


Aneurysm  :    dissecting  aneurysm 
Mediastinal  new  growths 
Mediastinitis 
Oesophageal   obstruction 
Diseases  of  tlie  spinal  cord. 


Diseases  of  the  Thoracic  Wall. — Pain  in  the  chest  due  to  inflammation  of  its  super- 
ficial tissues  should  not  be  hard  to  diagnose.  The  pain  will  be  confined  to  the  inflamed 
parts  and  their  immediate  neighbourhood,  and  the  other  three  cardinal  signs  of  inflam- 
mation— heat,  redness,  swelling — will  not  he  absent.  In  most  cases  a  superficial  wound 
or  abrasion  will  be  found  ;    in  others,  the  inflanmiation  will  have  spread  to  the  surface 


PAIN     IX    THE    CHEST  431 

from  some  deep-seated  lesion,  caries  of  a  rib,  for  example,  or  an  empyema  or  hepatic 
abscess,  or  a  metastatic  abscess  arisinji  in  the  course  of  ])ya?mia.  The  diagnosis  must  be 
made  on  general  lines  in  these  unusual  cases.  Mastitis  or  mammary  carcinoma  will  be 
diagnosed  by  palpation.  The  inflammatory  phenomena  of  licrpcs  zoster  are  considered 
below. 

The  very  rare  condition  known  as  adiposis  dolorosa,  or  Dercum's  disease,  is  character- 
ized by  symmetrical  and  painful  deposits  of  fat  about  the  body  and  limbs.  It  occurs 
mainly  in  middle-aged  women  of  full  habit,  though  males  are  not  exempt  •  chronic 
alcoholism  is  its  usual  precursor.  Xeurojibroniatosis  is  characterized  by  the  growth  of 
multiple  benign  false  neuromata  on  the  nerves,  which  give  rise  to  pain  ;  but  they  are  not 
tender  on  pressure,  and  so  contrast  with  the  single  false  neuromas,  which  equally  give  rise 
to  pain  over  the  area  or  distribution  of  the  nerves  on   which  they  are  situated. 

When  pain  is  felt  in  the  intercostal  or  other  muscles  about  the  chest,  and  can  be 
referred  to  nothing  more  definite  than  "  muscular  rheumatism,"  the  condition  is  referred 
to  as  one  of  mynlgin  or  pleurodynia.  Tenderness  of  the  affected  muscles  is  the  only 
physical  sign  present,  and  it  is  important  that  graver  mischief,  such  as  pleurisy  or  pneu- 
monia, should  be  excluded  before  the  diagnosis  of  pleurodynia  is  made.  The  sudden 
pain  in  the  side  familiar  to  untrained  athletes  as  stitch  comes  on  after  sudden  exertion, 
and  is  in  all  probability  due  to  overstrain  of  the  fibres  of  part  of  an  intercostal  muscle. 
All  these  muscular  pains  are  relieved  by  rest  or  pressure,  and  aggravated  by  exertion. 

Pains  in  the  chest  may  be  due  to  neuralgia,  a  term  which  is  theoretically  applied  to 
pain  felt  in  a  nerve  that  shows  no  evidence  of  active  or  old  disease.  Practically,  how- 
ever, neuralgia  is  the  name  also  given  to  nerve-pains  that  follow  organic  disease  both  in 
the  nerve  itself  (herpes,  neuritis,  etc.)  and  in  other  parts  of  the  body  (gout,  tabes,  etc.). 
In  intercostal  neuralgia  the  pain  is  felt  along  the  course  and  distribution  of  one  or  more 
of  the  intercostal  nerves.  There  is  marked  tenderness  on  pressure  in  the  affected  inter- 
costal space,  with  three  points  of  maximum  tenderness  corresponding  to  the  posterior 
primary,  lateral  cutaneous,  and  anterior  cutaneous  branches  of  the  nerve,  given  off  near 
the  vertebral  spines,  the  mid-axillary  region,  and  the  costosternal  articulations.  The 
pain  is  increased  by  movement  or  breathing.  I'nilateral  intercostal  neuralgia  often 
follows  herpes,  and  must  be  distinguished  carefully  from  pains  that  may  be  felt  in  organic 
disease,  such  as  tabes,  aneurysm  or  mediastinal  tmnour,  and  vertebral  caries,  in  which 
the  interco.stal  nerve  is  directly  or  indirectly  involved.  In  phrenic  or  diaphragmatic 
neuralgia,  a  rare  condition,  the  pain  is  felt  in  the  lower  part  of  the  thorax  along  the  line 
of  insertion  of  the  diaphragm,  which  may  be  tender  on  pressure  ;  coughing  and  breathing 
are  acutely  painful,  but  there  will  be  no  physical  signs  of  disease  except  the  tenderness 
on  pressure.  The  diagnosis  must  be  made  from  diaphragmatic  pleurisy  or  peritonitis, 
acute  hepatic  or  splenic  disorders,  and  spinal  caries,  on  general  lines.  Mastodynia, 
manunary  neuralgia,  or  the  '  irritable  breast  "  of  .\stley  Cooper,  occurs  in  women  during 
pregnancy  or  lactation,  or  in  connection  with  pelvic  disease.  The  pain  is  constant,  with 
paroxysmal  exacerbations,  and  its  severity  may  lead  to  the  fear  of  cancer.  Local  changes 
— redness,  swelling,  tenderness — may  be  found  about  the  breast  and  nipple. 

Pains  in  the  chest  are  habitually  felt  in  herpes  zoster  of  the  intercostal  nerves,  some- 
times before,  always  during,  and  often  after  the  attack  :  the  third,  fourth,  and  lifth  inter- 
costals  are  those  most  often  involved.  (ir()U[)s  of  vesicles  arise  over  the  area  of  distribution 
of  the  affected  nerve,  filled  with  serum  and  implanted  on  an  inflamed  base  ;  they  are  most 
marked  about  the  exits  of  the  ])osterior  prinuiry,  lateral  cutaneous,  and  anterior  cutaneous 
branches.  The  axillary  glands  become  enlarged  if  the  herpes  is  above  the  seventh  dorsal 
nerve,  the  inguinal  if  it  is  below  it.  In  alxnit  a  week  the  eruption  scabs  over  :  in  all  but 
the  mild  cases,  small  whitish  scars  remain  as  permanent  evidence  of  the  attack.  The 
diagnosis  is  obvious  in  cases  presenting  the  eruption  or  its  scars,  but  may  l»e  diHicult  until 
the  herpetic  vesicles  have  appeared.  It  is  especially  in  older  patients  that  se\-erc  neuralgic 
pains  arc  likely  to  remain  for  months  or  years  as  a  legacy  from  herpes,  and  they  may  be 
very  intractable. 

Pains  in  the  chest  will  be  felt  whenever  there  is  pressure  on  an  intcrcost(d  nerve:  in 
many  cases  such  pressure  is  bilateral,  when  the  ])alient  will  complain  of  girdle-pains. 
Injury  or  fracture  of  the  spinal  column  may  involve  the  posterior  nerve-roots  or  the  inter- 
costal nerves,  either  at  once  by  tlu'  pressine  of  fractured  bone  or  of  (-nused  blood,  or  later 


432  PAIN     IX    THE    CHEST 

by  the  pressure  of  callus  ;  abscesses,  aneurysms,  or  primary  or  secondary  new  growths, 
may  press  on  the  nerves  and  give  rise  to  severe  pain  in  their  areas  of  distribution.  In 
the  great  majority  of  cases  there  will  be  other  physical  signs  or  symptoms  to  point  to  the 
diagnosis  ;  but  where  there  are  none,  and  the  pain  is  due,  perhaps,  to  a  minute  carcinoma 
in  The  spinal  canal,  or  to  a  small  tiioracic  aneurysm  that  strikes  backwards  and  presses 
on  an  intercostal  nerve,  there  is  no  little  danger  lest  the  patient  be  treated  for  functional 
disorder  or  malingering.  The  pains  are  very  severe,  and  persist  for  months  in  spite  of 
treatment,  while  tlie  patient  is  likely  to  lose  health,  weight,  and  strength.  It  is  true  that 
these  phenomena  may  also  be  observed  in  functional  cases  :  but  the  diagnosis  of  functional 
disease  or  neuralgia" should  not  be  made  until  the  most  careful  physical  examination, 
including  the  use  of  the  .r-rays,  has  excluded  organic  disease  of  all  sorts. 

Chest-pains  are,  of  course,  common  in  inflammation  or  injuries  of  the  bones  of  the 
chest— coccal  infections,  tuberculosis,  hydatid  disease,  etc.— or  of  the  joints  connected 
with  these  bones.  In  few  such  cases  will  the  diagnosis  of  inflammation  present  difficulty. 
Diseases  of  the  Viscera. — Pain  in  the  chest  is  extremely  common  in  the  various 
diseases  of  the  thoracic  viscera,  inllammatory  or  otherwise.  In  acute  pleurisy  the  onset 
is  often  insidious,  and  the  pain  felt  most  acutely  in  the  mammary  or  axillary  region,  being 
made  worse  on  breathing  deeply  or  coughing.  The  pain  is  stitch-like,  lancinating, 
described  as  resembling  "  a  knite."  ■  stabbing,"  •  tearing "  :  it  is  relieved  by  anythmg 
that  assists  in  immobilizing  the  affected  side.  The  intercostal  spaces  are  tender  to  pressure 
in  pleurisy,  just  as  thev  are  in  intercostal  myalgia.  The  diagnosis  turns  on  the  discovery 
of  other  physical  signs  of  pleurisy,  whether  with  or  without  effusion,  particularly  of  pleural 
friction-sounds.  In  diaphragmatic  plcurisi/.  the  pain  is  felt  in  two  chief  sites  :  one  near 
the  costal  margin,  corresponding  to  the  attachment  of  the  diaphragm  ;  the  other  about 
the  crest  of  the  shoulder,  corresponding  to  the  cutaneous  distribution  of  the  fourth 
cervical  nerve  :  this  is  a  referred  pain,  due  to  afferent  stimuli  coming  up  the  phrenic  nerve 
to  the  spinal  centre  of  the  fourth  cervical  nerve.  The  pleuritic  friction  sounds  often  fail 
to  make  themselves  heard  in  diaphragmatic  pleurisy,  and  the  diagnosis  of  intra-abdominal 
disease  (cholecvstitis.  appendicitis,  peritonitis)  has  often  been  made  and  acted  upon  in 
such  instances.'  The  pain  in  empi/ema  is  much  like  that  of  pleurisy  ;  it  should  be  noted 
that  the  appearance  of  a  pleural  effusion,  whether  serous  or  purulent,  often  coincides  with 
a  diminution  in  the  amount  of  pain  felt,  because  the  two  inflamed  pleural  surfaces  become 
separated  by  the  fluid  and  cease  to  be  rubbed  together  by  the  respiratory  move- 
ments. Chronic  pleurisi/  and  old  pleural  adhesions  give  rise  to  much  of  the  chronic 
pain  in  the  chest  and  shoulders  and  root  of  the  neck  that  occurs  from  time  to  time  in 
patients  with  pulmonary  tuberculosis.  Pain  and  tightness  in  the  chest  are  common  in 
bronchitis,  with  or  without  emphysema  ;  here  the  diagnosis  will  not  be  difficult  if  pleurisy 
can  be  excluded,  and  much  of  the  pain  is  probably  due  to  overstrain  of  the  intercostal 
muscles. 

In  pneumofhora.r.  about  half  the  cases  show  an  acute  onset,  with  the  sense  of  some- 
thing tearing  or  uiving  way  in  the  chest  as  the  patient  coughs,  and  sudden  very  severe 
pain^in  the ^side,  aggravated  by  breathing.  In  addition  the  patient  exhibits  dyspnoea, 
prostration,  cvanosi's,  and  rapid'  and  feeble  action  of  the  heart.  The  onset  in  more  than 
half  the  cases'is  insidious,  and  the  condition  subacute  or  chronic,  with  comparatively  little 
complaint  of  pain.  The  diagnosis,  if  not  made  from  the  history,  should  be  manifest  on 
consideration  of  the  physical  signs.  The  affected  side  of  the  chest  moves  very  little  on 
respiration,  and  is  increased  in  measurement  :  vocal  fremitus  is  absent  :  the  note  on 
percussion  is  usuallv  tvmpanitic,  in  rare  cases  dull  ;  and  the  voice-  and  breath-sounds 
are  absent  on  auscultation.  If  the  pneumothorax  is  at  all  extensive,  the  heart  will  be 
displaced  considerably  towards  the  sound  side.  Examination  with  the  a;-rays  will  show 
that  the  diaphragm  is  immobile  on  the  affected  side,  and  the  air-containing  pleural  cavity 
extremely  translucent  (Fis.  226,  p.  531) :  the  lung  forms  a  shrunken  and  opaque  mass  near 
the  middle  line  and  against  the  spinal  column.  After  a  few  days,  more  or  less  evidence 
of  pleural  effusion  at  the  base  of  the  pleural  cavity  will  usually  be  found. 

In  pneumonia,  chest-pain  is  extremely  common,  and  is  due  to  pleurisy.  If  the 
physical  signs  characteristic  of  pneumonia  delay  their  appearance,  as  is  sometimes  the 
case,  and  if  the  pleural  friction  escapes  detection,  the  diagnosis  of  some  relatively  harmless 
condition  such  as  pleurodynia  or  intercostal  neuralgia  may  incautiously  be  made.     This 


PAIX     IN     THE     t'HEST  433 

mistake  should  never  occur  ;    nor  is  it  likely  to  do  so  if  due  attention  be  paid  to   the 
patient's  temperature,  aspect,  pulse,  and  pulse-respiration  ratio. 

Pain  in  the  chest  is  common  in  acute  pericarditis,  and  is  referred  to  the  precordia 
generally,  or  to  the  lower  part  of  the  sternum.  In  many  cases  no  complaint  of  pain  is 
made  :  in  a  few  instances  the  pain  is  exceedingly  severe,  resembling  that  of  angina 
pectoris.  The  diagnosis  will  turn  on  the  discovery  of  other  signs  or  symptoms  of 
pericarditis,  particularly  of  pericardial  to-and-fro  friction-sounds  :  the  patient  is  often 
pale  and  anxious-looking,  and  ^■e^y  short  of  breath.  It  should  be  remembered  that  the 
friction-sounds  often  remain  unchanged  when  a  dry  pericarditis  has  been  converted  into 
a  wet  one  by  the  effusion  of  fluid.  Pericardial  friction-sound  is  characteristically  a  super- 
ficial grating,  rubbing,  or  creaking,  usually  double  or  to-and-fro  :  in  rhythm  it  is  often 
not  synchronous  with  either  systole  or  diastole,  beginning  in  one  and  being  carried  on 
into  the  other.  It  can  often  be  altered  by  pressure  with  the  stethoscope  or  by  changing 
the  patient's  position  ;  often  it  varies  from  day  to  day  ;  and  it  is  not  conducted  well  in 
any  direction  beyond  the  precordia,  being  heard  within  an  area  that  often  does  not 
correspond  with  the  areas  of  audition  of  valvular  murmurs.  These  characters  should 
suffice  to  distinguish  pericardial  friction-sounds  from  the  murmurs  of  valvular  disease  ; 
but  it  may  be  very  dilHcult  in  certain  cases  to  distinguish  pericardial  from  pleuropericardial 
friction-sounds — that  is  to  say,  friction-sounds  generated  in  pleurisy  by  the  heart's  move- 
ments. If  there  is  pleurisy  of  the  thin  anterior  edge  of  the  left  lung  that  conies  between 
the  parietal  and  pericardial  pleunc.  the  beating  of  the  heart  will  readily  give  rise  to 
friction-sounds  that  have  a  cardiac  and  not  a  respiratory  rhythm,  but  are  due  to  |)leurisy 
and  not  to  i)ericarditis.  Pain  in  the  chest  will  be  felt  in  either  case  :  the  two  may  generally 
be  discriminated  by  the  influence  of  deep  inspiration  and  expiration  on  the  friction- 
sound.  In  pericarditis,  expiration  will  strengthen  and  inspiration  will  weaken  (but  not 
abolish)  the  friction-sounds.  Pleuropericardial  friction  will  in  all  probability  be  altered 
profoundly  by  respiration,  being  much  increased  in  one  phase  (whether  inspiration  or 
expiration),  nuich  diminished,  or  lost,  in  another. 

Pain  in  the  chest  is  common  in  cases  of  heart  disease,  taking  in  general  two  forms  : 
(1)  Precordial  pain  :  and  (2)  Palpitatiox  (p.  484).  There  is  nothing  characteristic  about 
the  precordial  pain  felt  in  heart-disease,  except  the  fact  that  it  is  brought  on  most  often 
by  exertion  or  excitement.  Very  similar  pain  may  be  experienced  by  patients  with  sound 
hearts  who  are  suffering  from  flatulent  di/spepsia  :  here  the  pain  is  usually  felt  after  meals, 
but  may  be  brought  on  by  exertion  if  the  latter  is  made  soon  after  food  has  lieen  taken. 
The  diagnosis  must  be  based  on  the  general  signs  and  symptoms  exhibited  by  the  cardiac 
l)atient.  In  aortic  incompetence,  the  precordial  pain  is  sometimes  exceptionally  severe, 
taking  the  character  of  angina  pectoris,  and  radiating  down  the  left  arm  or  through  to 
the  back.  The  sensory  ner\es  of  the  heart  arc  connected  with  the  spinal  cord  from  the 
first  to  the  eighth  dorsal  nerve  roots  ;  the  first  and  also  the  most  painful  impressions  are 
usually  received  at  the  second  dorsal  roots,  which  arc  described  as  being  most  central  to 
the  paths  of  ])ain  from  the  heart.  The  painful  imi)ressions  received  from  the  heart  at 
these  root-centres  are  referred  to  the  corres])onding  areas  of  cutaneous  nerve  distribution. 
Those  from  the  ventricle  ascend  from  the  second  to  the  fifth  :  from  the  auricle,  the  lifth 
to  the  eighth  :  from  the  ascending  aorta,  the  third  and  fourth  cervical,  and  the  lirst  to 
tlie  thin!  dorsal  root -centres.  These  anatomical  connections  explain  the  distribution  of 
the  pains  in  the  eliesi  and  elsewhere  lilt  in  diseases  of  the  heart  and  aorta.  .Severe  |)uin 
in  the  ehesf .  often  of  anginal  eliaraetcr,  is  fell  in  acute  or  elininie  aortitis  occurring  in  youtig 
syphilitic  or  rheumatic  patients,  with  or  without  valvular  disease  ;  the  pain  is  mosl 
marked  when  the  base  of  the  aorta  and  the  coronary  orifices  are  involved. 

Pains  in  the  chest,  together  with  mental  anguish,  are  the  outstanding  features  of  true 
angina  pectoris,  and  are  in  most  cases  brought  on  by  exertion.  The  \nun  is  in  the  region 
of  the  heart,  and  suggests  that  the  heart  has  been  caught  in  a  vice,  so  excruciating  is  it. 
A  sense  of  impending  dissolution,  or  of  a  jiausc  in  the  operations  of  nature,  has  been 
described  as  added  to  tlie  pliysical  torture.  Radiations  of  the  pains  through  to  the 
shoulder,  down  the  left  arm's  inner  side  to  the  little  and  ring  lingers  (less  often  down  the 
right  arm),  up  the  neck,  into  the  supra-orbital  region,  arc  very  common.  The  patient 
becomes  laiiit  and  collapsed,  pale,  and  elanmiy  ;  the  puKe  changes  ;  llatulcnce  and  the 
passa^'col  ahuiiilant  pair  urine  follow  the  attack,  which  ma\  last  lur  a  few  seconds  or  minutes, 
■  ■  -JS 


PUV     IN     THE    CHEST 
434 

•.,f„,witv  for  hours  The  diagnosis  will  rest  on  the  extreme 
or  may  continue.  ^v>th  varyn^g  nitens.t  for  hour^  Ih  or  arteriosclerosis,  or  both,  and 
severity  of  the"  pain,  its  association  with  ^^l;-^!^; jj?;*^^'^  ^  ^^„ti„„  „,  severe  emotion, 
the  fact  that  the  attacks  are  '^'T:  ^  ^r.'rfi^^^^^  pseudo-angina  or 

The  true  must  be  ^-t-gmsh^d  from /«A^^^^  ^^^^  ^^^^^^  ^  ^^^.^  ^^^^.^^^^,_ 

vasomotor  angina  pectoris.     This  commonly  n  commoner  in  women  than 

tea.  cotiee)  basis  ;   it  is  less  severe,  and  >s  n  v  i  fatal.  J*  -    -  ^  '  ^^^.^,^  ^,  ^^^  ,ge, 

i„  men  ;  often  comes  --;f^^J>^':^^,:^  Sase  Attacks  of  false  angina  la.t  for 
and  is  not  associated  with  cardiac  or  ^^^  '^^  '^''^^^^^^^^^r  in  men  than  in  women,  and 
,,n  hour  or  two.  True  angina  is  1^^'^^P^  *"V™' '  fX  an<.ina  is  perhaps  five  times  as 
occurs  between  the  ages  of  forty  and  sixty  as  a  r u^e      fab.e  an  p       ^1^^^^  ^^  ^^^  ^^^ 

common  in  women  as  in  "^f  ■/'^'^  "f'^""  ''^  ■^""Sierbut  everv  gradation  is  met  with, 
conditions  will  be  distinguished  readily  from  one  ^^f^^'^'^lj^"        i,,,t,  ^ith  severe 

^t;lSkr:::?'^^r '^:t;r^^1S:r:it.n^cisi  '^  ^/either  one  ^ss  or 

''"  S^mic  or  recurrent  pain  in  the  chest  is  ^^^  :-^:^-::::Z;::;:::!'Z 

In  some  patients,  a  large  aneurysm  may  erode  ^  ^-cart  l^ge    and    i^t  P      ^ 

present   ilself  at   the   surface  of  the  ^^"^^  .-^•-2f;;^^,re:n  aneurysm  at  the  root 

agonizing  pain  (true  angina  pectoris)  max   ''^  °;;*'^"' ,   ,,i^^l  ,i„n,  ^t  all  ;    in  these  the 

o!  the  aorta  has  grown  large  enough  to  P;;'-^^^-^  ^^^  ^  ^  o,t  par     or  to  obstruction  at  the 

pain  is  no  doubt  due  to  aortitis  -  "^^  '  Jn  of  aorti    anem'-sm  may  arise  in  two  ways  : 

coronary  orifices.     SP'^'^l^^'^g  g^""^"^;/''^*'"' °*  ^°'J^^^^^^        a„d   (2)'  From   pressure   on 

(1)  From   changes   in   the   -;t.c   wall,    a  ready    considered      and   ()^^  ^^   ^^^^ 

neighbouring    structures,   particularly   ^e  wall,   of     he   c  ^^^^^      ^^^^^.^^ 

sternum  or  costal  cartilages  may  ^e  .compai^^tn.  >       unlev  ,^ 

of  the  vertebral  bodies  commonly  gives  "^^.;°.;"  '"^^^^f^^ablc  ■    oirdle-pain  may  result 

the  chest  that  wear  the  patient  out  and  ;^;f:l'fj^'ZTlf^^^^^^^^^  the  neck  o, 

from  pressure  on  the  intercostal  nerves  «^'«'f  P^'^^p^^^^^^^'  „„  the  oesophagus  may  giv. 

down  the  inner  side  of  either  arm  may  also  ^^j.^;*'^  .^^  "J,,"^;^,,     Compression  of  th. 

rise  to  dysphagia  and  pain,  the  pain  ^"^8  'ne^-^^  b     -alU.w  ^^J     ^^^^^.^^    ^.^ 

lung  mav  lead  to  pulmonary  collapse  and  'f  "^"^   ™^  follows  compression  o 

probably  be  felt.     It  appears  that  no  P-t-"'---^^  '  "^  tTute  and  sever^e  pain,  o, 

he  trachea,  bronchi,  phrenic  or  vagus  ^''^'l^^^^.^^l.a  allow  blood  to  escap 

the  other  hand,  may  arise  should  the  aort.caneuosmpe    orate  ^  ,,_  ^sc 

into  the  adjoining  parts.     Such  V^r^r^^on  n^^J^e^^e        ^^^^^^    P^^^^^     ^^^^^^^ 

phagus.   large    intrathoracic   pulmonar>    m    ^>  ■jt";"^;^';;.^       physical  signs  will  snggee 

peritoneum,  or  spinal  canal      T^e  app.^raiK.  of      e  ^^^^.^^    ^^^  ^^^^.^^ 

the  diagnosis  of  such  a  perlorat.on.     "  t'^i  etluse.l  moo  ^ny  escapes,  rapid  ( 

^ill  appear  more  or  less  blanched  and  -"f P^^^ 'Z^; /^^^a^^^       the  pain  due  to  tl 

sudden  death  may  occur.     P-^'^'^-^'^J^T^^^l^^Z^,  sensitive  to  pain,  as  may  1 

formation  of  a  dissecUng  aneurysm,     ^he  arter  es  .cut  ^^^^^^^^^  ^^  ^  jj^,,,ti. 

seen  when  an  artery  is  ligatured  ,n  a  conscious  P'^*         ;   *;  ^,^  ^„^,k  of  true  angi. 

aneurysm  is  a  terribly  painful  experience    a'^^d  ^  3;^^  '    J  ^^^a.  recovery  is  likely 

pectoris.     If  the  escape  of  blood  is  limited  ^J  /'^^ jf^";^^';;  „^  grounds  of  probabilit 

occur.     The  diagnosis  of  such  an  incident  ^o^^"^ /"'^  „^^„"  f„  '  .°„,"„„,  „,w//^  and  var 

Pain  in  the  chest  is  usually  an  early  ^>-Pt""    "^Z ;f '^^^  ^''  "j\u,  growth  is  in  t 

in  its  nature  and  distribution  -'*  ^^.^^^  and  .^^    ^^'^e  posterior  mediastinu 

anterior  mediastinum,  the  pain  will  be  be   ind  tl  e  sternum  J    ^  .^  ^^f^n 

pressure  on  or  erosion  of  the  vertebra-  will  ^^t'^one  s  dlof  ^he  chest  is  involved,  the  p. 

\o  above  as  occurring  in  aortic  aneurysm      f^^^^^rhU  plexus  is  pressed  upon.      It 

..ill  be  felt  in  the  side,  and  down  the  •''™y ^    ''^.    ^^"^    '^„  „  the  neck  and  head,  or  do 

often  of  a  darting  and  lancinating  -character,  shooting  up  in  ot.  ^^^^^^  ^^^^ 

into  the  abdomen.     It  may  be.constant    int  i  n  -  oi^^^   a^^^^^^^^^    ^  ^^^^^^^^  .^  ^^^^  ^^^ 

is  a  discomfort  rather  than  a  pain,  the  ^"^Pl'l'"* '"     -j    /,    ^^    continuous  or  paroxys, 
Other  symptoms  of  mediastinal  tumour  are.  first. udfoicmo^^^^^^  ^^    ^^^^^^^_     ^^^ 

dyspna-a  ;     evidences   of  pressure   on     *e   a.r-passa  es     a.  op     .^^^^^^^^^^^  .^  ^^^^  ^^, 
expectoration,  haemoptysis,  alterations  in  the  ^olce  "^  ^^  -     •  cancerous  each, 

of  the  heart,  and  evidence  of  venous  obstruction.     An.rm.a 


PAIN     IX     THK    CHEST 


435 


are  not  rare.  The  general  diagnosis  of  mediastinal  tumour  (including  aneurysm)  is  seldom 
difficult  once  pressure-symptoms  of  any  sort  have  appeared,  for  these  are  very  rarely 
caused  by  other  lung-conditions  associated  with  pain  in  the  chest,  such  as  bronchitis, 
bronchiectasis,  or  pulmonary  tuberculosis.  But  it  may  be  very  dilhcult  to  decide  between 
aortic  aneurysm  and  mediastinal  new  growth  in  certain  eases.  Aneurysm  is  commoner 
in  men  than  in  women,  and  rare  in  persons  who  have  not  had  syphilis  ;  the  patients 
commonly  give  a  positive  Wassermann  reaction  :  anginal  pains  and  the  very  severe  pain  of 
bone-erosion  are  commoner  in  aneurysm  than  in  mediastinal  new  growth  ;  anaemia,  cachexia, 
and  irregular  ])vrexia  are  in  favour  of  new  growth  :  and  so  is  the  discovery  of  new  growth 
in  other  parts  of  the  body  and  of  secondarily-infected  lymphatic  glands.  Examination 
under  the  ,r-rays  will  prove  of  the  greatest  help  {Fig.  100,  p,  209,  and  Fig.  IS-t),  the  rays 
being  passed  through  the  patient's  thorax  in  a  number  of  horizontal  directions  succes- 
sively :  if  this  be  done,  the  presence  of  an  aneurysm  and  its  connection  with  the  aorta  can 
almost  always  be  established  when  one  is  present,  to  the  exclusion  of  mediastinal  new 
growth. 

In  acute  tiiediastiiiitis  and  mcdidstiuol  absress — both  of  tliem  rare  disorders  and  due 
to  sy])hilitie,  tuberculous,  or  other  infection  of  tlie  mediastinum — pain  behind  the  sternum 
is  commonly  the  chief  comi)laint,  with  marked  superficial  tenderness  and  a  tendency  to 
radiation  through  into  the  back  or  shoulder. 
Local  signs  of  fullness  and  inflammation  may 
develop,  particularly  about  the  intercostal  spaces 
in  front  and  the  episternal  notch  :  and  medias- 
tinal ere])itations  resembling  pleural  friction  have 
been  heard  about  the  sternum. 

In  chronic  mcdinstiiiitis  or  mediastino-peri- 
carditis,  another  rare  condition  due  to  inflam- 
mation arising  in  the  mediastinum,  or  spreading 
to  it  from  the  pericardium,  and  seen  in  youth  or 
early  adult  life,  chronic  pain  behind  the  sternum 
and  a  sense  of  lightness  and  dragging  in  the  chest 
may  be  present.  The  main  symptoms  will  be 
cardio-vascular.  valvular  disease  of  the  heart  ami 
adherent  pericardium  leading  to  cardiac  troubles, 
and  the  mcdiastinitis  causing  venous  obstruction. 
Shortness  of  breath,  with  sudden  and  severe 
attacks  of  dyspna'a,  lividity,  anasarca,  ascites, 
and  progrcssJNc  distention  of  the  thoracic  veins  ; 
new  growth  being  cxehidcd  by  the  duration  of 
the  case. 

Deep-seated  i)ain  within  the  clusl  and  at 
the     bottom    of    the    sicrmim     may    be     felt    in 

diseases  of  the  wsojiliiigii.'i,  being  evoked  by  the  act  of  swallowing.  In  cicatricial  stricture 
or  carcinoma  of  the  tube,  iKiin  is  less,])rominent  than  I)vsimi.v(jia  (j).  l!)t),  and  progressive 
emaciation  is  the  rule.  In  younger  and  neurotic  patients,  on  the  other  hand,  spasmodic 
stricture  of  the  ccsophagus  may  give  rise  to  dilTiculty  in  swallowing,  with  nmch  complaint 
of  i)ain  and  constriction  In  the  throat  and  chest.  This  condition,  termed  (rsiiiilKigi.sinits. 
or  cnrdioniKism  {Fig.  !)8,  p.  1!)«),  occurs  in  hysterical  young  persons  and  in  hypocliondriiical 
old  ones;  it  is  improved  or  cured  by  the  [lassage  of  a  biiiigie  ;  is  assnci;it<'d  with  oilier 
evidences  of  the  ncuiotir  IcrnpcraiiKiit  ;  and  nuisl  he  diagniised  froiii  oil' inic  (csoplnij/cal 
sti-nosis. 

I'ain  in  the  chest  is  met  with  rre(|U(iill\  in  diseases  of  the  abdominal  viscera,  partitru- 
larly  of  I  he  stomach,  ■  Fains  round  I  he  licail,"  often  accompanieil  by  or  productive  of 
Paf.i'i  I  \rio\  (p.  Wt),  are  the  cominon  hasis  upon  which  patients  build  when  they  come 
eoinpliiiniiiy  ol  •  heart-disease  "  or  "weak  heart,"  while  as  a  matter  of  fact  they  are 
sulTciirig  b'din  Ihe  less  serious  condition  i)[  giisliilis.  or  Jlutiilciil  (h/s/jc/isifi.  The  pain  is 
felt  at  (he  hcilhirn  iit  the  sternum  and  in  the  epigastrium;  it  is  often  of  a  dull 
horini;  chaiaclci .  and  radiates  out  towards  the  left  hreast  and  through  to  the  back  between 
the    hlade-boMcs.      II    is    deliiiilciv    <-oMii((t.d    with    the    taking    of    food,    and    relieved    by 


/■•/;/,  1S1.— S!,-i.i-iMm  or  iui  HMi'lir.vsiu  of  tho  iiinoilliimt. 
artery  (A),  witli  dilatod  aortic  arch  CB). 

(Bij  Dr.  Alfred  C.  Jordan.) 


4;-56  PAIN     IX    THE    CHEST 

vomiting  or  the  eructation  of  wind  :  anrl  these  are  the  characters  by  which  it  must  be 
diagnosed.  In  other  instances,  the  complaint  is  of  ■  heart-burn,"  a  burning  pain  felt 
over  the  lower  part  of  the  sternum,  and  probably  due  to  the  regurgitation  into  the  ccso- 
phagus  of  the  gastric  contents  during  digestion.  It  is  a  referred  pain  felt  in  the  area  of 
distribution  of  the  fifth  dorsal  nerve,  and  is  often  associated  with  jjyrosis  or  water-brash, 
the  regurgitation  of  acrid  waterv  gastric  contents  into  the  mouth.  For  the  most  part, 
however,  pain  due  to  gastric  disorders  (such  as  ulcer,  new  growth)  is  referred  to  the  upper 
part  of  the  abdomen  rather  than  the  chest. 

Pains  in  the  chest  are  not  rare  in  various  diseases  of  the  spinal  cord.  Girdle  pains  or 
girdle  sensations  are  common  in  tabes  dorsalis,  the  patient  feeling  as  if  constricted  by  a 
hot  or  painful  girdle.  They  occur  early  in  the  disease,  and  so  are  often  set  down  vaguely 
to  gout  or  rheumatism,  wlien  a  more  careful  examination  would  yield  early  evidences  of 
tabes.  In  tmnsvcrsr  nnjelilis,  ov  fracture  of  the  dorsal  colmiiii  with  injury  to  the  cord,  girdle 
pains  round  the  chest  may  be  felt  at  the  level  of  the  cord  lesion,  with  loss  or  abolition  of 
sensation  lielow   it.  A.J.Jcx-Bhihr. 

PAIN    IN    THE    EAR.      (See    1vu!AC1ik.   1).    21)2.) 

PAIN  IN   THE  EPIGASTRIUM. 

A.  Sudden,  severe  epigastric  pain  may  result  from  the  rupture  of  a  gastric  or 
duodenal  ulcer,  of  a  gangrenous  appendix,  or  from  acute  pancreatitis.  The  pain  in  such 
a  case  is  attended  by  severe  shock  and  signs  of  collapse,  and  it  may  be  dilfieult  to  say  to 
which  of  the  above  causes  it  is  due.  The  past  history  of  the  patient  and  a  careful  study 
of  the  other  signs  present,  may  guide  one  to  a  correct  conclusion  :  but  as  all  the  conditions 
mentioned  require  immediate  surgical  treatment,  the  differential  diagnosis  is  made  by 
lajjarotomv. 

When  the  diagnosis  of  an  abdominal  emergency  has  to  be  considered,  if  the  history, 
symptoms,  and  signs  do  not  exactly  fit  acute  intestinal  obstruction,  or  stomach  or  duodenal 
perforation,  perforating  appendix,"  or  acute  cholecystitis,  and  yet  have  some  resemblance 
to  each  of  them,  pancreatitis  is  the  nio.st  probable  cause. 

The  pain  of  acute  intestinal  obstruction  may  be  referred  chiefly  to  the  epigastrium. 
Vomiting  is  usually  a  prominent  symptom  in  such  a  case.  (See  t'oNsriPATiON.  p.  121  ; 
METiiOiusM,  p.  388  ;    Vomiting,  p.  707.) 

During  an  attack  of  bilianj  colic  the  pain  may  be  chiefly  epigastric.  The  restlessness 
of  the  patient  in  such  a  case  is  often  of  diagnostic  value. 

B.    Chronic   or   recurrent   pain   in   the   Epigastrium  may    be    due    to   a  variety  of 

causes  : —  .  ■  ,       ,        f 

(1).   It  should  be  remembered,  in  the  lirst  place,  that  epigastric  pain  may  be  due  to 
c.rtra-abdoniinal  causes.     Amongst  these  are  spinal  caries  (especially  to  be  thought  of  in 
children),  pleurisy,  and  intercostal  neuralgia.     The  first  two  of  these  can  be  distinguished 
by  the  usual  signs  ;    intercostal  neuralgia  is  to  be  diagnosed  by  the  presence  of  tender 
l/oints  along  the  course  of  the  nerve,  and  by  the  absence  of  all  signs  and  symptoms  of  j 
organic  disease.     An  .r-ray  examination  of  the  chest  should  be  resorted  to  to  exclude  gross  i 
intrathoracic  changes,  such  as  aneurysm,  before  intercostal  neuralgia  is  diagnosed  finally. 
A  dilated  right  ventricle  may  also  be  the  cause  of  severe  epigastric  pain,  which  may 
even  simulate  the  pain  of  gastric  ulcer  or  gall-stones.      In  cases  of  emiihysema  or  heart 
failure  this  should  be  borne  in  mind.      In  such  cases  the  pain  is  aggravated  by  exertion. 
Small  epigastric  hernice  may  cause  recurring  attacks  of  severe  epigastric  pain.     They 
can  be  detected  by  careful  palpation,  usually  in  the  linea  alba. 

Affections  of  the  abdominal  muscles,   e.g.,   strain  from  coughing,   or  rheumatism  (in 
'  cliildren),  may  also  cause  pain  in  the  epigastrium. 

(2).  Assuming  these  to  be  excluded,  the  cause  of  the  pain  may  be  looked  for  in  tht 
following  organs  : —  . 

(a).  Stomach. — The  chief  causes  of  gastric  pain  are  carcinoma,  ulcer.  hyi)erchlorliydri3 
and  gastralgia.     (See  iNnicESTiON,  p.  315.) 

The  pain  in  carcinoma  is  usually  more  or  less  continuous,  although  apt  to  be  aggravatec 
temporarily  by  food.  A  tumour  may  be  felt.  Vomiting  is  usually  present,  and  th 
jiastric  contents  show  absence  of  free  HC'l  in  most  eases. 


PAIX    IN    THE     EPIGASTRIUM  437 

In  cases  of  nicer  the  pain  is  sliarper  and  more  definitely  related  to  the  taking  of  food, 
and  often  passes  through  to  the  back.  Vomiting  is  usually  a  feature,  with  or  without 
haematemesis.  There  is  localized  deep  tenderness  on  pressure,  often  over  quite  a  small 
and  well-defined  area.  The  gastric  contents  usually  show  the  presence  of  an  excess  of 
acid. 

In  cases  of  hyperchlorhijdria  the  pain  is  less  severe  than  in  either  of  the  above  condi- 
tions ;  it  occurs  in  the  late  period  of  digestion,  and  is  relieved  temiiorarily  by  the  taking 
of  food.  There  is  an  absence  of  other  signs  and  symptoms,  and  of  local  tenderness  ;  and 
a  test-meal  shows  the  presence  of  an  excess  of  acid. 

Oaslralgia  should  only  be  diagnosed  when  all  other  possible  causes  of  gastric  pain 
have  been  excluded.  The  patient  is  usually  a  young  woman  :  the  pain  may  occur  even 
when  the  stomach  is  empty,  but  is  aggravated  by  food,  even  by  liquids.  Vomiting  is 
usually  absent,  and  on  physical  examination  there  is  diffuse  deep  tenderness  over  Ihe 
whole  of  the  gastric  area. 

Epigastric  jiain  may  also  be  felt  to  a  greater  or  less  degree  in  all  comiitions  of  the 
stomach  associated  with  flatulence,  and  in  that  case  it  is  relieved  by  the  bringing  up  of 
Avind.     (See  Flaitli:nce.  p.  2-10.) 

The  gnsitric  crises-  of  tabes  may  be  attended  by  severe  epigastric  ])ain.  and  as  these 
may  occur  in  the  pre-ataxic  stage  of  the  disease,  before  other  signs  are  present,  the 
diagnosis  may  be  in  doubt.  The  characteristic  features  are  the  sudden  onset  of  the  pain, 
and  the  fact  that  it  is  usually  attended  by  urgent  vomiting.  There  is  no  rise  of  tempera- 
ture, hut  during  the  attack  the  blood-pressure  is  raised  ;  whereas  in  all  other  forms  of 
acute  abdominal  pain  (except  lead  colic)  it  is  lowered.  Absence  of  the  knee-jerk,  and 
the  characteristic  pujiil  signs  of  tabes  are  not  necessarily  present. 

Perigastric  adhesions  are  a  jjossible  cause  of  epigastric  pain,  but  are  (lifliciilt  to  diagnose 
with  any  certainty.  If  the  pain  is  nuich  induenced  by  muscular  movements,  or  change 
of  posture,  it  is  in  favour  of  adiiesions  being  the  cause  :  but  except  for  this,  it  has  no  other 
characteristic  features. 

«/).  Diiofleiiiiiii.-  TUi-  characteristic  'hunger-pain"  of  duodenal  ulcer  (p.  271)  may 
be  referred  to  the  epigastrium. 

,  (<■).  Liver  and  (laH-hladder. — Epigastric  pain  may  be  produced  by  congeslion  of  lite 
liver,  either  active  (hei)atitis),  or  passive,  as  in  mitral  disease.  It  is  also  produced  Ijy  such 
conditions  as  hejiatic  abscess  and  carcinoma  (see  Liviut,  Enlauoejiknt  of  tui:.  11.  :5()(i). 
Sloue  ill  the  goU-lilodder  may  sometimes  be  the  cause  of  epigastric  pain,  which  may 
even  be  <lefinilely  related  to  meals,  or  to  the  taking  of  a  particular  article  of  food. 
Pressure  over  llie  gall-bladder  will  often  elicit  tenderness  :  and  if  the  patient  is  made  to 
take  a  deep  breath  whilst  the  ))ressure  is  applied,  there  will  be  a  paiiilul  catch  in  llie  breath 
as  the  diaphragm  descends.  In  a  doubtful  ease,  in  which  the  diagnosis  lies  between  gall- 
stones and  gastric  ulcer,  the  following  points  are  in  favour  of  gall-stones  ;  (i)  The  occtn-- 
rence  of  the  pain  at  rather  long  intervals,  with  comjiarative  freedom  from  symptoms 
between  :  (ii)  Eong  duration  of  the  attack  of  |)ain  ;  (iii)  Continuance  of  the  pain  in  spite 
of  \omiting  :  (iv)  'i'lie  occurrence  of  slight  shivering  and  rise  of  temperature  with  the 
attacks;  (v)  .V  comparatively  low  dCgree  of  acidity  of  the  gastric  contents.  (Jail-stones 
are  relatively  commoner  in  women  ;    ulcer  in  men. 

((/).  Pancreas. — Pancreatic  calculi,  chronic  pancreatitis,  or  new  growth,  m.iy  .ill  be 
the  cause  of  epigastric  pain.  An  accurate  diagnosis  of  these  conditions  is  dillicult,  and 
often  impossible  ;  but  other  signs  of  disturbed  function  of  the  pancreas  may  be  (iresent, 
suc-h  as  fatty  diarrlitra.  or  a  •  pancreatic  reaction  "  (p.  100)  in  the  urine.  .V  tmnoiu-  also 
may  be  felt.  (Jlycosuria  may  be  present.  l)ut  is  not  iii\  ariablc  In  cases  of  chronic  pan- 
creatitis there  is  usually  a  history  of  gall-stone.. 

((■).  .iltdominal  .lorla. — .An  altdomitial  aiieini/sin  may  cause  pain  in  the  e|)igHstrium. 
but  the  pain  is  more  nuirkcd  in  the  back.  The  patient  is  usually  a  young  man  with  a 
syi)liilitic  history,  anil  a  pulsating  exi)ansile  luinoiii  can  he  IVIt  on  deep  palpation.  The 
.r-rays  will  conlinn  tlic  diagnosis. 

.MidoniiiKil  angina,  which  is  associateil  with  arterial  atlurorua  and  a  high  blood- 
pressure,  is  an  occasional  cause  of  severe  epigastric  pain,  which  comes  on  in  paroxysms, 
especially  upon  exertion.  The  pain  in  such  a  case  tends  to  radiate  like  that  of  true 
angina,   and   is   often   atti-iuled    by   tial  iilcuce.    tcncsinus,   and    other  alxloiniiial   symptoms. 


4HS  PAIN     IX    THE    EPIGASTRIUM 

Tliere  are  usuallv  sifins  of  atheroma  in  the  peripheral  vessels  :  and  the  diagnosis  may  be 
confirmed  bv  the  yielding  of  the  pain  to  vascular  depressants,  and  especially  to  dmretm. 
(/).  Co?o»i.— Spasmodic  contraction  of  the  transverse  colon  (enterospasm)  may  be  a 
cause  of  epigastric  pain,  which  mav  simulate  gastric  pain  by  being  induced  by  the  taking 
of  food  Sucli  pain,  however,  tends  to  be  relieved  by  pressure,  and  by  the  passage  of  gas 
per  anum.  Obstinate  constipation  is  usually  a  feature  of  the  case,  and  there  are  often 
mucus  and  shreds  of  membrane  in  the  motions  (muco-membranous  colitis).  A  smrilar 
pain  may  be  due  to  plumbism.  for  the  diagnosis  of  which  see  p.  3-t.  Hoberl  Uutciiison. 

PAIN  IN  THE  EXTREMITY  (LOWER).— The  causes  of  pain  in  the  lower  limbs 
are  so  numerous  that  mucli  space  would  be  required  it  any  attempt  were  made  to  discuss 
them  in  full.  Fortunately  the  majority  are  detected  easily  when  attention  is  paid  to  the 
site  nature,  and  history  of  the  pain,  and  the  painful  spot  is  examined.  An  attack  of  gout 
in  the  bi<T  toe,  an  ingrowing  toenail,  a  flat  foot,  a  synovitis  of  the  knee  or  ankle,  phlebitis 
of  a  varicose  vein,  a  tumour  of  one  of  the  long  bones,  and  many  other  localized  pathological 
processes  require  only  an  elementary  medical  knowledge,  and  the  enlightened  use  of  eyes 
and  fintrers  for  a  correct  diagnosis  to  be  made.  On  the  other  hand,  there  are  many  con- 
ditions "of  which  pain  of  a  more  or  less  diffused  type  is  a  prominent  symptom,  and  which 
require  very  careful  investigation  if  mistakes  are  to  be  avoided  and  diagnostic  traps  escaped. 
The  fact  that  the  nerves  of  the  leg  spring  from  the  lower  part  of  the  spinal  cord  in  the  dorso- 
lumbar  part  of  the  vertebral  column,  and  that  they  have  a  somewhat  lengthy  course  within 
the  lumbo-sacral  vertebral  canal  and  the  pelvic  cavity,  where  they  are  comparatively  in- 
accessible before  they  reach  the  limb,  explains  why  the  origin  of  some  pains  referred  to 
the  lower  extremity  is  rendered  obscure.  Moreover,  some  of  the  painful  conditions  met 
with  are  connected  only  indirectly  with  the  nervous  paths,  and  are  more  directly  associated 
with  morbid  conditions  of  other  structures,  such  as  joints,  blood-vessels,  etc. 

The  classification  of  the  various  painful  conditions  in  the  lower  extremity  which  need 
our  attention  from  the  point  of  view  of  diagnosis  is  no  easy  matter.  One  may  consider 
first  those  which  are  primarily  nervous  in  origin,  and  use  them  as  a  basis  for  comparison 
with  those  due  to  disease  of  other  tissues. 

1.     Pains   of   Neuralgic   or    Neuritic   Origin. 

Sciatica.— -nus  name  is  api)lie.l  conunonly  to  a  condition  of  the  sciatic  nerve  which 
may  sometimes  be  described  as  a  neuralgia  an<l  sometimes  as  a  neuritis,  according  to  the 
severity  of  the  attack  and  the  amount  of  alteration  in  nervous  function  to  which  it  gives 
rise  it  is  characterized  bv  pain  of  a  neuralgic  type  referred  to  a  part  or  the  whole  of  the 
course  of  the  sciatic  nerye'and  its  branches,  from  the  sciatic  notch  to  the  sole  of  the  foot. 
Usually  the  pain  is  most  severe  along  the  back  of  the  thigh  and  along  the  outer  side  of  the 
le.'.  Tenderness  is  found  on  pressure  over  the  gluteal  region,  over  the  sciatic  notch,  and 
generally  al!  along  the  nerve.  Exacerbation  of  pain  is  produced  by  stretching  the  nerve, 
for  instance  by  forcibly  flexing  the  thigh  on  the  trunk  with  the  knee  fully  extended.  The 
pain  is  intensified  bv  muscular  exertion,  and  is  often  severe  at  night,  especially  when  the 
patient  lies  on  his  back.  Sciatica  is  often  associated  with  lumbago,  pain  an<l  tenderness 
in  the  muscles  of  the  lumbar  region.  In  long-standing  cases  the  nutrition  of  the  affected 
le<r  suffers  and  the  muscles  appear  generally  smaller  than  those  of  the  other  limb,  but 
localized  atrophy  picking  out  individual  muscles  suggests  that  there  is  something  more 
than  a  simple  neuralgia  or  neuritis  at  work.  Numbness,  and  even  slight  cutaneous 
anesthesia,  may  be  found  on  the  dorsum  of  the  foot,  in  the  distribution  of  the  musculo- 
cutaneous branch,  in  cases  of  simple  sciatic  neuritis.  The  knee-jerk  is  never  affected  m 
sciatica,  but  the  ankle-jerk  is  often  diminished  or  lost,  and  may  remain  absent  for  a  long 
period  after  the  pain  has  disappeared.     The  plantar  reflex  is  of  the  flexor  type. 

Before  making  a  diagnosis  of  sciatica  or  sciatic  neuritis  in  a  patient  who  complains  ot 
pain  in  the  course  of  that  nerve,  the  physician  must  satisfy  himself  that  there  is  no  gross 
disease  in  the  hip-joint,  pelvis,  or  spinal  column  which  could  give  rise  to  the  symptoms.  The 
mobility  of  the  hip-joint  must  be  investigated  carefully,  and,  if  doubt  exists  with  regard  to 
its  inteo-rity,  the  joint  should  be  skiagraphed.  The  pelvis  should  be  examined  externalv 
and  internally  per  rectum  or  per  vaginam.  The  writer  has  seen  a  case  of  sarcoma  of  tit, 
innominate  bone  mistaken  for  sciatica,  when  a  glance  at  the  pelvis  as  a  whole  was  sufficient 
to  demonstrate  the  swelling  on  the  affected  side.     In  the  same  way  the  mistaken  diagnosis 


PAIN     IX     THE    LOWER     EXTREMITY  439 

of  sciatica  has  frequently  been  made  wlien  a  rectal  or  vaginal  examination  would  detect  a 
pelvic  inflammatori/  or  mnligtiani  mass  pressii)g  on  the  nerve.  Even  a  retroverted  uterus  may 
sometimes  cause  pain  in  the  sciatic  distribution.  Tuberculous,  gumnialous.  or  malignant 
disease  of  the  lumbosacral  vcrtebrie.  tumour,  or  meningitis  involving  Die  loivcr  part  of  the  spinal 
cord  and  cauda  equina,  arc  also  capable  of  producing  pain  which  resembles  that  of  sciatica. 
In  such  cases,  inquiry  into  the  action  of  the  sphincters  of  the  bladder  and  rcctmn  may 
suggest  the  position  of  the  lesion,  and  should  always  be  made  in  patients  complaining  of 
sciatica.  Skiagraphy  of  the  lower  part  of  the  vertebral  column  may  help  to  disclose  disease 
of  that  structure.  Lumbar  puncture  may  be  necessary  for  diagnosing  syphilitic  meningitis. 
In  most  cases  of  this  kind,  however,  a  careful  scrutiny  of  the  lower  limb  will  show  that  the 
I)ain  is  not  limited  to  the  distribution  of  the  sciatic  nerve,  that  the  latter  is  not  acutely 
tender  on  pressure,  that  there  are  atrophy  and  paresis  of  certain  groups  of  muscles,  some 
of  which  are  supjilied  by  other  branches  of  the  lumbo-sacral  plexus,  that  there  are  patches 
of  ancESthesia  corresponding  to  root  rather  than  nerve  areas,  or  that  the  knee-jerk  is  lost 
and  perhajjs  the  ])lantar  reflex  altered  in  character.  It  should  also  be  remembered  that 
.sciatica  is  nearly  always  unilateral,  whereas  growths  or  inflammation  within  the 
vertebral  anal  tend  to  ])roduce  signs  and  symptoms  in  both  legs  at  a  comparatively 
early  stage. 

The  frccpiency  with  which  sciatica  is  diagnosed  when  some  much  more  serious  disease 
is  really  i)resent,  is  sufTicient  excuse  for  laying  emphasis  on  the  above  points,  and  every 
practitioner  would  do  well  to  make  it  his  invariable  rule,  when  faced  with  a  case  apparently 
conforming  to  the  picture  of  sciatica,  to  inquire  into  the  action  of  the  sphincters,  to  inspect 
carefully  and  ])alpate  the  pelvis  and  spine,  to  make  a  rectal  examination,  and  finally  to 
keep  a  sharp  look-out  for  signs  of  present  or  ])ast  malignant  disease  in  other  parts  of  the 
body.  In  all  cases  of  neuralgic  or  ncuritic  pain  the  urine  should  be  examined  for  the 
presence  of  sugar. 

Anterior  Crura!  \curalgia  and  Anterior  Cruritis. — Neuralgia  in  the  distribution  of  the 
anterior  crural  nerve  is  much  less  common  than  sciatica,  and  precautions  similar  to  those 
just  mentioned  nmst  be  adopted  before  the  diagnosis  is  made.  In  this  condition,  the  jiain 
and  tenderness  involve  the  front  of  the  thigh  as  far  as  the  knee,  and  the  knee-jerk  is  some- 
times diminished.  In  some  cases  the  pain  extends  along  the  saphenous  branch  to  the 
ankle,  inner  aspect  of  foot,  and  big  toe.  There  is  often  considerable  wasting  of  the  quad- 
riceps extensor  muscle,  which  may  also  exhibit  reaction  of  degeneration.  Occasionally 
the  affection  is  associated  with  sciatica. 

Obturator  Xeuralgia.  -I'ain  iti  the  distributit)n  of  the  obturator  nerve  is  rarely  of  simple 
neuralgic  origin.  Disease  of  the  hip-joint  and  obturator  hernia  are  two  of  tlie  conditions 
which  may  give  rise  to  it. 

Meralgia  Pareesthetiru  is  the  name  given  to  a  variety  ol'  pain  which  is  rclcrrcd  to  the 
course  of  the  external  cutaneous  nerve  of  the  thigh.  The  relations  of  this  nerve  to  the 
psoas  nuiscle  and  the  fascia  hita  render  it  liable  to  stretching  or  pressure  in  standing  or 
walking,  with  the  result  that  the  neuralgia  is  intensified  by  the  maintenance  of  the  erect 
posture.  In  certain  instances  of  great  obesity,  prolonged  sitting  has  been  supjioscd  to 
])lay  a  part  in  producing  this  type  (A  neuralgic  discomfort.  There  is  sometimes  a  painful 
pressure-spot  just  below  the  anterior  iliac  spine,  A  flat-fool  is  met  with  not  uiicommiiidy 
in  these  cases. 

Metatarsal  Xeuralgia.  or  .Morton's  .tffcction  of  the  Foot.  This  neuralgia  is  of  the 
paroxysmal  type,  and  is  described  as  dull  throbbing  |)ain  in  the  base  of  the  fourth — some- 
times of  the  second — toe,  and  sjjrcading  up  the  leg.  There  is  tenderness  on  pressure  over 
the  niclalaisus.  In  a  certain  number  of  cases  the  pain  is  i)robal)ly  related  to  the  wearing 
of  light  cii-  ill-lilting  boots,  or  to  the  presence  of  flat-foot. 

Calrauotlj/uia  is  another  form  of  pain  liable  to  occur  in  neuralgic  subjects  who  arc 
doing  much  walking.  The  pain  is  often  bilateral,  worse  in  the  evening  and  at  night,  and 
tends  to  spread  from  the  heel  to  the  base  of  the  toes.  There  are  no  objective  signs  of  disease. 
One  patient  who  consulted  me  for  this  condition  returned  a  year  or  two  later  with  a  typical 
brachial  neuralgia.  In  all  obscure  eases  of  painful  feet  the  possibility  of  a  gonorrhceal 
bursitis  or  librositis  shoidd  l)e  kept  in  mind  :  and  also  of  calcification  in  the  posterior 
end  of  the  long  plantar  ligament  producing  a  spine-like  projection  beneath  the  os  ealcis. 
visibh-  to  the  .(-rays  {Fig.  IS.")). 


440 


PAIN     IN    THP]     LOWER    EXTRE.^IITY 


Multiple  Neurilis. — The  lower  extremities  are  often  the  site  of  multiple  neuritis  giving 
rise  to  great  pain,  but  the  diagnosis  is  rarely  difficult  owing  to  the  association  of  atrophic 
palsy  of  the  muscles,  the  electrical  reaction  of  degeneration,  dulling  of  cutaneous  sensibility 
below  the  knees,  and  loss  of  the  knee-  and  ankle-jerks.  Perhaps  the  most  characteristic 
and  constant  phenomenon  in  such  cases  is  the  presence  of  marked  tenderness  of  the  muscles 
on  pressure.  The  nerve  trunks  are  sometimes  hypersensitive  also,  but  not  so  constantly 
as  are  the  muscles  below  the  knees.  The  pain  in  multiple  neuritis  is  often  acute,  worse  at 
night,  and  aggravated  by  movement  and  the  pressure  of  bed-clothes. 

Tabes  Dorsalis. — The  pains  of  tabes  are  more  often  complained  of  in  the  legs  than  in 
any  other  part  of  the  body.  Unlike  the  neuralgias,  they  are  usually  bilateral  and  not 
referred  to  the  distribution  of  any  ])articular  peripheral  nerve.  The  "  lightning  "  pains 
are  so  characteristic  that  they  can  hardly  be  compared  with  pains  of  any  other  origin. 
Whether  trivial  and  "  iiiggling,'  or  so  intense  as  to  draw  sweat  and  cries  from  the  most 
heroic  of  sufferers,  they  are  always  short  and  lightning-like  in  duration,  often  rapidly 
repeated  in  the  paroxysms,  irregularly  periodic  in  their  attacks,  and  fleeting  or  hovering  in 
their  localization.  It  is  a  practical  point  of  importance  to  remember  that  many  patients, 
when  asked  if  they  suffer  from  pains,  emphatically  deny  it.  but  readily  admit  to  '  rheu- 
matics." and  then  describe  in  a  graphic  manner  the  lightning  pains  of  tabes.      The  idea  of 

rheumatics  is  evolved  from  the 
fact  that  these  pains  are  often 
]jrovoked  by  changes  in  the 
weather.  In  additit)n  to  light- 
ning jiains.  sufferers  from  tabes 
often  complain  of  dull  aching  or 
boring  pains,  which  are  more 
continuous  and  less  intermittent 
than  tho.se  just  described.  Ta- 
betic pains  may  precede  all  other 
signs  and  symptoms  of  the  dis- 
ease, in  which  case  their  dia- 
gnosis may  be  difficult.  The 
following  points  should  be  in- 
vestigated carefully  when  pains 
answering  to  the  descrijjtion 
given  above  are  complained  of : 
(1)  .\  liLstory  of  syphilis,  con- 
genital or  acquired.  The  writer 
has  known  a  woman,  probably 
the  subject  of  congenita!  syphilis, 
to  suffer  from  lightning  pains 
from  early  childhood  up  to  forty  years  of  age,  when  she  ijresented  other  signs  of  tabes  ; 
(2)  The  presence  or  absence  of  a  positive  Wassermann  .serum  reaction,  though  this  test 
may  be  negative  without  tabes  dorsalis  being  excluded  ;  (3)  The  presence  or  absence  of  a 
lymphocytosis  in  the  cerebrospinal  fluid  ;  (4.)  The  reaction  of  the  pupils  to  light  ;  (5)  The 
condition  of  the  knee-  and  ankle-jerks  :  (6)  The  presence  of  deep  and  superficial  analgesia 
over  the  legs  ;  (7)  A  history  of  gastric  cri.ses  :  and  (8)  The  condition  of  the  sphincter 
vesicffi.  Particular  attention  is  drawn  to  a  valuable  sign  of  tabes  which  is  not  referred 
to  so  commonly  as  are  Argyll  Robertson  pupils  and  absent  knee-jerks,  i.e.,  the  impaired 
pain-sensibility  in  the  calf  and  other  muscles  when  they  ,ue  squeezed. 
.Icropdnvfitliesid. — (See  p.  444.) 

2.  Pain   in    connection    witli    Disturbances    of   tlie  Circulation. 

Iiitermilleiit  Cldiidiciitioii. — This  term  is  a|)plied  to  a  eoriditioii  the  pathology  of  which 
is  still  ol)scure,  but  which  certainly  depends  on  an  insulhcient  blnod-supply  to  the  muscles 
of  the  lower  extremities  when  they  are  called  into  activity  during  locomotion.  It  may 
lead  eventually  to  gangrene.  The  malady  occurs  chiefly  in  men  t)ver  forty  years  of  age, 
and  ])articulariy  in  those  who  have  indulged  freely  in  tobacco,  who  have  contracted  syphilis, 
or  who  have  thrown  strain  upon  their  legs  o\er  a  long  period  of  time.  The  patient  com- 
plains of  pain  in  one  or  both  legs,  generally  in  the  calf  muscles,  coming  on  after  walking 


Lockir.) 


PAIN     IN    THE    LOWER    EXTREMITY 


a  certain  distance,  and  disappearing  with  rest.  The  pain  becomes  so  intolerable  that  he 
is  obliged  to  stand  or  sit  still  until  it  passes  off.  As  time  goes  on  the  distance  he  can  walk 
in  comfort  becomes  progressively  shorter.  Examination  of  the  affected  limbs  reveals 
nothing  obvious  ;  they  are  well  nourished,  powerful,  and  normal  in  regard  to  sensation 
and  reflexes.  Probably,  however,  the  observer  will  fail  to  detect  pulsation  in  the  arteries 
of  the  foot,  and  perhaps  he  may  not  feel  the  popliteal  artery  behind  the  knee-joint.  The 
femoral  artery  can  usually  be  felt  to  pulsate  in  a  normal  manner.  After  the  exertion  of 
walking,  the  foot  may  appear  unduly  pale.  With  rest,  the  returning  flush  of  normal  colour 
spreads  gradually  over  its  surface.  In  several  cases  of  this  kind  the  writer  has  noticed 
myokymia  of  the  calf  muscles  ;  that  is  to  say,  slow  worm-like  contractions  of  individual 
muscle  bundles  without  any  movement  of  the  foot.  The  ankle-jerk  may  be  diminished 
or  absent.  The  condition  is  not  very  uncommon,  and  its  diagnosis  is  not  difTicult  if  the 
characteristic  history  of  jjain  coming  on  during  the  act  of  walking  is  borne  in  nund  and 
leads  to  the  search  for  the  signs  referred  to  above.  The  importance  of  its  recognition 
needs  no  emphasis  in  view  of  its  tendency  to  go  on  to  gangrene. 

RayiiaKd's  Disease. — The  pain  attendant  on  the  local  syncope  and  local  aspliyxia 
which  characterize  this  disease  may  be  severe,  but  the  diagnosis  is  obvious  owing  to  the 
onset  of  symmetrical  pallor  or  cyanosis  of  the  toes  preceding  the  acutely  painful  stage 
(see  Gangrknb,  p.  255).     The  hands  are  nearly  always  affected  at  the  same  time. 

Enjthromelalgia. — In  this  condition,  which  may  affect  various  parts  of  the  body,  but 
which  is  .seen  most  conunonly  in  tlie  feet,  jjain  may  jjrecede  any  other  phenomenon.  The 
pain  is  more  or  less  continuous,  with  paroxysmal  exacerbations,  and  it  is  aggravated  by 
the  dependent  position  of  the  limb  as  well  as  by  warm  applications.  The  raising  of  the 
foot  to.  or  above,  the  le\(l  of  the  body,  and  the  application  of  cold,  are  attended  by 
alle\  iation.  Local  ])atelKs  ol  cutaneous  flushing  follow,  or  sometimes  precede,  the  pain, 
and  are  often  found  about  the  ball  of  the  big  toe  or  along  one  edge  of  the  foot.  These 
patches  are  generally  rose-pink,  but  may  become  purplish-red  in  severe  paroxysms.  The 
local  temperature  is  raised,  and  pulsation  of  the  vessels  may  be  observed.  Superlieial  and 
deep  tenderness  is  also  i)re.sent,  but  no  changes  in  the  reflexes  are  noted.  In  long-standing 
cases  a  certain  amount  of  (cdema  results.  Erythromelalgia  occurs  in  persons  who  are 
apparently  healthy  in  other  resjjccts  ;  on  the  otlicr  hand,  it  may  be  an  early  symptom  of, 
or  be  associated  with,  some  disease  of  the  spinal  cord,  such  as  disseminated  sclerosis,  tabes 
dorsalis,  or  syringomyelia. 

The  following  table  is  drawn  up  with  a  view  to  sunuuarizing  the  chief  points  in  the 
differential  diagnosis  of  intermittent  claudication,  Havnaud"s  di.sease,  and  erythromelalgia  : 


ivTEnjirrTKXT  claudi- 
cation- 

EAYNAUD's  Disease 

Erythrojiklalgia 

Age 

K)  ;niil   over 

.Ml  a-cs 

20  to  60 

Sex 

.M:;lis  riKMc  lliaii  Icma 

es 

Kcniales  more  than  males 

Males  more  than  females 

Site 

1 

As    :i    riili-   •-vriMiK-tricil 
■  ■!il|-   IIIM-Clcs 

1  in 

Symmetrical  in  toes 

Asymmetrical  in  feet,  rarely 
lilatcral 

I    llSlllllilllll 


On.set   uliilr  ualkiii-  Durin:;    s\  ii<M,|,al  plc.M-  or    Precedes  vascmiuhir  plicrio- 

aliscril  nieiia 

CiiaUccl.d    l.v    pusilinii  A-.ravaUa      l.v-   ilcpi'iidciit 

p,,sl„,-,- 
.May  In-  <Mil<d  l)y  rcM  told   iKiiilicial 

Paroxysmal  .More    iir     less     eoiilliuioiis, 

with    ixaeerliatioMs 
Ana'sllicsia    and  anaL'csia     .Siipcilicial  and  deep  liiidcr- 
dnriiiL:   paniwsrn  ncss 

\..  I'l.ani.c  (a-  sli;;liMv  pale     I'allnrand  lividilv  I'inl,    lo   parplisli    llusli 

AbM-nc-     c,r    puKalidfi     In      Ischainia    ami    local    cold     Incivascd      pMls.ilion       and 
arlcric,-..      1-Vcl      scanc-  local  lical 


Worsi-  In  cold  wcallicr 
(MdN   Willi  exercise 


ay  chaiijie 


'    (iangrene  oeeaslonal 

I    .\rteriosclerosis 

'rohaeeo 
I    .Sypliilis 


(iaiigreiie  eoinmon  (;anyi<-nc    rare 

General     viisomotor     dis-     Kiinetional  and  oiganic  dis- 
tnrbunecs  ca.se  of  the  central  nervous 

system 


442  PAIN     IX    THE    LOWER    EXTRE.MITY 

3.  Referred  Pain  in  Visceral  Disease.— In  the  lower  extremity  the  referred  pain  of 
visceral  disease  is  not  reeouni/.ed  so  often  as  is  that  of  cardiac  disease  in  the  upper  extremity. 
Disease  of  the  rectum,  bladder,  prostate,  or  uterus  may,  however,  give  rise  to  pain  and 
cutaneous  tenderness,  chiefly  in  the  fifth  lumbar  and  sacral  areas.  Head  quotes  a  patient 
who  suffered  from  prostatitis  and  whose  complaint  was  as  follows  :  '"  My  life  is  a  burden, 
for  I  eaimot  stand  owing  to  the  pain  in  the  soles  of  my  feet.  I  cannot  walk  owing  to  the 
pain  in  my  calves,  or  sit  on  account  of  the  pain  over  the  ischial  tuberosities  and  m  the 
perineum,  "or  even  lie  owing  to  the  pain  in  my  loins  and  side."  A  careful  examination  of 
the  abdominal  and  pelvic  viscera  is  necessary,  therefore,  in  all  cases  of  pain  referred  to 
the  legs  withovit  obvious  local  cause.  K-  Pnr.iuhnr  Bu"md. 

PAIN  IN  THE  EXTREMITY  (UPPER).— Pain  in  some  part  or  other  of  the  upper 
extremity  is  a  conunon  complaint,  and  one  for  which  relief  is  often  sought.  This  article 
makes  no  pretence  to  deal  with  the  diagnosis  of  cases  in  which  there  is  some  obvious  local 
source  of  pain,  such  as  acute  arthritis  or  a  tumour,  but  is  intended  to  serve  as  a  guide  for 
the  diagnosis  of  cases  in  which  the  pain  is  more  obscure  in  origin. 

First,  it  is  always  essential  to  inquire  into  the  character  of  the  pain,  its  exact  site,  its 
duration,  and,  if  paroxvsmal.  its  usual  time  of  onset,  its  relation  to  movement,  rest,  etc. 
Secondly,  a  careful  examination  must  be  made,  not  only  of  the  offending  limb,  but  of  the 
functions  of  various  organs  and  of  the  nervous  system  in  ]5articular.  It  must  be  remem- 
bered that  the  arm  is  innervated  bv  branches  of  the  brachial  plexus,  and  that  the  latter 
is  made  up  of  nerve  fibres  derived  from  the  fifth  cervical  to  the  second  dorsal  spinal  seg- 
ments through  their  corresponding  roots.  Consequently,  complete  examination  may 
necessitate  an  investigation  of  the  spinal  functions,  and  an  inquiry  into  the  condition  of 
the  cervical  vertebral  column  and  the  cervical  meninges  ;  it  may  even  be  desirable  to  take 
a  skiagram  of  the  neck  or  to  make  a  lumbar  puncture  for  the  purpose  of  a  correct  diagnosis. 
Attention  may  be  drawn  especially  to  the  fact  that  pain  in  any  situation  may  be  a  fore- 
runner, the  first  symptom  of  a  nervous  or  spinal  lesion  which  ultinuitely  leads  to  more 
serious  disorders  of  function,  such  as  paralysis,  loss  of  sensibility,  and  alteration  of  reflexes. 
The  following  are  various  pathological  conditions  of  which  i)ain  in  the  arm  is  often  a 
prominent  svm])tom  : — 

Brachial  Neuralgia.— This,  like  neuralgia  in  other  parts,  is  characterized  by  pain 
and  tcndcriuss  in  tlic  distribution  of  one  or  more  nerves.  The  pain  may  be  referred  to 
the  course  of  all  the  branches  of  the  brachial  plexus,  but  sometimes  is  limited  to  that  ot 
one  or  two  nerves,  such  as  the  ulnar,  musculo-spiral,  or  internal  cutaneous.  It  may  occur 
only  in  paroxysms,  but  more  commonly  there  is  a  constant  aching  discomfort,  with  occa- 
sional severe  exacerbations  excited  by  exertion,  cold,  or  mental  worry.  The  patient  is 
generallv  glad  to  rest  the  limb  or  to  carry  it  in  a  sling,  in  order  to  avoid  the  more  acute 
attacks ";  on  the  other  hand,  the  continuous  aching  drives  him  to  find  temporary  relief  in 
frequent  changes  of  position.  Pressure  over  the  affected  nerves  is  accompanied  by  tender- 
ness, especialiv  over  the  brachial  plexus  in  the  posterior  triangle  of  the  neck,  over  the 
musculospiral  as  it  winds  round  the  humerus,  and  over  the  ulnar  along  its  superficial  course 
in  the  region  of  the  elbow.  The  tenderness  so  produced  may  be  associated  with  pain  or 
tingling  referred  to  the  more  peripheral  course  of  the  nerve.  The  skin  niay  be  hyper- 
ajstlietic  and  show  vasomotor  changes  in  the  way  of  flushing  or  hyperidrosis. 

In  making  a  diagnosis  of  brachial  neuralgia  it  is  desirable  to  seek  for  some  cause  to 
which  it  can  be  ascribed,  such  as  a  rheumatic  or  gouty  diathesis,  or  a  history  of  some  pre- 
ceding toxic  condition,  such  as  influenza,  malaria,  or  alcoholism.  In  some  cases  no  satis- 
factory explanation  bevond  unusual  worry  or  work  in  a  neuropathic  individual  is  forth- 
coming. The  urine  should  be  examined  for  sugar,  as  neuralgia  is  sometimes  of  d,abettc 
orio-in.  The  presence  of  muscular  atrophy  or  auiesthesia  removes  the  case  from  the 
cateo-ory  of  neuralgia,  and  the  diagnosis  of  neuritis  or  of  some  more  gross  organic  alfection 
must  be  substituted.  On  the  other  hand,  it  must  not  be  forgotten  that  a  cervteal  rib 
{Fi«.  187)  mav  produce  manv  of  the  symptoms  of  brachial  neuralgia  without  any  definiti 
nuiscular  atrophy  or  sensory  loss.  In  contradistinction  to  some  of  the  conditions  about 
to  be  described,  brachial  neuralgia  is  practically  always  unilateral. 

Brachial  neuralgia  may  be  diagnosed,  tlierefore,  if  there  is  pain  and  tenderness  n 
the  distribution  of 'the  brachial  plexus  without  paralysis  or  sensory  loss,  and  if  no  gros 


PAIN     IX    THK     UPPP:R     EXTREMITY 


443 


ISi;. — SkiiErra) i] I   fallowing   cervi^-a 
the  case  of  a  chiUl. 
{Skiarfram  by  Dr.  Giihert  Smtl.) 


lesion  can  be  fovnid  to  account  for  the  symptoms.     So-called  miisciihir  rheumatism,  differs 

from  brachial  ncuralf;ia  in  that  the  pain  is  generally  less  acute  and  the  points  of  local  tender- 
ness are  to  be  found  oyer  muscular  insertions  rather  than  oyer  the  nerye  trunks.     At  the 

same    time  it  must  be   admitted   that    the   muscles   as 

well  as  the  ncryes  are  hypersensitiye  in  seyere  cases  of 

neuralgia. 

Brachial    Neuritis. — When    muscular    atrophy    and 

sensory  loss  ;in'  found  in  addition  to  pain  and  tender- 
ness, the  condition  must  be  regarded  as  one  of  neuritis. 

Unilateral  brachial  neuritis  is  yery  uncommon  except  as 

a   result  of  some  gross  lesion,  such  as  pressure  on.  or 

irritation     of.     the     nerve-trunks.        Bilateral     brachi;il 

neuritis  is  conunon    enough,    but    is   then   a  jiart    of    a 

multiple  peripheral  neuritis  due  to  alcohol,  arsenic,  lead. 

diabetes,   etc..   in   wliidi  tlic   lower  extremities  also  iuc 

generally  involved. 

Uefore  making    a    diagnosis   of  one-sided    brachial 

neuritis,  careful  search   must  be  made  for  evidence  of 

such  conditions  as  cervical   rib.   (amour  in    ilic    pnsicriur 

Iriioifllc  of  tlie  )iech\  glands  in  the  a.rilla.  anrari/nm  of  the 

subclavian    arterij,    malignant    disease    or    caries    of    the 

cervical  vertebra-,  cervical  pachymeningitis,  sjiinul  luiiiour. 

or    spinal    gliosis.     Neuromata    or   fibroncaromala    mv 

generally  widely  distributed  about  the  peripheral  nerves. 

but  cases  have  been  recorded  in  which  they  have  been 

limited  to  the  brachial  plexus  and  have  given  rise  to  a 

brachial    neuralgia   or   brachial   neuritis.     Such   tumours   may   be   so  small    as    easily    to 

escai)e  observation  unless  looked  for.     Adiposis  dolorosa  (p.  410)  is  another  rare  condition 

wliich  may  gi\e  rise  to  neuralgic  pain  in  the  arm,  but  it  is  not  limited  to  one  limb. 

Cervical    Ribs. — A  supernumerary  .seventh    cervical  rib.    unilateral  or   bilateral,  is  a 

frequent  congenital 
abnormality.  In  a 
small  proportion  of 
cases  it  may  give  rise 
to  symptoms,  especi- 
ally in  adults  who  use 
their  arms  and  hands 
(■(in  I  i  nual  ly  in  the 
cdui'sc  (if  their  em- 
p  loy  nient  .  Women 
sillier  more  often  than 
men.  Pain  radiating 
liiim  the  root  of  the 
iKck  to  the  tips  of 
the  lingers,  niort'  (ilteli 
than  Udl  aloML;-  the 
ulnar  hiirdcr  of  the 
arm.  is  usually  the 
lirst.  and  may  be  the 
only,  symptom.  The 
pain  is  of  an  aching 
or  dull  l)oring  char- 
acter, and  is  much 
influenced  by  rest 
and  |)osition.  I*'or  in- 
stance, if  a  woman, 
ceases  to  use  her  arms 
■siMiics  her  occii|iat  inn. 


I'l:/.  I'iT.— .^ki.i;;raiii  ol  lurikal  rilji,  in  uii  udull.  Uii  Ihu  1(11.  ^iili;  ii(  thi'  Hkiunn 
I«  fully  (Icrvclopcd  ;  on  the  riflit  8i(l(;  only  ii  part  i<  bony,  «o  thiit  it  forma  u  fiiluc  c 
rib  coiitiMU(?il  hy  II  flhrmis  cord,  which  ikms  not  Hhow  with  the  r-rjiyw. 


who  has  Iii-CM  MilTcriug  iiiiich  when  at   work.   takc> 
for  scnibliing,  lilting,  etc.,  she  may  lose  the  pain  alt( 


L  hdliday.  and 
llii'i'  until  she  i 


444  PAIX     IN     THE     UPPER     EXTREMITY 

Similarly  the  pain  is  worse  at  night  after  a  day's  work,  and  may  be  influenced  favourably 
•by  keeping  the  arm  in  certain  positions.  Lying  in  bed  with  the  hand  behind  the  head  is 
a  favourable  attitude  in  many  cases.  Very  occasionally  the  pain  spreads  into  the  scapular 
region  along  the  course  of  the  suprascapular  nerve.  There  is  rarely  any  tenderness  along 
the  peripheral  parts  of  the  nerves,  but  pressure  in  the  posterior  triangle  of  the  neck,  just 
above  the  inner  part  of  the  clavicle,  may  give  rise  to  pain  radiating  down  the  arm. 

In  addition  to  pain  there  may  be  disturbances  of  motor,  sensory,  and  vasomotor  origin. 
Atroj)hic  ]3alsy  of  the  intrinsic  hand  muscles  and  of  the  flexor  muscles  in  the  forearm  are 
the  common  motor  disturbances,  and  may  lead  to  deformities  such  as  Claw-hand  (p.  109). 
Anaesthesia  along  the  ulnar  border  of  the  forearm,  and  perhaps  extending  on  to  the  inner 
fingers,  is  sometimes  observed.  In  one  bilateral  case  the  writer  has  observed  intense  vaso- 
motor disturbances  without  definite  muscular  atrophy  or  sensory  loss.  Both  hands  were 
the  seat  of  a  painful  cyanosis  involving  the  fingers,  and  almost  amounting  to  the  condition 
seen  in  cases  of  Raynaud's  disease.  Sometimes  there  is  a  diminution  in  the  radial  pulse 
on  the  affected  side.  The  diagnosis  of  cervical  rib  or  ribs  depends  on  the  use  of  the  .r-rays 
(Figs.  186,  187)  to  reveal  their  presence,  but  it  nmst  be  borne  in  mind  that  the  pressure 
on  the  trunk  or  trunks  of  the  brachial  plexus  is  usually  exerted  by  a  fibrous  band  passing 
from  the  tip  of  the  cervical  rib  to  the  first  dorsal  rib,  and  that  therefore  the  size  of  the  rib 
shown  by  skiagraphy  affords  no  guide  as  to  the  importance  of  its  effect.  The  most 
rudinieiilarv  rib  is  as  important  from  this  point  of  view  as  one  which  is  fully  developed. 

Acroparaesthesia. — This  term  is  applied  to  a  fairly  common  complaint,  usually  made 
by  women  between  thirty-five  and  fifty-five  years  of  age,  who  are  continually  using  their 
hands,  and  especially  by  those  whose  hands  are  frequently  immersed  in  waters  of  different 
temperatures.  Charwomen,  domestic  servants,  needlewomen,  and  washerwomen  are 
l);uticularly  liable  to  suffer.  Many  of  tiie  victims  indulge  to  a  moderate  extent  in  spirit- 
<h'inking.  They  complain  of  a  burning  pain,  associated  with  tingling  and  numbness,  in 
the  fingers  and  palms  of  their  hands.  It  is  noticed  chiefly  in  the  latter  part  of  the  day  after 
work  is  over,  and  becomes  intensified  when  they  are  warm  in  bed.  In  the  early  morning 
their  fingers  are  niunb  and  clumsy,  but  the  discomfort  passes  off  while  they  are  at  work, 
only  to  return  again  towards  evening.  As  a  rule  there  is  little  to  see  on  examination,  but 
there  may  be  redness  or  pallor  of  the  affected  parts,  associated  with  a  subjective  feeling 
of  heat  and  swelling.  Sensibility  i?  unimpaired  if  allowance  is  made  for  the  cutaneous 
thickening  usually  present  in  persons  whose  hands  are  much  exposed  to  moisture  and 
friction.  There  is  no  definite  palsy  or  muscular  atrophy.  Acroparaesthesia  as  a  rule  affects 
both  hands,  and  very  occasionally  is  accoinp;niicil  by  a  similar  condition  in  the  feet. 

Similar  para'Sthesia;  are  sometimes  comjilained  of  by  patients  suffering  from  tnbes 
(lor.siilis.  but  in  those  cases  the  pains  are  of  the  lightning  character,  and  never  limited  to 
the  hands.  Other  tabetic  signs,  such  as  Argyll  Robertson  pupils,  ulnar  analgesia,  impaired 
sense  of  position,  and  absence  of  tendon-jerks,  serve  to  make  a  diagnosis.  In  the  early 
stages  of  subacute  combined  degeneration  of  the  spinal  cord,  panesthesiae,  sometimes  of  a 
markedly  painful  character,  are  referred  to  the  hands  and  feet.  The  presence  of  some 
ataxia  or  spastic  paraplegia,  with  increased  tendon-jerks  and  extensor  plantar  reflexes, 
differentiate  this  disease  from  the  ordinary  acroparaesthesia?. 

Radicular  Pain. — Under  this  title  may  be  included  all  pains  in  the  arm  which  radiate 
through  till-  peri])heral  distribution  of  the  posterior  spinal  roots  from  the  fifth  cervical  to 
the  second  dorsal.  These  pains  extend  from  the  neck  towards  the  periphery  of  the  limb, 
and  are  usually  of  a  sharp,  lancinating  type.  In  the  large  majority  of  cases  they  are  pro- 
duced by  some  gross  morbid  process  involving  the  roots  within  the  spinal  canal  or  in  their 
course  through  the  intervertebral  foramina.  The  morbid  processes  most  commonly 
responsible  are  intravertebral  tumour,  cervical  pacfii/meiriiigitis,  cervical  caries,  and  malignant 
disease  of  the  cervical  vertebra'.  In  all  these  conditions  tlie  radicular  pain  may  precede  all 
other  symptoms,  with  the  result  that  the  diagnosis  is  often  difficult  and  sometimes  impos- 
sible until  further  phenomena  develop.  The  pain  is  occasionally  imilateral,  more  often 
bilateral  ;  there  may  be  tenderness  on  pressure  over  the  vertebrae,  especially  in  the  case 
of  vertebral  caries  or  malignant  disease.  Movements  of  the  neck  will  intensify  the  pain 
in  the  latter  conditions.  The  diagnosis  is  arrived  at  by  careful  attention  to  the  following 
points  :  (1)  Evidence  of  deformity,  rigidity  or  tenderness  of  the  cervical  vertebrae,  supple- 
mented by  an  .i-ray  examination  :   (2)  The  presence  of  other  root  symptoms,  such  as  localized 


PAIX    IX     THE    EYE  4J5 

atrophic  ])alsy,  ana>sthe.sia,  and  loss  of  tendon-jerks  in  the  arms  ;  (;})  Evidence  of  pressure 
on  tlie  spinal  cord,  producing  spastic  paralysis  of  the  trunk  and  lower  limbs,  together  with 
anaesthesia,  loss  of  abdominal  reflexes,  increased  knee-jerk,  ankle-clonus,  an'd  extensor 
plantar  reflexes  ;  (4)  The  occurrence  of  oculo-pupillary  phenomena  when  the  eighth  cervical 
and  first  dorsal  roots  are  involved  ;  and  (5)  The  condition  of  the  cerebrospinal  fUiid  obtained 
by  lumbar  jjuncture  (p.   804). 

In  addition  to  the  gross  extrinsic  processes  affecting  the  spinal  roots,  there  are  other 
cases  in  whicli  a  si)inal  root  is  the  site  of  an  intrinsic  inflammatory  or  vascular  lesion.  Herpes 
zoster  is  a  common  result  of  such  a  lesion,  and  may  be  found  in  the  jicripheral  distribution 
of  any  of  the  posterior  roots  which  go  to  form  the  brachial  plexus.  Pain  in  the  upjjer 
extremity  often  precedes  the  erui)tion.  and  post-herpetic  neuralgia  is  sometimes  long  per- 
sistent and  associated  with  marked  hypenesthesia  in  the  corrcspdnding  root  area,  "uni- 
radicular  pain,  followed  by  atrophy  of  the  muscles  sujjplied  by  the  cITcrent  root  fibres  and  by 
sensory  loss  in  the  region  innervated  by  the  afferent  fibres,  with  or  without  the  development 
of  an  herpetic  rash,  also  occurs  in  rare  instances  as  the  result  of  an  inflammatory  or  vascular 
lesion  of  the  spinul  nerve  in  the  neighbourhood  of  the  posterior  root  ganglion. 

Referred  Pain  in  Visceral  Disease.  -In  disease  of  the  heart  and  aorta,  especially 
with  sy])liilitic  disease  of  the  aortic  \alves,  or  with  atheroma  or  aneurysm  of  the  first  few 
inches  of  the  aorta,  attacks  of  pain  in  the  left  arm  are  often  complained  of.  These  may 
be  confined  to  the  arm,  or  may  be  associated  with  fully  developed  angina  pectoris  (p.  433). 
The  pain  is  radicidar  in  distribution,  referred  to  the  first  and  second  dorsal  root  areas— the 
ulnar  border  of  the  arm-  sometimes  extending  into  the  little  finger.  During  the  attacks 
cutaneous  hypera;sthesia  may  be  present  over  the  same  areas.  In  all  cases  of  paroxysmal 
pain  referred  to  the  left  arm  a  \  cry  careful  examination  of  the  thoracic  viscera  is  therefore 
indicated. 

Occupation  Neuroses.~The  upper  limb  is  the  common  site  of  occupation  neuroses 
—termed  writers  cramp,  typist's  cramp,  and  so  on,  according  to  whether  it  has  to  do  with 
writing,  typing,  needlework,  telegraphy,  hair-cutting,  etc.  These  neuroses  are  mainly 
characterized  by  some  form  of  muscular  spasm,  but  pain  of  a  cramp-like  character  is  a 
frecpient  accompaniment  of  the  spasm.  The  diagnosis  is  easy,  because  careful  incjuiry 
will  elicit  the  fact  that  the  pain  and  spasm  are  evoked  by  the  employment  of  the  limb  in  a 
particular  occupation,  and  that  other  mani|)ulations  involving  the  use  of  the  same  muscles 
may  be  carried  out  with  im|)unity.  The  acute  pain  associated  with  the  spasm  may  be 
followed  by  a  dull  aching  for  some  hours  after  the  occupation  has  been  indulged  in. 

Finally,  the  term  Psychalgia  may  be  applied  to  pain  referred  to  the ''arm.  as  well 
as  to  other  parts  ,.f  the  b.,.ly.  by  iMtieiits  whose  nervous  and  mental  resistance  is  under- 
mined or  exhausted.  Xeurastlicnic  puin  of  this  kind  is  rarclv  limited  to  the  arm;  it  is 
referred  more  commonly  to  various  parts  of  the  head  and  to  particular  regions  along  the 
course  of  the  vertebral  colunm.  ,,   ,,„„^„,^„,  /,„..„„/ 

PAIN  IN  THE  EYE  is  not  by  ilsHf  pMtlM.gnomonie  of  any  parli.-ular  lesi,,,,  :  but  it 
Miii\  be  ciiuiplairied  of  under  very  drvcrsc  ciicuiiislanees.  wliicii  max  he  raii-cd  into  the 
f(ill(j\ving  groups  :- - 

1.  Pain  associated  with  Visible  Inflammatory  Changes,  due  i<> 


KoRiliri  l.ndy  I    I  ■|ceiali(,ri       (it       llic  IrilcrsI  it  jmI  kcialilis 

f.iilnipinn  c.irnc.i  Irilis 

('iirijiiiicli\  it  is  I 


(;Imii( 


■uI;m-  luipi 


The  dilh-rcntial  diagnosis  lHlw(<n  tlics,-  js  discussed  in  llic  article  on  l':vK.  AccTic 
Im-i.a.\im.\i  ION  or  (p.  231). 

•2.  Pain  without  Visible  Changes  in  the  Eyeball,  but  with  Acute  Loss  of  Sight  in 
one  eye  only,  in  both  eyes  together,  or  in  one  eye  after  the  otlicr  :   Hetrobulbar  neuritis. 

The  iiaiii  is  generally  referred  to  the  back  rather  than  tn  the  front  of  the  eye.  The 
diagnosis  is  suggested  at  once  if  considerable  loss  of  sight  comes  on  acutely  in  an  eye  wliieh 
on  examination  jmivcs  not  to  be  alTected  by  glaucoina,  intra-oeular  Inemoriliage.  detacli- 
menl  of  the  retina,  or  any  visible  or  palpable  lesion,  especially  if  the  degree  of  vision  power 
waxes  and  wan<s.  owiiiir  to  \arying  degrees  of  engorgcmciil  nl  llic  vessels  in  the  optic  nerve 
where  it  is  inllanied  between  the  eyeball  and  the  brain.     After  a  day  or  two,  or  a  few  davs 


^^g  PAIN    IN    THE     EYE 


eves;    or  in  those  whose  work  has  to  be  earned  on  m  too  d  m  o^  ^^^^.'^^^f  error  of 

n.av  eonsidev  that  he  has  exceptionally  good  s.ght.  -P^J^^^^^;';'^  ^^^'^  °; '   "eevesr  but 
of  inpermetropia.  ^^'hieh  may  none  the    ess  cause  not  °"'>  ^1  ^Jf. ,•^^:''^^  "„„„.  ^,^,,^  the 

a,Kl  some  elderlv  persons  are  scarcely  able  to  read  or  ^vork  at  all  on  this  aceount, 
'''''V^^'^Z::^tri.a  out  under  exceptional    circumstances    of   HgM   or 
eloseness'ma°-  cause  eyestrain  even  in  those  -;>--  °"'l-^-^^™!;;°L' in'rnce   o    t^^  e 
e«„.pensated  by  glasses  ;   microscopists  are  apt  to  ^^^^^'"^^^  The  "    cun    tances  of 
.vho  are  exposed  to  the  glare  of  sunslune  upon  sno^v  ;    an.l  so  on.      1  he 

'^^T%:;:^le°^^lel"F^n:or  other  Constitutional  Causes.-The  moj 
..nillL^n'e'of  caLs  which  come  under  t^is  heading  ^^  ^^^^^^1:^'^^ 
The  pain  is  generally  referred  rather  to  the  b-ks  of  the  eyeballs  ^hant^^^^^^^  ^^^^ 

selves,  but  nevertheless  the  complaint  is  one  of  pam  m  the  e>es.  ^  ^e  ™"  ^^^^^  The 
■xs  an  earlv  svmptom  of  the  disease  and  as  a  sequela  when  the  fever  has  suDsia 
dlSc^^  I  LI  iVom  the  course  of  t.^  pyrexi.  ^^'^ J^l^^^^ZTZ:^.  loZ^. 
little  upon  whether  there  is  pain  at  the  back  of  the  e>es  ^  "°*-  JJ^^ "^"".^,1,.  guessed  ai 
be  reoarded  as  certain  without  bacteriological  confirmation,  for  it  is  "^  '''^  - 
r  tier  t  Ian  diagnosed-and  often  wrongly.  In  a  similar  way,  pain  m  *h^'  ^>*^^ '"^>  7^, 
:  ,\rt  f  he  general  clinical  picture  in  many  other  fevers,  "f  ^^'^  . '^"^'^"Xenced  ver- 
;\  1  o  d  e  er.  measles,  secondary  syphilis,  and  malaria.  The  diagnosis  -  '"fl"^'^^;^;/^^ 
laSt  [he  feet  that  the  patient  complains  about  h^  e>.s  exee,^v.ien^h  ^^^  |.^ 
.veil  as  ,.ain.  for  instance  in  the  early  stages  of  measles.  I"  °t'  .^  ;°^^ J;^^  ,,,e  article  upo 
,„OBiA  (p.  524)  rather  than  pain  in  the  eyes,  an.l  reference  ma>  be  made  ^^^^^^^  ^ J^^^ 

that  symptom. 

PAIN  IN  THE  FACE.-The  distinction  between  pain  in  the  face  ^nd  Pain  in  th 
head^Zift  ™me  extent  artificial,  is  ^^^^^^^^^ -^Z^:"^;  a^^cS^ 
with  its  diagnostic  significance,  is  discussed  under  H|=ad..ci.e    p.  -J^^^^ 

etiological  points,  however,  at  which  faceaehe  and  '^-.d-;;'^  ^^"''^i;;,^ °7,^^,7„f  ,efrac4 

orbital  pain  and  the  headache  which  may  both  originate  f™-"  °™  7^,^*^;;°^^  „„  discussio 

I'ain  in  the  face,  as  elsewhere,  may  be  due  to  very  obvious  causes,  whicnneea 
ulh  as  an  infiamed  parotid  gland,  a  gumboil,  or  an  acute  -;;J"- ^     ;,„Se,  exUin 

,a„d.  pain  in  the  face  may  be  complained  o   when  «"P";"^';- f/^^^^P^  ^  '.^..o^s  of  su. 

tion  fails  to  discover  an  adequate  basis.     Guidance  t°^  "f^^',%^°"7;,,,  „|  the  follow! 

cases  may  be  obtained  by  a  consideration  ot  the  course,  signs,  an.l  sv  mptoms 

clinical  types  of  facial  pain. 


PAIN     IX    THE     FACE  4i7 

Major  Trigeminal  Neuralgia  (tic  douloureux  or  ei)iIeptiform  neuralgia)  may  be 
regarded  as  a  distinct  disease,  owing  to  the  general  similarity  of  one  case  to  another.  Its 
pathology  is  unknown,  but  in  each  case  the  pain  is  attributed  in  its  early  stages  to  some 
local  defect,  such  as  a  carious  tooth,  and  many  sound,  as  well  as  many  diseased,  teeth  are 
removed  in  a  vain  endeavour  to  arrest  the  malady.  Beginning  usually  after  thirty-fi\e 
years  of  age,  tic  douloureux  is  characterized  by  paroxysms  of  acute  pain  in  the  distribution 
of  one  or  more  of  the  divisions  of  the  trigeminal  nerve,  usually  of  one  side  only.  The 
intervals  between  the  paroxysms  vary  from  .seconds  to  months,  and  may  be  influenced 
in  their  length  by  many  factors,  such  as  the  general  state  of  health,  mental  worry,  and 
exposure  to  cold.  The  intervals  tend  to  become  shorter  and  the  paroxysms  more  severe 
and  more  extensive  in  their  distribution.  The  pain  is  described  as  beginning  in  spots 
beneath  the  skin,  and  radiating  along  the  peripheral  branches  of  the  nerve.  These  spots 
correspond  to  points  where  the  nerve  bundles  penetrate  the  deeper  tissues  to  reach  the 
superficial  structures,  and  may  be  recognized  as  places  pressure  upon  which  is  particularly 
liable  to  start  an  attack.  In  severe  cases,  the  lightest  touch,  a  breath  of  wind,  attempts 
at  articulation  or  mastication,  and  even  the  act  of  deficcation  may  be  sufficient  to  provoke 
an  agonizing  spasm  in  which  the  violent  reflex  contraction  of  the  muscles  of  the  cor- 
responding side  of  the  face  affords  some  evidence  of  the  suffering  endured.  During  the 
paroxysm  the  patient  may  endeavour  to  obtain  relief  by  firm  pressure  with  his  hand  over 
the  starting-point  of  the  ])ain.  The  attack  may  be  accompanied  by  cutaneous  flushing, 
photophobia.  lachrymation,  and  salivation,  as  well  as  by  a  subjective  sensation  of  swelling 
in  the  affected  tissues.  When  the  tongue  is  affected  a  metallic  taste  is  sometimes  described 
by  the  sufferer.  Trophic  changes  in  the  hair  and  .skin  are  also  observed  as  a  result  of 
repeated  attacks.  The  diagnosis  of  major  neuralgia  depends  chiefly  on  the  following 
points  :  (1)  The  age  of  onset  ;  (2)  The  ab.sence  of  relief  or  only  temporary  alleviation, 
afforded  by  removal  of  possible  exciting  causes,  such  as  defective  teeth  ;  (3)  The  presence 
of  definite  starting-points  of  the  pain  corresponding  to  exits  of  branches  of  the  fifth  cranial 
nerve,  and  the  spread  of  the  pain  along  the  corresponding  nervous  paths  ;  (4)  The 
paro.xysmal  character  of  the  pain,  its  intense  severity,  and  its  unilateral  distribution ; 
(5)  The  excitability  of  the  attacks  by  peripheral  stimuli  ;  and  {(i)  The  various  reflex,  vaso- 
motor, secretory,  and  trophic  phenomena  to  which  the  attacks  of  pain  give  rise.  From 
a  practical  standpoint  the  most  important  task  in  diagnosis  is  to  discriminate  between 
cases  of  idio[)athic  major  neuralgia  and  those  which  belong  to  the  next  group. 

Trigeminal  Neuralgia  due  to  Organic  Lesion  of  the  Nerve  or  its  Roots.— This 
form  of  niuralgia  may  simulate  tic  douloureux  in  every  |)articular,  and  its  diagnosis  can 
be  made  only  by  careful  systematic  examination  of  the  patient,  with  the  possibility  of  an 
organic  lesion  being  the  source  of  pain  before  the  physician's  mind.  Tumours  al  the  base 
of  Ihr  liruhi  in  the  middle  fossa,  tumours  f^roiciii<^  from  the  liusc  of  tlw  skull  in  the  neighbour- 
hood of  the  foranien  o\alc  and  foramen  rolunduui.  as  well  as  tumours  of  the  trauiot  ncrvi's 
themselves,  are  amongst  the  causes  of  trigeminal  neuralgia.  Gummatous  meningitis  and 
gunniKttous  periostitis  may  be  mentioned  in  the  same  connection.  In  every  case  of  trigeminal 
neuralgia,  therefore,  headache  and  *"omiting  should  be  en(|uired  after,  and  optic  neuritis 
liKiUcd  for.  Kxaniination  of  the  functions  of  each  cranial  nerve  must  be  carried  out.  and 
in  particular  those  of  the  fifth  nerve  carefully  tested.  Any  impairment  of  sensibility  in 
till-  cutaneous  territory  of  this  nerve  nmst  be  regarded  as  evidence  that  the  ease  is  not  one 
ol'  ididpal  hie  neuralgia,  and  tlie  .same  may  be  .said  when  there  is  impaired  motor  ])ower 
in  I  lie  niusclis  of  mastication.  In  several  cases  of  .severe  trigeminal  neuralgia  I  have 
round  alniphic  paK\  (jC  IIic  masseter  and  temporal  muscles  on  the  same  side,  with  slight 
annslhrsia  on  Ihr  liicr,  and  these  cases  have  always  ])roved  to  be  instances  of  growth 
invoking  the  slrnclures  at  the  base  of  the  skull.  In  one  patient  the  neoplasm  (iriginalcd 
in   the  spliitiomaxillarv   fossa. 

Trigeminal  neuralgia  may  also  occur  as  the  result  of  intrinsic  disease  of  the  (iasserian 
ganglion,  e.g.,  in  cases  oi  herpes  zoster.  This  condition  is  fairly  conunon  in  the  distribution 
of  the  first  division  of  the  trigeminus,  much  less  conunon  in  that  of  the  seconil  and  third. 
The  pain  usually  precedes  the  herpetic  eruption  by  some  days,  and  is  associated  with  con- 
stitutional malaise  and  sometimes  with  |)yrexia,  two  im[)iirtant  points  in  diagnosis.  The 
latter  Incomes  clear  with  the  de\(lopinenl  of  the  rash,  but  even  then  it  is  necessary  to 
bear  in  mind   IIk'  possibilily   Ihal    llic  (Jasserian  ganglion  ma\-  l)e  alTeeled  by  gross  external 


448  PAIN    IX    THE    PACE 

disease  such  as  neoi^lasm  or  gumma,  or  an  extension  of  bony  disease.  In  persons  over 
fifty  years  of  age  it  is  found  frequently  that  pain  of  a  neuralgic  character  persists  after 
the  herpes  has  disappeared,  and  mav  last  for  months  and  even  years.  Careful  examma- 
tion  may  discover  cutaneous  marks  corresponding  to  the  site  of  the  previous  vesicular 

eruption.  ,     ,  ...         no-. 

Neuralgia  Minor.— I'nder  this  heading  may  be  classed  the  varieties  of  facial  pain 
which  are  secondarv  to  disease  of  various  local  structm-es,  such  as  the  teeth,  the  eye,  the 
e-ir  the  nose  and  the  tongue.  The  pain  can  be  distinguished  by  certain  features  as  belong- 
ing'to  one  or  other  of  two  tvpes.  The  first  is  a  true  neuralgia,  that  is  to  say  a  pain  which 
is  distributed  along  the  course  of  one  or  more  divisions  of  the  trigeminal  nerve,  usually 
starting  in  the  neighbourhood  of  the  diseased  structure.  The  second  is  a  visceral  pain, 
referred  to  some  spot  which  may  be  at  a  distance  from  the  disease,  and  which  is  usually 
the  site  of  superficial  hypera?sthesia  or  tenderness. 


Ftg.  100.  -f'^-  1"1- 

SENSORY    AREAS    OF    THE    FACE,    HEAD,    A.NU    NECK 

Su.  L.  Superior  laryngeal ;     T,  Temporal ;    V,  vertical. 

The  history  of  a  dccmjins  tooth  affords  an  example  of  how  these  types  of  pain  may 
arise  In  the  earlv  stages  of  ^caries  the  pain  is  limited  to  the  tooth  With  -nflanima  u,n 
Tn  1  destruction  of'the  j^ilp,  pain  is  referred  to  a  segmental  area  on  .*>- -f^; °4  -f-^ 
varving  with  the  particular  tooth  implicated  ;  thus  a  diseased  canine  tooth  s  associated 
v^th  pain  and  tenderness  in  the  naso-labial  area  (F/«.  188,  Na.L).  Finally,  after  he  pulp 
d  ad  local  suppuration  may  start  a  neuralgia  which  may  not  only  spread  along  the  ner^^ 
~h  Seh  supplies  the  tooth  socket,  but  may  extend  into  neighbouring  branches  and 
;"  old  visions  of  the  trigeminal  nerve.     The  maximal  points  in  the  segmental  areas 


PAIN    IX    THE    PACE  449 

referred  to  are  shown  in  the  accompanying  diagrams,  and  the  general  relationshiij  between 
individual  teeth  and  their  segmental  areas  may  be  described  as  follows  : 

Upper   Jaw. 
Incisors         Fronto-nasal       |        1st  molar Maxillarv 

V'""'"'"        •, Naso-labial  I       2nd Alaiulibiilar 

1st   hituspid  .  .  .  .  3p(J 

-id        ,,        •  •  Teiii|)oral   or  maxillary  " 

LowEU    Jaw. 


Ineisors         Mental 

Canine 

1st   bicuspid 

2nil Dollbtfiil 


1st  molar Ilyoid 

2nd 

3rd       .,  .  .  .  .  Hyoid  or  superior 

laryngeal. 


The  value  of  this  knowledge  in  relation  to  diagnosis  lies  in  the  fact  that  pain,  with 
tenderness,  referred  to  any  one  of  these  segmental  areas  should  lead  the  observer  to  seek 
for  its  cause  in  disease  of  the  corresponding  viscus. 

The  headache,  sometimes  called  neuralgia,  which  results  from  errors  of  refraction, 
especially  astigmatism,  is  referred  to  the  nud-orbital  area,  where  superficial  tenderness 
may  often  be  discovered  on  examination.  This  form  of  pain  comes  on  in  tlie  morning  as 
soon  as  the  eyes  are  opened,  and  is  intensified  by  reading  or  sewing.  It  disappears  under 
the  use  of  atropine,  and  wears  off  of  itself  if  the  eyes  are  not  used  for  near  work.  Occa- 
sionally it  takes  on  a  paroxysmal  charactei  without  any  particular  relationship  to  the 
use  of  the  eyes.  In  iritis-  and  glaucoma,  referred  pain  may  be  intense,  and  it  is  usually 
situated  in  the  temporal  and  maxillary  segmental  areas  as  well  as  in  the  eyeball  itself.  The 
occurrence  of  referred  pain  in  chnMiic  glaucoma  without  pain  in  the  eyebatl  is  a  point  which 
may  be  of  great  diagnostic  iiiiportance.  as  it  may  draw  attention  to  the  unsuspected  ocular 
disease. 

In  car  disease  the  hyoid  area  is  that  to  which  pain  is  referred  and  in  which  hvperaisthesia 
ol  the  skin  may  sometimes  be  found.  In  the  more  severe  tvpes  of  disease,  such  as  sup- 
puration in  the  middle  ear.  the  pain  may  also  be  referred  to  the  vertical  and  temporal  areas. 

Lesions  of  the  tongue  may  produce,  in  addition  to  local  pain  in  the  organ  itself,  referred 
pain  in  three  other  areas  :  the  mental  area  when  the  disease  allects  the  anterior  portion  of 
the  tongue  ;  the  hyoid  area  when  the  lateral  portion  is  involved  :  and  the  occipital  area 
when  the  dorsum  is  the  site  of  the  lesion. 

In  inflammatory  affections  of  the  nose  and  fnintnl  sinuses,  pain  is  iilcired  to  the  fronto- 
nasal antl  mid-orbital  areas  on  the  forehead. 

The  \arious  lorms  of  pain  in  the  head  associated  with  ilisease  of  the  thoracic  and 
al.donnnal  organs  are  discussed  under  IIkadachk  (|).  -ilKi).  and  Ihe  same  article  deals  with 
the  aches  which  accompany  general  constitutional  diseases. 

In  talies  ilorsalis  pains  are  sometimes  described  in  the  face,  and  ha\e  Ihe  same  charac- 
teristics as  those  in  other  jiarts  of  the  body.  Thev  nre  paroxysmal,  sucklen,  severe,  and 
liKhlning-hke.  They  are  rarely  liinite(J  to  Ihe  Imcc.  'I'Iuv  may  be  accompanied  bv  a  more 
continuous  ,1,111.  boring  kin.l  of  pain.  The  .liagiiosis  is  easy  if  a  sysLmatie  examination 
of  tlie  iicrMius  sysliiii  is  carried  out. 

Pseudo-neuralgias,  or  psychnlgias,  whi<.h  are  complained  of  by  hysterical  and 
neurasthenic  individuals,  ar.-  vague  in  their  distribution,  not  limited  to  the  trigeminal 
area,  and  often  bilateral.  '|-hey  ten.l  to  disat)pear  when  attention  is  drawn  in  other  direc- 
tions, and  are  less  intense  dininu  eating  and  lalkinu.  Thev  are  .lia-nose.l  by  the  method 
Ofe.xclusio,,  of  other  causes.  ,,      ,,,„^,„,,,     /,,,^^,^^^, 

PAIN    IN    THE    FOOT.      (Se..  I'ain  ,n  tmk  Isxtukmitv,   I,<,w,-..<.  p.    |.;!H.) 

PAIN    IN    THE   FOREARM.    -(.See  I'aiv   ,n    i,„:  KxriiKMiry.  Vvvvm.  p.   H.2.) 

PAIN,   GIRDLE.  -(.See  (;ini)i.|.:  Pain.  p.  2lilt.) 

PAIN    IN   THE   HAND.-  (S.c  I'ain  in  tin:  ICxtkkmi  tv.    Ippkh.  p.   112.) 

PAIN  IN  THE  HEAD.    (S,.e  iiks,.^.  .11;,  p.  2!i:i.) 


450  PAIN    IX,   THE    HYPOCHOXDRIUM 

PAIN  IN  THE  HYPOCHONDRIUM  (LEFT).-  1 'a in  in  the  left  liypochondrium  may 
procecil  fidni  : — 

The  Stomach. — Any  ])ainful  condition  of  the  stomach  may  cause  pain  to  be  felt 
lielow  tlie  left  costal  margjn.  In  particular",  a  new  growth  or  an  ulcer  towards  the  cardiac 
end  may  produce  it.  For  the  differential  diagnosis,  see  Indigestion,  p.  315,  and  Pain 
IN  THE  Epigastrium,  p.  436.  Flatulent  distention  of  the  fundus  ma.y  also  be  a  cause, 
which  can  be  diagnosed  by  the  fact  that  the  pain  disajjpears  on  eructation. 

The  Gail-Bladder. — In  cases  of  cholelithiasis  the  jjain  is  sometimes  referred  to  the 
left  hy]]ocliondriuiu  (sec  Pain  in  the  EpiGASTiiUM,  p.  436). 

The  Spleen. — Some  eniai'gemcnts  of  the  spleen  are  painful  (see  Spleen,  Enlarge- 
ment OF,  ]).  628)  :  or  the  pain  may  be  caused  by  perisplenitis,  in  which  case  a  friction- 
sound  can  sonietinies  be  heard  on  auscultation  over  it. 

The  Left  Kidney. — Stone  in  the  left  kidney  may  cause  pain  which  has  the  characters 
described  in  tlic  section  on  ])aiu  in  the  right  liypochondrium  (see  below).  A  movable 
left  kidney  is  rarely  a  cause  of  pain.  A  perinephric  abscess  may  cause  jiain,  as  it  does  in 
the  right  liypochondrium  (see  p.  451). 

The  Colon. — A  new  growth  in  the  splenic  flexure  of  the  colon,  or  obstruction  of  it 
lower  down,  may  cause  pain  in  the  left  liypochondrium.  In  the  former  case  a  tumour 
can  usually  be  felt  on  bimanual  palpation  :  in  the  latter,  signs  of  chronic  obstruction  will 
be  present  (see  Constipation,  p.  121).  Apart  from  growth,  a  mere  acnniiiddlitm  of  faces 
in  the  transverse  and  descending  colon  may  cause  a,  feeling  of  pain  and  weight  in  the  left 
hypochondriupi.  The  disappearance  of  the  jjain  after  tlK^  administration  of  a  few  large 
eiiemata  will  establish  the  dia.gnosis. 

Pleurisy,  Intercostal  Neuralgia,  and  Herpes  Zoster  may  all  cause  pain  in  the  lett 
I'.ypochondriuiu.  In  the  first  of  these  .a  frictidu-sound  will  be  heard  :  in  intercostal 
neuralgia  there  will  be  tender  points  over,  the  course  of  the  intercostal  nerve.  In  the  ease 
of  herpes,  the  cause  of  the  pain  will  be  clea,red  up  by  the  appearance  of  the  eruption,  but 
pain  may  persist  long  after  this  has  disappeared. 

Subdiaphragmatic  Abscess. — (See  ji.  45l.)  "  Robert   Iliilcliisoii. 

PAIN  IN  THE  HYPOCHONDRIUM  (RIGHT).-Tlie  differential  diagnosis  of  the 
cause  of  |)ain  in  the  right  hypoehondriuni  is  nftdi  a  matter  of  great  difficulty,  or  even  of 
impossibility,  as  it  may  inoeeid  from  any  of  the  following  organs  :  (1)  Liver  and  gall- 
bladder, (2)  Duodenum,  (3)  Head  of  the  pancreas,  (4)  Right  kidney,  (5)  Appendix  vermi- 
forniis,  (6)  Colon,  (7)  Uterine  appendages.  Intrathoracic  disease,  affections  of  the  spine 
or  chest  wall,  and  subdiaphragmatic  abscess  ma.y  also  cause  pain  in  this  situSttion.  The 
diagnosis  is  rendered  still  more  difficult  by  the  fact  that  disease  may  easily  be  present  in 
more  than  one  of  these  situations  at  the  same  time. 

Liver. — Various  forms  of  enlargement  of  the  liver  are  apt  to  be  attended  by  pain 
in  the  right  hypoehondrium,  e.g.,  hepatitis,  passive  congestion,  hepatic  abscess,  and 
carcinoma  (see  Liver.  Enl.vrgements  of  the,  p.  366). 

Disease  of  the  gall-bladder  must  also  be  thought  of.  e.g.,  gall-stones,  cholecystitis,  and 
carcinoma.  In  these  it  will  usually  be  found  that  there  is  tenderness  on  pressure  over 
the  gall-bladder,  with  the  characteristic  catch  in  the  breath  when  the  patient  is  asked  to 
take  a  deep  inspiration  while  the  fingers  of  the  observer  are  jiressed  in  over  the  organ.  In 
acute  cholecystitis  there  will  be  ]ijTexia,  and  probably  rigors. 

The  pain  of  biliary  colic  may  be  felt  chiefly  in  the  right  hypoehondriuni.  but  tends  to 
radiate  through  to  the  back  and  up  towards  the  right  shoulder.  It  may  be  simulated 
closely  both  by  the  kinking  of  a  movable  kidney  and  by  renal  colic  (see  below).  When 
the  attacks  occur  during  the  night  as  well  as  in  the  day,  this  is  in  favour  of  biliary  colic. 

It  must  be  noted  specially  that  the  absence  of  jaundice  in  no  way  contra-indicates 
a  diagnosis  of  gall-bladder  disease. 

Duodenum. — A  duodenal  ulcer  may  cause  deeii-seated  pain  in  the  right  hypoehon- 
drium. which  usually  has  the  character  of  hunger  pain  (p.  271).  It  must  be  remembered, 
however,  that  ])aiii  due  to  chronic  cholecystitis,  or  appendicitis,  may  also  have  this 
character,  and  an  exact  differentiation  of  them  may  not  be  possible  without  exploration. 
The  ]3ain  in  duodenal  ulcer,  liowe\er,  occurs  in  more  definite  attacks  with  intervals  of 
freedom  ;    it  is  often  nocturnal,  waking  the  patient   in  the  small  hours    of  the  morning. 


PAIN     IN    THE    HVPOCHONURILM  ir.l 

Duodenal  ulcer  is  commoner  in  men,  disease  of  the  gall-bladder  in  women,  whilst 
appendicitis  may  occur  with  almost  equal  probability  in  either  sex.  The  percentage  of 
free  HC'l  in  the  stomach  contents  is  more  persistently  high  in  duodenal  ulcer  than  in  either 
appendix  dyspepsia,  or  gall-stones.  A  history  of  melaena,  or  the  presence  of  occult  blood 
in  the  f;cces.  would  determine  one  in  favour  of  ulcer. 

Pancreas. — Malignant  disease  of  the  pancreas  may  cause  pain  in  the  right  hypochon- 
drium.  In  such  a  case  a  deep-seated  tumour  may  be  felt,  and  there  is  often  jaundice 
:\long  with  a  distended  gall-bladder.  On  the  other  hand,  when  gall-stones  lead  to  jaundice, 
the  gall-bladder  is  not  usually  distended  (see  .Jaundice,  p.  324). 

Right  Kidney. — A  freely  movable  right  kidney  may,  by  ureteral  kinking  or  dragging 
on  the  bile-duct,  cause  sudden  attacks  of  pain  in  the  right  hypochondrium  which  may 
exactly  simulate  gall-stone  colic.  Indications  of  intermittent  hydronephrosis  should  be 
looked  for.  e.g.  the  appearance  of  a  renal  tumour,  and  the  occasional  discharge  of  large 
quantities  of  urine  ;  urinary  symptoms,  however,  may  be  entirely  absent.  The  attacks 
tend  to  occur  by  day,  whilst  biliary  colic  often  begins  in  the  night. 

Stone  in  the  right  kidney  may  cause  chronic  pain  in  the  right  hypochondrium  and 
back.  The  kidney  is  often  found  to  be  enlarged  and  tender  <in  bimanual  ]ialpation  in 
such  a  case,  but  it  must  be  remembered  that  the  urine  may  furnish  no  diagnostic  indication. 
The  .r-rays,  however,  may  make  the  diagnosis  clear  (Fig.  V.V.i.  p.  279).  although  a  negative 
result  does  not  exclude  the  possibility  of  stone. 

The  pain  of  renal  colic  may  be  dillicult  to  diagnose  during  an  attack  from  gall-stone 
colic,  lead  colic,  or  appendicitis,  but  it  begins  below  the  lower  ribs  and  has  a  characteristic 
tendency  to  pass  downwards  into  the  groin.  It  may  be  attended  by  vomiting  and  fever. 
During  or  after  the  attack  there  may  be  blood  and  gravel  in  the  urine  :  but  it  must  be 
remembered  that  the  urine  may  be  heavily  loaded  with  urates  after  an  attack  of  biliary  colic. 

Pyelitis  may  also  be  the  cause.  The  urine  will  then  furnish  diagnostic  indications 
(see  PviTUiA,  p.  574,  and  BACTERiuniA,  p.  69)  ;  and  the  kidney  may  be  felt  to  be  enlarged 
on  bimamial  palpation.  The  |)atient  is  often  a  pregnant  woman,  and  the  pain  may  begin 
;  cutely,  starting  in  the  loin  and  right  hypochondrium  and  ])assing  downwards  towards 
the  iliac  fossa  and  pelvis.  There  is  a  high  tcmiierature,  rigidity  of  the  muscles,  and  hyper- 
:estliesia  both  in  the  loin  and  in  the  right  side  of  the  abdomen. 

.V  perinephric  abscess  may  cause  pain  in  the  right  hypochondrium  and  lumbar  region. 
.\  liunour  will  be  fell,  and  tlic  loin  may  be  filled  out.  and  there  will  be  the  usual  signs  of 
dec|i-seatcd  suppuration. 

Appendix. — The  pain  of  chronic  appendicitis  nuiy  be  felt  chielly  in  the  right  hypo- 
chondrium, and,  as  already  remarkeil,  may  be  of  the  nature  of  a  hunger  ])ain.  Tenderness 
over  Mcliurney"s  point  should  be  looked  for.  When  an  acute  attack  of  ajipendicitis  simu- 
lates gall-stones,  it  may  be  of  help  to  remember  that  indicanuria  is  ci)ni:non  in  the  former, 
liul   is  usually  absent  in  the  latter. 

Colon.  .Veil'  grincths  in  the  neiglibourhood  of  llie  hepatic  flexure  niay  cause  pain 
in  Die  ri'ilil  liypnehoMdrii'm  :  but  in  that  cas<'  a  tumiiur  can  usually  be  felt,  anil  signs  of 
i'liniuic  iiilcstin;)!  obstrr.elion  arc  present. 

Uterine  Appendages. — Salpingitis,  a  twi.slerl  ovarian  peilicle.  and  a  raptured  e.vlra- 
iitcrinc  gcsldliiiii.  may  all  cause  pain  in  the  right  side  of  the  abdomen  which,  however,  has 
usually  its  maxiuiiim  intensity  rather  below  the  hypochouilriac  region.  .\.  c, ireful  pelvic 
examination  will   usually  make  tlie  dianuosis  clear. 

Pleurisy,  Intercostal  Neuralgia,  and  Herpes  Zoster  may  l)c  e;iuses  of  p:iiu  in  I  he 
right    liypoclidndriMm. 

Subdiaphragmatic  Abscess.  -In  this  ease  there  will  be  a  history  pointing  to 
prceedenl  gastric  or  duodenal  ulcer.  :ippendieitis,  or  hepatic  abscess.  The  onset  of  the 
])ain  may  be  sudden  or  gradual.  I'liiic  will  be  |)yrexia  and  leueocytosis,  pointing  to  dccp- 
.•icaled  suppuration.  There  is  usuiilly  an  abdominnl  swelling,  whieli  does  not  move  with 
respiralinn.  The  note  over  liiis  may  be  lynipanil  i<\  from  the  presence  of  gas  in  the  abscess, 
"and  in  llial  e\(ul  the  coin-sound  will  be  oljtaineil  on  percussion.  There  are  usually  indica- 
tions of  |)l(uris\  at  the  base  of  the  corresponding  lung,  but  the  liver  is  nnl.  as  a  rule, 
pusheil  iloun.  The  use  of  the  ,r-rays  may  help  in  locating  the  abscess  :  but  the  exploring 
needle  should  not  be  u.scd  except  when  llie  pati<iil  is  on  the  operaling-lable.  and  one  is 
j)rcpared  to  open  the  abscess  at  oiuc  it  found.  Untint  Itutchi.ion. 


452  PAIN    IX    THE    ILIAC    FOSSA 

PAIN  IN  THE  ILIAC  FOSSA  (LEFT).  Alth()ut;h  many  of  the  causes  of  ])aiii 
complained  of  mainly  or  entirely  in  the  left  iliac  fossa  are  the  same  as  those  which  cause 
similar  pain  in  the  right  iliac  fossa,  there  are  certain  differences,  as  will  be  seen  on 
comparing  the  table  on  p.  454  with  the  following  : — 

Causes  of  Pain  in  the  Lei-t  Iliac  Fossa. 

1.  Causes  of  Acute  Pain  : — 

Acute  diverticulitis  |  Pelvic  abscess  Coli  li;i(iliiiiiii 

Ureteral  ealeulus  |  Retaiucfl  left  testis  Local  injury 

Acute  urcliiitis  I  Suppurative   ))eriostitis  <if  the        Stitch 

Twistcil    kit    (ivarian  !        ilium  Volvulus  of  the  sifjuioid  coldii 

cyst  pedicle  I  Appendicitis    (exceptional  '     Strau<;ulatcd     retroperitoneal 

Sidpintjitis                                 cases)  hernia. 

Oiipluiritis  1 

2.  Causes  of  Subacute,  Chronic  or  Recurrent  Pain  : — 

Most  of  the  conditions  mentioned  under  Group  1.  and  also  : — 


Carcinoma       of      the 

sigmoid  colon 
Carcinoma  recti 
Massive  impaction  of 

fieces  [        bar  spine 

Chronic   diverticulitis   1     Herjjes  zoster 
Spastic     constipation       Inflamed  iliac  glands 
Psoas  abscess  Tuberculous  iliac  glands 


.Sacroiliac  joint  disease 
Tuberculous  hip 
Osteoarthritis  of  the  spine 
Infective  arthritis  of  the  lum- 


Periproctal  abscess 

Periprostatic  abscess 

Dysentery 

Ulcerative  colitis 

Aneurysm    of   the    left    iliac 

artery 
Tumours  of  the  left  iliac  bone 
Tuberculous  left  kidnev- 


Acute  Lesions. — \Vhat  is  said  on  p.  454.  et  set].,  in  regard  to  ureteral  calculus,  acute 
iiiclcrilis.  tivistcit  ovarian  ci/st  pedicle,  salpingitis,  oophoritis,  pelvic  al>scess.  retained  testis, 
suppnridive  periostitis  of  the  ilimn,  injurij  and  stitch,  applies  in  the  case  of  the  left  iliac 
fossa  as  it  docs  to  the  rinht,  so  that  here  we  need  discuss  only  acute  diverticulitis,  appendi- 
citis, coli  bacilluria,  volvulus  of  the  sigmoid,  and  strangulated  retroperitoneal  hernia.  Of 
these,  the  last  two  call  for  immediate  operation  on  account  of  urgent  symptoms  of  intestinal 
obstruction — especially  persistent  constipation  and  vomiting,  which  becomes  fajculent  if 
o|)erative  measures  are  not  adopted  soon.  The  preci.se  nature  of  the  obstruction  may 
not  be  certain  imtil  the  abdomen  has  been  opened.  Abdominal  distention  is  apt  to  be 
general,  and  there  is  visible  peristalsis  of  the  oblique  or  transverse  type  in  the  case  of 
strangulated  retroperitoneal  hernia,  a  rare  condition  in  which  a  coil  of  small  intestine 
becomes  herniated  through  the  normally  small  retrosigmoid  pouch  of  peritoneum  ;  whereas 
in  the  case  of  sigmoid  volvulus  the  distention  is  at  first  much  more  marked  in  the  left  iliac 
fossa,  before  general  colonic  dilatation  with  vertical  peristaltic  waves  a])pear.  In  cither 
case  the  abdominal  wall  ri mains  siip])le  as  a  rule  imtil.  if  the  case  should  be  left  unoperated 
u])on.  general  pcritfuiitis  supcr\cncs. 

Coli  l/acilluria  is  nuicb  less  commonly  a  cause  of  pain  in  the  left  iliac  fossa  than  it  is 
of  corresponding  ))ain  on  the  right  side  (p.  455)  ;  and  when  it  does  cause  left-sided  pain, 
it  nearly  always  causes  an  even  worse  pain  on  the  right  side  also.  It  is  a  clinical  fact  that 
coli  bacilluria  affects  the  right  kidney  and  ureter  very  nnich  more  conuuonly  than  the 
left,  especially  perhajis  in  pregnant  women,  in  whom  its  incidence  on  the  right  side  lirsl  or 
solely  is  an  almost  constant  rule  ;  why  this  should  be  so  is  not  dear,  although  various 
theories  have  been  put  forward  to  account  for  it. 

Appendicitis  is  perhaps  almost  the  last  thing  that  occurs  to  one  as  the  cause  of  acute 
pain  referred  entirely  to  the  left  iliac  fossa,  just  as  it  is  the  tirst  thing  in  one's  mind  when  the 
pains  are  on  the  right  side  ;  but  it  should  not  be  omitted  altogether  from  consideration  : 
first,  because  in  some  cases,  in  which  the  vermiform  appendix  is  very  long,  and  inflammation 
starts  at  its  tip  and  spreads  to  the  left,  as  it  sometimes  does,  the  symptoms  and  even  the 
swelling  may  be  to  the  left  of  the  middle  line  instead  of  in  the  right  iliac  fossa  as  usual  ; 
secondly,  because  in  a  few  cases  pains  produced  on  one  side  of  the  body  are  referred  to 
the  corresponding  region  on  the  other  side — ^just  as  some  patients  with  a  right  renal 
calculus  complain  of  pain  in  the  left  loin,  so  do  some  with  ai>pcn(licular  trouble  confined  to 
the  right  side  complain  of  pain  in  the  left  iliac  fossa  ;  and  thiidlv.  because  very  occasionally 
one  comes  across  a  patient  with  transposition  of  the  viscera,  in  whom  the  ca-cuui  and 
vermiform  appendix  are  on  the  left  side. 


PAIN    IN    THE    ILIAC     FOSSA  453 

Acute  iliverticiililis  has  bcfii  dcscribftl  as  '  left-sided  appendicitis,'  and  this  nickname 
is  a  good  one  in  that,  if  one  imagines  acute  a[)pendicitis  developing  in  the  left  iliac 
fossa,  one  has  a  very  good  idea  of  what  the  symptoms  of  acute  diverticulitis,  and  its  degrees 
and  results,  may  be.  In  some  it  causes  an  acute  abscess  needing  surgical  measures  for 
its  cure  ;  on  the  ntlier  hand,  there  may  be  an  acute  attack  without  suppuration,  sponta- 
neous resolution  occurring  just  as  it  often  does  in  the  case  of  acute  appendicitis.  The 
jiiiticiit  is  seized  almost  suddenly  with  acute  pain  in  the  left  iliac  fossa,  and  generally 
vomits.  It  lunts  him  to  walk,  so  he  lies  down  or  goes  to  bed.  His  temperature  and  pulse- 
rate  rise,  appetite  fails,  the  tongue  is  coated,  there  is  generally  either  diarrhcca  or  constipa- 
tion, or  the  two  may  alternate.  Micturition  is  often  frequent  because  there  is  jiain  if  the 
urine  is  held  long  ;  locally  there  are  acute  tenderness  and  pain,  with  rigidity  of  the  muscles 
over  the  lower  left  <|uadrant  of  the  abdomen,  generally  palpable  fullness  in  the  same 
region,  and  often  an  actual  tumour  <lillicult  to  define  well  ;  on  rectal  or  vaginal  examina- 
tion pain  is  complained  of  when  the  examining  finger  is  pressed  U])wards  and  to  the  left. 
After  a  day  or  two  these  symjjtoms  mav  begin  to  abate,  and  within  a  fortnight  they  may 
have  disappeared  ;  on  the  other  hand,  they  may  increase  rajiidly,  and  call  for  urgent 
surgical  measures  ;  or  they  may  subside  considerably  without  clearing  up  altogether, 
and  may  recur  after  a  few  weeks  or  months.  At  the  operation  the  cause  of  the  persistence 
of  s\inptonis  will  be  found  to  be  a  local  thick-walled  abscess  in  the  left  side  of  the  pelvis, 
|)ossibly  suggesting  a  pyosalpinx  if  the  patient  is  a  woman.  General  peritonitis  may 
supervene  at  any  stage,  just  as  it  may  with  any  form  of  appendicitis.  The  cause  of  the 
<lisease,  whicli  is  not  so  very  uncommon,  though  it  is  not  always  recognized,  is  the 
<levelopment  of  exaggerated  sacculations  of  the  colon  with  narrowing  of  their  mucus- 
aspect  orifices,  so  that  if  the  interior  of  the  intestine  is  seen  it  looks  as  if  it  had  been 
punched  with  a  series  of  small  holes  into  which  the  end  of  the  little  finger  may  just  pass, 
each  such  hole  leading  into  a  more  or  less  dilated  pouch  or  sacculus,  generally  with  an 
appendix  epiploica  attached  to  its  free  end  ;  such  a  diverticulum  seems  liable  to  inllannna- 
tion  just  as  the  vermiform  api)endix  is.  and  the  result  is  s])oken  of  as  acute  diverticulitis. 
Long  cotitimied  constipjitinn.  togethci  with  chronic  colitis,  seem  to  be  ])redis|)osing  factors 
in  the  origin  of  these  diverticula,  and  acute  diverticulitis  is  a  disease  of  the  second  half  of 
life  rather  than  the  lirst.      lather  sex  may  be  attacked. 

Subacute  or  Chronic  Lesions. — Carcinomn  of  the  nigitioiil  cohui  or  of  the  ircliiiii  may 
cause  pain  in  the  colon  generally,  owing  to  its  distention  with  accumulated  fieccs  ;  some- 
times this  pain  is  eom])lained  of  chiefly  over  the  descending  colon,  and  thus  in  tlie  left 
iliac  fossa.  .\s  a  rule  increasing  constipation  will  be  a  more  i)rominent  symptom,  or 
all(  iiiati\<l\  a  constantly  repeated  desire  and  necessity  to  defa'catc  without  satisfaction 
in  the  result.  If  l)lood  and  mucus  are  piissed  |)er  rectum,  if  the  patient  is  over  forty,  has 
had  no  bowel  symptoms  at  all  until  the  last  two  or  three  months,  and  has  hciri  losing 
weight,  the  careinr)ma  and  its  Njcalily  will  suggest  themselves  at  (iii(<-.  and  ,in  actual 
tumour  may  be  felt  in  the  left  iliac  fossa  ;  the  chief  dillieulty  arises  in  cases  who  liaAc 
long  been  habitually  constipated,  so  that  it  is  dilliciilt  to  assess  the  importance  of  the 
increased  dillieulty  complained  of.  J{ectal  examination,  the  sigmoidoscope,  .c-rays  aft<'r 
a  bismuth  meal  (Fifl.  .53.  p.  I'i.l)  or  after  a  bismuth  enema  (Fig.  5 4,  p.  120),  may  all  be 
needed  to  exclude  simpler  conditions  such  as  ini/Kiclcd  fwrcs  or  spdHtiv  cniislipatinii,  which 
arc  discussed  un<ler  CoNsni-Ai  lox  (p.  121). 

Cliioiiic  (livvrtitutilis  is  referred  to  under  the  heading  of  aciilc  divcil  ienlil  is  above: 
vvlicM  il  hasi;i\cii  rise  to  a  chronic  thick-walled  absi'css  in  the  left  side  of  llie  pelvis,  it 
may  pr'jduic-  symptoms  very  like  those  of  carcinoma  of  the  pelvic  colon  on  the  one  hand. 
ami  111  (itlicr  I'oiriis  of  pelxic  abscess  on  the  other,  especially  pyosalpinx.  or  periproetal  or 
[icriprostatic  abscess.  Naginal  and  rectal  cxaminalioii  sIkimIcI  he  made,  and  then  perhaps 
a  piimarv  source  for  one  oi'  dllirr  uf  Ihcsc  may  lie  lound  :  liiil  iiol  inl'ieiiiKail  ly  v\i-\\  wluai 
op<rativc  measures  arc  resorted  to,  a  chronic  rliverl  icular  or  a  ehnmie  periproetal  abscess 
and  its  lesulting  matting  and  thickening  arc  mistaken  I'or  ni'w  yrowlh.  and  the  patient 
is  r<'garilcd  as  dying  of  a  cancer  unless  a  full  pcist-morlem  examination  is  undertaken  to 
verify   the  di;igtiosis. 

.Ml  the  other  condiliiiiis  inciit  idiicd  in  llic  table  alidve  are  discussiil  in  llie  article  on 
I'.MN  IN  'rui':  Il.iAC  Fossa  (Kn.nr)  (p.  l.")l).  and  wlial  is  saiil  tin  ic  applies  as  much  to  the 
left    iliac   fossa   as   to   the   right.  Ilirhirl  I'rrmli. 


454 


PAIN    IN    THE    ILIAC    FOSSA 


PAIN  IN  THE  ILIAC  FOSSA  (RIGHT).~When  a  patient  complains  of  pain  in  the 
right  ihac  fossa,  ])iol)al)ly  the  first  thing  tliat  occurs  to  one  as  a  possible  if  not  even  probable 
diagnosis,  is  ap])endicitis.  As,  however,  there  are  a  large  number  of  other  conditions 
which  may  produce  the  same  symptom  also,  it  is  important  to  consider  the  possibility  of 
each  before  concluding  that  the  patient  really  has  appendicitis.  The  ]jains  may  be  either 
acute  and  severe,  or  they  may  be  subacute  or  chronic  ;  they  may  be  complained  of  by  a 
patient  now  for  the  first  time,  or  there  may  have  been  previous  attacks.  These  characters, 
however,  do  not  distinguish  any  one  cause  with  certainty  from  the  rest,  though  they  may 
serve  as  a  basis  for  classification  as  follows  : — 


C'ause.s  of  Pain  in  tue  Right  Iliac  Fossa. 
1 .  Acute  and  severe  pain  may  be  produced  by  : — 

Acute  appendicitis  Acute  ureteritis  I     Suppurative  ])eiiostitis  of 

Acute  salpingitis  Coli  liacilluria  I        the  ilium 

Acute    distention    of       Twisted  pedicle  of  riulit  ovur-         Acute  stitch 

ian  cyst  After  local  injury. 

Pelvic  abscess  | 

Retained  right  testis  | 


the  c;FCum  with  gas 
Calculus  impacted  in 
the  right  ureter 


Tul)erculous    iliac     lymphatic 

Osteo-arthritis  of  the  lum- 

glands 

l)ar  vertebra; 

Tuberculous  Ciccum 

Infective   arthritis    of  the 

Actinoniyco.sis  of  the  ca'cum 

lumbar  vertelira^ 

Carcinoma  of  the  ca-cum 

Dysentery 

Movable  right  kidney 

Ulcerative  colitis 

Tuberculous  right  kidney  and 

Typlioid  fever 

ureter 

Aneurysm     of    the    riglit 

Intestinal     obstruction     at    a 

iliac  artery 

point     further     on     in     the 

.Sarcoma,    osteoma     or 

intestines,  due  to  any  cause. 

chondroma  of  tlie  iliac 

such    as    carcinoma    of   the 

bone 

sigmoid  flexure,  etc. 

Lobar  pneumonia,    pleur- 

Obturator hernia 

isy,  or  other  clicst  con- 

Ilerjics zoster 

ditions. 

2.  Subacute,  chronic,  or  recurrent  pain  in  the  right  iliac  fossa  may  be  caused  by  :- 

Most  of  the  con- 
ditions already 
e  »  u  m  e  r  a  t  e  d  in 
Group  1. 

Ileo-ea!Cal  kink  (Lane) 

Peri-appendicular 
adhesions 

Peri-ca;cal    adhesions 

Psoas  abscess 

Sacro-iliac  joint  dis- 
ease 

Tuberculous  hip 

Inflamed  iliac  lym- 
]>hatic  glands 

Formidable  though  the  above  list  may  seem,  in  the  great  majority  of  cases,  when  a 
patient  c(Mn])lailis  of  ])ain  in  the  right  iliac  fossa,  the  first  point  to  be  decided  if  possible  is 
whether  that  ])atient  has  appendicitis  or  not.  In  an  acute  case,  in  which  the  pains  have 
come  on  rapidly  and  have  become  severe,  are  associated  with  an  increased  jjulse  rate,  and 
some  rise  of  temperature  ;  vomiting  at  the  beginning  :  a  coated  tongue  ;  local  rigidity 
over  the  right  iliac  fossa  :  pcrhai)s  with,  in  addition  to  a  sense  of  resistance,  a  diffuse  palp- 
able fullness  in  the  right  iliac  fossa,  or  even  a  more  or  less  localized  tender  swelling,  together 
with  tenderness  of  the  right  side  of  the  rectum  on  rectal  examination  ;  the  great  proljability 
will  be  that  the  patient  has  acute  appendicitis,  and  although  the  circumstances  of  the  case 
may  prohibit  operation,  in  most  instances  surgical  measures  will  be  employed  to  cure  the 
condition,  and  at  the  same  time  the  cause  will  be  verified.  The  pain  in  cases  of  acute 
appendicitis  is  often  associated  with  a  remarkably  localized  acute  tenderness  referred  to 
AIcBurney's  spot,  which  is  situated  at  the  outer  point  of  trisection  of  a  line  joining  the 
umbilicus  to  the  right  anterior  superior  iliac  spine.  Another  sign  which  is  sometimes 
helpful  is  the  presence  of  congestion  of  the  right  superficial  circumflex  iliac  vein  ;  this 
may  be  obvious  at  a  glance,  and  it  is  suggestive  of  active  inflammation  of  the  underlying 
appendix. 

Occasionally,  when  acute  a]>pendicitis  has  been  the  ap])arcnt  diagnosis  before  operation, 
some  other  focal  sii])puration  will  be  found  when  an  o])cration  is  jierformcd.  ami  it  is 
generally  in  this  way  that  (uutc  suppurative  periostitis  of  ttie  inuer  surface  of  tin'  ilium  is 
discovered,  a  somewhat  rare  but  very  important  condition  which  simulates  acute  appendi- 
citis very  closely,  and  which  can  only  be  cured  by  immediate  surgical  treatment. 

.-V  ureteral  calculus  generally  becomes  impacted  in  the  lower  end  of  the  ureter  close  to 
the  bladder  (Fig.  192),  and  it  sometimes  gives  rise  to  little  pain  :  occasionally,  how- 
ever, it  i)roduces  acute  ureteral  colic,  the  jjain  being  referred  to  the  right  iliac  fossa  in  a 
way  which  simulates  the  pain  of  ai)pendicitis  closely  ;    there  may  be  local  rigidity  of  the 


PAIN     IX    THE    ILIAC    FOSSA 


nuisdes  but  no  tumour  can  be  felt,  and  as  a  rule  the  patient  is  much  less  ill  than  he  is  with 
appendicitis.  In  a  first  attack  of  such  pain,  however,  an  operation  for  supposed  appendi- 
citis may  very  easily  be  performed  ;  it  is  when  the  patient  lias  had  recurrent  attacks, 
associated  perhajjs  with  transient  haeniaturia,  that  the  real  cause  is  suggested,  or  more 
often  still  perhaps,  the  diagnosis  is  arrived  at  as  the  result  of  routine  examination,  incUidIng 
the  iise  of  the  .r-rays.  The  only  conditions  likely  to  simulate  a  stone  in  the  ureter  wlien 
the  .r-rays  are  employed  are  either  calcareous  iliac  glands  or  a  phlcbolith  in  formerly 
thrombosed  iliac  veins.  Sometimes  it  is  possible  to  tell  the  difference  between  these  three 
conditions  by  the  relative  situations  of  the  shadows  ;  more  often  there  will  remain  some 
doubt,  however,  as  to  what  the  .r-ray  api)earances  signify,  and  it  may  be  necessary  to  use 
the  cystoscope  and  a  ureteral  bougie  or  catheter  to  determine  whether  there  is  a  stone  in 
the  ureter  or  not. 

Acute  ureteritis  produces  symptoms  almost  exactly  like  those  of  an  actual  stone  in 
the  ureter,  and  in  some  instances 
at  any  rate  it  is  due  to  inflam- 
mation of  the  lower  end  of  the 
ureter  resulting  from  a  stone 
which  has  already  passed.  Oc- 
casionally, however,  it  arises 
ap])arently  as  a  primary  con- 
dition or  as  part  of  a  bacillus 
coli  infection  of  the  urinary  pas- 
sages, and  in  some  such  cases 
()l)eration  for  supposed  api)en- 
dicitis  has  been  perfornied  :  the 
vermiform  ajjpendix  proving 
perfectly  normal,  but  the  ureter 
being  seen  to  be  thickened  and 
inllamed.  There  can  be  no 
doubt  that  some  such  cases, 
diagnosed  and  operated  upr)n  for 
appendicitis,  escape  recognition 
allogcllicr,  for  it  is  not  ahva\s 
easy  to  tell  wlictlicr  th<-  lower 
end  of  till'  iirclcr  is  inllariicd 
when  the  lul)e  is  inspected 
merely  from  outside,  but  the 
writer's  post-mortem  exi)eriences 
show  that  the  lesion  is  com- 
moner than  might  be  expected. 

Coli  iHirilliniii  is  MOW  a 
familiar  dilHeiilty  in  tlie  dilTcr- 
ential  diagnosis  of  appendicitis  : 
allhough  theoretically  the  pain 
would  be  rercrrcd  mainly  to  tin- 
kidney,  generally  llie    liglil,  il   is 

f|uitc  coimnon  Uiv  palicnls  suriciiiig  Irdin  this  ciindit  ion  to  iclir  their  pain  not  t(i  llic 
back  or  loin  at  all,  but  to  the  front  of  the  lower  part  of  the  abiloinen.  and  paitieiilarly  over 
the  right  iliac  fossa,  in  such  a  way  that  acute  appendicitis  is  simulated  very  closely.  I'Acn 
though  the  urine  be  examined  and  a  haze  of  albumin  I'ound.  together  with  an  excess  of 
ieueoeytes,  the  aeuteness  of  the  condilioti  may  be  such  that  the  singeon  may  not  feel  Justi- 
fied In  waiting  for  cultures  of  a  catheter  specimen  of  the  uriru-  to  be  made,  to  see  whether 
bacillus  coli  eonununis  is  present  in  pure  culture  :  and  not  a  few  patients  of  this  kind  are 
una\(iidal)ly  op<rated  upon  for  acute  ap|)endieit  is  wlien  the  appendix  is  perfectly  normal. 
Till'  condition  of  coli  baeilluria  is  reeogni/,ed  most  readily  when  one  has  become  familiar 
with  pre\ious  <'ases  ;  the  main  features  of  the  condition  are  described  on  page  (i'.t.  and 
Fili-  li*."!  is  a  temperature  chart  IVoni  a  case  in  which  appenilieitis  was  simulated  so  closely 
that  operation  was  performecl  and  the'  diagnosis  of  coli  infcilion  of  the  liglil  urinary 
passages,  including  the  kidney,  conlirnied  by  the  surgeon. 


-Skiai^n 


of  calculus  impacted  in  lower  end  of  risht  ureter.    Tlie 
contirmed  at  opemtion  bv  Mr.  Thelwall  Tliomiw. 

(Stiw/ram  hi/  llr.  C.   Tlairslnu  Ih'Udiiil.) 


456 


PAIN     IN    THE    ILIAC    FOSSA 


Tivistiiig  of  the  pedicle  of  an  ovarian  ei/st  uiion  the  right  side  generally  produces 
symptoms  analogous  to  those  of  strangulated  hernia,  and  the  diagnosis  may  only  be 
established  when  urgent  laparotomy  is  performed,  unless  the  jiaticnt  is  already  knowni  to 
have  an  ovarian  cyst.  As  a  rule  the  pain  starts  in  the  lower  part  of  the  abdomen  before  it 
becomes  general,  and  in  the  case  of  a  cyst  upon  the  right  side  it  may  be  referred  particu- 
larly to  the  right  iliac  fossa,  so  that  appendicitis  may  be  simulated,  especially  as  the  patient 
may  be  very  tender  in  the  right  lower  ([uadrant  of  the  abdomen,  and  adifiiise  swelling  may 
be  felt  here.  Kllusion  of  lluid  into  the  geiural  jieritoneal  cavity  takes  jjlace  rapidly,  so 
that  there  may  be  dullness  in  the  Hanks,  tlunigh  the  peritonitis  which  produces  this  is 
generally  non-suppurative.  The  emergency  is  one  which  calls  for  laparotomy  at  once, 
and  the  diagnosis  is  confirmed  after  the  abdomen  has  been  opened. 


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Aeiile  salpingitis  or  injJamniation  of  the  riglil  oinry  are  generally  secondary  to  some 
other  pelvic  inilammation  which  has  been  diagnosed  on  account  of  other  symptoms  such 
as  a  vaginal  discharge  (]).  185),  or  ])ain  in  the  pelvis  (p.  -167),  or  some  menstrual  irregularity 
such  as  menorrhagia  (p,  385).  The  skilled  gynrecologist  may%  by  vaginal  ])rtlpation.  be 
able  to  determine  the  cause,  though  doubts  may  very  often  persist  as  to  whether  the  con- 
dition is  one  affecting  the  right  uterine  appendages  on  the  one  hand,  or  the  vermiform 
appendix  on  the  other,  unless  laparotomy  is  performed.  This  procedure,  as  a  rule,  is 
nuieh  less  urgent  in  the  case  of  salijingitis  or  ovaritis  than  with  ai)pendicitis.  and  the 
doubts  may  therefore  remain  unresolved  even  for  a  period  of  months.  .SliouM  the  jiains 
in  the  right  iliac  fossa  be  relatively  slight  in  the  intermenstrual  periods,  but  severe  at  the 
time  of  the  periods  themselves,  this  fact  will  suggest  that  the  mischief  is  pelvic    and  not 


PA  IX     IX     THE    ILIAC    FOSSA  457 

appcndiciilai-  :  but  evon  tliis  conclusion  is  oix-n  to  fallacy,  because  wlicn  there  lias  been 
preceding  appendicitis  with  extensive  adhesions  which  may  very  likely  include  the  uterine 
appendages,  the  pains,  though  jjrimarily  the  result  of  appendicitis,  may  be  recurrently 
worse  at  each  monthly  period.  An  important  point,  however,  is  that  salpingitis  and 
ovaritis,  though  possibly  unilateral,  are  much  more  commonly  bilateral,  so  that  the 
distribution  of  the  ]iains  is  likely  to  be  much  wider  in  the  case  of  ovarian  or  Fallo])ian  tube 
mischief  than  it  is  with  or  after  a|)i)endicitis. 

Acute  fitikli  generally  alfects  the  flank  in  the  lower  costal  region  on  one  side  or  the 
other,  but  sometimes  the  muscles  over  the  right  iliac  fossa  are  invohed  instead  of  the 
abdominal  muscles  higher  up,  or  the  diaphragm,  and  acute  pain  results  in  the  right  iliac 
fossa  and  the  patient  may  fear  appendicitis.  The  general  character  of  the  |)ain.  however, 
the  fact  that  it  apjiears  to  be  definitely  in  the  abdominal  wall,  and  that  it  is  unassociated 
as  a  rule  with  acute  hy))cra"Sthesia  or  with  any  swelling  or  ])yrexia  will  generally  serve  to 
distinguish  stitch  from  aijpcndicitis. 

Distention  nf  the  colon  ivitli  fd'ces  or  zvith  gas  seldom  ))roduces  very  acute  ])ain  in  the 
right  iliac  fossa,  but  rather  a  severe  grumble ;  and  although  in  a  first  attack  api)endicitis 
may  be  feared,  recurrence  of  similar  attacks  without  any  obvious  illness  on  the  patienfs 
part,  and  the  way  the  jiains  are  almost  inmicdiately  relieved  if  the  jiatient  can  jiass  flatus 
abundantly,  or  has  liis  bowels  evacuated,  cither  naturally.  l)v  medicines,  or  by  means  of 
an  enema,  will  generally  serve  to  exclude  acute  appendicitis  at  any  rate,  though  doubt  may 
remain  as  to  whether  there  may  not  be  apjiendicular  or  pcrityphlitic  adhesions.  In  .some 
such  cases  examination  of  the  bowel  with  bisnuith  and  the  .r-ravs  may  serve  to  show  the 
distended  condition  of  the  ca'cum.  or  on  the  otlicr  hand  evidence  of  deformity  from 
adhesions. 

Hctention  of  the  light  testis  is  a  thing  which  should  not  be  forgotten,  especially  when 
a  lad  at  about  the  time  of  puberty  coni))lains  of  acute  pain  in  the  right  iliac  fossa,  suggest- 
ing ai)|jendicitis.  The  testis  at  this  time  swells,  and  if  it  is  situated  at  the  ujjper  end  of 
the  inguinal  canal,  distention  of  it  may  cause  acute  pain  of  a  character  very  similar  to  that 
of  apiiendicitis.  especially  as  at  the  same  time  there  may  be  local  resistance  suggesting  a 
swelling  in  the  iliac  fossa.  It  is  im])ortant  therefore  to  examine  tlie  scrotum  to  see  whether 
both  testicles  are  |)rcsciit  tlicrc  or  not.     'i'here  is  no  pyrexia. 

Injun/  to  the  rigid  iliac  fossa  may  be  followed  by  acute  |iaiii.  In  most  instances  the 
history  will  indicate  the  diagnosis  clearly,  especially  if  there  is  local  evidence  of  bruising. 
Sometimes,  however,  the  (latieiit  may  have  injured  himself  when  he  was  unaware  of  floing 
.so.  for  instance  during  times  of  great  excitement,  or  jierhaps  when  he  was  under  the  iiillu- 
encc  of  drink,  or  again  during  a  nocturnal  attack  of  cpilcjjsy.  and  it  may  then  be  very 
dillicult  sometimes  to  tell  whether  the  fiains  arc  due  to  injury  or  not.  The  jibsence  of 
pyrexia  and  of  an  increased  pulsc-ratc  will  be  points  against  acute  apiiendicitis.  though 
there  may  be  local  swelling  from  a  deep  ha-matoma.  and  the  injured  muscles  may  be  rigid. 

I'assing  on  now  to  a  consideration  of  the  dilTcrcntial  diagnosis  of  conditions  which  may 
jiroducc  subacute,  chronic,  or  recurrent  attacks  of  pain  in  the  right  iliac  fossa,  it  is  clear 
tir.il  most  of  the  conditions  dcscribc(l<al)ove  need  to  be  borne  in  mind  again,  though  one 
iiecil  not  rccapitulalc  what  has  already  been  said  in  regard  to  them.  Many,  if  not  all.  ol 
the  additional  causes  nicntioinil  under  the  second  lieading.  iiowcxcr.  may  simulate  or  be 
coiilijsid  witli  suliacutc  (jr  rcrurrcnl  appendicitis. 

[  The    iliocarni  l.ini:    of  .Sir    .\rliutlinot     I.ane   is   now     familiar    lo   most    physicians   and 

surgeons  as  a  cause  of  constipation  by  interfering  with  the  free  passage  of  the  intestinal 
contents  from  tlie  lower  end  of  the  ileum  into  the  ca'cuni.  and  as  a  result  ol'  this  kink  dis- 
comfort, or  a  rliill  grumbling  pain,  or  e\<n  an  occasional  acute  pain,  may  result  in  the  right 
iliac  fossa  :  it  may  be  very  dillicult  to  tell  whether  there  is  not  some  degree  of  appendicular 
trouble  at  tlie  same  time,  but  the  diagnosis  of  the  kink  itself  is  relatively  easy  if  a  serial 
[■xamiiial  ion  of  Ihc  iliinciiliirv  eaiiid  is  iiiadi'  willi  llie  ,i'-ra\s  alter  1  lie  admiriisi  rat  ion  of 
hisnnilii.  The  a<'lii;il  riaiinu  |<iiinl  helweeii  the  hisrniilh  Uipl  in  the  loucr  end  ol'  the 
ileum  beyond  its  proper  time  and  the  hismulli  whieli  has  got  past  tlie  l<iiik  into  Ihc  ea'ciim 
L'an  generally  be  seen  \(rv  clearly;  tliou;;h  it  is  important  in  making  Ihc  examination 
;hat  the  patient  should  not  lia\c  any  paraMin.  aperient,  or  enema  <luring  the  period  of  the 
lUceessive  .i-ray  examinations. 

Adhesions   round  the  a/i/iendi.i    itself,   or   round    the   ea-emn.    may    be     \(iy   dillieult    lo 


PAIX    L\    THE    ILIAC    FOSSA 


fiiagnose  unless  the  patient  has  recurrent  jiains  in  the  iliac  fossa  subsequent  to  a  preceding 
attack  of  appendicitis  but  without  any  recurrence  of  signs  of  inflammation,  pyrexia,  or 
raised  pulse-rate.  In  some  such  cases,  however,  it  is  only  when  ojieration  is  performed 
for  the  relief  of  the  symptoms  that  the  adhesions  can  be  diagnosed  with  certainty. 

Tiibcmilosis  of  the  aeciim  is  being  recognized  nowadays  with  increasing  frequency 
{Fig.  194)  :  it  is  nearly  always  associated  with  chronic  phthisis,  of  which  there  will  be 
either  definite  physical  signs  or  .T-ray  shadows,  and  the  siKitum  will  generally  contain 
tubercle  bacilli.  When  the  phthisis  is  active  and  extensive  the  number  of  bacilli  swallowed 
are  generally  so  numerous  that  if  ulceration  of  the  bowel  occurs  at  all  the  ulcers  are  diffused 
widely  through  the  ileum,  cipcum,  and  ascending  colon  ;  but  even  in  such  a  case  the  post- 
mortem evidence  shows  that  the  maximtmi  incidence  of  the  bowel  tuberculosis  which 
results  from  the  swallowing  of  tuberculous  sputum  is  in  the  region  of  the  ileocsecal  valve, 
presumably  because  some  delay  occurs  here  in  the  jjassage  of  the  motions  and  gives  the 

bacilli  a  better  opportunity  of  attacking 
the  mucous  membrane.  In  cases  which 
are  much  less  acute  the  bowel  tuberculosis 
is  sometimes  confined  entirely  to  the  ileo- 
caecal  valve  region,  invohing  perhajis  the 
last  inch  or  two  of  the  ileum,  the  ileoca-cal 
valve  itself,  the  caput  cicci,  and  the  first 
inch  or  two  of  the  ascending  colon.  There 
may  be  diarrhoea  as  a  result  of  this  chronic 
ulceration,  but  as  a  rule  there  is  none,  and 
the  )>atient  has  become  so  accustomed  to 
his  lung  condition  that  he  presents  himself 
to  the  physician  complaining  of  a  sense  of 
dull  pain  in  the  right  iliac  fossa  with  occa- 
siaiial  exacerbations.  There  may  or  may 
not  he  p\  rexia  owing  to  the  phthisis.  On 
cxainination  an  indeterminate  fullness  or 
even  a  dehnitely  palpable  mass  may  be  felt 
ill  the  right  iliac  fossa,  and  the  first  im- 
pression will  probably  be  that  the  i)atient 
has  chronic  appendicitis,  or  even  ])ossibly 
carcinoma,  of  the  caecum.  It  is  the  con- 
comitant lung  trouble  which  gives  the  dia- 
gnosis, and  possibly  tubercle  bacilli  may 
also  be  detected  in  the  fseces  by  the  anti- 
formin  process.  A  certain  number  of  these 
cases  have  now  been  cined  of  their  bowel 
trouble  completely  by  excision  of  the 
affected  parts,  accompanied  by  anastomosis 
between  the  healthy  lower  end  of  the  ileum 
and  the  healthy  large  bowel  beyond  the 
ulceration  in  the  ca'cum. 

.Irtiiiotiii/cos'is  of  the  cwciim  is  rare,  but 
it  is  a  well  recognized  condition  which,  when  it  does  appear,  often  baffles  diagnosis.  In 
some  cases  the  nature  of  the  mischief  in  the  right  iliac  fossa-is  suggested  by  the  fact  that 
the  patient  has  a  chronic  inflammatory,  suppurative  or  ulcerative  condition  either  of  the 
jaw  or  cheek,  or  of  the  pleura  and  chest  wall,  or  of  the  liver  at  the  same  time,  for  these, 
in  addition  to  the  cajcum,  are  the  sites  most  usually  involved  by  actinomycosis.  The 
chronicity  of  the  affection  is  aencrallv  pronoimced,  but  the  ultimate  diagnosis  depends  upon 
the  discoVcry  of  ray  fungi  fmni  Ihc  all.  , led  part  (Plate  VAT///,  p.  614).  Were  the  ca-cum 
involved  primaiily  tlie  symptoms  would  be  more  or  less  like  those  of  either  chronic  appen- 
dicitis or  of  carcinoma  of  the  caecum,  and  laparotomy  would  probably  be  resorted  to. 
though  if  the  nature  of  the  malady  were  suspected  large  doses  of  iodide  of  potassium 
would  be  jirescribed  with  or  without  actinomycotic  vaccine  treatment,  cure  jjossibly 
resulting  without  operation. 


Fi<j.  10  \. — Photograph  of  ciironic  tuberculosis  of  the  louor 
end  of  tlie  ileum :  ileoaecal  valve  and  ciC3um  successfully 
excised  in  a  c^se  of  chronic  phthisis  with  symptoms  suggesting 
chronic  appendicitis.  Patient  alive  and  well  seven  years  after 
the  operation. 

A.  Normal  ilium.  B.  Dense  tuberculous  infiltration  of  the 
bowel  wall.  c.  Ileocecal  valve,  deformed  by  the  tuherciiluu-^ 
inliltratio;i.     D.  Iiililtrated  c*cum. 


PAIX     IX    THE    ILIAC     FOSSA  459 

Inflamed  iliiic  lyDiplidlic  glands  may  cause  Ijotli  piiiii,  tenderness  and  obscure  swelling 
in  the  right  iliac  fossa,  and  appendicitis  may  be  simulated.  There  will  generally  be  pyrexia ; 
if  the  inflammation  in  the  internal  glands  is  due  to  spread  from  the  femoral  or  inguinal 
glands  there  will  generally  be  some  sore  place  upon  the  skin  in  the  area  drained  by  the  latter 
to  indicate  the  diagnosis,  but  the  inflammation  of  the  iliac  may  also  occur  independently  of 
the  inguinal  lymphatic  glands  when  the  source  of  the  infection  is  in  the  pelvis  or  secondary 
to  periproctal  or  periprostatic  inflammation.     Rectal  examination  will  assist  the  diagnosis. 

Tuberculous  iliac  li/uiplialic  alands  generally  form  part  of  tabes  mesenterica  or  of 
tuberculous  peritonitis  (p.  47),  but  sometimes  the  tuberculous  deposits  occur  mainly,  or 
even  solely,  in  the  glands  in  the  region  of  the  caecum,  in  which  case  it  may  be  very  difficult 
to  l)e  sure  without  (i|)eration  that  the  patient  has  not  got  chronic  appendicitis  or  alterna- 
ti\ely  tviberculous  lesions  in  the  ciecuni  itself  (see  above).  It  is  only  when  one  can  feel 
multiple  small  but  (irni.  tender  swellings,  as  is  sometimes  possible  in  a  thin  person,  that 
the  diagnosis  of  tuberculosis  of  these  glands  may  be  guessed  at  ;  as  a  rule  the  patient  is  a 
child  suffering  from  general  delicacy,  and  the  condition  is  not  one  in  which  the  symptoms 
call  for  urgent  laparotomy.  Von  Pirqucfs  skin  reaction  may  be  positive,  though  even 
when  it  is  the  diagnosis  of  tuberculosis  of  these  glands  will  often  remain  one  of  conjecture 
only.  .Sometimes  the  .r-rays  show  multiple  shadows  in  the  position  which  the  glands 
normally  ficcupy,  and  thus  assist  the  diagnosis. 

Carvinnma  of  the  ea'cuiu  is  generally  characterized  much  less  by  pain  in  the  iliac  fossa 
than  by  a  definite,  usually  irregular  Hrm  mass,  at  first  movable,  later  more  fixed.  This 
mass  is  distinguished  from  an  accuniidation  of  fieces  in  the  csecum  by  its  greater  firmness, 
by  the  fact  that  it  cannot  be  moulded  by  the  fingers,  and  that  it  does  not  disappear  when 
the  bowels  are  thoroughly  evacuated.  It  may  enlarge  very  slowly  ;  in  cases  of  doubt, 
operation  with  a  view  to  possible  excision  will  probably  be  resorted  to,  and  the  diagnosis 
thus  confirmed.  .Sometimes  carcinoma  of  the  ciecum  may  be  .simulated  by  accumulated 
fa-ces,  howe\er.  when  there  is  obstruction  to  the  bowel  further  on  ;  there  may  for  instance 
be  adhesions  obstructing  the  sigmoid  colon,  or  a  partial  volvulus,  or  a  carcinoma  of  the 
rectum,  or  of  the  sigmoid  colon,  leading  to  partial  intestinal  obstruction  and  jjrcventing 
the  fa-ces  from  leaving  the  ca'cum  thoroughly  even  when  evacuant  measures  have  been 
employed.  The  pain  which  the  patient  then  comijlains  of  may  be  not  at  the  site  of 
obstruction  so  much  as  in  the  riglit  iliac  fossa.  A  bismuth  and  ,r-ray  examination  may- 
assist  materially  in  detecting  the  cause  of  the  symptoms  in  such  a  case,  and  careful  exam- 
ination of  the  rectum  with  the  finger,  or  of  the  sigmoid  colon  by  means  t)f  the  sigmoido.scope 
may  be  re(|uircil.  It  is  noteworthy  that  when  there  is  obstruction  to  the  colon  in  its  distal 
part,  it  is  particularly  in  the  <:ecum  that  stercoral  ulcers  are  apt  to  occur,  and  these  may  be 
associated  with  perityplilitis  and  pain  in  the  riglit  iliac  fossa,  more  or  less  simulating 
appciulieitis. 

In  di/seuter//  and  ulcerative  colitis  I  he  al)diimin:d  pains  arc  usually  general,  or  at  least 
referred  now  lo  one.  now  to  another  part  of  the  whole  colon,  so  that  inthese  conditions  the 
patient  seldom  complains  mainly  fif  |)ain  in  the  right  iliac  fossa  ;  occasionally,  however, 
pain  in  the  right  iliac  fossa  may  l>e  ifiore  pronounced  than  over  other  |)arts  of  the  colon, 
tiKMigli  the  diignosis  of  a  more  widespread  inficlion  will  generally  be  indicated  by  the 
history,  especially  as  to  residence  in  the  tropics  in  1  he  ease  of  dysentery,  or  of  recurrent 
intraet;iblc  diiirrlnea  with  the  passiiuc  of  blood  and  mucus  in  one  suffering  from  ulcerative 
colitis. 

In  h/pliiiid  fiTcr  Ihe  gencril  syinploms  will  marly  always  be  out  of  all  proportion  to 
any  pain  in  the  abdomen,  but  occasionall\-  so  mild  a  (••ise  of  typhoid  fever  is  met  with  the 
umbulatory  type  that  the  patient  has  [lol  been  ill  enough  even  to  go  to  bed.  and  in 
some  of  these  acute  pains  in  the  right  iliac  foss;i  have  been  Ihe  lirst  thing  to  call  attention 
to  the  nature  of  the  diseise  ;  in  some  indeed  Ihe  patient  has  had  a  perforation  low  down 
in  the  ileum,  so  Ijiit  a  local  abscess  in  the  right  iliac  fossa  has  formed,  and  the  patient, 
though  sulTcririg  livun  lyphoiil  fever,  has  been  operated  upon  as  an  ordinary  case  of 
appendieilis  until  llie  subse(|U<iil  couisc  of  the  pxnxia  his  indicalcd  llril  sometliing  else 
was  wrong,  and  if  has  occurred  looiic  lo  liivi-  Ihe  liL.od  l-slcj  for  a  Widal's  i<-:hI  ion.  which 
has  then  been  found  posit i\e. 

Discomfort  oi- acdi.il  pain  in  tlic  right  iliac  lossi  in:i\  lie  the  llrsi  (■oinplainl  of  patients 
suffering    from    a    tumour    of    llic    iliac    bow:      lliis    tumour    m:i>     be    simple      (,sle<ii>ia  <tT 


4f)0 


PAIN    IX    THE    ILIAC    FOSSA 


<)i(i)i<hotii(i — (ir  it  may  be  niali<;naiit  siirronin.  In  cither  case  the  diagnosis  is  arrived  at 
liv  larefiil  dee])  iialpation.  when  tlie  tmiKinr  will  he  felt  to  be  (irni  or  even  bony  hard,  and. 
nnlike  ntlur  tumours  in  the  iliac  fossa,  completely  lixed  to  the  deep  ])arts. 

\n  (iiu'iiryniii  tij  the  iliac  iirtcrij  is  very  imconniion  :  when  it  does  occur.  ])ain  in  the 
iliac  fossa  may  be  considerable,  and  this  pain  may  radiate  thence  down  the  right  thioh  ;  the 
diagnosis  would  be  made  by  carefid  pal])ation  and  the  disco\erv  of  a  tumour  with  expansile 
])ulsation. 

Although  liotli  iiKiral/le  risllil  Itiilin'i/  and  nllicr  lesions  of  the  rinlit  kidiiei).  esi)ecially 
Itibcreulosis,  cause  |)ain  in  the  k)in  to  a  more  pronounced  extent  than  ]«iiu  in  the  right  iliac 
fossa,  some  patients,  esjiccially  those  sulTering  from  unduly  movable  right  kidney, 
complain  of  nnich  more  ])ain  in  the  lower  right  abdominal  quadrant  than  in  the  loin, 
and  the  dilliculty  of  distinguishing  between  such  pains  when  due  to  movable  kidney  only, 
and  a  subacute  ai)pendicitis  occurring  in  a  person  who  has  at  the  same  time  a  movable 
kidiicx .  mav  sometimes  be  considerable.     Careful  urine  exanu'nation  should  be  made  ;   with 

icnal  tuberculosis  pus  cells  and  tubercle 
bacilli  may  be  detected  ;  with  movable 
kidney  the  urine  is  generally  normal,  though 
sometimes  there  may  be  a  little  albimiin  or 
occasionally  a  trace  of  blood.  With  mov- 
al)le  kidney,  however,  there  will  be  no 
pyrexia,  such  as  one  would  expect  were 
there  also  ai)i)eiidicitis.  and  on  careful  pal- 
pation the  ])atient  will  tell  tlie  examiner 
that  she  e.xi)eriences  the  pain  when  he  has 
the  kidney  between  his  two  hands  and  not 
when  he  [)resses  into  the  right  iliac  fossa 
without  toucliing  the  kidney. 

Herpes  zoster  is  a  condition  which 
always  needs  bearing  in  mind  when  pains 
are  unilateral  without  objective  signs,  and 
these  pains  due  to  herpes  zoster  may  be 
])resent  some  time  before  the  actual  erup- 
tion appears,  and  also  in  a  few  cases  for 
weeks  or  months  after  the  eru])tion  has 
subsided.  It  is  even  probable  that  in 
some  cases  there  are  pains  from  her]3es 
zoster  without  any  eruption  at  all,  though 
then  the  diagnosis  is  almost  impossible. 
.'^s  a  rule,  with  herpes  zoster  occurring  in 
such  a  way  as  to  produce  ])ain  referred 
to  the  right  iliac  fossa,  the  pain  will  not  be 
eonlined  to  this  fossa,  but  will  be  referred 
also  to  the  inner  side  of  the  u])per  part  of 
the  thigh  and  to  some  ]joint  in  the  right 
loin.  The  characteristic  vesicles  will  also  be  looked  for.  or  the  slight  scabs  that  may  l)e 
left  for  some  time  after  the  vesicles  have  dried  up. 

The  remaining  conditions  in  the  list  above  are  some  in  wliieh  pain  may  be  referred  to 
the  right  iliac  fossa  by  lesions  at  a  distance,  and  it  is  only  by  bearing  them  in  mind  and 
looking  for  evidence  of  them  that  tliey  can  be  recognized.  Thus,  the  fact  that  a  ])atient 
who  is  sulTering  from  aeiile  pleurisy  at  the  base  of  the  right  lung,  or  from  pneiniioiii/i  in  the 
lower  Idbi'  of  the  right  lung,  may  eoiuplain  of  i)ain  in  the  lower  part  of  the  abdomen  rather 
than  in  the  chest,  is  familiar:  and  sometimes  it  may  be  very  dillicult  to  decide  whether  the 
|)atient"s  lesion  is  abdominal  or  thoracic.  Even  when  there  are  definite  lung  signs  there 
may  be  doubt  as  to  whether  there  may  not  be  a])pendicitis  as  well  :  acute  pleurisy,  for 
example,  may  result  from  the  rapid  tracking  up  along  the  posterior  abdonunal  wall  of 
infection  from  the  apjjendicular  region.  In  such  cases  it  is  only  by  can  ful  judgement  that 
a  decision  can  be  come  to.  .\s  a  rule,  in  such  eases  there  is  neither  rigidity  nor  tenderness 
in  the  right  iliac  fossa  ujjon  examination,  although  the  patient  may  i)ut  his  hand  over  the 


lli'lluii.l.) 


PAIN".     IXTERSCAPLLAR  461 

riiilit  iliac  fossa  wlien  indicating  wliere  he  has  the  pain.  In  a  similar  way  climnic  ])ain 
suggestive  of  ureteral  calculus  or  of  appendicular  colic  or  even  a  subacute  appendicitis  may 
be  complained  of  by  persons  whose  posterior  nerve  roots  on  the  right  side  are  being  irritated 
by  bony  or  other  changes  in  connection  with  the  lower  dorsal  or  upper  lumbar  vertebra", 
for  instance,  from  spoiirli/lilis  (kformans  (]).  648)  in  an  early  stage  :  ostcoiirtlin'tis  of  the 
spine  :  infective  changes  in  the  spine  of  the  same  nature  as  rheiiinriloid  (irtliriiin  ;  spinal 
caries  with  or  without  psoas  abscess.  Such  cases  will  be  of  chronic  (hiration,  and  it  may 
be  only  after  nnich  deliberation  and  repeated  examinations  that  a  conclusion  will  be  come 
to  that  the  ])ains  are  referred  from  the  spine  and  not  due  to  primary  trouble  in  the  right 
iliac  fossa  itself.  Tlie  ,r-rays  will  sometimes  be  of  assistance  in  detecting  the  osteophitic 
or  other  bony  changes  in  the  vertebra-  (Fig.  195),  and  if  the  patient's  complaints  can  be 
analysed  successfully,  it  will  generally  be  found  that  he  has  definite  localized  pain  in  the 
back  as  well  as  in  the  iliac  fossa.  The  difficulty  of  being  sure  of  the  cause  of  the  pains 
in  such  a  case,  however,  may  sometimes  be  very  great,  and  c\cn  after  weeks  of  observa- 
tion their  nature  may  still  remain  one  of  doubtful  opinion  only.  Herbert  French. 

PAIN,  INTERSCAPULAR.— (See  also  P.vin  in  the  Back,  p.  427.)  Pain  referred  to  by 
the  patient  as  being  •■  in  the  back,  between  the  shoulder  blades,"  is  due  in  the  great  majority 
of  cases  to  simple  indigestion,  llatulencc,  or  biliousness.  Sometimes  it  is  in  the  middle 
line,  with  a  maximum  intensity  at  the  r>th.  the  6th,  the  7th  or  the  8th  dorsal  vertebra  ; 
sometimes  it  is  referred  more  to  one  side  of  the  mid-line  than  the  other  ;  often  it  varies  in 
position,  being  sometimes  near  the  mid-line,  at  other  times  right  under  the  blade  of  one 
scapula — particularly  on  the  left  side  in  the  case  of  indigestion  and  stomacli  conditions, 
on  the  right  side  when  the  patient  is  'bilious"  or  his  liver  is  out  of  order.  It  is  very  impor- 
tant, however,  not  to  conclude  forthwith  that  a  patient  who  has  this  symptom  is  merely 
bilious  or  suffering  from  dyspepsia,  for  pain  of  a  similar  kind  may  be  the  result  of  more 
serious  lesions,  amongst  which  one  must  think  of: — 

I'.pitlieliotna  ol  the  o-sopiiai/us  .Aortic  aneurysm  erodin;;  tlic  vertebra' 

-Mciliiistiiiii!  saicdiiia  (Jastric  ulcer 

.S|)iiiiil  caries  Duodpnal  ulcer 

Sarcoma  of  the  vertebric  (Jastric  carcinoma 

Carcinoma  of  the  vertehne  (Jall-^toiics 

Infective  arthritis  (if  the  s|iiiie  ,  Hepatic  alisecss 

Fibnisitis  I      '  Chrdiiic  Carcinoma  of  the  g:ill-hlaii(lcr 

.Myositis  ,  rliciiiiiiitiMn  '        Carcltioina  of  tlic  liver. 

Spondylitis   (IcIurTiiMtis  ) 

Tlic  lirsl  step  ill  arri\iiig  at  a  diagnosis  will  be  lo  examine  I  he  bare  back  very  carcfidly 
by  inspection  in  a  good  light,  and  by  pal|)ation.  Hroadly  speaking,  the  conditions  men- 
tioned abo\c  divide  themselves  into  two  main  groups — namely,  (1)  Those  in  which  the  pain 
is  not  produced  locally,  but  is  referred  to  the  interscapular  region  from  a  distance  (/<'/<;.  2!)4, 
p.  71*;;  ;  (2)  Those  in  which  the  pain  is  delinitcl\  of  local  origin,  so  that  llierc  is  t<Ti(l(rness 
on  palpation  as  well  as  piin.  When  [jn-  pain  is  due  to  local  causes,  there  will  generally  be 
some  dclieieiicN  in  the  lice  mnvcmcnl  of  the  s|)inal  colunm  when  the  patient  bends  forwards 
and  hiiekwaiils.  oi'  Irom  side  In  side,  or  when  he  twists  round  ;  and  attemf)ts  at  such  move- 
ments will  iiicrcasr  llic  |i:iin  jn  ;i  w.iy  which  is  not  the  ease  when  the  cause  is  gastric  or 
hepatic. 

The  maNimmii  aiiioiml  of  rigidity  is  found  in  eases  in  which  the  bones  themselves  are 
invoKed,  whetlier  by  spinal  caries,  ncxv  "riKVlh.  an  anenri/sni.  sjtDndi/lilis  deformans,  or 
arlhritis.  The  diagnosis  of  each  of  these  may  be  clinched  by  ,i'-ray  examination  in  all  but 
!i  few  cases.  Skiagraphy  will  also  serve  to  detect  niediaslinal  netc  <iroii'lli  ;  or,  with  tlie 
help  of  ii  bisnmth  meal,  cjiillielionia  of  llic  (rsnpliagus.  which  is  generally  suggested  by  the 
progressive  l)^•sl>Il,\(;l  \  (p.  \'.)\)  long  before  it  produces  pain  between  the  shoulders. 

Infective  arthritis  of  llic  s/iine.  fitirositis  and  nii/ositis  are  all  associated  with  local  lender- 
ness  and  local  sliMiu'ss  or  dclieicney  in  movcmcnl  as  well  as  with  kx'al  piin  :  in  only  a  few- 
Cases  will  Ihe  parts  aliiclcil  hi-  the  mid-dorsal  region  of  the  vertebral  column  alone;  in 
most  iiistaiHTs  till  re  will  lie  piiiii-,  in  otiier  parts  of  the  body  as  well,  referred  to  vaguely 
a.s  '  neuritie,'  togcllicr  with  innic  or  less  alicetion  of  maiiv  joints  of  the  multiple  rheuma- 
toid arthritis  type  Ip.  ;i  tl).      All  lline  are  closely  nlaled  to  one  aiiol  her,  and  where  fibrosilis 


462  TAIX     IN     THE    JAW  ^ 

or  myositis  end  and  infective  arthritis  begins  is  usually  impossible  to  define.  Local 
infiltration  may  sometimes  be  recognized  on  minute  ])alpation,  especially  by  those  who 
have  had  training  in  massage.  The  diagnosis  should  not  be  made,  however,  before  caries, 
aneurysm,  and  other  serious  deeper  lesions  have  been  excluded  by  skiagraphy. 

When  there  is  no  local  thickening,  tenderness,  or  rigidity,  and  no  local  abnormality  i 
to  be  made  out  with  the  a^-rays,  it  will  be  probable  that  the  interscai)ular  pain,  or  the  pains  I 
beneath  the  blade  of  one  or  other  scapula,  is  a  referred  pain,  either  of  gastric  or  hepatic  I 
origin.  In  many  such  cases  the  diagnosis  of  Flatulence  (p.  240).  or  simple  Indigestion 
(p.'^31.5),  or  of  biliousness  is  guessed  at  rather  than  made,  and  the  chances  are  that  the 
patient  will  be  suffering  from  one  or  other  of  these  ill-defined  '  simple '  conditions  rather 
than  from  something  more  serious,— such  as  gastric  or  duodenal  ulcer,  gastric  carcinoma, 
gall-stones,  hepatic  abscess,  or  carcinoma  of  the  li\er  or  gall-bladder  ;  especially  if  he  has 
had  similar  pains  on  many  previous  occasions,  losing  them  completely  in  the  intervals.  The 
severity  of  the  scapular  or  interscapular  i)ain  is  no  guide,  for  it  may  be  extreme  even  when 
the  patient  is  suffering  from  nothing  worse  than  flatulence  or  biliousness.  It  is  important, 
however,  not  to  jump  too  readily  to  the  conclusion  that  the  pain  is  due  to  these  simple  con- 
ditions e.spccially  if  it  does  not  yield  easily  to  simple  treatment,  such  as  bicarbonate  of 
soda  or  a  little  calomel.  Careful  abdominal  palpation  is  indicated,  lest  a  gastric  or  hepatic 
tumour  escape  detection  ;  with  these  the  pain  will  seldom  be  solely  interscapular,  however, 
and  here,  just  as  in  the  case  of  gastric  or  duodenal  ulcer,  hepatic  abscess,  or  gall-stones, 
there  would  be  ]3ain  in  the  epigastrium  or  hypochondrium  to  direct  attention  to  the  nature 
of  the  lesion,  which  would  be  suggested  further,  perhaps,  by  such  other  symptoms  as 
Vomiting  (p.  763)  or  Jaundice  (p.  324).  Nevertheless,  in  some  cases  it  may  only  be  by 
watching  the  patient  for  a  time  that  an  exact  diagnosis  can  be  made  ;  and  occasionally 
that  which  at  first  apjiears  to  be  no  more  than  the  interscapular  pain  of  dyspepsia 
or  biliousness   iiroves  to  have  been  reallv  due  to  gall-stones  or  a  carcinoma. 

Herbert  Freneli. 

PAIN  IN  THE  JAW  (LOWER)— unaccomijanied  by  I'.ny  swelling  (see  Swelling  of 
the  Jaw,  Lower,  p.  683)— is  generally  due  to  dental  caries,  i.e.,  toothache,  and  it  is  with 
this  thought  in  the  mind  that  an  examination  should  first  be  made.  The  decayed  tooth 
may  be  obvious  at  once,  or  it  may  be  so  hidden  as  to  call  for  the  services  of  a 
skilled  dentist.  Occasionally  an  unerupted  molar  may  be  the  cause  of  the  pain,  and  a 
skiagram  mav  be  needed  to  complete  the  diagnosis. 

Neuralgia. Here,  pain  is  the  essential  feature,  and  it  may  be    of  two  kinds.       It 

either  follows  the  course  of  a  nerve  such  as  the  inferior  dental  in  the  lower  jaw,  or  it  affects 
a  considerable  part  of  the  jaw  without  special  reference  to  any  nerve.  It  varies  greatly 
in  severity,  being  sometimes  slight,  at  other  times  so  severe  as  to  call  for  all  the  fortitude 
of  the  patient  to  bear  it.  Usually  neuralgia  of  the  inferior  dental  nerve  is  combined  with 
neuralgia  of  the  other  branches  of  the  fifth  nerve,  and  this  in  conjunction  with  the 
spasmodic  character  of  the  pain  makes  the  diagnosis  easy.  Some  cases  of  neuralgia  an- 
embarrassing,  especially  when  sources  of  irritation  in  decayed  teeth  are  present  as  well 
and  it  may  be  that  the  true  condition  can  only  be  settled  after  all  the  teeth  have  been 
extracted. 

Other  causes,  such  as  epithelioma  or  other  neoplasm,  do  not  jjroduce  pam  as  a  rule 
until  the  diagnosis  has  been  arrived  at  on  other  grounds.  George  E.  Grisk. 

PAIN  IN  THE  JAW  (UPPER).— U  hat  has  been  said  above  as  to  pain  in  the  lower 
jaw  being  caused  liv  dental  caries  and  neuralgia  applies  equally  to  jjain  in  the  upper  jaw, 
but  there  is  an  important  additional  cause  to  be  sought  for  in  the  latter,  and  one  easily 
overlooked,  namelv.  inlhunmatorv  affections  of  the  antrum  of  Highniore. 

Abscess  of  the  Antrum  of  lliglimore. ~The  presence  of  pus  within  the  antrum  is  indicated 
by  local  pain  generally  dull  in  character,  but  sometimes  acute.  On  examination  of  the 
jaw  the  oums  will  often  be  found  tender  and  swollen,  and  a  carious  tooth  is  frequently 
the  source  of  the  infection.  So  far,  the  signs  are  comijatible  with  those  arising  from  a 
septic  tooth,  without  implication  of  the  antrum,  and  further  evidence  is  required  ;  the 
most  certain  is  the  periodical  discharge  of  pus,  which  may  run  from  the  corresponding 
nostril  when  the  head  is  bent  forwards,  or  trickle  down  the  pharynx  when  the  patient  is 
lyin"  on  the  back.      If  the  normal  opening  of  the  antrum  into  the  nose  becomes  closed,  as 


PAIN     IN     THE     LIMRS  463 

it  may  from  inflammation,  this  valuable  sign  is  lost,  and  though  local  signs  of  inflanmiation 
and  general  febrile  disturbances  are  present,  it  may  be  difficult  to  arrive  at  a  diagnosis,  for 
the  condition  is  simulated  by  inflammation  in  the  nasal  fossa-  or  suppuration  in  the  ethmoidal 
and  frontal  sinuses.  It  must  also  be  remembered  that  a  growth,  either  innocent  or  malig- 
nant, starting  in  the  antrum  and  not  yet  big  enough  to  cause  a  swelling,  may  easily  be 
mistaken.  Recourse,  therefore,  should  be  had  to  the  method  of  transillumination,  and 
the  antra  on  the  two  sides  compared  (see  Fig.  84,  p.  ISO).  The  position  of  the  antrum 
should  be  shown  by  a  bright  red  area,  and  if  instead  a  shadow  is  thrown,  there  is  presumably 
some  affection  of  the  antrum.  It  does  not  mean  necessarily  that  there  is  an  abscess,  for  a 
growth  or  a  thickening  of  the  bone  may  cast  a  shadow  equally  well.  In  these  conditions 
a  skiagram  may  help.  A  growth  may  indicate  its  presence  by  pain  before  the  appearance 
of  any  swelling,  but  the  differential  diagnosis  is  discussed  under  Swelling  of  the  J.wv, 
LowKR  (p.  683).  The  only  certain  method  of  diagnosis  of  an  antral  abscess  is  by  tapping 
the  antrum  with  an  ex|)loring  syringe.  This  can  be  done  through  the  nose  immediately 
under  the  anterior  part  of  the  inferior  turbinate  bone.  The  fluid  withdrawn  may  be 
subjected  to  microscopical  and  bacteriological  examination.  Gcorae  E.  Gask. 

PAIN   IN   THE  JOINTS.— (See  Joints,  Affections  of  the,  j..  :i;i7.) 

PAIN    IN   THE   LEG.— (.See  Pain  in  the  Kxtuemitv,  Lowioii.    |).  438.) 

PAIN  IN  THE  LIMBS  (General).  -In  the  great  majority  of  cases  pains  in  the 
limbs  are  the  result  of  some  general  or  systemic  disease  :  in  but  few  instances  can  they 
result  from  symmetrically  distributed  local  lesions.  For  clinical  purposes  they  may  be 
classified  by  their  duration,  according  as  they  are  acute  or  chronic. 


1.  Acute    General    Pains    in    the    Limbs 

Hheumatie  fever 
Muscular    overstrain 
.Mvdsitis^ 


•ur  in 


Acute  Polymyositis 
.\euroinvositis 

Tricliinosis 

rcriplKial   neuritis 

Niurastlunia 


Hysteria 

Acute  infections  sueh  as- 
Acute  corvza 
Tonsillitis" 
Febricula  or  chill 
Influenza 

Acute  specific  fevers 
l{;it-hite   fever 


Chronic   General    Pains    in    the    Limbs    occur  in 


I'eripherul  neurit 
TuIk-s  (lorsalls 
Chronic    rlicniniil 
Mviil-i.i 
I'rruicidu: 
Osleiiaith 


nil: 


Hheumatoid  arthritis 
(ionoeoecal  arthritis 
Chronic   wasting;  (lisea> 
pulinoiiarv  lulieieuU 
(Jastrilis  , 
Cirrhosis  of  the  liver 


Iiillamnuitioris  of  tlie 
lungs,   kidneys,   etc. 

Secondary  syphilis 
Tropical  fevers — 

Dengue,  Malta  fever, 
cholera,  yellow  fever, 
dvsenterv,  malaria,  etc. 


Bronchitis 
Em|iliyseina 
Morlms  cordis 
Severe  aiuemia 
.Malijiiiaiit  disease 
Neplirilis. 


These  general  pains  may  be  fell  ;nost  acutely  somclimes  in  one  tissue  or  pari  of  the 
limbs,  sometimes  in  another.  The  muscles,  for  example,  may  be  the  chief  seats  of  pain  in 
a  child  with  rheiunalism  :  in  a  rheumatic  adidt  the  pains  are  usually  worst  in  and  about 
the  joints  :  in  a  patient  with  secondary  syphilis  the  pain  is  often  deep  in  the  bones,  the 
•  called  oslcoeopic  pain.  (Icneral  limb-pains  arc  uMially  made  worse  by  movement, 
particularly  when  they  arc  acconipaiiic.l  by  inllanimalory  changes  in  Ihe  joints  :  but  the 
general  pains  of  chronic  rhciimal  ism.  or  the  stiffness  and  pains  left  after  muscidar  over- 
strain, will  ollen  pass  oil  if  the  mo\cmeiils  be  i)ersiste(l  in  for  a  little  time.  .\s  a  rule,  general 
pains  in  the  limbs  arc  least  fell  when  the  patient  is  at  rest,  especially  when  he  is  at  rest 
in  bed  :  but  in  some  eases  rest  leads  to  slilTncss  and  increased  discomfort,  change  of  position 
giving  temporary  relief:  in  others  parlicularly  the  muscular  pains  of  rheumalisni  and 
the  ostcocopic  pains  of  specific  disease  the  pains  are  mI  their  wursl  as  sooti  as  Ihe  paliiiil 
gets  warm  in  bed. 

Acute  Pain,  (iencral  pains  in  the  limbs  arc  common  in  rlifiiitititic  fever,  occurring 
mainly  in  Ihe  limbs  in  which  there  is  aciile  inllanunalion  of  Ihe  joints.  In  severe  cases 
the  cause  will  not  readily  be  overlooUed  :  il  is  in  llu'  eoinpaial  ively  mild  cases  in  children 
that   failure   I ike   Ihe  pro|Mr  dia-iiiisis  is  liU.ly    I ciM-,   ulicii   llie  ;;cii>'ial   pailis  In   I  lie 


464  PAIN     IX     THE    LIMBS 

limbs  may  be  set  down  as  merely  '  growing  ])ains.'  There  is  no  donbt  that  '  growing 
pains  ■  oecur  in  healthy  children,  quite  indeijendently  of  rheumatism  :  but  any  complaint 
of  growing  pains  should  lead  to  a  careful  investigation  of  the  patient's  history,  and  of  the 
condition  of  his  heart  ;  a  family  history  or  past  [jersonal  history  of  either  rheumatism  or 
chorea  will  often  be  made  out  :  and  not  rarely,  examination  of  the  heart  will  lead  to  the 
discovery  of  valvular  disease.  The  joint-affections  of  rheumatism  are  far  more  prominent 
in  adults  than  in  children  ;  in  children  the  non-arthritic  lesions  are  the  most  conspicuous — 
endocarditis,  pericarditis,  pleurisy,  chorea,  inflammations  of  the  fibrous  tissues  generally 
and  of  the  skin,  sore  throats.  The  way  in  which  both  the  pains  and  the  jivrexia  are  relieved 
by  salicylates  may  often  assist  the  diagnosis  ;  if  both  are  relieved  within  forty-eight  hours 
after  salicylate  treatment  is  begun  acute  rheumatism  is  probable,  whilst  conversely  if  the 
pains  persist  in  spite  of  salicylates  acute  rheumatism  is  not  probable  {Fig.  150,  p.  338). 

Few  people  can  be  unacquainted  with  the  general  pains  and  stiffness  due  to  muscular 
overstrain,  the  result  of  some  violent  and  imusual  muscular  exertion — walking,  running, 
playing  games,  etc. — luidertaken  when  the  body  was  out  of  training.  The  pains  are  accom- 
]>anied  by  local  tenderness  of  the  affected  muscles,  and  there  may  be  slight  fever. 

Myositis,  or  inflammation  of  the  muscles,  is  a  comparatively  rare  cause  of  general 
pain  in  the  limbs.  Acute  polijnn/ositis.  also  described  as  dermatomyositis  and  as  psftudo- 
trichinosis,  is  characterized  by  pain,  rigidity,  and  tenderness  in  the  muscles,  oedema  of  the 
extremities,  and  a  rash  resembling  one  or  other  of  the  exudative  erythemas.  In  addition, 
there  are  the  general  symptoms  of  malaise,  anorexia,  general  debility,  and  fever.  It  must 
Ije  distinguished  from  trichinosis,  in  which  the  affected  muscles  are  found  to  contain 
Trichiiiclla  spiralis,  the  face  and  eyes  are  oedematous,  and  the  blood  shows  eosinophilia. 
A  second  rare  form  of  myositis  is  the  tieuromyositis  described  by  Senator,  in  which  the 
nerves  are  involved  as  well  as  the  muscles.  In  this,  sensation  is  lessened,  the  reflexes  are 
lost,  and  vasomotor  phenomena  are  seen  in  the  extremities.  The  affected  limbs  are  tender 
on  pressure,  and  ])ainful  wlien  movement  is  atteini)ted. 

Trichinosis,  or  infection  with  Tricliinella  spiralis,  is  \ery  rare  in  Great  Britain,  though 
common  in  countries  where  pork  is  eaten  uncooked.  Its  symptoms  are  due  to  gastro- 
enteritis, and  to  invasion  of  the  tissues  of  the  body,  particularly  the  muscles,  by  young 
trichinelte.  For  the  first  week  or  ten  days  the  main  symptoms  are  gastro-intestinal,  and 
may  suggest  cholera.  Then  the  second  stage  comes  on  with  pains  and  swellings  in  the 
muscles,  particularly  the  flexors.  The  face,  neck,  and  trunk  are  affected  as  well  as  the 
limbs  ;  the  face  and  eyes  become  ccdematous  ;  jirofuse  perspirations  are  common,  and 
high  fever  is  not  rare  ;  eosinophilia  and  leueocytosis  are  usual.  If  not  fatal  the  symptoms 
last  a  month  or  more,  subsiding  gradually  into  the  third  stage,  that  of  convalescence,  a  ; 
the  lar\al  triehinella;  V)ecome  encysted  in  the  muscles.  The  diagnosis  of  trichinosis  is 
likely  to  be  difficult  because  of  its  rarity  ;  it  is  most  likely  to  suggest  itself  when  it  occurs 
in  epidemic  form.  In  the  early  stages,  acute  gastro-enteritis.  enteric  fever,  or  even  cholera, 
will  be  suspected,  the  main  symptoms  arising  from  the  irritation  of  the  alimentary  canal 
set  tip  by  the  parent  trichinelhe  breeding  in  it.  Later,  rheumatism  will  be  simulated  ; 
but  the  pain  and  swelling  are  in  the  muscles,  not  the  joints,  and  the  occurrence  of  oedema 
and  of  eosinophilia  should  help  in  the  diagnosis.  It  may  be  added,  that  adult  tricliinella; 
may  be  found  in  the  stools  of  a  patient  with  trichinosis,  and  larval  tricliinella^  in  portions 
of  the  affected  niuseles  removed  intra  vitani  for  microscopical  examination  :  encysted 
larva-  will  also  be  seen  in  the  infected  meat  that  gave  rise  to  the  attack,  should  any  of 
it   have  been  preserved. 

Aching  pains  all  over  the  limbs  or  body,  or  both,  are  quite  common  at  the  onset  of 
many  of  the  acute  infectious  disorders,  or  of  acute  diseases  that  mainly  affect  one  or  another 
of  the  organs  of  the  body.  Associated  with  these  pains  are  other  general  symptoms,  in 
most  instances,  such  as  malaise,  headache,  anorexia,  and  more  or  less  fever.  Thus,  a 
severe  acute  coryza  or  tonsillitis  may  be  ushered  in  by  general  pains  in  the  limbs  ;  so  may 
the  obscure  and  elusive  acute  attack  known  as  a  febricula  or  a  chill,  in  which  the  fever  and 
general  symptoms  persist  for  a  day  or  two,  but  no  localizing  signs  or  symptoms  can  be 
detected  to  give  evidence  as  to  "  where  the  chill  has  settled."  Such  febricula»  may  really 
be  abortive  attacks  of  pneumonia  or  rheumatism,  the  onset  or  recrudescence  of  pulmonary 
tuberculosis,  instances  of  undetected  sore  throat,  acute  gastro-intestinal  iqisets,  cases  of 
larval  enteric,  scarlet  fever,  measles,  or  what  not.     If  they  are  associated  with  much  ])ain 


PAIN     IX     THE     LIMBS  465 

or  prostration,  thei-e  is  a  great  tendency  to  apply  the  term  '  influenza  "  to  them  indis- 
criminately, quite  ajiart  from  considerations  of  fact — evidence  of  infection  with  Pfeiffers 
bacillus  ;  or  of  ])robability — the  detection  of  any  source  whence  influenzal  infection  could 
have  been  derived.  But.  however  satisfactory  it  may  be  to  the  patient,  the  diagnosis  of 
influenza  should  not  be  made  without  further  evidence,  such  as  is  furnished  by  the  dis- 
covery of  Pfeiffer's  bacillus  in  the  patient's  nasal  or  bronchial  secretions,  or  by  the  occur- 
rence of  the  attack  as  one  of  many  in  an  influenzal  epidemic.  Influenza  is  well  known  to 
be  a  jirotean  disorder.  In  many  instances  its  main  symptom  is  a  severe  coryza,  with  head- 
ache, lachrymation,  pyrexia,  and  much  prostration.  In  others  the  type  is  respiratory, 
brf)nchitis  with  cough  and  viscid  expectoration  taking  the  place  of  the  coryza,  and  leading 
up  to  a  bronchopneumonia  or  lobar  pneumonia  that  not  infrequently  results  in  death.  A 
third  variety  of  influenza  is  the  abdominal  and  gastro-intestinal  ;  abdominal  pain,  vomiting, 
diarrhoea,  and  perhaps  jaundice,  being  the  main  phenomena.  In  all  of  these  the  ))ains, 
depression,  and  jirostration  come  on  very  rapidly,  and  appear  severe  out  of  all  proportion 
to  the  objective  signs  of  the  disease,  while  the  fever  is  usually  of  short  duration.  The 
diagnosis  of  epidemic  cases  should  not  be  diflicult,  but  in  the  sporadic  cases  it  may  be  far 
frf>m  easy,  and  must  be  made  on  the  general  lines  indicated  above. 

It  is  not  necessary  to  refer  in  detail  to  the  many  other  acute  infections  or  inflammatory 
processes  in  which  general  jjains  occur  in  the  limbs.  In  measles,  searlet  fever,  or  small-pn.v, 
for  exam])lc,  the  pains  often  occur  at  the  outset,  but  the  diagnosis  will  be  made  on  the 
other  symptoms,  and  confirmed  by  the  appearance  of  the  chai'acteristic  rash.  Recurrent 
attacks  of  high  fever  with  pains  in  the  limbs  are  characteristic  of  the  little  known  and  rarely 
recognized  Rat-bile  Fever  (see  p.  59S).  Various  febrile  disorders  of  the  lungs,  such  as 
broiicliilis.  tuberculosis,  or  pleiirisij,  may  begin  with  similar  pains  :  so  maj'  gastro-intestinal 
infections,  or  acute  inflanmiations  of  the  kidneys.  The  diagnosis  in  these  instances  will  be 
made  from  the  special  symptoms  developed  in  each  ;  the  pains  in  the  limbs  will  rarely 
be  the  only  or  the  most  prominent  complaint. 

In  periplieral  neuritis  of  the  symmetrical  multiple  tj'pe,  the  amount  of  pain  is  very 
variable — great  in  some  cases,  little  in  others.  The  peripheral  nerves  contain  motor, 
sen.sory,  and  vasomotor  fibres  ;  in  peripheral  neuritis,  therefore,  motor  and  vasomotor 
symptoms  are  habit ually  present,  as  well  as  sensory.  Alcoholism  is  the  conunonest  cause 
of  multiple  synuiRtrieal  |>iriphcral  neuritis;  the  chief  complaints  are  of  numbness  and 
tingling  in  the  extremities,  "pins  and  needles,'  sensations  of  "  dead  fingers."  cramps  in 
the  legs,  ami  severe  gnawing  or  aching  ])ains  in  the  limbs.  Beginning  in  the  hands  and 
feet,  they  tend  to  s|)read  to  the  trunk  ;  motor  weakness  comes  on,  the  skin  develops  hyper- 
a>stliesia,  the  limbs  become  very  tender  to  pressure.  The  deep  reflexes,  originally  increased, 
are  now  lost  :  the  sphincters  are  hardly  ever  involved  in  alcoholic  neuritis  unless  the  mind 
is  affected.  Mental  symptoms  are  conunon  in  alcoholism,  taking  the  form  of  Korsakow's 
j)syc-hosis  ;  memory  for  recent  events  is  lost  :  the  patient  may  lorget  liis  name  and  address, 
and  not  know  where  lie  is  ;  and  in  the  eiideaxour  to  mak<'  good  the  Jaeuiia-  In  his  recollec- 
tions, he  is  likely  to  lie  freely,  and  ((uite  uitlionl  any  delinite  wish  to  dcc<i\c.  The  physical 
signs  of  arsenieal  neuritis  are  similar  to  those  of  the  alcoholic  form,  but  ineo-ordination 
and  the  cutaneous  and  deep  hypera'sthesia'  are  more  marked,  and  muscular  paresis  and 
wasting  come  on  earlier  :  and  there  may  be  other  arsenical  symptoms  (p.  (il).  In  the 
neuritis  due  to  acute  leail  poisoning  the  sensory  signs  are  entirely  subordinated  to  the 
motor,  and  pains  in  the  limbs  are  absent.  Peripheral  neuritis  is  a  fairly  frcciuent  legacy 
of  influeirza,  and  may  then  be  characteri/.ed  by  great  severity  and  persistence  ;  it  may 
also  occur  as  a  t'omplication  of  other  infectious  disorders  -such  as  diphtheria,  tid)erculosi6, 
or  syphilis.  Th<-  diagnosis  of  peripheral  neuritis  will  be  suggested,  speaking  generally, 
if  the  pains  in  the  limbs  arc  associated  with  marked  sensory  changes  anaesthesia, 
para'sthesia.  liypera'sthesia  with  tenderness  of  the  skin,  nuiseles,  or  along  the  course  of 
the  nerves,  and  with  weakness,  atrophy,  and  the  reaction  of  degeneration  in  the  muscles. 
Ili/sterieal  and  neurastlwnic  patients  sometimes  sidicr  acuti'ly  from  pains  in  the  lindis 
that  lack  any  objec'tive  basis  on  examination,  an<l  may  give  rise  to  much  trouble  in  dia- 
gnosis. It  is  of  grejd  importance  that  orj;anic  disease  of  every  kin<l  should  be  excluded 
before  the  diagnosis  of  hysteria  or  neurasthenia  is  given  out.  The  hysterical  patient  i-- 
generally  a  woman,  and  is  likely  to  exhibit  several  of  the  many  phi-nomena  eomnion  in 
hysteria,  such  as  funelional  aphonia,  globus  or  clavus  hystericus,  stoeking-and-glove 
ij  :!(J 


466  PAIN     IN     THE     LLMBH 

ansesthesia,  hemianaesthesia,  variable  paralyses  often  due  to  the  contraction  of  antagonistic 
muscle-groups,  hysterical  seizures,  and  the  like.  The  signs  and  symptoms  of  hysteria 
change  from  time  to  time,  the  recovery  from  any  particular  affection  often  being  as  sudden 
as  its  onset.  The  neurasthenic  patient,  on  the  other  hand,  is  oftener  a  man  than  a  woman, 
usually  overworked,  run  down  in  general  health,  and  worried.  The  symptoms  are  those 
of  '  brain-fatigue  '  for  the  most  part  ;  inability  to  attend  to  or  take  interest  in  either 
work  or  pleasure  ;  the  bodily  strength  is  lessened,  and  subjective  sensations  of  all  sorts 
may  be  felt  in  the  back  or  limbs.  Headache  is  a  prominent  feature  in  some  neurasthenic 
patients  ;  dyspepsia  or  palpitation  in  others  ;  imaginary  sexual  disorder  in  others. 
Exaggerated  knee-jerks  accompany  plantar  reflexes  that  are  still  normally  flexor,  and 
the  temperature  is  often  subnormal. 

General  pains  in  the  limbs  are  common  in  certain  diseases  of  hot  countries,  of  which 
only  two  need  be  considered  here.  Both  occur  in  Southern  Europe,  as  well  as  in  more 
tropical  regions. 

Dengue  is  an  epidemic  infectious  disease,  much  like  influenza  in  many  respects.  Its 
onset  is  sudden,  with  headache  and  pains  all  over,  fever,  sore  throat,  an  initial  erythe- 
matous rash,  and  rapid  pulse.  The  pains  may  be  in  the  joints  mainly,  or  diffused  through- 
out the  muscles  of  the  limbs,  and  are  made  worse  by  movement.  After  two  or  three  days 
the  patient  feels  better,  and  begins  to  get  about  again  ;  but  after  an  interval  of  a  day  or 
two  a  slight  or  severe  relapse  occurs,  with  pains  as  before,  fever,  and  a  secondary  roseolar 
rash,  which  begins  on  the  hands  and  wrists,  later  spreading  in  patches  over  the  whole  body. 
The  relapse  is  soon  over  ;  but  convalescence  may  be  slow,  with  persistence  of  the  general 
pains  in  the  limbs.  The  diagnosis  should  be  easy  in  epidemics  of  dengue  ;  the  sudden 
onset,  extent  of  the  pains  in  limbs,  head,  and  loins,  and  the  characteristic  course,  should 
suffice  to  distinguish  sporadic  cases  from  other  acute  disorders  such  as  measles,  scarlet 
fever,  rlieumatic  fever,  etc. 

Malta  fever  occurs  mainly  in  the  Mediterranean  and  on  its  shores  :  it  is  a  chronic  fever, 
characterized  by  perspirations,  constipation,  and  rheumatic  pains  in  the  limbs  ;  arthritis, 
orchitis,  and  enlargement  of  the  sjileen  are  common.  The  early  symptoms  are  obscure  : 
but  pains  in  the  limbs  and  general  debility,  gastric  derangements,  headache,  bronchitis, 
and  continued  fever,  are  the  general  characteristics  when  the  disease  is  established.  The 
diagnosis  would  turn  on  the  discovery  of  exposure  to  infection,  the  milk  of  goats  that  are 
carriers  of  the  Micrococcus  melitensis  being  the  actual  vehicle  of  infection  :  the  patienfs 
serum  shows  the  specilic  agglutinating  reaction. 

Chronic  General  Pains  in  the  Limbs  will  often  remain  after  several  of  the  disorders 
mentioned  under  the  former  lieading.  Tlius,  the  pains  due  to  peripheral  neuritis  may 
become  a  chronic  affection  in  cases  of  chronic  alcohol,  arsenic,  or  lead  poisoning,  after 
influenza,  or  in  gouty,  diabetic,  or  syphilitic  patients.  Usually  only  one  or  two  of  the 
limbs  will  be  aflected  in  these  cases  :  and  the  diagnosis  will  not  have  to  be  made  from  the 
occurrence  of  the  pains,  but  will  have  become  evident  from  the  de\elopment  of  other  signs 
of  disease  :  a  blue  line  on  the  gums  (p.  34),  tophi,  and  previous  attacks  of  acute  gout,  sugar 
in  the  urine,  and  so  fortli. 

To  certain  unconmion  cases  of  tabes  dorsalis  the  name  tabes  dolorosa  has  been  given, 
owing  to  the  severity  and  extent  of  the  pains.  Tire  patient  presents  the  usual  symptoms 
of  tabes  (p.  609) ;  in  addition  he  has  frequently  repeated  lightning  pains  in  the  limbs,  so 
severe  as  to  form  the  dominating  element  in  his  disorder  from  the  subjective  point  of 
view.  The  diagnosis  will  be  made  from  the  suddenness  and  shocking  intensity  of  the 
pains  on  the  one  hand  ;  and  on  the  other,  from  the  discovery,  of  further  signs  of  tabes — 
Argyll  Robertson  pupil,  loss  of  knee-jerk,  ataxia,  sphincter  troubles,  areas  or  zones  of 
anaesthesia.  The  pains  will  have  a  radicular  distribution,  and  the  nerve-trunks  and 
muscles  will  not  be  tender  on  pressure. 

General  pains  in  the  limbs  are  common  in  chronic  rheumatism,  occvirring  particularly 
in  consonance  with  changes  in  the  weather.  In  some  instances,  the  muscles  are  the  chief 
seat  of  the  pain  ;  in  others,  the  joints  or  the  fibrous  tissues  round  them.  In  most  cases, 
exercise,  massage,  or  movement  tend  to  diminisli  these  pains,  if  the  patient  can  be  induced 
to  submit  himself  to  the  discomforts  of  motion  or  exertion.  Occurring  in  children,  these 
chronic  pains  are  usually  set  down  as  '  growing  pains  '  ;  but  their  association  with  acute 
rheumatism  is  so  frequent  that  the  patient  sliould  always  be  examined  for  other  evidences 


PAIN    IX     THK     PELVIS  467 

of  tlie  rheumatic  infection  (see  p.  464).  In  adults,  on  the  other  hand,  chronic  rlieumatism 
is  less  often  an  inheritance  from  acute  rheumatism,  and  is  not  so  frequently  combined  with 
valvular  disease  of  the  heart  ;  but  it  aives  rise  to  pseudo-ankylosis  of  the  joints.  Inability 
to  work,  and  much  impairment  of  the  general  health.  The  possibility  of  gonorrhcral 
arthritis,  miscalled  gonorrhoeal  rheumatism,  must  not  be  overlooked. 

Mi/algia,  or  the  so-called  '  muscular  rheumatism  '  is  a  common  affection  of  certain 
groups  of  muscles,  and  may  in  some  instances  affect  the  limbs  generally.  It  is  due  to  chill, 
exposure  to  cold  after  sweating,  sitting  in  a  draught,  and  the  like.  Its  commoner  forms, 
such  as  lumbago,  stiff  neck,  pleurodynia,  stiff  back,  need  only  be  mentioned  ;  in  the  rare 
cases  where  the  limbs  are  attacked,  the  diagnosis  of  muscular  rheimiatism  will  probably 
be  made  faute  de  7nieux,  although  there  is  nothing  to  show  that  the  affection  is  rheumatic, 
and  no  proof  that  it  is  the  muscles  (and  not  their  sensory  nerves,  for  example)  that  are 
affected  primarily.  It  happens  occasionally  that  severe  pains  in  the  limbs,  or  pains  all 
over  the  body,  are  felt  by  patients  with  peniicions  ancemia.  In  some  instances  these  pains 
are  associated  with  great  tenderness  of  the  bones  of  the  limbs  and  trunk  to  pressure,  which 
may  be  connected  with  the  hypertrf)])hic  changes  taking  place  in  the  marrow  within  them. 
Similar  aches,  pains,  and  tenderness  may  be  found  in  any  of  the  severe  ansemias  or 
leukiemias. 

There  remains  for  consideration  the  large  class  of  diseases  characterized  by  chronic 
zvastiiig  or  caclicrici.  in  which  general  pains  in  the  limbs  are  often  prominent.  These  pains 
are  due  to  widely  different  causes  in  different  instances.  In  some  they  may  be  due  to 
nothing  more  than  exaggerated  muscular  fatigue  or  overstrain  ;  the  debilitated  patient 
has  but  little  muscle,  and  that  little  is  exhausted  by  exertions  that  would  be  trifling  for  a 
normal  subject,  so  that  the  cachectic  patient  becomes  the  victim  of  general  pains  by  the 
mere  fact  of  being  up  and  about.  In  other  cases  the  pains  are  connected  with  peripheral 
neuritis,  set  up  by  the  circulation  of  toxins  in  the  patient's  blood,  though  few  or  none  of  the 
other  signs  or  symptoms  of  neuritis  may  be  detected  on  investigation.  In  others,  again, 
the  jjains  seem  to  be  connected  with  the  occurrence  of  fever,  being  lessened  or  absent  when 
I  he  patient's  ten\perature  is  normal.  In  the  great  majority  of  cases  these  pains  are  lessened 
\>\  rest,  or  by  any  treatment  that  builds  the  patient  up  and  increases  his  strength.  Either 
the  lungs,  the  heart,  the  liver,  and  gastro-intestinal system,  or  the  kidneys  may  be  the  organs 
primarily  at  fault,  and  bodily  wasting  and  weakness  will  be  among  the  main  symptoms. 
In  eases  where  the  organic  disease  is  deep-seated  and  out  of  reach,  there  is  danger  lest  the 
patient  who  is  really  seriously  ill  should  be  suspected  of  nothing  more  than  functional 
disease  and  treated  for  such.  Thus,  ])atients  with  carcinoma  of  the  stomach  may  be  treated 
for  hysterical  vomiting  or  anorexia  nervosa  ;  the  victim  of  a  carcinoma  or  aortic  aneurysm 
invading  the  spinal  canal  may  receive  the  treatment  usually  meted  out  to  the  malingerer. 
It  is  important,  therefore,  that  the  most  thorough  examination  should  be  made,  and  deep- 
seated  organic  disease  of  every  sort  excluded  as  far  as  is  possible,  before  tlie  diagnosis  of 
functional  disease  be  made  in  a  eaclicctic  patient.  This  is  all  tlie  more  necessary  bei'ause 
there  is  no  doubt  that  jjurely  functional  disease  of  long  standing  may  reduce  nutrition  or 
bodily  strength  to  a  very  low  ebb.  .(.  ./.  .fer-lllal;e. 

PAIN    IN    THE    NECK. -(Sec  Soin:  'ruiioAT.  p.  (it:!  :    and  Srii'i-  Xkck.  p.  047.) 

PAIN  IN  THE  PELVIS.  -In  practice,  pelvic  pain  can  usually  l»-  .hissilicd  under 
four  headings.  iiaiiiel\  :  (1)  Dccp-HCdlctl  ixiin  :  (2)  Siiperficidl  pain  in  llic  al.iii  i  (:$) 
.Sj/dsiiiinlii-  /Klin  ;    ( t)  ISdclidclic  or  Sdcrdlsiid. 

Deep-seated  Pain  is  aching  in  character,  continuous,  and  may  l)c  acute  in  onset,  or 
may  be  cluoni<'  in  duration.  It  is  associatcil  with  tension  in  the  pchie  organs,  usually  the 
result  of  overlillcd  ncsscIs,  or.  in  other  words,  of  congestion.  If  the  result  of  actual  inllam- 
mation,  i.e.,  congestion  due  to  infection,  it  is  acute,  and  very  severe.  It  is  elicited  by 
pressure,  and  thereby  made  worse.  In  its  worst  form  it  is  of  peritoneal  origin  ;  but  it  may 
be  due  to  simple  congestion  of  the  uterus,  tubes,  or  ovaries,  without  infection  or  evidence 
of  actual  inilammation.  The  presence  of  adhesions  between  the  pelvic  organs  is  an  impor- 
tant factor  in  the  dillcrential  diagnosis  of  this  type  of  pain,  making  it  abundantly  clear 
that  there  has  been  a  past  peritoneal  iMllaiiniiat ion.  and  that  the  len^i  m  in  the  organs  is 
the  roult  (if  tlic  liiiidirii^  anil  |)rcssurr  of  new   lilirous  tissue.      Thus  il   iiia\    lie  caused  !>>■  :  — 


468  PAIN     IN     THE     PELVIS 

Local  peritonitis  due  to  infection,  recent  or  remote,  caused  by  salpingo-oophoritis, 
infection  after  labour  or  abortion,  ovarian  cyst  with  torsion  of  the  pedicle,  extra-uterine 
gestation,  appendicitis. 

Simple  congestion .  caused  by  retroversion  and  flexion  of  the  uterus,  prolapsed  ovaries, 
sclerosed  ovaries,  ha-morrhagic  corpus  luteum  cyst,  endometritis. 

Superficial  Pain  in  tlie  Sl<in. — This  is  elicited  bv  pinching  or  touching  the  skin  with 
the  head  or  point  oi'  a  pm.  it  is  essentially  a  referred  pain,  and  may  radiate  very  widely 
over  the  abdominal  area,  down  the  groins,  over  the  crest  of  the  ilium,  aiid  down  the  thighs. 
The  area  on  the  skin  in  which  referred  pain  is  felt  in  coiinection  with  uterine,  tubal,  or 
ovarian  disease,  is  that  to  which  the  tenth  dorsal  nerve  is  distributed  :  aiid  the  area  is 
that  which  is  commonly  known  as  the  "  ovarian  region.'  It  is  not.  however,  ovarian 
only,  and  it  is  not  even  uterine  and  tubal  only,  but  may  be  affected  also  by  lesions  of  the 
kidney,  ureter,  gall-bladder,  and  some  parts  of  the  intestines.  Consequently,  referred 
pain  in  the  skin  in  this  so-called  ovariaii  regioii  caiiiiot  be  taken  to  iiidicate  disease  of  the 
generative  organs  at  all,  unless  other  lesions  can  be  eliminated.  The  region  of  the  tenth 
dorsal  segment  is  simply  a  liorizontal  band  spreading  behind  from  the  first  to  third  lumbar 
spines,  and  extending  round  the  body  with  its  upper  level  in  front  at  the  umbilicus.  All 
parts  of  the  region  are  not  necessarily  affected  equally,  and  there  may  be  points  of  maxi- 
mum intensity  ;  one,  notably,  is  midway  between  the  mnbilicus  and  anterior  superior 
spine.  This  spot,  especially  on  the  left  side,  has  often  been  taken  erroneously  to  indicate 
pain  due  to  ovarian  inflaiiimatioii.  It  is  interestiiig  to  note  that  referred  pain  is  commonly 
more  marked  on  the  left  side  of  the  body,  the  exjjlanation  of  which  is  not  (piite  clear. 
Referred  pain  in  this  segment  may  not  be  due  to  any  local  lesion  at  all,  but  may  be  a 
marked  maiiifestation  of  hysteria  in  its  graver  forms.  When  extreme  hypera?sthesia  of 
this  area  on  the  left  side  is  accompanied  by  anaesthesia  of  the  skin  of  the  legs  and  feet  up 
to  the  level  of  the  knees,  with  brisk  knee-jerks  and  ab.sence  of  the  palate  reflex,  the  dia- 
gnosis of  Insterin  is  almost  certain. 

Spasmodic  Pain  in  the  jielvis  is  nearly  always  due  to  painful  uterine  contractions 
wlien  it  is  of  genital  origin.  The  exception  to  this  is  the  pain,  certainly  spasmodic  in 
character,  which  occurs  in  connection  vi'iihtxibal  gestation,  as  a  rule  in  the  week  or 
two  preceding  tubal  abortion  or  rupture  of  the  tube.  In  this  case  it  is  supposed  to  be  due 
to  contraction  of  the  muscle-coats  of  the  tube,  but  there  is  no  real  evidence  that  this  is  a 
fact.  There  can  be  no  doubt  that,  even  though  a  part  of  the  pain  is  muscular,  some  of  it 
at  least  must  be  due  to  peritoneal  irritation.  The  oiily  way  to  diagnose  between  this  tubal 
pain  and  that  due  to  uteriiie  contractions,  is  by  a  careful  consideration  of  the  history  of  the 
case,  and  the  finding  of  a  definite  tiibal  swelling  by  the  bimanual  method.  Even  then  the 
diagnosis  is  exceedingly  difiicult  and  often  impossible.  Spasinodic  pain  due  to  uterine 
contractions  is  caused  by  :  The  onset  of  abortion  or  labour  :  deficient  development  of  the 
uterine  muscle  in  spasmodic  dysmenorrhoea  (p.  1!I2)  :  expidsion  of  a  growth  from  the 
uterus  such  as  a  fibroniyoma  ;  "  after-pains  "  following  labour  ;  gauze  packing  of  the 
uterus  after  operations. 

The  differential  diagnosis  of  these  conditions  is  fortunately  easy  ;  but  a  much  greater 
diflieulty  is  .sometimes  met  with  when  spasmodic  pain  has  to  be  diagno.sed  which  is  due  to 
causes  which  may  not  be  of  genital  origin  at  all.  The  possible  extraneous  causes  of 
spasmodic  pain  have  already  been  outlined  (see  Dvs.menorrhcea,  ]>.  192),  and  are  : 
Appendicitis,  intestinal,  renal,  or  hepatic  colic,  leaking  gastric  ulcer,  ruptured  tubal 
gestation,  twisted  ovarian  pedicle,  hseiiiorrhage  into  a  Graafian  follicle,  rupture  of  an 
ovarian  cyst  or  ])yosalpinx.  dyspe])sia,  and  flatulent  distention  of  the  bowels. 

Backactie,  or  Sacralgia,  is  a  very  common  symjjtom  in  all  classes  of  pelvic  disorders  ; 
and  may  be  present  at  the  same  time  as  deej)-seated  pain  and  superficial  skiii  tender- 
ness. It  is  associated  especially  with  chronic  uterine  congestion  and  endometritis, 
backward  displacement  of  the  uterus,  downward  displacement  (prolapse),  and  impacted 
uterine  or  ovarian  tumours.  Sometimes  the  only  lesion  to  be  demonstrated  is  a  chronic 
cervical  catarrh  or  a  cervical  erosion.  It  is  a  very  difficult  pain  to  explain  in  all  cases  ; 
but  it  is  usually  regarded  as  one  referred  to  the  roots  of  the  actual  nerves  which  supply  the 
uterus,  tubes,  and  ovaries.  In  cases  of  impacted  tumours  it  is  possible  that  the  pain  is  due 
to  actual  pressure  on  the  sacral  nerves  at  their  exit  from  the  bone,  in  which  ease  |)ain  will 
also  be  felt  down  the  inner  side  and  backs  of  the  thighs.     In  eases  iit'  ctircinonia  of  the  cen-ix 


P.'vIN     IX     THE     PENIS  469 

backache  is  complained  of,  but  is  always  associated  with  pain  in  the  "  ovarian  regions." 
inguinal  region,  and  also  radiating  down  the  legs.  It  must  not  be  forgotten  that  this  form 
of  backache  is  not  necessarily  of  genital  origin,  but  may  be  the  result  of  many  other  lesions. 
Thus,  it  may  be  the  result  of  some  irritating  urinary  constituent,  like  excess  of  urates  and 
phosphates  ;  also  it  may  accompany  a  calcidus  in  the  ureter  or  some  lesion  of  the  renal 
pelvis.  As  a  rule,  in  renal  cases,  the  pain  is  situated  rather  higher  up.  Further,  caries  of 
the  spine  low  down,  growths  of  the  spine,  or  of  the  spinal  cord  membranes,  may  give  rise 
to  it.  Inflammation  of  the  sacro-iliac  joint,  rectal  growths,  haemorrhoids,  and  idcers,  may 
be  its  originating  cause.  It  is  clear  that  a  correct  diagnosis  in  any  case  cannot  be  made 
without  a  complete  examination  of  all  these  structures,  combined  with  careful  urinary 
analysis.  Tims.  G.  Stevens. 

PAIN  IN  THE  PENIS — is  a  symptom  which  occurs  frequently  in  urinary  surgery, 
not  only  in  association  with  lesions  of  the  penis  or  urethra,  but  also  as  a  referred  pain  with 
disease  of  the  prostate,  bladder,  or  kidney.  The  symptom  is  one  which  is  common  to  many 
diseases,  so  that  in  the  diagnosis  of  any  case  due  consideration  must  be  given  to  the  other 
symptoms  accompanying  it,  without  placing  too  much  reliance  on  a  single  symptom  which 
may  point  strongly  to  the  urethra  or  bladder. 

Penile  pain  may  be  present  either  during  or  immediately  after  micturition,  or  may  be 
entirely  independent  of  the  act.  It  may  be  said  generally  that  if  pain  is  felt  only  during 
micturition  there  is  some  inflammatory  lesion  of  the  urethra  or  prostate  ;  whilst  if  it  occurs 
immediately  after  the  How  of  the  urine,  it  suggests  some  lesion  in  the  urinary  bladder.  On 
the  other  hand,  pain  may  be  present  quite  apart  from  micturition,  due  to  various  diseases 
of  the  penis,  bladder,  ureter,  or  kidney. 

The  term  '  pain."  too.  is  a  relative  quantity,  varying  with  the  nervous  susceptibility 
of  the  patient,  for  what  is  pain  in  one  may  be  merely  discomfort  in  another,  so  that  the 
patient"s  account  may  have  to  be  discounted  to  a  certain  extent  by  the  clinician. 

I.  CAUSES  OF  PAIN  IN  THE  PENIS  EXPERIENCED  DURING  MICTURITION. 

1.  Diseases  of  the    Vrelliiit —  Prostatic  abscess 

Acute   iuflaminatloiis  Prostatic  carcinoma. 

The  passage  of  a  cakiiliis  or  Hie  iiii|ia(ti(in  .'i.   Diseases  of  the  Bladder — 

of  tlie   latter  Acute   cystitis 

•Stricture  of  tlip  iirotlira  Vesical  cakiilus 

Injury  of  the  urethra.  Villous   papilloma 

2.  Disiiises  of  the  Prostate —  Pcdimculatcd    caixiiioma. 

Acute  ])rostatitis         ,, 

Diseases  of  the  Urethra.  -My  far  the  most  common  cause  of  |)ain  in  the  penis 
occurring  iliiring  micturition  is  acute  inflammation  of  the  urethra,  usually  gonorrhceal,  but 
occasionally  .septic.  In  the  earliest  stages  of  an  acute  urethritis,  before  any  marked 
urethral  discharge  is  ap|)arent,  there  is  usually  a  sense  of  smarting  or  tingling  in  the  ter- 
minal urethra,  more  marked  as  the  discharge  increjiscs,  when  it  is  of  a  burning  or  scalding 
character.  The  oeciirrence  of  this  ])ain  during  micturition  within  a  few  days  of  sexual 
coimection  is  frequently  the  earliest  symptom  of  urethral  infection,  whilst  a  purulent 
discharge  from  the  urethra  is  usually  present  when  the  case  comes  under  observation. 

'I'lic  jtassiisie  of  a  caliiiliis  through  the  urethra  causes  a  sharj).  cutting  pain  along  the 
urethra,  the  cause  of  which  is  apparent  when  the  calculus  is  voide<l.  Occasionally  it  n\ay 
happen  that  miclurilion  occurs  in  these  cases  in  tlu:  dark,  or  that  urine  is  not  jiassed  iido  a 
vessel,  so  thai  tli<-  calculus  is  nol  actually  seen  by  the  pallcnl  :  but  if  there  is  a  history  of 
previous  renal  descent  of  a  stone  or  symptoms  |)oirding  to  vesical  calculus,  the  sharp 
urethral  |)ain  during  micturition  occurring  upon  one  single  occasion  is  signilicant  of  the 
passage  of  a  calculus.  A  stone  may,  however,  pass  on  to  the  urethra  during  micturition 
and  become  tirrcsleil  at  sonic  narrowed  portion  of  the  canal,  usually  at  the  membranous 
portion  or  at  the  distal  end,  when  a  sudden,  sharp  pain  is  felt  in  the  urethra,  and  at  the 
same  time  the  flow  of  urine  is  partially  or  completely  stopped  before  the  bladder  has  been 
emptied,  whilst  further  elTorls  fail  to  re-start  the  stream.  In  these  cases  the  presence  of  a 
stone  should  be  sus|)e<'tcd.  and  the  whole  leiiglh  of  the  urethra  examined  by  passing  the 
finger  along  its  course,  when  a  slorie  may  be  aclUMJIy  IVII.  or  the  canal  iiia\  lie  illuminated 
by  an  endoscope  and  the  calculus  seen. 


470  PAIN     IN     TIIK     PENIS 

Vrethral  siriclure  occasionally  causes  pain  in  the  urethra  during  micturition,  esjje- 
cially  if  the  calibre  is  small,  and  if  there  is  septic  infection  or  ulceration  of  the  urethral 
mucous  membrane  behind  the  stricture.  The  forced  efforts  at  urination  may  cause  pain 
in  the  urethra  during  micturition,  but  as  a  general  rule  stricture  causes  but  little  pain. 
The  gradually  increasing  difliculty  in  micturition,  the  feeble  stream,  and  the  dribbling  of 
urine  from  the  meatus  after  the  stream  has  terminated,  are  symptoms  pointing  to  stricture 
of  the  urethra  ;  the  diagnosis  will  be  confirmed  readily  by  the  obstruction  offered  to  the 
passage  of  a  full-sized  bougie,  or  better,  by  direct  observation  of  the  urethra  by  means  of 
the  endcscope. 

Injury  of  the  urethra  may  cause  pain  during  micturition.  The  urethra  may  be  injured 
by  a  fall  on  the  perineum,  by  a  kick  or  blow,  or  by  the  faulty  or  careless  passage  of  instru- 
ments :  it  may  also  be  injured  or  lacerated  in  association  with  a  fracture  of  the  pelvis. 
The  urethra  may  be  merely  bruised,  may  be  lacerated  on  one  aspect,  or  may  be  completely 
ruptured.  If  the  urethra  be  injured,  there  is  usually  an  appearance  of  blood  at  the  external 
urinary  meatus,  together  with  a  contusion  in  the  perineum  or  along  the  course  of  the 
urethra,  if  the  laceration  is  caused  by  direct  injury.  .\ny  attempt  at  micturition  causes 
pain  in  the  penis,  whilst  urine  may  or  may  not  be  expelled  from  the  meatus,  depending 
upon  the  extent  of  the  injury,  or  may  be  extravasated  into  the  perineal  or  scrotal  tissues. 
As  a  rule,  no  diniculty  will  be  experienced  in  the  diagnosis,  but  in  any  suspected  case  the 
greatest  care  should  be  exercised  in  passing  an  instrument  into  the  urethra. 

Diseases  of  the  Prostate. — Acute  prostatitis  and  prostatic  abscess  both  give  rise  to 
pain  during  micturition,  in  addition  to  increased  frequency  and  difficulty  during  the  act. 
Both  are  usually  sequehc  of  an  acute  urethritis,  and  whereas  an  acute  prostatitis  is  accom- 
panied by  a  temperature  raised  to  100^  F.  or  101°  F.,  a  prostatic  abscess  causes  the  usual 
rise  and  fall  in  temperature  common  to  septic  processes.  The  diagnosis  of  the  two  condi- 
tions is  made  readily  on  careful  rectal  examination,  when  the  acutely  inflamed  gland 
presents  a  much  enlarged,  smooth-surfaced  prominence  in  the  rectum  :  whilst  if  an  abscess 
be  present,  a  softer  area  in  the  inflamed  gland  can  usually  be  detected.  An  acute  prosta- 
titis may  accompany  a  haematogenous  bacterial  urinarj'  infection  as  distinct  from  a 
venereal  urethritis. 

Adenomatous  enlargement  of  the  prostate  gives  rise  to  no  penile  pain  during  micturi- 
tion ;  neither  does  the  prostate  containing  tuberculous  deposits,  but  pain  in  the  penis  is 
present  during  micturition  occasionally  in  cases  of  prostatic  carcinoma,  owing  to  the  direct 
infiltration  of  the  urethral  mucous  membrane.  Prostatic  carcinoma  is  by  no  means  un- 
common, and  whilst  in  its  general  symptoms  it  resembles  those  of  prostatic  adenoma, 
there  is  a  marked  difference  found  on  digital  examination  of  the  gland  per  rectum.  The 
carcinomatous  gland  presents  roimded  areas  of  densely  infiltrated  tissue,  in  contradistinc- 
tion to  the  elastic,  uniform  feel  of  the  adenomatous  variety  ;  the  whole  gland  is  fixed  and 
immovable,  and  in  advanced  stages  distinct  infiltration  of  the  lateral  pelvic  lymphatics 
may  be  felt  extending  laterally  from  the  affected  organ. 

Care  nuist  be  taken  not  to  mistake  the  hard  nodules  felt  in  a  prostate  containing  calculi 
for  carcinoma.  With  calculous  disease,  the  gland  is  not  flxed  and  is  only  slightly  enlarged, 
whilst  on  gentle  pressure  with  the  examining  finger  the  calculi  may  be  felt  to  grate  upon 
each  other.  During  the  passage  of  a  catheter  through  the  prostatic  urethra,  distinct  grat- 
ing may  be  felt  if  any  calculus  has  ulcerated  the  urethral  wall. 

Diseases  of  the  Bladder  may  cause  penile  pain  during  micturition  under  certain 
circumstances,  although  it  is  much  more  common  to  find  that  ])ain  in  vesical  disease 
follows  the  completion  of  micturition.  In  acute  cystitis,  penile  jiain  is  present  throughout 
micturition,  due  to  the  intense  congestion  of  the  vesical  mucous  membrane  of  the  trigone 
and  around  the  internal  urethral  orifice.  The  other  symptoms  of  acute  cystitis,  namely, 
suprapubic  pain,  pyrexia,  increased  frequency  of  micturition,  and  the  presence  of  pus  and 
blood  in  the  urine,  are  sufficient  for  the  diagnosis. 

Pain  during  micturition  in  other  vesical  lesions  is  caused  whenever  there  is  any  sudden 
obstruction  to  the  normal  flow  of  urine  by  the  implantation  of  some  body  against  the  inter- 
nal urethral  orifice.  This  may  occur  with  a  small  calculus  or  with  a  pedunculated  tumour, 
whether  simple  or  malignant,  when  during  micturition  the  flow  is  arrested  suddenly, 
accomiianied  by  a  shooting  pain  in  the  urethra,  whilst  after  an  interval  of  a  few  seconds 
the  stream  may  be  re-established.     ^Vith  vesical  calculus,  the  urine  may  be  normal  or  may 


PAIN     IX     THK     PENIS  471 

contain  pus  and  blood  if  tlio  bladder  has  become  infected  ;  tliere  is  penile  i)ain  after  mic- 
turition, and  the  stone  may  be  felt  with  a  sound.  With  a  simple  villous  papilloma  there 
is  no  pain  unless  part  of  the  fimbriated  ijortion  of  the  tumour  engage  in  the  urethral  orifice 
during  micturition,  but  there  are  usually  recurrent  attacks  of  profuse  ha?maturia.  whilst  with 
a  villous-covered  carcinoma  there  is  increased  frequency  of  micturition,  with  pain  following 
the  act,  more  or  less  constant  hsematuria,  and  usually  pyuria.  Upon  rectal  or  vaginal 
examination,  the  base  of  the  bladder  may  be  felt  to  be  infiltrated,  but  by  far  the  most 
valuable  means  of  diagnosis  between  the  three  conditions  is  cystoscopy,  when  a  calculus  or 
villous  tumour  is  seen  readily,  whilst  a  pedunculated  carcinoma  appears  as  a  dark  red 
tumour  covered  with  stunted  processes.     (See  Plate  XVI,  p.  284.) 

II.  PENILE    PAIN    FOLLOWING    MICTURITION. 

This  symptom  is  common  to  many  lesions  of  the  urinary  bladder,  more  especially 
those  in  which  there  is  ulceration  or  infiltration  of  the  basal  areas.  The  particular  pain 
felt  by  the  patient  is  described  as  a  sharp  pricking  or  tingling  at  the  terminal  part  of  the 
penis  on  the  cessation  of  micturition,  lasting  some  minutes  and  causing  a  desire  to  squeeze 
the  glans.  It  has  often  been  described  as  typical  of  vesical  calculus,  but  this  is  far  from 
being  the  case,  for  it  may  be  due  to  almost  any  affection  of  the  trigone. 

The  common  causes  of  pain  in  the  i)enis  following  upon  micturition  are  : — 

1.    J'csical —  2.    Vreteric —  4.    J'esicular — 

Calculus  Calculus  in  lower  end  Acute  spermato-vcsiculltis 

Tuberculosis  Descending  ureteritis  5.   Rectal — 

Tumour — carcinoma  Descending  tuberculosis.  Carcinoma. 

papilloma  :i.  Prostatic —  6.  Anal — 
.Acute    cystitis                                      .\eute  inflammation  Fissure 

Bilharzia.  .\bscess  Inflamed    ha'inorrhoids. 

Calculus. 

In    Diseases   of   the    Bladder. 

.\  cdlciiliis  in  flic  l)la(ldcr.  unless  it  is  trapped  in  the  pouch  behind  an  enlarged  prostate, 
causes  pain  in  the  glans  ]Knis  after  micturition.  It  may  exist  without  causing  cystitis, 
although  commonly  there  is  some  degree  of  pyuria  when  the  case  is  first  seen.  There  is 
increased  frequency  of  micturition  during  active  exercise  or  during  the  jolting  of  travelling, 
but  not  during  complete  rest  unless  cystitis  is  marked.  The  terminal  drops  of  urine  during 
micturition  are  often  tinged  with  blood,  and  on  some  occasions  there  may  liave  been  a 
sudden  stoppage  of  the  stream  during  micturition.  In  some  cases  there  is  a  history  of  the 
descent  of  a  stone  from  the  kidney  without  the  subsc<|ucnt  ap])carance  of  a  calculus  in  the 
urine.  Patients  sidjjcct  to  vesical  stone  have  usually  reached  the  later  jjart  of  life,  and 
although  the  symptoms  are  as  a  rule  suHiciently  marked  to  render  the  diagnosis  easy, 
sometimes  they  may  be  so  few  that  vesical  calculus  is  quite  unexpected,  or  the  symptoms 
are  so  like  those  caused  by  other  lesions  of  Ihc  bladder  that  error  is  easy.  In  such  a  case 
it  is  advisable  to  examine  the  intcrioj  of  Ihc  bladder  with  a  cystoscope  rather  than  b\'  the 
usual  vesical  sound  :  with  a  sound  a  small  calculus,  or  one  contained  in  a  vesical  pouch, 
may  be  missed,  whilst  with  a  cy.stoscopc  it  is  seen  readily,  its  approximate  size  determined, 
and  any  other  condition  of  the  bladder  accompanying  or  simulating  calculus  may  be  dia- 
gnosed with  certainty.     (Sec  Plate  Xl'I.  p.  284,  and  Fig.  1;J5,  p.  282.) 

I'e.iical  tuberculosis  may  be  a  jirimary  aricetion.  but  is  more  fre(|ucntly  secondary  to 
tuberculous  disease  in  some  other  part  of  the  genito-urinary  tract.  It  causes  marked 
penile  pain  after  micturition,  together  with  pyuria  and  a  tinge  of  blood  in  the  terminal 
drops  of  urine  ;  the  frc<|Mcncy  of  micturition  is  iticrcased  during  both  day  and  tiiglit,  and 
is  uniiilluenced  by  rest,  thus  diliering  from  the  increased  frccjuency  of  c'aleulous  disease. 
Vesical  tuberculosis  usually  occurs  in  yoimg  adults,  but  it  must  be  distinguished  carefully 
from  other  vesical  infections,  and  more  particularly  from  renal  tuberculosis,  in  which 
.symptoms  referable  to  the  bladder  arc  eotnmonly  present  before  the  bladder  is  attaiked  b> 
disease.  In  a  young  patient  in  whom  increased  fre(|uenev  of  micturition,  pyuria,  and 
penile  pain  arc  present,  a  search  should  be  made  for  any  tuberculous  focus,  especially  in 
the  testes,  prostate,  and  seminal  vesicles,  or  for  marketl  thickening  of  the  terminal  mrter 
as  felt  per  rectum,  whilst  a  careful  search  should  be  made  for  tubercle  bacilli  in  the  urine. 
A  cystoscopic  examination  may  be  necessary  to  determine  the  extent  of  the  disease  (Plate 


472  PAIN     IX    THE    PENIS 

AT,  Fig.  E,  p.  282).  but,  speaking  generally,  the  less  instrumentation  that  is  carried  out 
in  these  cases  the  better. 

I'esical  Tumours. — Carcinoma  of  the  bladder  occurs  in  two  forms  :  the  infiltrating 
epithelioma  and  the  villus-covered  carcinoma.  Either  begins  most  commonly  in  the  basal 
portion  of  the  bladder,  the  muscular  planes  of  which  become  infiltrated.  For  this  reason, 
the  contraction  of  the  bladder  wall  during  micturition  causes  pain  which  is  referred  to  the 
terminal  portion  of  the  urethra.  Both  forms. occur  in  elderly  patients,  and  give  rise  to 
increased  frequency  of  micturition  during  both  day  and  night,  and  to  hematuria.  They 
also  often  give  rise  to  renal  pain  when  the  infiltration  has  extended  to  the  ureteric  orifice 
in  the  bladder.  The  base  of  the  bladder  may  be  foiuid  per  rectum  to  be  infiltrated,  or 
enlarged  glands  may  be  felt  in  the  lateral  pelvic  space,  and  a  cystoscopic  examination  will 
usually  clear  up  the  diagnosis  (Plate  XVI,  p.  284). 

Whereas  the  carcinomatous  growths  of  the  bladder  give  rise  to  penile  pain  after 
micturition  from  the  direct  infiltration  of  the  vesical  walls,  the  pedunculated  villus- 
covered  carcinoma  and  the  simple  villous  papilloma  may  give  rise  to  sharp  penile  jiain 
during  micturition,  from  the  blocking  of  the  internal  urethral  orifice  with  a  process  of 
growtli.  The  <K'currence  of  this,  together  with  attacks  of  profuse  ha-maturia,  are  evidence 
of  a  pedimculated  growth.  On  cystoscopic  examination  the  carcinomatous  pedunculated 
tumour  is  seen  to  be  covered  by  blunt,  stunted  processes  ;  it  is  often  multiple,  whereas  the 
innocent  villous  papilloma  is  single  and  presents  much  more  delicate  fimbria". 

Acute  cystitis  causes  tingling  pain  in  the  penis  after  micturition  from  the  inflammatory 
infiltration  of  the  trigonal  area.  The  mode  of  onset,  the  character  of  the  pain,  and  other 
symptoms  of  cystitis  will  point  to  the  cause  of  the  pain. 

Bilharzia  luemdtobia  gives  rise  to  clinical  symjjtoms  very  similar  to  those  of  vesical 
tuberculosis.  The  history  of  residence  in  an  infected  district,  the  microscopical  examin- 
ation of  the  urine  for  ova  (see  Fig.  26,  p.  79),  and  the  typical  cystoscopic  appearance  of  the 
bladder  (see  Plate  XVI,  Fig.  K,  p.  284)  will  render  the  diagnosis  apparent. 

Ureteric  lesions  not  infrequently  produce  jjain  in  the  glans  penis  after  micturition, 
and  may  cause  considerable  difficulty  in  the  diagnosis  from  vesical  disease. 

When  a  calculus  becomes  impacted  in  the  narrowed  terminal  or  intramural  portion  of 
the  ureter,  symptoms  are  produced  almost  exactly  similar  to  those  of  vesical  calculus  or 
tuberculosis,  namely,  increased  frequency  of  micturition,  pain  in  the  glans  penis  after 
micturition,  and  a  small  amoimt  of  pus  and  blood  in  the  urine.  Intimate  knowledge  of 
the  history  of  the  illness  will  often  be  of  value  in  these  cases  ;  the  first  attack  of  pain  is 
usually  described  as  being  sudden,  and  felt  in  the  renal  angle  posteriorly,  passing  forward 
above  the  iliac  crest  and  spine,  and  finally  becoming  localized  at  the  situation  of  the  external 
abdominal  ring.  The  calcidus  may  become  impacted  in  the  terminal  inch  of  the  ureter, 
when,  in  addition  to  this  pain,  increased  frequency  of  micturition  and  penile  pain  are  added. 
In  a  recent  case  imder  the  author's  care,  in  which  a  small  oxalate  calculus  was  impacted  in 
the  terminal  ])art  of  one  ureter,  there  were  frequent  attacks  of  fairly  profuse  hiiematuria. 
suggesting  a  villous  ])api!loma,  but  this  is  probably  infrequent.  With  ureteric  calculus 
there  is  usually  [jain  in  the  kidney  of  the  affected  side  from  the  dilatation  of  the  pelvis  of 
the  latter,  due  to  the  increased  renal  tension.  The  diagnosis  of  these  cases  is  not  so  diffi- 
cult if  a  careful  enquiry  is  made  into  the  history  and  symptoms,  and  so  long  as  it  is  remem- 
bered that  increased  frequency  of  micturition  and  penile  jiain  may  be  caused  by  ureteric 
impaction  of  a  calculus.  A  good  skiagrapliic  examination  of  the  pelvic  areas  may  show 
the  shadow  of  a  stone  (Fig.  13.5.  p.  282),  whilst  the  latter  may  be  felt  occasionally  as  a  small, 
painfid  nodule  above  the  seminal  vesicles  upon  examination  per  rectum.  A  cystoscopic 
examination  also  affords  valuable  information,  not  only  in  excluding  vesical  lesions,  but 
by  giving  a  distinct  indication  of  ureteric  calculus  by  the  marked  congestion  and  dilatation 
of  the  blood-vessels  in  the  immediate  vicinity  of  the  ureteric  orifice.  ,A  small  bougiepassed 
into  the  ureter  may  meet  with  obstruction  in  its  passage,  whilst  a  wax-tipped  bougie  may 
be  grooved  or  indented  by  the  stone. 

Ureteritis  descending  from  infection  of  the  renal  pelvis  may  give  rise  to  slight  penile 
I)ain  and  to  increased  frequency  of  micturition,  and  thus  simulate  vesical  disease  before  the 
Ijladder  is  actually  affected.  This  is  most  commonly  seen  in  the  tuberculous  form,  but  is 
])resent  in  a  less  marked  degree  with  infection  by  other  organisms,  of  which  the  most  com- 
mon are  the  Bacillus  coli  communis  and  the  staphylococcus.     In  the  non-tuberculous  form. 


PAIN     IN    THE    PENIS  47H 

the  ureter  may  be  felt  per  rectum  to  be  slightly  thickened,  but  the  cystoscopic  appearance 
of  the  inflamed  ureteric  orifice  is  quite  distinctive  (Plate  XI'.  Fig  C.  p.  282).  In  descending 
tuberculosis  from  the  kidney,  the  ureter  may  be  felt  as  a  firm,  infiltrated  cord  on  the  bladder 
base,  the  penile  pain  and  increased  frequency  of  micturition  are  more  marked,  the  kidney 
may  be  felt  enlarged  and  tender,  and  tubercle  bacilli  will  be  found  in  the  urine.  Apart 
from  this,  typical  changes  in  the  ureteric  orifice  are  seen  on  cystoscopic  examination,  the 
orifice  being  ])ulled  up  or  retracted  or  horse-shoe  .sliape,  and  usually  occupying  a  position 
slightly  above  and  outside  the  situation  of  the  normal  orifice,  due  to  the  actual  shortening 
of  the  duct  by  infiltration  of  the  submucous  coats  (Plate  ATI',  Fig.  D,  p.  282). 

Diseases  of  the  Prostate  often  cause  pain  in  the  penis  immediately  following  mic- 
turition. This  is  most  commonly  seen  with  acute  inHanunation  or  abscess  in  the  gland  as 
a  sequela  of  acute  gonorrhoea  or  septic  urethritis.  In  either  ease  there  is  penile  pain,  some- 
times associated  with  erection,  but  little  dilficulty  will  be  experienced  in  the  diagnosis  on 
due  consideration  of  the  symptoms  and  upon  rectal  examination. 

Prostatic  calculi  are  not  uncommon,  and  there  may  be  a  single  calculus  or  a  nest  of 
them  in  the  prostate.  They  tend  to  ulcerate  into  the  urethra,  so  that  small  calculi  may  be 
passed  in  the  urinary  stream,  or  some  may  pass  back  along  the  dilated  prostatic  urethra 
into  the  bladder.  If  a  calculus  projects  from  the  prostate  into  the  urethra,  it  causes  pain 
in  the  penis  after  micturition.  A  diagnosis  of  prostatic  calculus  is  often  made  by  the  grat- 
ing sensation  imparted  to  a  catheter  in  traversing  the  prostatic  urethra,  whilst  on  rectal 
examination  the  calculus  may  be  felt  as  an  isolated,  hard  nodule  in  the  gland,  or,  if  more 
than  one  is  present,  by  the  crepitation  of  one  upon  another  on  digital  pressure  in  the 
rectum. 

Diseases  of  the  Seminal  Vesicle  are  seldom  present  without  accompanying  disease  of 
the  prostate  or  bladder.  Acute  vesiculitis  may  follow  a  urethritis  and  give  rise  to  pain 
after  micturition,  but  in  most  cases  will  be  associated  with  prostatitis.  Similarly  tuber- 
culous nodules  in  the  vesicle  will  be  associated  with  foci  in  the  epididymis,  prostate,  or 
bladder. 

Diseases  of  the  Rectum  and  Anus  may  occasionally  give  rise  to  penile  pain  following 
micturition,  apart  fnini  any  infection  of  the  bliiddcr  or  prostate.  Thus,  a  carcinoma  in 
the  anal  canal,  a  rectal  fissure,  or  an  inflamed  hanuirrlioid  may  occasionally  cause  pain 
in  thi-  penis,  but  in  each  the  local  symptoms  of  the  trouble  will  be  the  more  marked,  and 
little  dilliculty  will  be  found  in  the  diagnosis  if  a  locai  examination  is  made  with  care. 

III.   PAIN    IN    THE    PENIS    APART    FROM    MICTURITION. 

I'nilci-  llic  above  divisions  the  symiitoni  |)enilc  pain  has  been  considered  in  relation  to 
the  act  of  micturition,  and  it  remains  to  consider  some  eonditiniis  giving  rise  to  pain  in  the 
penis  apart  from  urination.  These  include  certain  local  lesions  of  the  penis  and  urelhra, 
and  also  the  pains  referred  from  disease  elsewhere.  .Mthough  a  local  lesion  may  cause 
little  more  than  discomfort  in  many  patients,  in  some  it  is  described  as  pain,  the  degree  of 
which  <lepends  upon  the  nervous  su.sceptibility  of  the  patient.  Thus,  penile  jiain  may  be 
present  with  acute  urethritis,  with  Ijalanitis  in  association  with  jihimo.fis.  with  paraphinuisis, 
or  with  the  li/miiluingilis  of  the  organ  due  to  a  septic  sore  or  abrasion  of  the  skin  or  mucous 
membrane.  In  some  instances  herpes  of  the  jirepuee  or  penile  skin  causes  dislincl  pain. 
Any  inlillralioii  of  the  cavernous  tissue  of  the  penis  causes  pain  during  erection  of  the  oi'gan  ; 
thus  dining  an  attack  of  acute  urethritis  the  eonunon  symptom  known  as  chordec  arises 
from  this  cause,  whilst  in  a  chronic  form,  cavernitis  may  be  due  to  infiltration  in  associa- 
tion with  tertiary  syphilis  or  the  gouty  diathesis,  .so  that  erection  of  the  organ  is  only  partial 
or  confined  to  I  he  proximal  pari,  and  causes  ]>ain.  .Vnolher  condilion  causing  the  same 
condition  arises  fnirii  the  organization  of  a  lurniatoiiia  In  llic  eaxcrnous  (issues  of  the  penis 

■  following  upon  a  local  injiHy,  eillier  I'rorii  external  \  jolcncc  or  during  I'oreilile  alleinpis  at 
coitus. 

Kpithclionia  ol  llic  penis  oceasidiially  gives  rise  to  pain  in  Hie  organ. 
I'aiii  may  be  fell  in  the  jienis  in  some  cases  of  renal  colic,  in  which  ease  il  is  classed  as 
a  relerrcd  pain.     Thus,  in  the  acute  colic  accompanying  the  passage  of  a  calculus,  blood- 
clot,  or  debris  of  <'aseous  material,  aching  pain  may  be  felt  in  the  penis  quite  apart  from 
the  increased  desire  to  jiass  urine.      I'enile  jiain  is.  however,  only  a  minor  detail  in  Hie  pre- 

-seneeof  the  .severe  pain  in  the  loin,  and  is  often  only  lightly  alluded  to. 


474 


PAIN    IN    THE     PKRINEFM 


Pain  in  the  penis  was  a  prominent  early  symptom  in  two  recent  cases  of  ncuic  appendi- 
citis under  the  writer's  care.  In  neither  case  was  it  associated  with  micturition,  nor  was 
there  any  increased  frequency  of  micturition,  but  in  both  the  a])pendix  was  found  to 
occupy  a  very  low  position,  turning  down  into  the  pelvis,  which  in  one  case  contained  a 
foul  abscess.  /?.  //.  Jocehjn  Sxvan. 

PAIN  IN  THE  PERINEUM — is  a  symptom  often  mentioned  by  ]]atients  in  giving 
their  history  of  some  aUrclion  of  the  genito-urinary  apparatus  or  of  other  organs,  but 
usually  only  as  a  dull  aching,  of  which  little  notice  is  taken,  as  it  is  generally  of  minor  con- 
sequence in  comparison  with  other  more  striking  symptoms.  The  complaint  of  perineal 
pain  per  se  does  not  convey  much  information  to  the  clinician,  and  it  is  practically  never 
present  as  the  only  symptom  in  a  case. 

Aching  in  the  perineum  is  frequently  present  in  diseases  of  the  following  organs  : — 


Prostate — 

Acute  or  subacute  in- 
flammation 

Abscess 

Tuberculosis 

Calculus 

Acicnomatous     en- 
largement 

Carcinoma. 
Seminal  7 'esiclcs — 

Acute  inflammation 

Tuberculosis. 
Urinary  Bladder — 

Cystitis 

Tuberculosis 


Calculus 

Carcinoma 
Urethra — 

Injury  and  rupture 

Stricture  with  extravasa- 
tion or  urethral  abscess 

Fistula 

Calculus  impacted  in  Inil- 
bous  portion. 
Testicle — 

Congenital     misplacement 
in  perineum. 
Anal  Area — 

Hiemorrhoids 

Fissvirc 


Boil 

Carbuncle 

Ulcer 

Carcinoma. 
J'agina — 

Acute  inflammation 

Inflammation    or    abscess 
of  Bartholin's  glands 

Cystocele 

Epithelioma. 
Ciiliincous  Diseases — 

Intertrigo 

Eczema,   gouty   and    dia- 
betic 

Condylomata. 


From  the  foregoing  list  it  will  be  seen  that  aching  in  the  perineiuu  occurs  with  numerous 
different  lesions,  but  other  symptoms  discussed  elsewhere  are  in  almost  every  case  more 
marked.  B.  H.  Jocelyn  Swan. 

PAIN,  PRECORDIAL.— (See  P.\in  in  the  Cuf.st.  p.   480.) 


PAIN  IN  THE  SHOULDER  (see  al.so  P.\in  in  the  Extremity,  Upper,  p.  442)  may 
l)e  due  to  two  entirely  dillcicnt  main  groups  of  causes,  namely  :  (1)  Direct  causes,  in  which 
the  shoulder-joint  itself  is  involved,  or  the  nerves,  ligaments,  muscles,  fasciae,  bursae,  close  to 
it  ;  and  (2)  Indirect  causes,  in  which  the  pains  are  referred  to  the  shoulder  region  when  the 
real  scat  of  disease  is  at  a  distance,  as  in  the  case,  for  instance,  of  angina  pectoris,  or  gastric 
or  hepatic  disorders.     The  conditions  to  be  thought  of  include  the  following  : — 


1.  Direct  Causes  :- 

Injury 
Arthritis 
Synovitis 
Fibrositis 


Myositis 
Neuritis 

Effects  of  exposure  to  cold 
or  damp 


2.  Indirect  Causes  : — 

(a).   Cardiovascular  lesions. 
Angina  pectoris  |        .4ortic  atheroma  (sy])hilitic) 

Aortic  valvular  disease         j 

(b).  Pleural,  pulmonary,  or  vicdiaslinal  lesions. 
Pleurisy 
Pneumonia 

(c).  Gastric  lcsio)is. 
Flatulence 
Indigestion 

(d).  Duodenal  lesions. 
C'atarrh.  with  or  witliout 
jaundice 


Plithisis 

Intrathoracic  new  nrowtli 


Gastritis,  acute  or  chronic 
Gastric  idccr 


Duodenal  ulcer. 


Effects  of  occupations 
Subacromial  bursitis 
Muscular  jiaralysis,  local. 


Aortic    aneiuvsm. 


Pneumothorax. 


Gastric  carcinoma 


PAIN     IN    THE    SHOULDER 


(e).  Hrpalic  lesions. 

Biliousness 
Gall-stones 
Cholecystitis 

(/).  Nervous  lesions. 

Hemiplegia 
Herpes  zoster 
Acute  bracheitis 


Nutmeg  liver 
New  gro%vth 


Cervico-dorsal  spinal  caries 
New     growth      in    cervioo- 
dorsal   spine 


Hepatitis,  acute  tropical 
Abscess. 


Pachymeningitis,  syphilitic 

ccrvieo-dorsal 
Cervico-brachial  neuralgia. 


Tlie  term  shoulder  is  not  explicit,  and  a  patient  may  complain  of  pain  in  the 
shoulders  when  careful  inquiry  shows  that  it  has  widely  different  situations  in  different 
cases  ;  in  one  it  may  be  mainly  in  the  root  of  the  neck  or  in  the  central  clavicular  region  ; 
tinder  the  deltoid  region  in  a  second  ;  under  the  lower  part  of  the  blade  of  the  scapula  in 
a  third  ;  and  so  on.  The  first  step  in  making  the  diagnosis  is  to  locate  the  pain  complained 
of  as  definitely  as  possible. 

It  is  often  easy  to  diagnose  its  cause  with  some  certainty  from  this  point  alone.  If, 
for  instance,  the  pain  is  mainly  under  the  left  shoulder-blade,  its  origin  is  likely  to  be  gastric 
or  intrathoracic  ;  if  mainly  under  the  right  shoulder-blade,  duodenal  or  hepatic.  (See 
P.\iN,  Interscapul.\r,  p.  461.)  If  on  the  other  hand  the  pain  is  definitely  localized  to 
the  region  of  the  shoulder-joint,  the  mischief  is  probably  within  the  joint  itself,  or  in  tin- 
fibrfius  tissues,  ligaments,  bursae,  muscles  or  ner^'cs  around  the  joint. 

The  next  point  to  investigate  is  the  condition  of  the  parts  at  and  I'ound  the  shoulder  ; 
if  there  is  definite  tenderness  as  well  as  pain,  increased  ))ain  on  attempted  movement, 
local  deformity  from  swelling  or  from  wasting,  or  impaired  mobility  at  the  shoulder-joint, 
the  trouble  is  jirobably  local  and  the  iiains  are  not  referred  from  the  viscera.  It  may  be 
dillicult  to  be  sure  that  there  is  no  local  tenderness  as  well  as  pain,  for  the  patient  may 
have  suffered  so  much  that  he  winces  on  palpation,  from  an  expectancy  of  pain,  when 
palpation  or  attcnijjts  at  moving  the  joint  are  really  painless  ;  considerable  judgement 
is  rc(|uircd  in  deciding  just  how  much  tenderness  is  present  as  well  as  pain,  especially 
in  nervous  subjects.  If,  however,  there  is  definite  tenderness  as  well  as  pain,  the  trouble 
is  most  likely  local  ;  and  the  same  applies  when  the  ]>ain  is  made  materially  worse  by  local 
movements. 

In  testing  the  mobility  of  the  shoulder-joint,  it  is  important  not  to  rely  on  the  patient's 
statements  or  on  inspection  only  ;  (ar<  lul  ])alpation  is  required.  Fre(iuintly  the  patient 
may  seem  to  move  his  shoulder  well  when,  if  the  angle  of  the  scapula  is  gras])ed  whilst  the 
patient  moves  his  liunierns,  it  will  be  found  that  the  shoulder-blade  moves  synchronously 
with  abduction  of  the  arm.  there  being  little  or  no  l)lay  at  the  glenoid  fossa.  Normally, 
when  the  humerus  is  abducted,  the  seajjula  sliould  remain  stationary  \mtil  the  arm  is  at 
a  right-angle  with  the  trunk  :  if  the  upward  movement  of  the  extended  and  abducted  arm 
is  eontimied  beyond  the  right-angle,  the  seajnila  normally  mo\(s  with  it.  If  it  begins  to 
move  before  the  right-angle  is  reached,  there  is  something  the  matter  in  or  around  the 
shouldcr-joinl.  More  often  than  not  the  mischief  is  <luc  to  periarlliritle  changes  rather 
than  to  osteoarthritis  or  other  intra-articular  inflammation  :  the  fixation  is  due  to  the 
muscles  being  on  guard  to  ])revent  any  movement  that  would  produce  pain.  Under  an 
ana-stlictic  mol>iIity  may  be  found  to  be  nearly  perfect. 

'J'bc  diUcrciilial  diagnosis  between  the  \arious  conditions  that  may  affect  the  joint  is 
discussed  in  Ihc  arliele  fin  .loiNrs  (p.  .'{.'JT).  I'lbrosilis  and  myositis  arc  in  most  res])ccts 
C(|ui\alent  to  infective  ])eriartliritis.  and  il  i^  ottcii  a  inallcr  of  opinion  whether  any 
particular  itd'cctive  indanunatory  condition  aidund  I  be  joint  is  to  be  styled  infective 
synovitis,  or  librositis,  or  myositis.  Any  of  the  three  may  involve  one  shoulder  region  only, 
but  more  often  the  ])aticnt  has  signs  and  symptoms  of  rheiunaloid  arthritis  elsewhere  also. 

'I'hc  ellVcIs  of  injury,  exposure  to  cold  and  damp,  and  of  occupations,  when  (hey  involve 
the  shoulder  region,  arc  only  partic^idar  varieties  of  librositis,  myositis,  and  arthritis.  The 
stiffness  and  pain  that  may  result  from  sleeping  in  a  damj)  room  with  the  shoulders  im- 
covcrerl  by  the  Ix'dclothes  may  be  very  severe,  and  they  may  take  weeks  or  months  to 
pass  off.  The  chief  question  will  be  whether  the  exposure  may  not  hiive  <'aused  actual 
rhciniiatoid  artbrilis.  ur  ha\<-  brougbl  on  a  gouty  iiillaimnalion  or  neuritis,  Iti  addition  to 
mere  slilincss  and    pain   (if  a    Ivpc  alliid    h,  slid   iiccU   .,r   lijiribaLio  ;     and    Ihc  difrerciil  iai  ion 


476  PAIN    IX    THE    SHOULDER 

will  often  be  a  matter  merely  of  opinion.  The  same  applies  to  the  effects  of  injury  :  in 
some  cases  the  bruising  or  the  tearing  of  ligaments,  or  the  fracture  of  bones,  or  their  dis- 
location, may  be  followed  by  pain  and  stiffness  continuing  to  affect  the  shoulder  region 
for  months  or  years  afterwards  :  in  addition.  howe\'er,  the  injury  may  set  up  actual 
arthritis  allied  to  osteo-arthritis,  and  like  the  latter,  more  or  less  permanent.  The  .r-rays 
may  help  in  determining  the  exact  degree  of  local  disease  the  injury  has  produced.  Occupa- 
tions inxolving  constant  use  of  the  shoulder  often  result  in  permanent  intra-articular 
changes  also — a  sort  of  osteo-arthritis  ;  the  tendency  increases  with  age  ;  and  very  likely 
the  occupation — such  as  that  of  porters  who  carry  llea^y  weights  on  the  shoulder — deter- 
mines the  site  of  the  first  joint  to  be  affected  rather  than  actually  initiates  the  disease. 
Besides  intra-articular  changes,  however,  occupations  in^•olving  strenuous  and  constantly 
repeated  use  of  the  shoidders  may  cause  pain  in  them  of  the  same  nature  as  that  of  wTiter"s 
cramp  and  other  occupation  neuroses.  Rowing  men.  navvies,  stokers,  and  so  on,  may 
suffer  in  this  way.  It  is  often  very  difficult,  however,  to  distinguish  between  the  occupa- 
tion neurosis  and  organic  fibrositis.  myositis,  neuritis,  or  arthritis. 

One  well-defined  but  often  unrecognized  cause  of  painful  shoulder,  in  wliich  both 
recurrent  slight  injury  and  occupation  play  an  important  part,  is  subacromial  biiisilis. 
Outside  the  upper  part  of  the  capsule  of  the  shoulder-joint,  between  it  and  the  under  surface 
of  the  acromion  process,  there  is  a  fairly  large  bursa.  This  becomes  inflamed  from  overuse 
or  overstrain  of  the  shoulder  in  much  the  same  way  that  housemaid's  knee  results  from 
])ersistent  kneeling  :  but  with  this  difference,  that  the  swollen  subacromial  bursa  cannot 
be  seen  or  grasped  as  an  inflamed  prepatellar  bin-sa  can.  Pain  on  using  the  shoulder  in 
certain  positions  is  the  chief  complaint.  The  trouble  arises  from  falls  or  blows  upon  the 
a])ex  of  the  shoulder,  or  from  occu]3ations  involving  rejjeated  sudden  jerks  to  the  shoulders 
— it  is  common  in  golfers,  tennis  jjlayers,  bowlers,  or  in  those  who  throw  the  cricket  ball 
or  put  the  weight  ;  it  also  arises  when  the  daily  work  involves  the  maintenance  of  a  strain 
against  interrupted  resistance,  as  in  the  case  of  certain  tools  employed  in  electric  steel 
grooving  and  the  like.  The  diagnostic  point  is  as  follows  :  on  minute  palpation  of  the 
shoulder  region,  when  the  arm  is  at  the  patient's  side  there  is  a  definitely  and  often  acutely 
tender  s])ot  immediately  below  the  tip  of  the  acromion  process,  but  if  the  patient  now 
abducts  the  arnr  as  far  as  he  can,  palpation  of  the  previously  tender  spot  no  longer  elicits 
any  tenderness  at  all  ;  on  adducting  the  arm  to  the  side  the  tender  focus  is  again  discover- 
able with  ease.  The  explanation  of  the  disappearance  of  the  tenderness  on  abduction  of  the 
arm  is  that  this  movement  takes  the  subacromial  bursa  far  enough  under  cover  of  the 
acromial  process  for  it  to  be  no  longer  open  to  direct  palpation.  In  cases  of  this  sort  .r-ray 
examination  generally  shows  a  wider  clear  space  between  the  acromion  process  and  the 
head  of  the  humerus  on  the  affected  than  on  the  normal  side. 

In  any  case  of  doubt  .c-ray  examination,  not  only  of  the  shoulder  region  but  also  of  the 
\Nhole  thorax,  should  be  resorted  to  :  now  and  again  an  unsuspected  aneurysm  of  the  aortic 
arch  interfering  with  the  lower  part  of  the  right  brachial  plexus  will  be  found  to  be  the 
cause  of  acute  pains  in  the  right  <leltoid  region  ;  or  a  mediastinal  new  growth,  or  rarities 
such  as  a  hydatid  cyst  in  the  chest  (Fig.  137,  p.  291)  may  be  discovered  when  mere  arthritis 
has  been  alone  suspected.  Angina  pectoris  is  responsible  for  very  acute  pain  in  the  left 
shoulder  region,  but  hardly  ever  here  alone  ;  the  attacks,  and  the  spread  of  the  jiain  from 
the  precordial  region  to  the  left  shoulder  and  down  the  left  arm  are  generally  characteristic  ; 
and  their  nature  will  be  confirmed  by  examination  of  the  heart,  including  resort  to  electro- 
cardiograms if  need  be,  and  by  the  inHuencc  of  amyl  nitrite  or  nitroglycerine  on  the 
])aroxysms. 

I'ains  referred  to  the  shoulder  in  cases  of  phthisis  are  generally  of  the  nature  of  dull 
discomfort  or  of  aching  than  of  acute  pain  ;  and  the  patient  generally  has  had  cough, 
wasting,  night  sweats,  and  so  on,  to  indicate  the  diagnosis,  which  is  confirmed  by  the  exist- 
ence of  abnormal  apical  signs,  by  the  discovery  of  tubercle  bacilli  in  the  sputum,  or  by 
a,'-ray  examination  of  the  chest  {Fig.  41,  p.  103).  Pleurisy,  pneumonia  and  pneumothorax 
will  hardly  ever  cause  pain  in  the  shoulder  as  their  only  symptom,  and  they  will  be 
diagnosed  on  other  groimds. 

Gastric,  hepatic  and  duodenal  lesions  causing  pain  in  the  shoulder,  do  so  in  the  sul)- 
scapular  region  rather  than  in  the  region  of  the  shoulder-joint  itself — stomach  disorders  on 
the  left  side,  hepatic  and  duodenal  on  the  right.     They  are  discvissed  in  the  article  on  Pain. 


PAIN     I\    THE    TESTICLE  477 

Interscapular  (p.  461).  The  cliicf  (iilfieulties  that  remain  arc  the  nervous  causes,  direct 
and  indirect.  Herpes  zoster  will  be  recognized  by  the  characteristic  eruption  (p.  7.54),  and 
the  pains  will  nearly  always  extend  down  the  arm  and  not  be  confined  to  the  shoulder 
region.  The  cliief  jjoint  to  bear  in  mind  is  that  the  jiains  resulting  from  herpes  may  persist 
for  months  after  the  eruption  has  disappeared,  and  maybe  severe  before  the  vesicles  come 
out.  If  there  is  local  wasting  of  the  muscles  of  the  shoulder  region,  it  does  not  follow  that 
the  ))rimary  lesion  is  nervous,  because  precisely  similar  muscular  atrophy  results  very 
rapidly  from  joint  lesions;  with  the  latter,  however,  there  is  no  R.  D.  (p.  582),  whereas 
with  true  neuritis  there  is.  It  is,  however,  only  when  all  intrathoracic  lesions  have  been 
excluded,  and  when  physical  and  a'-ray  examination  point  to  there  being  no  affection  of 
the  shoulder-joint,  that  neuritis  of  the  circumflex  nerve,  for  instance,  should  be  diagnosed  ; 
an  inaccurate  diagnosis  of  neuritis  is  so  often  made  sim])Iy  because  the  ))atient  has  pains 
and  no  apparent  cause  can  be  found  to  account  for  them.  Acute  bracheitis  is  allied  to  acute 
sciatica  and  acute  anterior  cruritis  ;  it  is  diagnosed  by  analysing  the  distribution  of  the 
pains  carefully,  and  by  excluding  gross  lesions  of  other  structures  in  the  shoulder  region 
or  in  the  chest.  It  is  often  associated  with  marked  nuiscular  atrophy,  so  that  the  humerus 
tends  to  fall  away  from  the  glenoid  fossa  and  the  patient  invents  all  sorts  of  slings  or  splints 
for  the  better  sujiport  of  his  arm.  When  there  is  no  nuiscular  wasting,  the  same  lesion 
would  often  be  termed  eenico-brochial  neuralgia.  Some  such  cases  are  due  to  mucli  more 
serious  lesions,  which  may  baffle  diagnosis  until  the  patient  has  been  watched  for  weeks  or 
months — new  groicth  in  the  cer\ico-dorsal  spine,  for  example  ;  or  cervico-dorsal  tuberculous 
caries  ;  a.'-ray  examination  of  the  vertebra  may  assist  in  the  earlier  recognition  of  these 
conditions,  but  sometimes  it  is  not  until  post-mortem  examination  is  made  that  the  exact 
cause  of  the  [jains — jjossibly  regarded  jireviously  as  in  the  main  neurotic — is  demonstrated. 
The  liemiplcgic  arm  is  sometimes  the  site  of  great  pain,  especially  in  the  shoulder  ;  the  pain 
is  ijrobably  referred  from  the  sensori-motor  cortex  of  the  cerebrum  :  the  differential 
diagnosis  will  be  found  in  the  article  on  Hemiplkgia  (p.  302).  Cervico-dorsal  pachy- 
meningitis of  syphilitic  origin  may  cause  no  more  symptoms  than  ill-defined  though  acute 
paitis  in  various  parts  of  the  neck,  shoulder,  arm  or  hand  ;  peripheral  neuritis  or  myo- 
fibrositis  may  be  the  diagnosis  made.  In  most  cases  it  is  almost  impossible  to  diagnose  the 
pachymeningitis  with  certainty,  though  it  may  be  guessed  at:  and  in  obscure  cases  of 
pain  in  the  shoulder,  apparently  of  nervous  origin,  it  is  often  wise  to  have  a  Wassermann 
test  made.  If  it  is  positive,  approi)riate  anti-syphilitic  treatment  may  cure  the  patient; 
and  it  is  remarkable  how  often  .syphilis  is  found  to  be  at  the  root  of  obscure  pains  and  other 
ill-dcdncd  nervous  complaints,  even  «hen  anv  suspicion  of  svpliilis  miiiht  sccni  to  be  out  of 
""■  ''"f-^''""-  llerl,ert  French. 

PAIN    IN    THE    SPINAL    REGION.-    (.See  I'ain   ,n  tmk  Hack.  p.  427.) 

PAIN  IN  THE  STERNAL  REGION,     (.s,-,-  I'.un  ,n  •,„,,  (■„,,:«•,■,  ,,.  i-o.) 

PAIN    IN    THE   TESTICLE      of  larying  degree  may  be  present  in   many  conditions, 

and  may  be  discussed  under  separate  headings  as  follow.s  : 

I.  Diseases  of  the  lio/li/  of  the  le.itis  or  cpiilidi/mis. 
II.  .iffcclions  of  the  coverings  of  the  testicle. 
III.  Affections  of  the  spermatic  cord. 
W .  A   rrtdincd  or  misplnccil  testicle. 
\ .   I'ain  from   lesions  remote  from   the  testis. 

I.   DISEASES    OF    THE    BODY    OF    THE    TESTIS    OR    EPIDIDYMIS. 

Inflammatory  Lesions  may  attack  the  testis  picper,  or,  as  is  more  coinmoM,  may 
)egin  in  the  eiiididyiiiis  ;  they  ranly  remain  eonlincd  to  one  pari  of  the  organ,  however, 
"or  the  process  lends  to  spread  rapidly  from  one  part  to  the  other,  so  that  the  whole  organ 
S  involved  ari<l  the  result  termed  an  ■■  cjiiilidi/mo-orchitis."  An  inllaiMtii.'ilory  affection 
)f  the  testicle  may  be  acute,  suhaculc,  or  (liniMic,  llic  hitler  lieiiig  the  Icrminal  r.siiil  of 
he  former. 

An  acute  e|)ididymo-orchitis  arises  most  conunonly  by  the  direct  infection  of  the  organ 
'roni  the  urethra  via  the  vas  deferens.     When  any  inllammation  has  reached  the  prostatic 


Causes  of  urethral  origin  : —  j  Ulceration  behind  a  stricture 

Goiiorrhtral  uretliritis  ,  Ulceration     about     an     ini- 

Septic  urethritis  i  pacted     calculus      or     a 

Passage  of  catheters  |  jjrostatic  calculus. 


Urethral  instrumentation 


Injections  into  the  posterior 
urethra. 


47,s  PAIX     IN     THE    TESTICLE 

portion  of  the  urethra,  the  orifices  of  the  vasa  deferentia  may  become  infected,  and  inflam- 
mation spreads  rapidly  along  the  duct  to  the  epididymis  and  testis.  Whilst  formerly  the 
occurrence  of  an  acute  inflammatory  condition  of  the  testis,  following  upon  some  form  of 
urethritis,  was  looked  upon  as  '•  metastatic,"  it  has  been  shown  that  this  view  is  no  longer 
tenable,  and  that  we  must  look  upon  it  as  a  direct  spread  of  infection  via  the  vas  deferens. 
Causes  of  Acute  Epiclidymo-orcliitis  : — 

General  causes  : — 

Fevers — Parotitis  (mumps) 
Enterica 
.Scarlet  fever 
Injury 
Influenza 

(iout  and  rheumatism 
In  haematogenous    urinary 
infections. 

Acute  epididymo-orchitis  begins  as  a  painful  thickening  of  the  epididymis  associated 
with  febrile  symptoms.  Before  any  actual  pain  is  noticed  in  the  testis  there  is  often  a 
sense  of  discomfort  and  weight  over  the  external  abdominal  ring  and  inguinal  canal  due 
to  the  inflammatory  process  extending  along  the  vas  deferens.  The  swelling  of  the 
epididymis  increases,  and  with  it  the  tubules  of  the  testis  proper  become  infected,  causing 
swelling  of  its  body  and  increase  of  pain.  The  whole  organ  thus  becomes  enlarged,  and 
it  is  often  exquisitely  tender,  the  touch  of  the  clothes  or  the  most  gentle  examination  causing 
pain.  The  swollen  gland  is  often  flattened  on  the  outer  and  posterior  aspect  from  pressure 
against  the  adductor  muscles  of  the  thigh  ;  the  vas  deferens  and  tissues  of  the  spermatic 
cord  are  thickened. 

By  far  the  most  common  cause  of  an  acute  epididymo-orchitis  is  an  acute  gonorrhoeal 
urethritis.  During  the  third  week  of  the  disease  the  prostatic  portion  of  the  canal  fre- 
quently becomes  infected,  when  the  orifices  of  the  ejaculatory  ducts  may  share  in  the 
inflammation,  and  infection  be  conveyed  by  the  vas  deferens  to  the  testicle.  Similarly, 
but  less  frequently,  infection  may  arise  from  a  septic  jiosterior  urethritis,  contracted  during 
connection  with  a  woman  the  subject  of  a  vaginal  leucorrhcea.  The  gonorrhoeal  form 
of  acute  epididymo-orchitis  usually  resolves  slowly,  and  shows  very  little  liability  to  sup- 
purate, whereas  the  inflammation  resulting  from  a  staphylococcal  or  a  streptococcal 
infection  may  break  down  into  a  testicular  abscess. 

Acute  epididymo-orchitis  may  also  arise  from  septic  processes  in  the  urethra  following 
upon  the  passage  of  catheters,  of  instruments  for  vesical  operations,  such  as  lithotrity,  from 
ulceration  behind  a  urethral  stricture  or  about  a  calculus  in  the  prostatic  urethra,  and  occa- 
sionally after  the  instillation  of  strong  solutions  into  the  jjosterior  urethra  in  the  treatment  of 
a  chronic  urethritis.  In  any  case  the  onset  of  pain  and  rapid  swelling  of  the  testis  should 
always  lead  to  the  suspicion  of  urethral  infection,  and  attention  should  be  directed  to  the 
urethra  with  that  in  view.  Bacteriological  examination  of  any  urethral  discharge  is  essential 
(see  Discharge,  Uretiiual,  p.  181). 

Acute  epididymo-orchitis  occasionally  arises  without  any  preceding  urethral  infection, 
and  uncommonly  occurs  as  a  complication  of  acute  specific  parotitis  (mumps),  enterica, 
scarlet  fever,  influenza,  or  as  a  complication  of  a  urinary  infection  by  Bacillus  coli  or  other 
organisms.  The  testicle  becomes  painful,  and  enlarges  rapidly  in  the  same  manner  as  in 
acute  inflanmiation  from  urethral  infection,  and  under  appropriate  treatment  gradually 
resolves.  Less  frequently  testicular  inflammation  may  occur  with  gout  or  acute  rheu- 
matism, or  after  a  direct  injury  to  the  organ,  such  as  a  bloio  or  squeeze. 

The  pain  in  an  acute  inflammation  is  generally  of  an  aching  character  at  first,  felt 
not  only  in  the  testis,  but  at  the  external  abdominal  ring,  and  often  as  a  heavy  dragging 
pain  in  the  loin  of  the  affected  side.  As  the  testis  enlarges,  the  local  pain  becomes  more 
severe,  so  that  the  swollen  gland  is  exquisitely  tender  to  pressure  or  to  the  touch.  After 
a  few  days  the  pain  subsides  to  a  large  extent,  but  remains  as  a  dull  ache  until  the  swelling 
becomes  greatly  reduced,  and  usually  disappears  some  time  before  the  organ  returns  to 
the  normal  size.  In  a  few  cases  in  which  a  fibrous  scar  remains  in  the  epididymis,  pain 
may  remain  and  cause  some  dilBculty  in  the  diagnosis  from  a  commencing  tuberculous 
lesion,  but  the  earlier  history  of  acute  inflanmiation  will  help  in  forming  an  opinion.  In 
other  cases  the  persistence  of  the  pain  and  swelling  may  indicate  the  formation  of  an  abscess 


PAIX     IX     THE     TKSTR'LE  479 

in  the  testicle,  wlicn,  after  decrease  at  first,  the  swelhng  increases,  the  skin  covering  it 
becomes  reddened,  and  a  soft  area  becomes  evident  in  one  or  other  side  of  tlie  organ. 

Tuberculosis  of  the  Testicle  is  comi)arati\ely  common,  occurring  as  a  primary 
disease  or  secondary  to  tuberculous  disease  of  the  liidney.  bladder,  or  prostate.  It  begins 
as  a  localized  deposit  in  almost  all  cases,  causing  a  roimded,  firm  nodule  in  the  epididymis. 
It  frefjuently'  arises  in  the  upper  pole  of  the  epididymis,  whereas  the  inflammatory 
affections  secondary  to  urethral  infection  begin  in  the  lower  pole.  This  nodule  mav 
remain  unaltered  for  many  months,  or  may  enlarge,  soften,  become  adherent  to  the  skin 
and  coverings  of  the  testicle,  or  actually  ulcerate  through  them  to  form  a  discharging 
fistula  in  the  scrotum.  The  small  commencing  nodule  in  the  epididymis  is  usually 
painless  at  first  and  may  be  found  by  accident,  but  later,  as  it  gradually  enlarges,  it 
causes  an  aeliing  pain  in  the  organ.  Other  nodules  may  be  formed  in  the  epididymis, 
or  the  body  of  the  testis  may  become  involved,  whilst  commonly  small  shot-like  thickenings 
may  be  felt  in  tlie  course  of  the  vas  deferens.  In  the  most  advanced  stages,  nodules  may 
be  felt  upon  rectal  examination  in  the  seminal  vesicles  or  prostate,  or  there  may  be  some 
in  the  epididymis  of  the  other  side. 

Tuberculous  disease  of  the  testicle  usually  presents  little  difficulty  in  the  diagnosis. 
In  an  early  case  the  occurrence  of  one  or  more  nodules  in  the  epididymis,  which  are  painful 
on  pressure  and  whicli  have  not  resulted  from  a  preceding  acute  epididymo-orehitis,  should 
always  suggest  a  tuberculous  focus,  and  a  careful  search  should  be  made  for  any  other 
tuberculous  lesion  in  the  body.  Should  none  be  found,  the  estimation  of  the  opsonic  index 
of  the  blood  to  tubercle,  or  one  of  the  several  clinical  tests  for  tubercle,  such  as  von  I'irquet's 
tuberculin  skin  reaction,  may  clear  up  the  diagnosis.  In  later  stages  the  diagnosis  is  less 
diHicult  ;  the  gradual  enlargement  of  the  nodules,  their  craggy  or  bossy  feel,  the  infection 
of  the  vas  or  other  genilo-urinary  organs  with  tuberculosis,  and  above  all,  the  tendency  of 
the  focus  in  the  e))ididymis  to  soften  and  to  become  adherent  to  the  scrotal  coverings, 
are  points  to  be  looked  for  ;  v/hilst  if  it  should  have  led  to  the  formation  of  a  fistula, 
tubercle  bacilli  may  be  detected  in  the  discharge. 

Syphilitic  Disease  of  the  Testis  causes  very  little  pain  in  the  organ,  but  there  is 
often  a  sense  of  dragging  or  heaviness,  and  for  this  reason  it  must  be  considered. 

.Syphilis  may  attack  the  testicle  in  several  different  ways,  producing  : — 

///  -Icijuirerl  Sij/iliilis  : —  In    Coiigeiiilal  Sij/iliilis  : — 
Oifruse  interstitial  oicliilis  Interstitial  (ircliltis 

(itiiiiniatoiis  orchitis  Gumniatous  (iriliitis. 

Kpidiilyniilis. 

The  outstanding  feature  of  syphilitic  disease  of  the  testicle  is  that  it  affects  the  body 
of  tlic  testis  rather  than  the  epididymis,  thus  diliering  in  a  marked  degree  from  tuberculous 
disease.  In  the  interstitial  form  then-  is  thickening  of  the  intertubular  connective  tissue, 
with  an  infiltration  of  spindle  (ills,  wliirli,  forming  young  connective  tissue,  vield  fibrous 
tissue  when  untreated.  The  subsecjucnl  contract  ion  of  this  fibrous  t  issue  may  cause  atrophv 
of  the  testis.  The  testis  iiiay.  on  seclioii,  show  small  gunuiiala  in  addition  to  the  diffuse 
orchitis,  or  if  the  inllainmation  is  more  Idealized,  gurnniata  may  be  the  main  feature,  these 
varying  in  size  from  that  of  a  pea  to  thai  ula  walnut,  or  larger.  The  epididymis  is  affected 
but  rarely,  though  eases  are  on  record  nf  a  nodular  swelling  in  the  epididymis  dining  the 
secondary  stage  of  syphilis,  which  disappeared  rapidly  under  antisyphilitie  treatment. 

In  congenital  syphilis,  both  the  interstitial  and  gummatous  forms  exist  :  thev  usually 
occur    in   childhood  or  in  young   adult  lil'c.  and    in  many   cases  the  alleclion    is   bilateral. 

Syphilitic  inllaii itioii  of  the  testicle  may  be  accompanied   in  cilhcr  the  ac(|iiirc(l  or  the 

congenital   form   b\    a   \aginal   h\(lrocelc. 

There  is  a  sense  of  weight  in  the  scrntiirn  rather  than  pain,  and  often  an  aeliing  or 
dragging  feeling  in  the  inguinal  or  Imiiliar  i<i;iiin.  On  palpation,  the  body  of  the  testis 
feels  enlarged  anil  nodular  with  llic  jiuiniiialnus  deposits,  but  the  epididymis  can  usually 
be  dislingnishcd  from  the-  testis  and  lie  liMirid  to  be  imalleclcd.  The  lissiics  of  the  cord 
remain  unthickcncd. 

The  (lidjluosix  of  .•inpliililic  (lisriisc  of  the  testis  is  usually  simple.  There  may  or  may 
not  be  a  history  of  syphilis,  but  other  signs  of  the  disease  should  be  looked  for — thus,  in 
the  aecpiired  form,  any  scar  of  previous  ulecratioTi  or  periosteal  thickening,  or  in  the  con- 
genital   \ariel\,    sii;ns    in    the    teeth.    e\  is,    or    cars.      If  any    doubt    remains,    a    positive 


4,yo  I'AIN     IN    THE    TESTICLE 

Wasserniann  reaction  of  the  blood  or  tlie  behaviour  of  the  swclHiifi  when  treated  with  large 
doses  of  potassium  iodide  and  mercury,  or  salvarsan,  should  be  noted.  Syphilitic  disease  is 
distinguished  from  tuberculous  disease  of  the  testis  by  the  fact  that  the  epididymis  is  usually 
free  from  infection  ;  that  the  cord,  prostate,  and  vesicles  remain  normal  ;  and  by  the 
comparative  absence  of  jjain  in  the  testicle  upon  pressure  being  made  upon  it.  Tuber- 
culous deposits  tend  to  soften  and  to  involve  the  scrotal  coverings  in  spite  of  treatment. 
From  chronic  orchitis  it  is  differentiated  by  the  history  of  injury  and  by  the  absence  of  the 
history  or  signs  of  syphilis.  From  malignant  tumours  of  the  testis  it  is  distinguished  by 
the  history  of  syphilis,  the  tendency  of  syphilitic  disease  to  be  bilateral,  the  slow  enlarge- 
ment, and  a  positive  Wassermann  reaction.  In  malignant  disease,  the  increase  in  the 
size  of  the  testicle  is  more  rapid,  whilst  the  tumour  often  shows  areas  of  varying  consistence  ; 
the  cord  is  often  enlarged  in  malignant  cases. 

Malignant  Tumours  of  the  Testis  may  give  rise  to  pain  in  the  organ,  but  as  a  rule 
pain  is  only  experienced  in  the  later  stages  of  the  disease.  Both  carcinoma  and  sarcoma 
may  arise  in  the  testis,  but  embryoma  is  more  common,  exhibiting  both  epithelial  structures 
and  a  combination  of  several  forms  of  connective-tissue  type— cartilaginous,  myxomatous, 
etc.  flinically,  without  microscopical  examination,  a  soft  carcinoma  and  a  sarcoma  can 
rarely  be  differentiated,  and  as  their  symptoms  and  history  are  so  similar,  they  may  for 
convenience  be  considered  together.  A  testicle  that  is  the  seat  of  a  malignant  growth 
enlarges  rapidly,  but  as  pain  isat  first  absent,  there  may  be  nothing  to  arouse  the  patient's 
suspicions.  As  long  as  the  tunica  albuginea  remains  intact  the  swelling  retains  the 
shape  of  the  testis,  but  when  perforation  of  the  fibrous  covering  takes  place  nodular 
projections  appear  and  render  the  tumour  irregular.  These  projections  are  softer  than 
the  remainder  of  the  growth,  and  form  a  valuable  point  in  the  diagnosis.  A  rapidly 
growing  sarcoma  or  carcinoma  of  the  testis  may  be  so  soft  as  to  appear  to  be  a  fluid 
collection  in  the  tunica  vaginalis.  Generally,  however,  although  a  growth  may  be  accom- 
panied by  a  small  amount  of  fluid  in  tiie  timica  \aginalis,  the  more  solid  mass  can 
be  felt  through  the  fluid  on  careful  examination  ;  this  fluid  is  often  bloodstained.  The 
epididymis  nray  become  incorporated  in  the  growth  so  that  it  cannot  be  distinguished, 
and  the  tissues  "of  the  cord  become  thickened.  The  coverings  of  the  testis  become  stretched 
over  the  tumour  ;  the  mass  does  not  become  adherent  to  the  scrotal  skin  until  late  in  the 
disease.  In  both  carcinoma  and  sarcoma,  the  iliac  and  lumbar  glands  become  enlarged, 
and  may  be  felt  in  a  thin  subject  at  the  brim  of  the  pelvis,  and  pain  due  to  the  pressure 
of  these  glands  upon  nerve  structures  may  become  marked.  The  inguinal  glands  are 
usually  not  enlarged  unless  the  scrotal  skin  is  affected.  The  diagnosis  of  malignant  disease 
of  the  testis  may  be  quite  easy  in  the  case  of  rapidly  growing  tumours,  but  in  others, 
especially  in  the  early  stages,  it  may  present  great  difficulty. 

Between  sarcoma  and  carcinoma  it  may  be  clinically  impossible  to  distinguish.  In 
quite  early  life  the  tumour  is  more  likely  to  be  a  sarcoma  ;  the  cord  is  thickened  earlier 
in  carcinoma,  but  with  rapidly  growing  tumours  it  may  be  quite  impossible  to  say  whether 
it  is  a  sarcoma,  carcinoma,  or  embryoma  until  a  piece  is  examined  under  a  microscope. 

Orchitis  may  be  confused  witli  the  m<ire  slowly-growing  forms  of  sarcoma.  In  both 
the  swelling  may  have  followed  an  injury,  and  in  both  there  may  be  a  syphilitic  history. 
Orchitis  is,  however,  either  more  acute  or  more  cluonic,  it  retains  more  the  oval  shape  of 
the  testis,  and  does  not  present  the  rounded,  slightly  raised  bosses  which  are  commonly 
present  in  a  sarcomatous  testis.  In  orchitis  the  epididymis  is  usually  distinguished  more 
easily,  and  the  cord  is  not  so  thickened  as  with  a  growth.  Finally,  the  result  of  treatment 
with  strapping  and  with  mercury  and  iodide  will  often  show  the  disease  to  be  of  a  non- 
malignant  nature. 

Chronic  torsion  of  the  testicle  is  not  very  miconunon  amongst  habitual  horse-riders, 
and  sometimes,  if  there  is  no  clear  history  as  to  the  relationship  between  the  swelling  and 
a  saddle  injury,  the  nature  of  the  painful  tumour  may  be  so  uncertain  that  operation  and 
histological  examination  are  resorted  to. 

Tvbcrculons  disease  is  usually  diagnosed  easily  from  malignant  disease  by  the  tendency 
of  tubercle  to  attack  the  epididymis,  to  caseate,  suppurate,  and  to  become  adherent  to 
the  scrotal  skin  comparatively  early.  Tuberculosis  occasionally  attacks  the  body  of  the 
testicle  first,  however,  forming  an  oval,  smooth  tumour  of  the  organ  ;  the  epididymis  and 
vas  deferens  may  be  unaffected  for  a  time,  and  if  no  deposit  is  found  in  the  prostate  or 


PAIX    IX    THE    testicle:  4si 

vesicles,  the  differential  diagnosis  between  tubercle  and  growHi  may  be  far  from  easy  before 
operation. 

Hwtnfitocele. — The  diagnosis  between  a  hsematocele  and  a  malignant  tumour  of  the 
testis  may  present  considerable  difficulty.  In  both  the  swelling  may  date  from  an 
injury,  whilst  the  indistinct  fluctuation  obtained  in  the  soft  areas  of  a  growth,  accompanied 
sometimes  by  some  fluid  in  the  tunica  vaginalis,  may  simulate  a  h;ematocele.  The  latter 
feels  heavy  to  the  hand,  but  is  usually  softer  in  its  wliole  mass  and  more  regular  than  a 
growth.  Care  must  be  taken  not  to  place  too  much  reliance  upon  the  withdrawal  of  a 
few  drops  of  blood  from  the  tumour  by  means  of  a  trocar  and  cannula,  a  result  which  may 
happen  equally  with  growth  or  hsematocele.  A  hiematocele  may  cease  to  enlarge,  or  even 
diminish  in  size,  whereas,  in  growth,  increase  in  size  is  progressive.  The  cord  remains 
unaffected  with  hsematocele.  ami  testicular  sensation  is  more  likely  to  be  lost  in  growth. 
If  any  doubt  exist,  it  is  advisable  to  make  an  exploratory  incision  rather  than  a  i)uncture, 
when,  if  necessary,  a  radical  operation  can  be  proceeded  with. 

Ih/drocele. — A  hydrocele  of  very  long  standing,  with  an  irregular,  nodular  surface, 
and  absence  of  transhicency  due  to  the  thickened  tunica  vaginalis  and  the  thick  contents 
of  the  .sac.  may  simulate  a  new  growth,  but  the  long  history  of  the  case,  and  the  absence 
of  progressive  increase  in  size  of  the  swelling,  will  prevent  a  mistake  of  this  kind. 

Cysts  of  the  Testis  occur  most  frequently  in  connection  with  the  epididymis,  very 
rarely  with  the  body  of  the  testis.  These  cysts  are  quite  dillerent  from  hydrocele  of  the 
tunica  vaginalis,  and  are  often  sjjoken  of  as  encysted  hydrocele  of  the  epididymis  or  testis, 
or  as  a  spermatocele,  although  all  do  not  contain  spermatozoa.  They  cause  a  swelling 
of  varying  degree  in  the  scrotum,  and  usually  an  aching  in  the  testicle,  groin,  or  lumbar 
region.  They  may  arise  as  retention  cysts  of  the  tubules  of  the  epididymis  or  from  one 
of  the  f(t-tal  remains  which  occur  about  the  globus  major  of  the  epididymis,  namely,  the 
organ  of  (;iraldes,  the  hydatid  of  JMorgagni.  or  the  vas  aberrans  of  Haller.  These"  cysts 
are  usually  placed  above  and  to  the  outer  side  of  the  testis,  occasionally  behind  it.  They 
move  with  the  organ,  and  can  usually  be  distinguished  from  the  latter  by  the  test  of  trans- 
hicency. 'I'heir  increase  in  size  is  very  slow,  but  they  may  cause  aching  pain  in  the  testicle 
by  pressure  ui)on.  or  stretching  of.  the  tissues  of  the  epididymis.  They  can  be  distinguished 
from  hydrocele  of  the  tunica  vaginalis  by  the  (tosition  of  the  swelling  relative  to  the  testicle, 
and  by  the  fact  that  the  fluid  contaiiied  in  them  is  colourless  or  slightly  opalescent  from 
the  <'onl;iin(il  sperniMlozoa.  in  distinelion  to  the  straw-coloured  ffui<l  of  a  vaginal  hydrocele. 

H.  AFFECTIONS  OF  THE  COVERINGS  OF  THE  TESTIS  CAUSING  PAIN  IN  THE  ORGAN. 

'I'he  only  eonunon  lesions  of  the  coverings  of  the  testis  are  lii/dnirrlr  and  Irritiatorrle  ; 
new  growths  of  tlic  testicular  tunics  are  so  rare  as  to  render  them  surgical  curiosities. 

Hydrocele  max  occur  occasionally  as  an  acute  alTection  accompanying  an  acute 
i|)i.lid\iiio-(irehilis,  injury  to  the  scrotum,  or  in  the  course  of  acute  specific  fevers  such 
as  small-pox,  rheumatism,  or  mumps.  Kecently  acute  hydrocele  has  been  described  in 
conjunction  with  acute  lesions  of  olher  serous  membranes  -multiple  scrositis  or  poly- 
orrhymenitis.  The  more  usual  IWnn'df  hy<lrocele  is  the  chronic  variety,  which  may  bs 
due  to  some  disease  of  I  he  lislici,  ,  bm  fur  which,  in  the  majority  of  cases,  no  ascertainable 
cause  can  be  found. 

.\  hydrocele  may  cause  some  aching  in  llie  testicle,  bul  mon'  fniiuentlv  it  causes  a 
dragging  sensation  In  the  loin  from  the  iiicchanical  eriect  of  ils  weight.  It  forins  a  swelling 
on  one  side  of  the  scrotum,  oval  with  smooth  imiforin  surface:  it  gives  a  distinct  .sense 
of  fluctuation.  The  swelling  is  limited  distinctly  above  from  the  cord  or  externa! 
abilominal  ring,  and  gives  no  sense  of  impulse  on  coughing  :  with  a  good  light  it  can  be 
loimd  in  most  cases  to  be  traMslucenl.  Ilie  leslielc  oeeiipying  a  posterior  and  low  position 
in   the  swelling. 

The  diagnosis  of  hydrocele  is  usually  easy,  but  occasionally,  when  in  old-standing 
cases  the  walls  are  much  thickened,  dilliculty  may  be  experienced.  .\  hyilroeele  must 
be  diagnosed  from(l)  .V  scn.tal  hernia,  (2)  irainalocele.  (li)  New  growth,  and  ( t)  An 
ency.sted    hydrocele   of  the   testis. 

Scroliil  llirnid.  Isually  a  hernia  gixcs  an  impulse  on  coughing,  can  be  reduced  into 
the  abdomen  with  a  sudden  slip  or  gurgle,  and  varies  in  size  with  the  position  of  the  patient. 
A  hernia  comes  down  from  above  and  descends  into  the  .scrotum.     In  a  large  irreducible 


482  FAIN     IN     THE     TESTICLE 

hernia,  some  part  of  it  is  usually  resonant  from  the  contained  intestine,  the  swelhng  is  not 
limited  above,  and  the  testis  can  be  distinguished  at  the  bottom  of  the  scrotum.  .\ 
hydrocele  is  distinctly  limited  above,  gives  no  impulse,  is  translucent,  and  the  spermatic 
cord  can  be  distinguished  easily.  The  testis  in  a  hydrocele  cannot  usually  be  distinguished 
in  the  scrotum  as  in  a  hernia.  Difficulty  may  arise  between  the  two  conditions  when  the 
hydiocele  extends  along  the  inguinal  canal,  and  thus  gives  an  impulse  on  coughing,  or 
if  [he  translucency  is  lost  owing  to  the  thickness  of  the  walls  or  contents  of  the  sac.  A 
scrotal  hernia  in  an  infant  may  be  tran.slucent. 

Ihematocele  is  distinguished  from  hydrocele  by  the  absence  of  translucency.  the 
greater  weight,  and  the  suddenness  of  the  onset,  usually  after  an  injury  or  puncture.  If 
any  doubt  exist,  an  incision  may  be  made  into  the  swelling,  permission  being  obtained 
to  proceed  to  any  form  of  cure  that  may  be  found  desirable. 

Nnv  Groivtlis  of  the  Testis. — A  hydrocele  is  of  much  slower  rate  of  increase  in  size,  of 
smooth  surface  and  uniform  consistence,  and  is  translucent. 

Kiiciialcil  Iliidrueele  of  the  Testis  (see  above). 

Hematocele  may  occur  as  the  result  of  tajjping  a  hydrocele,  from  puncture  of  a  vein 
in  the  sac  or  of  the  testicle,  or  by  the  occurrence  of  bleeding  into  a  hydrocele.  It  may 
occur  quite  indeijciidently  of  a  hydrocele,  usually  after  direct  injury.  As  a  rule  there  is 
a  rapid  onset  of  swelling  in  the  scrotum  following  the  injury,  with  ecchymosis  of  the  scrotal 
skin  :  the  resulting  tumour  resembles  a  hydrocele  in  its  clinical  symptoms,  save  that  it 
is  not  translucent.  In  other  cases  the  swelling  arises  more  slowly,  when  a  pyriform  or 
oval  swelling  is  present  in  one  side  of  the  scrotum  covered  by  normal  skin  ;  the  surface 
of  the  swelling  is  smooth,  and  gives  a  sense  of  fluctuation  and  elasticity.  There  is  no  trans- 
lucency, and,  on  tapping,  dark  blood-stained  fluid  is  withdrawn. 

The  diagnosis  in  the  less  acute  cases  often  presents  a  difficulty,  especially  with  regard 
to  malignant  disease  of  the  testicle  (see  above).  From  hydrocele  it  is  distinguished  by  the 
absence  of  translucency  :  from  hernia  by  the  same  points,  except  translucency.  mentioned 
above  in  the  diagnosis  between  hydrocele  and  hernia. 

III.   AFFECTIONS    OF    THE    SPERMATIC    CORD    CAUSING    TESTICULAR    PAIN. 

An  inflanunatory  ali'ection  of  the  cord  secondary  to  lu'ethral  infection  is  nut 
uncommon.  Similarly,  tuberculous  infection  of  the  cord  is  practically  never  present 
without  corresponding  infection  of  the  testis  or  epididymis.  New  growths  of  the  cord, 
lipomata,  myxolipomata,  and  sarcomata  or  hydroceles  of  the  cord,  cause  no  pain  in  the 
testis.  A  varicocele,  especially  if  large,  in  a  pendulous  scrotum,  is  a  frequent  cause  of  a 
dull,  aching  pain  in  the  testicle.  The  characteristic  feel  of  the  enlarged  veins  of  the  cord 
in  the  erect  position,  and  the  slight  impulse  on  coughing,  will  readily  ]ioint  to  the  correct 
diagnosis. 

IV.  THE    RETAINED    OR    MISPLACED    TESTIS. 

This,  in  its  various  situations,  may  give  rise  to  pain,  and  may  cause  some  dilficulty 
in  the  diagnosis  of  the  condition  present.  A  testis  may  be  arrested  in  its  descent  at  the 
external  abdominal  ring  in  the  inguinal  canal,  may  remain  inside  the  abdomen,  or  may 
pass  (1)  into  the  perineum  after  traversing  the  inguinal  canal,  (2)  to  the  upper  part  of  the 
thigh  via  the  crural  ring,  or  (3)  to  the  root  of  the  penis  in  front  of  the  pubes. 

In  the  various  situations  in  which  an  undescended  or  ectopic  testicle  is  placed,  it  may 
be  attacked  by  the  several  diseases  which  affect  the  normally  placed  organ,  and  thus  give 
rise  to  pain  ;  but  in  addition,  owing  to  the  eifect  of  constant  muscular  strains  and  the 
comparative  immobility  of  the  organ,  it  is  particularly  liable  to  recurrent  attacks  of  trau- 
matic inflammation,  especially  when  the  testis  is  retained  in  the  inguinal  canal  :  in  the 
intra-abdominal  position  it  remains  protected  from  muscular  injury,  whilst  ectopic  testicles 
have  a  greater  range  of  mobility  than  has  one  that  is  retained  in  the  inguinal  canal.  The 
inflammation  of  an  undescended  testicle  may  be  so  acute  as  to  lead  to  gangrene  of  the 
organ,  with  or  without  torsion  of  the  cord. 

The  pain  may  be  complained  of  first  when  the  testes  begin  to  swell  at  ])uberty,  at 
which  time  an  undescended  right  testicle  may  produce  symptoms  easily  mistakeable  for 
appendicitis. 

The  diagnosis  of  undescended  testicle  rests  upon  the  following  points  :    the  fact  that 


PAIN     IX    THE     U-MBILICAL    REGION  48H 

one  side  of  the  scrotvim  is  empty,  the  oiitHne  and  situation  of  a  swelling  in  the  inguinal 
canal  or  elsewhere,  the  testicular  sensation  upon  pressure,  and  the  recurrent  attacks  of 
pain.  An  undescended  testicle  may  give  rise  to  acute  pain  from  inflammatory  lesions  or 
from  acute  torsion  of  the  organ,  and  may,  if  placed  in  the  inguinal  canal,  give  rise  to 
syinj)toms  suggestive  of  a  strangulated  hernia.  It  must  be  remembered  also  that  a  par- 
tially descended  testicle  is  often  accompanied  by  an  inguinal  hernia.  It  is  also  stated 
that  the  misplaced  testis  is  prone  to  become  the  seat  of  malignant  disease. 

V.  TESTICULAR    PAIN    FROM    LESIONS    OTHER    THAN    IN    THE    TESTICLE. 

It  is  necessary  to  mention  this  class  of  case,  in  which  complaint  is  made  of  testicular 
pain,  when  on  clinical  examination  the  testis  is  found  to  be  normal.  After  an  acute  inflam- 
mation of  the  organ,  even  when  no  palpable  nodule  remains,  the  resulting  cicatrization 
may  cause  an  aching  in  the  organ,  especially  after  sexual  excitement  or  prolonged  desire. 
Apart  from  former  testicular  disease,  pain  may  be  felt  in  the  organ  if  a  calculus  be  present 
in  the  pelvis  of  the  kidney  or  upper  ureter,  with  a  marked  degree  of  oxnluria,  or  from 
stimutafion  of  the  peripheral  nerves  bij  carcinoma  of  the  bodies  of  the  lumbar  verlebrce  or  the 
pressure  of  an  aiieuri/snt  in  this  situation.  Pain  in  the  testicle  is  occasionally  present  in 
iippoidical  inflammation,  when  the  appendix  turns  down  into  the  pelvis. 

I{.    II.   .Joccljiti  Swan. 

PAIN   IN   THE   THIGH.  -;See  Pain  in  the  Lowku  ExTRi-.MtTV.  ]>.  488.) 

PAIN   IN   THE   THROAT.-    (See  Souk  Tiihoat,  p.  (il3.) 

PAIN  IN  THE  UMBILICAL  REGION. 

Pain  associated  with  External  Swelling. — This  may  be  due  to  the  following  causes  : — 

Cmbilical  Hernia.  —This  is  common  in  young  infants,  and  also  in  fat,  middle-aged 
jKiiple.  |)articularly  women  who  have  borne  children.  .Vttention  is  often  called  to  the 
protrusion  lirsl  by  the  pain.  In  the  early  stages,  while  the  hernia  is  yet  small,  it  may 
easily  be  o\<>rlooked,  especially  if  the  ])atient  is  obese.  The  swelling  is  usually  globular 
in  shape,  has  an  impulse  on  coughing,  and  may  or  may  not  be  reducible.  In  a  very  large 
|)ioiK)rtion  of  cases  the  hernia  is  irreducible,  and  it  nearly  always  contains  omentum. 

Sebaceous  Ci/st.  —This  is  not  uncommon  at  the  umbilicus.  It  presents  itself  as  a 
small  spherical  swelling,  which  might  be  mistaken  for  a  small  irreducible  lunbilical  hernia. 
There  is,  however,  no  direcl  impulse  on  coughing,  and  the  swelling  is  attached  to  the  skin. 
There  is  generally  but  little  pain  unless  the  cyst  has  become  injured  or  inllamed. 

.\V:t'  f»'i-o:i///.  -  Occasionally  the  umbilicus  is  the  seat  of  a  small  secondary  nodule  of 
growth  which  has  been  hniught  by  the  vessels  in  the  round  ligament  from  the  neighbour- 
hood of  the  liver.  It  may  ruriiisli  a  clur  in  making  the  diagnosis  of  an  obscure  abtlominal 
ailment.  Epillicliotnn  is  the  onl\  likely  primary  growth  here;  it  has  to  be  distinguished 
from  a  mass  of  simple  flraiiulation  tissue  here,  and  from  tuberculous  ulreralion  of  the  skin 
at  the  umbilicus  ;  all  three  are  uncommon  :  in  some  cases  the  diagnosis  between  them 
may  be  obvious  almost  at  sight  ;  in  others  the  distinction  may  be  so  dillicull  that  inicro- 
Mopical  examination  of  a  portion  of  the  mass  has  to  be  resorted  to. 

Eczema  Intertrigo. — Very  obese  people  of  uncleanly  habits  may  sullcr  Ironi  Ibis  I  rouble 
at    the  umbilicus. 

Divarication  of  the  Itccli  Muscles.  A  palieiit  lying  in  the  recuinbeni  position  may 
show  no  e\i(lence  of  this  condition.  Dilluse  ))aiii  is  c[iiMpIaiiieil  of  about  the  umbilicus, 
anil  the  divarication  is  made  evident  at  once  if  the  |)ati<nl  is  asked  to  lift  the  head. 

Ci/sl  of  the  Om/ihalo-mcsculci  ic  Duel,  a  rare  condition,  may  be  found  at   birth. 

Pain  associated  with  Internal  Swelling. 

'I'uliirrulous  I  crilouilis  with  formalioii  of  a  locali/cd  abscess  is  tlie  coininoncst  cause 
of  pain  and  a  swelling  situated  inside  the  abiloineii  at  the  umbilicus.  The  patient  is 
Usually  a  child,  anil   presents  well-marUcil   signs  of  chronic  abilouiinal  disease. 

Carcinoma  of  the  I'l/lorus  or  Carcinoma  of  tin-  Colon  may  present  as  an  umbilical  tumour, 
especially  If  it  has  become  fixed  by  adhesions,  but  It  can  usually  be  diagnosed  without 
dilliculty  on  accoimt  of  the  special  symptoms  arising  in  each  case. 

Pain  without  Swelling  or  other  Localizing  Symptoms. 

The  caUM-s  of  umbilical   pain   are   so   nuiiurous  anil   \arii-il.    Ilial    in  order   to   mention 


4S4  PAIN     IN    THE     UMBILICAL    REGION 

all  it  would  be  necessary  to  enumerate  nearly  all  abdominal  complaints.  This  cannot 
be  done  here,  but  one  should  bear  in  mind  the  following  as  possible  causes  in  patients  in 
whom  no  trace  of  abdominal  disease  can  be  found,  and  who  still  complain  of  pain  at  or 
about  the  umbilicus. 

Tubes  Dorsfilis. — The  only  complaint  of  the  patient  may  be  of  abdominal  pain,  often 
referred  to  the  region  of  the  umbilicus.  The  typical  gastric  crises  may  be  replaced  by  a 
much  more  diffuse  pain,  and  more  than  one  person  has  been  operated  on,  and  a  gastro- 
enterostomy performed,  under  a  mistaken  diagnosis.  A  systematic  examination  of  the 
knee-jerks,   pupil-reflexes,   etc.,   should  be  made  in  all  cases. 

Lead  Poisoning. — Severe  attacks  of  cramp-like  abdominal  pains  referred  to  the 
umbilicus  may  be  the  chief,  or  even  the  only,  symptom  of  phmibism.  The  ])atient"s 
occupation  may  suggest  the  diagnosis,  or  other  characteristic  signs  of  lead  poisoning  may 
be  found  (p.  34.) 

Ttimotir  of  Ihe  Spinnl  Column  or  Cord,  Spinal  Caries,  and  Compression  Myelitis. — 
Though  a  less  common  source  of  error,  these  must  be  borne  in  mind.  Owing  to  its  situation, 
a  growth  in  the  spine  may  be  very  hard  to  locate  ;   a  skiagram  may  be  of  service. 

Plithisis. — In  this  disease  gastric  ])ains  are  a  common  symptom,  and  the  pains  may 
even  be  referred  to  the  umbilicus.  George  E.  Gask. 

PAINFUL  COITUS.— '.See  »vfsi'Aiu-.LM.\,  j).  1!»:5.) 

PAINFUL  MICTURITION.     (See  Mictirition,  ABNORMALrniis  of.  j).  393.) 

PAINFUL  SWALLOWING.  -(See  DYSPnA(;iA.  p.  liU.) 

PALLOR.  (See  An.emia.   )).  21.) 

PALPITATION  signifies  the  sensation  experienced  by  a  ]ierson  who  is  conscious  ol  his 
heart  beats.  It  is  not  necessarily  associated  with  pain.  It  may  be  due  to  many  different 
causes,  of  which  the  folljwing  are  the  chief : — 


1.  Valvular  Heart  Disease,  especially  : — 

Mitral   stenosis  .Aurtic   stenosis 

Mitral  rcgiiijjitntinn      i    Aortic  regurgitation 
l\Iitral     stciKisis     ;uul    (    Aortic  stenosis  and  regurgita- 
rogurgitutiiin  tion 

2.  Heart  Affections  associated  with  very  High  Blood-pressure  :- 

Arteriosclerosis.  |  (Jraniilar  kidney. 

3.  Myocardial  Affections  : 


Pulnionarv  stenosis. 


Fatty  heart 
Fibroid  heart 
Primary     alcoholic 
licart 


"  Blaiksniitli  "   heart  '   .Senile  changes  with    atheroma 

Cloudy  swelling  Congenital   deformity. 

Pericarditis 

.\(  II  If  rent    [lerieardiiMii 


4.  Lung  Affections  leading  to  Failure  of  the  Right  Side  of  the  Heart  : — 

Chronic    broneliitis  I  Fibroid  lung 

Kmphysema  |  Large      pleural       or       pleuritic 

effusions 

5.  The  Effect  upon  the  Heart  of  certain  Drugs,  etc. : — 

Tobacco  ;        Ak'uliul  ,  Cocaine 

Tea  Absinthe  i  Digitalis 

Coffee  I        Morphia  1  Thyroid  extract 

6.  Heredity,  Nervousness,  and  Allied  Causes  : — 

Fright  or  other  emo-  Paroxysmal  laeliyeardia  Epilepsy 

tion  Neurasthenia  i         Tabes  dorsalis. 

Graves's    disease  ;        Hysteria 

7.  Anaemia  from  whatever  cause,  but  ])articularly 

Chlorosis  I  Pernicious  anieniia 


PALPITATION  485 

8.  Mechanical  Interference  with  the  Heart  by  : — 

Mediastinal  new  growth  i  Ascites 

Chronic  metiia-itinal  fibrosis  Pregnancy 

Thoracic  aneurysm  of  large  size  I  Ovarian   cyst   or  other  large   intra- 

Tynipanites  i  abdominal    tummir. 

9.  Dyspepsia  :    especially  that   which  is  associated  with  llatulciicc  and  witli  stout- 

ness from  lack  of  exercise. 

The  majority  of  patients  who  complain  of  palpitation  jump  to  the  conclusion  that 
they  have  somethinij  the  matter  with  the  heart,  and,  although  the  above  list  is  a  long  one, 
the  diagnosis  resolves  itself  in  all  but  a  few  cases  into  deciding  whether  the  palpitations 
are  cardiac  or  gastric  in  origin.  A  routine  examination  of  the  various  systems  will  very 
often  indicate  the  correct  diagnosis  at  once. 

Valviilnr  heart  disease  will  be  indicated  by  the  history  of  rheumatic  fever,  scarlet  fever, 
chorea,  syphilis,  or  the  like,  and  by  the  alteration  in  the  size  of  the  heart,  together  with 
the  various  bruits.  Mitral  stenosis  is  sometimes  more  difficult  than  the  others  to  diagnose 
on  account  of  the  jjossible  absence  of  a  bruit  or  of  enlargement  of  the  left  ventricle,  but 
it  may  be  suggested  by  the  ])atient"s  malar  flush,  by  the  history  of  acute  rheumatism,  and 
by  the  loud,  sharp,  slapjjing  character  of  the  first  sound  at  the  impulse.  Aortic  regur- 
gitation is  sometimes  present  without  a  bruit,  but  it  can  generally  be  detected  in  these 
cases  by  the  typical  collapsing  character  of  the  pulse  ;  if  there  is  still  doubt,  and  the  patient 
is  able  to  take  exercise,  it  is  frequently  possible  to  bring  out  an  aortic  regurgitant  bruit 
by  asking  him  to  take  a  few  stc|)s  liriskly. 

Ilia/i  bliioil-jircssiiir  CDiiililioiis  are  l)cst  detected  by  means  of  a  sphygmomanometer  ; 
the  diagnosis  will  be  conlirmed  by  the  big  heart,  the  albuminuria  with  tube  easts,  and 
pcrha])s  by  retinitis. 

Of  the  mi/oriinlia/  afferlions.  pericarditis  and  cloudy  swelling  arc  both  acute  conditions, 
often  associated  with  fever  and  with  suflicient  general  illness  to  confine  the  patient  to  bed, 
so  that  the  iial])itations  are  a  minor  part  of  the  malady.  The  diagnoses  of  fatty  or  fibroid 
heart  and  of  adherent  ])cricardium  are  discussed  on  pp.  i53,  .'j-t..  Palpitations  due  to 
heart-nuisele  affeclion  are  sometinies  most  dillicult  to  distinguish  from  similar  pali)itations 
due  to  dyspepsia.  'I'his  applies  particularly  to  fatty  changes  in  the  heart.  Xol  a  few 
mi<ldlc-agcd  persons  suffer  from  |>alpitations  which,  by  some  observers,  will  be  attributed 
to  gastric  trouble,  whilst  by  others  both  the  palpitations  and  the  dyspepsia  will  be 
attributed  to  fatty  hear!  :  nor  can  the  diagnosis  be  made  by  watching  the  effect  of 
slight  exercises  upon  the  pulse-heal,  for  in  typical  dyspeptic  persons  without  fatty  heart, 
the  general  conflilion  is  usually  sulliciently  lacking  in  tfnie  for  the  |)idse-rate  to  be  increased 
readily  by  exercise.  If  materiid  benefit  results  from  the  giving  of  digitalis,  from  the 
adoption  of  Schotfs  Xauheim  treatment,  or  some  modification  of  the  latter,  the  argument 
will  be  in  favour  of  some  myocardial  degeneration  ;  but  in  many  instances  of  llatulcnce 
and  ])alpitation  the  diagnosis  betwceji  fatty  heart  and  mere  dys|)cpsia  will  reuTain  largely 
a  matter  of  opinion.  I'",lccl  roeardiogranis  may  throw  light  upon  the  nuhu-e  of  some  cases 
f)f  myocardi'd  disease  Ihe  n-ilure  of  whi;'h  is  not  obvious  (o  pen'ussion  and  slelhoseopic 
<'xaniination  only:  auricul-ir  lilirillal  ion  may  be  found,  for  example  (l''ii>.  1!M>).  Ihougli 
llirre  Miriy  li''  rm  \  :il\Mlar  disease. 

1,11/iLi  iiJIcrl/ifii.'i  causing  strain  of  Ihe  righl  \'eiilr'cle,  and  llius  leading  lo  palpilalions, 
are  (litcetefl  iis  a  rule  by  physical  examination,  but  here  again  Ihere  may  be  so  much 
<lillicully  in  inlerpreling  the  physical  signs  that  when  a  sloul,  middle-aged  person,  with 
ob\  ious  emphysema,  and  with  whee/ing  anil  shortness  of  breath  on  exertion,  complains 
of  dyspeptic  s\niptonis  and  also  of  palpitations,  it  may  be  very  dillicidt  indeed,  except 
by  watching  the  elleet  of  different  lines  of  trealrneiit,  to  say  whether  the  actual  cause  of 
the  palpitations  is  einpliyscniii  with  secondary  dilatation  of  Ihe  heart,  or  dyspepsia  with 
reflex  palpitations  ur  Ihe  result  of  fatty  changes  in  the  heart  nuiM-le  of  a  (l\speptic  person 
of  sedentary   occupation    who   is   both   stout    and   empli\  semiilous. 

'/'(ihiicco  is  a  \-ery  important  cause  for  palpitations  in  a  patient  who  may  seeni  to  be 
perlcetiv  healthy  :  the  degree  to  whi<Oi  dillerent  indi\i(luals  <mii  smoke  tobacco  with 
impunity  \ari(s  ciiornionsly.  and  whereas  sonic  may  smoke  from  morning  to  night  and 
develop    no    nnlowai'd    sMiiptoms    at    all,    others    de\clop    some    ill    ellerls    Irom    what    arc 


4H6  PALPITATION 

relatively  quite  small  quantities.  Cigarettes  seem  to  be  the  greatest  offenders  in  this 
respect,  particularly  cheap  cigarettes  sold  in  packets  of  considerable  numbers  for  a  penny. 
In  bad  cases  the  heart  becomes  absolutely  irregular  ;  in  all  cases  of  the  kind  any  extra 
exertion,  such  as  trotting  a  hundred  yards,  causes  a  rise  in  the  pulse-rate  out  of  all  pro- 
portion to  what  it  should  :  the  pulse  may  rise,  for  instance,  from  70  to  150  or  160  per 
minute  as  the  result  of  slight  exertion  which  in  an  ordinary  individual  would  only  increase 
it  to  90  or  100.  Those  jjatients  may  have  jjalpitations  at  any  time  of  the  day  or  night, 
but  particularly  when  they  first  get  into  bed,  when  violent  thumpings  may  cause  them 
considerable  alarm.  Similar  thumpings  of  the  heart,  closely  allied  to  but  hardly  identical 
with  palpitations,  are  complained  of  by  elderly  men,  particularly  those  of  the  gouty  habit, 
probably  with  atheromatous  degeneration  of  their  coronary  arteries.  Another  condition 
in  which  the  heart  may  produce  similar  symjitoms  is  epilepsy,  in  which  disease,  quite  apart 
from  the  major  attacks,  there  are  innumerable  accessory  symptoms  of  which  cardiac 
thumpings  in  bed  at  night  are  one.  In  that  jjarticular  variety  of  epileptic  convulsions 
which  is  associated  with. a  sudden  halving  of  the  pulse-rate  and  coma— sometimes  spoken 
of  as  Stokes-Adams  syndrome — palpitations  may  also  be  a  prominent  symptom  :  the 
diagnosis  is  established  best  by  obtaining  electro-cardiographic  records  of  partial  or  com- 
plete heart  block  (Fig.  .37,  p.  88).  Ten.  eoffee.  alcohol,  and  absinthe,  as  causes  of  cardiac 
irregularity  and  c(insei|uent  iialpitations,  can  be  diagnosed  best  bv  the  historv  and  bv  the 


Bifillt 
left  a 


Fiij.  19G. — Klectrocardiogram  to  illustrate  auricular  fibrillation.  Ventricular  beats  are  marked  R.  The 
auricular  beats  are  unmarked  except  in  the  central  part  of  the  middle  curve,  where  three  of  them  are  marked  x  x  x  . 
The  ventricular  beats  (R)  do  not  recur  at  equal  iriterrals.  so  that  the  pulse  was  irresular  in  time ;  but  the  aver.a2e 
ventricular  rate  was  100  per  minute.  The  auricles  were  not  beating  regularly  ;  but  where  marked  x  x  x  the  beais 
occurred  appro.ximately  one  every  fifth  of  a  second,  the  auricular  rate  at  this  point  being  about  300  per  minute. 


effects  of  stopping  the  drugs  in  question.  Morphia  and  cocaine,  if  taken  over  periods 
sufliciently  long  to  lead  to  palpitations,  will  generally  be  indicated  by  the  presence  of 
nuilti[)le  prick-marks  iqion  the  body  or  limbs.  The  jjalpitations  and  other  cardiac  sym- 
jitoms  arc  worse,  not  while  the  drug  is  being  taken,  but  when  it  is  being  intermitted. 
Digitnlis  and  thyroid  extract  will  be  recognized  as  the  cause  at  once  if  they  are  being  pre- 
scrilied  by  the  medical  attendant. 

When  paljjitations  are  due  to  nervousness,  fright,  or  other  emotion,  they  are  transient 
and  not  diflicult  to  diagnose  ;  if  they  keep  on  recurring  from  apparently  trivial  causes 
in  a  iierson  who  has  not  hitherto  been  nervous,  it  is  important  to  bear  in  mind  the  possi- 
bility of  Graves's  disease,  for  although  exophthalmos  and  enlargement  of  the  thyroid  gland 
are  important  .symptoms  of  this  di.sease,  it  is  not  at  all  unconnnon  for  them  to  be  absent 
especially  in  the  early  stages,  and  for  the  only  sign  of  the  malady  to  be  undue  nervousness 
of  the  patient  with  a  tendency  to  tachycardia  and  palpitations.  Any  condition  in  which, 
the  nervous  system  seems  to  be  lacking  in  force  or  in  control  is  liable  to  be  termed  neuras- 
thenia nowadays,  and  if  neurasthenia  be  defined  in  this  broad  .sense,  then  one  variety  of| 
it  has  palpitations  for  a  chief  symptom  :  the  making  of  a  diagnosis  of  neurasthenia,  in  such! 
cases,  however,  is  equivalent  to  saying  that  the  palpitations  are  of  purely  nervous  origin, 
so  that  all  one  has  really  done  is  to  exclude  organic  changes.  Tlie  same  applies  to  hysteria, 
though  it  should  be  borne  in  mind  that  modern  authorities  distinguish  between  hysteria 


I 


PAPULES  4S7 

and  neurosis,  conflnino;  the  word  hysteria  to  those  cases  in  which  the  symptoms  are  directly 
controllable  by  suggestion.  Locomotor  ataxia  may  give  rise  to  symptoms  referable  to 
almost  any  of  the  viscera,  and  there  seems  no  reason  why  cardiac  crises  should  not  occur 
as  much  as  laryngeal,  gastric,  or  intestinal ;  they  are,  however,  rare,  and  when  cardiac 
symptoms  develop  in  a  patient  suffering  from  locomotor  ataxia,  syphilitic  affection  of  the 
heart  would  be  a  safer  diagnosis  than  would  cardiac  crises. 

Anwmia.  when  it  produces  palpitations,  is  usually  obvious  from  the  patient's  appear- 
ance, and  it  can  be  confirmed  by  blood  examination.  As  a  rule.  ))alpitations  in  anemic 
]>atients  are  entirely  absent  while  the  patient  is  at  rest  in  bed,  occurring  mainly  when  she 
exerts  herself  and  causes  temporary  dilatation  of  the  anicmic  heart.  Tlie  palpitations  dis- 
appear when  the  ana?mia  is  cured. 

Palpitations  due  to  mechanical  interference  tvith  the  heart,  by  masses  of  fluid  or  wind 
displacing  it.  can  generally  be  relegated  to  their  correct  cause  by  physical  examination  of 
the  chest  and  abdomen  ;  mediastinal  new  growth,  tympanites,  ovarian  cyst  of  large  size, 
and  the  other  conditions  referred  to  above,  generally  make  their  presence  obvious  before 
they  are  of  sullicient  size  to  produce  palpitations.  Herbert  French. 

PAPULES  may  be  defined  as  solid,  circumscribed  elevations  of  the  skin,  not  larger 
than  a  pea.  Similar  formations  exceeding  that  size  are  classed  as  nodules  or  as  tumours. 
From  Vesici.es  (p.  7.5;J)  they  are  distinguished  by  their  solidity  ;  if  a  papule  is  punctured, 
nothing  but  blood  exudes  ;  but  in  many  instances  papules,  especially  those  of  an  inflam- 
matory kind,  are  transitional  lesions,  passing  into  (a)  vesicles,  (6)  pustules,  (c)  scales,  or 
(tl)  breaking  down  into  ulcers,  (e)  undergoing  hypertrophy,  as  warts,  or  (/)  atrophying. 
If  the  transformation  into  pustules  or  vesicles  is  only  partial,  the  lesions  are  described 
as  papulo-pustwies  or  papulo-vesicies.  and  if  this  is  characteristic  of  the  greater  number 
of  the  lesions,  the  eru])tion  is  said  to  be  papulo-vesicular,  vesiculo-papular,  or  papulo- 
pustular.  If  the  lesions,  originating  as  erythematous  macules,  do  not  take  on  the  full 
character  of  papules,  they  are  said  to  be  maculo-papular  or  erythemato-papular. 

In  size,  pajjules  may  vary  from  a  pin's  head,  as  in  lichen  scrofulosorum,  to  a  pea,  as 
in  lichen  ruber  planus.  The  most  typical  shape  is  that  of  the  papule  of  lichen  planus, 
flattened  and  with  an  irregular  base  :  but  they  may  be  rounded  or  oval,  as  in  prurigo,  or 
cone-shai)ed,  as  in  pityriasis  rubra  pilaris,  or  triangular,  or  umbilicated,  as  in  lichen  planus. 
In  colour,  they  may  be  pink  or  rose-coloured,  as  in  the  inflammatory  papules  of  urticaria 
papulosa,  violet  or  purplish  as  in  lichen  planus,  bright  red  as  in  eczema,  dark  or  coppery 
as  in  syphilis,  yellow  as  in  xanthoma,  whitish  as  in  milium,  almost  black,  as  in  inflltration 
sometimes  met  with  in  sarcoma,  or  simply  skin-coloured,  as  in  prurigo  or  verruca  plana. 
They  may  be  discrete,  as  in  prurigo,  or  may  occur  in  patches,  as  in  lichen  scrofulosorum  ; 
sometimes  they  form  round  a.  hair  follicle,  as  in  eczema  folliculorum  and  pityriasis  rubr.i 
l>ilaris  ;  they  arc  also  met  with  in  cnnnection  with  the  sebaceous  glands,  the  sweat-glands, 
or  the  papilhe.  They  may  be  inflammatory,  as  in  eczema,  or  non-inllainmatory,  as  in 
severe  goose-skin,  or  when  they  are  ttie  rcsiflt  of  retained  secretion,  as  in  acne,  or  of  exces- 
sive cornilication  round  the  mouths  of  hair-follicles.  (Usually,  inflammatory  papules  give 
ri.se  to  itching:  with  I  he  non-iiiflammatnry  kind  Ihire  arc  seldom  nr.uUcd  subjective 
symptom-^. 

Papules  may  occur  in  the  c|)idcniiis,  as  in  \crrura  plana,  or  in  the  dcrnKi.  when  they 
may  be  o-dematous,  as  in  urticaria,  or  inliltratcd,  as  in  lichen  scrofulosorum  :  or  they  may 
affect  both  structures,  as  in  lichen  |)lanus  and  the  strophulus  papifle  of  acute  prurigo.  The 
epidermic  papule  rna\  he  recognized  l)y  its  solidity,  its  hardness  and  dryness,  and  its  super- 
ficial cIcNaliiiii  ;  ihr  (cilcmatous  dermic  jjapulc  by  its  pinkish  colour  and  its  momentary 
yielding  to  p|■(■s^uI■(•  :  I  he  iiililtratcil  dermic  papule  by  its  redness,  induration,  and  clast  icity  ; 
the  (  pideiniii-chrniic  papule  1)\   its  union  of  sonic  of  the  characters  of  the  other  varieties. 

'file  Miulliple  small  papules  which  occur  in  jinpular  eczema  are  usually  conical  with 
riiiiriiled  base  and  bright-rcil  colour  :  owing  to  rupture  by  scratching  they  are  covered  with 
a  liny  dome  ol  blood-cru.st  :  there  is  usually  intense  itching.  P^czcma  of  this  type  may 
resemble  lichen  ruber  /ilanus,  but  in  that  alTection  the  papules,  as  a  rule,  arc  flat  or  umbili- 
cated, with  an  irregular  base,  dark-red  or  violaceous  colour,  and  glistening  surface  :  there 
is  no  (lischarg<-  or  crust -formal  ion  :  the  papules  an-  not  transilionil.  .iiid  they  leave 
browniNli    stains,    while  those  of   eczejna    frequentlx    pass   into    vesicles  and  selilom  produce 


488  PAPULES 

discoloration.  Confusion  between  the  jjlaques  of  lichen  i)Ianiis  and  those  of  scaly  eczema  may 
be  obviated  by  attention  to  the  differences  in  colour  and  in  definition  ;  in  the  former  the 
plaques  are  generally  dark-red  or  purplish,  and  sharply  defined  ;  in  the  latter,  bright-red 
and  not  clearly  marked  off  from  tlic  surrounding  skin.  I'nder  tlie  lens,  a  minute  vesicle 
can  often  be  seen  on  the  to])  of  each  pa])ule  in  eczema  ])apulatuni.  which  is  not  the  case  in 
lichen  planus.  Yet  another  jjoint  of  distinction  between  the  two  is  that  in  lichen  planus 
characteristic  discrete  papules  can  usually  be  found  at  the  margin  of  the  patches.  This 
feature  serves,  too,  to  differentiate  lichen  planus,  in  its  turn,  from  generalized  psoriasis, 
which  is  marked  also  by  more  scaliness  and  less  thickening. 

Lielten  serofulosorum  is  a  papular  dermatosis  which  clinically  bears  some  resemblance 
to  lichen  planus,  but  it  has  no  right  to  the  designation  lichen,  and  belongs  rather  to  the 
tuberculides.  The  ])apules  are  seldom  larger  than  a  pin's  head,  are  usually  Hattish  hut 
occasionally  conical,  very  slightly  resistant,  sometimes  smooth  and  shiny  but  more  often 
covered  with  a  tiny  .scale  which  is  but  .slightly  adherent  ;  occasionally  the  summit  is  occu- 
pied by  a  pu.stule  instead  of  by  a  scale.  The  ])revailing  colour  is  red,  but  it  varies  from  a 
pale-yellow  through  red  to  violet.  At  first  the  lesions  are  disposed  in  groups,  forming 
patches  of  various  sizes.  Others  are  arranged  in  arcs  of  circles,  which  are  usually  seen 
about  the  orifices  of  the  sebaceous  glands.  The  eruption  shows  a  distinct  predilection  for 
the  trunk — the  lower  part,  and  the  back  of  the  abdomen  :  but  occasionally  it  extends  to 
the  beginnings  of  the  limbs  and  may  invade  the  face.  If  the  affection  becomes  generalized 
by  the  spread  and  coalescence  of  the  scattered  groups  of  jjapides.  the  whole  skin  is  covered 
with  thin  scales  and  is  of  a  dirty  reddi.sh-brown  hue.  Itching  is  absent,  or  so  slight  as  to 
be  negligible.  The  eruption  begins  insidiously  and  may  last  for  several  months  ;  and, 
having  disappeared,  leaving  behind  it  no  trace,  it  may  reappear  again  and  again  over  a 
period  of  several  years.  In  the  great  majority  of  cases  the  disease  is  associated  with  some 
form  of  tuberculosis — phthisis,  or  necrosis  of  bone,  or  scrofulous  ulceration  of  the  skin  : 
but  much  more  commonly  with  enlarged  glands,  submaxillary,  cervical,  or  axillary.  Its 
usual  subjects  are  children  and  adolescents  :  it  is  uneonmion  after  the  age  of  twenty.  The 
characters  of  the  |)apules — their  homogeneity,  situation  on  the  trunk,  flatfish  sha])e, 
arrangement  in  groups,  painlessness,  and  chronicity — with  tfic  absence  of  itching,  and  the 
youth  of  the  patient,  are  generally  sufficient  to  determine  the  nature  of  the  affection.  In 
papular  eczema  the  papules  are  not  limited  to  the  trunk,  are  bright  red,  and  there  is 
troublesome  itching  :  moreover,  in  many  cases  there  are  vesicular  or  papulo-vesicular 
lesions  as  well  as  papules.  From  miliar//  papular  si/philides  lichen  serofulosorum  can  be 
distinguished  by  the  ab.sence  of  any  other  sign  of  syi)hilitic  affection,  and  by  the  usually 
restricted  distribution  of  the  lesions. 

In  keratosis  pilaris,  or  xerodermia,  the  papules  do  not  form  groups  or  patches  as  in 
lichen  serofulosorum,  and  usually  they  appear  on  the  limbs,  mo.st  frequently  the  thighs  : 
they  consist  of  projecting  hair-follicles,  which  convey  to  the  hand  the  sensation  of  a  nut- 
meg-grater. This  affection  has,  in  turn,  to  be  distinguished  from  scosc-flesli.  in  which  the 
elevations,  besides  being  evanescent,  are  not  rough  or  scaly.  Ivcratosis  pilaris  is  one  form 
of  ichthyosis  :  another  form,  sometimes  met  with  in  association  with  xerodermia,  but  more 
often  alone,  is  ichthyosis  hyslrix,  in  which  the  lesions  consist  of  small  jjapillary  papules  with 
horny  tops,  which  stud  the  skin  as  with  minute  nail-heads,  and  sometimes  develop  into 
large  warty  masses.  The  condition,  dating  back  to  infancy,  or  at  least  to  early  childhood, 
is  easy  of  identification. 

The  same  may  be  .said  of  the  ordinary  wart  (vcrraca  vulgaris).  The  small  flat  wart 
(verruca  plana  jui'etrilis)  may  sometimes  suggest  lichen  planus,  but  it  is  smaller  than  the 
pa])ule  of  that  affection,  it  has  not  the  dark  colour,  it  gives  rise  to  no  itching,  nor  is  there 
any  tendency  for  the  growths  to  run  together  into  rough,  .scaly,  infiltrated  patches. 

In  pityriasis  rubra  pilaris,  papules  form  at  the  orifices  of  the  hair-follicles,  usually 
following  in  the  wake  of  an  eruption  of  scaly  patches,  or  of  a  dry  eruption  covered  with 
eczematous-looking  crusts.  The  papides,  when  they  appear,  are  small,  red,  and  dry,  liarsli 
to  the  touch,  more  or  less  conical,  and  the  centre  of  each  is  pierced  by  a  single  atrophied 
hair,  which  is  surrounded  by  a  sheath  that  jienetrates  into  the  follicle.  The  surface  of  the 
integument,  thus  roughened,  has  been  likened  to  the  skin  of  a  newly-plucked  fowl.  At 
first  the  papules  are  discrete,  but  later  tliey  tend  to  run  together  into  patches  which  pre- 
sent the  aspect  of  pale  yellowish-red  areas  covered  with  pajjery  scales  resembling  mica. 


PAPULES  4H9 

They  mostly  affect  the  hmbs,  especially  the  surfaces  where  hair  is  most  abundant  ;  if  they 
encroach  upon  the  trunk  they  are  usually  found  at  the  waist  and  the  lower  jjart  of  the 
abdomen.  Itching  is  sometimes  absent,  and  when  present  is  always  insignificant.  When 
the  patches  are  covered  with  mica-like  scales  and  are  met  with  in  the  situations  most  com- 
mon to  psoriasis — the  tips  of  the  elbows,  fronts  of  the  knees,  and  the  extensor  surfaces  of 
the  limbs — there  is  some  danger  of  confusion  with  that  disease  ;  but  at  the  edge  of  each 
patch  the  characteristic  conical  papule  with  its  single  hair  plugging  the  mouth  of  a  follicle 
is  always  to  be  seen.  The  best  place  to  look  for  the  papule  is  on  the  backs  of  the  fingers. 
In  psoriasis,  again,  the  lesions  grow  by  jjeripheral  extension  instead  of  by  the  accretion  of 
new  papules.  The  fact  that  the  general  health  is  not  affected  sufTices  to  mark  off  pityriasis 
rubra  pilaris  from  other  forms  of  exfoliative  dermatitis,  in  which  also  there  is  rarely  any 
ai)preciable  thickening  of  the  skin,  while  the  colour  is  redder  than  in  pityriasis  and  the 
scaliness  more  marked.  From  liclien  ruber  planus,  jjityriasis  rubra  pilaris  is  distinguished 
by  the  absence  of  itching  and  of  impaired  nutrition,  and  by  its  irresponsiveness  to  arsenic. 
In  lichen  planus,  too,  the  papules  are  flattened,  and  often  umbilicatcd. 

In  acne  vulgaris,  the  iiapule  forms  the  primary  lesion.  If  the  obstruction  is  at  the 
mouth  of  the  sebaceous  gland-duct,  the  plug  appears  on  the  surface  as  a  small  black  point 
— the  comedo  ;  if  it  is  in  the  gland  itself,  the  obstructing  material  is  seen  as  a  tiny  whitish 
mass  in  the  substance  of  the  skin — the  milium.  The  lesion  may  not  develop  beyond  this 
stage,  but  usually  it  grows  into  a  reddish  papule  alioiit  the  size  of  a  pea,  and  in  niuiy  cases 
the  papule  passes  into  a  pustule.  .\ene  can  usually  be  recognized  by  the  distribution  of 
the  lesions — on  the  face,  especially  the  cheeks,  nose,  forehead  and  chin,  and  less  frequently 
the  back  of  the  neck,  the  back  between  the  shoulders,  and  the  chest — their  discrete  charac- 
ter, the  presence  of  comedones  or  of  milia,  and  the  patient's  age,  for  the  affection  is  essen- 
tially one  of  ))uberty.  Usually,  too,  the  several  stages  through  which  the  lesions  pass  are 
l)resent  at  the  same  time — the  comedo  or  milium,  the  papule,  the  pustule.  Rosacea  differs 
from  acne  in  that  it  chiefly  affects  the  flush  area  of  the  face,  is  marked  by  much  congestion, 
and  is  most  common  in  middle  life.     (See  also  Pistllks,  p.  557.) 

In  erytliema  miiltiforrtie,  jiapules,  tubercles,  vesicles,  bulhe.  nodules,  macules  may  all 
be  present  at  the  .same  time.  Any  one  of  these  lesions  may  be  predominant  in  a  particiflar 
ease  or  at  a  given  time  :  but  the  type  of  eruption  most  frec|uently  met  with  is  that  which 
consists  wholly  or  predominantly  of  papules  cri/llieina  jxipidiitHtii.  This,  too,  is  usually 
the  first  stage  of  the  eruption  in  cases  wliieh  go  on  to  other  tyiJes.  The  |)apules  are  gener- 
ally, at  the  begimiing,  no  larger  than  a  pin's  head,  bright-red  in  colour,  and  llattish,  some- 
times umbilicatcd.  If  grouped  closely  together  they  may  coalesce  and  form  raised  ])atches 
as  large  as  a  threepenny  or  a  six|)enny  piece  :  each  patch  has  a  sharply  defined  border,  and 
is  surrounded  by  an  areola  of  congested  skin  :  the  tint  in  the  centre  soon  deepens  to  violet, 
and  afterwards  to  purple.  The  favourite  sites  are  the  dorsal  surfaces  of  the  hands  and 
forearms;  sometimes,  too,  the  legs,  feet,  and  the  face  arc  involved.  Papular  erythema 
multiforme  is,  as  a  rule.  c;isy  of  recognition.  Urticaria  of  the  papular  variety — the  stro- 
phulus or  prurigo  simplex  aigu  of  Kreijch  dermatologists — in  which  the  wheals  are  no  larger 
than  a  lentil,  and  leave  papules  when  they  subside,  occasionally  offers  some  resemblance  to 
it  :  but  the  two  alTcctions  dilfer  in  that  the  lesions  of  erythema  papulalum  are  much  more 
persisteiil.  are  not  while  in  tlie  centre.  d<i  not  gi\e  rise  to  ileliing,  but  do  leave  stains.  One 
of  the  most  niMrkcd  of  these  diircreiices  is  llial  which  eonecrns  ileliing.  for  in  papular  urti- 
caria IJiis  syrn|il(jiii,  IIkiumji  \  ariahlc.  is  ri<'(|iicnll\  srvcic.  In  uiliearia.  Iiid,  it  is  chiefly 
the  (■(,\(TC(I  pnilions  of  llic  \,n<\\  ,  and  (■s|)cciall\  llic  iciwcr  iuriiiiar  i(i.niiri.  IJKil  aic  allackcd, 
and  Ihc  .iHcetion  is  niel    with   mostly  in  cliildren. 

I'apules  like  those  of  urticaria  papulosa  are  dIIch  iiicl  uilli  in  pnirign.  Imlli  in  prurigo 
fcro.r  of  Ilebra.  the  severe  form  of  the  alleetion.  and  in  prurigo  luilis.  the  mild  and  ordinary 
form.  The  charaeteristic  lesion  is  im  eruption  of  discrete,  firm,  very  slightly  raised  pafjules, 
more  or  less  licmisplicrieal  in  shape,  with  a  rounilish.  somelinu's  oval  contour,  and  a  glisten- 
ing sMrlMcc.      A I   lirsl   llii-  pMpule  is  of  I  lie  same  ecil ■  :is  Ihc  skin,  bill  afterwards  it  becomes 

retl.  yclliiuisli,  m-  liriiu  iiisli,  increases  in  size,  and  is  Iii(|U(mI  ly  covered  by  a  blood-crust. 
Ill  slrueliirc.  ;iccording  In  Darier.  it  is  a  liicaii/cd  acanthosis.  .Most  abundant  on  the 
exlciisor  surfaces  of  the  limbs,  and  rarely  seen  on  the  flexor  aspects,  or  on  the  face,  the 
pa|iiilcs  occur  not  infrc(|iicnl  ly  on  the  clicsl.  the  lower  part  of  the  abdomen,  the  sacral 
iiuiun.  Mild  llic  liiilliicUs.     The  itching   is  iiilciisc.  miuI  iiii\cd  willi  llic  secondary  changes 


490  PAPI'LES 

produced  by  scratehiiig,  there  may  be  found  others  not  unlike  those  of  eczema.  Pustules 
and  sores  are  common,  often  accompanied  by  great  enlargement  of  the  axillary  and 
femoral  glands.  In  prurigo  ferox  the  papules  are  much  larger  and  more  numerous,  and  in 
parts  the  skin  feels  to  the  touch  like  very  coarse  brown  paper  or  a  nutmeg-grater.  The 
changes  secondary  to  the  inflammatory  process  in  prurigo  are  summed  up  by  French 
dermatologists  in  the  term  liclienisrition  or  Uchenification.  The  skin  is  thickened  and 
rugose,  and  owes  its  peculiar  aspect  to  an  exaggeration  of  the  fine  striic  of  the  normal 
integument,  so  that  it  becomes  quadrillaled  into  a  network  of  which  the  meshes  are  square, 
lozenge-shaped,  or  polygonal,  with  a  fiat  surface  which  often,  as  Darier  says,  presents  the 
aspect  of  glossy  and  brilliant  facets,  as  of  a  mosaic.  Sometimes  it  is  covered  with  fine 
scales.  The  skin  is  less  supple  than  normal  skin,  and  though  in  colour  it  may  undergo  no 
change,  it  is  more  often  greyisli  or  brownish.  The  condition  has  to  be  distinguished  from 
the  lichenization  met  with  in  other  dermatoses.  In  eczema  and  psoriasis,  the  thickened 
and  rugose  skin  is  red,  has  no  glistening  facets,  and  the  margins  are  clearly  defined.  In 
lichen  planus  the  plaques  are  formed  by  confluent  papules  and  are  surrounded  by  charac- 
teristic papules. 

Apart  from  these  secondary  characters  of  prurigo,  the  diagnosis  is  made  by  excluding 
other  itching  affections,  such  as  scabies  and  pediculosis,  on  account  of  the  absence  of  the 
lesions  characteristic  of  those  conditions,  and  by  the  positive  characters — the  origin  of  the 
affection  in  infancy,  and  its  persistence,  the  poor  general  health,  the  preference  the  papular 
eruption  shows  for  the  extensor  surfaces  of  the  limbs,  the  freedom  of  the  bends  of  the 
joints,  and  the  glandular  enlargement,  especially  in  the  inguinal  region. 

In  si/jiliilis.  i)a])ules  are  met  with  frequently  in  association  with  macules,  but  they  may 
occur  independently.  They  may  be  divided  into  two  main  classes  :  (1)  Miliary  papular, 
and  (2)  Flat  papular  supliiloderms. 

1.  Miliary,  or  follicular,  papular  syphilides  are  the  result  of  infiltration  around  and 
beneath  the  pilo-sebaceous  follicles  ;  they  are  rough  to  the  touch,  and  feel  like  small  shot  ; 
they  vary  in  size,  from  a  pin-head  upward,  and  may  be  either  acuminate  or  rounded. 
The  sites  of  election  are  the  trunk,  back,  shoulders,  and  loins,  but  the  limbs  may  be 
invaded,  and  also  the  face.  Very  frequently  the  lesions  appear  in  groups  which  run  into 
each  other  ;  and  they  are  sometimes  disposed  in  rings.  The  characteristic  colour  is  that 
of  raw  ham,  but  at  first  they  may  be  jjink  or  red.  Involution  proceeds  slowly,  the  stain 
left  behind  is  long  in  dying  away,  and  is  sometimes  succeeded  by  a  shallow  depression 
which  may  last  for  years.  There  is  often  a  slight  scale  on  the  surface  of  the  papule,  and 
not  seldom  a  tiny  vcsieo-pustulc  or  pustule  may  be  detected  on  the  summit.  Sometimes 
there  is  overgrowth  of  the  papiihe  :  and  if  tlie  lesion  is  situated  in  a  moist  ])art  the  Avarty 
growth  is  covered  with  sodden  white  epithelium,  when  the  lesion  is  known  as  a  mucous 
papule.  A  more  marked  degree  of  hyjiertrophy  transforms  the  moist  papule  into  a  mucous 
tubercle  or  condyloma,  distinguishable  from  a  wart  in  that  the  overgrown  papilte  are  welded 
into  a  coherent  mass  by  swelling  of  the  intervening  tissue,  while  in  the  wart  they  are  free. 

2.  Flat,  or  lenticular,  papular  sypliilides  \ary  in  size  from  a  jiin-head  to  a  bean,  and  the 
small  or  the  large  lesions  may  predominate  in  a  given  case.  They  may  develop  directly 
out  of  macular  syphilides.  In  contour  they  are  almost  perfectly  roimd.  with  a  flattened  toj). 
are  but  slightly  elevated,  and  in  colour  usually  brownish-red.  The  whole  body  is  affectetl 
pretty  impartially  ;  there  is  little  tendency  to  agmination  ;  sometimes  the  lesions  form  a 
kind  of  circlet  on  the  brow  round  the  margin  of  the  hair  (the  corona  veneris).  In  some 
cases,  ring-like  patches  (the  circinate  or  annular  syphiloderm)  appear  on  the  chin,  around 
the  lips  or  nostrils,  or  sometimes  on  the  vulva  :  they  are  made  up  of  small  yellowish-red 
papules,  with  fine  scales  ;  elsewhere  the  papules,  in  the  same  case,  are  of  the  ordinary 
kind.  In  other  instances,  the  flat  lenticular  papules  of  this  group  become  seborrhoeic  ; 
these  are  characterized  by  their  obduracy  to  treatment.  When  there  is  marked  scale- 
formation,  the  papules  being  covered  with  a  dry.  dirty-grey  scale,  they  are  styled  papulo- 
squamous. Favourite  situations  for  |)apulo-squamnus  syphiloderms  arc  the  palms  and 
the  soles,  where  they  may  be  mixed  with  maculo-papular  and  papido-tubercular  lesions. 
Syphilides  in  tiiese  sites  are  often  rounded  or  irregular  in  shape,  have  but  slight  elevation, 
are  at  first  brownish-yellow  or  brownish-red,  but  presently  become  of  a  dirty  grey,  and  on 
the  disappearance  of  the  scales  have  tlie  characteristic  colour  of  raw  ham.  When  the  scales 
arc  more  abimdant  than  usual,  they  form  the  syphilides  cornees  of  French  dermatologists. 


PARALYSIS.     FACIAL  491 

The  small  papular  syphilides  may  in  some  cases  be  dillieult  to  distinguish  from  a 
widely  diffused  lichen  ruber  planus  :  but  in  this  affection  the  rash  is  uniform,  the  papules 
generally  have  a  linear  arrangement,  and  there  is  usually  severe  itching.  The  pajjules  of 
syphilis  are  most  likely  to  be  confused  with  psoriasis — the  squamous  papules  with  the 
ordinary  form  of  jjsoriasis.  the  painilcs  in  rings  with  annular  psoriasis.  .Attention  must 
be  paid  to  the  polymorphism  of  the  sy))hilitic  eruption,  the  coppery  colour,  the  enlarged 
glands,  the  sore  throat  or  tongue,  and  the  distribution  of  the  lesions,  no  such  partiality  for 
the  elbows  and  knees  being  shown  as  is  observed  in  psoriasis,  and  the  papular  syphilide 
having  a  preference  for  the  flexor  surfaces  of  the  limbs,  while  jisoriasis  affects  ratlier  the 
e.\tensor  aspects.  The  sy))hilitic  scales,  too.  are  thin  and  dirty-white,  while  those  of  psori- 
asis are  heaped  up  in  layers  and  have  a  silvery  sheen.  In  psoriasis,  the  subject  will  usually 
have  a  history  of  jirevious  attacks  to  relate  :  and  often  the  affection  can  be  traced  back  to 
early  life,  whereas  in  syphilis  a  particular  lesion  is  seldom  repeated.  The  palmar  and 
plantar  sj'philoderms  described  above,  which  occur  symmetrically  as  secondary  and  unila- 
terally as  tertiary  lesions,  may  be  confused  with  the  dry  chronic  eczema  of  those  regions  : 
but  in  eczema  there  arc  heat  and  itching,  and  usually,  in  the  case  of  the  palms,  the  fingers 
also  are  involved,  and  at  some  point  or  other  the  process  is  vesicular  or  moist.  Palmar 
.syphilides  may  be  distinguished  from  eczema  seborrhoeicum  by  the  fact  that  in  the  latter 
there  are  coincident  lesions  in  the  common  situations — the  scalp  and  eyebrows,  the 
neighbourhood  of  the  beard,  the  naso-labial  folds,  the  sternal  and  interscapular  regions  ; 
nor  do  they  usually  assume  the  form  of  crescents  or  segments.  Whenever  the  diagnosis 
is  doubtful,  recourse  may  be  had  to  Wassermann's  serum  test.  Malcolm  Morris. 

PARjCSTHESIA.— (See  Sens.\tiox,  .Vrnoiuialities  of.  j).  (>r)4  ) 

PARALYSIS  OF  BOTH  LEGS.     ;.Scc  Pauai-i.i-<;ia.  ,,.  .-,10.) 

PARALYSIS,  CROSSED.  -(Sec  IIkmum.kiua,  p.  :!()•_'.) 


PARALYSIS,  FACIAL.  This  term  is  applied  to  coiuplclc  or  partial  paralysis  ol' 
I  lie  muscles  sui)plicd  by  the  7th  cranial  nerve.  One  or  both  sides  of  the  face  may  be 
iii\c>lved,  the  imilateral  being  more  connnon  than  the  bilateral.  It  is  in  some  cases  the 
result  of  a  morbid  process  limited  to  the  7th  nerve,  known  as  Hell's  palsy  :  in  other 
instances  it  is  one  of  the  signs  of  more  eomijlex,  or  more  remote,  disease.  In  eomi)lete 
unilateral  facial  jjalsy,  whatever  its  origin,  the  asymmetry 
of  the  face  may  be  so  marked  that  the  diagnosis  can  be  made 
at  sight.  Less  severe  facial  weakness  may  be  o\-erlook<'(l 
unless  the  means  for  its  detection  arc  ciiiiiloNcd.  It  is  well. 
therefore,  to  recall  the  evidences  of  larial  palsy  heinn 
pointing  out  Ihc  rialiucs  which  cliaractcri/c  lis  \:ui<ius 
forms.  , 

I'A-eti  with  the  face  at  rest  there  arc  certain  appearances 
on  the  alTeeted  side  which  attract  attention.  The  natural 
lines  and  wrinkles  are  less  marked,  and.  with  the  ol)lil<rat  ion 
(il  till-  naso-labial  fold,  the  check  has  a  smncwIiMl  llallcnc.l 
or.  in  oM  persons.  i)aggy  as|)cet.  If  the  paliinl  is  uncdn- 
seioiis  or  asleep  the  llabbiness  of  the  tissues  ina\  be  cnipli:i- 
sized  by  Ihc  Happing  olthc  check  with  respiration.  csijccialK 
if  breathing  is  laboured  or  stertorous.  The  palpebral  lissnrr 
is  wider  llian  its  Icllnw,  and  the  eurncr  cif  Ihc  mkmiIIi  may 
droop. 

When  the  facial  muscles  arc  thrown  into  action  by 
attempts  to  raise  the  eyebrows,  to  close  the  eyelids,  or  to 
cxi)ose  the  teeth  (/•'/.;.  I!t7),  the  <lilTcrence  bctwiMii  the  two 
sidis  is  rcndcn-d  nion-  oIj\  icjiis,  the  ni(  i\  cnicnls  on  tin-  paretic  li:ill  iif  the  lace  being  earric<l 
(Hit  with  less  p,,u(r  an<l  mnic  sicwix  liian  llinsi-  cf  tlir  jiciillis  half,  'i'lie  ability  to  whistle 
or  to  niM\c  one  nosliil  iriav  also  he  inipaircd,  ami  <\(n  with  slight  <legrces  of  paresis,  a 
person    who    has    pre\i.>iisly    been    able    to    close    the   ev.'  ..f  1  In    allVeted  side,  the  other  eve 


y'l;/.  197.— rnMl.vsw  of  the  lislit  side 
of  llie  fiu-e,  the  jjiitient  nttcinptini?  to 


Icetli.    Note  tliut  tlio 
paliiehral  fissure  is  wider  tlinii  the 
{Pliolo  by  Dr.  «.  .1.  A'.   lliVj 


■i\\t 


49-i 


PARALYSIS.     FACIAL 


I'cmaiiiinj;  o])cn.  is  no  lonjicr  able  to  perform  the  feat.  The  same  dillieulty  is  experienced 
in  making  movements  of  the  ear,  by  patients  who  have  formerly  possessed  that  accom- 
]ilishment. 

Having  cstabhshed  the  ])resence  of  some  facial  weakness,  it  is  necessary,  in  order  to 
take  full  advantage  of  its  diagnostic  value,  to  make  certain  careful  observations  with  a 
view  to  determining  the  site  of  the  lesion  which  is  responsible  for  the  defect.  Thus,  facial 
paralysis  may  be  brought  about  by  :  (1)  A  lesion  anywhere  in  the  course  of  the  pyramidal 
fibres  passing  from  the  lower  end  of  the  preeentral  gyrus  in  one  cerebral  hemis])here  to 
the  facial  nucleus  on  the  opposite  side  of  the  pons  Varolii  {suprniuiclear  paralysis)  ;  (2)  .\ 
lesion  involving  the  facial  nucleus  it.self  (nuclear  paralysis)  ;  and  (3)  A  lesion  of  the  7th 
nerve  between  its  origin  in  the  nucleus  and  the  point  where  it  divides  in  order  to  supply 
the  \arious  facial  nuiseles  (peripheral  paralysis). 

Supranuclear  Paralysis. — Owing  to  the  fact  tliat  tlie  fibres  of  tlic  pyramidal  tract 
concerned  with  facial  movements  cross  the  mid-line  of  the  brain-stem  only  a  very  short 
distance  above  the  7th  nucleus,  the  facial  paralysis  is  on  the  side  opposite  to  the  lesion. 
Occasionally  these  fibres  are  involved  alone  :  more  often  those  destined  to  the  correspond- 
ing arm  and  leg  suffer  as  well,  in  wliieli  case  the  facial  ])alsy  forms  |jart  of  a  hemiplegia. 
In  this  type  of  paralysis  the  diflcrcncc  lietwcen  the  two  sides  is  not  nearly  so  marked  in 
the  ujiper  as  in  the  lower  lialf  of  tlie  face.     For  instance,  the  patient  is  able  to  elevate  both 


i-acture              Fig.  l'J9. — Post-paralytic  contracture.  Fig,      200. — Post-paralytic      contrac- 

.a  first         The  same  patient  closing  her  eyes  and  ture.     The  same  patient  smiling,  with 

le  over-iiction  of  all  tlie  facial  an    involuntary    wink. 

1  the  aefccted  left  side,  [Pholos  b]/  Dr.  .■<.  A.  K.  Witmn.) 


eyebrows  and  to  close  both  eyes,  although  it  will  be  found,  on  testing,  that  he  is  not  able 
to  resist  an  attempt  on  the  part  of  the  observer  to  open  the  eye  of  the  affected  side  with 
tlie  same  degree  of  success  as  attends  his  efforts  on  the  healthy  side.  (Figs.  198.  199.  200.) 
In  the  attempt  to  expose  the  teeth,  the  facial  asymmetry  is  more  striking,  the  lip  remaining 
immobile  or  retracting  .slowly  and  feebly  on  the  paretic  side,  and  the  contrast  between  the 
deptli  of  the  naso-labial  folds  on  the  two  sides  becoming  clearly  empliasized. 

Notwitlistanding  the  im])airinent  of  voluntary  movement  on  one  side,  the  face  may 
l)resent  perfect  synmietry  when  it  responds  automatically  to  emotional  or  reflex  impulses. 
In  laughing  or  crying  the  lines  and  wrinkles  are  developed  equally,  while  protective  closure 
of  the  eyelids  is  accomplished  as  well  on  one  side  as  the  other  in  response  to  any  threatened 
violence  to  the  eyes.  The  preservation  of  these  automatic  movements  depends  on  the 
integrity  of  a  facial  reflex  centre  in  the  mid-brain.  When  this  centre  is  involved  at  the 
same  time  as  the  fibres  of  the  pyramidal  sysstem.  the  emotional  movements  are  lost  or 
impaired  along  with  those  of  voluntary  origin. 

The  corneal  reflex  can  generally  be  elicited  in  this  form  t)f  facial  paralysis,  provided 
there  is  no  co-existent  diminution  of  sensibility  within  the  area  supplied  by  the  trigeminal 
nerve  of  the  same  side.  In  sharp  contradistinction  to  what  obtains  in  the  nuclear  or 
peripheral  types  of  ])alsy.  the  nutrition  and  electrical  excital)ility  of  the  facial  muscles 
undergo  no  alteration  when  the  lesion  is  situated  abo\  e  llie  mieleus. 


PARALYSIS,     FACIAL 


493 


Bilateral  supranuclear  paralysis,  such  as  is  seen  in  cases  of  cerebral  diplejiia  and 
pseudo-bulbar  jiaralysis.  is  characterized  by  a  general  impairment  of  the  natural  move- 
ments, and  tends  to  the  production  of  a  stiff,  expressionless  physiognomy  (Fig.  201).  With 
the  consequent  defective  inhibition  of  the  reflex  centre,  emotional  movements  are  often 
uncontrolled,  and  with  little  jjrovocation  the  ])atient  betrays  in  his  face  degrees  of  mirth  or 
distress  which  he  is  very  far  from  feeling.  This  condition  can  be  distinguished  from  true 
bulbar  palsy  by  the  preservation  of  the  nutrition  and  the  normal  electrical  excitability 
of  the  muscles,  and  by  the  absence  of  accompanying  atrophic  paralysis  fif  the  tongue, 
niasseters,  etc. 

Heference  must  be  made  to  the  occurrence  of  cases,  the  result  of  inid-lnaiii   lesions, 
in  which  the  emotional  movements  are  lost  and  the  voluntary 
movements  are  preserved  on  one  side  of  the  face.     .Asym- 
metry is  then   only    noticeable   when    the  patient   smiles  or 
cries. 

Finally,  it  must  not  be  forgotten  that  in  long-standing 
eases  of  infantile  hemiplegia,  facial  weakness  may  be  associ- 
ated with  spontaneous  athctoid  movements  similar  to  tliosc 
observed  in  tlie  arm  and  leg. 

Nuclear  Paralysis. — Lesions  of  the  facial  nucleus  nia\ 
be  slight  or  severe,  and  the  resulting  facial  paralysis  ma\ 
consequently  be  ]>artial  or  complete.  As  a  rule,  all  tin 
muscles  supplied  by  the  nerve  are  affected  more  or  less 
e(iually,  and  the  im])airment  of  movements  obtains  whether 
they  are  \(ihmtary.  emotional,  or  reflex  in  origin.  In  eases 
of  complete  nuclear  palsy  certain  additional  effects  are  |)ro- 
dueed.  The  inability  to  close  the  eye,  and  the  di'ooping  of 
the  lower  lid,  lead  to  imperfect  protection  of  the  eyeball,  and 
to  the  overflow  of  tears  on  to  the  cheek  (epiphora).  Con- 
.junetivitis  and  blepharitis  may  result.     Paralysis  of  the  lip 

muscles  allows  of  saliva  escaping  from  the  corner  of  the  mouth,  and  m,<y  interfere  materially 
with  the  articulation  of  labial  consonants.  Paralysis  of  the  stapedius  muscle  disorganizes 
the  control  of  tympanic  tension,  so  that  the  patient  suffers  from  excessive  sensiti\encss 
to  deep  tones  (hypcraeusis)  and  perhaps  from  tinnitus.  I'niike  supranuclear  paralysis,  the 
nuclear  form  is  accompanied  by  alni|iliy  and  alleration  in  the  electric  excitability  of  the 
facial  muscles.  In  slow  degrMriatix c  (usually  bilateral)  processes  allecting  the  facial 
miclcus,  the  el--etrieal  response  shows  a  quantitative  moditicalioii  :  in  aiiili-  destructive 
(usually  utiilat{-ral)  lesions  of  the  nucleus,  the  facial  paralysis  is  follc.ucd  rapidly  by  Hie 
reaction  of  degeneration. 

Owing  to  the  situation  of  the  facial  micleiis  in  liic  pons,  unilateral  nuclear  palsy  may 
be  associaterl  with  i)aralysis  of  the  external  nilus  nuisrle  of  llic  same  side  and  jiaralysis 
of  Hie  op|)ositc  arm  and  Icj;'  (' crossed"  paralysis). 

Peripheral  Paral.vsis.  'I'he  clinical  picture  of  a  periplieial  facial  paraKsis  resembles 
in  its  most  important  details  that  which  has  already  been  described  under  the  heading  of 
nuclear  paralysis.  .Ml  the  muscles  supplied  by  the  nerve  arc  affected  in  more  or  less  e(|ual 
degree,  and  the  palsy  is  associatc<l,  within  a  short  time  of  its  onset,  with  atrophy  and 
allirations  in  electrical  exeitabilitv  of  llic  muscles  eoneerned.      'I'he  diagnosis  between  the 


Tlie  pliotogr.qih  shows  absence  of  all 
lines,  and  Slurping  of  both  corners  of 
the  iiiouTh. 


two  ty[>es  depends  {•liictly  upon  the  prcsrnee  of  additional  symptoms 
Icreiicc  with  the  function  of  neighbouring  tissues,  and  this  \ari<s  aga 
of  llic  lesion  in  the  peripheral  course  of  the  ner\e. 

A   lesion   alTeeting   the  libres  within   th<-   pons   is   likily   to   prodia 


resulting  from  inter- 
n  Willi  the  cxaci   site 


^vrnpl, 


iiilcrn 
<>r  llic 


'.    in   addillMii    lo   llu 
ill   priiporlion   to  tin 


il    au<lil< 
SIh    nci 


■alus    will 


ind 


faj'ial   paralysis,  exicrnal   rectus  ])alsy,  together  willi  oilier 

extent   of  the  dcsl  riietivc  process. 
!  .\    lesion    between    the    surface    of    Hie    pons    and    Ihr 

■probably   interfere   with    the   vestibular  and   ((jcliliar   parts 
i  rise  to  vertigo  and  impairment  of  hearing. 

•M  the  level  of  the  geniculate  ganglion,  the  chorda  tympani  is  unlikely  to  escape,  and 

the  taste  fibres  coming  from  the  anterior  two-thirds  of  the  tongue  lose  their  function.  .\t 
■  tlie  same  time,  irritation  of  the  ganglion  may  proxokc  an  herpetic  eruption  on  Hie  auricle 
I  and  around  the  external  auditory  meatus. 


494 


PARALYSIS.    FACIAL 


In  the  upper  part  of  the  Fallopian  canal  a  lesion  produces  complete  facial  paralysis 
and  loss  of  taste  on  the  anterior  part  of  the  tongue  ;  in  the  lower  part  of  the  canal  the 
resulting  symptoms  are  the  same,  with  the  exception  that  paralysis  of  the  stapedius,  with 
its  consequent  hyperacusis,  does  not  occur.  The  nerve  to  the  stapedius  leaves  the  facial 
nerve  between  these  two  points.  Involvement  of  the  chorda  tympani  may  also  cause 
deficiency  in  the  salivary  secretion  of  the  submaxillary  and  sublingual  glands  of  the  same 
side. 

At  the  stylomastoid  foramen,  the  effects  of  a  lesion  are  limited  to  the  facial  nerve, 
the  taste  fibres  being  no  longer  in  close  apposition  to  the  latter. 

From  the  above  data  the  site  of  any  lesion  causing  peripheral  facial  palsy  can  be 
<letcrmined  api)roximately,  and  it  is  only  necessary  to  add  that  the  term  Bell's  palsy  is 
generally  limited  to  eases  in  which  the  exciting  cause,  probably  an  acute  inflammatory 
])ro(ess,  operates  at  some  jjoint  within  or  just  below  the  Fallopian  canal. 

I'liiin  the  diagnostic  standpoint  it  is  important  to  remember  that  a  condition  which 
often  results  from  a  long-standing  BelKs  palsy  may  produce 
a  facial  asymmetry  capable  of  erroneous  interpretation, 
unless  the  observer  is  familiar  with  it.  This  is  the  so-called 
post-paralytic  contracture,  which  emjihasizes  the  folds  and 
lines  on  the  affected  side  in  such  a  way  that  the  opposite 
side  of  the  face  may  appear  at  first  sight  to  be  the  weaker 
{Fig.  IScS).  It  will  be  noticed,  however,  that  an  attempt 
to  close  the  eye  is  imperfectly  carried  out,  and  that  the 
angle  of  the  mouth  is  strongly,  although  involuntarily, 
retracted  at  the  same  time.  Similarly,  on  asking  the 
patient  to  show  his  teeth,  he  can  only  do  so  slowly  and 
with  effort,  while  the  eye  is  almost  closed  on  the  same  side 
bv  a  powerful  associated  contraction  of  the  orbicularis 
lialpebra;.  The  only  comjjlaint  of  a  girl  suffering  from  a 
slight  degree  of  this  contracture  was  to  the  effect  that  she 
was  unable  to  smile  without  at  the  same  time  giving  the 
impression  that  she  was  winking. 

Hysterical  facial  spasm  is  another  condition  which  may 
suggest  weakness   of  the  opposite  side  of  the  face,  but  the 
nature  of  tlie  defect  will  he  made  obvious  when  the  whole  face  is  put  into  action. 

Facial  hemiatrophy  often  simulates  facial  paralysis  (Fig.  *i02)  :  it  may  be  difierentiated 
by  the  fact  that  not  only  the  muscles,  but  all  the  tissues  of  the  face  on  the  affected  side, 
undergo  atro])liie  changes.  E.  Ftiniuhar  Buzuird. 


r.ij.  ■JOJ.— Ili;iuiatro|.hv  of  the  left 
tide  of  tlir;  face  in  an  early  stage.  Tl^s 
condition  is  sometimes  mistaken  for 
facial  palsy. 


PARALYSIS    OF    THE     HAND.  -  (See    Par.m.vsis    oi-    one    Extremity,    Upper, 
p.   51)0  :    (  i.wv-IIami.  p.  1o:t:    Atrophy,  Muscular,  p.  59  :  and  IIkmipi.ecia,  p.  302.) 


PARALYSIS,  LARYNGEAL. — Laryngeal  paralysis  is  to  be  distinguished  from 
interference  with  the  vocal  cords  by  inflammatory  or  ulcerative  lesions,  fixation  of  the 
arytenoid  joints,  and  other  affections  which  mechanically  ))revent  free  movements  of  the 
cords.  The  distinction  can  scarcely  be  made  without  carefifl  examination  of  the  i)arts 
with  the  laryngoscope. 

In  some  cases,  especially  when  bilateral  abductor  paralysis  comes  on  suddenly,  the 
symptoms  may  be  urgent  and  extreme  ;  in  others,  there  may  be  no  definite  symptoms  at 
all,  particularly  if  there  is  but  partial  paralysis  of  one  vocal  cord,  the  other  being  freely 
movable  and  able  to  cro.ss  the  middle  line  so  as  to  meet  its  fellow  for  purposes  of  speech 
or  coughing.  In  most  cases  the  symptoms  which  point  to  paresis  or  parah'sis  of  a  vocal 
cord  are  a  change  in  the  character  of  the  patient's  voice,  as  noticed  by  himself  and  his 
friends,  and  difficulty  in  coughing  effectually  when  need  arises,  the  act  of  coughing  being 
sometimes  associateil  with  a  peculiar  sound  described  by  the  terms  •  brassy  cough  '  or 
'  bovine  cough.' 

For  purposes  of  dilTerentiaJ  diagnosis  laryngeal  paralysis  may  be  divided  into  three 
main  groups,   namely:  (1)  Fmirlioiril ;    (2)  Unilateral  organic:    (3)  Bilateral  organic. 

1.  Functional    Paralysis    of   the    Vocal    Cords    has  lor  its  main  sj-mptom  aphonia 


PARALYSIS.     LARYX(;EAL  495 

without  pain  or  discomfort,  the  patient  nearly  always  being  a  young  woman,  or  a  girl  over 
the  age  of  puberty,  who  complains  that  she  has  almost  suddenly  become  quite  unable  to 
speak  otherwise  than  in  a  whisper.  There  may  have  been  other  functional  nerve  symptoms, 
the  commonest  being  perhaps  difficulty  in  swallowing  owing  to  globus  hystericus. 
This  form  of  loss  of  speech  is  due  to  fimctional  adductor  paralysis  during  vocalization  ; 
but  when  the  patient  is  asked  to  cough  she  does  so  with  ease,  and  thus  demonstrates  that 
the  adductor  paralysis  is  not  real,  for  one  cannot  cough  properly  without  adducting  the 
vocal  cords.  If  the  larynx  is  examined  with  the  laryngoscope,  the  cords  will  be  seen  to 
move  perfectly  both  with  respiration  and  when  the  patient  retches,  though  they  may 
remain  in  the  abductor  jjosition  if  the  patient  is  asked  to  make  any  particular  voice 
sound.  The  condition  always  gets  well  :  it  may  pass  off  almost  instantaneously  as  the 
result    of  local   electrical   application   or  of  treatment   by   suggestion. 

2.  Unilateral  Organic  Affection  of  a  Vocal  Cord  is  obvious  on  laryngoscopic 
examination.  It  is  nearly  always  the  result  of  interference  with  the  corresponding 
recurrent  laryngeal  nerve,  and  owing  to  anatomical  differences  between  the  two,  the  left 
is  affected  more  conunonly  than  the  right.  It  may  be  jjaralyzed  by  pressure  from,  or 
infiltration  by.  an  norlic  rincurtisin  :  a  rneilidstiiial  nnv  gron'tli  ;  secondnry  deposits  in  the 
deep  cervical  or  mediastinal  lymijhatic  glantls — for  instance,  in  a  case  of  squamous-celled 
carcinoma  of  the  irsojihagus  ;  hjnipbddenomii  :  oitmmd  :  or  mediastinal  fibrosis,  particularly, 
though  not  very  commonly,  in  association  with  syphilis,  or  with  fibroid  phthisis  affecting 
the  upper  part  of  the  left  lung.  Two  rare  causes  are  mitral  stenosis,  in  which  the  over- 
distended  left  auricle  sometimes  compresses  and  paralyzes  the  left  recurrent  laryngeal 
nerve,  and  lol)ar  pneumonia  f)f  the  left  upper  lobe  :  extreme  stridor  has  been  known  to 
result  during  convalescence  from  the  latter  in  consequence  of  the  cord  paralysis.  The 
differential  diagnosis  between  these  various  conditions  will  be  found  discussed  elsewhere  ; 
•r-ray  examination  of  the  thorax  may  he  helpful.  In  the  absence  of  special  indications, 
paralysis  of  the  left  %ocal  cord  in  a  man  of  about  forty-five  is  always  suggestive  of 
an  aneurysm  of  the  distal  portion  of  the  arch  of  the  aorta,  particularly  if  the  patient 
has  had  sy])hilis.  has  not  been  an  abstainer,  and  has  undergone  strenuous  physical 
exertion. 

3.  Bilateral  Affections  of  the  Vocal  Cords  arc  seldom  due  to  thoracic  aneurysiu. 
but  some  of  the  other  diseases  mentioned  in  the  i)reccding  paragraph  may  extend  far 
enough  up  into  the  mot  of  the  neck  on  the  right  side  to  reach  and  involve  the  right  recurrent 
laryngeal  ncr\c  as  it  passes  bencatli  the  right  subclavian  artery,  as  well  as  the  left  recurrent 
laryngeal  nerve  as  it  turns  round  the  arch  of  the  aorta  to  the  left  of  the  left  subclavian 
artery.  Careful  examination  of  the  chest  for  evidence  of  new  growth  or  of  syphilitic  or 
tuberculous  fibrosis  is  necessary,  therefore,  before  one  is  in  a  position  to  diagnose  the  more 
common  cause  for  bilateral  paralysis  of  the  vocal  cords,  namely  degeneration  of  the  nerve  eells 
in  the  va/ius  eentres  in  the  medulla  oblongata.  It  should  also  be  remembered  that  some 
particularly  malignant  enlargements  of  the  thi/roid  gland,  and  also  seeondary  deposits  in  the 
deep  een-ieal  li/niphatie  glands,  or  even  extensive  infiltration  of  the  latter  by  tidiereiiloas 
processes,  may  iiivohc  both  rccurrciil  laryngeal  ncr\  es  as  they  lie  on  either  side  in  the 
sulcus  between  the  trachea  and  (esi)|)liagus,  and  thus  cause  bilateral  paralysis  of  the  \()eal 
cords.  When  the  paralysis  is  due  to  degeneration  in  the  \agal  iiikIcI  llicie  is  generally 
abductor  before  eonibined  abductor  and  adductor  pMial\sis:  when  llic  affection  is 
symmetrical  fnini  the  beginning  the  bilateral  adductor  spasm  may  result  in  acute  dyspno-a 
siinulating  acute  suffocative  (edema  of  the  larynx  and  re(|uiring  immediate  tracheotomy. 
More  often,  fortunately,  cjiie  vocal  cord  passes  through  the  stage  of  abductor  paralysis 
into  that  of  complete  paralysis  before  the  other  is  affected,  so  that  the  dangerous  condition 
of  simultaneous  iibduetor  paralysis  of  both  vocal  cords  is  avoided.  The  diagnosis  depends 
upon  the  alteration  in.  or  the  loss  of,  voice,  together  with  the  iiial)ility  to  cough  clllciently, 
except  with  the  sound  which  simulates  the  coughing  of  a  cow  (bovine  cough)  :  upon 
observation  of  the  bilateral  paresis  of  the  cords  with  the  laryngoscope  :  upon  the  exclusion 
of  gross  lesions  within  the  thorax,  or  in  the  neck;  and  upon  the  co-existence  of  other 
indications  of  changes  in  the  central  nervous  system.  These  in  younger  people  are 
generally  tlie  result  of  syphilis,  often  taking  the  form  of  strabismus,  or  of  locomotor  ataxy, 
or  general  paralysis  of  the  iiisaiu-  ;  whilst  In  older  people  there  may  be  vascular  degenera- 
tion associated  with  e\  ideiiee  of  cerebral  softeiiitig  with  or  without  albuiniiiiiria,  glycosuria. 


496  PARALYSIS    OF    ONE    LOWER    EXTREMITY 

thickenerl  arteries,  an  enlargert  lieart.  and  a  high  blood-iiressure.  Only  in  very  rare  cases 
is  the  symptom  due  to  haemorrhage  or  neoplasm  in  the  medulla  oblongata,  for  with  these 
the  patient  does  not  usually  survive  to  show  signs  of  the  laryngeal  paralysis. 

Ilerberl  French. 

PARALYSIS,  OCULAR.~(See  STRAiiisMis.  ]>.  (Uf)  ;  Pupii.,  Arnoumai.itiks  oi^ 
THK.   p.  .").")!  :    and  Dipi.oima.  p.  174.) 

PARALYSIS  OF  ONE  EXTREMITY  (LOWER). -The  diagnosis  of  the  conditions 
in  which  paralysis  of  both  legs  occurs  is  dealt  witli  under  P.\uapi.ei;ia  (p.  .510)  ;  the  present 
article  refers  only  to  cases  in  which  paralysis  of  one  leg  is  complained  of.  It  is,  however, 
a  common  experience  for  the  clinician  to  lind  signs  pointing  to  a  bilateral  affection  when 
the  patient  is  only  aware  of  disability  affecting  one  lower  extremity.  A  notable  and 
common  example  of  this  is  afforded  by  many  cases  of  disseminated  sclerosis.  The  patient 
complains  of  weakness  in  one  leg,  and  the  physician  finds  exaggeration  of  both  knee-jerks 
as  well  as  extensor  plantar  responses  on  both  sides,  and  is  led  to  the  conclusion  that  both 
pyramidal  tracts  are  affected,  althougli  one  may  be  damaged  more  severely  than  the  other. 

The  various  types  of  crural  monoi)legia  may  be  divided  roughly  into  two  classes,  one 
of  which  includes  those  cases  without  nuiscular  atro])hy,  and  the  other  those  which  present 
greater  or  less  degrees  of  muscular  wasting. 

Paralysis  of  One  Leg  without  Muscular  Atrophy. — The  cases  in  this  class  may  be 
sub-divided  into  two  groups,  the  first  comprising  those  in  which  the  ])yramidal  tract  is 
affected,  and  the  second  those  in  which  there  is  no  evidence  of  pyramidal  affection. 

Spastic  paralysis  of  one  leg  may  result  from  a  lesion  of  the  pyramidal  tract  in  any  part 
of  its  course,  but  for  anatomical  reasons  it  is  more  likely  that  the  paralysis  will  be  confined 
to  one  side  when  a  lesion  affects  the  opposite  cerebral  hemisphere  above  the  pons,  that  is 
to  say,  above  the  level  at  which  the  two  ])yramidal  tracts  run  in  close  proximity.  Spastic 
paralysis  of  one  leg  may.  however,  result  from  a  lesion  at  any  level,  and  the  diagnosis  of 
the  level  must  be  made  from  a  consideration  of  other  symptoms.  In  all  cases  the  condition 
of  the  leg  is  qualitatively,  if  not  quantitatively,  the  same.  A  spastic  leg  is  characterized 
by  a  certain  amount  of  weakness  and  rigidity,  exaggeration  of  the  knee-  and  ankle-jerks, 
and  the  extensor  type  of  plantar  response.  It  is  useful  to  remember  that  the  weakness 
in  a  spastic  leg  does  not  affect  all  the  movements  to  the  same  extent.  If  the  movements 
at  the  various  joints  are  tested  against  the  observer's  resistance,  it  will  generally  be  found 
that  dorsiflexion  of  the  ankle  and  Hexion  of  the  knee  are  affected  more  than  other  move- 
ments. It  is  for  this  reason  that  the  patient  tends  to  drag  his  toes  more  on  the  affected 
side  than  on  the  other,  and  evidence  of  this  is  often  forthcoming  in  the  fact  that  he  tends 
to  wear  away  the  toes  of  his  boot.  The  muscles  of  a  spastic  leg  show  no  localized  wasting, 
and  i)re.sent  no  alteration  from  the  normal  in  their  response  to  electrical  stimulation. 

In  the  attem])t  to  diagnose  the  level  of  the  lesion  which  gives  rise  to  spastic  paralysis 
of  one  leg  certain  considerations  are  of  particular  importance.  If  the  lesion  is  situated 
immediately  above  the  lumbar  enlargement  of  the  cord,  the  abdominal  reflexes  can  be 
obtained.  If  the  lesion  is  situated  at  the  level  of  the  10th  dorsal  segment,  the  lower 
abdominal  reHex  on  that  side  will  be  absent,  while  the  epigastric  reflex  remains  intact.  A 
lesion  of  any  of  the  upper  dorsal  segments  causes  abolition  of  all  abdominal  reflexes  on 
the  corresponding  side.  A  lesion  above  the  cervical  enlargement  will  lead  jjrobably  to 
.some,  even  if  slight,  weakness  in  the  corresponding  upper  extremity,  in  which  the  tendon- 
jerks  will  be  exaggerated.  A  lesion  of  the  higher  part  of  the  ])ons  or  of  any  level  between 
the  pons  and  the  cerebral  cortex  will  produce  some  asynunetry  in  the  facial  movements 
as  well  as  weakness  in  the  arm  and  leg. 

Dinsemindled  sclerosis  has  been  mentioned  already  as  a  disease  in  which  spastic  i)aralysis 
of  one  leg  may  result  from  a  lesion  situated  in  the  spinal  cord.  In  ail  probability  evidence 
of  other  patches  of  disease  will  be  discovered  in  such  cases  if  a  careful  examination  is  made. 
Some  intention  tremor  in  one  or  both  hands,  nystagmus,  diplopia,  optic  atrophy,  and 
sphincter  troubles  are  among  the  signs  which  may  be  forthcoming.  Less  commonly,  a 
one-sided  affection  of  the  spinal  cord  above  the  lumbo-sacral  enlargement  is  due  either 
to  some  intra-medullary  disease,  such  as  a  patch  of  myelitis,  a  gumma,  or  a  neiv  growth. 
When  this  occurs  there  may  arise  a  symjitom-complex  to  which  the  term  Broivn-Sequard 
paralysis  is  applied.     In  this  condition  there  is  spastic  paralysis  of  the  leg  on  the  same 


PARALYSIS    OP    ONE     LOWER     EXTREMITY 


side  as  the  lesion,  together  with  loss  of  sensibility,  especially  of  thermal  and  painful 
sensibility,  in  the  opposite  leg.  The  physical  signs  in  Brown-Sequard  paralysis  are 
represented  in  greater  detail  in  the  accompanying  diagram  : — 

Zone  of  Hyper.Tpsthesia 


Local 
Effects 


I  Atrophic  Paralysis 
Painful   and   Thermal   Loss 
I  Loss  of  all  Reflexes 


Spastic  Paralysis 


Not 
Constant 


( Loss  of  sense    of  passive    position 

and  movement 
I  Loss  of  tactile  discrimination 


=  Diniinislied   skin   reflexes 

:  Increased   tendon   reflexes 

r  .\iikle-cloiuis 

Extensor  plant;ir  reflex 
Fitj.  2il;j. — Diajjrammatic  repreaoutatiun  o(  the  res 


^J  Xo  Local  Effects 


(4  to   6   normal   segmental   areas) 
No  paralysis 


Loss  of  sensibility  to  painful  and  thermal  stimuli 
Loss  of  tactile  and  pressure  | 
sensibility  and  localization/' 


uncommon 


I  Normal  skin  reflexes 

Normal  tendon  reflexes 
I  No  clonus 
'  Flexor  plantar  reflex 
one-sided  lesion  of  tlie  spinal  cord — Bro\vn-S6quard  Paralysis 


Uifslericdl  piir/ilifsis  of  one  leg  usually  does  not  afford  much  dilhculty  in  diagnosis. 
The  affected  limb  may  be  cither  rigid  or  llaccid  ;  in  either  case  there  is  no  true  muscular 
atrophy  and  no  alteration  in  the  muscular  response  to  electrical  stimidation.  The  con- 
dition of  the  reflexes  provides  the  most  important  information.  In  the  hysterical  forni 
of  paralysis  the  knee  and  ankle-jerks  may  be 
exaggerated,  but  they  are  never  lost.  A  true 
anklc-elonus  is  never  obtained,  and  the  plantar 
reflex  is  cither  abs<-nt  or  of  the  llexor  type.  As 
a  general  rule  the  tendon  reflexes  in  the  opposite 
luiaffccted  limb  will  be  found  to  be  equally  brisk. 
In  contradistinction  to  spastic  paralysis  resulting 
from  a  i)yramidal  lesion,  in  which  it  has  already 
been  iHiinlcd  oul  Hint  dinsidcxion  of  the  ankle 
and  llcxion  of  the  knee  arc  the  movements  most 
profoundly  alTcctcd.  the  movements  of  the  leg  in 
a  case  of  hysterical  paralysis  are  found  to  be  more 
or  less  equally  delicicnt  at  all  joints  and  in  all 
directions.  Certain  attitudes  and  certain  types 
of  gait  are  almost  characteristic  o!'  hysterical 
paralysis  of  one  leg.  In  one  form  the  whole  leg 
is  kept  rigidly  extended,  and  the  foot  strongly 
inverted,  so  that  the  patient  walks  on  the  outer 
plantar  edge  with  a  slilT  leg.  In  another  form, 
till'  leg  is  llaeci.l  and  is  dragged  behind  I  he- 
opposite  liiTd)  with  the  toes  scraping  the  lloor. 
In  some  cases,  examination  of  the  limb  when  tin 
patient  is  at  rest  in  bed  re\'cals  lit  lie  or  no 
|i;ir:ilysis,  bul  in  llic  alleiiipl  I.,  slarid  or  walk  llie 
liinl)  appears  lo  be  cpillc  uscliss.  Il\s(crical 
paralysis  of  a  leg  may  of  course  be  associated  with  similar  palsies  of  the  opposite  leg,  or  of 
the  arm  on  the  same  side  (hysterical  paraplegia,  hysterical  hemiplegia).  .More  often  thiin 
not   a    leg   which    is    the    scat   of  lixslcrieal  paralysis  als<i  presents  complete  insensibility  to 


wns  epiwtic  pnmlysis  ol  the  right  log  only. 


of  the  lower 
s  insensitive  to 
all  decrees  of 
.  The  senno  of 
1  tJictile  cllseri- 
ri«ht  foot.     There 


498 


PARALYSIS     OF     ONE     LOWER     EXTREMITY 


all  forms  of  stimulation,  and  the  iippir  limit  of  such  an;psthesia  may  correspond  to  the 
line  of  the  knee,  the  yroin.  or  the  umbilicus. 

In  the  early  stages  of  paralysis  agitaiis  a  patient  may  complain  of  lo.ss  of  power  in  one 
Ico,  and  the  diagnosis  may  present  considerable  dilliculty  if  the  characteristic  tremor  of 
this  disease  has  not  made  its  appearance.  Examination  of  the  limb  may  show  little 
abnormal.  Some  slight  paresis  and  slight  stiffness  to  jjassive  movements  may  be  detected, 
but  no  alteration  in  the  character  of  the  reflexes  will  be  observed.  The  diagnosis  must 
depend  more  upon  the  general  aspect  and  the  attitude  and  gait  of  the  patient.  Some  loss 
of  facial  expression,  the  general  slowness  of  his  movements,  and  the  tendency  to  shuffle 
with  the  alTected  leg,  are  ])oints  which  may  lead  the  observer  to  form  a  correct  opinion. 

Paralysis  of  One  Leg  with  Muscular  Atrophy. — In  a  case  which  jjresents  atrophic 
palsy  of  one  leg,  the  first  essential  for  making  a  diagnosis  is  to  ascertain  the  exact  distribu- 
tion of  the  atrophied  muscles,  and  to  review  this  distribution  in  the  light  of  what  we  know 
with  regard  to  the  central  and  peri])luial  innervation  of  the  muscles  of  the  lower  limb. 
(.See  table  below. 

Single  nerve  palsies  are  not  so  common  in  the  lower  extremity  as  in  the  upper,  but 
they  may  occur,  especially  as  the  result  of  injury.  Isolated  paralysis  of  the  anterior  crural 
nerve  and  of  the  obturator  nerve  are  quite  imcommon,  and  when  they  do  occur  are  generally 
the  residt  of  compression  of  the  nerve  within  the  abdominal  cavity,  either  by  growths  or 
during  the  act  of  parturition.  In  affections  of  the  anterior  crural  nerve,  the  movements 
of  flexion  of  the  thigh  on  the  trunk  and  extension  of  the  leg  upon  the  thigh  may  both  be 
impaired  or  lost.  Wasting  of  the  anterior  thigh  muscles,  and  diminution  or  loss  of  the 
knee-jerk,  are  other  obvious  signs  of  this  condition.  When  the  obturator  nerve  is  injured. 
the  patient  can  flex  his  hip  but  cannot  adduet  the  thigh,  and  so,  when  sitting,  he  can  raise 
his  knee  but  cannot  throw  it  across  the  other  leg.  He  can  walk  about  with  no  obvious 
disturbance  of  gait,  but  he  cannot  rotate  the  thigh  either  outwards  or  inwards,  with  any 
degree  of  force. 


Tablk 


-iiiowiNG  THii  Muscles  to  which  the  various  Nerves  ov  the  Lu.mbar  and 
Sacral  Plexuses  are  Distributed. 


Nerx'e. 
Obturator  (L.  2,  3,  4) 


( Adductor  loiigiis 
'  Gracilis 
(Adductor  brevis 


Muscles. 

Obturator  externus 
Adductor  magnus 


Anterior  crural   (L.  2,  3,  4) 
Sciatic  nerve  (L.  4,  5,  S.  1,  2,  3) 


I  Iliacus 
( Pectiiicus 
I  Semitenditiosus 
I  Bieejjs 
/Tibialis  anticus 
It     1  /T      1    -   V    1    <)\ '  Extensor  i)roprius  liallueis 
External  poi.litea!  (L.  4,  o,  !>.  1,  2)-  g^j^,,^^,,^  ,j„^„„^  dif-itoruin 

vPeroneus  tertius 
/  Gastrocnemius 

T   .         1         ■•.      1  ,r     .   .    .  Plantaris 

Internal  popliteal  (L.  4, ."..  S.  1 .  2, 3)-  Soi^^, 


Internal  |)lantar 

External  plantar 

Nerve  of  the  quadratus  fenioris 
(L.  5,  S.   1) 

Nerve  of  the  obturator  internus 

(L.  5,  S.   1,  2) 
Nerve  of  the  pyriformis 
Superior  gluteal  nerve    (L.  4    5, 

S.   1,  2) 

Inferior   gluteal    nerve    (L.  5,  S.    i 
1.  '-')  'l 


vPoplitcus 

I  Flexor  brevis  hallucis 

I  Abductor  hallucis 

I  Aceessorius 
Abductor  minimi  digiti 
Flexor  bresis  minimi  diiiiti 

I  Interossei 


Quadratus  femoris 

Obturator  internus 

Pyriformis 
(  Gluteus  medius 
I  Gluteus  minimus 

Gluteus  maximus 


Sartorius 

QuadrieeiJS  extensor 
Sem  i  membranosus 

Extensor  brevis  digitorum 
Peroneus  longus 
Peroneus  brevis 

Tibialis  jjosticus 
Flexor  longus  digitorum 
Flexor  longus  hallucis 

Flexor  brevis  digitorum 
1st   luinbrical 

■Ailduetor  obliquus  hallucis 
.Adductor  transversus   hallucis 
Outer  3  lumbricals 


Gemellus  inferior 
Gemellus  superior 

Tensor  vaijinte  femoris 


PARALYSIS    OF    ONE     LOWER     EXTREMITY  499 

Paralysis  of  the  mail)  trunk  of  the  sciatic  nerve,  which  would  inchide  paralysis  of  all 
the  muscles  supplied  by  the  internal  and  external  popliteal  nerves,  points  to  disease  or 
injury  affecting  the  pelvis.  It  may  be  brought  about  by  a  fracture  of  the  pelvis  or  of  the 
upper  end  of  the  femur,  or  by  injuries  to  the  hi|)  joint  :  on  the  other  hand,  the  sciatic  nerve 
may  be  compressed  by  timiours  or  inflammatory  masses  within  the  pelvis.  Such  an 
extensive  palsy  has  considerable  effect  on  the  patient's  gait,  as  he  is  unable  to  Hex  the  knee, 
and  consequently  has  to  use  the  leg  as  a  stiff,  extended  support  ;  the  disability  is  increased 
by  the  absence  of  all  movements  at  the  ankle  joint.  The  sensory  loss  in  such  a  condition 
includes  the  outer  side  of  the  leg  and  the  whole  of  tlie  foot,  except  a  small  area  on  its  inner 
and  upper  aspect. 

Palsy  of  the  externa!  popliteal  ucitc  is  the  conuuonest  isolated  nerve  palsy  in  the  lower 
extremity.  Not  only  is  it  ])articularly  exposed  to  injury  in  its  course  through  the  popliteal 
space,  and  as  it  winds  round  the  fibula,  but  a  primary  neuritis  of  it  is  by  no  means 
uncommon,  especially  in  cases  of  diabetes  mellitus  and  lead  poisoning.  Isolated  paralysis 
of  the  external  popliteal  nerve  has  been  observed  frequently  in  tabes  dorsalis.  Its  most 
obvious  result  is  the  droi)ped  foot  to  which  it  gives  rise,  and  the  high-stepping  gait  which  is 
necessary  if  the  patient  is  to  clear  the  ground  with  his  toes. 

Injury  to  the  internal  popliteal  nerve  is  very  much  less  common,  but  it  may  be  involved 
by  tumours  or  the  products  of  inflammation  in  the  upper  part  of  the  leg.  Paralysis  of  the 
calf  muscles  is  the  chief  consequence,  preventing  the  patient  from  extending  his  foot  and 
standing  on  tip-toe.  or  from  making  any  springing  movement  in  the  attempt  to  walk  or 
run.  The  paralysis  of  the  interossei  and  the  unopposed  contraction  of  the  long  extensors 
may  lead  to  Cl.vw-foot  (p.  109). 

T.\BLi-;  SHOWING  riii:  Misclks  Innerv.^teo  by  the  different  Roots  of  the  Ll'.mbar  and 

S.iCUAL  Plexuses.* 
L.   1.  2.  Ilio/isoas.     (^ii/i(triiliis   liimborum.     Sartorius.     Creniaster.     Quadriceps. 

(iuailrieeps.     .Sartorius.     Quadratus     lumboruin.      Adductorcs     femoris.      Obturator 

externus. 
Adrluclores  femoris.     Quadriceps.     Sartorius.     Tensor  fascia'  femoris.     Tibialis  anticus. 

Kxtensor  communis  digitorum.     Extensor  hallucis. 
Tifiialis     milieus.      Extensor     communis     digitorum.      Extensor      hallucis.      Peronei. 
.VI)du<tors   and   external    rotators   of  the   hip.     Gastrocnemii.     I^ong   flexors   of 
the   toes.     Hamstrings,     (ilutei. 
Gastrociieiiiii.     Itdmslriiigs.     Long    flexors     of    the     toes.     Peronei.     .\bduetors     and 

external   rotators   of  the   hip.     Ghitei. 
tllulei.      Intrinsic    iiiiitclcs    of    the   fool.     Gastrocnemii.     Hiiinstriugs.     Long    flexors 
of  the   toes. 
S.   ;i.   .).    Tlie  iniisculiiliirc  (if  llic  /irriiniiiii  coiiii'-cleit  icilh  ilfieriilioii.  iiiicliiriliiiii . 

In  addition  to  these  peripheral  nerve  palsies  of  the  lower  limb,  we  have  to  consider 
paralysis  due  to  lesions  of  the  roots  leaving  the  lumbo-sacral  region  of  the  cord,  and  forms 
resulting  from  disease  of  that  part  of  the  spinal  cord  itself  (see  table  above)  :  atrophic  palsy 
of  one  leg  is  not  commonly  the  result  t)f  spinal  caries,  although  it  may  occur  when  the  caries 
affects  the  lower  lumbar  or  sacral  region.  On  the  other  hand,  paralysis  of  one  leg,  generally 
associated  with  acute  |)ain  of  root  distribution,  is  not  a  very  rare  early  symptom  of 
malignant  disease  of  the  loxuer  part  of  the  vertebral  column.  In  the  abseni-e  of  any  ob\ious 
deformity,  the  diagnosis  in  such  cases  is  often  didieult,  and  much  may  depend  on  the  use 
of  skiagraphy  or  upon  the  history  of  a  growth  elsewhere  which  may  have  been  removed, 
from  the  breast  for  instance,  excii  years  previously.  In  some  eases  a  good  deal  may  be 
learnt  from  observing  loss  of  the  natural  spinal  lumbar  curM'.  and  from  a  suggestion  of 
shortening  in  the  stature  of  the  patient,  and  particularly  by  noticing  the  diininished 
interval  between  the  lower  ribs  and  I  lie  iliac  crisis.  These  are  signs  of  collapse  on  the 
part  of  the  softened  vertebra',  and  const  il  ulc  a  cnndilioii  to  which  the  name  '  entassement  ' 
is  applied. 

Siijiliililic  iiiciiiiigilis.  iiuoMrig  the  niiils  u\'  llic  iMMihn-saiTal  curd,  is  aiiotlier  not  \ cry 
uncominon  source  of  crural  niorioplcgia.  The  iliagnosis  clcpciids  upon  the  history  of 
syiihilis,  a  positive  Wassermann  serum  reaction,  the  results  ol  an  examination  of  the 
cerebrospinal  fluid,  and  the  fact  that  both  the  motor  palsy  ami  the  sensory  loss  follow  a 
root  disi  ribulion. 

*  Tlic  muscle.*  wliicli  ulTord  tlin  most  useful  liuidinurks  are  prinle  1  in  itjilios. 


L. 
L. 

3 
4 

L. 

■' 

S. 

1. 

.S. 

2. 

500 


PARALYSIS    OP    ONE    LOWER    EXTREMITY 


Probably  more  common  than  any  other  cause  for  atrophic  paralysis  of  one  leg  is  the 
disease  known  as  acute  poliomyelitis  (p.  512). 

Tumours  of  the  spinal  cord  and  syringomyelia  are  very  much  rarer  causes  of  paralysis 

of   one    lower    extremity,    although    the 
possibility  of  their  occurrence  may  some- 
times need  to  be  taken  into  consideration. 
Various   forms    of    progressive    muscular 
atrophy,     of    either    spinal    or    primary 
.nuscular     origin,    are    more    important 
causes    of   Paraplegia  (p.  510)  than  of 
unilateral   paralysis.     As  a   general   rule 
they  are    symmetrical,  or  approximately 
symmetrical,  in  their  onset  and  progress, 
but  every  now  and  then 
one  may  meet  with  cases 
in    their   earliest   stage, 
when  the  complaint  of 
the   patient    is  referred 
to    one    limb    only.     A 
good  example  is  afford- 
ed by  the  case  of  a  lad 
who  was  brought  to  me 
on  account  of  weakness 


Fig,  205. — Diagram  to  illustrate  the  larabo-sacral  plexus  ajid  its  branches  (ajicr  KocJier). 


in  one  foot,  which  had  appeared  quite  insidiously  and  was  tending  to  progress.  The  affected 
limb  showed  atrophic  palsy  of  the  long  extensors  of  the  toes  and  of  the  peroneal  muscles. 
The  diagnosis  of  peroneal  muscular  atrophy  (p.  60)  was  confirmed  by  the  appearance  of 
similar  physical  signs  in  the  other  leg  some  months  later.  In  addition  to  their  early 
symmetrical  distribution,  these  progressive  degenerative  diseases  can  be  distinguished  from 
gross  diseases  of  the  spinal  cord  and  its  envelopments  by  the  absence  of  pain  in  the  course 
of  their  evolution.  E.  Farguhar  Buzzard. 

PARALYSIS  OF  ONE  EXTREMITY  (UPPERl.— The  word  -paralysis'  has  come, 
by  general  use.  to  include  jjartial  as  well  as  complete  palsies,  and  to  embrace  all  varieties 
of  impaired  voluntary  nn)venient.  It  is  in  this  sense  that  the  word  is  used  for  the  purpose 
of  this  article.  No  other  interpretation  would  be  of  value  in  discussing  diagnosis,  because 
the  latter  depends,  not  upon  the  degree  of  paralysis,  but  upon  its  nature,  distribution, 
and  associated  phenomena.  Accurate  diagnosis  is  often  most  diflicult,  although  perhaps 
more  important  from  the  point  of  view  of  successful  treatment,  when  the  limitation  of 
voluntary  movement  is  only  slight.  Before  discussing  the  various  forms  of  paralysis  met 
with  in  the  arm,  some  reference  must  be  made  to  a  few  practical  points  which  are  important 
in  the  proper  investigation  of  cases  complaining  of  inability  to  use  an  arm. 

The  medical  man  must  not  be  satisfied  with  the  patienfs  statement  that  he  has  lost 
power  or  that  he  is  weak  in  his  limbs.  Tests  must  be  employed  to  ascertain  whether  this 
is  really  the  case.  The  movements  at  each  joint,  of  flexion,  extension,  pronation,  supina- 
tion, must  be  investigated,  and  if  necessary  their  power  measured  against  the  observer's 
resistance.  It  may  be  found  that  the  grasp  is  powerful  in  a  patient  who  is  unable  to  use 
his  hand  on  account  of  loss  of  control  over  the  finger  movements.  In  such  a  case  there  is 
not  paralysis,  but  inco-ordination  (see  Ataxy,  p.  55).      Similarly,  there   is  certain  to  be 


PARALYSIS  OF  ONE  UPPER  EXTREMITY"  r.oi 

difficulty  in  carrying  out  delicate  movements  if  there  is  loss  of  cutaneous  sensibility.  With- 
out tactile  sense  it  is  impossible  to  handle  a  pen  in  a  proper  manner.  Sometimes  a  patient 
will  complain  of  loss  of  power,  when  investigation  shows  that  the  ability  to  execute  move- 
ments is  inhibited  by  the  pain  in  a  muscle  or  joint  evoked  by  the  attempt.  In  other 
instances,  mechanical  limitation  of  movement  by  arthritic  changes,  without  pain,  may 
lead  the  patient  to  believe  that  there  is  loss  of  power.  He  finds  he  cannot  lift  his  arm. 
and  ascribes  the  disability  to  paralysis  instead  of  to  ankylosis  of  the  shoulder  joint.  On 
the  other  hand,  it  must  be  remembered  that  pain  and  loss  of  power  may  be  associated  in 
some  forms  of  neuritis.  If  the  patient  says,  "  My  arm  is  so  painful  that  I  cannot  lift  it," 
examination  must  be  directed  to  ascertain  whether  the  inability  is  due  only  to  painful 
inhibition  or  to  real  paralysis  in  addition. 

.Stress  must  be  laid  upon  the  necessity  for  obtaining  a  careful  history,  and  especially 
an  accurate  account  of  the  duration  of  the  trouble,  whether  its  onset  was  sudden,  rapid, 
or  slow  and  progressive,  and  whether  the  loss  of  power  was  accompanied  or  preceded  by 
pain,  numbness,  or  tingling.  The  family  and  jjrevious  history  must  not  be  neglected.  In 
examining  the  paralyzed  arm.  care  should  be  taken  that  the  whole  of  holli  upper  limbs,  as 
well  as  the  neck,  upper  part  of  thorax,  and  shoulders  are  stripped,  so  as  to  be  inspected 
easily  and  the  two  sides  compared.  It  will  also  be  necessary,  in  the  large  majority  of 
instances  to  investigate  the  functions  of  the  cranial  nerves  and  the  reflexes,  etc.,  of  the 
trunk  and  lower  extremities.  This  is  often  imperative  even  when  no  complaint  is  made 
of  loss  of  power  or  other  sym])toms  in  any  part  of  the  body  except  one  upper  limb.  The 
importance  of  this  full  examination  is  perhaps  obvious,  but  it  may  be  illustrated  by 
reference  to  two  points.  A  lesion  of  one  internal  capsule  may  give  rise  to  paralysis  of  the 
opposite  arm,  but  it  will  be  likely  to  cause,  in  addition,  some  alteration  in  the  abdominal 
and  leg  reflexes  of  the  corresponding  side.  Similarly,  a  lesion  of  the  8th  cervical  or  1st 
dorsal  spinal  segments,  or  of  their  corresponding  spinal  roots,  will  also  affect  the  fibres 
leaving  the  cord  at  that  level  and  passing,  via  the  cervical  sympathetic,  to  the  eye  of  the 
same  side.  In  this  way  atro|)hic  |)aralysis  of  the  muscles  of  one  hand  may  be  associated 
with  a  small  pupil  and  a  small  palpebral  fissure  on  the  same  side,  a  coincidence  which  at 
once  points  to  the  cord  or  roots  as  the  site  of  the  lesion,  and  acquits  the  peripheral  nerves 
of  being  concerned  in  the  production  of  the  palsy.  In  such  a  case  the  further  investiga- 
tion of  the  abdominal  reHexes.  the  knee-jerks,  and  plantar  responses,  will  help  to  decide 
whether  the  lesion  is  inlramedullarv  or  cxtrainedullary  :  in  the  former  event  the  abdominal 
rellcx  on  the  same  side  would  be  absi-iit.  tin-  kiue-jcrk  would  be  inercascd,  and  the  plantar 
resjjonse  would  be  of  the  extensor  type,  while  in  the  latter,  unless  the  lesion  exerted  con- 
siderable pressure  on  the  cord,  the  rellexes  below  the  arm  would  be  normal. 

.\ny  attempt  to  enumerate,  let  alone  discuss,  all  the  possible  lesions  which  can  give 
rise  to  paralysis  in  the  upper  extremity,  is  out  of  the  question,  and  we  must  be  content 
to  consider  the  broad  principles  of  diagnosis  in  connection  with  the  more  familiar  instances 
of  brachial  palsy.  For  this  purpose  a  elassilication  based  ehielly  on  the  presence  or  absence 
of  nniscular  atrophy  will  be  adoptud.  This  will  be  of  praelical  use  because  the  mere 
inspection  of  a  paraly/.ed  limb  generally  enables  the  observer  to  detect  whether  a  case 
biloiigs   to   the  oni-  category  or  the  other. 

PARALYSIS    WITHOUT    MUSCULAR    ATROPHY. 

This  heading  embra<'es  cases  in  which  there  may  be  general  impairment  of  nutrition, 
and  perhaps  [uuseular  wasting,  due  to  disuse,  but  in  which  there  is  no  localized  muscular 
atrophy  and  no  alteration  in  the  resjjonse  of  the  muscles  to  electrical  stimulation.  The 
cases  may  be  divided  into  two  groujjs  :  (1)  Those  in  which  there  is  some  alfecticui  of  the 
upper  motor  neuronic  system  (pyrami<lal  lesions),  and  (2)  Cases  without  lesion  of  the 
pyramidal  tract. 

Paralysis  clue  to  Pyramidal  Tract  Lesions.  The  most  familiar  example  of  (his 
group  is  alTorded  by  cases  of  l)ra(hial  monoplegia  due  to  a  viisniUir  lisiaii  (lliri)Hihosis.  Iiti'iniir- 
rhnfif.  or  irnholism)  in  tlir  inliT/iiil  riipsiih'  or  other  part  of  the  pyramidal  tract  in  its  course 
through  the  brain.  In  the  diagnosis  of  this  condition  the  points  of  importance  arc  :  The 
presence  of  some  cardiovascular  condition  capable  of  producing  thi'  lesion,  such  as  disease 
of  I  lie  licarl,  kidneys,  or  arteries  :  the  sudden  or  rapid  onset  of  the  symptoms,  with  or 
witliuut   loss  of  consciousness  or  other  ccribral  disturbance.     The  arm  retains  its  natural 


50-2  PARALYSIS  OF  OXK  UPPER  EXTREMITY 

contours,  and  the  nuiscles  are  not  atrophied,  although  they  may  appear,  after  some  time 
has  elapsed,  to  be  smaller  than  those  of  the  other  arm.  The  paralysis  may  affect  the  whole 
limb  and  include  inability  to  shrug  the  shoulder  ;  or  the  movements  of  the  hand  and 
fingers  may  be  more  impaired  than  those  of  the  elbow  and  shoulder.  There  is  a  tendency 
for  the  arm  to  exhibit  more  and  more  resistance  to  passive  movement,  that  is  to  say.  to 
develop  spasticity.  At  the  same  time,  if  left  to  itself,  the  limb  will  adopt  a  fixed  position, 
which  includes  adduction  of  the  upper  arm  to  the  trunk,  flexion  and  pronation  of  the  fore- 
arm, and  flexion  of  the  wrist  and  fingers.  If  any  movements  are  possible,  they  will  be 
those  of  flexion  rather  than  of  extension  at  the  various  joints.  The  muscle  tone  is 
increased,  and  the  tendon-jerks,  such  as  the  ulnar  and  radial  wrist-jerks,  the  triceps,  biceps 
and  supinator  jerks,  are  exaggerated  when  compared  with  those  of  the  opposite  limb. 
Eventually  contractures  may  develop,  and  it  will  be  found  impossible  to  extend  the  upper 
arm,  forearm,  hand,  and  fingers  into  one  straight  line. 

Such  is  the  clinical  j)icture  afl'ordcd  by  spastic  paralysis  of  the  arm.  and  one  case  will 
differ  from  another  only  in  the  degree  of  spasm  and  the  degree  of  paralysis  :  but  the  amount 
of  spasticity  and  the  paresis  do  not  always  correspond.  In  one  patient  the  rigidity  forms 
the  chief  obstacle  to  voluntary  movement  ;  in  another  the  arm.  though  powerless,  shows 
comparatively  little  increase  in  tone. 

The  fact  that  the  pyramidal  fibres  destined  for  the  face,  trunk,  and  leg  run  in  close 
proximity  to  those  for  the  arm,  is  sufficient  reason  for  suspecting  that,  even  if  no  other 
paralysis  is  complained  of,  there  may  be  signs  of  disturbed  function  in  other  parts.  The 
side  of  the  face  corresponding  to  the  paralyzed  arm  may  not  move  so  quickly  or  so  power- 
fully as  the  other  side  in  a  voluntary  effort  to  show  the  teeth,  although  no  difference  may 
be  detected  when  the  patient  smiles.  The  corresponding  abdominal  reflexes  may  be  found 
wanting.  The  knee-jerk  may  be  increased  ;  ankle-clonus  and  an  extensor  plantar  response 
may  be  elicited  :    all  on  the  same  side. 

This  spastic  arm,  in  all  degrees  of  severity,  may  result  not  only  from  a  vascular  lesion 
in  the  brain,  but  also  from  a  cerebral  abscess,  a  cerebral  tumour,  or  cerebral  inflammation 
(encephalitis).  The  arm  will  present  identical  features,  so  that  the  diagnosis  must  be 
made  from  a  consideration  of  other  data.  Thus  a  cerebral  abscess  only  becomes  likely  when 
there  is  some  infective  process  either  in  the  bones  of  the  skull  (mastoid  or  frontal  sinus 
disease)  or  in  a  distant  part  such  as  the  heart  or  lungs  (ulcerative  endocarditis  or  bronchi- 
ectasis). Headache,  vomiting,  and  optic  neuritis,  with  a  slow  pulse,  slow  respiration, 
and  subnormal  temperature  may  help  in  the  diagnosis.  In  cases  of  cerebral  tumour  the 
development  of  the  brachial  palsy  is  nearly  always  slow  and  progressive,  spreading  from 
one  part  of  the  limb  to  another,  and  again  there  may  be  headache,  vomiting,  and  optic 
neuritis.  It  should  be  remembered,  however,  that  these  signs  of  increased  intracranial 
pressure  are  not  always  present,  and  that  the  presence  of  a  tumour  is  always  to  be  suspected 
when  a  spastic  paralysis  of  one  limb  comes  on  in  a  slow  and  progressive  manner.  Some 
tumours  grow  at  the  expense  of  neighbouring  tissues  in  such  a  way  that  pressure  is  raised 
but  little  or  not  at  all.  Euccptiitlitis  will  need  to  be  considered  when  there  is  a  history  of 
acute  constitutional  disturbance  with  fever,  vomiting,  headache,  and  perhaps  convulsions 
preceding  or  attending  the  onset  of  the  paralysis.  The  latter,  however,  is  not  progressive. 
It  reaches  its  maximmn  within  a  few  hours,  and  shows  a  general  tendency  to  improve 
after  the  acute  symptoms  have  passed  off. 

Disseminated  sclerosis  is  another  disease  in  which  a  spastic  monoplegia  is  not  uncommon. 
The  diagnosis  is  easy  if  it  occurs  late  in  the  disease,  when  nystagmus,  optic  atrophy,  spastic 
paraplegia,  and  sphincter  trouble  are  already  present,  or  if  there  is  a  history  of  previous 
transient  palsies  affecting  other  limbs.  When,  however,  paralysis  of  one  arm  is  the  first 
symptom,  as  it  may  be.  the  diagnosis  may  be  difficult.  The  rapid  onset  of  the  palsy  in  a 
healthy  yoimg  adult  without  constitutional  disturbance,  severe  headache,  or  vomiting,  and 
perhaps  the  discovery  of  absent  abdominal  reflexes  and  an  extensor  jjlantar  response, 
should  direct  suspicion  to  the  possibility  of  a  patch  of  disseminated  sclerosis  being  responsible 
for  the  trouble. 

Diseases  of  the  pons,  medulla,  and  that  part  of  the  spinal  cord  ivhich  lies  above  the  cervical 
enlargement,  whether  vascular,  inflammatory,  or  neoplastic,  may  cause  .spastic  palsy  of 
the  upper  limb,  but  it  is  rarely  a  monoplegia.  The  arm  and  leg  on  one  side,  or  both  arms 
and  both  legs  (double  hemiplegia),  arc  much  more  likely  to  be  involved  simultaneously. 


PARALYSIS     OF    ONE     UPPER     EXTREiMITY  5()y 

and  the  site  of  the  lesion  is  inferred  from  the  knowledge  that  the  two  |)yramidal  tracts 
are  in  close  proximity  in  those  regions. 

Paralysis  without  Lesions  of  the  Pyramidal  Tract. — It  is  not  imcommon  for  a 
patient  in  the  earliest  stage  of  paralysis  agitans  to  complain  of  loss  of  power  in  one  arm. 
This  sometimes  leads  to  a  wrong  diagnosis,  the  trouble  being  described  vaguely  as  due  to 
neuritis,  or  even  hysteria.  This  mistake  will  be  avoided  if  notice  is  taken  of  the  fact  that 
the  limb  is  not  only  weaker  than  its  fellow,  but  that  it  is  somewhat  stiff  and  conspicuously 
slow  in  carrying  out  movements.  .\  lack  of  expression  in  the  face,  or  tendency  to  carry  the 
arm  in  a  flexed  position  across  the  trunk,  and  perhaps  some  hesitancy  in  the  gait,  should 
guide  the  obser\er  to  a  correct  diagnosis  even  if  tremor  is  absent,  as  it  often  is  at  this  stage 
of  tlie  malady.     This  form  of  paralysis  is  unattended  by  changes  in  the  reflexes. 

Children  suffering  from  clinrea.  and  especially  hemichorea,  are  often  brought  to  a 
doctor  with  the  complaint  that  he  or  she  has  lost  the  use  of  an  arm.  Examination  will 
show  that  there  is  really  some  weakness  of  the  affected  limb,  which  is  demonstrated,  not 
so  much  by  the  poorness  of  the  grasp,  as  by  tlie  fact  that  the  child  is  unable  to  maintain  a 
steady  pressure.  He  will  grasp  the  ot)server"s  fingers,  but  quickly  release  the  pressure, 
although  urged  to  continue  the  squeeze.  In  the  same  way,  when  asked  to  put  out  his 
tongue  he  will  do  so,  but  withdraw  it  at  once.  When  required  to  extend  his  arm  in  front 
of  him  with  the  palm  of  the  hand  facing  downwards,  it  will  generally  be  noticed  that  the 
wri.st  is  slightly  flexed  although  the  fingers  are  extended.  These  are  points  which  may  be 
useful  in  coming  to  a  right  conclusion  when  choreic  movements  are  not  consjjicuous  :  but 
attention  nuist  also  be  paid  to  the  condition  of  the  heart  and  to  any  history  of  rheumatism. 
No  information  of  value  can  be  obtained  from  the  reflexes  unless  perha])s  the  choreic  form 
of  knee-jerk  is  present  (p.  359). 

Hysterical  brachial  palsy  may  resemble  one  due  to  a  pyramidal  lesion  in  presenting  a 
marked  amount  of  rigidity,  or,  on  the  other  hand,  the  whole  limb  may  be  flaccid  and  limp. 
Some  general  wasting  of  the  muscles  may  be  present,  but  there  is  no  alteration  in  their 
electrical  reactions.  Organic  pyramidal  lesions  must  be  excluded  by  an  examination  of 
the  reflexes.  The  supinator,  bicejjs.  and  triceps  jerks  may  be  tried,  but  they  will  not  be 
appreciably  more  brisk  than  those  of  the  ojjposite  limb.  The  abdominal  and  leg  reflexes 
will  be  natural.  If  the  limb  is  rigid  the  observer  will  probably  be  able  to  overcome  the 
rigidity  by  steady  pressure,  and  to  extend  the  arm.  forearm,  hand,  and  fingers  into  one 
straight  line.  When  the  patient  is  asked  to  perform  a  certain  movement,  the  observer 
can  often  see  that  in  the  eliort  to  carry  it  out  the  antagonistic  muscles  are  put  into  action 
rather  than,  or  as  well  as,  those  which  are  necessary  for  its  execution.  Thus  the  triceps 
will  contract  as  well  as  the  biceps  when  the  patient  is  requested  to  flex  the  elbow,  with 
the  result  that  the  forearm  is  moved  very  little  or  not  at  all.  This  may  also  be  demon- 
strated when  the  observer  resists  the  movement  of  flexion  by  grasping  the  wrist  and  then 
unexpectedly  relaxes  his  resistance  :  in  an  organic  palsy  this  will  be  followed  by  further 
uncontrolled  flexion  at  the  elbow,  whereas  in  a  hysterical  jiatient  tlie  contraction  of  the 
trii'eps  iiiiiintaiiis  the  forearm  in  it*  former  posilion.  Anollier  imporlant  i)oint  in  dis- 
tinguishing a  palsy  of  cerebral  origin  from  one  whicli  is  hysterical  is  that  in  the  organic  ease, 
even  when  no  voluntary  movement  whatever  can  be  carried  out  by  tlic  fingers,  the  latter 
may  move  involuntarily  in  association  with  energetic  movements  in  the  op|)osite  limb. 
Thus,  when  the  patient  is  asked  to  grasj)  some  object  as  tightly  as  he  can  with  the  sound 
hand,  flexion  of  the  lingers  may  be  detected  in  the  paralyzed  side.  'l"he  same  plienonienon 
is  seen  in  eomiection  with  involuntary  movements,  such  as  yawning.  The  writer  remeinljcrs 
being  requested  to  see  a  case  in  which  there  was  paralysis  of  one  arm,  and  in  which  the 
diagnosis  between  organic  and  functional  disease  was  in  doubt.  The  first  (|uestion  he 
asked  the  patient  was  whether  he  could  open  his  hand  and  extend  his  fingers  ;  the  patient 
replied  in  the  negative,  but  immediately  vohmteered  the  statement  that  the  fingers  became 
extended  whene\er  he  yawned.  'I'liis  settled  the  point  in  dispute  at  once,  because  such 
associated  movements  do  not  occur  in  hysterical  palsies.  In  many,  if  not  most,  cases  of 
hysterical  palsy  of  an  arm,  the  limb  is  also  ana'sthetic,  and  this  ana-sthesia  can  generally 
be  recognized  as  hysterical  on  accnuril  of  its  complete  character.  In  a  cerebral  palsy  there 
may  be  some  loss  of  sensil)ilil\  In  liglit  touches  and  some  im[)airtnent  of  pain  sense,  but 
the  hysterical  [)atient  is  usually  insensitixc  to  all  forms  of  stimulation,  even  [jinching  or  a 
strong  faradic  current,     iMorover,  the  (list  ribul  imi  nf  the  ana-sthesia  does  not  correspond 


504  PARALYSIS    OP    ONE    UPPER    EXTREMITY 

to  any  form  seen  in  organic  disease,  and  is  frequently  of  a  glove  or  sleeve  type  with  a  very 
sharp  line  of  demarcation. 

PARALYSIS  WITH  MUSCULAR  ATROPHY  (OR  ATROPHIC  PALSY). 

In  this  category  are  included  all  cases  of  brachial  palsy  in  which  there  is  true  muscular 
atrophy  associated  with  some  alteration  in  electrical  reactions,  either  the  typical  reaction 
of  degeneration  or  quantitative  diminution  of  excitability  to  galvanic  and  faradic  currents. 
In  all  such  cases  there  is  some  organic  lesion  affecting  some  part  of  the  lower  motor  neurons  : 
there  must  be  some  disease  involving  (1)  the  spinal  .segments  from  the  5th  cervical  to  the 
1st  dorsal,  (2)  the  corresponding  anterior  spinal  roots,  (3)  the  brachial  plexus,  (4)  the 
peripheral  nerves  of  the  arm,  or  (5)  the  muscles  themselves. 

In  addition  to  atrophy  and  alteration  in  electrical  response,  each  paralyzed  muscle 
tends  to  lose  its  tendon-jerk.  For  instance,  the  tendon-jerk  of  an  atrophied  biceps  cannot 
be  obtained,  and  in  all  probability  direct  percussion  of  the  mu.scle  itself  will  also  fail  to 
elicit  a  contraction,  or  will  give  rise  only  to  an  abnormally  slow  contraction.  Muscles 
which  are  undergoing  atrophy  may  also  exhibit  fine  fibrillary  contractions  of  a  spontaneous 
kind,  but  these  are  seen  only  when  the  disease  affects  the  nerve  fibres,  and  not  when  the 
muscles  themselves  are  affected  primarily.  These  fibrillations  are  very  rarely  seen  in  the 
group  of  muscular  atrophies  to  which  the  name  of  '  myopathy  '  is  given. 

When  making  a  diagnosis  of  the  site  of  the  lesion  in  cases  of  atrophic  brachial  paralysis, 
it  is  essential  to  analyze  carefully  the  distribution  of  the  atrophied  muscles.  This  must 
be  done  in  order  to  answer  the  questions  :  Are  all  the  atrophied  muscles  supplied  by  one 
peripheral  nerve,  or  are  they  innervated  by  one  or  more  spinal  segments,  or  by  one  or  more 
anterior  spinal  roots  ?  The  diagnosis  will  be  comparatively  simple  when  it  is  found,  for 
instance,  that  all  the  atrophied  muscles  are  supplied  by  the  musculo-spiral  nerve,  and  that 
all  the  muscles  supplied  by  that  nerve  are  atroijhied  and  paralyzed,  A  lesion  of  that  nerve 
can  then  be  diagnosed  and  its  nature  inferred  from  other  data,  such  as  the  use  of  a  crutch 
or  the  history  of  a  fractured  humerus,  with  the  detection  of  callus  involving  the  nerve  at 
the  site  of  the  fracture. 

Let  us  now  consider  briefly  some  of  the  various  conditions  giving  rise  to  atrophic  palsy 
of  the  upper  extremity,  and  the  features  which  are  most  characteristic  for  the  purpose 
of  their  diagnosis. 

In  cases  of  neun'lis  there  may  be  paralysis  of  the  muscles  supplied  by  one  nerve  only, 
or  of  muscles  supplied  by  several  nerves  (multiple  neuritis).  In  the  former  case  the  correct 
diagnosis  of  the  lesion  depends  on  a  knowledge  of  the  muscles  innervated  by  each  of  the 
chief  brachial  nerves,  and  this  mav  be  gleaned  from  the  following  list  : — 


Nerve. 
Posterior  scapular  (C.  5) 

Long  thoracic  (C.  5, 6,  7) 

Suprascapular  (C.  5,  6) 

Anterior  thoracic 

(C.  5,  6,  7,  8  ,  D.  1) 

Muscnlocutaneous(C.5,6)  '  5""'^?^   i- 

'I  Brachialis  anticus 


Muscles. 


(  Levator  anguli  scapiiire 
I  Rhomboideus  minor 

Serratus  niagnus 

Supraspinatus 

Pectoralis  major 


Jledian  (C.  0,  7,  8,  D.  1) 
forearm 


Ulnar  (C.  8,  D.   1) 

forearm 


I  Pronator  radii  teres 

'  Flexor  carpi  radialis 

j  Palmaris  longus 

'  Flexor  sublimis  digitorum 

I  Abductor  pollicis 
I  Opponens  pollicis 

I  Flexor  carpi  ulnaris 

/  Palmaris  brevis 

Flexor  brevis  minimi  digit! 
-  Abductor  minimi  digiti 

Opponens  minimi  digiti 
\  Interossei 


Rhomboideus  major 

Infraspinatus 
Pectoralis  minor 
Coraco-brachialis 


Flexor  longus  pollicis 
Pronator  quadratus 
Flexor   profundus   digitorum    (outer 
half) 

Flexor    brevis      pollicis     (superficial 

head) 
Two  outer  limibricals 

Flexor    profundus    digitorum    (inner 
half) 

Two  inner  limibricals 
.•\dductor  obliquus  pollicis 
.\dductor  transvcrsus  pollicis 
Flexor  brevis  pollicis  (deep) 


PARALYSIS    OF    ONE     UPPER     EXTREMITY 


\crve. 

Circumflex  (C.  5,  6) 

Musculospiral 

(C.  6,  7,  8)  upj)er  arm 

forearm 

(posterior  inter- 

osseus  branch) 


I  Triceps 
I  Anconeus 

I  Extensor  carpi  radialis  brcvior 

Supinator  brevis 
-.  Extensor  communis  digitonim 

Extensor  minimi  digit! 
'  Extensor  carpi  ulnaris 


Subscapular  (C.  ">,  0.  7.  8) 


Subscapularis 
I  Teres  major 


Teres  minor 

Supinator  longus 

Extensor  carpi  radialis  longior 

Extensor  ossis   metacarpi   pollicis 
Extensor  longus  pollicis 
Extensor  brevis  pollicis 
Extensor  indicis 


Latissin\us  dorsi 


When  several  nerves  are  involvefl  in  neuritis,  the  condition  is  one  of  niiiltiplc  neuritis 
and.  being  generally  due  to  some  toxic  cause,  tends  to  be  bilateral  and  synnnctrical. 
Multiple  neuritis  is  further  characterized  by  the  facts  that  the  jieripheral  muscles  are  more 
affected  than  the  proximal,  that  the  extensors  of  the  wrist  and  fingers  suffer  out  of  propor- 
tion to  the  flexors,  and  that  there  are  often  pain  and  tenderness  in  the  iiaralyzed  muscles. 
These  features  are  present  in  alcoholic  neiirilis,  the 
most  common  form  (p.  (id).  In  lead  palsy  the 
extensors  of  the  wrists  and  fingers  are  particularly 
.susceptible,  although  other  muscles  supplied  by  the 
musculospiral  nerve — such  as  the  supinator  longus 
and  triceps — may  escape  altogether.  The  associ- 
ation of  dropped  wrist  with  a  blue  line  on  the 
gums,  and  other  signs  of  pinmbism  (p.  34),  is 
diagnostic  of  this  form  of  brachial  palsy.  In  some 
cases  of  nudtiple  ncvuitis  it  is  impossible  to  identify 
tlic  causative  toxin,  but  glycosuria,  mercury,  and 
arsenic,  in  addition  to  alcohol  and  lead,  must  be 
rcnicmbcriil  in  this  connection.  Leprosy  may  ])ro- 
<lucc  a  |)rcciscly  similar  condition  [Fig.  200).  but 
it  is  rarely  met  with  in  tJreat  l?ritain.  (.Sec  also 
.AruociiY.  .Ml  scii.AH,  p.  .5!>.) 

In  most  cases  of  single  nerve  palsy  I  lie  dia- 
gnosis, based  on  the  distribution  of  the  inusculai' 
alrciphy  and  par.dysis  with  allercd  elect  ricaj  re- 
JH-Iicns,  can  l>r  ronliinicd  l)\  I  lie  detection  of 
sensory  loss  in  the  cutaneous  area  su|iplied  by  the 
same  nerve.  In  other  eases  the  sensoiy  fibres  appear 
to  olfcr  more  resistance  llian  the  motor  to  the  excit- 
ing cause  of  I  he  neuritis.  :iricl  lil  I  le  nv  no  disturbance 
of  sensibility  can  be  found.  (I'or  areas  supplied  b\- 
the  peripheral  nerves,  see  I'lale  .V.\  T.  p.  (iOS.  and 
ScAsAiioN.  soMK  .Aunohmalitiios  OI',   p.  ()(>!.). 

Hcference  may  be  made   to  one   or   two    of  the 
single  nerve   palsies  wliieli  pnscnl    special  points  in      .Vm».,i,.) 
relation  to  diagnosis. 

In  paralysis  of  the  sirratiis  iKiifiiiiis  (I'lg.  '207)  due  to  injury  or  neuritis  of  lb<' 
long  thoracic  ncr\c.  Ilie  patient  may  cotnplain  of  general  weakness  of  the  arm.  and 
particularly  of  inabilit\  to  raise  it  above  the  horizontal  position.  The  trouble  arises  from 
the  fact  that  llu'  scapula  is  no  longer  held  against  tli<'  thoracic  wall,  and  catmot  be  rotated 
with  the  movcMients  of  the  limb.  The  origin  of  this  disability  may  be  overlooked  if  the 
arm  only  is  examined.  If,  liowcvci-.  t  be  position  of  the  scapula  is  observed  wbcu  the  arm 
is  moved  in  dilTcreiil  diiiet  ions,  the  cdrrect  diagnosis  can  be  arrived  at.  W  lun  the  arm 
hangs  at  rest  by  the  side,  the  scapula  is  seen  to  be  slightlv  raised  and  displaced  outwards, 
with  the  infiTior  angle  inclining  towards  the  vertebral  eohnun  and  perhaps  somewhat 
separated  from  the  eliesi  wall  (/''/£,'.  -207).  When  the  arm  is  raised  forward  to  tin-  horizontal 
p(i-~ilinn    and    pies-,((l    against    some    resislanci-.    Ilic    imicr   bordei-   of   the   scapida    projects 


t'lg.  '-'Uli.— I'aresis  o(  tlic  arms  due  to  peripliorul 
neuritis  in  an  arrested  case  of  lei)ru  niaculo-aiuvs- 
tlietica  in  a  Norwcfiiaii.  (Fmm  a  iihnlograph  hi/ 
Ilie  l<ilr  fir.  Hansen,  Insiitrlor-GeHirut  u/  Leiiro.vj  in 


50(5 


PAKALVSIS  OP  ONK  PPPER  EXTREMPrV 


backwards  and  presents  a  'winged"  a|)|)earance.  Tliis  deformity  ouglit  always  to  suggest 
paralysis  of  the  serratiis  magnus. 

The  movements  of  the  upper  limb  are  also  hamijered  somewliat  in  cases  of  neuritis 
or  injury  to  the  supriincnpiilar  nerve,  and  the  patient  may  com])lain  of  ditliculty  or  fatigue 
in  writing.  Examination  will  show  flattening  of  the  infraspinous  fossa  and  weakness  in 
rotating  the  Inniierus  outwards  against  resistance.  The  infras])inatus  muscle  may  show 
tlie  reaction  of  degeneration,  but  the  supraspinatus  is  not  accessible,  being  covered  by 
the  trapezius. 

.\dhesions  within  the  shoulder-joint,  with  secondary  wasting  of  the  deltoid,  may 
simulate  jjaralysis  in  the  distribution  of  the  eireumfle.r  nerve,  owing  to  the  dillieulty  in 
abducting  the  arm  ;  but  a  little  care  in  examination  and  electrical  testing  of  the  deltoid 
muscle  will  sullice  to  make  a  diagnosis.  In  circumflex  palsy,  moreover,  some  sensory  loss 
may  be  found  in  the  skin  over  the  upper  and  outer  aspect  of  the  arm. 

In  cases  of  miiseiilospirni  parnlysis  it  nuist  be  remembered  that  the  injury  to  the  nerve 
may  be  above  or  below  the  points  where  branches  leave  to  sujjply  the  triceps  and  supinator 
longus  muscles,  and  that  these  muscles  may  therefore  escajjc.  Sensory  symptoms  are 
often  absent,  but  sonu'  anaesthesia  is  sometimes  found  on  the  radial  border  of  the  hand. 


In  connection  with  traumatic  affections  of  the  median  neri'e.  the  di-stribution  of  the 
paralysis  depends  on  the  site  of  the  wound  :  the  branch  which  supplies  the  nuiscles  of  the 
hand  may  leave  the  main  nerve  in  the  forearm,  and  thus  escape  injiny  when  the  wound 
is  at  the  wrist. 

Iseha'mie  paralysis  of  the  hand  (Volkmann's  eontraetine.  Fig.  58.  p.  141)  nuist  not 
be  forgotten  in  cases  of  injury  to  the  forearm  when  there  is  a  history  of  the  ])atient  wearing 
a  splint,  and  the  condition  must  not  be  mistaken  for  ulnar  or  median  paralysis.  The 
diagnosis  depends  partly  upon  the  history,  but  chiefly  upon  the  rigid  contracture  of  all  the 
flexor  tendons  of  the  wrist  and  fingers  with  wasting  of  the  muscles  and  other  trojjhic  changes. 
The  electrical  excitability  of  the  flexor  muscles  is  sometimes  impaired. 

Paralysis  of  one  arm  due  to  a  lesion  of  the  hrneliial  plejpus  is  a  common  event,  the  most 
freciuent  cause  being  some  injury.  When  the  whole  ])lexus  is  damaged,  complete  brachial 
palsy,  with  atrophy  of  the  muscles  and  extensive  sensory  loss,  results.  The  diagnosis  of 
such  a  lesion  is  simple,  because  it  would  be  impossible  for  the  spinal  cord  to  be  damaged 
sufHciently  to  bring  about  such  a  paralysis  without  giving  rise  to  symptoms  of  atrophic 
palsy  in  the  opposite  arm,  and  spastic  paralysis,  with  disturbances  of  sensibility,  in  the 
trunk  and  legs. 


PARALYSIS    OF    ONE     UPPER     EXTREMITY 


.■)07 


In  addition  to  a  lesion  of  the  brat'liial  j)k'xiis  as  a  wliole,  two  forms  of  partial  palsy 
are  not  uncommon,  and  have  received  special  names.  The  first  is  known  as  Erh's  palsy, 
and  is  due  to  a  lesion  of  the  upper  trunk  of  the  brachial  plexus,  composed  of  fibres  from 
the  5th  and  6th  cervical  roots.  The  paralyzed  muscles  include  the  spinati,  deltoid,  biceps, 
supinator  longus,  and  to  a  less  extent  the  extensors  of  the  wrist  and  fingers.  The  arm 
hangs  by  the  side,  and  the  forearm  remains  pronated  owing  to  weakness  of  the  sujjinator 
muscles,  and  especially  of  the  biceps.  There  is  sometiriies.  but  not  always,  anaesthesia 
over  the  outer  aspect  of  the  forearm  and  hand.  This  form  of  palsy  is  usually  produced  by 
a  fall  on  the  shoulder  of  such  a  kind  as  to  separate  the  latter  forcibly  from  the  head,  and  so 
to  exert  sudden  and  severe  traction  on  the  upper  part  of  the  brachial  plexus.  A  similar 
lesion  is  often  seen  in  infants  as  a  result  of  injury  during  birth,  and  has  been  called 
Duclien tie's  palsy,  after  the  observer  who  first  described  it.  In  both  Erb's  and  Duchenne"s 
palsy,  the  grou])ing  of  the  jjaralyzed  nuiscles  resembles  that  which  may  follow  an  injury 
to  the  5th  and  (ith  cervical  segments  of  the  spinal  cord,  but  in  the  latter  case  bilateral 
.symptoms  are  ))raetieally  certain  to  be  present,  as  well  as  more  extensive  disturbances  of 

sen.sation  of  the  trimk  and  limb,  ])robably  of 
the  di.s.soeiative  type.  (See  Sens.\tion,  So.me 
Abnorm.vlities  of,  p.  604.)  In  spinal  cord 
lesions,  moreover,  we  may  .see  an  atro[)hic 
j)aralysi.s  of  the  muscles  supplied  by  the  Sih 
and  6th  cervical  segments,  together  with  a 
sjjastic  paralysis  of  the  remaining  muscles  in 
the  arm — that  is  to  say,  of  the  muscles  inner- 
\ated  from  the  7th  and  8th  cervical  and  1st 
dorsal  segments.  This  mixture  of  atrophic 
and  spastic  ■i)aralysis  in  the  upper  limb  can 
only  be  brought  about  by  some  injury  or 
disease  of  the  spinal  cord. 


lie-  (iijlrr   Kochr 


The  other  form  of  partial  brachial  plexus  palsy,  Khniipkc's  palsy,  depends  on  a  iesion 
of  the  trunk  I'ormed  by  the  8th  cervical  and  1st  dorsal  roots.  The  flexors  of  the  wrist  and 
fingers,  anfl  the  intrinsic  muscles  of  the  hand,  undergo  atrophy,  and  although  the  patient 
can  carry  out  all  movements  at  file  shoulder  and  elbow,  he  is  unable  to  use  his  lingers. 
The  ar<-a  of  aiiastlicsia  in  this  form  iliMilves  the  ulnar  border  of  the  forearm  and  hand 
from  the  elbow  downwarils.  This  condition  may  be  dislinguished  from  a  spinal-cord 
lesion  affecting  the  Slli  ((iNical  and  Kl  cIoismI  segments,  not  only  by  its  limitation  to  one 
upper  extremity,  but  also  l)\  the  alisciicc  ol  llic  oculo-pupillary  symi)toms  whii'h  are  nearly 
always  preseni  in  spinal  lesions  of  thai  lexcl  ;  a  lesion  of  the  spinal  segments  in  that  region, 
or  of  the  corresponding  spinal  roots  in  their  inlra-verlcbral  course,  produces  a  dimimilion 
in  the  si/.e  of  the  pupil  and  a  narrowing  of  thi'  palpebral  aperture  on  the  same  si<le.  Such 
a  pupil  does  not  dilate  to  shade,  nor  when  the  skin  of  the  neck  is  pinched,  nor  when  a 
cocaine  solution  is  dropped  into  the  eye.  .Mthough  the  presence  or  absence  of  oculo- 
pupillary  symptoms  allorrls  a  point  of  dilTcrenliation  between  lesions  of  the  8lh  cervi<'al 
anil  Isl  dorsal  segments  ol  the  spinal  cord,  or  of  their  {•orresi)on(ling  roots  on  the  one  hand. 
and  a  Icsidti  of  the  lower  trunk  of  the  Ijracliial  plexus  on  the  ollwr,  in  llie  majority  of  cases 
in  \ery  severe  injuries  to  the  iieek  llie  louer  tools  ol   llie  plexus  tna\    lie  aeluallv    lorn  awa\ 


50H 


PARALVSIS    OF    ONE     UPPER     EXTREMITY 


from  their  connection  witli  the  spinal  cord,  in  which  case  the  oculo-pupillary  symptoms 
mentioned  above  will  be  present. 

Amyotrophic  lateral  sclerosis  is  a  condition  dependent  on  a  <;radiial  degeneration  and 
disappearance  of  the  anterior  corniial  cells  of  the  spinal  cord,  associated  with  sclerosis  of 
the  upper  motor  neuron  tracts.  The  muscular  atrophy  begins  insidiously  and  progresses 
gradually.  It  often  begins  in  the  intrinsic  hand  muscles  (Aran-Duchenne  type),  less  com- 
monly in  the  shoulder  and  upper  arm  muscles.  The  loss  of  power  is  in  proportion  to  the 
amount  of  atrophy.  The  alteration  in  electrical  reactions  is  usually  more  a  quantitative 
diminution  of  excitability  to  both  currents  than  a  true  reaction  of  degeneration.  Fibrillary 
contractions  are  common.  The  atrophy  usually  begins  in  one  limb  before  the  other, 
but  soon  becomes  more  or  less  symmetrical.  The  tendon-jerks  of  all  muscles  which  are 
not  atrophied  are  exaggerated.  The  abdominal  reflexes  may  be  absent,  and  the  plantar 
reflexes  may  be  of  the  extensor  type.  There  are  no  pains,  no  sensory  loss,  and  no  oculo- 
pupillary  phenomena. 

In  si/riugoniijclia  the  spinal  changes  frctiucntly  begin  in  the  cervical  enlargement  of 
the  cord,  with  the  result  that  atrophic  paralysis  is  first  noticed  in  the  upper  extremity, 
generally  in  the  intrinsic  nuiscles  of  the  hand  and  the  flexor  muscles  on  the  ulnar  aspect  of 
the  forearm.  The  onset  is  insidious  and  the  progress  gradual.  One  limb  is  generally 
affected  many  months,  perhaps  years,  before  the  other.  Manual  deformities  are  common. 
(See  Claw-hand,  Fig.  4.5,  p.  110.)     The  electrical  reactions  vary  like  those  of  amyotrophic 

lateral  sclerosis.  The  knee-  and  ankle-jerks 
are  increased  as  a  rule,  and  spastic  paralysis 
of  the  lower  extremities  usually  develops  in  the 
later  stages,  with  extensor  plantar  responses. 
Pains  shooting  down  the  arms  from  the  neck 
occiu',  but  are  not  common.  Trophic  changes 
develop  in  the  skin,  subcutaneous  tissues,  and 
joints.  There  is  sensory  loss  of  a  dissociative 
type,  i.e.,  loss  of  sensibility  to  pain,  heat,  and 
cold,  with  preservation  of  tactile  sensibility. 
()culo-pu|)illary  phenomena  and  nystagmus  are 
conuiion  Spinal  curvature,  in  the  form  of  a 
dorsal  scoliosis,  is  another  frequent  physical 
sign.  It  is  not  necessary  that  all  these  signs 
and  symptoms  should  be  present  for  making 
a  diagnosis.  The  combination  of  muscular 
atroijhy,  dissociative  anaesthesia,  and  trophic 
changes  in  the  skin  is  usually  sufficient. 

A  cervical  rib  may  be  responsible  for 
atrophic  palsy  in  the  upper  extremity.  Para- 
lysis is  usually  preceded  by  pain,  chiefly 
referred  to  the  inner  aspect  of  the  arm,  and 
sometimes  shooting  into  the  little  and  ring  Angers.  The  pain  is  worse  after  exertion,  and 
often  relieved  by  placing  the  hand  behind  the  head.  Muscular  atrophy  begins  in  the  hand 
muscles  {Fig.  209),  the  interossei.  thenar,  and  hypothenar  eminences,  and  often  involves 
the  flexors  of  the  wrist  and  fingers.  It  develops  gradually  and  does  not  spread  beyond 
the  distribution  just  described.  There  is  often  sensory  loss  in  regions  corresponding  to 
the  cutaneous  areas  supplied  by  the  1st  dorsal  and  8th  cervical  spinal  roots.  The  loss  is 
usually  less  marked  to  touch  than  to  painful  and  thermal  stimuli.  The  atrophied  muscles 
show  reaction  of  degeneration.  There  are  no  oculo-pupillary  phenomena  and  no  signs  of 
disease  in  other  parts  of  the  body.  The  condition  is  usually  one-sided,  occasionally 
bilateral,  and  the  chief  point  in  diagnosis  is  the  discovery  of  the  ribs  by  means  of  skiagraphy 
(Fig.  187.  p.  443).  At  the  same  time  it  must  not  be  concluded  that  the  absence  of  a  rib 
shadow  in  an  .r-ray  photograph  is  in  all  cases  a  contra-indication  to  the  diagnosis.  A 
ligamentous  band,  undetected  by  the  skiagraphic  examination,  is  sometimes  found  to 
occupy  the  position  of  a  supernumerary  rib  and  to  be  responsible  for  similar  results  in  the 
way  of  pain  and  atrophic  palsy.  (See  also  Pain  in  the  Extremity,  Upper,  p.  442  ;  and 
Claw-hand,  p.  109.) 


!  !:■      ]■•■-'.    ot    riKlit  hand    assoi-iat.-d 

I  I  '■    ■    ili:ttsKle,    Note  tlie  iriitrkeii 

!i.  i.r   [  ..lliiis  as  compared  with  the 

'•■■    II I    emiuence.      According:  to 

I  iii^    i>   :i   common  fe.iture  of   these 
I  pathognomonic. 
(Pliolo  hy  Dr. 


PARALYSIS    OF    ONK     irPER     EXTRKMITV  509 

Another  disease  in  which  atrophic  ])alsy  of  the  intrinsic  hanii  muscles  is  a  prominent 
feature  is  peroneal  alroplii/.  As  the  name  suggests,  the  muscular  atro|)hy  and  ])aralvsis 
generally  begin  in  the  lower,  before  they  affect  the  upper,  extremities,  and  further  details 
concerning  the  condition  may  be  found  imder  Pauai.ysi.s  of  the  Extremitv,  Lower, 
p.  -i98  :   and  Atuophy,  Miscilar  (Figs.  20  and  21,  p.  (iO). 

The  diagnosis  of  muscular  atrophy  in  the  arm  dependent  on  a  jjreceding  aciile  polio- 
myelitis (Fig.  19,  p.  59)  is  not  dillieult  if  an  accurate  history  can  be  obtained.  The  onset 
was  acute,  with  constitutional  disturbance,  varying  from  a  transient  and  perhaps  over- 
looked malaise  to  a  pyrexia  up  to  104'  F.,  with  generalized  pains  all  over  the  body, 
vomiting,  and  convulsions.  It  is  almost  invariable  that  the  initial  paralysis  was  more 
extensive  than  that  which  remained  ])ermanent.  Attention  to  the  distribution  of  the 
paralysis  shows  that  it  is  irregular  and  different  in  every  case,  but  there  is  more  liability 
on  the  part  of  the  shoulder  and  upper  arm  muscles  to  suffer  than  those  of  the  forearm  and 
hand.  If  both  arms  are  affected  there  is  little  likelihood  of  any  great  degree  of  symmetry 
in  the  distribution  of  the  atroi)hy.  With  regard  to  the  electrical  reactions,  much  will 
de])end  on  the  stage  at  which  the  case  comes  under  observation.  Some  muscles  may  show 
the  reaction  of  degeneration,  others  may  respond  fairly  well,  and  others  show  no  res]jonse 
whatever  to  either  faradism  or  galvanism.  Vasomotor  changes,  general  defects  in  the 
growth  of  the  limb,  deformities,  and  contractures  are  common,  but  no  sensory  changes  and 
no  oculo-])upillary  phenomena  are  to  be  observed.  Only  those  reflexes  are  altered  or  lost 
which  are  concerned  with  atro|)hied  muscles. 

Ha-morrhagc  into  the  spinal  cord,  or  lia-iiiutoiiii/elia.  due  to  injury,  occurs  more  often 
at  the  level  of  the  8th  cervical  and  1st  dorsal  segments  than  at  any  other.  The  resulting 
paralysis  has  much  the  same  distribution  as  that  described  in  Klumpke"s  palsy  (p.  507), 
but  the  diagnosis  may  be  made  from  the  fact  that  the  former  also  produces  spastic  jiaralysis 
of  the  trunk  and  legs,  and  fre(|ueiitly  gives  rise  to  areas  of  dissociated  anafsthesia.  Oculo- 
|)U])illarv  phenomena  are  usual  as  well  in  cases  of  ha'matomyelia  at  this  level.  Injuries 
to  the  cord  result  in  bilateral  symptoms,  whereas  Klumpke"s  palsy  is  confined  to  one  arm. 

\'arious  forms  of  ro(jt  palsies  may  be  caused  by  tuberculous  or  malignant  disease  of  the 
lerlel/ra'.  and  also  by  pachymeningitis,  frequently  syphilitic.  The  diagnosis  of  the  nature 
of  such  lesions  dejjcnds  on  examination  of  the  vertebral  colunm  and  of  the  cerebrospinal 
lluid.  The  symptoms  are  more  often  bilateral  than  unilateral,  and  may  be  complicate! 
by  the  results  of  |)ressure  on  the  spinal  cord,  leading  to  spastic  paralysis  of  parts  below  tlic 
level  of  the  disease. 

Tumours  originating  in  the  meninges  or  in  the  s/tinal  cord  at  Ihe  le\cl  of  (lie  cervical 
enlargement  are  rare,  but  they  niay  ))roduce  atrophic  j)aralysis  of  the  arm  muscles,  with 
spastic  paralysis  of  the  trunk  and  lower  ext  remit  ies.  These  phenomena  may  be  more 
marked  on  one  side  at  first,  but  they  tend  to  become  bilateial  with  tlie  gradual  growth  nf 
the  tumour. 

In  the  grou])  of  diseases  to  wliieh  the  nana-  mi/ojialhi/  or  muscular  (li/slropli//  is  applied. 
the  arm  is  often  more  or  less  corwijletely  paralyzed.  The  diagnosis  of  this  condition 
depends  on  a  consideration  of  various  factors.  The  gradual  onset  and  the  bilateral  sym- 
metry of  the  affection,  the  marked  involvement  of  the  shoulder  and  upper  arm  as  compared 
with  the  forearm  and  hand,  are  important  characteristics.  The  absence  of  fibrillary  eon- 
traction  and  of  the  rcac'lion  of  degeneration  are  also  to  be  noted,  while  the  history  of  a 
similar  aliectioii  in  <ither  members  of  the  family,  and  the  ])resence  of  nuiscular  atrophy 
or  muscular  pseudo-hypertrophy  in  other  parts  ol'  the  body,  serve  to  confirm  the  diagnosis. 

Tauii;  Siii)«im;   iiii.  Mi  ^(  i  i.Aii   t  )r-,  i  iMiii  ii(i\  i>i    iiii.  X'ahioi  s  N|-,iiVK  Hoois  oi'  Tnu 

liltAC  MIAI.    I'l.l.Xl   s." 

(  .   .■).  Dilldiil.  Spinali.   Terrs  minor,   lihoinlioids.   I  )i:iplir;igMi.    Hiceps.  .Sii|iiii;il(ir  liiiigus. 

Serrattis  niagniis.     I'eclonitis  major.     Uniehialis  aiit  ii'iis.      Coracii  hniciiialis. 
('.   0.  Iliirps.  Coraco-ltrachialis.   I{rarlii(dis  .tiiliriis.    SiijiiiKildr  liiiiiiiis.   Dcllniil.  .S|iliiati. 

Teres  major.     Scrratiis  magiiiis.    IVclmiilis  riiajnr.    Siihsc.ipiilar  is.    I'rDiialors 

of  forearm.     lOxIciisdrs  ciC  wrist. 
(.  7.  'I'rirr/ts.      Kxlensnrs  of  <vrisl  tnid Jiiifiers.     I'roiialors  of  ruriarm.     I'l-clciiaiis  major. 

.Siil)s<  apiilaris.     I.alissirTiiis  dcirsi.     Teres  major. 
('.  S.  h'lcjars  of  ivrinl  iniil  Idiifi  Jlerors  of  Jiiigers.     Interossei  and  iuiiilirieales.     .Muscles 

of  thenar  and   liypntliciiar  eniinenees. 
1).   1 .         Muscles  of  Ihe  tlieiiur  and  hii/iiilheiiar  eitiiuenees.    Iideriissei  uiid  hnnhrieales.    Flexor 

car])!   iilnaris.     Oeulo-piipillary  lil)res. 
"  'I'hobC  luusclos  wliicli  urc  tliu  luost  ubiliil  '  liiiiiliii^irka  '  for  imlivuluui  :-c<;iiic]H.s  iirc  iJiinluJ  in  italifs. 


riio  PARAPLEGIA 

A  glance  at  this  list  shows  that  nearly  all  muscles  derive  innervation  from  more  than 
one  sjjinal  segment,  generally  from  two  or  three.  The  table  does  not  ])uri)ort  to  give  a 
complete  anatomical  list  of  all  the  muscles  of  the  arm.  but  provides  a  guide  to  clinicians 
in  their  endeavours  to  localize  s])inal  or  root  lesions  from  the  distribution  of  atrophic 
muscular  paralysis.  e.  Farquliar  Buzzard. 

PARAPLEGIA  implies  partial  or  complete  paralysis  of  both  legs,  with  or  without 
part  of  the  trunk.  It  does  not,  however,  include  inability  to  walk  owing  to  mechanical 
defects,  such  as  old  fractures,  joint  disease,  and  so  forth  ;  it  is  due,  as  a  rule,  to  changes 
either  in  the  brain,  the  spinal  cord,  the  peripheral  nerves,  or  in  the  muscles  themselves, 
though  sometimes  it  is  caused  by  errors  of  fimction  without  any  structural  change  in  the 
neuro-muscular  system.  For  clinical  purposes,  although  naturally  a  paraplegia  that  has 
ari.sen  in  childhood  may  persist  into  adult  life  and  thus  cause  overla])ping  of  the  classifi- 
cation, paraplegia  in  children  may  be  discussed  separately  from  paraplegia  in  adults.  Let 
us  suppose  that  the  patient  is  a  child,  and  that  the  chief  complaint  is  weakness  or  paralysis 
of  both  legs.  The  following  table  indicates  some  of  the  causes  that  may  produce  this 
condition  :  — 

I.  THE    CAUSES    OF    PARAPLEGIA    IN    CHILDREN. 

(.1).  Coiiditioiis  ill  icliich  there  is  no  ilcfiiiilc  loeal  iliseasc.  tliiiiigli  tliere  may  be  some 
general  pathological  condition  : — 

(1)  Simple  delayed  walking  :    (2)  Hickets  ;    (3)  Cretinism  ;    (4)  Idiocy. 
(/?).  Paraplegia  associated  ivith  a  definite  upper  neuron  iien'c  lesion  : — 

1.  Infantile  diplegia  due  to  :    (a)  Congenital  defect  of  the  cortex  :    poreneephalus  ; 

(b)  Infantile  encephalitis  ;  (c)  Injury,  for  exam])le  by  forceps  at  delivery  ; 
(rf)  Superior  longitudinal  sinus  thrombosis  ;  (c)  Meningitis  :  (/")  Congenital 
or  acquired   hydrocephalus. 

2.  Congenital   malformation,    such    as    meningocele.    si)ina    bifida,    or   spina    bifida 

occulta. 

3.  Spinal  caries,  w'ith  compression  of  the  spinal  cord. 

4.  Friedreich's  ataxy. 

(C).  Paraplegia  due  to  a  lesion  of  the  lower  neuron  type  : — 

1.  Acute  anterior  poliomyelitis,  leading  to  infantile  paralysis. 

2.  Tooth's  peroneal  type  of  progressive  muscular  atrophy. 

3.  Peripheral  neuritis. 

(D).  Paraplegia  of  the  primary  muscular  type  : — 

1.  Pseudo-hypertrophic  muscular  paralysis. 

2.  The  infantile  type  of  primary  muscular  dystrophy. 

3.  The  juvenile  type  of  primary  muscular  dystrophy. 

In  arriving  at  the  diagnosis,  the  first  [joint  to  pay  attention  to  is  the  history :  the  case 
will  belong  to  one  or  other  of  two  main  groups,  the  first  containing  those  that  have  never 
been  able  to  use  the  legs  properly,  the  second  those  that  have  lost  the  use  of  the  legs  after 
having  been  at  one  time  able  to  walk,  or  otherwise  use  them  efficiently. 

To  the  first  group  belong  all  cases  of  congenital  malformation,  such  as  hydrocephalus 
or  meningocele,  and  most  cases  of  infantile  diplegia.  Before  diagnosing  any  of  these,  how- 
ever, it  is  necessary  to  exclude  rickets.  creiiiiis7n.  idiocy,  and  simple  delayed  zvalking.  as 
causes  of  an  apparent  rather  than  real  paraplegia.  These  cannot  be  the  sole  diagnosis 
if  there  is  absolute  flaccidity  on  the  one  hand,  or  if  there  is  spasticity  upon  the  other.  It 
is  important  to  remember  how  deceptive  the  reflexes  may  be  ;  almost  any  illness  in  an 
infant  or  young  child — bronchopneumonia  for  example,  or  simple  diarrha-a — may  so 
depress  the  knee-jerk  that  it  is  often  unobtainable  until  the  patient's  general  health  is 
restored  ;  the  plantar  reflex  is  normally  more  often  extensor  than  flexor  in  infants  ;  ankle- 
clonus,  however,  does  not  occur  except  when  there  is  degeneration  of  the  lateral  columns. 
If  there  is  neither  absolute  flaccidity  nor  intermittent  spasticity,  and  if  the  limbs  are  moved 
.spontaneously,  the  mere  fact  that  the  child  is  late  in  walking  by  no  means  necessarily 
indicates  nerve  disease  ;  the  delay  may  commonly  extend  to  the  second  year,  and 
occasionally  even  to  the  third  or  fourth.     The  main  factor  in  making  a  diagnosis  in  such 


I'AHAPLE(;iA  511 

a  case  is  time.  for.  until  with  tlit-  lapse  (if  time  the  little  ])atient  hei;ins  to  walk,  it  may 
sometimes  be  difficult  to  exclude  oroanic  paraplegia.  If  there  are  definite  signs  of  rickets, 
or  if  the  patient  is  a  cretin  or  an  idiot,  the  diagnosis  is  more  obvious.  The  good  effects  of 
giving  thyroid  extract  over  a  jirolonged  ])eriod  may  be  the  only  conclusive  means  of  dis- 
tinguishing cretinism  from  idiocy,  and  this  remedy  should  be  employed  in  all  such  cases, 
however  hopelessly  idiotic  the  infant  may  seem  to  be.  If  there  is  congenital  optic  nerve 
blindness,  the  case  is  one  of  idiocy  and  not  cretinism. 

Having  excluded  the  above,  the  next  thing  to  consider  is  whether  there  is  any  con- 
genital malformation  of  the  brain  or  cord.  Cases  of  meningocele,  nii/elocele.  or  spina  bifida 
will  generally  be  obvious  enougli  :  even  .spina  bifida  occulta  will  often  suggest  itself  from 
the  presence  of  a  pigmented  or  hairy  mole  over  the  lower  part  of  the  lumbar  spinal  region, 
and  the  diagnosis  may  be  confirmed  by  careful  palpation  there.  Congenital  findroceplialiis 
makes  itself  evident  from  the  characteristic  enlargement  of  the  head,  which  in  extreme 
cases  can  be  mistaken  for  nothing  else,  and  which  in  lesser  degrees  can  be  distinguished 
from  the  enlargement  due  to  rickets  or  to  congenital  syphilis  by  the  fact  that  it  is  more 
uniform,  and  that  the  bones  are  fragile  and  thin,  and  separated  at  the  sutures.  The  only 
df)ubt  that  arises  in  a  case  of  infantile  hydrocephalus  is  as  to  whether  it  is  truly  congenital 
or  was  caused  by  an  early  but  post-natal  posterior  basal  meningitis.  There  is  increasing 
evidence  to  show  that  the  majority  of  these  cases  are  not  really  congenital,  that  the  head 
is  not  large  at  birth,  and  that  the  enlargement  follow's  some  febrile  illness,  witli  or  without 
convulsions — really  a  meningococcal  meningitis. 

Congenital  defect  of  the  cortege  woidd  suggest  itself  as  the  cause  of  infantile  diplegia  in 
a  case  in  which  delivery  had  taken  place  without  difficulty  and  without  the  use  of  forceps, 
the  head  and  spine  not  being  hydrocephalic  or  deformed,  and  yet  the  limbs  being  paralyzed 
from  birth  :  they  niay  be  flaccid  or  they  may  be  spastic,  and  there  is  no  constant  type  of 
reflex,  tliough  there  is  a  tendency  to  increased  knee-jerk,  ankle-clonus,  and  extensor  plantar 
reflex.  Intelligence  will  very  likely  be  defective  at  the  same  time.  In  rare  cases  the 
kidneys  may  be  so  large  and  cystic  tliat  they  can  he  palpated,  and  the  brain  may  then 
be  cystic  also    -porencej)haliis. 

Parajjlegia  due  to  injiiri/  at  l/irlli.  citiier  by  tlic  use  of  forceps  or  l)y  excessive  com- 
pression in  a  contracted  maternal  pelvis,  is  a  diagnosis  that  can  only  be  made  when  there 
has  been  an  unusual  amount  of  difliculty  at  fjirth,  for  it  is  remarkable  to  what  extreme 
degrees  the  chiUfs  head  may  be  s()uec/.ed  and  altered  in  shape  without  apparent  detriment. 
Seeing  thai  it  is  the  lateral  aspects,  especially  the  arm  areas  of  the  Holandic  cortex,  that 
will  be  most  alTccte<l  by  forceps,  these  instruments  are  more  likely  to  cause  bilateral  arm 
paralysis  than  ordinary  paraplegia.  .lust  the  converse  of  this  is  true  of  superior  longitudinal 
sinus  thrombosis,  for  the  leg  areas  of  the  brain  lie  close  uj)  against  either  side  of  this  sinu.s, 
whilst  the  arm  areas,  being  more  distant  from  it,  are  likely  to  be  less  affected.  The 
symptoms  of  su|X'rior  longitudinal  sinus  thrombosis,  of  acute  encc])halitis,  and  of  menin- 
gitis, may  be  so  similar  pyrexia,  general  head  symptoms,  vomiting,  and  convulsions-  ■ 
that  it  is  almost  a  iiiatler  of  guess-wdrk  to  choose  between  them  when  they  are  actually 
in  progress  :  if  death  occurs  in  a  few  days.  suppurati\i'  meningitis  is  likely  ;  if  in  a  few 
weeks.  tul)erculous  meningitis:  if  Ihc  |iali<nl  lingers  for  many  weeks  l)el'iire  dying,  or  if 
recovery  occurs  with  hydroei  phaliis.  posteiior  lasal  oi-  cereliidspinal  meningitis:  if 
re(o\crv  occurs  without  hydrocephahis,  it  may  be  almost  impossible  to  decide  between 
nieningoeoeeal  meningitis,  acute  encephalitis,  and  superior  longitudinal  simis  thrombosis  ; 
nor  is  the  distitu'tion  material,  except  in  so  far  that  it  is  important  to  remember  always  that 
a  favourable  issue  may  occur  even  in  a  case  that  .seems  to  be  hopelessly  comatose  and 
dying  a  diagnosis  of  meningitis  may  have  been  made  erroneously  when  the  condition 
was  really  one  of  acute  encephalitis  only.  If  it  seems  to  be  of  great  importance  to  arrive 
at  the  accurate  diagnosis  in  the  acute  stages,  it  may  be  justifiable  to  perform  lumbar 
puncture.  .V  cytological  examination  of  the  cerebrospinal  fluid  may  show  many  poly- 
morphonuclear cells  in  a  suppurative-  case,  or  many  l\  inphoeytes  in  a  tuberculous  case. 
Of  more  \aliie  tlian  the  cylologieal  examination,  however,  is  tlie  b;ieteri()logieal  lest,  which 
may  succeed   in   isdlalirit;   llic  eiiusai  cir-g:nii^ni. 

If  niH-  is  ;dilr  In  exclude  I  he  iiilaTilile  (liplei;i;is.  ;ind  the  erindilioiis  which  simulate 
them,  the  probaliihis  is  Mial  Ihc  palicnl  will  h;i\c  sliowii  cilnious  signs  of  licing  able  to 
use   the    111:--    or   nia\    c\eri    lia\e    liei-ii   :dilc   lo    uajk    lielore    llie   paraplegia   set    in.       In    that 


512  PARAPLEGIA 

case,  if  the  paralysis  is  of  the  upper  neuron  type,  with  spasticity,  no  wasting  except  suclt 
as  may  be  due  to  disuse  and  non-development,  no  reaction  of  degeneration,  increased  knee- 
jerks,  extensor  plantar  reflexes,  ankle-clonus,  and  probably  bladder  and  rectal  trouble — 
especially  if  there  is  anassthesia  in  the  legs  at  the  same  time — by  far  the  commonest  cause 
for  the  condition  is  spinal  caries  with  compression  of  the  cord. 

If.  on  the  other  hand,  the  patient  develops  a  lower  neuron  type  of  paralysis,  with 
wasting  of  the  affected  muscles  and  reaction  of  degeneration,  the  chances  will  be  greatly 
in  favour  of  acute  anterior  poliomyelitis  followed  by  infantile  paralysis,  particularly  if 
diphtheria  can  be  excluded,  and  if  a  clear  history  can  be  obtained  that  the  child  was 
perfectly  well  until  he  developed  an  obscure  febrile  complaint,  which  may  at  first  have 
been  regarded  as  of  gastric  origin,  but  which,  in  a  day  or  two,  led  to  one  or  more  limbs, 
possibly  all  four,  becoming  limj)  and  paralyzed,  with  rapid  subsidence  of  the  fever  and 
great  imiirovement  in  the  paralysis  during  the  next  few  weeks.  It  is  possible  for  a  child 
to  have  had  absolute  paralysis  of  all  four  limbs  from  acute  anterior  poliomyelitis,  and  yet 
for  complete  recovery  to  occur  ;  more  often,  however,  one  or  another  group  of  muscles 
remains  weak  ;  in  a  typical  case,  the  extensors  of  the  toes  and  ankle  are  affected  jjernia- 
nently,  the  consequent  contraction  of  the  unparalyzed  calf  muscles  leading  to  talipes 
equinus  or  equino-varus.  Weakness  of  other  groups  of  calf  muscles  leads  in  a  similar  way 
to  other  forms  of  club-foot,  such  as  T.  calcaneus.  T.  valgus,  and  so  on.  In  other  cases, 
the  muscles  below  the  knee  recover  completely,  but  some  other  group  is  involved — the 
quadriceps  extensor  femoris  for  instance,  or  the  adductors  of  the  thigh.  It  is  of  course 
possible  for  the  legs  to  recover  completely,  whilst  paresis  of  some  group  of  muscles  in  the 
shoulder,  arm,  or  forearm  persists.  The  infantile  paralysis  which  follows  acute  anterior 
poliomyelitis  is  nearly  always  asymmetrical,  but  it  is  by  no  means  necessarily  so.  and  it 
may  cause  persistent  partial  |iaraplegia.  It  is  important  to  remember  that  the  knee-jerk 
is  deficient  or  absent  only  when  the  quadriceps  extensor  femoris  muscle  is  affected  :  and 
also  that  reaction  of  degeneration  is  no  longer  obtainable  in  the  muscles  when  the  disease 
is  of  sufficiently  long  standing  for  all  the  degenerate  fibres  to  have  become  fibrous,  by  which 
time  the  only  muscle  and  nerve  fibres  that  remain  are  normal,  though  they  are  fewer  in 
niunbcr  than  they  should  be. 

Peripheral  neuritis  in  a  child  is  decidedly  uncommon,  except  as  the  result  of  diplitlieriri  : 
it  should  not  be  diagnosed  lightly.  Being  an  affection  of  the  lower  neuron  type,  with 
wasting  of  the  muscles,  flaccidity,  reaction  of  degeneration,  and  deficiency  in  the  tendon 
reflexes,  it  may  be  difficult  to  distinguish  between  it  and  acute  anterior  poliomyelitis.  It 
might  be  urged  that  the  occurrence  of  pain  or  other  sensory  symptoms  is  in  favour  of 
peripheral  neuritis  and  against  poliomyelitis,  but  this  is  not  really  the  case  :  the  inflamma- 
tion in  poliomyelitis  is  by  no  means  necessarily  restricted  to  the  grey  matter  of  the  anterior 
cornua.  and  the  acute  stage  of  the  disease  is  often  accompanied  by  severe  pains  referred  to 
the  peripheral  parts.  There  may,  however,  be  bacteriological  or  other  evidence  of  the 
patient's  having  had  diphtheria  during  the  preceding  few  weeks,  in  which  case  peripheral 
neuritis  would  be  diagnosed  :  if  there  is  paresis  of  the  soft  palate,  as  evidenced  by  the 
regurgitation  of  fluids  through  the  nose  when  the  patient  tries  to  swallow  them,  or  by  the 
nasal  character  of  the  voice,  diphtheritic  neuritis  would  be  very  probable. 

There  remains  for  discussion  the  following  causes  of  paraplegia  in  children  :  Fried- 
reich's ataxy.  Tooth's  peroneal  type  of  progressive  muscular  atrophy,  and  the  primary 
muscular  dystrophies,  particularly  pseudo-hypertrophic  muscular  paralysis.  There  are 
two  points  common  to  all  these,  namely,  that  they  all  are  insidious  in  onset,  slowly  pro- 
gressive for  years  before  the  end  comes  as  the  result  of  an  intercurrent  malady  :  and  that 
they  are  familial  diseases,  the  family  history  having  an  important  bearing  upon  their 
diagnosis. 

Friedreich's  ataxy  is  characterized  by  paraplegia,  often  associated  with  deformity, 
such  as  talipes  and  scoliosis,  owing  to  persistent  error  of  posture,  without  wasting  except 
such  as  may  be  due  to  disuse  or  non-development  :  the  knee-jerks  are  absent,  but  the  pupils 
react  normally  ;  there  is  no  sphincter  trouble  imless  quite  late  ;  ankle-clonus  is  absent, 
but  there  is  generally  a  remarkable  condition  of  hallux  erectus,  which  anioimts  to  a  sort 
of  permanent  extensor  plantar  reflex  ;  there  are  no  sensory  disturbances  ;  the  arms  may 
not  be  affected  at  all,  or  they  may  present  some  degree  of  ataxy,  with  or  without  intention 
tremors — that  is  to  say.  tremors  which  are  increased  wl^n  the  patient  tries  to  perform 


PARAPLEGIA  513 

voluntary  movements — sometimes  even  choreiform  movements  are  present  ;  speech  is 
monotonous,  nystagmus  is  sometimes  present,  and  occasionally  there  is  optic  atrophy.  If 
progressive  paraplegia  develops  at  about  8  or  9.  years  of  age  in  a  child  with  a  family  history 
of  similar  trouble  :  if  the  knee-jerks  are  absent,  whilst  the  big  toes  are  permanently  erect, 
and  if  there  is  neither  atrophy  nor  ])seudo-hypertrophy  of  the  muscles,  the  diagnosis  is  in 
all  probability  Friedreich's  ataxy.  The  patient  may  survive  to  puberty  or  even  longer, 
but  is  liable  to  death  from  phthisis,  pneumonia,  or  other  intercurrent  malady — the  same 
applying  to  all  the  familial  diseases  now  under  discussion. 

Tooth's  peroneal  ti/pe  of  progressive  muscular  atroplitj  is  apt  to  develop  after  some  simple 
specific  fever,  such  as  wliooping-cough  or  measles.  The  first  point  the  mother  notices  is 
that  the  child — hitherto  normal — is  unable  to  bend  the  big  toes  upwards  ;  a  condition 
of  permanent  plantar  flexion  of  the  big  toes  ensues  :  inability  to  extend  the  other  toes 
follows  ;  and  presently  the  patient  cannot  dorsiflex  the  ankles.  It  is  chiefly  the  muscles 
sui>plied  by  the  external  popliteal  nerve,  formerly  called  the  peroneal  nerve,  that  are 
aflected  :  hem  e  the  name  of  the  disease.  Talipes  may  result.  The  lesion  is  not  primarily 
in  tlic  muscles,  but  in  the  anterior  cornual  cells  of  the  himbo-sacral  part  of  the  cord,  so 
that  reaction  of  degeneration  is  obtainable  in  the  wasted  muscles.  The  knee-jerks  remain 
normal  so  long  as  the  quadriceps  extensor  femoris  is  unaH'ected,  there  is  no  ankle-clonus, 
and  the  big  toe  may  not  move  at  all  when  the  sole  is  stimulated.  A  brother  or  a  sister  is 
very  likely  to  have  suffered  from  the  same  complaint  (see  Figs.  20,  21,  p.  00). 

In  the  primarji  muscular  dystrophies  the  nerves  are  normal,  so  that  there  is  no  reaction 
of  degeneration  :  if  a  muscle  has  become  entirely  atrophied,  there  will  be  no  reaction  in 
it  at  all  ;  but  as  long  as  any  reaction  is  obtainable  it  is  of  the  normal  type.  The  same  applies 
to  the  reflexes.  The  most  easily  recognized  of  all  the  primary  muscular  dystrophies 
is  pseudo-hypertrophic  muscular  paralysis,  the  only  difTiculty  being  when  no  family  history 
is  obtainable,  and  when  the  case  is  still  in  too  early  a  stage  to  be  typical.  Boys  are 
affected  more  (jftcn  than  girls,  but  it  is  generally  inherited  from  the  mother's  side."  It  is 
|)(issil>lc  for  some  members  to  have  presented  atrophic  myopathy,  whilst  others  suffer 
from  the  pseurlo-hypcrtrophic  form.  When  fully  developed",  the  most  striking  feature  of 
the  case  is  the  marked  weakness  of  the  legs,  notwithstanding  the  apparent  firnmess  and 
great  size  of  the  calves.  The  muscles  are  really  atrophied,  their  apparent  enlargement 
being  due  to  extensive  deijosition  of  intramuscular  interstitial  fat.  Ultimately,  if  the 
patient  survives,  all  the  muscles  in  the  body  become  wasted  and  fibrous  ;  but  whereas 
some  of  them  atrojjhy  from  the  first,  others  exhibit  marked  iiseudo-hypertrophy  before 
they  atrophy—particularly  the  gastrocnenni.  the  soici,  tlic  glutei,  tlic  deltoids,  the  supra- 
and  infra-spinati,  and  portions  of  the  triee])s.  Tlic  muscies  of  the  hands  and  feet  are 
generally  unalfeeted.  The  muscles  most  frequently  atrophied  are  the  lower  half  of  the 
peetoralis  major,  the  latissimus  dorsi,  the  serratus  magnus.  the  biceps,  and  the  flexors  of 
the  knee.  There  are  no  sensory  or  sphincter  troubles.  When  the  case  is  well  advanced, 
the  way  in  wliieh  the  patient  gets  up  from  a  lying  posliue  is  very  characteristic;  it  is 
generally  deserib(<l  as  -climbing  up  himself.'  He  first  rolls  over  and  rests  on  his  hands 
ind  knees  ;  then  puts  his  head  between  his  arms  and  raises  the  knees  from  the  groinid.  so 
that  he  is  now  supported  on  his  hands  and  feet  ;  he  next  brings  one  hand  nearer  to  his 
toes,  and  then,  swinging  his  body  over  first  to  one  side,  places  his  o|)posite  hand  on  the 
corresponding  knee,  straightens  that  leg,  and  repeats  the  performance  on  the  other  side, 
so  that  he  now  stands  with  his  legs  widely  separated  and  with  a  hand  resting  on  each  knee  ; 
he  then  works  each  hand  alternately  hjglicr  up  his  thighs,  until  liiially,  by  a  sudden  baek- 
wanl  niovenient  of  his  shonlderv,  j'l,-  tiltaiiis  Ihe  erect  altitude.  .Vnother  feature  of  the 
ease  is.  that  if  one  lri(s  |,,  |i||  |  |„-  b,,y  up  by  putting  one's  hands  under  his  armpits,  his 
shoulders  rise  right  up  I,,  his  cars,  .nid  li.-  very  easily  slips  through  one's  hands.  He  is 
ilso  unable  to  sliin.l  on  tip-loe.  and  the  gait   is  waddling. 

The  two  (illicr  types  (,r  muscular  dystrophy  meidioned  almve  Ihe  inranliic  and  Ihe 
juvenile  are  l>ul  dilTcniil  varieties  of  the  same  malady:  both  are  eharael.ri/.ed  by 
progressi\e  wasting  of  \\u-  niusclcs  without  pseudo-hypertro|)liy  ;  in  the  itdantile  form 
Ihe  muscles  have  been  almphic  tiom  the  first,  whereas  in  the  juvenile  form  the  muscles 
levelop  in  what  seems  to  be  a  normal  way  up  to  a  certain  puiiil.  and  llun  gradually 
waste  away.  The  disease  is  distinguished  from  peripheral  M(  nrilis.  (1)  l)y  llie  absence 
it  reaction  of  d<'generation  ;    (2)   bv  the  pcrsislcnee  of  llie  rcllcxcs  as  long  as  anv  muscle 


514  PARAPLEGIA 

tissue  is  left  to  respond  ;  (3)  by  the  family  liistory  as  mentioned  above  ;  (4)  by  tlie 
absence  of  sensory  changes  ;  and  (5)  by  the  absence  of  improvement  with  time.  An 
attempt  is  sometimes  made  to  classify  the  primary  muscular  dystrophies  into  different 
kinds,  according  to  the  groups  of  muscles  first  affected.  In  the  Landouzy-Dejcrine  type, 
for  instance,  the  face  muscles  are  first  attacked,  the  trouble  slowly  spreading  to  tlic 
shoulder  and  upper  arm.  It  is  probable,  however,  that  whatever  groups  of  muscles  may 
be  the  first  affected,  the  differences  are  those  of  degree  and  type  rather  than  of  kind,  and 
that  the  muscular  wasting,  wherever  it  may  begin,  ultimately  becomes  widespread,  and 
finally  involves  all  the  muscles. 

II.  THE  CAUSES  OF  PARAPLEGIA  IN  ADULTS. 

We  may  now  pass  on  to  a  discussion  of  the  differential  diagnosis  of  paraplegia  in 
adults.  It  is  clear  that  a  paraplegia  that  has  arisen  during  infancy  or  childhood  may 
persist  into  adult  life,  in  which  case  the  diagnosis  will  be  made  upon  the  lines  indicated 
above.  It  is  also  possible  for  some  of  the  causes  of  paraplegia  that  usually  affect  young 
patients  not  to  do  so  until  they  have  grown  up.  The  chief  causes,  however,  for  paraplegia 
arising  for  the  first  time  in  adult  life  are  as  follows  : — 

(A).  Causes  of  the  loiver  neuron  iy^je  of  paraplegia  : — 

1.  Peripheral  neuritis,  which  may  be  due  to  various  different  causes  (p.  (>.'}) 

2.  Anterior  poliomyelitis 

3.  A  pelvic  tumour  interfering  with  the  lumbo-saeral  plexus 

4.  .\  tumour  affecting  the  eauda  equina 

5.  Compression  of  the  lumbar  enlargement  of  the  cord. 

(B).  Causes  of  the  upper  neuron  type  of  paraplegia  : — 

1.  Transverse  myelitis. 

(a).  Primary 

(b).  Due  to  compression   by  :     (i)  Spinal  caries  :    (ii)  New  growth  in    the 
vertebrie  or   meninges  ;     (iii)  Injury  ;     (iv)  Aortic   aneurysm 

2.  Disseminated  sclerosis 

3.  Aniyiitnipliie  lateral  sclerosis 
■1.  I'liiiiarv   lateral  sclerosis 

5.  Ataxic  paraplegia 

0.  Combined  scleroses  of  the  cord 

7.  Syringomyelia 

8.  Meningitis 

9.  Ha*inorrhage  into  the  cord 

10.  Cerebellar  tiunour  or  abscess 

11.  Bilateral  cerebral  softening  or  lucmorrliage. 

(C).  Causes  not  conforming  either  to  the  iozcer  or  to  the  upper  neuron  type: — 

1.  Tabes  dorsalis 

2.  General  paralysis  of  the  insane 

3.  Landry's  paralysis 

4.  Functional  paraplegia 

5.  Malingering. 

The 'first  points  which  call  for  attention  in  making  a  diagnosis  are  the  history  and 
progress  of  the  case.  In  only  a  few  of  the  above  conditions  is  the  onset  sudden  ;  these 
are  certain  cases  of  acute  anterior  poliomyelitis,  transverse  myelitis,  meningeal  ha-morrhage, 
Landry"s  paralysis,  functional  paraplegia,  and  malingering.  If  the  paraplegia  is  of  sudden 
onset,  of  the  upper  neuron  type,  and  not  the  result  of  injury,  it  is  almost  certainly  due 
to  some  form  of  transverse  myelitis.  The  great  majority  of  cases  of  paraplegia,  howc\er, 
have  an  onset  that  is  not  absolutely  acute,  and  generally  it  is  quite  gradual. 

There  are  certain  conditions  that  can,  as  a  rule,  be  either  diagnosed  or  excluded  at 
once.  If  the  patient  has  Argyll  Robertson  pupils  and  no  knee-jerks,  tabes  dorsalis  can  be 
diagnosed  at  once.  It  is  necessary  to  remember,  however,  that  the  pupil  may  react  neither 
to  light  nor  to  accommodation  in  some  cases  of  jjcripheral  neuritis,  so  that,  if  care  be  not 
exercised,  the  reaction  may  be  mistaken  for  the  Argyll  Robertson  type  of  tabes,  the  latter 
being  diagnosed  when  peripheral  neuritis  is  the  lesion  really  present.  The  converse 
mistake  is  also  possible,  especially  if  the  actual  strength  of  the  leg  muscles  be  not  tested  ; 
in  both  conditions  there  may  be  patches  of  impaired  sensation,  but  in  peripheral 
neuritis  with  absent  knee-jerks,  there  are  absolute  wasting,  loss  of  power,  and  reaction  of 


PARAPLEGIA  515 

degeneration,  whilst  in  tabes  there  is  no  tropliic  wasting,  and  often  no  great  loss  of 
power  in  individual  muscles,  though  there  is  apparent  weakness  owing  to  the  action  of 
opposing  muscles  being  inco-ordinate,  and  there  is  no  reaction  of  degeneration. 

.Another  difficulty  in  connection  with  tabes  dorsalis  arises  in  anomalous  cases  in  whicli 
either  the  pupil  reaction  has  not  yet  become  typical,  or  else  the  knee-jerks  are  not  yet 
gone.  If  the  reaction  of  the  pupil  is  of  the  .\rgyll  Robertson  type,  tabes  may  sometimes 
be  diagnosed  even  in  the  presence  of  knee-jerks,  if  there  is  an  obvious  history  of  other  con- 
comitants of  the  disease,  such  as  lightning  pains,  gastric  crises,  or  any  of  the  rarer  crises — 
laryngeal,  rectal,  urethral,  vesical,  renal,  general  abdominal,  or  sweating — marked  ataxy, 
history  of  syi)hilis,  jierforating  ulcer  of  the  foot,  a  Charcot's  joint,  or  bladder  or  rectal 
trouble,  particularly  if  the  ))atient  be  a  male  who  has  had  much  brain  wear.  The  tendo 
Achillis  jerks  may  disappear  before  the  knee-jerks  do,  and  they  should  be  carefully  tested. 
There  is  also  in  many  cases  a  remarkable  deficiency  or  even  complete  absence  of  deej) 
tenderness  in  such  organs  as  the  testis,  tongue,  larynx,  or  mamma.  In  certain  cases  the 
knee-jerk  may  still  be  obtainable  on  one  side  after  it  has  been  lost  u])on  the  other,  so  that 
both  should  always  be  tested  and  not  one  only. 

If  the  ])araplegia  is  obviously  of  the  lower  neuron  type,  with  dehciency  or  absence 
of  the  superficial  and  deep  reflexes,  atrophy  of  the  muscles,  and  reaction  of  degeneration, 
with  or  without  panesthesia,  the  probabilities  are  that  it  is  due  to  one  of  the  many  different 
causes  oi  peripheral  neuritis  that  are  discussed  on  page  63.  If  the  onset  has  been  sudden, 
however,  and  if  the  paralysis  began  to  clear  up  again  rapidly,  except  possibly  in  one  grouj) 
of  muscles  in  one  leg,  there  would  necessarily  be  a  suspicion  of  acute  anterior  poliomyeUtis 
which  occurs  occasionally  in  adults. 

It  is  important  in  all  cases  of  suspected  peripheral  neuritis  to  make  a  rectal  examina- 
tion, lest  there  should  be  some  iielvic  mass,  malignant  or  otherwise,  interfering  with  the 
lumbo-.sacral  plexus.  Perij)heral  neuritis  may  also  be  simulated  closely  by  either  a  tumour 
or  a  gumma  interfering  with  the  cauda  equina,  an  uncommon  condition  that  suggests  itself 
if  there  is  severe  pain  referred  to  the  lower  part  of  the  spinal  column  behind,  or  if  the 
paraplegia  comes  on  in  such  a  way  as  to  affect  one  leg  before  the  other,  the  pelvis  being 
f'(iuti<l  free  from  growth.  It  is  also  im|)cirlant  to  remember  that  transverse  myelitis  due  to 
lesions  which,  if  they  are  situated  a  little  higher  up  in  the  cord,  cause  a  paraplegia  of  the 
upper  neuron  type,  produces  wasting,  reaction  of  degeneration,  and  loss  of  reflexes  when 
they  affect  the  cord  at  the  level  of  the  lumbar  enlargement. 

When  the  paraplegia  is  definitely  of  the  up])er  neuron  type,  with  spasticity  of  the 
legs  without  wasting,  with  increased  knee-jerks,  extensor  plantar  reflexes,  ankle-clonus, 
and  perhajjs  retention  of  urine  with  overflow,  and  incontinence  of  fteces,  the  hrst  step  in 
arriving  at  the  diagnosis  is  to  determine  if  there  is  any  sensory  disturbance  at  the  same 
time.  The  only  diseases  mentioned  under  heading  B.  that  produce  obvious  sensory  dis- 
orders, are  transverse  myelitis,  syringomyelia,  luemorrhage  into  the  cord,  and  very  rarely 
meningitis  or  bilateral  cerebral  softening.  The  latter  can  only  be  diagnosed  when  there 
has  been  an  jipoplcetic  sci/.urc  associated  with  hemiplegia,  followed  after  an  interval  by 
another  cerebral  sci/.urc  which,  by  producing  hemiplegia  of  the  opposite  side  to  the  one 
first  iiivohcfl.  results  in  paraplegia,  or  rather  diplegia.  The  arms  and  face  are  likely  to 
be  affected  as  well  as  the  legs,  and  there  will  be  either  a  history  of  syphilis  to  account  for 
endarteritis  and  thrombosis  in  a  young  male,  or  a  bruit,  a  history  of  acute  rheumatism, 
or  other  evidence  of  a  hciirt  lesion,  to  account  for  embolism  :  or  senile  changes,  with  or 
witliout  albumimiria.  a  high  blood-pro«sure,  retinitis,  and  other  signs  of  renal  and  arterial 
dcgencralion.  to  account  for  ha-morrhagc. 

IlaiiiDrrliaflr  into  the  eoril  is  hardly  ever  spontaneous  ;  it  may  follow  an  injury,  such 
I  as  a  bullet  woiukI  or  a  stab  in  the  back,  and  then  the  hi.story  will  indicate  the  diagnosis. 
Acute  tnniingitis.  whether  tuberculous,  sup])urative,  posterior  basal,  or  cerebros|)inal, 
seldom  causes  complete  ])araplcgia  until  a  late  stage  of  the  illness  is  reached,  by  which  tin\e 
the  nature  of  the  malady  will  generally  be  indicated  \)\  the  cerebral  symptoms,  particularly 
headache,  vomiting.  con\  uKions,  sliabisiniis.  and  opiitlialmoscopic  changes  such  as  optic 
neuritis  or  choroidal  tubercles.  Haeteriological  in\  estigations  of  the  lluid  obtained  by 
lumbar  puncture  may  assist  the  diagnosis  materially.  There  is  a  chronic  form  of  menin- 
gitis, however,  of  which  the  diagnosis  is  not  so  easy,  antl  that  is  the  rhroiiie  hypertrophic 
■hwinorrhauir  /lachi/iiienin^iilis:  which   aHccIs  chiclly    llie   \ertex   and   tlie  cer\ical   portion   of 


516  PARAPLEGIA 

the  cord.  The  condition  is  generally  caused  by  chronic  alcoholism  in  syphilitic  subjects, 
especially  if  there  has  also  been  some  injury  :  the  diagnosis  is  difficult,  but  it  may  bi- 
suggested  by  the  history,  and  by  the  degree  of  pain  referred  to  the  nerves  that  are  involved 
in  the  meningeal  Ihiekeniiig — the  chief  dilliculty  being  to  exclude  spinal  caries  in  cases 
involving  the  cord.  ^Vasse^mann■s  reaction  may  be  positive  if  no  antisyphilitic  remedies 
have  been  employed.  In  syririgomi/elin — a  very  slowly  progressive  disease  that  is  by  no 
means  always  associated  with  paraplegia,  the  nature  of  the  symptoms  depends  upon  the 
degree  to  which  the  central  canal  of  the  cord  and  the  gelatinous  substance  around  it  are 
affected,  and  also  upon  the  level  in  the  cord  at  which  the  changes  occur.  The  diagnostic 
symptom  is  that,  in  some  region  or  another,  the  skin  will  be  found  to  have  lost  its  power  of 
distinguishing  heat  from  cold  and  pain  from  toucli.  though  it  still  retains  ordinary  cutaneous 
sensibility.  It  is  a])t  to  give  rise  to  skin  lesions  in  the  parsesthetic  parts  (Morvan"s  disease), 
and  also  to  acute  painless  swelling  of  the  joints,  with  deformity  from  destruction  of  the 
ends  of  the  bones — C'harcofs  joints — precisely  similar  to  those  that  may  occur  in  tabes 
dorsalis. 

If  the  patient  has  marked  impairment  of  all  kinds  of  sensation  in  both  legs,  with  para- 
jjUgia  of  the  upper  neuron  type,  and  no  paralysis  of  the  arms,  the  lesion  is  almost  certainly 
transverse  niijelitis  of  some  kind.  The  absence  of  sensory  disturbance,  howe\'er,  does  not 
exclude  transverse  myelitis,  for  when  the  conductivity  of  the  spinal  cord  is  interfered  with, 
without  being  entirely  inhibited,  the  sensory  columns  are  able  to  transmit  impulses  longer 
than  the  pyramidal  tracts,  so  that  paralysis  appears  before  anesthesia.  The  same  applies 
to  a  transverse  myelitis  that  is  getting  better,  the  patient  recovering  sensation  in  his  legs 
before  he  is  able  to  move  them.  The  chief  dilliculty  will  be  to  determine  the  nature  ol 
the  transverse  myelitis.  There  are  two  main  types  :  (1)  That  due  to  causes  outside  tin 
cord  compressing  it — especially  spinal  caries,  secondary  ^roit'//;,  the  effects  of  such  injnri<^ 
as  fractures  of  the  spine,  bullet  woimds  and  stabs,  or  more  rarely  erosion  of  the  bones  li\ 
an  norlic  aneurysm  ;  and  (2)  That  due  to  softening  from  thrombosis  of  a  spinal  artery, 
the  result  of  syphilis,  or  a  fever  such  as  enteric  or  scarlet.  One  of  the  first  points  to  attend 
to  is  the  presence  or  absence  of  pain.  Lesions,  such  as  thrombosis,  which  affect  the  cord 
hut  not  its  posterior  nerve  roots,  are  painless,  whereas  swellings  which  compress  the  cord 
from  without  almost  always  produce  pain,  sometimes  a  typical  girdle  pain,  on  accoimt  of 
their  irritating  the  jjosterior  nei've  roots.  If,  therefore,  there  is  or  has  been  any  pain  in  the 
back  other  than  what  may  be  due  to  a  known  injury,  it  is  probable  that  transverse  myelitis 
is  not  primary  but  due  to  compression.  If  the  spine  presents  an  obvious  Potfs  curvature, 
or  if  the  patient  has  other  evidence  of  peripheral  tuberculosis,  such  as  enlarged  or  caseating 
glands  in  the  neck,  hip,  knee,  or  other  joint  disease,  a  psoas  abscess,  lupus  vulgaris,  and 
so  on,  especially  in  a  young  person  wlio  has  been  in  the  habit  of  drinking  much  milk,  com- 
pression by  spinal  caries  is  fairly  certain.  The  main  dilBcidty  arises  when  the  cord  becomes 
compressed  without  deformity  of  the  spinal  coliunn,  and  with  no  other  tuberculous  lesion 
apparent.  Local  tenderness  over  one  or  more  vertebral  spines  will  help  to  suggest  the 
diagnosis,  especially  if  local  pain  is  complained  of  in  the  same  region,  and  if  the  pain  is 
increased  by  any  jarring  of  the  spine.  Growth  is  fortimatcly  much  rarer,  and  it  is  to  be 
excluded  by  a  routine  examination  of  all  the  viscera,  most  cases  of  spinal  new  growtli  being 
secondary  to  a  neoplasm  elsewhere,  especially  of  the  breast ;  primary  growths  of  the  spine 
are  so  rare  that  they  are  generally  taken  for  caries  at  first,  and  the  correct  diagnosis  is  not 
always  arrived  at  before  post-mortem  microscopical  examination  has  been  made.  Aortic 
aneurysm  is  a  still  rarer  cause  of  compression  myelitis  ;  if  there  is  a  distinct  pulsatile 
tinnour  along  the  course  of  the  aorta,  the  nature  of  the  case  may  be  obvious  ;  more  often, 
however,  an  aneury.sm  which  erodes  the  vertebr;r  sufficiently  to  bidge  into  the  spinal  canal, 
does  not  at  the  same  time  enlarge  forward  to  jjroduce  a  tumour  that  can  be  recognized 
easily  by  palpation.  The  patient  will  genei-ally  be  a  man  in  the  prime  of  life  who  has  had 
syphilis,  who  is  not  a  life  abstainer,  and  who  has  worked  hard  ;  Wassermann"s  reaction 
may  be  positive.  A]jart  from  a  pidsatile  timiour  the  symptoms  will  be  very  like  those  of 
])araplegia  from  spinal  caries. 

The  relationship  of  injury  to  transverse  myelitis  is  not  always  quite  straightforward. 
If,  for  example,  a  patient  who  has  syjjhilitie  endarteritis  of  his  spinal  vessels  receives  a 
'icick  in  the  back  from  a  horse,  he  may  find  that,  by  next  day,  he  is  unable  to  move  his  legs  : 
it  may  at  first  seem  obvious  that  the  kick  has  been  the  sole  cause  of  the  paraplegia,  when 


i 


PARAPLEGIA  517 

tlic  real  cause  is  sy]jliilis— the  kick  liaving  been  the  final  factor  which  led  t(i  thrombosis 
in  a  diseased  spinal  artery.  Transverse  myelitis  due  to  syphilis  is  exactly  comparable  in 
its  mode  of  origin  to  the  hemiplegia  which  results  from  endarteritis  obliterans  in  a  middle 
cerebral  artery.  There  is  no  pain  and  no  deformity  of  the  spine,  but  in  other  respects  the 
paraplegia  presents  the  same  features  as  does  that  which  is  due  to  compression  of  the  cord. 
Syphilis  is  by  far  the  most  important  cause  of  this  primary  transverse  softenino-.  but  there 
arc  a  considerable  number  of  other  maladies  in  which  a  similar  result  ensues  occasionally  ; 
almost  any  infective  disease  may  lead  to  it  :  one  may  perhaps  mention  typhoid  fever, 
scarlet  fever,  and  influenza  in  particular.  In  infective  endocarditis  there  may  be  an 
additional  factor,  namely  embolism  of  the  cord,  though  this  is  decidedly  rare. 

If  it  is  found  that  the  arms  are  affected  as  well  as  the  legs,  it  is  imlikely  that  the  lesion 
is  transverse  myelitis,  unless  in  rare  and  anomalous  cases  such  as  those  mentioned  on 
])age  02.  If  the  onset  has  been  slow,  the  course  progressive,  and  wasting  is  present,  with 
reaction  of  degeneration  in  the  muscles  of  the  hands  or  arms,  with  increased  knee-jerks, 
ankle-clonus,  and  extensor  plantar  reflexes,  but  no  anaesthesia,  the  malady  is  almost 
certainly  amyotrophic  lateral  sclerosis. 

If  there  are  increased  knee-jerks,  extensor  plantar  reflexes,  ankle-clonus,  ataxy, 
intention  tremors  in  the  hands,  nystagmus,  and  a  hesitancy  in  the  voice,  which  may  even 
be  of  the  tyiie  described  as  ■  scanning,'  the  disease  is  either  cerebellar  abscess  or  tumour, 
or  disseminated  sclerosis.  If  headache  and  vomiting  have  been  severe,  the  former  is  the 
more  probable,  and  the  diagnosis  may  be  clinched  by  finding  double  optic  neuritis. 
Abscess  will  be  more  likely  than  tumour  if  there  is  otorrhd-a  or  ])yrexia.  It  is  not 
uncommon  to  find  optic  atrophy,  with  either  concentric  diminution  in  the  fields  of  vision 
or  else  a  central  scotoma,  in  disseminated  sclerosis,  but  optic  neuritis  is  uncommon.  The 
difliculty  in  diagnosing  disseminated  sclerosis  arises  mainly  when  the  complaint  is  in  its 
early  stages  ;  the  patches  of  sclerosis  may  be  anywhere  in  the  cord,  and  before  the  affected 
fibres  atro])hy  there  is  a  period  when  they  are  sometimes  able  to  conduct  impulses,  some- 
times not  ;  when  they  are  not  able  to  conduct,  there  are  numerous  .symptoms,  and  in  a 
day  or  two,  when  conducting  power  recovers,  these  symptoms  are  gone  again  :  this  varia- 
tion from  day  to  day  nearly  always  leads  to  a  diagnosis  of  neurosis  for  months  or  years 
before  the  true  nature  of  the  malady  becomes  obvious.  In  some  patients  a  central  scotoma 
may  develop  early,  leading  to  peculiar  symptoms,  such  as  the  inability  to  distinguish  a 
sovereign  from  a  shilling  if  the  light  is  not  good,  or  the  liability  to  rim  into  i>eople  without 
seeing  them  when  cycling.  If  ataxy  is  marked,  the  staggering  gait  may  lead  to  a  suspicion 
of  alcoholism  :  the  patient  staggers  alternately  to  either  side  in  disseminated  sclerosis, 
whereas  in  tumours  of  one  cerebellar  hemisphere  the  tendency  is  to  stagger  constantly  to 
the  same  side.  Bladder  and  rectal  troubles  are  not  common  in  cither  case,  and  yet  they 
amy  be  prominent.  Para'sthesia  may  also  .l(\(lo|)  in  disseminated  sclerosis,  altlioimh  as 
I  rule  there  is  no  sensory  disturbance  at  all. 

If  a  palieni  has  the  symptoms  of  spaslic  paraplegia  and  alaxy,  williout  ana-stliesia, 
aystagmus.  or  changes  in  the  voice,  a  diagnosis  of  ata.ric  jHirnplcflia  will  usually  be  made, 
"here  is  really  no  difference  between  this  and  what  has  been  called  coiidiiiicd  scleroses  of  the 
■ord  :  in  both  conditions  there  is  degeneration  of  the  posterior  columns,  th-.-  crossed 
)yramidal,  and  the  cerebellar  tracts.  Some  observers  use  the  leiin  cornliincd  scleroses 
nly  for  syphilitic  cases,  reserving  ataxic  paraplegia  f)r  similar  non-syphilitic  eases. 

I'rimarji  lateral  sclerosis  was  a  rcliiti\ely  common  diagnosis  until  it  was  found  that 
he  more  careful  the  cxanutiation  the  greater  was  the  likelihood  that  more  than  simple 
leg<ii(ration  of  the  crossed  pyramidal  tracts  would  be  found.  Partial  compression  of  (he 
ord  produces  spastic  |)araplegia  without  anicsthcsia,  and  thus  simulates  primary  lateral 
elerosis  as  described  above.  DisscniiniUed  sclerosis  may  do  so  likewise,  and  so  on. 
'rimary  lateral  sclerosis  should  never  be  diagnosed,  therefore,  till  all  the  other  affections 
n  which  the  lateral  columns  may  be  affected  have  been  excluded.  There  is  such  a  disease 
s  primary  lateral  sclerosis,  however;  if  is  generally  syphilitic  in  origin,  and  it  leads  to 
ypical  spastic  paresis  of  the  legs,  with  increased  knee-j<rks,  ard<le-elonus,  extensor  plantar 
cflcxes,  no  wasting,  no  U.  I).,  no  scnsnry  dislurhaiKcs.  and  in  the  later  stages,  retention 
f  urine  with  overflow,  and  iricoriliiuncr  ol  faces:  Ibc  disease  is  generally  progressive, 
ut  after  reaching  a  ccilain  pninl  il  may  remain  slalioriaiv  for  scars,  or  even  improve  to 
slight  cxlriil    liM  a  liiiK.      Wlicn   lateral   sclerosis  is  yel    in  :in  early  stage,  a  valuable  sign 


PARAPLEGIA 


of  it  is  the  disappearance  of  the  abdominal  reflexes  ;    the  diagrams  (Figs.  210,  211)  may 

be  of  assistance  in  locating  the  level  of  the  cord  at  which  a  lesion  may  be  present. 

The  causes  of  paraplegia  that  remain  for  discussion  are  Landry"s  paralysis,  general 

paralysis  of  the  insane,  functional  paraplegia,  and  malingering. 

Landry's  paralysis  is  probably  not  a  distinct  entity,  but  rather  a  very  acute  type  of 

perhaps  more  than  one  variety  of  paraplegia.     It  is  rare.     It  affects  young  adults,  who. 

hitherto  strong  and  well,  become  rapidly 
affected  by  paralysis  which  starts  in  the  legs 
and  quickly  ascends  to  the  trunk  and  arms, 
and  may  even  involve  the  neck  and  cranial 
nerves.  It  either  gets  well  quite  rapidly,  or 
else  kills  the  patients  in  a  few  hours  or  days 
by  affecting  the  intercostal  muscles  and  dia- 
))hragm,  with  consequent  asphyxia.  There 
may  be  slight  pains  in  the  affected  parts 
sh(irtly  before  paralysis  sets  in,  but  sensory 
symptoms  are  generally  slight,  or  absent.  The 
nature  of  the  malady  is  obscure,  but  if  one 
were  to  regard  it  as  a  very  acute  and  wide- 
s|)read  anterior  poliomyelitis,  one  could  account 
both  for  its  main  symptoms,  its  rapid  fatality 
in  some  cases,  and  its  equally  rapid  recovery 
in  others.  Moreover,  seeing  that  the  patient 
cither  dies  or  recovers  so  quickly,  it  is  not 
surprising  that  there  is  no  time  for  the  develop- 
ment of  obvious  muscular  wasting  or  reaction 
of  degeneration. 

Paraplegia  in  cases  of  general  paralysis  of 
tlie  insane  does  not  arise  until  the  third  stage 
of  tliat  malady  is  reached  ;  by  that  time  the 
diagnosis  is  generally  obvious  ;  the  paraplegia 
is  part  of  a  general  and  extreme  weakness,  and 
the  patient  is  bedridden. 

Functional  para/jlegia  and  malingering 
should  never  be  diagnosed  until  all  organic, 
causes — particularly  disseminated  sclerosis  and 
spinal  caries — have  been  excluded.  Malinger- 
ing may  be  suggested  by  the  particular  circum- 
stances of  the  case — the  patient  may  be  a 
nervous,  self-conscious  girl  who  desires  to 
attract  sympathy,  or  an  out-of-work  who 
wants  to  get  a  nighfs  shelter  in  a  hospital  ; 
careful  observation  generally  leads  to  the 
detection  of  the  fraud.  Functional  paraplegia 
is  less  easy  to  be  sure  of,  and  in  many  patients 
that  which  may  at  first  be  regarded  as  func- 
tional ultimately  turns  out  to  be  organic  :  this 
is  especially  true  in  the  case  of  disseminated 
sclerosis.  The  paraplegia  is  never  of  the 
l)rimary  muscular,  or  the  lower  neuron  type, 
there  being  no  wasting  and  no  R.D.  The 
muscles  remain  of  good  bulk  as  they  do  in 
the  ui)iier  neuron  type  of  jjaraplegia,  but 
although  the  knee-jerks  may  be  imduly  brisk, 
the  plantar  rcllexes  remain  flexor,  and  there  is 
no  maintained  ankle-clonus.  If  there  is  anassthesia,  the  distribution  of  the  latter  is  some- 
times obviously  functional  ;  it  may,  for  instance,  start  sharply  at  the  knee  and  cease 
suddenly  at   tlie  ankle,  or  in  some  other  way  indicate  that  it  corresponds  neither  to  the 


PARASITES.     INTESTINAL  519 

segments  of  the  spinal  cord  nor  to  the  distribution  of  the  peripheral  nerves.  It  is  bv 
anoniahes  of  this  l<ind.  which  make  it  impossible  to  fit  in  the  case  with  any  organic 
lesion,  that  functional  paraplegia  is  diagnosed  by  a  process  of  exclusion.         Ihrbcrl  Firncli. 


PARASITES,  INTESTINAL.-- r^pc-aorms.— The  commonest  symptom  of  the 
existence  of  a  tape-worm  is  the  passMgc  of  tlie  detached  terminal  segments  per  rectum  in 
longer  or  shorter  tape-like  strips.  The  only  condition  for  which  these  might  be  mistaken 
is  muco-membranous  colitis,  in  which  long,  narrow,  white  mucous  casts  of  the  bowel  may 
be  passed  with  the  motions  {Fig.  172,  p.  398).  It  is  easy  to  distinguish  these,  however, 
if  the  suspected  material  is  floated  in  water,  for  in  the  case  of  a  cast  of  the  bowel  a  central 
lumen  vvill  be  found  wliich  is  not  present  in  the  ta]je- 
worm.  There  is,  moreover,  no  regular  segmentation  in 
the  case  of  muco-membranous  colitis,  whereas  tape- 
worms are  ob\iously  segmented.  If  any  doubt  remains, 
examination  with  a  lens  will  show  the  glandular  structure 
of  the  uterus  in  the  tape-worm  segments,  and  no  such 
structure  in  the  strips  of  mucus  in  muco-membranous 
colitis.  It  is  sometimes  stated  that  ])icking  of  the  nose 
and  a  voracious  appetite  are  symptoms  of  the  presence 
of  some  kind  of  intestinal  parasite  ;  but  this  is  hardlx 
ever  the  case  ;  if  constitutional  symptoms  develop  at  all. 
they  take  the  form  of  deficiency  of  ap])etite.  with  more 
or  less  ana'mia.  wliich  may  become  |)rofoimd  :  there  is 
often  considerable  Eosinopuii.ia  (p.  "ilK).  The  three 
forms  of  tape-worm  that  occur  in  the  human  intestine 
are  Tmnia  solium.  T.  mediocaiielhilii.  and  Jiotlirioceplidliin 
laius.  the  commonest  in  Great  Britain  being  the  T.  mcdio- 
canellata,  the  cystic  stage  of  which  is  spent  in  cattle.  T. 
solium  is  derived  chictly  from  pig-meat,  whilst  Bolhrio- 
ceplialus  talus  occurs  mainly  in  those  who  live  nuich  on 
fresh-water  fish.  It  may  be  possible  to  make  the  dia- 
gnosis of  T.  mediocauelUita  by  holding  the  segments  up  against  a  bright  light  and  seeing 
a  median  streak  or  water-channel,  in  addition  to  one  down  either  edge  of  eacli  strip, 
this  middle  water-channel  giving  the  name  to  the  parasite.  The  ultimate  ))roof  of  the 
nature  of  the  tape-worm.  ho,ve\er,  is  ariVir<le(I  by  the  characters  of  the  head,  thai  of 
T.  solium  having  four  sucking  discs,  with  a  rostrellum  surrounded  by  thirty-four  hoiiklets 
{Figs.  212    2i;i)  ;     that  of  7'.   nicdiiwdiiclliiUi   four  circular  sucking  discs  and   no  liooklcts 

{Fig.  21  I.)  :  whilst  that  of  the 
Hollinoccphalus  lalus  has  a 
more  or  less  conical  luad.  with 
two  elongated  lateral  sucking 
discs  and  no  Iwioklcts  (/•'iV.  21.'.). 
'I'lic  degree  of  ana'inia.  clilorotic 
in  type,  is  usually  greatest  with 
liotlirioct'itlidlus  lulus,  least  with 
7'.  luftliocuncllulii.  and  the  same 
also  applies  to  the  degree  of 
I'osinophilia.  The  eggs  of  the 
tape-worm  are  umnistakable 
{Fig.  21(>):  they  are  spherical, 
with  a  dark-brown  central  por- 
tion, and  a  lighter  striated 
broad  capsule. 

-(      wavs     111"     pi'c|i:iiiii;;     r:i'ci's     lor 
r  solid' parliclcs.   is  U<  pul   mImmiI    as 


Fill.  L'12.— Iloail  of 
Bliowirif?  four  sucking  ^li 
four  liooklef.s,  altenmteh 
(JleUiuiu  power.)  (Froi,. 
lilt  imsscusiim  oj  Mr.  Ptilis 
tflnci,    IK.) 


Fiq.    :i: 
TiEiiia    totiiim, 
diofimmintttic. 
p  o  w  e  r  .  )     f  P  r 
French's    Mfilira/   /.a- 
horatory   Mcthotis.) 


Fig.  2M.— Tlca.I  of 
Vc/lia  mediucamllti'a. 
Ijovi  power.)  fl'rom 
Vetich'.s  Mritieal  La- 
iradinj  .Miilmli.) 


Fill.  21.'>.  —  r.atorul 
view  of  head  of  Jiiithrio- 
Cfiilialiis  lattts,  showinc 
lonsiluiJiiml  suckinfT 
dific.     (f-ow  power.) 


.Minns,„i,in 
iiiirnis('r)|il('al  rx 
tiiiicli  as  Wdiilil 
soliilion  (1  1  ilr. 
lircnU  ii|>  the  Inv 
<>l    ll.c    fluid    nil 


>tli( 


•liiiiilinii     (if     rinrs.      One     i>i     tlic 

111   liii-  llic'iiNM  nC  iiMrnsilcs  or  Cor 

sliilliiij;  iiilo  a  lcs(-liil)i-,  lilliiig  till-  liillcr  Uvd-lhinls  lull 

II  a  piiil   111'  water),  ciirkiiig  llic  tulic,  anil  shaking  it   \ignninsly  in  iinliT  In 

iirli  as  piis'ihjc  :    on  Mlldwiny  In  staiicl  Icir  Iwcniy  niiniilcs.  llic  n|>|ii'i'  part 

;ir|iir    wilh    line   drliris.    uhiM    liic    Iiimx  irr    |p:ii  I  icics.    iiicliniin^;   the   (i\a   of 


520 


PARASITES.     INTESTINAL 


i 

i 


Fig. 


'<. —  Oviiiu    0 
lumbriiokh's 
flligli    power.)     (Vi 


parasites,  have  sunk  to  the  bottom  ;  tlie  suijernatant  opalescent  or  opaque  fluid  may  now  be  poured 
off,  and  the  more  definite  residue  again  shaken  up  with  normal  saline  and  allowed  to  stand  for 
Mnotlitr  twenty  minutes  ;  this  process  is  repeated  initil  the  sujicrnatant  lluid  becomes  clear  after 
it  has  stood  for  the  twenty  minutes,  and  then,  when  as  much  of  the  fluid  as 
possible  has  been  poured  away,  a  dro]i  of  the  sediment  is  taken  U])  in  a  pipette, 
transferred  to  a  microscope  slide,  covered,  the  excess  of  fluid  removed  with 
filter  i)a])cr.  and  the  sjiccimen  examined  either  with  the  |  in.  or  J  in.  objective, 
preferal)ly  with  tlic  nicchanical  stage.  Such  a  specimen  exhibits  all  sorts  of 
vegetable  cells,  keratin  ])articlcs.  and  so  forth,  which  may  at  first  be  regarded 
as  ova,  but  when  the  actual  ovum  of  an  intestinal  ])arasite  is  seen,  there  is 
Fiq  211'.  — nwim  of       seldom  anv  doubt  almut  it. 

r.nn.i     <  limn,     sonil- 

iiV,«!  I    '    (  I'lo'm  Round-ioorms. — The  only  round-worm  that  occurs  in  Great  Britain 

'"'"''  i;"'/!,"/'i  '"  '*  *'^^  Ascnris  lumbricoides.  This  parasite  may  or  may  not  give  rise  to 
symptoms  ;  if  it  does  so,  they  take  the  form  of  slight  and  obscure 
nervous  and  gastro-intestinal  disorders.  More  often  the  diagnosis  is  quite  unsuspected 
>mtil  one  of  the  worms  is  found  in  the  bed.  having  crawled  out  jier  anum,  especially  when 
the  patient,  generally  a  child,  falls  ill  of  some  febrile  malady.  If  round-worms  have  been 
found  previously,  and  if  the  existence  of  others  is  suspected,  the 
diagnosis  may  be  confirmed  by  discovering  the  typical  ova  (Fig.  JIT) 
in  ,  the  fieces  :  their  chief  characters  are  their  relatively  large  size, 
oval  shape,  and  irregular  membranous  envelope  outside  the  chitinous 
shell.  This  worm  does  not  produce  eosinophilia  as  a  rule,  but  in 
exceptional  cases  it  may  do  so. 

ThiriKt-iViirttis. — Oxiiiiiis    ivrmiculnris,    if   present   at   all,   usually 
occurs  in  lumdreds.  and  can  be  detected  immediately  by  examination 

of  the  fa'(?es  witli  the 
naked  eye.  Each  |)ara- 
site  is  rather  more  than 
]  in.  in  length,  without 
any  colour;  its  extremi- 
ties project  from  the 
ficcal    mass,    and    move 

about  .slowly,  like  threads  waving  in  the  air. 
Tliese  parasites  produce  no  cDsinopliilia.  The 
patients  are  nearly  always  children,  and  there 
may  be  no  symptoms  at  all  ;  but  more  often 
there  is  considerable  irritation  around  the 
anus,  and  in  young  girls  about  the  vulva, 
(.imorrhcea  has  before  now  been  suspected 
when  the  vulvar  infection  was  really  due  to 
I  he  Oxi/iiris  vcrmiciiUiiis. 

The  Wltip-ivoim  (Triclioceplinlus  dispar) 
1^  in  itself  an  entirely  unimportant  parasite 
.Hcurring  in  the  cfecum  and  large  intestine 
(Fig.  218).  and  producing  no  symptoms  what- 
ever. The  worm  with  its  tail  is  al)i)ut  H  in. 
in  length,  and  it  is  often  coiled  up  watch- 
spring-wise.  Its  appearances  are  unmistak- 
able ;  its  ovum  (Fig.  219)  looks  more  or  less 
like  a  running-cork,  and,  with  its  deei)  brown 
central  parts  and  clear  ends,  it  is  (piite 
characteristic.  Whip-worms  are  ])resent  to 
the  extent  of  nearly  10  per  cent  of  all  the 
inhabitants  of  some  cities.  They  produce  no 
eosinophilia,  blood-changes,  or  .symptoms. 

The  Hook-'d.wm   (Ankiihsiomum    duoden- 
nle)  (Fig.  220). — This  is  not  a  general  para.site 
in     Great    Britain,    but     has    ailected    many 
persons   in  certain   districts  as  the  result  of 
niroduction  from  abroad,  i)artieularly  amongst  lead-miners  in  Cornwall.     t)utl)rcaks  also 


\ 


and   ascending   colon.      i./ 
Museum,  Oui/'s  Hospital.) 


/.■plia/ti!<Llispar)  in  tlie  c 


PERISTALSIS.     VISIBLE 


521 


^"17.  2la.— Ovum  of  Tri- 
choceiihalus  dispar,  (Hi^h 
power.)  CFi'^ni  French's 
Mi-dkal  Labnralonj  Mer- 
liads.) 


occurred  in  the  workers  in  the  St.  Gothard  tunnel,  and  the  disease  is  prevalent  in  many 
parts  abroad,  especially  in  India,  Egypt,  Brazil,  and  Jamaica.  The  infection  is  carried 
from  feces  to  soil,  from  the  soil  to  the  hands,  thence  to  the  mouth, 
and  so  to  the  alimentary  canal.  The  symptoms  are  for  the  most  part 
those  of  progressive  anoemia  and  asthenia,  inability  to  continue  with 
work,  cedema  of  the  lower  extremities,  anasarca,  shortness  of  breatli. 
and  the  occurrence  of  boil-like  skin  eruptions,  described  popularly  as 
the  '  flowers '  of  the  disease.  The  appearance  of  the  patient  may 
suggest  pernicious  aniemia,  and  the  blood-count  may  sometimes 
seem  to  confirm  this  diagnosis  at  first  ;  for  whereas  a  great  many  of 
the  patients  have  a  severe  chlorotic  type  of  ansemia,  some  have  a 
marked  reduction  of  the  red  corpuscles  and  a  slightly  less  reduction  of 

the  h:em(>gl()l)in,  so  that  there  is  a  high  colour-index  such  as  is  characteristic  of  per- 
nicious ana>mia.  There  is  generally  no  leucocj'tosis.  but  the  differential  leucocyte-count 
may  suggest  the  diagnosis  at  once,  for  nearly  all  the  patients 
present  a  considerable  degree  of  eosinophilia.  The  adminis- 
tration of  anthelmintics  such  as  thymol  may  lead  to  the 
evacuation  of  the  mature  worms,  which  may  be  recognized  in 
the  faeces  {Fig.  27,  p.  79),  each  being  from  i  to  §  in.  in  length. 
The  ova  (Figs.  "28  and  2!),  p.  80)  are  oval,  with  a  clear  transpar- 
ent shell  and  coiled-up  embryo  parasite.  Melaena  is  another 
symi)tom  which  may  be  prominent  in  some  of  these  cases. 

The  two  intestinal  parasitic  affections  which  produce  the 
most  serious  anaemias  and  otlier  toxic  effects  in  man  are  Ankij- 
loslomutn  duodeiiale  and  Boifirioceplialus  latus.      Herbert  French. 

PARESIS.— (See  Paralysis,  p.  -191,  et  seq.) 

PENIS,    DISCHARGE     FROM.     (See   DistnAiujE,  Uiu;- 

lllltAI..    p.  181.1 

PERISTALSIS,  VISIBLE.  'Pbe  inii)ortance  of  visible 
peristalsis  lies  in  tlic  fact  that  it  is  always  pathological 
cxeejjt  in  a  few  cases  in  which  its  unimportant  nature  is 
immediately  obvious.  The  two  chief  conditions  which  render 
liie  normal  movements  of  the  bowels  visible  are  divitrication 
III'  llic  iiliiloniiiiol  recti  nniscloi.  and  ventrnl  licniintion  of  a 
laparotomy  sear.  The  latter  is  obvious  at  once  :  the  former 
is  best  detected  wheti  the  recumbent  patient,  who  is  generally 
a  nuiltiparous  woman  with  a  soft  flabby  abdomen,  tries  to 
raise  her  head  and  thorax  from  the  couch  without  the  use  of 
her  arms  :  the  contracting  recti  come  together  then,  and  close 
over  the  gap  in  the  middle  line  in  which,  under  the  stretched 
and  unsupported  skin,  the  bowel  movements  had  been  seen. 
In  almost  all  other  circinnstaiiees  \isibN'  peristalsis  is  patho- 
logical :  it  ina\  llien  br  clivided  into  tun  types  gastric,  and 
intestinal.  » 
l"«"<J/'iri';;,','I.' '/',',  Gastric  Peristalsis   lakes    the    form    of   a    comparatively 

.  uui/s  llo»iiiiai.)  large  swellini;  in  the  up|)er  part  of  the  abdomen,  coming  and 
going,  generally  appearing  from  under  the  region  of  the  left 
ribs,  ])rogressing  slowly  <lownwards  and  to  the  right,  where  it  fades  away  and  disappears  ; 
t  corresponds  more  or  less  with  the  greater  curvature  of  the  stomach.  It  is  often  stated 
that  :i  return  wave,  passing  along  the  lesser  curvature  from  right  to  left,  can  also  be  made 
)Ut,  but  this  is  exc<'ptional.  .Sometimes,  instead  of  progressiu'j,  it  comes  and  goes  almost 
n  the  same  spot,  varying  in  shape  but  scarcely  in  position.  The  exact  site  of  the  wave 
nust  depend  mainly  upon  the  size  and  [Misition  of  the  stomach.  It  indicates  jx/loric  or 
luoriciifil  i)l)nlnictitiii.  and  its  presence  serves  to  exclude  atonic  gast  reetasis.  There  may  or 
nay   not    be   otlier   si;;ns  of  ililalcd    slimiarli.    part  ieularl>-   a    \vid(l>    disi  riliuted    sMccussinii 


-rl'l  PERISTALSIS.     VISIBLE 

splash,  vomiting  of  large  volumes  of  fermenting  fluid  at  relatively  long  intervals,  and  a 
greatly  increased  bismuth  .r-ray  shadow.  Whetlier  the  pyloric  stenosis  is  simple  or  malig- 
nant has  to  be  decided  ujion  other  grounds. 

Visible  Intestinal  Peristalsis  is,  with  the  limitations  discussed  above,  one  of  the 
surest  signs  of  grave  intestinal  obstruction.  There  are  almost  certain  to  be  abdominal 
distention,  vomiting,  and  constipation  along  with  it,  and  the  discussion  of  the  differential 
diagnosis  of  the  different  causes  of  these  symptoms  will  be  found  elsewhere.  The  great 
importance  of  visible  peristalsis  is  seen  in  those  doubtful  or  obscure  cases  in  which  the 
patient  seems  hardly  ill  enough  to  be  suffering  from  intestinal  obstruction.  It  may  be 
thought  that  colic,  the  result  of  some  indigestible  article  of  diet,  is  a  more  likely  diagnosis, 
and  that  a  dose  of  castor  oil  will  cure  the  malady.  Rather  than  wait  for  increasing 
severity  of  the  symptoms  to  clinch  the  diagnosis  in  these  cases,  it  is  most  important  to 
arrive  at  a  diagnosis  of  the  necessity  for  laparotomy  at  the  earliest  possible  moment  if  life 
is  to  be  saved.  If  the  small  intestine  alone  is  involved,  the  waves  are  multiple,  and  they 
run  more  or  less  transversely  across  the  abdomen — the  ladder-rung  type  :  when  the  colon 
is  obstructed,  vertical  waves,  especially  in  one  or  both  flanks,  are  the  chief  form  the  peri- 
stalsis takes.  Definite  and  visible  intestinal  peristalsis  is.  so  far  as  any  single  sign  can  be 
relied  on,  an  almost  infallible  indication  of  the  need  for  laparotomy  in  any  case  in  which 
the  other  symjitoms  and  the  history  jjoint  to  a  [jossibility  of  intestinal  obstruction. 

Herberl  French, 

PERSPIRATION,  ABNORMALITIES  OF.     (See  Sweating,  p.  6.54.) 

PHOSPHATURIA. — This  is  a  term  the  precise  significance  of  which  is  by  no  means 
clear  ;  the  meaning  it  conveys  to  one  observer  is  not  always  that  which  it  implies  to 
another.  Some  restrict  it  to  conditions  in  which  the  total  quantity  of  phosphates  in  each 
day"s  urine  is  greater  than  the  average  maximum.  Others  use  the  term  when  there  is  a 
spontaneous  deposit  of  phosphates  in  the  specimen  glass.  Others  would  include  cases  in 
which,  on  applying  the  boiling-test  for  albumin,  a  cloud  of  phosphates  comes  down.  So 
loose  is  the  application  of  the  word  ])hos|)haturia  that  it  is  generally  used  whenever  anything 
arises  to  remind  the  observer  ocularly  of  the  fact  that  the  urine  contains  any  phosphates 
at  all. 

What  is  really  required  is  a  series  of  different  terms  to  express  the  following  conditions  : — 

1.  Circumstances  in  which  a  greater  quantity  of  phosphates  is  habitually  passed 
in  the  urine  than  is  the  average  maximum  in  health. 

2.  The  spontaneous  deposition  of  phosphates  in  a  urine  that  has  stood  in  a  specimen 
glass  until  cold. 

3.  The  spontaneous  deposition  of  phosphates  in  the  bladder,  so  that  the  urine  is  thick 
and  milk-like  when  it  is  being  passed. 

■l.  The  deposition  of  |)hosphates  as  a  white  cloud  when  the  urine  is  heated. 
Absolute  Phosphaturia. — The  phosphoric  acid  in  the  urine  is  chiefly  exogenous,  i,e,, 
derived  from  ])hosphates  in  the  food.  It  is  chiefly  in  inorganic  combination  as  salts  of  the 
alkalies  and  alkaline  earths.  There  is  a  certain  small  percentage  of  urinary  phosphorus 
derived  from  the  katabolism  of  nuclein  and  lecithin,  but  the  amount  derived  from 
these  in  healthy  persons  is  very  slight  as  compared  with  that  which  comes  direct  from  the 
food,  so  that  the  phosphates  almost  disappear  from  the  urine  during  starvation.  There 
are  wide  variations  in  the  amounts  excreted  by  normal  persons  ;  the  average  is  3-5  grams 
per  diem,  but  the  healthy  limits  are  as  far  apart  as  1  gram  and  8  grams. 

It  has  been  asserted  that  persons  whose  business  entails  great  wear  and  tear  of  the 
nervous  system  excrete  more  than  the  average  amount  of  phosphates,  and  the  same  has 
generally  been  held  to  be  true  of  sufferers  from  certain  nervous  disorders  of  the  hysterical 
or  neurasthenic  type,  particularly  when  sexual  matters  are  in  question.  There  is  very 
little  evidence,  however,  to  show  that  there  is  any  real  increase  in  the  urinary  phosphates 
in  these  cases.  There  is  often  a  very  abundant  deposit  of  phosphates  on  applying  the  heat 
test  to  the  urine,  and  this  may  give  the  impression  that  the  total  quantity  of  phosphates 
present  must  be  above  the  normal  ;  but  the  impression  has  not  been  confirmed  by  exact 
analysis.  There  is  only  one  well-defined  condition  in  which  there  is  absolutely  and  persist- 
ently more  phosphate  in  the  urine  than  healthy  limits  would  allow,  and  that  is  pliospliaUc 
(lidbeies — a  very  rare  condition,  of  which  the  main  features  are  thirst,  emaciation,  aching^ 


PHOSPHATURIA  5-23 

in  the  loins  and  back,  and  polyuria  without  sugar  but  witli  an  absolute  excess  of  phos- 
phates in  the  urine. 

Physiology  of  Phosphatic  Deposits. — In  nearly  every  ease  the  deposition  of  phos- 
pliates  is  a  |>urily  ])liysi(iliiiiical  prueess.  A  molecule  of  phosphoric  acid.  HjPO^,  contains 
three  hydrogen  atoms.  Each  of  these  can  be  replaced  separately  by  an  atom  of  any  mono- 
bai-ie  metal,  such  as  sodium.  Three  types  of  salts  are  formed,  according  as  one,  two,  or 
three  of  the  hydrogen  atoms  have  been  replaced,  as  in  the  following  examples  : — 

NaHjPOj^       -  -       Sodium    dihydric    phosphate 

Na,,HPO^       -  -       Sodium  nionohydric  phospliate 

Na^POj^  -  -        Sodium  phosphate 

These  .salts  may  all  be  present  in  the  same  urine,  the  proportions  of  each  varying  with 
the  amount  of  phosphoric  acid  present,  on  the  one  hand,  and  the  total  amount  of  bases 
(i.e.,  sodium,  potassium,  etc.).  and  the  total  quantities  of  other  acids  ])resent  in  the  form 
of  chlorides,  sulphates,  and  so  forth,  on  the  other.  The  greater  the  quantity  of  chlorides 
and  sulphates,  the  greater  will  be  the  amoimt  of  the  metallic  bases  required  to  form  them, 
and  consequently  the  less  will  be  the  amount  of  bases  left  to  combine  with  phosphoric 
acid  ;  the  result  must  then  be  a  relative  excess  of  NaH^PO^.  Conversely,  the  scantier 
the  chlorides  and  suljjhates,  and  the  more  abundant  the  bases,  the  greater  will  be  the  pro- 
portion of  Xa.iIIFOj  and  NagPOj. 

Now  the  three  sodium  salts  differ  from  one  another  in  at  least  two  physical  respects — 
their  action  ujjon  litmus,  and  their  solubility  in  water.  Sodium  dihydrogen  phosphate 
(XaHjPOj)  turns  blue  litmus  red — in  other  words,  it  is  an  acid  phosphate.  The  acidity 
of  ordinary  urine  is  mainly  due  to  it.  Sodium  monohydrogen  phosphate  (XaoHPOj)  is 
also  an  acid  salt  technically  speaking,  and  there  are  some  colour  tests  which  exhibit  the 
acid  reaction  with  it  :  litmus,  however,  is  not  one  of  these,  for  Xa.,HP()^  turns  red  litmus 
blue.  When  a  given  urine  contains  more  Xa.jHPOj  than  XalljPO^,  the  reaction  of  that 
urine  to  litnuis  is  alkaline  ;  that  is  to  say,  it  turns  red  litmus  blue  and  does  not  turn  blue 
litmus  red.  Some  urines  have  what  is  known  as  an  amphoteric  reaction — they  turn  red 
litmus  bluish  and  blue  litnnis  reddish — a  diflerent  thing  from  neutrality  of  reaction,  in 
which  neither  red  litmus  nor  blue  is  turned  in  colour  at  all.  The  cause  of  the  amphoteric 
reaction  of  a  urine  is  the  even  balance  in  that  urine  of  the  Xa2HPO^  on  the  one  hand  and 
of  the  XaII.,POj  on  the  other. 

Xow  the  dihydrogen  ])hos])hate  is  nuieh  more  soluble  in  water  than  is  the  mono- 
hydrogen  phosphate,  whilst  the  tribasic  phosphates  are  as  a  rule  far  less  soluble  still. 
AVhen  it  is  stated,  therefore,  that  phosphates  are  more  soluble  in  acids  than  they  are  in 
alkalies,  it  must  be  remembered  that  it  is  not  a  (juestion  of  a  difference  of  solubilities  of  the 
same  salt  of  phosphoric  acid,  but  of  an  acid  urine  containing  the  bulk  of  its  phosphates  in  a 
salt  (lijjcroit  from  the  one  present  in  an  alkaline  urine.  The  very  fact  of  a  urine  being 
alkaline  means  that  there  is  relatively  little  of  the  more  soluble  Xall.,POj  present,  and  rela- 
tively nmeli  of  the  less  soluble  .XaollPOj  and  XajPO,.  ('on\crsely.  the  fact  that  a  urine 
is  acid  implies  that  the  phosphates  arc  relatively  more  abundant  in  the  soluble  XalLPO^ 
form  than  they  are  either  as  XajHPO^  or  Xa.jP(),.  As  a  matter  of  fact,  the  three  degrees 
of  phosphates  of  sodium,  potassium,  and  arTunonium  are  all  so  soluble  that  they  practically 
never  become  precipilaled  spontaneously,  nor  do  tliiy  take  part  in  rormiiig  calculi.  It 
is  the  |)hosphatcs  of  calcium  and  magn<sium  that  form  precipitates,  but  what  has  been 
said  above  of  sodium  phosphate  applies  e(pially  to  calcium  and  magnesium  phosphates. 
The  less  acid  a  urine  is,  the  more  wifl  the  less  soluble  varieties  of  calcium  and  magnesium 
phosphate  preponderate,  and  it  is  on  this  account  that  phosjihalcs  {ome  down  in  alkaline 
or  neutral  rather  than  in  acid  urines. 

.\gain,  it  is  often  stated  that  phosphates  are  less  soluble  in  hot  mine  than  tlu\  are  in 
cold,  and  this  is  given  its  the  reason  for  the  cloud  of  precipitated  phosphiitcs  that  so  oftctj 
liiniis  when  a  urine  that  is  not  already  very  acid  is  boiled.  This,  however,  does  not  express 
the  real  rcasim  lor  the  cloud  :  I  he  heat  iliics  not  pri'cipilate  llie  same  phospliate  as  the  <'old 
urine  contaiiic.l.  hut  leads  lo  the  lorniali(iii  i.l'  a  diHir<iil.  and  less  soluble,  phosphate. 
The  ealciiun  iiioiiciliydiiigcii  phosphate  dissdciales  into  <-al(iiini  dihydrogen  phosphate  .and 
lionnal  ralcluni  phiisphale  :    il    is  liie  latlcr  wliieh  is  si>  iusoluhir  that  it  comes  diiwn  : 

KaliPO,  ----  Ca.,(P(J.,),,  I  tn(ll.,PO,),, 

MirliuMi  !<oliil.l.ily.  nclntivclv'inHoliilile,  nnci  m  Ili'lalivcl.v  the  iixjst 

coitiin;;'(luwii  nsa  cluiid.  solulik- o(  ttie  ttirei-. 


;->24 


PHOSl'HATURIA 


Milky  Urine. — The  urine  of  many  healthy  people,  especially  children,  and  eaters  of 
large  public  dinners,  is  sometimes  milk-like  when  it  is  passed  soon  after  a  full  meal.  Many 
a  person  has  become  alarmed  at  the  sight,  ami  has  iVared  some  grave  disorder  of  the  sexual 
organs  or  functions,  especially  either  gonurrhaa  or  s])ermatorrha?a.  The  condition  is 
])hysiological.  It  results  from  increased  quantities  of  hydrochloric  acid  being  required  in 
the  stomach  at  the  time.  The  result  of  this  is  that  the  urine  temporarily  contains  such  an 
abundance  of  bases  in  proportion  to  acids  that  the  less  soluble  monohydrogen  phosphates 
exceed  the  more  soluble  dihydrogen  ])hosi3hates,  and  they  may  become  precipitated  even 
in  the  urine  that  is  still  within  the  bladder.  The  commonest  salt  to  come  down  is  calcium 
monohydrogen  phosphate,  CallPO,.  which  is  either  amori)hoiis.  or  else  assumes  the  form 
familiar  as  "  stellar  phosphate."  MgllPO^  may  come  down  with  it  in  the  form  of  amor- 
l)lious  particles,  or  as  needles. 

The  alternation  between  oxnluria  and  phospluituria  exhil)itcd  by  some  individuals  is 
discussed  on  ]).  424. 

Ammonio-magnesiuin  Phosphate.  Tliis,  gcmralh  known  as  triple  phosphate, 
MgNIIjl'O,,  is  comparatively  insoluble,  and  when  preeiijitated  it  nearly  always  assumes 
the  form  of  prisms — the  familiar  "  knife-rester  '  or  "  cofHn-lid  '  crystals  (Fig.  221).  It 
IS  clear  that  these  will  come  down  only  when  the  urine  contains  ammonia.  The  latter  may 
of  coiu'se  have  been  produced  by  ammoniacal  decomposition  of  urea  after  the  urine  was 
])assed.  If  urinary  decomposition  after  passage  can  be 
excluded,  however,  it  is  usually  stated  that  the  presence 
of  anunonio-magnesic  jihosphate  crystals  indicates  a  puru- 
lent lesion  in  the  urinary  tracts,  especially  in  the  bladder. 
It  is  quite  true  that  ammoniacal  urines  from  cases  of 
cystitis  often  abound  in  crystals  of  triple  phosphate.  The 
diagnosis  is  given  by  the  pus  cells  and  so  forth,  however, 
and  not  by  the  tri])le  phos|)hate  crystals.  It  is  ini])ortant 
to  remember,  moreover,  that  each  day's  urine  normally 
(■(intains  enough  ammonia  for  amnionio-magnesic  phos- 
phate crystals  to  occur  in  an  absolutely  healthy  urine, 
even  apart  from  decomposition  on  standing.  This  fact 
detracts  very  greatly  from  the  value  formerly  attributed 
to  the  detection  of  triple  ])hosphate  crystals  in  the  urine. 
Indeed,  the  importance  of  phosphates  in  the  urine  lies 
almost  entirely  in  the  fact  that  errors  of  interpretation  may  arise  unless  their  physi- 
ological behaviour  is  clearly  understood.  Microscopically  they  are  often  amorphous, 
but  the  three  well-defined  forms  of  crystals  shown  in  Fig.  221  may  be  recognized  micro- 
seopically.  The  chief  chemical  test  is  the  addition  of  dilute  acetic  acid,  which  causes  a 
precipitate  of  phosphates  to  clear  up.  The  main  importance  of  recognizing  them  correctly 
is  to  avoid  mistaking  phosphates  for  pus  in  the  ease  of  a  spontaneous  deposit,  for  sper- 
matozoa, or  gonorrhoea,  when  the  urine  comes  milky  from  the  urethra,  and  for  albumin  in 
the  case  of  the  boiling-test  for  the  latter.  Herbert  French 


USl.— Triple  phosiihr 


PHOTOPHOBIA, 

namelv  ; 


)r  intolerance  of  light,  may  be  due  to  three  main  groups  of  causes, 


] .  Causes  in  the  Eye  itself : 


Foreign  body 

Injury 

t'onjunctivitis 

Oplithalmia 

Keratitis 

I'lccnitionottlK 


Iritis 

C'vclitis 

Glaucoma 

Hctinitis 

Hctiol«ilbar  neurit i: 


Eye-strain  from  close  work  in 
those  suffering  from  uncor- 
rected errors  of  refraction, 
especially  astigmatism  and 
hypermetropia. 


2.  Certain  Occupations 

IiiV(]|viriLi  work 


llviri;^ 


iffett  furnace  stokers,  electric 
■x|>(>sccl  til  the  da/.zle  of  snow 


aider  eye-straining   conditions,  sue! 

iirkers  in  strong  sunliglit.  those  wlio 
in  sIiohl;  suiisliine,  those  who  come  out  into  stniiiu  daylii;lit  alter  ])n)longed   work   in 
the  dark,   as  in   coal  pits  :    those  who  work   nuicli   with  ,i-rays.     Some   persons   are 
unable  to  stand  any  strong  liylit.  whether  of  the  sun.  i;as,  or  electric. 


PHOTOPHOBIA 


3.  Causes  not  primarily  in  the  Eye  itself : — 

(a).  Some  fevers,  espccialli/  ; — 

Jleasles  |       IiiMueiiza 

(b).  Inlracrauinl  lesions  : — 
Tuberculous     uicuiii 

gitis 
Suppurative     nienin 


"itis 


Epidemic  ccrebros]iinal  uien- 

iuyitis 
Acute  encephalitis 


(c).  After  the  (tdmiiiistrnlinn  nf  some  drugs  : — 
Arsenic  |       Potassium  ioflide 

(d).  Finielioiiiil  roiidilioiis  : — 

Migraine  Ti:-    lioulnureux  |    Hysteria 


Typhus. 


Syphilitic  pachymeningitis 
Cerebral   tumour. 


Potassium  broniliie 


I    Sick  hcaiiache. 


(f).  Siipra-orbilal  lierpcs  zoster, 
if).  Severe  (iiiivinin  (see  An.i;:\ii\.  ]>.  -JO). 
(.«).  Seeondarfi  to  di/spepsia  or  euiistipation. 
(h).  Malingering. 

Some  idea  of  the  cause  will  generally  present  itself  as  soon  as  the  patient  elves  an 
accoiuit  of  how  the  trouble  Ijegan  and  how  it  has  progressed.  By  itself  pliotophohia  is 
seldom  a  symptom  of  diagnostic  significance,  and  nearly  always  tliere  will  he  other  sym- 
ptoms to  assist  one.  The  eyes  should  he  examined  carefully  in  the  first  place,  to  find  or 
exclude  a  local  cause,  especially  glaucoma,  which  is  the  most  serious  of  the  local  lesions  ; 
it  is  associated  in  acute  cases  not  only  with  .severe  j)hotophobia,  but  also  with  acute  pain 
m  the  eye  (see  Eyk.  Acvti^.  Ixfl.vmm.vtiox  ok.  p.  *231).  Retinal  changes  will  be 
discovere<i  by  ophthalmoscopic  examination  (see  Ophth.vl.mgscopic  Appe.\r.\nces,  p. 
H.".).  lietrotmlbar  neuritis  may  not  cause  any  \isible  changes  in  the  optic  disc,  at  any 
rate  not  until  several  days  have  elapsed,  by  which  time  optic  neuritis  may  be' visible'; 
but  it  ma>-  lie  suggested  by  the  rajjid  on.set  of  impaired  vision  without  increased  intra- 
oeiilar  tension  as  in  glaucoma,  going  on  perhaps  to  temporary  complete  blindness, 
(p.  TOO). 

ICi/e-strain  from  errors  of  refraction  requires  special  ophthalmic  knowledge  for  its 
exact  determination,  though  it  may  be  suggested  by  the  circumstances  of  the  case. 

Oeriipalion  pimtopliobin  will  be  likely  if  the  patient  works  under  peculiar  conditions 
of  light,  though  it  will  be  necessary  to  exclude  organic  lesions  in  the  eyes  by  a  thorough 
opiilbalmie  exaniinaf ion.  When  local  eye  conditions  have  been  excluded  definitely,  the 
cause  of  pliolopliohia  will  gviu^rally  be  either  [m'tty  clear  at  once  or  soon,  or  else  oi)en  to  .so 
nuich  doubt  that  Ihc  actual  cause  may  be  one  of  conjecture  only. 

It  will  not  be  Ihc  photophobia,  but  other  symptoms,  sucii  as  the  rash,  the  fever  and 
the  course  of  the  .liscase.  which  will  give  the  diagnosis  in  cases  of  wcsles.  in/lneni,,, 
or  ti/p/iKs  fever:  headache,  vomiting.  oi)tie  neuritis,  and  the  results  of  lumbar  punelure 
or  the  ^\•assermann  test  in  the  case  of  meningitis,  eneepluililis.  eerehrnl  tunionr  «r  si/phililic 
paehipneniniglis;  km)wledge  of  the  drug  given  and  cessation  of  the  i)hol,, phobia  when  it 
is  stopped   in  the  case  of  orsenie,  potiissiinn  iotlide  or  lironiide.  or  :piinine. 

Migraine  an.l  lie  donlonreii.r  ar<'  so  eharaclcrisl  ie  in  their  attacks  that  thcv  are  both 
diagnosable  as  a   rule  fn„n   the  palieufs  sl,,r\   :    photophobia  may  be  severe  in  cither,  or 

even  extreme  ui  lie  di.iil -euN.  in  wimb.  dnriuH  Ihc  excruciating  |)aroxvsms  offacial  pain, 

the  patient  will  (,11.  r.  desire  to  remain  for  days  in  an  abs„l,ilely  .larkened  room  :    exposun^ 
to  any  light  may  l)ring  on  a  paroxysm. 

Snpra-orbiial  herpes  is  generally  obvious  from  the  eruption  of  groups  of  vesicles  on  a 
reddened  ba^-c  aloni;  lli<-  c.iiirse  of  one  supra-orbital  nerve;  and  the  pholophobia  is 
geiwrally  nnilalcral  :  il  may  jjcrsist  however  for  weeks  or  months  after  (he  crupli.ui  has 
subsided.  an<l  I  hen  its  (uigin  may  be  ovcrlo(,kcd. 

Malingering  can  be  diagnosed  only  l,y  catching  the  patient  unawares  and  diseoM^ring 
that  when  he  is  not  watched  he  is  able  to  read  in  an  .irdinary  ligbl  notwithstanding  I  lie 
photophobia  he  c.unplains  of.  I),,spepsia.  eonslipalion.  an.l  severe  anirmia  arc  sonu'what 
problematical  as  causes  ,,f  pli.,to|.hol>ia.  but  mi-lit  be  rcL'ar.l.'.l  as  its  origin  in  a  patient 
iwho,  suffering  fr.im  .inv  of  th.-  Ih 


ds.i  had  phot.ipbobia  withoul 


a   p; 
.liscoN  crab 


526  PHOTOPHOBIA 

cause,  especially  if  the  photophobia  disappears  wlien  tlie  [jatient  is  cured  of  the  constipa- 
tion, the  dyspepsia,  or  the  ansemia,  respectively. 

Sick  headacJie  is  a  periodic  malady  of  many  women  and  some  men.  Headache  of 
great  severity  is  the  chief  sym])tom,  lasting  a  whole  day  or  even  longer  :  gastric  functions 
are  in  abeyance  during  the  attack,  so  that  food  in  the  stomach  remains  undigested  and 
medicines  unabsorbed  ;  the  patient  may  feel  ill  enough  to  have  to  stay  in  bed  ;  towards 
the  end  of  the  attack  vomiting  occurs  once  or  several  times,  and  l)y  the  next  day  the 
patient  feels  perfectly  well  again.  Dislike  of  any  but  a  dim  light  is  common  during  the 
attack.  The  diagnosis  is  generally  based  upon  the  patienfs  familiarity  with  similar 
symptoms  on  many  previous  occasions.  The  malady  is  often  hereditary  ;  possibly  it  is 
related  to  migraine. 

liiliousness  is  a  very  common  ailment,  due  to  many  different  causes,  especially 
mjudicious  eating  or  drinking,  or  to  deficient  fresh  air  or  exercise.  Some  cases  of  recurrent 
biliousness  are  closely  allied  to  sick  headache  and  to  migraine.  During  an  attack  the 
tongue  is  coated  and  the  bowels  inactive.  The  precise  pathology  of  the  condition  is  little 
understood,  but  the  diagnosis  is  not  difficult  although  it  is  important  to  make  a  routine 
examination  to  exclude  more  serious  lesions.  Photophobia,  though  common  in  a  minor 
degree  in  bilious  attacks,  is  seldom  very  marked. 

Ili/sterhiil  photophobia  is  met  with  only  occasionally,  but  when  it  occurs  it  may  be 
extreme  ;  that  is  to  say,  the  patient  may  mimic — not  intentionally,  as  in  the  case  of  a 
malingerer,  but  without  at  all  wishing  to  do  so — so  extreme  a  degree  of  intolerance  to  light 
that  she  may  cover  her  eyes  with  deep-tinted  glasses,  or  even  cover  her  whole  head  with 
an  impervious  dark  robe  :  and  may  perhaps  require  to  be  led  about  when  she  walks,  like 
a  person  totally  blind.  It  is  this  over-doing  of  the  ])art  that  may  give  the  clue  to  the 
diagnosis.  Naturally  a  thorough  examination,  particularly  of  the  eyes,  will  be  required 
to  exclude  organic  disease,  but  if  functional  photophobia  appears  to  be  the  diagnosis  in 
a  particular  case,  the  suspicion  may  be  confirmed  by  the  way  the  symptom  can  be  made 
to  disapjiear  by  sufficiently  bold  suggestion.  Herbert  Freiieli. 

PIGMENTATION  IN  THE  MOUTH  generally  consists  of  flecks,  streaks.or  spots  of 
pale  brown  or  jialc  sepia  discoloration  of  tlie  mucosa,  especially  upon  the  inner  aspect  of 
tlie  cheeks  along  a  line  roughly  corresponding  to  the  level  of  the  closed  teeth  ;  with  or 
without  similar  pigment  spots,  streaks,  or  patches  upon  the  mucous  surface  of  the  lips, 
seen  best  when  the  latter  are  everted  in  a  good  light  ;  U])on  the  roof  of  the  mouth,  generally 
upon  the  soft  palate  or  upon  the  posterior  part  of  the  hard  palate  rather  than  more 
anteriorly  ;  upon  the  gums  occasionally  ;  and  sometimes  upon  the  sides  of  the  tongue 
{Plate  XXI).  Such  pigmentation  of  the  buccal  mucosa  immediately  suggests  Addison's 
disease,  especially  if  there  is  generalized  pigmentation  of  the  skin  at  the  same  time, 
extreme  asthenia,  a  low  blood-pressure,  a  tendency  to  vomiting  or  to  fainting  attacks 
on  any  exertion,  with  inability  to  maintain  any  effort,  mental  or  physical,  t'nfortun- 
ately,  however,  although  such  buccal  pigmentation  is  highly  suggestive  of  Addison's 
disease,  it  is  not  pathognomonic,  for  it  has  been  noted  in  a  variety  of  other  conditions  also. 

Thus,  it  is  an  almost  constant  feature  in  persons  who  have  negro  blood  in  their 
ancestry,  even  though  this  be  from  one  great  grandparent  only.  This  source  of  difficulty 
in  interpretation  is  commoner,  perhaps,  in  Africa,  the  West  Indies  and  America,  than  it  is 
in  Britain,  but  even  here  it  makes  it  uncertain  sometimes  whether  one  is  to  diagnose 
Addison's  disease  or  not. 

Then  in  pernicious  anwviia  buccal  pigmentation  precisely  similar  to  that  of  Addison's 
disease  is  met  with  occasionally  [Plate  XXII,  p.  528),  and  unless  the  blood-count 
is  very  definite  (p.  24)  it  may  be  difficult,  even  up  to  the  time  of  post-mortem  examination, 
to  say  whieli  of  the  two  conditions  the  ))atient  is  suffering  from.  Probably  the  right  course 
to  follow  tlun  would  be  to  treat  the  case  with  salvarsan  and  arsenic,  and  watch  the  effect ; 
pernicious  ana;mia  rallies,  temporarily,  to  these  remedies  much  more  certainly  than 
Addison's  disease  does. 

Arsenic  itself  may  cause  pigmentation,  not  only  of  the  skin,  but  also  within  the  mouth, 
as  was  shown  by  some  of  the  cases  in  the  Manchester  epidemic  of  arsenic  in  beer  poisoning. 
Some  have  su]5posed  that  the  buccal  pigment  in  pernicious  anaemia  is  due  to  the  arsenic 
employed  in  treatment  ;   that  this  is  not  so,  however,  is  shown  by  the  fact  that  some  casei 


1 


PLATE     XXI. 


PIGMENTATION       OF      TONGUE      AND       MOUTH       IN       ADDISON'S       DISEASE 


t 


I'ii-'meiiliition  of  the  tuni-uc  and  buccal  miicosi  ill  Addison's  disease. 


IXIlKX    OF    IIIAflXOSlS— Tn  /«<■/•  ;i.  .I^il 


PIGMEXTATIOX    OF    THE    SKIN 


527 


of  pernicious  an;rmia  exhibit  |)ignieiited  spots  inside  the  month  even  before  any  arsenic 
has  been  given  ;    the  patient  from  wlioin  Plate  XXII  was  taken  was  an  instance  in  point. 

One  has  also  seen  pigmentation  of  the  bueeal  mucosa,  suggesting  Addison's  disease, 
in  chronic  cachectic  cnncliiio».<i  in  which  the  suprarenal  capsules  have  proved  to  be 
healthy  at  autopsy.  In  a  case  of  plitliiiis  recently,  for  example,  so  pigmented  was  the 
mouth  that  it  seemed  reasonable  to  diagnose  that  the  tuberculous  process  was  affecting 
the  suprarenals  as  well  as  the  lungs  ;  yet  after  death  the  siiprarenals  were  normal,  and  one 
can  only  suppose  that  the  buccal  jjigment  resulted  from  the  phthisical  cachexia  which  had 
caused  a  general  tendency  to  pigmentary  degeneration  everywhere.  In  another  case 
Addison's  disease  was  diagnosed  during  life  for  the  same  reason,  but  at  autopsy  a  carci- 
iiunia  of  the  s|jlenic  flexure  of  the  colon  was  found,  with  secondary  deposits  in  the  liver  ; 
there  had  been  asthenia  and  general  cachexia,  and  apparently  it  was  the  latter  which  was 
responsible  for  the  pigment  changes.  In  a  third  case  the  patient  was  both  ana;mic  and 
cachectic,  without  any  other  definite  symjitoms,  and  there  was  extensive  pigmentation 
in  the  mouth.  The  blood-count  showed  extreme  aniemia  with  a  colour  index  that  was 
ap])roximatcly  1.  The  doidjts  during  life  lay  between  .\ddison's  disease  and  pernicious 
aniemia  :  both  suggestions  proved  wrong,  for  at  autopsy  syphilitic  gummata  of  the  liver 
were  found,  together  with  tertiary  syphilitic  amyloid  disease 

Fortunately,  buccal  pigmentation  from  cachectic  states  such  as  phthisis,  cancer,  and 
syphilis  is  rare,  though  the  possibilities 
have  to  be  kept  in  min<l.  In  the  great 
majority  of  cases,  however,  if  pernicious 
aiKcmia,  arsenic,  and  negro  blood  can  be 
excluded,  Addison's  disease  will  be  dia- 
gnosed correctly  if  the  patient  is  clearly 
asthenic  and  ill  without  any  very  definite 
physical  signs,  but  with  marked  ])igmenta- 
tion  within  the  mouth.  IIitIhtI  FicikIi. 

PIGMENTATION    OF    THE    SKIN. 

— .\nomalies  of  the  natural  pigmentation 
of  (he  skin,  on  the  side  either  of  excess  or 
deficiency,  may  be  due  to  irritation  of  the 
abdominal  sympathetic,  and  particularly 
the  .solar  plexus,  leading  to  general  pig- 
mentation, or  to  the  exudation  or  extra- 
vasation of  the  colouring  matter  of  the 
blood.  producing  local  pigmentation. 
Local  pigmentation  may  be  brought  aboul 

by  the  aclicjn  of  irritanls.  may  result  IV 

a  condition  of  hyperainia,  or  mas  be  a 
sequela  of  skin  eruptions.  'I'hc  most 
familiar  errors  of  pigmentation  arc  covered 
by  the  term  chloasma.  This  may  be  either 
ifliopathic  or  symptomatic.  liliopathic 
chloasma  is  usually  caused  by  eounlii- 
irritanls,  such  as  vesicants,  or  some  olhei 
form  of  external  irritalion.  especially 
scratching,  as  in  vagabond's  disease 
phtheiriasis  :  but  in  some  cases  it  is  im- 
jtossiblc  to  trace  the  cause.  Symptomatic 
chloasma  is  a  s(i|uela  or  an  accompanin 
abnormal  conditions  of  the  uterus  or  of 
most  often  met  with  as  chloasma  iitcriiiini 
pregnancy.  Iiul  mIsi,  in  association  uilli 
yellowish-brown  pulihes  are  seen  most  <ii 


■A  II. 


1   U(   till 


1  this  dial 


■rit  of  cidaneoiis  eruptions,  or  is  the  result  of 
illiei'  abdominal  \  isccra,  or  of  cachexia.  It  is 
.  which  may  occur  not  only  in  connection  with 
aii\  liirm  of  uterine  irritation.  The  smooth 
lunonly  on  the  l'<>rehca<l,  but  almost  the  entire 
face  may  be  involved,  and  also  the  trunk  and  limbs.  .Somewhat  similar  irregularities  of  pig- 
mentation occur  in  rlienmatoid  arthritis,  pcriiicioas  aiarmia.  llodglnn's  di.scase.  Graves's  disease 


528 


PKiMEXTATIOX     OF    THE    SKIN 


(Fig.  222),  alidoiiiiiKil  tiihcrciilosis.  coiislipation.  clironic  intestinid  stasis,  and  other  disorders  of 
the  abdominal  viscera,  and  in  cases  in  which  arsenic  lias  been  given  over  long  periods.  In 
Addison's  disease  there  is  a  general  bronzing  of  the  skin,  together  with  pigment  deposits  in 
the  mucous  membranes  of  the  mouth  {Plate  XXI),  anus,  vulva,  and  urethra  :  buccal 
pigment,  however,  does  not  by  itself  prove  that  Addison's  disease  is  present,  for  precisely 
similar  pigmentation  in  the  mouth  is  observed  in  some  cases  of  pernicious  ana?niia  {Plate 
A'.Y7i),  of  phthisis  without  suprarenal  disease,  and  of  malignant  disease  ;  whilst  negro 
blood  in  the  ancestry  often  causes  buccal  pigmentation  in  perfectly  healthy  persons. 

Pigmentary  abnormalities  of  the  skin  occur  also  in  cachexia  associated  with  malaria, 
cancer,  nodular  le])r<isy.  and  secondary  syphilis — in  malaria,  a  yellowish-brown  to  black  : 
in  cancer,  a  sallow  tint  :  in  nodular  leprosy,  a  fawn  colour  early  in  the  disease,  and  a  genera! 
bronzing  at  a  later  stage  ;  in  secondary  syphilis,  an  earthy  tint  affecting  the  face.  In  the 
rare  condition  known  as  ochronosis,  the  skin,  cartilages,  and  sclerotics  are  blackened,  as 


rig.    ^2:;— K> 


TlliiHtio    Icucciiielain-.lc-i 


tlie  result  in  some  cases  of  alkaptonuria,  in  others  of  the  prolonged  absorption  of  carbolic 
acid.  In  hamocliromatosis.  another  rare  condition,  apparently  due  to  diseases  of  the 
alimentary  tract  and  liver,  the  patient  may  be  pigmented  from  head  to  foot,  the  prevailing 
colour  being  a  deep  blue-grey  slate  tint.  The  diagnosis  of  urticaria  pigmentosa  sen  nigri- 
cans is  generally  clear.  Pigmentary  deposits  in  the  skin  form  only  part  of  the  skin  changes 
characteristic  of  Kaposi's  disease.  The  pigmentation  of  bronzed  diabetes  can  scarcely  ba 
misinterpreted  if,  when  the  urine  is  examined,  glyco.suria  be  found  ;  most  cases  of  this  for 
of  diabetes  have  cirrhosis  of  the  liver  as  well,  so  that  there  is  a  non-teetotal  history. 

The  diagnosis  of  the  various  forms  of  chloasma  is  usually  easy,  though  the  particular 
cause  of  the  pigmentation  can  only  be  deduced,  of  course,  from  the  general  symptoms! 


PLATi:     XXII 


PIGMENTATION       OF       MOUTH       IN       PERNICIOUS       AN>EMlA 


rk'moiitaiion  ul  the  mucous  mernliraiif-  of  Ihn  lip«.  c-lieok,  nii'I  |t:il,ii 
I  antcnic  hud  yet  lietMi  jfiveii.  AdilJson's  tiit*oa.se  wns  sitnul^toil,  )n 
nfinne'l  by  HUtopsy. 


ISIU'X  oi-  in\i;N09IS— 7"o  face  p.  .V-'8 


PNEUMATURIA 


r.29 


Chloasma  can  be  differentiated  from  chromidiosis,  by  observing  that  in  the  latter  condition 
the  colour,  which  is  derived  from  the  exuded  secretions,  disappears  if  washed  with  ether 
or  chloroform.  In  tinea  versicolor,  and  sonie  other  fungous  diseases  which  resemble 
chloasma,  the  jiatches  are  not  smooth  but  scaly,  and  the  discoloration  can  be  scraped  off. 
The  pigmentarii  si/philide.  which  may  take  the  form  of  a  diffused  brownish  hue,  brownish 
spots,  or  dai)pled  patches,  is  seldom  met  with  except  on  the  n<'ck,  but  sometimes 
it  may  take  the  form  of  widespread  leucomehinodermia  {Figs.  223  and  224).  Question 
may  arise  between  chloasma  and  leucodcniiiii  (vitih'siD)  when  in  the  latter  condition 
the  white  areas  have  spread  over  the  greater  part  of  the  body,  and  are  taken  for  tlie  normal 
colour  ;  but  in  leucodermia  the  border  of  the  area  is  concave,  whereas  in  chloasma  it  is 
convex.  Moreover,  in  leucodermia  the  history  is  that  of  the  formation  of  white  patches, 
surrounded  by  a  (ligmented  border,  which  may  spread  until  large  areas,  and  even  the  whole 
surface  of  the  body,  are  affected. 

Leucodermia  has  in  its  turn  to  be  distinguished  from  sclerodermia,  morphtt»a,  macular 
leprosy,  pigmentary  syphilide,  and  partial  albinism.  The  skin  is  not  stiff  and  thickened 
as  it  is  in  .sclerodermia.  The  edges  are  not 
streaked  with  small  dilated  vessels,  making  a 
pink  or  violet  border,  as  in  niorpliaea,  nor  is 
there  any  intermingling  of  atrophic  stria>.  The 
patches  are  not  destitute  of  sensation  as  in 
nerve-leprosy,  nor,  though  it  lias  been  styled 
'  white  leprosy,"  has  leucodermia  any  other 
resemblance  to  that  affection  save  the  colour 
of  the  patches.  Doubt  as  between  leucodermia 
and  a  congenital  condition  like  partial  alliinisin 
could  only  arise  by  disregarding  the  history. 
Of  albinism  itself,  whether  partial  or  universal, 
nothing  more  need  be  said  here  :  for  though 
it  is  an  abnormality  of  |)igmentation,  its  true 
character  can  ne\er  be  in  <)uestion.  Nor  need 
I  speak  of  jaundice,  for  that  condition  forms  the 
subject  of  a  separate  article. 

Discoloration  of  the  skin  may  be  due  to  the 
prolonged  administration  of  drugs.  Thus  picric 
acid  may  turn  the  skin  and  the  conjunctivic 
yellow,  arsenic  may  cause  a  ])eculiar  greyish, 
brownish  or  freckle-like  |>igmentatic)n  (/''/;;.  22.'), 
and  I'late  I'//,  p.  64),  nitrate  of  silver  may 
set  up  the  condition  known  as  argi/ria.  in  which 
the  integument  and  the  mucous  membrane,  par- 
ticularly in  situations  exposed  to  light,  take  on  a 
bluish-grey  or  greyish-black  colour,  especially  on 
the  face  and    the   llexf)r  aspects   of  the    limbs. 

This  condition  may  closely  resemble  lia-mochromatosis  and  similar  abnormalities,  but  the 
history  of  protracted  use  of  the  drug  will  mike  the  diagnosis  clear.  Since,  however, 
arsenic  may  be  il(ri\crl  I'roni  smiie  unsuspected  source,  as  was  the  case  in  the  peripheral 
neuritis  ipidiinic  in  and  around  Mafichester  due  to  beer  containing  it  as  an  impurity, 
eheinical  analysis  of  llic  h:iir  should  he  niadc,  for  arsenic  becomes  stored  up  in  the  hair 
that  grows  whilst  lliis  is  being  lakcii.  Mnliulni  .Morris. 


PLANTAR  REFLEX,  EXTENSOR.     (See  Hmunski-s  Sn;N,  p.  (i«.) 
PLEURAL  EFFUSION.     (.See  Cukst.  p.  I(t2.) 


PNEUMATURIA— or  the  passage  of  gas  per  uretlirani.  either  along  with  or  indepen- 
dently of  urine — is  a  rare  .symplom,  but  when  it  does  occiu-  il  is  \cry  striking,  particularly 
in  males. 

It  inav  be  due  to  one  or  other  of  two  eidirely  distinct  groups  of  causes,  namely  : 


530  PNEUMATURIA 

1.  Coninuinication  between  the  rectum,  caecum,  vermiform  appendix,  or  other  part 
of  the  alimentary  canal  and  the  bladder,  ureter,  or  renal  pelvis  ;  either  directly,  or  via  an 
intermediate  gas-containing  abscess  cavity. 

2.  Infection  of  the  bladder  or  other  part  of  the  urinary  tract  by  micro-organisms  that 
produce  gas.  without  there  necessarily  being  any  breach  of  surface  of  the  mucosa. 

When  the  cause  lies  in  the  first  group,  the  patient  is  very  liable  to  pass  facal  material 
at  the  same  time  as  the  gas,  and  the  differential  diagnosis  between  the  various  possible 
lesions  is  discussed  under  F^ces  passed  per  Urethr.^m  (p.  238).  It  should  be  added, 
however,  that  the  passage  of  gas  without  fa-ces  per  urethram  by  no  means  excludes  there 
being  a  fistulous  communication  between  some  part  of  the  alimentary  canal  and  the 
urinary  tract  :  the  fistula  may  be  tortuous,  so  that  gas  gets  along  it,  but  not  fa;ces.  It 
may  happen,  moreover,  that  "a  lesion  such  as  appendicitis  has  led  to  the  formation  of  a 
local  abscess  which,  owing  to  its  infection  by  the  Bacillus  coli  communis,  contams  gas  ; 
this  abscess  may  open  into  the  bladder  and  cause  the  discharge  of  jjus  and  gas,  but  no 
faces,  per  urethram.  The  same-applies  to  other  abscesses  which,  though  not  arising  pri- 
marily in  connection  with  the  bowel,  nevertheless  occasionally  contain  gas  from  infection 
by  the  B.  coli  commMHiS— a  suppurating  hydatid  or  ovarian  dermoid  cyst,  for  instance,  or 
a  pyosalpinx. 

Sometimes  there  may  be  serious  doubts  as  to  whether  the  gas  is  finding  its  way  mto 
the  urinarv  passages  from  some  external  source,  as  above,  or  whether  it  is  being  produced 
in  silu.  In  the  absence  of  any  rectal  or  other  pelvic  or  abdominal  evidence  of  disease  out- 
side the  bladder,  it  will  be  remembered  that  certain  organisms  produce  gas  when  they  grow 
in  urine  :  notablv  the  Bacillus  coli  cotnmunis.  and  in  glycosuric  cases,  various  yeasts. 
The  urine  will  be  examined  for  sugar,  and  if  it  be  present,  a  catheter  specimen  will  be  ob- 
tained to  see  if  saccharomvces  are  present  in  the  bladder-urine  :  if  so,  and  if  there  is  no  pus 
or  evidence  of  infection  bV  other  micro-organisms,  the  nature  of  the  pneumaturia  will  be 
clear  ;  as  a  rule,  in  these  cases  the  patient  voids  urine  that  is  bubbly  rather  than  distinct 
and  separate  from  the  gas.  If,  on  the  other  hand,  no  sugar  is  present,  a  catheter  specimen 
will  be  cultivated  to  find  out  whether  the  B.  coli  communis  is  present,  and  if  so,  in  what 
quantity.  If  it  is,  and  if  no  sign  of  any  fistulous  communication  between  any  part  of  the 
bowel,  or  a  gas-containing  abscess  cavity,  and  the  urinary  tracts,  can  be  made  out,  the  pre- 
sumption will  be  that  the  pneumaturia  is  due  to  coli  bacilluria,  although  the  latter  is  far 
commoner  without  than  with  pneumaturia.  The  urine  in  these  cases  may  contain  very 
little  obvious  pus  and  onlv  a  trace  of  albumin  :  it  may  be  acid,  and  not  foul  smelling  or 
ammoniacal  ;  on  the  other  hand,  it  may  sometimes  be  so  foul  and  fa-culent  as  to  cause 
serious  suspicions  of  a  communication  between  the  colon  and  the  bladder,  even  when  there 
is  none.  A  cystoseopic  examination  will  serve  to  exclude  a  fistulous  opening  into  the 
bladder,  but  it  mav  be  much  more  difficult  to  exclude  a  similar  communication  with  the 
higher  parts  of  the  urinarv  tract,  especially  the  renal  pelvis.  The  latter  condition  is  so 
rare,  however,  that  it  is  wiser  to  diagnose  coli  bacilluria  only  unless  there  is  direct  evidence 
of  a  cause  for  coninuinication  between  the  bowel  and  the  renal  pelvis,  such  as  a  carcinoma 
pqIj  Herbert  French. 

PNEUMOTHORAX,  or  gas  in  the  pleural  cavity,  may  exist  with  or  without  clear 
fluid,  pus,  or  blood  in  the  lower  part  of  the  pleura  at  the  same  time.  If  there  is  any  kind 
of  lluid  in  the  cavity  along  with  the  air,  the  fact  is  generally  made  obvious  at  once,  when 
the  patient's  thorax  is  auscultated  whilst  it  is  being  actively  or  passively  shaken,  so  as  to 
produce  tlie  typical  succussion  splash,  often  followed  by  the  ringing  sounds  made  by  drops 
of  fluid  fiilling  from  the  compressed  lung  into  the  pool  of  fluid  beneath.  Tlic  nature  of  the 
fluid— hydro-pneumothorax,  pyo-pneumothorax,  or  hxmo-pneumothorax.  as  the  case 
may  be— can  seldom  be  diagnosed  except  by  means  of  an  exploring  needle  and  syringe. 
Whether  the  pneumothorax  is  or  is  not  associated  with  any  of  these  fluids,  the  diagnosis  is 
generally  easy  on  account  of  the  deficiency  in  movement  of  the  affected  side  of  the  chest, 
the  displacement  of  the  heart  in  the  opposite  direction,  and  hyper-resonance  to  percussion, 
together  with  remarkable  deficiency  or  complete  absence  of  the  vesicular  murmur  and 
voice  sounds.  The  coin-tap  sound,  obtained  by  placing  one  silver  coin  on  the  chest  wall, 
tapping  it  with  another  silver  coin,  and  listening  through  the  stethoscope  for  the  ringing 
echo  produced,  when  the  sign  is  positive,  may  serve  to  confirm  the  diagnosis,  but  it  is  not 


PNEUMOTHORAX 


531 


essential.  Partial  pneumothorax,  in  which  complete  collapse  of  the  lung  is  prevented  by 
adhesions,  is  proportionately  more  didieult  to  diagnose,  but  the  same  type  of  physical 
signs,  including  the  coin-tap  sound  or  hruH  d'uiraiti,  will  generally  be  found  in  these  cases, 
though  in  less  degree  than  when  the  pneumothorax  is  complete.  The  .I'-rays  show  an 
abnormal  clearness  corresponding  to  the  air  in  the  pleural  cavity  (Fig.  226.)  It  is  not 
sufficient,  however,  merely  to  diagnose  pneumothorax  ;  its  cause  has  to  be  determined 
from  amongst  the  following  : — 

Phthisis  :    (a)  early,  (b)  late. 

Rupture  of  an  emi)hysematous  bleb. 

Gangrene  of  the  lung  with  necrosis  of  the  pleura. 

Empyema  ruptured  through  the  lung. 

Instrumental  :    e.g.,  after  tapping  a  pleural  effusion. 

Stabs,  or  gunshot  wounds  of  the  chest  wall. 

Epithelioma  of  the  oesophagus  ulcerating  into  the  pleura. 

Gastric  ulcer  or  carcinoma  ventriculi,  leaking  so  as  to  produce  a  gas-containing 
subdiaphragmatic  abscess,  which  in  its  turn  may  perforate  the  diaphragm  and  cause  a 
pneumothorax. 


Infection  of  the  pleural  cavity  by  gas-producinsj 
communis. 


irganisms.  such  as  the  Bacillus  colt 


Fig.  i'^ti. — Skiagram  u(  u  riKlit-:3idcU  pyopiieuiiiotliorax  (left  side  uf  tlie  skia^runi).     Nolo  tlie  liori/iOtital  upper 
level  of  the  piw  (bhick)  and  the  clearness  of  the  ])iieumothora.x  above  it.    {Skiiujram  by  Dr.  LimUay  Locke.) 


The  conunoncst  cause  l>y  fir  is  iihlhisis  :  and  when  the  occurrence  of  the  pneumo- 
thorax docs  give  rise  to  syiiiplonis.  il  is  generally  due  to  comparatively  early  phthisis  ; 
indeed,  when  it  comes  on  acutely  with  sudden  lant'inating  ])ain  in  one  side  of  the  chest, 
associated  with  rapid  shallow  breathing,  and  cyanosis  with  or  without  ha-moptysis  in  a 
young  apparently  healtliy  adult,  il  is  almost  certain  that  the  patient  has  a  tuberculous 
focus  at  one  apix.  excii  though,  as  fre(|ueiitly  happens,  there  ha\c  been  no  abnormal  sym- 
ptoms previously,  su<'h  as  cough  or  night  sweats,  and  excii  though  absolutely  no  abnormal 
physical  signs  can  be  detected  at  tlu>  apex  of  I  he  oilier  hiiig.  Thrn-  ina\  be  a  little  spiiluni, 
and  in  this  tubercle  bacilli  may  be  detected. 

When  pneumothorax  is  attributed  to  rupture  of  on  cnijihfiscmolous  hlch,  there  imist 
always  remain  in  the  physieianVs  mind  a  serious  doubt  as  to  whether  it  is  not  really  due  to 


532  PNEUiMOTHORAX 

a  bleb  in  the  immediate  neighbourhood  of  an  undiagnosable  tuberculous  deposit,  and  the 
case  should  be  treated  as  one  of  potential  phthisis. 

If  the  tuberculous  process  in  the  lung  has  made  considerable  advance  pneumothorax 
is  far  less  common,  because  there  will  almost  certainly  have  been  pleurisy  with  thickening 
and  adhesions  sufficient  to  iirevent  pneumothorax  occurring  ;  nevertheless,  in  some  such 
cases  pneumothorax  does  develop,  and  the  diagnosis  of  its  cause  is  easy  both  on  account 
of  the  abnormal  physical  signs  and  of  the  sputum  with  the  tubercle  bacilli  in  it.  In  a 
later  stage  still,  the  occurrence  of  pneumothorax  may  cause  very  little  additional  disturb- 
ance, on  account  of  the  extent  of  lung  already  diseased,  and  although  its  cause  would  be 
obvious  enough,  the  occurrence  of  the  pneumothorax  often  escapes  detection. 

When  the  patient  has  had  a  pleuritic  or  pleural  effusion  tapped,  detection  of  air  free 
in  the  pleural  cavity  next  day  is  by  no  means  uncommon  ;  it  does  not  follow  that  this  air 
has  leaked  in  through  the  tapping  instrument,  for  it  is  quite  as  commonly  derived  from 
the  rupture  of  su]3erficial  alveoli  which  have  been  re-expanded  rather  too  rapidly  in  the 
withdrawal  of  fluid  by  the  aspirator.  The  air  generally  becomes  reabsorbed  in  a  few 
days,  and  the  temporary  jineumothorax  is  of  little  significance. 

Similar  escape  of  air  into  the  pleural  cavity,  as  the  result  of  cuts,  stabs,  fractured  ribs, 
or  gun-shot  wounds,  is  remarkably  rare  ;  this  rarity  depends  upon  the  fact  that  the  two 
layers  of  pleura  tend  to  cohere  in  a  way  similar  to  that  which  makes  two  thin  sheets  of 
Indian  paper  difficult  to  separate,  so  that  when  an  injury  from  outside  penetrates  one  layer 
it  nearly  always  perforates  both,  and  air  from  within  the  lung  escapes  into  the  subcutan- 
eous tissues  instead  of  into  the  pleural  cavity,  and  produces  surgical  emphysema  instead 
of  pneumothorax.  It  rarely  happens  that  an  injury  separates  a  sufficient  area  of  the  two 
layers  of  pleura  one  from  the  other  to  cause  a  pneumothorax. 

All  the  remaining  causes  of  j^neumothorax  in  the  list  above  are  uncommon,  and 
none  of  them  will  arise  without  there  having  been  other  symptoms  to  indicate  the  nature 
of  the  malady.  It  is  possible  for  an  empyema  to  rupture  into  a  bronchus,  and  so  lead  to 
the  sudden  expectoration  of  much  foul  pus,  without  any  pneumothorax  arising,  or  at  least 
none  of  any  extent,  because  for  such  an  empyema  to  rupture  into  the  lung  it  must  have 
been  shut  oft  all  round  by  firm  pleural  adhesions.  When  pneiunothorax  results  from 
gangrene  of  the  lung  due  to  any  cause  (p.  259),  it  is  but  a  terminal  factor  in  an  already 
serious  disease,  and  may  even  pass  without  recognition  on  account  of  the  severity  of  the 
symptoms  already  existing  in  the  case.  Gas-containing  abscesses  l>eneatti  the  diaphragm. 
such  as  may  either  perforate  directly  into  the  pleural  cavity  or  lead  to  infection  of  that 
cavity  by  tiie  Bacillus  coli  communis  or  other  gas- forming  organism,  never  arise  suddenly, 
but  are  preceded  bv  a  simple  or  malignant  ulceration  of  either  the  stomach,  duodenum,  or 
colon,  the  symptoms  of  which  will  generally  have  existed  for  days,  weeks,  or  months  :  so 
that  if  the  possibility  of  gas  appearing  in  the  pleural  cavity  in  this  way  is  borne  in  mind, 
the  diagnosis  of  its  origin  need  not  be  difficult.  The  .r-rays  may  ser\e  to  show  a  large  gas 
bubble  below  the  diaphragm  as  well  as  gas  in  the  ])leural  cavity,  and  that  the  gas  bubble 
is  not  intragastric  may  be  demonstrated  by  filling  the  stomach  with  a  bisnuith  meal  and 
finding  that  the  gas  bubble  does  not  become  blackened.  Herbert  French. 

POLYCYTHyEMIA  is  the  tenu  used  to  denote  a  material  increase  of  the  red  cor- 
puscles above  their  normal  number  per  cubic  millimetre  of  blood.  In  males  they  should 
average  5,000,000  jier  c.mni.  :  in  females.  4.500,000,  ,\ny  considerable  increase  above 
these  figures,  for  instance  up  to  6,000,000  per  c.mm.,  or  more,  constitutes  polycythiemia. 
Figures^as  high  even  as  14.,000,000  are  reached  sometimes.  The  following  are  some  of  the 
conditions  in  which  polycythsemia  occurs  : — 

1.  Congenital  heart  disease  of  the  type  spoken  of  as  morbus  cceruleus— generally  due 
to  pulmonary  stenosis  (see  Fig.  46,  p.  111.  and  Fig.  67,  p.  157.) 

2.  Persons  who  live  in  high  altitudes. 

3.  Patients  afflicted  with  chronic  shortness  of  breath,  with  a  tendency  to  periodic 
cyanosis,  particularly  cases  of  {a)  mitral  stenosis,  (b)  fibroid  lung  with  and  without  bron- 
chiectasis, (f)  chronic  bronchitis  and  emphysema,  (rf)  spasmodic  asthma,  (e)  some  renal 
cases.  , 

4.  Patients  who  have  recently  lost  a  quantity  of  fluid  from  the  tissues,  the  result  ot 
such  conditions  as  (a)  severe  vomiting,  e.g.,  the  uncontrollable  vomiting  of  pregnancy  ; 


POLYCYTHEMIA  533 

{h)  severe  diarrhfra.  e.u;..  the  summer  diarrhoea  of  infants,  cholera,  ptomaine  poisoning, 
arsenic  ;  (c)  inability  to  obtain  fluid  to  drink,- especially  if  there  exists  already  a  disease 
tending  to  polyuria,  such  as  diabetes  mellitus,  diabetes  insipidus,  or  granular  kidney. 

5.  From  the  prolonged  use  of  certain  drugs,  especially  acetanilide,  veronal,  and  some 
others  of  the  type  that  may  cause  methicmoglobinuria  (p.  284). 

6.  Splenomegalic  polycythaemia. 

As  a  rule,  the  diagnosis  of  the  cause  of  polycythaemia  in  a  given  case  is  not  difficult. 
When  it  is  due  to  congenital  heart  disease  it  is  nearly  always  associated  with  an  extreme 
degree  of  cyanosis  without  proportionate  dyspncea,  and  with  clubbing  of  the  fingers,  both 
these  dating  from  birth  or  early  childhood.  The  patient  is  generally  young,  though  some 
survive  into  adult  life.  There  is  not  always  a  cardiac  bruit,  and  the  precise  lesion  will 
then  be  obscure  :  often,  however,  percussion  shows  increased  cardiac  dullness  to  the  right 
of  the  sternum,  and  upwards  towards  the  second  left  rib,  indicating  increased  size  of  the 
right  auricle  and  ventricle  :  and  in  most  cases  there  is  either  a  loud  rumbling  or  blattering 
systolic  bruit  of  pulmonary  stenosis,  heard  loudest  in  the  second  left  space  close  to  the 
sternum,  but  also  audible  over  the  greater  part  of  the  precordial  region,  and  often  over 
both  sides  of  the  chest  in  front  and  behind  ;  or  else  a  very  similar  universal  systolic  bruit, 
differing  chielly  in  having  its  maximum  intensity  either  behind  the  sternum  between  the 
two  fourth  ribs,  or  else  in  the  fourth  left  intercostal  spaces  close  to  the  sternum,  indicative 
of  patent  septum  ventriculorum.  These  two  lesions  may  both  be  present  in  the  same 
patient,  and  they  are  the  commonest  cause  in  cases  of  morbus  eneruleus  that  survive 
infancy.  The  red  corpuscles  seldom  number  less  than  6,000.000  per  c.nmi.,  and  in  some 
cases  they  have  been  no  fewer  than  14,000,000  per  c.nim.  The  percentage  of  haemo- 
globin is  also  increased  greatly,  but  usually  to  a  less  degree  than  are  the  red  cells,  so  that 
the  colour  index  falls  Vjelow  1.  This  applies  to  nearly  all  causes  of  polycythiemia.  There 
is  no  simultaneous  increase  in  the  number  of  leucocytes  per  c.mm.,  and  the  differential 
leucocyte  count  falls  within  the  normal  limits.  It  is  noteworthy  that  cases  of  persistent 
ductus  arteriosus  seldom  present  either  cyanosis,  clubbed  fingers,  or  polycythicmia. 

Residence  at  high  altitudes  often  causes  polycytha?mia.  The  increase  is  seldom 
extreme,  but  the  red  cells  not  infrequently  reach  6,000,000  or  more  per  c.mm.  This  rule  is 
not  by  any  means  universal,  however,  though  upon  the  whole  the  higher  the  altitude  the 
higher  the  normal  average  number  of  red  cells  per  c.mm.,  particularly  in  those  who  have 
resided  long  and  continuously  in  the  mountains.  The  individuals  arc  not  ill  :  it  is  merely 
that  their  red  cells  stand  at  a  higher  figure  normally  than  do  those  of  dwellers  nearer  sea  level. 

Quite  apart  from  the  presence  or  absence  of  anasarca,  patients  suffering  from  chronic 
lesions  which  lend  to  produce  dyspnoea  are  also  very  apt  to  have  polycythaemia,  particu- 
larly when  the  lesion  causes  marked  redness  of  the  lips.  This  is  well  seen  in  many  cases  of 
mitral  stenosis  when  there  has  been  a  tendency  to  failure  of  compensation  for  some  time 
past.  There  is  no  similar  polycytha*mia  in  aortic  cases  unless  mitral  disease  is  present  as 
well,  and  the  red  cells  are  much  less  increased  in  mitral  regurgitation  than  in  mitral  stenosis. 
In  the  hill<r  (he\-  often  reach  (i.OOO.OOO  or  even  7.000,000  per  c.mm.,  and  it  would  seem  to 
be  an  atteni|)t  on  nature's  part  to  try  and  compensate  for  the  failing  circulation  by  dis- 
tributing the  luemoglobin  over  a  larger  corpuscular  area.  The  same  explanatif)n  probably 
accounts  for  the  similar  polycyth:emia  due  to  morbus  cocruleus,  and  to  high  altitudes,  and 
to  certain  cases  of  fibroid  lung,  bronchiectasis,  enipht/sema,  chronic  bronchitis,  renal  disease 
with  chronic  dyspnica,  and  spasmodic  astliniii,  in  which  some  degree  of  poIyeyth;Emia, 
though  not  the  rule,  is  sometimes  met  with,  just  as  it  is  in  mitral  stenosis.  The  colour 
index  is  less  than  1.  for  although  the  luemoglobin  is  increased,  it  is  less  so  than  arc  Ihc  red 
cells.  The  leucocytes  remain  unaltered.  The  iiolycytha-mia  will  seldom  if  ever  be  the 
most  prominent  symj)tom  in  the  case,  .so  that  the  diagnosis  will  nearly  always  have  been 
mafic  upon  other  grounds  the  i)resystolic  bruit  at  the  impulse  ;  the  displacement  of  the 
heart  towanis  thai  side  where  the  hmg  presents  an  impaired  note,  with  or  without  crackling 
rales  and  bronchial  bnalhing  :  and  so  on.  The  mainlcniince  of  the  polyeytluemia  is 
im|)ortant,  however,  and  therapeulie  measures  should  be  direeled  to  this  end,  for  many 
cases  of  mitral  stenosis  with  5,000,000  red  cells  |)er  e.mni.  arc  relatively  anaimic  ;  they 
should  have  (i,()0().000  or  more. 

The  effect  of  cholera,  ptomaine  poisoning,  arsenic,  summer  diarrluea  of  infants,  severe 
thirst  that  cannot  be  assuaged,  the  toxtvmia  of  pregnancy,  and  so  on,  in  concentrating  the 


534  polycyth.e:\[ia 

blood  by  withdrawing  or  withholding  fluid  from  it,  and  thus  producing  some  degree  of 
polyeythaemia,  is  an  acute  condition  which  is  to  be  counteracted  by  continuous  sahne  in- 
fusion or  some  similar  method  of  restoring  fluid  to  the  tissues.  The  polyeythaemia  seldom 
reaches  any  marked  degree  except  in  quite  early  stages,  for  instance,  in  cholera  ;  later, 
the  red  cells  disintegrate  more  rapidly  than  they  are  replaced.  In  measuring  the  concen- 
tration of  the  blood  in  these  conditions,  it  is  of  less  value  to  count  the  red  cells  than  to 
measure  the  specific  gravity.  This  is  done  most  readily  by  the  chloroform  and  benzene 
method.  The  specific  gravity  of  chloroform  is  high,  that  of  benzene  is  low,  and  by  mixing 
the  two  in  different  proportions  it  is  possible  to  obtain  fluids  of  every  intermediate  specific 
gravity.  A  mixture  of  the  two  of  the  normal  specific  gravity  of  the  blood,  viz.,  1056,  is 
made,  and  poured  into  a  specimen  glass  of  sufficient  depth  to  allow  o,  urinometer  to  float 
in  it.  For  strict  accuracy,  certain  corrections  in  the  readings  of  the  ordinary  urinometer 
are  required,  but  for  emergency  use  the  instrument  will  serve.  The  lobule  of  the  patient's 
ear  is  pricked,  a  large  drop  of  blood  is  allowed  to  fall  into  a  suitable  small  cup  or  other 
receiver  containing  some  of  the  chloroform-benzene  mixture,  and  thence  transferred  to  the 
main  bulk  of  the  fluid  in  the  specimen  glass.  If  the  blood-drop  sinks,  more  chloroform 
must  be  added  :  if  it  floats,  more  benzene  :  ultimately  a  point  is  reached  at  which  the 
blood-drop  neither  sinks  nor  floats  ;  the  specific  gravity  of  the  chloroform-benzene  mix- 
ture is  then  the  same  as  that  of  the  blood.  In  cases  of  collapse  from  loss  of  fluid  there 
is  a  rise  in  the  specific  gravity  of  the  blood  even  when  there  is  no  polyeythaemia, — and 
the  greater  the  rise,  the  greater  the  need  for  infusion. 

Splenornegalic  polycythivrmn  is  a  somewhat  rare  condition  that  is  also  termed  erythrce- 
mia.  or  eri/throcyllupmia.  Its  name  suggests  its  main  features,  which  are  :  Enlargement 
of  the  spleen,  increase  in  the  red  cells  up  to  as  many  as  10,000,000  per  c.nnn.,  or  even  more, 
and  duskiness  or  lividity  of  the  face  (Pliiie  A'A'7A',  p.  034)  and  of  the  extremities.  The 
nature  of  the  malady  is  still  obscure,  though  some  regard  it  as  due  to  disease  of  the  bone- 
marrow.  It  aflects  adults  and  females  rather  than  children  and  males,  and  its  course  is 
chronic.  It  only  remains  to  add.  that  whereas  to  be  typical  the  .spleen  must  be  enlarged,  there 
arc  cases,  probably  of  the  same  affection,  in  which,  without  the  spleen  becoming  palpable, 
the  only  definite  clinical  signs  are  progressive  lividity  and  polyeythaemia.      Herbert  French. 

POLYDIPSIA.— (See  Thirst.   Extiik.me.   p.  719.) 

POLYURIA. — The  term  polyuria  signifies  the  passage  of  more  than  the  average 
amount  of  urine  per  diem.  It  may  be  either  (I)  Transient,  or  (II)  Continued.  It  is  impor- 
tant not  to  mistake  frequency  of  micturition  for  ]3olyuria,  for  although  the  latter  almost 
necessarily  causes  the  former,  there  are  many  conditions  that  lead  to  frequency  of  micturi- 
tion without  polyuria — for  example,  tuberculous  ulceration  of  the  bladder,  enlargement  of 
tlie  prostate,  or  urethral  stenosis,  in  all  of  which  urine  may  be  passed  frequently,  but  in 
small  quantities  at  a  time.  In  case  of  doubt  the  total  amount  of  urine  passed  in  each 
period  of  twenty-four  hours  shoidd  be  measured.  The  normal  limits  are  very  wide,  the 
average  being  about  50  ounces  per  diem,  more  being  passed  in  cold  weather  than  in  warm, 
during  rest  than  after  exercise,  waking  than  sleeping,  and  after  drinking  than  after  taking 
little  fluid  by  the  mouth.  The  point  at  which  polyuria  begins  is  arbitrary  ;  if  a  jjatient 
passes  70  ounces  or  more  per  diem  it  is  almost  certain  to  attract  attention,  and  therefore 
to  merit  the  term  polyuria.  In  degree,  the  polyuria  due  to  causes  in  Group  I  seldom 
exceeds  100  ounces  a  day  ;  some  of  the  causes  in  Group  II,  especially  diabetes  mellitus 
and  diabetes  insipidus,  may  cause  polyuria  to  the  extent  of  200  ounces,  or  even  300,  400, 
500,  600,  or  more,  per  diem. 

In  arriving  at  the  difl'erential  diagnosis  of  the  cause  in  any  given  case,  one  of  the  first 
points  to  note  is  whether  the  polyuria  is  persistent  ;  or  whether,  even  if  recurrent,  it  is 
transient.  Any  of  the  causes  that  usually  give  persistent  polyuria  may  in  some  individuals 
produce  the  symptom  intermittently,  but  upon  the  whole  one  may  classify  the  causes  of 
polyuria  as  follows  : — 

I.  CAUSES    OF    TRANSIENT    POLYURIA. 

1.  After  drinking  abundance  of  water  or  other  fluid. 

2.  After  drinking  fluids  containing  diuretic  principles,  such  as  alcohol  (wine,  malt  liquors, 

spirits) ;  caffeine  (tea,  cocoa,  coffee) ;    citrates  or  tartrates  (artificial  lemonades). 


POLYURIA  5;!5 

3.  As  the  result  of  nervousness,  or  of  nervous  attacks,  such  as  : — 

(a)  Medical  examination  for  life  assurance 

(6)  Preparation  for  some  physical  or  mental  competition 

(c)  Hysteria,  especially  during  recovery  from  an  acute  outburst 

(rf)  Neurasthenia 

(e)  After  an  epileptic  attack 

(f)  After  migraine 

(g)  After  an  asthmatic  attack 

(//)  After  an  attack  of  angina  pectoris 

(i)  Periodic  polyuria,  apparently  withovit  cause. 

4.  Hydronephrosis,  with  periodic  emptying  of  the  renal  sac. 

5.  The  cold  stage  of  a  malarial  attack. 

6.  In  some  cases  of  convalescence  from  a  febrile  illness,  such  as  enterica. 

7.  As    the    result    of   the    clearing  up  of   extreme  oedema  or    serous    effusions,^for 

instance,  during  recovery  from  acute  nephritis  ;  mitral  stenosis,  with  heart 
failure  ;  cirrhosis  of  the  liver,  and  so  on  ;  especially  if  the  fluid  clears  up 
quickly  after  giving  diuretic  remedies,  such  as  blue  pill,  digitalis,  calomel, 
copaiba  resin,  potassium  salts,  diuretin,  sodium-theocin-acetate,  uva  ursi, 
broom  tops,  or  dwarf  elder. 

When  the  cause  lies  in  Group  I  its  nature  is  generally  obvious,  though  it  is  essential 
to  examine  the  urine  carefully  for  sugar,  albumin,  and  renal  tube-casts,  for  purposes  of 
exclusion.  Nevertheless,  the  diagnosis  may  be  in  doubt  until  the  course  of  the  symptom 
has  been  watched  for  a  while.  For  instance,  polyuria  may  seem  to  be  due  to  profuse 
drinking,  when  really  the  kidneys  are  granular  and  contracted  ;  or  in  a  life  insurance  case, 
nervousness  may  seem  to  be  the  cause,  when  there  has  really  been  a  bout  of  drinking  ;  or, 
again,  the  drinking  may  be  secondary  to  the  extreme  thirst  produced  by  diabetes  insipidus. 

Excessive  Drinking. — When  due  to  drinking  water,  tea,  wine,  spirits,  or  artificial 
lemomules,  the  polyuria  ceases  when  the  drink  in  question  is  limited. 

Nervousness.  -The  history  and  circumstances  of  the  case,  together  with  the  absence 
of  signs  of  gross  disease  of  heart  or  kidneys,  will  be  the  main  factors  in  deciding  whether 
the  polyuria  is  caused  by  excitement,  nervousness,  hysteria,  or  neurasthenia. 

Epilepsy. — ^The  character  of  the  convulsive  seizures,  their  recurrence  at  intervals, 
and  the  inlluenee  of  bromides  upon  them,  will  serve  to  diagnose  epilepsy,  for  polyuria  in 
association  with  the  latter  nearly  always  follows  immediately  after  an  attack  of  grand  mal. 
It  may,  however,  be  associated  with  petit  mal.  or  even  be  the  chief  phenomenon  in  some 
cases  of  epilepsy. 

Migraine. — The  diagnosis  of  migraine  depends  on  the  history  of  the  case  and  the 
iibsenee  of  optic  neuritis  and  other  evidence  of  gross  intracranial  disease. 

Asthma.  — .\sthma  is  sometimes  easy  to  diagnose,  sometimes  very  dillieult  ;  it  may 
he  inistiken  for  recurrent  brorifhitis.  cardiac  dyspna-a,  renal  dyspncea  or  uriemie  '  asthma,' 
mediastinal  new  growth,  thoracic  aneurysm,  thymic  '  asthma. "  laryngeal  paijilloma  or 
fibroma,  foreign  body  in  the  air-passages,  syphilitic  stenisis  of  a  bronchus,  goitre,  or 
hysteria.  It  so  frequently  develops  into  emphysema  and  bronchitis  that  one  Is  apt  Id 
forget  that  the  essential  symptom  of  asthma  is  dyspno-a,  and  not  cough.  To  diagnose  a 
dillieult  case  it  may  be  necessary  to  axamine  the  chest  with  the  ,r-rays  to  exclude  aneurysm 
an<l  new  growth  ;  to  examine  the  larynx  and  vocal  cords  :  the  heart,  the  retina-,  and  the 
urine  to  exclude  renal  and  cardiac  mischief  ;  and  even  then,  doubt  may  remain  unless 
there  is  a  clear  anrl  typical  account  of  the  nature  of  the  earlier  attacks  in  a  patient  who  has 
had  recurrences  for  years,  and  who  is  relieved  by  cocaine  sprays  to  the  nose,  by  ethereal 
tincture  of  lobelia,  by  inhalations  of  stramonium  fumes,  by  injections  of  small  doses  of 
adrenalin,  or  by  other  anti-asthmatic  remedies  :  I'^osinoimiii.ia  (p.  218)  is  more  likely  to  be 
found  durinj;  an  attack  of  asthma  than  as  the  result  of  any  of  the  other  conditions  that 
may  simulate  it.  'I'lie  polyuria  occurs  in  by  no  means  every  case;  when  It  does  so,  it 
generally  follows  immediately  after  an  att.iek.  and  this  applies  also  in  cases  of  onginii 
pectoris,  the  diagnosis  of  which  is  not  dillieult  when  the  acute  atliieks  of  prceorillal  pain 
radiate  upwards  and  outwards  to  the  left  shoulder  and  down  the  left  arm,  and  when  there 
is  evidence  of  an  aortic  lesion,  or  of  atheroma  and  arteriosclerosis  wivh  high  l)lo()d-|)ressure. 


586  POLYURIA 

Periodic  Polyuria,  apparently  without  cause,  is  a  condition  which  is  regarded  by 
some  as  a  clinical  entity  ;  the  diagnosis  must  always  be  difficult  to  be  sure  of  liowever, 
and  the  more  carefully  a  cause  is  looked  for,  the  fewer  will  be  the  cases  remaining  in  this 
category  ;  it  will  be  found  that  some  are  due  to  epilepsy  ;  others  to  secret  drinking  ; 
others  to  granular  kidney  ;    others  to  hydronephrosis,  and  so  on. 

Hydronephrosis,  with  periodic  emptying  of  the  renal  sac,  is  the  chief  cause  of  typi- 
cally periodic  polyuria.  The  diagnosis  is  arrived  at  by  having  the  urine  measured  care- 
fully each  day,  and  by  palpating  the  loins  bimanually  for  evidence  of  renal  enlargement. 
When  a  kidney  swelling  can  be  detected,  and  when  this  increases  in  size  at  the  same  time 
that  less  urine  is  being  passed,  whilst  it  materially  decreases  on  the  days  when  the  polyuria 
occurs,  the  diagnosis  of  hydronephrosis  or  pyonephrosis  is  clear  :  and  the  distinction 
between  the  two  depends  on  whether  there  is  or  is  not  pyuria.  The  commonest  causes 
for  hydronephrosis  are  movable  kidney  and  renal  calculus  :  and  the  .r-rays  often  serve 
to  distinguish  the  latter  from  the  former. 

Fevers. — The  polyuria  that  occurs  during  the  cold  stage  of  a  malarial  attack  is 
replaced  speedily  by  the  opposite  condition  when  the  hot  stage  is  reached  ;  the  diagnosis  is 
afforded  by  the  circumstances  of  the  case,  such  as  residence  in  a  malarial  district  and  pre- 
vious attacks  of  the  malady  ;  by  the  discovery  of  malarial  parasites  in  blood-films  ;  by 
the  absence  of  leueocytosis.  the  relative  increase  in  the  large  lymphocytes  in  the  differen- 
tial leucocyte  count,  and  by  the  beneficial  effects  of  quinine  upon  the  disease.  Polyuria 
during  convalescence  from  other  fevers,  such  as  enterica  or  pneumonia,  is  not  uncommon  : 
it  is  a  phenomenon  that  may  attract  some  attention  at  the  time,  but  it  seldom  gives  rise  to 
difficulty  in  diagnosis. 

(Edema  and  Diuretics. — The  considerable  polyuria  that  often  results  in  renal  or 
cardiac  eases  when  (edema  is  clearing  up  under  treatment  is  noteworthy,  but  the  diagnosis 
is  not,  as  a  rule,  difficult.  If  the  polyuria  is  due  merely  to  the  excretion  of  accumulated 
fluid  it  will  cease  when  there  is  no  longer  any  cedema  ;  whilst  if  it  is  due  to  granular  kidney, 
or  other  underlying  malady,  it  will  continue  even  after  the  oedema  has  gone. 

II.  CAUSES  OF  CONTINUED  POLYURIA. 

1.  Diabetes  mellitus. 

2.  Red  granular  contracted  kidneys. 

3.  Arteriosclerosis. 

4.  Pale  granular  contracted  kidneys. 

5.  Lardaeeous  or  amyloid  kidneys. 
G.  Cystic  kidneys. 

7.  Diabetes  insipidus  : 

(a)  Due  to  no  gross  nervous  lesion 

(h)   Due  to  tumour  or  injury  of  the  medulla  olilongata. 

8.  Incorrigible  drinking  of  beer  or  si)irits. 

9.  Phosphatic  diabetes. 

10.  Azotic  diabetes. 

11.  Some  cases  of  acromegaly. 

12.  Some  cases  of  myxoedema. 

Diabetes  Mellitus. — .\  very  important  step  in  the  diagnosis  is  to  examine  the  urine 
carefully.  If  sugar  is  present,  a  diagnosis  of  diabetes  mellitus  will  be  made,  especially 
if  diacetic  acid  and  acetone  are  also  present,  and  the  specific  gravity  is  between  1035  and 
1045.  Some  authorities  distinguish  in  kind  as  well  as  in  degree  between  what  they 
term  true  diabetes  mellitus  on  the  one  hand,  and  alimentary  glycosuria  on  the  other, 
though  others  hold  that  these  differ  only  in  degree  :  it  is  chiefly  in  severe  diabetes  of  young 
people  that  polyuria  is  marked,  something  between  100  and  600  oimees  of  m-ine  being 
passed  per  diem  ;  in  elderly  people  with  glycosuria  the  polyuria  is  often  slight  :  in  these 
cases  the  specific  gravity  need  not  be  above  the  normal,  and  diacetic  acid  and  acetone  are 
generally  absent.  If  no  sugar  is  present  U])on  one  occasion  it  may  be  on  another,  so  that 
several  examinations  may  be  required. 

Albuminuria. — If  albumin  is  present,  and  the  polyuria  cannot  be  attributed  at  once 
to  anything  so  obvious  as  the  clearing  up  of  cedema  or  the  administration  of  a  diuretic, 


PRIAPISM  537 

a  careful  microscopical  examination  of  the  centrifugalizecl  deposit  for  renal  tube-casts 
should  be  made  ;  if  the  latter  are  absent,  and  if  the  patient  is  a  young  adult  male,  who 
seems  to  be  in  good  health,  whose  heart  and  other  organs  present  no  abnormal  [ihysical 
signs,  and  whose  polyuria  troubles  him  chiefly  at  times  of  excitement,  for  instance  when 
he  is  in  for  an  examination,  the  diagnosis  is  very  likely  to  be  that  of  "  fimetional  "  or 
'  physiological  "  albuminuria,  in  which  case  repeated  tests  will  show  that  the  urine  is  often 
quite  free  from  albumin,  especially  the  first  thing  in  the  morning,  and  the  blood-pressure 
would  not  be  rai.sed.  If.  on  the  other  hand,  more  than  an  occasional  renal  tube-cast  was 
found,  and  the  albumin  and  polyuria  were  persistent,  the  diagnosis  of  red  granular 
contracted  kidney,  arteriosclerosis,  pale  granular  contracted  kidney,  lardaceous  kidney,  or 
cystic  kidney  would  suggest  itself.  The  differential  diagnosis  between  these  is  discussed 
under  Ai.BiMiNnuA  (p.  6.  et  seq.). 

Diabetes  Insipidus. — If  neither  albumin  nor  sugar  is  found,  even  on  repeated  testing, 
and  if  the  polyuria  is  extreme  and  persistent,  whilst  the  specific  gravity  of  the  urine  is  con- 
stantly low  (1004  to  1008),  a  diagnosis  of  diabetes  insipidus  will  suggest  itself.  Before 
this  diagnosis  is  made  finally,  however,  precautions  must  be  taken  to  determine  that  the 
patient's  thirst  and  ])olyuria  are  not  due  to  habits  of  drinking  to  excess  :  it  may  be  dilfi- 
cult  to  decide  this  in  cases  in  which  alcoholic  beverages  are  consumed  :  but'  when  the 
patient  is  a  water-drinker,  and  yet  cannot  do  with  less  than  8  or  10  pints  a  day.  the  drinking 
is  probably  a  necessity,  and  not  a  habit  ;  and  diabetes  insipidus  is  the  probable  diagnosis. 
In  cases  of  doubt,  the  difficulty  can  be  decided  by  restricting  the  intake  of  fluid  and  deter- 
mining the  specific  gravity  of  the  blood.  This  should  be  about  l().5(i.  and  in  a  case  where 
polyuria  is  due  to  drinking  habits,  restriction  of  fluids  will  not  alter  it  materially  :  in  a 
case  of  diabetes  insipidus  with  restricted  intake  of  fluids,  however,  the  drain  of  the  latter 
from  the  blood  still  goes  on.  and  the  specific  gravity  rises  to  1060,  or  1065,  imkss  the  patient 
is  allowed  fluid  by  the  mouth  again. 

There  are  two  classes  of  diabetes  insipidus,  according  as  there  is,  or  is  not.  a  gross 
lesion  of  the  central  nervous  system.  If  the  malady  follows  on  a  fractured  base  of  the 
skull,  or  if  there  are  vomiting,  headache,  optic  neuritis,  or  other  symptoms  of  cerebral 
tumour,  there  is  probably  a  gross  lesion  of  the  base  of  the  brain  in  or  near  the  medulla 
oblongata — thrombosis,  softening,  haemorrhage,  small  aneurysm,  gununa.  glioma  or  other 
neoplasm.  In  other  cases,  the  complaint  arises  after  a  fright  or  shock,  or  even  without 
any  apparent  cause,  and  there  seems  to  be  no  gross  lesion  to  account  for  it. 

Phosphatic  and  Azotic  Diabetes. — Another  point  that  needs  investigation  in  a 
case  suspected  to  be  dialiclcs  insipirlus.  is  the  amount  of  solids  excreted  daily  in  the  urine. 
In  orilinary  diabetes  insipidus  the  total  solids  are  normal,  the  only  increase  being  in  the 
water.  There  are  rare  cases  in  which,  in  addition  to  i)olyinia.  there  is  a  great  increase  in 
the  total  solids  in  the  urine  also — so-called  Ixiniria.  Hare  though  these  cases  are.  they 
have  been  divided  into  two  types,  namely,  those  in  which  the  inorganic  salts  are  most  in- 
creased— phosphatic  diabetes  (p.  .522).  and  those  in  which  the  nitrogenous  constituents 
are  augmented  mainly  azotic  diabetes.  The  diagnosis  here  depends  mainly  on  (|uan- 
tilalivc  csliiiiation  oC  the   \iirious  urinary  substances. 

Acromegaly  and  Myxcedema.  It  oidy  remains  to  add  thai  symptoms  not  unlike 
those  of  diabetes  insipidus  have  sometimes  arisen  in  cases  of  acromegaly  and  in  myxce- 
dema. There  is  ])rol)ably  a  nervous  factor  in  both  cases,  coupled  in  myxo-dema  witll 
flryness  of  the  skin,  and  conse(|uent'derici<'ncy  in  perspiration  ;  whilst  in  acromegaly  there 
is  the  lumour-Iike  erdargement  of  the  i)ituitarv  body  which  may  cause  polyuria  like  any 
other  lesion  near  the  medulla  oblongata.  The  diagnosis  of  acromegaly  may  be  confirmed 
by  the  .r-rays,  which  will  show  the  great  enlargement  of  the  bones  of  the  hands,  feet,  and 
head,  or  even  perluips  of  the  pituitary  fossa  itself;  whilst  in  myxcedema.  if  the  general 
symptoms,  the  pseudo-cedema  of  the  legs,  the  ae<(uired  dullness  of  intelleel,  tlic  increasing 
weight,  and  the  broarlening  oftlie  features  (/''/g.  101.  j).  2.'{4).  the  fingers,  and  the  hands,  do 
not  al  onrc  indicate  llii'  nalMic  of  the  c<implaint.  the  beneficial  elTeels  of  treatment  by 
thvniid  ixiraci   niM\    serve  lu  cliricli  IIh'  diagnosis.  Ilt-rbfrl  French. 

PRECORDIAL    PAIN.      (S,-,-    I'xrN    in    vuv.   (Hist,    p.    t:!0.) 

PRIAPISM  sigriili<s  iicction  of  111.'  penis,  cord  iiuial.  nf  I  roublcsorne  degree,  anil  not 
necessarily    aeeonipaiiiid    by    sexual    <lesire.      Though    generally    spiiken    of    in    eoimeelion 


53H 


PRIAPISM 


with  tlie  male  sex,  a  precisely  similar  affection  may  occur  in  the  female  clitoris.  The 
symptom  is  not  often  by  itself  of  diagnostic  importance,  though  it  may  be  due  to  a  con- 
siderable number  of  different  causes.  Most  of  the  latter  need  be  little  more  than  enumer- 
ated, for  if  they  are  borne  in  mind  they  will  nearly  always  lead  to  a  speedy  diagnosis.  Two 
in  particular  merit  s))ecial  mention,  however.  The  first  is  priapism  in  elderly  men.  In 
some  such  cases  there  may  be  enlargement  of  the  prostate,  or  local  inflammation  such  as 
gouty  urethritis,  but  in  many  the  priapism  .seems  to  occur,  without  pathological  cause,  as 
a  sort  of  final  outburst  of  sexual  energy  before  the  on.set  of  .senile  impotence. 

The  other  special  condition  under  which  priapism  may  be  extreme  is  after  injury  to 
tlie  u])per  dorsal  region  of  the  spinal  cord.  The  damage  may  be  so  serious  as  to  have  pro- 
duced a  fracture  dislocation  of  the  spine  with  paraplegia,  in  which  case  the  diagnosis  will 
be  obvious  ;  short  of  this,  however,  there  may  have  been  only  a  minor  degree  of  injury, 
with  contusion  and  ])erhaps  multiple  small  hsemorrhages  into  the  substance  of  the  cord,  in 
association  with  which  priapism  may  in  some  instances  be  very  pronounced  and  last  for 
weeks  or  months  before  recovery  occurs. 

For  the  rest,  the  cavises  of  priapism  may  be  summarized  briefly  according  to  age 
periods,  the  chief  being  : — 


Priapism  in  infancy  : — 
Phimosis 
Oxalurla 

Worms,  especially  oxyuris  vermicularis 
Balanitis 

Priapism  at  puberty  : — 

The  changes  in  the  genital  ( 


Posthitis 

Calculus,   urethral  or  vesical 

Certain   conditions   of  mental   deficiency 

Circumcision. 


associated  with  the  onset  of  puberty. 


Priapism  in  young  adult  life  : — 
Sleei)ing  on  the  back 
Non-emptying  of  the  blailder  when  full 
Ill-litting  trousers 
.Sexual  excitement  r^*^*^*^ 
Gonorrlxra 
Kpilepsy 

After   circiuneision 
-Masturbation 

Convaleseenee  from  an  acute  disease 
Tetanus 
Hydrophobia 
I-t'uk:i'!nia 
Throml)Osis  of  the  pampiniform  plexus 


Fracture  of  the  dorsal  spine 

Transverse  myelitis  of  the  upper  dorsal  region 

Spinal  meningitis 

Certain    aphrodisiac   drugs  : — 

Cantharides 

Turpentine  — 

Alcohol,    especially   port    wine    in    some 
persons,  champagne  in  others 

Strychnine 

Cannabis  indica 

Camphor 

Phosphorus 

Damiana. 


Priapism  in  older  men  : — 
The  male  menopause 
Local  irritation  as  the  result  of  ; — 

Ciouty   urethritis  |  Haemorrhoids 

Enlarged    prostate  ]  A.  loaded   rectum. 

Hamorrhage  into  the  middle  lobe  of  the  cerebellum 
Lesions  of  the  i)ons  varolii 

Very  seldom  indeed  will  priapism  be  the  only  symptom  in  the  case  :  the  diagnosis 
will  be  made  from  the  history  and  from  the  other  symptoms.  Herbert  French. 

PROLAPSE  OF  THE  UTERUS.— .As  a  matter  of  practical  fact,  the  uterus  only 
descends  as  a  result  of  a  nnich  wider  displacement  of  all  the  movable  structures  which  go 
to  make  up  the  pelvic  floor.  This  is  composed  of  a  movable  or  pubic  portion,  and  a  fixed 
or  .sacral  portion,  and  it  is  descent  of  the  pubic  ])ortion  which  produces  the  actual  lesion 
known  as  prolapse  of  the  uterus.  In  other  words,  the  uterus  only  descends  because  it  is  a 
part  of  the  pubic  portion  of  the  pelvic  floor.  The  uterus,  bladder,  and  anterior  vaginal 
wall  are  normally  kept  in  position  chiefly  by  the  connective  tissue  sheaths  which  accom- 
pany the  blood-vessels  supplying  them,  and  it  is  injury  and  stretching  of  this  connective 
tissue  which  allows  of  descent  of  the  organs  named.  There  is  no  doubt,  however,  that 
injuries  to  the  fixed  portion  of  the  pelvic  floor,  the  perineal  body,  and  levatores  ani  muscles 


PROLAPSE    OP    THE     UTERUS  539 

and  their  fasciir.  will  contribute  something  to  the  facility  witli  which  the  structures 
mentioned  may  descend.  In  practice,  therefore,  prolapse  of  the  uterus  and  descent  of  the 
pelvic  floor  lead  to  the  appearance  of  a  swelling  at  the  vaginal  orifice.  There  are  other 
swellings  which  come  down  the  vagina  and  appear  at  the  vulva,  and  from  them,  therefore, 
prolapse  of  the  uterus  has  to  be  diagnosed.  These  swellings  are  :  (1)  Hi/pertrojihic  elonga- 
tion of  the  eeri-i.r  uteri  :  (2)  A  tumour  protruding  from  the  vagina  ;  (3)  Inversion  of  the 
uterus  ;    (4)   C'l/storele  anil  rectoeele  :    (5)  Extroversion  of  the  bladder. 

Hypertrophy  of  the  Cervix  may  be  of  the  vaginal,  the  intermediate,  or  the  supra- 
vaginal portion.  The  first  is  always  congenital,  and  consists  of  elongation  of  the  portio 
vaginalis.  It  may  jirotrude  from  the  vaginal  entrance,  but  the  vaginal  fornices  will  be 
found  vinaltered  at  their  usual  level,  and  the  sound  will  pass  an  increased  distance  ])ropor- 
tioniitc  to  the  length  of  the  portio.  The  os  uteri  forms  the  apex  of  the  [irotrusion.  The 
fundus  remains  at  its  usual  level.  In  hypertroj)hy  of  the  intermediate  portion  the  anterior 
fornix  of  the  vagina  is  carried  downwards  with  the  cervix  and  may  be  obliterated,  whilst 
the  posterior  fornix  remains  at  its  usual  level,  because  the  elongated  portion  lies  between 
the  insertion  levels  of  the  anterior  and  posterior  vaginal  walls.  The  sound  passes  an 
increased  distance,  and  the  os  uteri  forms  the  apex  of  the  protrusion.  The  fundus  remains 
at  its  usual  level.  In  hypertrophy  of  the  supravaginal  portion  both  fornices  are  carried 
down  with  the  cervix,  and  both  may  be  obliterated.  The  bladder  is  displaced  down- 
wards, but  the  rectum  does  not  descend.  The  fundus  uteri  will  be  found  on  bimanual 
examination  to  be  at  its  usual  level,  whilst  in  true  prolapse  the  fundus  uteri  descends  as 
a  whole  with  the  rest  of  the  uterus.  It  is  common  for  some  jirolapse  of  the  uterus  as  a 
whole  to  accompany  elongation  (if  the  cervix,  and  this  can  be  appreciated  only  by  a  care- 
ful bimanual  exaniinatidii. 

A  Tumour  protruding  into  nr  fnmi  the  vagina  is  most  commonly  a  /ibroiui/oma  of 
the  uterus.  It  may  be  a  pedunculatcti  growth  either  of  the  cervix,  or  protruding  through 
it.  in  either  case  hanging  free  in  the  vagina.  It  may  grow  from  the  cervix  in  the  connec- 
tive tissue  in  front,  between  the  uterus,  bladder,  and  anterior  vaginal  wall  ;  or  behind, 
between  the  uterus,  rectum,  and  jjosterior  vaginal  wall  :  in  either  case  the  vaginal  wall 
is  stretched  over  the  growth.  The  uterus  will  be  felt  high  up.  When  the  i)eduneulated 
growth  is  protruding  from  the  os  the  liard  ring  of  the  cervix  is  felt  encircling  the  pedicle. 
In  the  case  of  sessile  interstitial  growths,  the  cervix  is  high  up  in  front  or  behind  the 
growth,  as  the  case  may  be,  and  if  the  tumour  is  a  large  one,  may  be  out  of  reach 
altogetlier.  In  any  case  there  is  no  descent  of  the  uterus,  and  it  may  even  be  higher  than 
usual.  The  growth  may  be  a  fibroid  groici}ig  from  the  vagiuul  nail,  a  mucous  poll/pus  of 
the  eer\  ix.  or  ii  maligiiaiil  gronlh. 

Inversion  of  the  Uterus  may  be  ehmiiic.  or  may  (ncur  immediately  after  labour  as 
an  acute  condition  which  could  hardly  be  mislakeii  lor  anything  el.se,  except  perhaps 
extrusion  of  a  fibroid  immediately  after  delivery.  In  Ihr  latter  case  the  tumour  protrudes 
through  the  cervix,  whilst  the  whole  uterus  can  be  felt  above  it  bim-imially.  whereas  in 
iriMTsion  the  uterus  turns  inside-out.  partially  or  completely,  a  cup-shaped  de))ression  is 
felt  above  instead  of  the  rounded  fundus,  and  a  finger  or  the  sound  will  only  pass  a  short 
way  by  the  side  of  the  mass,  or  not  at  all  if  inversion  is  complete.  Hoth  conditions  may  be 
aceompanie<l  by  luemorrhage,  but  that  with  inversion  may  be  exe<u'(liiigiy  severe,  .\cute 
inversion  is  always  accompanied  by  great  shock,  whilst  extrusion  of  a  fibroid  is  not. 
t'lironic  inversicm  is  more  likely  to  1)e  mistaken  for  prolapse  or  a  polypoid  libromyoma. 
It  is  distinguished  from  prolapse  in  that  the  uterus  does  mil  necessarily  deseend  as  a  whole, 
the  cervical  ring  is  felt  high  up  in  its  usual  position,  and  the  sound  will  onl\  pass  a  short 
<list!in(e  all  roimd  the  protruding  mass,  according  to  the  degree  to  which  the  uterus  is 
inverted.  A  ciipslMprd  depression,  instead  of  llir  roUTided  lundus.  is  felt  in  I  he  vaginal 
vault   by  a  liarid  on  the  abdominal  wail. 

Cystocele  and  Rectoeele  more  often  accfunpany  (irolapse  of  the  uterus,  but  may 
occur  indepeiiileni  ly  ol  it .  They  are  essentially  bulgings  of  the  anterior  or  posterior  vaginal 
walls  towards  or  through  the  vagin:d  entrance,  the  bladder  or  rectum  being  attached,  and 
following  them  of  necessity.  .\  sound  passed  itdo  the  bladder,  or  a  finger  in  the  rectum, 
will  directly  enter  th<-  bulging  vaginal  wall,  whilst  the  uterus  will  be  felt  bimanually  above 
in    Its   normal   position. 

Extroversion    of    the    Bladder   can    oi-cur    either   through   a   congenital   d<leet    in   its 


540  PRURITUS 

wall,  or  through  an  injury  tii  its  basal  portion  :  for  instance,  in  removing  a  growth  from 
the  vaginal  wall  a  ga])  may  be  left  in  the  bladder  through  which  extroversion  may  occur. 
The  mucous  membrane  will  be  exposed  in  the  vagina,  and  on  it  will  be  seen  the  two  orifices 
of  the  ureters,  with  urine  issuing  by  intermittent  jets.  The  uterus  in  such  a  case  may 
have  its  normal  position.  Thos.  G.  Stevens. 

PROPTOSIS.— (See  ExoPHTn.\LMOS.  p.  229.) 

PRURITUS. — Itching  may  occur  without  visible  lesions  of  the  skin,  saVe  those  due 
to  scratcliing.  or  may  be  associated  with  various  cutaneous  eruptions.  It  is  to  the  former 
condition  that  the  word  '  pruritus  "  should  be  restricted.  ■  The  diseases  of  which  itching 
is  a  symptom  may  be  either  neuroses,  such  as  hysteria,  hypochondriasis,  and  other  affec- 
tions of  the  nervous  centres,  or  general  nutritive  disorders  affecting  the  nervous  system 
secondarily,  such  as  arthritism  and  diabetes  mellitus  ;  or  the  irritation  may  be  set  up  by 
the  attacks  of  parasites,  or  by  definite  skin  lesions.  Itching  varies  in  character  :  it  may 
be  interpreted  by  the  patient  as  a  tingling,  or  jirieking,  or  as  a  formication — ^a  feeling  as  of 
insects  crawling  on  the  skin.  It  varies  also  in  degree,  from  a  mild  sensation  which  is  wel- 
come to  the  patient  from  the  pleasure  he  finds  in  scratching,  to  an  irritation  so  severe  and 
persistent  as  to  endanger  his  life  from  sleeplessness,  or  liis  reason  from  the  nervous  irrita- 
bility which  it  sets  up.  The  affections  in  which  itching  is  .slight  are  seborrhoea.  erythema, 
pityriasis  rubra  pilaris,  and  pemphigus  ;  it  is  more  severe,  in  varying  degrees,  in  eczema, 
prurigo,  some  cases  of  psoriasis,  dermatitis  herpetiformis,  dermatitis  gestationis,  applica- 
tion dermatitis,  lichen  planus,  lichenization,  lichen  urticatus,  pityriasis  rubra,  mycosis 
fungoides,  pityriasis  rosea,  cheiropompholyx,  chilblain,  prickly  heat,  tinea  marginata, 
urticaria,  scabies,  the  various  kinds  of  pediculosis.  Hea-,  mosquito-,  and  bug-bites,  jellyfish 
and  other  stings.  Even  in  the  affections  in  which  it  is  usually  severe  it  varies  much  in 
degree  in  different  cases.  Itching  seldom  has  any  distinct  diagnostic  value,  but  in  cases  in 
which  the  cutaneous  lesions  may  admit  of  more  than  one  interpretation,  its  presence  or 
absence  may  suffice  to  turn  the  balance.     Syphilides  hardly  ever  itch. 

Pruritus  proper  may  be  general  or  local.  Of  general  pruritus  tliere  are  four  varieties 
— pruritus  universalis,  pruritus  hiemalis,  pruritus  senilis,  and  bath  pruritus.  The  local 
varieties  affect  chiefly  the  anus,  the  vidva,  and  the  scrotum,  but  the  nares,  the  palms  of 
the  hands,  and  the  soles  of  the  feet  may  be  the  seat  of  the  irritation.  One  of  the  most 
curious  forms  of  pruritus  is  that  which  is  associated  with  bathing.  According  to  Stelwagon, 
who  has  made  it  a  subject  of  special  study,  it  most  commonly  affects  the  legs  from  the  hips 
downwards  :  but  the  forearms  also  may  be  involved,  and  it  may  have  even  wider  range. 
It  is  an  affection  of  adolescence  and  adult  life,  and  is  more  frequent  in  males  than  in 
females. 

If  no  lesions  of  the  skin  are  present  save  those  which  can  be  accounted  for,  directly  or 
indirectly,  by  the  scratching,  the  diagnosis  of  pruritus  '  imposes  itself."  Care  must,  how- 
ever, be  taken  to  exclude  all  possible  sources  of  parasitic  irritation  ;  and  it  must  always 
be  remembered  that  lice  and  acari  sometimes  find  harbourage  in  the  mo.st  unexpected 
quarters.  If  the  scratches  are  on  the  shoulders,  or  in  the  genital  region,  the  ])resence  of 
lice  must  be  suspected  ;  if  on  the  wrists  and  between  the  fingers  the  burrows  of  the  Acririis 
scabiei  must  be  sought  for.  Some  patients,  without  developing  actual  lu'ticaria.  suffer 
from  severe  itching  after  the  ingestion  of  certain  foods,  notably  strawberries,  or  crab. 
After  serum  injections  pruritus  may  be  extreme,  especially  about  the  ninth  day.  though 
urticaria  generally  accompanies  it.  Piniritus  from  the  irritation  of  sugar  (grocer's  itch), 
or  of  primula  obconica  or  rhus  toxicodendron  (gardener's  itch)  ;  or  of  satin  wood  sawdust 
(carpenter's  itch)  ;  or  of  some  kinds  of  soaps  ;  or  of  the  hairs  of  some  caterpillars,  may 
or  may  not  be  associated  with  objective  evidence  of  dermatitis.  Only  when  careful  inves- 
tigation fails  to  reveal  any  local  soiu'ce  of  irritation  should  the  case  be  diagnosed  as  one  of 
pruritus  pure  and  simple.  Malcolm  Morris. 

PTOSIS  is  the  term  applied  to  drooping  of  the  upper  eyelid  with  inability  to  raise  it  to 
the  full  extent  {Figs.  227,  228,  229,  230);  it  must  not  be  confused  with  the  inequality 
of  the  palpebral  apertures  sometimes  observed  in  people  accustomed  to  screw  up  one  eye. 

It    is   usually   caused  by  paralysis  of  the  third  nerve,  in  which  case   it   may  also  be 


PTOSIS 


associated  with  paralysis  of  other  ocular  muscles,  either  external  or  internal  (Fig.  itiS). 
Sometimes  it  is  accompanied  by  paralysis  of  other  motor  cranial  nerves  the  7th  for  instance 
(Figs.  229  and  "ilJO).  in  which  case  the  multiple  cranial  nerve  paralyses  immediately  sujiijest 
a  syjjhilitic  cause,  wliich  may  be  verified  in  many  cases  by  means  ot  Wassermann's  .serum 
reaction. 


Paralysis  of  thk  Left  Third  Xkrve. 


/'!-).  nil.  -Tlie  patients  f.ic«  :it  rest ;  lliere 
is  complete  ptosis  from  paraljrsis  of  the  left 
levator  palpebre  superioris.-  Note  the  scar 
of  the  healed  gumma  on  the  left  cheek  near 
tlie  left  angle  of  the  nose. 


J''i(;.  L':;s. — The  i 
his  right ;    the  left  . 
show  that  the  left 
the  right  owing  to 
ternal  rectus  muscle, 


iNFRAXCrLKAK    7111    N'F 


In  /«/;f////s/.s-  of  llif  rcrrinil  si/iiiiiiilliilic.  sllylil  pliisis  may  Ix'  associated  with  diininiilioii 
ill  (he  vi/i'  (il  III.'  pupil  on  the  allcclcil  side,  and  rrdaclion  of  the  eyeball  or  cnoplillialiiKis. 
11   in:i\   :iK(i  (icciir  in  im/d.sllicnin  griwi.i  (Fiu .  111.  p.  2:!.")). 

i'lcisis  of  Ihc  lids,  associated  with  much  .edema  ami  inllll  rali.iii  of  the  li.K.  is  als.i  r.>iiii.i 
ill  all  iii/fiiDiwiiloii/  iiflnliolin  of  the  conjiincl  i  va.  in  (iiigitiiitiiiiilic  iriliiiids  (Fig.  ITS.  p.  H'.'). 
aii.l  is  a  very  constant  sympt.)m  in  Iriulmmn. 


542  PTYALLSM 

Congenitdl  ptosis  is  usually  bilateral,  and  associated  with  sniootliness  of  the  upper  lids 
and  absence  of  all  the  usual  cutaneous  folds.  The  levator  palpebnc  is  absent  or  ill-developed, 
and  efforts  to  open  the  eye  are  made  by  the  occipito-frontalis  muscle.  Herbert  L.  Enson. 

PTYALISM  denotes  excessive  secretion  of  saliva.  It  is  not  easy,  however,  to  deter- 
mine in  every  case  whether  there  is  really  excess,  or  whether  the  patient  is  not  merely 
allowing  the  normal  saliva  to  dribble  from  the  mouth.  It  is  dilTicult  to  draw  an  absolute 
distinction,  therefore,  between  dribbling  of  saliva  and  ptyalism.  though  in  practice  the 
nature  of  the  case  may  be  obvious  enough.  One  has  but  to  consider  the  various  condi- 
tions under  which  trouble  with  the  saliva  may  arise  to  see  how  in  some  cases  the  difficulty 
is  solely  one  of  swallowing  the  normal  secretion,  as  in  bulbar  paralysis  and  in  babies  ;  how 
in  others  there  is  both  excess  of  secretion  and  difficulty  in  swallowing  it,  as  in  mercurial 
stomatitis  ;  and  how  in  others,  again,  there  is  too  much  secretion  but  no  difficulty  in 
swallowing  it,  as  in  fimctional  or  hysterical  ptyalorrhoea.  The  first  step  in  arriving  at 
the  diagnosis  of  the  cause  is  to  inquire  carefully  as  to  any  medicine  or  drug  the  patient  may 
be  taking  orally  or  applying  externally,  especially  : — 

Mercury  i  Bromide  Aconite 

Pilocarpine  Phosi)hoiiis  Chlorate  of  potash 

Jaborandi  !  .\rsenic  Cantharides 

Iodide  I  Antimony  Copper  salts. 

Mercury  is  the  most  important  of  these  ;  its  effects  are  most  serious  when  the  mouth 
is  not  kept  scrupulously  clean,  particularly  when  there  is  also  nephritis,  as  is  not  uncom- 
mon in  severe  secondary  syphilis.  The  saliva  is  also  apt  to  have  peculiar  effects  when 
mercury  is  being  taken  ;  thus,  in  repairing  submarine  cables  it  is  customary  to  use  saliva  in 
completing  the  process  of  covering  in  the  central  core,  and  it  has  been  found  that  if  the 
repairer  is  taking  mercury  medicinally  the  repaired  part  of  the  cable  speedily  becomes 
defective  again,  in  a  way  which  does  not  residt  when  the  repairer  is  a  healthy  man  taking  no 
medicine. 

If  the  salivation  is  not  due  to  any  drug,  it  may  be  the  result  of  one  of  the  many  forms 
of  general  stomatitis  : — 

Aplithous  Variolous  ,  Due  to  angina  Ludovici 

Dyspeptic  '  Diphtheritic                                                    ,,        cancrum  oris 

Septic  Syphilitic  I  ,,        pernicious  anaemia 

Suppurative  I  Tuberculous  I            ..        haemophilia 

Ulcerous  I  Due  to  pyorrhoea  alveolaris                     ,,        sprue 

Malignant  I          „       necrosis  of  the  jaw  |           „       scurvy. 

The  exact  nature  of  a  severe  stomatitis  will  be  diagnosed  by  making  a  careful  local 
examination,  ocular  and  digital,  assisted  by  the  history  and,  if  need  be,  by  bacteriological 
examination  of  swabbings  from  the  mouth,  by  Wassermann's  serum  reaction  for  syphilis, 
or  by  microscopical  examination  of  a  fragment  of  the  affected  tissues.  Tuberculous  stoma- 
titis is  one  of  the  rarer  forms,  but  when  it  occurs  it  is  severe  ;  it  may  be  primary,  but  more 
often  is  associated  with  obvious  phthisis. 

If  drugs  and  general  stomatitis  can  be  excluded,  local  examination  may  still  serve  to 
detect  a  local  cause  acting  by  reflex  irritation  of  the  fifth  nerve,  especially  : — 


A  jagged  carious  tooth  I    A  ranula 

A  rough  filling  \  gumboil 

A  stump  left  beneath  a  tooth-plate  An  epulis 

A  broken  or  ill-fitting  tooth-plate 
A  foreign  body,  such  as  a  fishbone,  impacted 

in  the  gum 
Neuralgia  of  the  fifth  nerve 


A  myeloid  sarcoma  of  the  jaw 
A  sniivary  calculus 

An  eschar  kit  by  some  recent  irritant  or  corro- 
sive substance,  or  injury. 


If  careful  examination  serves  to  exclude  all  these,  the  salivation,  apparent  rather 
than  real,  may  be  found  to  result  from  mechanical  difficulties  in  szvalloiving.  the  effect  of 
such  lesions  as  : — 


Mumps 

Acute  tonsillitis 

Quinsy 

Fracture  of  the  jaw 

Dislocation  of  the  jaw 


Fixation  of  the  j.aw,  as  by  osteoarthritis  of 

the  temporo-maxillary   joint 
Painful  affections    of  the  larynx,    pharynx, 

or  oesophagus. 


PULSATION.     UNDUE    ABDOMINAL    AORTIC  543 

In  the  absence  of  any  obvious  structural  lesion  locally,  it  may  yet  be  clear  that 
inability  to  swallow,  owing  to  paralysis  of  some  kind,  is  the  cause  of  the  apparent  sali- 
vation, for  instance  in  cases  of  : — 

Bulbar  paralysis  I     Myasthenia  gravis  '      Paralysis   agitans 

Pseufio-bulbar   ])aralysis  Hypoglossal  nerve  paralysis        i      Hydrophobia. 

Bilateral  facial  paralysis      I     Diphtheritic    paralysis 

The  differential  diagnosis  of  these  conditions  is  discussed  elsewhere,  and  of  them  all 
it  is  only  in  bulbar  and  pseudo-bulbar  paralysis  that  the  dribbling  of  much  saliva  is  a  pro- 
minent symptom.  The  sequence  of  events  summarized  by  the  term  labio-glosso-pharyngo- 
laryngeal  paralysis  is  sufficiently  characteristic  as  a  rule  ;  pseudo-bulbar  paralysis,  bein" 
of  cortical  instead  of  medullary  origin,  has  not  the  wasting  of  the  tongue  that  is  prominent 
in  the  latter. 

The  salivation  that  results  from  gastric  or  hepatic  reflexes  is  almost  physiological, 
though  sometimes  it  reaches  a  pathological  degree  in  certain  cases  of  : — 

Dilatation  of  the  stomach  I      Acute   dyspepsia  I    Biliousness 

Gastric  ulcer  I       Acute  gastritis  Hepatic   disorder 

Duodenal  ulcer  I      Gastric  carcinoma  I     Pancreatitis. 

Mere  slovenliness  and  lack  of  ])roper  cerebral  control  are  responsible  for  the  slobbering 
and  salivation  of  : — 

Idiots  I       Imbeciles  |       Dements  and  otiiir  mental  cases. 

Finally,  a  remarkable  degree  of  salivation  can  sometimes  be  attributed  to  nothing  but 
functional  disorder — pti/alorrlioea.  It  can  scarcely  be  called  hysterical,  because  it  may 
occur  in  men  as  well  as  in  women,  generally  in  later  life  rather  than  at  a  time  when  hysteria 
is  commonest.  The  condition  is  a  sort  of  salivary  neurosis,  which  may  come  on  suddenly 
and  without  obvious  cause,  or  as  the  result  of  some  worry,  shock,  or  mental  emotion.  It 
may  possibly  be  a  functional  affection  of  the  oth  nerve  analogous  to  the  far  more  distress- 
ing tic  douloureux.  It  is  sometimes  prominent  amongst  the  neuroses  that  are  apt  to 
accompany  |)regnancy.  It  can  only  be  diagnosed  when  a  careful  examination  has  served 
to  exclude  any  likelihood  of  organic  disease,  when  the  history  is  suggestive,  and  when  the 
excessive  salivation  ceases  after  a  time  almost  as  suddenly  as  it  began.  In  some  male 
cases,  notwithstanding  the  diagnosis  being  '  functional,"  a  high  blood-pressure  will  be 
found,  with  other  signs  of  arteriosclerosis,  suggesting  that  errors  in  the  circulation  involv- 
ing the  vasomotor  and  other  brain  centres  are  responsible  for  the  symptom. 

Ilerliert  French, 
PULSATING    TUMOURS.— (See  Swiclmnc.  PrLs.vTii.K.  p.  093.) 

PULSATION,  UNDUE  ABDOMINAL  AORTIC— Excessiv.  pulsation  of  the 
abdominal  aorta  may  occur  in  cases  of  aortic  regurgitation,  when  all  the  arteries  through- 
out the  body  may  pulsate  with  imdue  violence.  Apart  from  aortic  regurgitation,  how- 
ever, it  is  nearly  always  an  entirely  functional  disorder  of  the  aorta.  It  occurs  nuich 
more  frequently  in  women  than  in  men.  the  patients  generally  being  mnnarricd  or  child- 
less, between  20  and  K)  years  of  age.  They  com])lain  of  |)ain  in  the  abdomen,  especi-dly 
in  the  cpigastriiUTi  :  a  feeling  of  discomfort  and  distress  ;  a  sensation  of  pulsation  and 
throbbing  o\(r  the  abdominal  aortiu;  nausea,  retching,  sickness,  and  eonstipal  ion  :  they 
arc  usually  thin,  an;emic.  extremely  nervous,  often  hysterical,  and  sometimes  decidedlv 
hypochondriacal.  TIutc  may  be  nothing  else  the  matter  with  them  at  all.  or  they  may 
be  suffering  from  some  other  complaint  of  which  nuich  nervousness  is  a  feature,  exoph- 
thahnic  goitre  for  example.  The  condition  is  frcipicntly  associated  with  movable  kidney 
and  <iilcroptosis  ;  the  symi)toms  may  suggest  som<-  organic  disease,  such  as  gastric  ulcer, 
appiiidicitis,  or  ovaritis,  without  any  of  these  being  present. 

On  palpation  of  the  abdomen  the  pulsation  may  be  foimd  to  be  forcible  ;  but  the 
normal  eyliiwlrical  outline  of  the  aorta  can  gciuTally  be  felt  to  be  (piitc  free  from  any 
siiceular  bulging  or  fusiform  dilatation  ;  there  is  no  thrill  over  it  ;  on  applying  a  stetho- 
scope lightly  to  the  pulsating  region  no  nuirmur  will  be  audible,  but  firmer  pressure,  sulli- 
eicnt  to  compress  the  aorta  slightly,  will  bring  out  a  systolic  bruit.  The  heart,  lungs,  and 
urine   are   usually    niirriial.      The   Uiiei-jirks  are   apt    lo   he   much   exaggcralc<l,    (hough   the 


544  PULSE.     IRREGULAR 

plantar  reflexes  remain  flexor,  and  tliere  is  no  ankle-clonus.  The  chief  importance  of  the 
condition  clinically  is  that  it  is  apt  to  be  mistaken  for  an  aneurysm  of  the  abdominal  aorta. 
Abdominal  aneurysm  is  so  extremely  rare  in  women,  however,  that  it  should  never  be 
diagnosed  unless  the  pulsation  can  be  made  out  to  be  definitely  expansile,  or  unless,  in 
addition  to  pulsation,  a  definite  swelling  of  the  aorta  can  be  felt.  Herbert  French. 

PULSE,  IRREGULAR.  — Xo  advance  in  clinical  medicine  is  more  striking  than  the 
chancre  which  lias  come  ()\cr  our  view  of  the  arrhythmic  pulse  during  the  past  decade. 
Formerly  we  felt  that  our  duty  was  finished  when  we  had  recorded  the  main  facts  :  as  to 
whether  the  force  or  the  frequency  varied,  or  both,  and  so  forth.  Now,  however,  it  is 
possible  to  refer  almost  every  type  of  irregularity  to  a  definite  cause,  and  thus  to  gain 
information  of  the  utmost  value  for  prognosis  and  treatment.  To  this  end  it  is  advisable 
that  each  case  should  be  investigated  by  means  of  the  recording  polygraph,  and  the  jugular 
and  arterial  curves  compared. 

The  Mackenzie  ink  polygraph,  the  best  of  these  instruments,  consists  of  (1)  .\ 
clockwork  machine  drawing  a  band  of  paper  at  a  uniform  rate  over  a  flat  surface  : 
(2)  Tambours  for  a])]5licati()n  to  different  parts  of  the  body  where  there  is  superficial 
pulsation  :  (3)  I.e\ers  connected  by  tubing  with  these  tambours,  carrying  pens  at  their 
free  ends  which  write  upon  the  travelling  paper  ;  (4)  A  time-marking  lever,  also  driven 
by  clockwork,  and  marking  five  times  per  second.  One  of  the  tambours  is  applied  to 
the  radial  artery,  and  the  other  to  the  internal  jugular  vein  at  the  root  of  the  neck  as  a 
rule.  The  result  is  a  synchronous  record  of  (i)  time  in  one-fifth  second  intervals, 
(ii)  the  movements  of  the  radial  artery,  (iii)  the  movements  of  the  jugular  vein.  In  the 
records  from  this  last,  each  cardiac  cycle  exhibits  three  jirincipal  waves.     Hy  comparison 


veritrioiiinr  systolic  pliiKe.      T.  Terminal  systolic   phas 
premature,  aiid  its  form  (diphasic)  indicates  that  only  a 


;ir  extnisystoles.     p.    Aurifiiliir  sy^loln-  ]iliasv. 

'  .   Ventricular  extrasystolic   pha-se.      This  movement 

of  the  ventricle  has  contracted  instead  of  the  whole. 


with  the  radial  trace  the  identity  of  the  ventrieulo-systolic  wave  (f)  is  established.  The 
wave  immediately  preceding  this  is  the  auriculo-systolic  (n).  and  the  interval  between 
its  origin  and  that  of  the  ventrieulo-systolic,  normally  about  -2  second,  is  spoken  of  as 
the  •  (i-c  interval."  It  constitutes  an  index  of  auriculo-ventricular  conductivity.  The 
third,  or  v  wave  arises  at  the  end  of  ventricular  systole.  The  chief  value  of  the  method 
lies  in  the  accuracy  with  which  it  enables  us  to  study  the  time  relations  of  auricular  and 
ventricular  svstole. 

A  still  newer  method,  of  great  value  in  dilferential  diagnosis,  is  by  means  of  eiectrocardio- 
grams.  Tfiis  method  depends  on  the  fact  that  contracting  muscle  is  an  electrical  battery, 
the  currents  in  which  can  be  appreciated  and  their  movements  recorded  by  a  suflicientiy 
delicate  galvanometer.  The  contracting  heart  thus  generates  currents  which  are  led  off 
to  an  extremely  sensitive  galvanometer,  and  the  photographic  records  made  from  this  can 
be  interpreted  in  terms  of  cardiac  movement  (Fig.  231).  Practically  every  one  of  the  large 
medical  schools  throughout  the  count ly  has  one  of  these  electrocardiographic  outfits, 
so  that  there  are  few  patients  to  whom  this  method  cannot  be  applied  if  the  practitioner 
feels  that  the  accuracy  of  the  information  derived  is  so  valuable  as  to  justify  the  expendi- 
ture of  time,  trouble,  and  money  involved.  Many  practitioners,  however,  are  obliged  to 
learn  what  they  can  about  their  ])atienfs  heart  without  these  means,  and  in  what  follows 
this  has  been  borne  in  mind. 


PULSE.     IRREGULAR  545 

First,  it  must  be  remembered  that  the  heart  generates  its  own  stimuH  ;  that  these 
normally  arise  at  the  sino-auricular  node,  a  relic  of  the  primitive  cardiac  tube  lying  at  the 
junction  of  the  sinus  venosus  with  the  right  auricle  ;  that  thence  they  pass  tlirough  the 
auricular  walls,  and  are  conducted  along  the  aiu-iculo-ventricular  bundles,  narrow  strips 
of  nuiscle — also  relics  of  the  primitive  cardiac  tube — into  the  ventricular  walls,  one  branch 
from  the  stem  of  the  main  bundle  running  to  each  ventricle  :  and  that  each  portion  of 
the  cardiac  muscle  contracts  as  this  stinuilus  provokes  it  to  do  so.  the  result  being  a  co- 
ordinated and  economical  movement  of  the  whole  heart. 

Pulse  irregularities  may  be  (1)  Perversioits  of  the  normal  rlii/tinn  :  (2)  lihifthms  origin- 
ating nhnorniallj).  Under  the  first  heading  fall  (a)  Irregularities  of  the  whole  heart — 
'sinus  arrhythmias" — due  to  extracardiac  influences  acting  through  the  vagus  on  the  sino- 
auricular  node  ;  (/;)  Irregularities  due  to  interference  with  the  conduction  of  impulses 
through  the  heart,  and  (■s])ecially  with  their  passage  from  aiiriclc  to  ventrick — "heart 
block'  :  and  (c)  Irregularities  in  the  response  of  the  musculature  to  the  stimuli  reaching 
it,  of  which  the  outstanding  example  is  the  "alternating  pulse."  Of  abnormally  originating 
rhythms  there  are  three  chief  examples  :  (a)  The  simple  extrasystole  or  premature  con- 
traction :  (h)  Paroxysmal  tachycardia,  and  (c)  The  totally  irregular  pulse  of  auricular 
fibrillation. 

1 .  Perversions  of  the  Normal  Rhythm  : — 

(a).  Sinus  irregiiliirilics  arc  s])((i:iliy  common  in  children  and  nervous  subjects,  in 
convalescence  and  a;-ate  illiu-ss.  and  in  the  presence  of  increased  intracranial  pressure. 
The  difference  in  length  between  two  sequent  beats  is  never  great,  and  sulliciently 
prolonged  observation  is  nearly  always  rewarded  by  the  discovery  of  a  '  dominant  rhythm ' 
— i.e..  a  normal  rhythm — from  which  the  pulse  departs  from  time  to  time.  This  type  of 
irregularity  is  singularly  apt  to  be  exaggerated  by  excitement,  and  by  bidding  the  patient 
swallow  or  hold  his  breath.  -As  it  does  not  depend  on  intracardiac  causes.  ])hysical  examin- 
ation of  the  heart  detects  no  sign  of  disease.  It  is  generally  possible  to  distinguish  it  from 
other  forms  of  Irregularity  without  instrumental  help  ;  but  sometimes  it  is  dillicult  to 
be  quite  sure  that  the  arrhythmia  is  of  this  type,  and  if  a  tracing  be  taken  it  shows  that 
auricular  and  ventricvilar  systole  are  following  each  other  in  normal  sequence. 

(h).  Ilcdrl-ljlock  is  of  various  grades.  The  mildest  type  is  that  in  which  the  interval 
elapsing  between  the  start  of  auricular  systole  and  that  of  ventricular  systole  is  prolonged 
(/•'/;.'.  ■2.'i2.  XX);  this  of  course  can  only  be  detected  by  graphic  records  of  the  arterial  and 

Tt^ne  =  2  second. 


Fi(f.'2Z'2. — Incomplete  heart-block.  Jfoteatx;  (i)  The  radial  pulse  misses  a  beat  entirely;  (ii)  The 
ju(,'ular  pulse  sbows  an  a  wave  without  a  sequent  c  wave.  This  means  that  auricular  systole  occurred 
at  the  normal  interval  after  the  preceding  cardiac  cycle,  but  that  ventricular  syptol*.  f:nlfMl  to  follow; 
tine  reason  beiiii^  that  disease  implicating  the  conductin^r  paths  liindered  the  noun  d  rrn    mh    nm  of 

stimuli  from  auricle  to  ventricle.     Note  at  xx  ;    The  loot.'  a-c  interval  (about  I'l    nnni In  atin^. 

considerable  thouL'h  incomplete  hindrance  to  tnuismisson  of  the  impulse  from  ;iumi  Ii    im  -• ).■. 

v<-nous  pulses.  The  next  graile.  in  wliich  some  oC  I  lie  descending  impulses  are  completely 
'blocked"  in  their  passage  from  auricle  to  ventricle,  reveals  itself  in  ordinary  observation 
of  the  pidse  as  a  dropping  of  beats  :  a  gap.  ecpiivalent  in  length  to  two  whole  ])ulse- 
beats,  separates  one  beat  from  that  which  preceded  it.  Here  the  auricle  has  contracted 
in  the  ordinary  way,  but  since  the  stimulus  which  ])rovoked  that  contraction  has  not 
passed  into  the  ventricle,  the  hitter  has  failed  to  contract  (Fig.  2;J2.  x).  This  jjroves 
that  there  is  some  disease  or  disorder  of  the  conducting  ajiparatus.  In  higher  grades 
of  block,  every  third  or  every  other  stinuilus,  or  even  two  out  of  three,  or  three  out  of 
four.  m;iy  fail  to  jiass  over  from  .■luricle  to  ventricle  (Fig.  2!!:!)  :  so  thai  the  auricle  may 
be  beating  72  to  the  minute  while  I  he  pulse  counlid  at  the  wrist  comes  to  18,  Itti.  21.,  or  18 
only.  In  the  higlicsl  grade  of  all  the  auricle  is  completely  dissociated  from  Hie  \cntricle. 
which  assumes  a  rliylhni  of  its  own,  usually  at  :i()  to  l()  p<'r  minul<'  ;  thus  the  :iiiriele  is 
L)  35 


546  PULSE.     IRREGULAR 

beatinff  regularly  at  one  rate  and  the  ventriele  at  another  quite  independent  of  that  of  the 
auriele. 

To  make  sure  that  a  dropped  heal,  or  a  slow  regular  pulse,  is  due  to  heart-bloek.  it  is 
therefore  necessary  to  prove  that  the  auriele  eontraeted  while  the  ventricle  failed  to  follow 
suit.  The  only  means  of  sueh  jjroof.  apart  from  the  use  of  the  polygraph,  is  furnished 
by  ob,servation  of  the  venous  pulse  in  the  neck.  If  this  can  be  seen  to  continue  regularly, 
during  the  radial  pauses,  as  well  as  immediately  before  the  radial  beats,  then  it  is  safe  to 
assume  tliat  the  condition  is  one  of  heart-block.  It  must  be  confessed,  however,  that 
this  is  very  often  dillicult,  and  sometimes  impossible,  and  that  the  observer  is  on  much 
firmer  ground  if  he  obtains  solid  proof  of  his  suspicion  in  the  form  of  a  graphic  record. 
This  will  show  that  in  the  intervals  when  the  pulse  failed  at  the  wrist,  the  wave  which 
represents  auricidar  systole  made  its  apjiearance  at  the  proper  moment  in  the  jugidar 
curve  (see  Fig.  232).  It  is  particularly  desirable  to  obtain  graphic  evidence  when  it  is  a 
matter  of  accounting  for  occasional  failures  of  the  radial  beat  ;  for,  as  will  be  shown 
below,  this  grade  of  block  may  be  simidated  by  extrasystoles  too  feeble  to  reach  the 
wrist  (see  F/f.  234).  and  also  in  extreme  exhaustion  of  contractility. 

In  the  higher  grades  of  block  the  patient  often  suffers  from  severe  syncopal  and 
epileptiform  attacks,  the  coincidence  of  which  with  heart-block  con.stitutes  the  Stokes- 
Adams  syndrome.  In  these  attacks  the  pulse  usually  becomes  slower  than  ever.  It 
is  not  quite  safe,  however,  to  conclude  from  the  coincidence  of  such  attacks  with  slow 
pulse  that  a  lesion  of  conductivity  is  present  ;  one  or  two  cases  have  been  described  in 
which  tracings  have  proved  that  the  whole  heart — auricle  as  well  as  \entricle — was  slowed  ; 
i,e.,  that  the  rhythm  was  altered  at  its  origin  at  the  sino-aurieular  node  and  not  in  its 


5CC, 


sec 


^6  se^s.  f 


\AJ 


Fig.  233. — Heart-blcck.    Tbe  ventricle  only  responds  to  every  fourth  stimulus  descending  to 
it  from  tlie  auricle.    Ttie  a-c  interval  is  more  than  twice  its  normal  length. 

passage  through  the  heart.  The  distinction  between  this  condition  and  that  of  heart - 
block  is  important,  for  the  latter  signifies  organic  di.sease  of  the  heart,  while  the  former 
does  not  ;  and  their  distinction  cannot  be  safely  founded  excejit  on  the  evidence  of 
graphic  records. 

If  the  existence  of  heart-block  l)e  definitely  i)roved.  it  points  practically  always  to 
the  existence  of  organic  disease  iin|)lieating  the  bundle  which  connects  auricle  with 
ventriele.  Heart-block  may  arise  in  connection  with  acute  infections  such  as  diphtheria, 
rheumatism,  influenza,  pneumonia,  or  ulcerative  endocarditis  ;  or  as  part  of  a  chronic 
disease  such  as  gumma  or  cardiosclerosis.  In  any  given  case  the  cause  of  the  block  can 
only  be  determined  by  a  general  consideration  of  all  its  features. 

(<■).  The  term  'pulsus  alternans'  is  reserved  for  cases  in  which  beats,  equal  in  lengtli. 
alternate  in  force  ;  that  is,  for  an  alternation  of  a  large  beat  with  a  small  beat,  but  not  of 
a  long  beat  with  a  short  beat.  This  jjhenomenon  is  an  expression  of  exhaustion  of  the 
contractile  power  of  tlie  ventricle,  and  it  is  therefore  of  serious  import.  In  some  instances 
it  can  be  detected  clearly  with  the  finger  on  the  pidse  ;  a  full  wave  is  followed  by  a  small 
wave,  and  this  again  by  a  fidl  wave,  and  so  on,  each  beat  being  of  equal  duration.  Often, 
however,  the  difference  in  the  amplitude  of  the  waves  is  so  minute  that  it  can  only  be 
detected  by  a  tracing.  Wliere  alternation  is  suspected,  confirmatory  evidence  may  some- 
times be  afforded  by  a  corresponding  alternation  in  the  intensity  of  the  first  cardiac  sound, 
particularly  if  it  be  accompanied  or  followed  by  a  bruit. 

In  connection  with  this  form  of  irregularity,  it  is  important  to  note  that  tlie  smaller 
beat  may  sometimes  be  so  feeble  as  to  fail  to  reach  the  wrist  ;  consequently  the  pidse 
appears  to  drop  a  beat. 


PULSE      IRREGULAR 


547 


2.  Rhythms  Originating  Abnormally  : — 

(a).  Turnins;  to  those  forms  of  irregularity  which  are  due  to  ectopic  generation  of 
stimuli,  one  finds  that  the  simplest  type,  the  exirnsi/stole,  is  very  common.  It  is  associated 
with  nervous  states  and  with  coronary  sclerosis,  and  though  it  is  of  no  great  import,  it 
is  often  productive  of  uncomfortable  sensations  which  distress  the  patient  ;  it  is  therefore 
necessary  to  recognize  its  nature  in  order  that  a  reassuring  statement  may  be  made.  The 
extrasystole  is  "  a  premature  contraction  of  auricle  and  ventricle  in  response  to  a  stimulus 
from  some  abnormal  part  of  the  heart,  where  otherwise  the  fundamental  rhythm  of  the 
heart  is  maintained  "  (Mackenzie). 

The  patient  sometimes  complains  of  feeling  as  if  his  heart  had  stopjied.  and  then  gone 
on  again  with  a  jerk  :  or  it  may  be  that  the  jerk  alone  is  felt.  The  oijserver,  with  his  Hnger 
on  the  radial  pulse,  feels  a  small  beat  occur  before  its  time,  i.e.,  at  a  shorter  interval  after 
the  preceding  beat  than  the  usual  pause  between  beats.  The  beat  which  follows  this 
premature  one  is  generally  more  forcible  than  normal  ;  in  some  cases  it  follows  after  a 
compensatory  pause,  i.e.,  a  pause  of  such  length  that  it  makes  up  for  the  brevity  of  the 
premature  beat,  the  two  together  being  equal  in  duration  to  two  normal  beats.  It  is  the 
small  ])remature  beat  which  signittes  the  occurrence  of  an  extrasystole  {Figs.  231.  234). 
Confirmatory  evidence  of  its  nature  may  often  be  found  in  the  heart-sounds  :  simul- 
taneously with  the  small  premature  beat  at  the  wrist,  a  premature  feeble  jiair  of  heart- 
sounds  (or  in  some  cases  the  first  sound  only)  is  heard. 

It  might  be  argued  that  if  the  extrasystole  can  be  thus  detected  by  ordinary  methods 
of  examination,  and  that  if  it  has  little  positive  significance  in  assisting  to  a  full  diagnosis 
of  the  case,  it  is  needless  to  apply  graphic  methods  to  its  elucidation  :    and  it  is  certainly 


Fif.  '2Zi. — Ventricular  extrasystole.  Note  at.  x  a  small  premature  raiUal  beat  :  tiiat  this  coincides  with  a  lartte 
wave  (c' )  in  the  jugular  curve,  (c)  is  therefore  a  ventricuio-systolic  wave,  and  as  it  is  itot  preceded  by  any  auri- 
mlar  movement,  it  denotes  a  premature  contraction,  or  *  e.>:trasystole,'  arising  in  the  ventricle.  Clinically  this  case 
simulated  '  heart  block  '  until  the  triw^ing  made^the  truth  plain. 


true  that  it  is  of  ill  forms  of  irregularity  the  one  in  which  tracing  is  least  esseiititil.  How- 
ever, there  are  one  or  two  considerations  which  may  make  a  tracing  advisable  and  c\en 
necessary  :  (i)  The  premature  contraction  may  be  so  small  that  its  beat  is  not  felt  at  the 
wrist  :  a  dro|>|)ed  beat  may  be  thus  simulated.  es))ecially  where  the  extrasystole  is  followeil 
by  a  compensatory  jjause.  In  such  cases  heart-block  may  be  wrongly  diagnosed,  iniless 
clearer  information  be  sought  in  a  tracing.  This  will  show  the  fault  to  be  due  to  a  feeble 
premature  beat,  and  not  to  a  bloekeil  auricular  im|)ulsc  (see  Fig.  234).  (ii)  lOxtrasystoles 
may  ocein-  in  eumplcNcs,  e.g.,  at  every  second  or  lliiril  beat.  In  the  former  case  an  alterna- 
tion will  restdt  :  a  full  beat  is  followed  at  a  short  interval  by  a  small  beat,  and  this  after  a 
long  interval  by  a  full  beat,  and  so  on  (pulsus  bigeminus).  The  true  nature  of  such  an 
arrhythmia  is  nnieh  easier  to  a|)preciafe  when  it  is  seen  mapped  out  in  a  tracing,  (iii)  .V 
polygraphie  record  enables  the  observer  to  discover  whether  the  prematiuH-  beat  arose  in 
the  auiiele,  in  the  ventricle,  or  in  the  junctional  tissues.  In  the  first  case  the  jugular  curve 
.shows  an  auricular  wa\e  preceding  the  premature  arteriid  beat  at  the  proper  interval  ; 
in  the  second  ease  there  is  no  such  auricular  wav<'  :  while  in  the  third  ease,  auricle  and 
ventricle  conlracl  simullane:>usly,  and  the  result  is  an  abnormally  large  wave  in  the 
jugular  eiir\c  A  knowledge  of  the  source  of  extrasystoles  may  occasionally  be  of  material 
value:  for  instaiiee.  in  mitral  slinosis  the  linal  breakdown  of  the  auricle  is  sometimes 
her.'llded  by  a  series  of  extrasystoles  of  auricular  origin.  II  is  true  that  as  i  rule  iiurieidar 
extrasystoles  are  not  followed  by  a  compensatory  pause,  while  I  hose  of  xcnlrieular  origin 
are;  but  it  is  not  always  easy  to  appreciate  Ibis  distinction  aparl  IVoiii  a  Iraiing.  and, 
moreover,  it  does  not  invariably  hold  good. 

{b).  In  paro.V!/smfil  Iddn/airdia,  as  (he  term  is  used  nowadays,  the  patient  sulTers  from 


548  PULSE.     IRREGULAR 

attacks  of  fast  hut  leoiilar  cardiac  action.  The  duration  of  these  may  vary  from  seconds 
to  days  ;  what  is  cliaracteristic  is  tlie  abrupt  transition  from  the  normal  to  the  rapid 
rhythm  and  back  ajiain.  at  the  onset  and  offset  of  the  attack.  Tlie  patient  is  conscious 
of  discomfort,  and  indeed  there  is  good  cause  if  the  sjjeed  be  above  a  certain  pitch  ;  for 
in  sucli  a  case  the  auricle  gets  no  time  for  emptying  itself,  and  becomes  over-distended, 
pulmonary  stagnation  with  cyanosis  and  venous  engorgement  resulting.  Tachycardial 
paroxysms  may  appear  on  a  background  of  organic  disease,  cardiosclerosis  and  mitral 
stenosis  in  particular  :  or  tlie  patients  lieart  may  be  normal.  This  form  of  iiregularity 
has  especially  to  be  distinguished  from  that  next  to  be  described,  the  total  arrhythmia  of 
auricular  fibrillation,  which  may  manifest  itself  in  paroxysms,  particularly  in  its  earlier 
stages.  The  distinguishing  point  is  that  in  true  paroxysmal  tachycardia  the  pulse  is  regular, 
whereas  in  the  other  it  is  quite  irregular 

IJy  means  of  a  ])olygraph  tracing  it  is  possible  to  discover  the  source  of  the  rajiid 
rliythm,  whether  it  is  auricular  or  ventricular,  in  most  eases.  The  complexity  of  the 
subject  of  cardiac  arrhythmia  is,  however,  illustrated  by  the  fact  that  there  is  a  form  of 
paroxysmal  tachycardia  arising  in  the  auricles,  which  beat  at  great  speed,  up  to  and  even 
exceeding  300  ]jcr  minute,  in  which  a  certain  jjroportion  of  the  beats  is  blocked  ;  so  that 
only  every  second,  third,  or  even  fourth  impulse  passes  over  into  the  ventricle.  That  is  to 
say,  the  auricle  may  be  in  a  state  of  paroxysmal  tachycardia,  and  yet  the  radial  jiulse  is 
hastened  but  little  or  not  at  all.  The  dilliculty  of  diagnosis  is  heightened  by  the  fact  that 
the  auricular  beats  do  not  always  appear  in  the  jugular  curve  of  a  polygraph  record,  though 
they  are  manifest  in  an  eleetroeardifigram.  This  form  of  tachycardia  goes  by  the  name  of 
'auricular  friction.' 

(c).  The  last  form  of  irregidarity  to  be  recognized  is  in  many  senses  the  most  important 
— the  total  nrrhj/lliDiid  which  is  associated  with  breakdown  and  fibrillation  of  the  auricles. 
This  is  essentially  a  terminal  phase  of  chronic  organic  disease,  especially  of  mitral  stenosis 
and  cardiosclerosis  ;  it  may  be  prolonged  for  years,  but  nevertheless  it  marks  a  certain 
'last  state"  of  the  auricular  musculature.  The  features  which  characterize  it  are  of  two 
kinds  :  those  which  mark  the  disa])pearance  of  auricular  systole,  and  the  evidences  of 
absolute  irregularity  of  the  pidse.  To  the  observer  using  ordinary  methods  of  examination 
without  apparatus,  this  latter  is  the  more  obvious  and  striking  side  of  the  ])icture.  If  the 
pulse  be  counted  for  one  or  two  niiiuites,  it  will  be  found  that  there  is  no  "dominant 
rhythm'  ;  anarchy  is  complete.  The  ])ulse  is  usually  hasty — over  100  per  minute — but 
not  always.  The  heart's  action  is  similarly  irregular,  and  on  comparing  it  with  the  arterial 
pulse,  a  certain  number  of  beats  too  feeble  to  reach  the  wrist  will  be  discovered.  Cessation 
of  effective  auricular  systole  is  manifested  in  two  ways  if  the  case  be  one  of  mitral  stenosis  :; 
by  disappearance  of  the  presystolic  thrill  and  bruit  (the  diastolic  vibration,  however,  per- 
sisting), and  by  disappearance  of  the  auriculo-systolic  wave  from  the  jugular  tracing.  Of 
course,  if  the  ease  be  not  one  of  mitral  disease,  there  are  no  jiresystolic  vibrations  to  dis- 
appear. However,  the  absolute  disorder  of  the  pulse,  coupled  with  evidences  of  organic 
disease  of  the  heart  and  a  gi'a\ely  embarrassed  circulation  combine  to  form  a  picture  so 
characteristic  that  there  is  little  fear  of  a  mistake.  Nevertheless,  there  are  cases  of  sinus 
irregularity  so  profound  that  without  a  polygraph  tracing  it  is  difficult  to  exclude  auriculai 
fibrillation  ;   the  same  may  be  said  of  some  few  cases  of  multiple  extrasystolic  irregularity. 

SUMMARY    OF    VARIATIONS    IN    RHYTHM    OF    PULSE. 

I. — The  raiiinl  jiiiisc  nnii/  be  ivhollij  regular,  Ijiit  aliiioniuilli)  slmc  or  aliiuirmallfj  quick. 

A. — Regular  Slow  Pulse  may  be  due  to — 

1.  Extraairdiac  causes  (convalescence  from  acute  illness,  sinus  irregularity,  raisec 
intracranial  pressure,  jaundice).  In  such,  the  whole  heart  is  slowed,  auricle  and  ventricle 
alike  ;   there  are  no  signs  of  cardiac  disease  ;   and  there  are  signs  of  extraeardiac  disease. 

■2.  Intracardiac  causes,  (a)  Alternating  extrasystotes  may  cause  an  apparent  regulai 
slowing  of  the  pulse  :  if  each  'normal"  beat  is  followed  by  a  premature  one  too  small  to  b« 
felt  at  the  wrist,  the  radial  pvdse  will  appear  slow.  The  real  interpretation  may  be  dis> 
covered  by  a  jjolygraph  tracing,  and  by  comparing  the  heart-sounds  with  the  pulse  at  th« 
wrist  ;  by  these  means  the  occurrence  of  the  small  premature  beat  after  every  normal  beat 
will  be  observed.     {Ij)  Hcarl-bliiek,  <ither  partial  or  complete,  will  render  the  radial  pulse 


PULSE,     IRREGULAR  549 

slow.  If  the  bii)ck  he  jjartial  but  regularly  recurrent,  the  pulse  at  the  wrist  will  be  regular 
and  slow  ;  e.g.,  if  the  auricle  is  beating  at  72  per  minute,  and  every  other  stimulus  is  blocked 
in  its  passage  from  auricle  to  ventricle,  a  regular  pulse  of  36  per  minute  will  be  the  result  ; 
while  if  two  out  of  every  three  stimuli  are  blocked,  the  ])ulse  will  beat  regularly  24  times 
l)er  minute.  If  the  block  be  complete,  auricle  and  ventricle  will  each  have  its  own  regular 
rhythm  :  that  of  the  ventricle  is  usually  at  the  rate  of  30  to  40  per  minute,  and  this  will 
accordingly  be  the  rate  of  the  pulse.  The  occurrence  of  e])ileptiform  and  syncopal  attacks 
is  to  a  large  extent  confirmatory  of  the  diagnosis  of  heart-block  ;  but  this  cannot  be 
accepted  as  proved  unless  it  has  been  demonstrated  that  when  the  auricle  contracts,  the 
ventricle  sometimes  or  always  fails  to  follow  suit.  This  evidence  is  provided  (i)  by  naked- 
eye  observation  of  jugular,  i.e.,  auricular,  movement,  (ii)  by  auscultation  detecting  auricular 
sounds  during  the  \entrieular  pauses,  (iii)  by  polygraph  records,  which  not  onlj^  afford 
conclusive  evidence,  but  also  facilitate  the  study  of  the  degree  of  block  pi-esent. 
Ii. — Regular  Rapid  Pulse  (and  see  Tachycardia,  p.  702)  may  be  due  to — 

1.  E.vlnicnnlinc  causes  (tuberculosis  and  other  infections,  excitement,  Graves's  disease, 
etc.).  Here  the  whole  heart  is  persistently  hurried,  and  the  cause  is  usually  manifest  ; 
moreover,  change  to  or  from  a  slower  rate  is  gradual  and  not  abrupt. 

2.  Intracardiac  causes.  The  only  important  intracardiac  condition  giving  rise  to  a 
quick  but  regular  pulse  is  that  form  of  ectopic  stimulus  production  which  manifests  itself 
in  paroxysmal  inclii/rardia.  Here  there  may  or  may  not  be  other  signs  of  cardiac  disease, 
mitral  stenosis  and  cardiosclerosis  being  the  commonest  ty])es  ;  the  tachycardia  is  tempo- 
rary, its  onset  and  cessation  being  abrupt. 

II. — The  radial  pulse  may  shoiv  a  fiindameiiial  rcgitlnrity.  nccasionaUy  interrupted  by 
premature  beats,  intermissions,  or  periods  of  irregularity. 

A. — Premature  Beats  may  be  single  or  midtiple  ;  they  may  recur  at  regular  or 
irregular  intervals  :  the  pause  following  them  may  or  may  not  be  compensatory  ;  the  beat 
next  following  the  jjause  is  often  increased  in  magnitude.  The  premature  beat  bespeaks 
an  extrasystole  ;  it  is  a  small  beat,  accompanied  by  heart -sounds  feebler  than  those  coincid- 
ing with  the  normal  beats. 

B. — Intermission  of  a  beat  or  beats  may  be  due  to  one  of  three  causes  :  a  premature 
extrasystolic  beat  too  feeble  to  reach  the  wrist  ;  a  blocked  auricular  stimulus  ;  or  a  com- 
parative failure  in  the  contractility  of  the  ventricle. 

1.  If  the  intermission  be  due  to  a  feeble  extrasystole,  tlie  im])erfect  heart-sounds  wliich 
accompany  the  prem.iture  beat  will  be  audible.  A  spliygmographic  tracing  will  sometimes 
bring  to  light  a  wave  too  feeble  to  be  perceived  with  the  finger.  The  pause  due  to  the  inter- 
mission is  shorter  than  the  duration  of  two  complete  beats,  if  the  gap  is  due  to  an 
nnperccived  extrasystole  which  is  not  followed  by  a  com])ensatory  pause. 

2.  If  it  be  due  to  a  blocked  auricular  impulse,  this  can  only  be  proved  by  deniouslruting 
the  oceuvrenec  of  auricular  systole  wilhoul  a  corresponding  ventricular  systole  following 
it  (he  usual  interval  :  and  it  is  scarccl\'  possibli-  to  do  this  wKliont  a  polygnipli  record  of 
jugular  and  radial  pulses.  The  auricular  systole  may  be  audible,  and  its  etlcet  visible  in 
the  Jugular  vein  :    bul  in  liolli  cases  timing  is  a  dillicult  matter. 

3.  If  it  be  due  l<>  a  iiornnilli/  timed  vnilricular  systole  loo  fcchlc  In  scud  u  xcai'i-  to  the  n'rist, 
other  evidences  of  failing  eontraclilc  p^)\ver,  among  them  llie  allernatiiig  pulse,  are  sure  to 
be  detected  ;  indeed,  this  type  of  intermission  is  in  realily  an  exaggeration  of  the 
alternating  pulse,  wilhoul  wliieli  il  will  not  occur. 

<".  Short  Periods  of  Irregularity  due  to  a  "sinus  disturbance"  are  very  common, 
especially  in  children  and  nervous  sohjeels.  The  diagnostic  features  are  absence  of  physical 
igns  of  cardiac  disease,  inarUed  \;iiialion  of  the  rhythm  with  n^spiralion  and  swallowing, 
»nd  implication  of  the  wIkjIc  liearl  auricle  as  well  as  ventriele  in  I  lie  irregularity. 
This  latter  fact  is  of  course  only  discerned  by  means  of  graphic  records  ;  bul  I  he  diagnosis 
jan  usually  be  inatlc  wilhout   rei'oursc  lo  Ihese. 

Longer  periods  of  total  arrhythmia  (r.  iufru.  IV,  ./),  sunielimes  interrupl  a  norma 
■hythm. 

]\l.    -The  radial  pulse  Is  arranged  in  pairs  of  beats. 

.1.— The  Pulsus  Bisferiens  is  a  single  beat  with  a  (loid)li-  suiinnil  (  A'/a'.  23.")).  This  can 


550  PULSE.    IRREGULAR 

easily  be  recojinizefl  by  the  faet  that  the  two  summits  are  very  elose  together,  and  that  one 
cycle  only  of  heart -sounds  corresponds  to  each  pair. 

B. — Alternating  Extrasystoles  cause  the  pulse  to  be  paired  (pulsus  bigeminus)  ;  each 
pair  consists  of  a  full  beat,  followed  after  an  abnormally  short  pause  by  a  small  beat.  F^ach 
beat,  whether  normal  or  abortive,  is  accompanied  by  a  cycle  of  heart-sounds  :  though  the 
second  sound  may  fail  if  the  accompanying  ])remature  extrasystolic  beat  be  too  feeble  to 
open  the  aortic  vahes.  A  sphygmographie  or  polygraphie  record  will  help  to  make  the 
nature  of  the  irregularity  clear. 

C. — The    Pulsus    Alternans 

is  associated  with  other  evidences 

Kadiat       ^^  inadefpiate  contractile  power. 

Each  jjair  consists  of  a  full  beat 

and  a  small  beat,  and  each  beat 

Jugular    is  equidistant  in  time  from  that 

preceding    and    that    following. 

X  similar  alternation  in  cardiac 

force   may   be    detected    in    the 

heart-sounds.      In    many    cases 

the  alternation  can   only  be   recognizecl  crrtainly  by  means  of  a  sphygmographie  tracing. 

D. — Blocking  of  every  third  Auricular  Stimulus  results  in  the  ventricular  contractions 

being  arranged  in  ])airs.     Each  beat  is  of  equal  force,  and  the  inteival  separating  each 

l)air  from  that  following  it  is  equivalent  to  the  duration  of  two  normal  pulse  waves. 

Heats  may  fall  regularly  in  groups  of  three  or  four  if  every  fourth  or  fifth  beat  is  either 
an  extrasystole,  or  missing,  owing  to  auriculo-ventricular  block. 

IV. — T]ic  pidnc  in  tiitiiUji  iirc«iil(ir.  no  fundamental  rhytlim  being  discoverable. 

A. — True  Total  Irregularity  is  associated  with  organic  disease,  either  post -rheumatic 
or  cardiosclerotic.  The  pulse  and  heart-sounds  are  altogether  irregular,  and  the  circula- 
tion is  obviously  embarrassed.  The  picture  is  therefore  characteristic  :  if  any  doubt  be 
present,  discovery  of  evidences  of  auricular  asystole  (loss  of  presystolic  thrill  and  murmur, 
failure  of  auriculo-systolic  wave  in  juguhir  curve  of  polygraph  tracing)  will  remove  it, 

B. — Total  Irregularity  may  be  Simulated  by  extreme  sinus  irregularity,  by  depres- 
sion of  conductivity  leading  to  variations  in  the  a-c  interval,  and  also  by  multiple  extra- 
systoles.     In  any  such  case  all  that  is  needed  to  establish  a  diagnosis  is  a  polygraph  tracing. 

It  is  clear  from  this  brief  siuimiary  that  most  forms  of  arrhythmia  can  be  recognized 
without  the  use  of  special  api)aratus  ;  but  that  in  many  cases  a  polygraphie  record  is  valu- 
able on  account  of  the  certainty  which  it  gives  to  the  diagnosis,  while  in  a  few  it  is  impossible 
to  be  sure  of  the  meaning  of  the  irregulaiity  without  such  a  record.  Curetj  Coombs. 

PULSE,   UNDULY    RAPID.   -(Sec  Tachvcaruia.  p.  702.) 

PULSE,   UNDULY    SLOW.— (See  Bradycardia,  p.  82.) 

PULSES,  UNEQUAL. — Inequality  of  the  pulses  may  be  a  perfectly  natural  phen- 
omenon ;  one  frequently  finds  that  the  radial  arteries  of  the  two  sides  are  not  of  the  same 
calibre,  owing  to  variable  degrees  of  collateral  circulation  by  an  enlarged  comes  nervi 
mediani.  Inequality  of  the  pulses  is  a  much  more  important  sign  when  known  io  have 
developed  in  a  patient  whose  pulses  were  formerly  normal.  In  such  a  ease  the  cause  is 
])robably  one  of  the  following  : — 

Thoracic  aneurysm  Accessory   cervical    rib  1         Atluronia. 

Mediastinal  new  growth      i        Embolism  I 

Pathological  inequality  of  the  pulses,  or  definite  delay  of  one  behind  the  other,  as 
gauged  by  simultaneous  palpation  of  the  two  radial  pulses,  is  distinctly  uncommon.  e\en 
in  cases  of  thoracic  aneurysm  ;  it  is  true  that  when  very  careful  simultaneous  records  are 
made  from  the  two  radial  pulses  slight  differences  in  size  and  definite  differences  in  time 
can  be  detected,  the  one  being  delayed  behind  the  other  ;  but  in  clinical  medicine  such 
minute  metliods  of  investigation  are  seldom  applicable  ;     if  the  aneurysm  involves  the 


PUPIL,     ABNORMALITIES    OF    THE  551 

origin  of  the  innominate  artery,  the  right  pulse  will  be  smaller  than  the  left  ;  whereas  if 
it  affects  that  part  of  the  arch  from  which  the  left  subclavian  artery  is  derived,  the  left 
radial  pulse  will  be  smaller  than  and  delayed  behind  the  right.  Sniiilar  delay  or  inequality 
might  be  produced  by  7iew  grozvlh  compressing  either  the  innominate  artery  on  the  right 
side  or  the  subclavian  artery  on  either  side  ;   but  this  is  rare. 

An  accessor))  cervical  rih  might  stenose  the  subclavian  artery,  but  the  condition  is 
generally  bilateral,  so  that  it  rarely  produces  inequality  of  the  radial  pulses:  its  sym- 
|)toms  are  more  likely  to  be  those  of  interference  with  the  lower  jiart  of  the  brachial  plexus, 
with  consequent  |)ain,  para-sthesia  or  ]jaresis  corresponding  to  the  nerves  distributed 
upon  the  ulnar  aspect  of  the  arms  and  hands  (p.  -1-13). 

Embolism  of  one  or  other  radial  artery  will  rather  obliterate  it  altogetlier  than  cause 
it  to  be  less  in  size  than  that  of  the  other  side.  It  will  almost  always  be  due  to  fungating 
endocarditis  (p.  .S4). 

Atheroma  of  the  brachial  or  subclavian  artery  on  one  side  might  cause  the  correspond- 
ing radial  pulse  to  be  less  than  that  on  the  other  :  but  this  very  rarely  happens,  and  in 
such  a  case  it  would  be  more  probable  that  atheroma  of  the  aorta  with  an  aneurysmal 
dilatation  would  be  diagnosed  than  atheroma  restricted  to  the  vessels  in  the  upper  arm, 
unless  the  .I'-rays  exhibited  no  trace  of  aneurysmal  opacity  in  the  thorax.        Herbert  French. 

PUPIL,  ABNORMALITIES  OF  THE.— .Abnormalities  of  the  pupil  may  be  classified 
into:--!.   Irrcfiiilinilics  in  sliiipc  :    II.   Irregularities  in  siie. 

I.  Irregularities  in  Shape. — The  normal  pupil  is  circular  or  slightly  oval.  Its  out- 
line may  become  hiegiilar  owing  to  an  adhesion  between  the  iris  and  the  lens,  the  result  of 
old  iritis.  These  adhesions  are  most  evident  when  tlie  ])upil  is  dilated.  A  similar  irregu- 
larity sometimes  occurs  with  the  persistence  of  a  papillari/  iiicnilirane — a  congenital  affection. 
The  adhesions  due  to  this  cause  may  be  distinguished  from  inllanunatory  adhesions  by  the 
fact  that  they  arise  from  the  anterior  surface  of  the  iris  at  a  slight  distance  from  the  pupil, 
and  not  from  the  posterior  surface  and  the  extreme  edge. 

The  ])upil  may  also  become  irregular  in  shape  as  the  result  of  injuries,  such  as  rupture 
of  the  sphincter,  and  tearing  of  tlic  root  of  the  iris  from  its  ciliary  adhesion  (iridodialysis)  ; 
of  dislocation  of  the  lens  :   or  of  partial  adherence  to  an  old  perforated  corneal  ulcer. 

II.  Irregularities  in  Movement  and  Size.  -Before  considering  the  irregularities  in 
tlie  movements  and  size  of  the  pupil,  it  is  desirable  to  remendjer  that  its  normal  size  varies 
during  life.  In  extreme  infancy  it  is  small.  It  becomes  larger  during  young  adult  and 
middle  life,  and  ultimately  becomes  small  again  in  old  age.  It  is  also,  as  a  general  rule, 
small  in  hypermetropic,  and  large  in  myopic  eyes. 

There  are  also  four  normal  |)upilltuy  rellexes  ;  (i)  The  light  rcllex  :  (ii)  The  rellex  to 
acconunodation  ;  (iii)  The  rellex  to  sensoi-y  stinudation  ;  (iv)  Psychic  rellexes.  The 
reflexes  to  light  and  to  accommodation  are  both  constrictive,  the  constriction  in  accommo- 
dation being  more  in  the  nature  of  an  associated  nuiscular  action.  The  sensory  and  psychic 
reflexes  are  both  dilatations,  the  dilatation  being  caused  by  either  sudden  sensory  stinnili 
or  some  sudden  emotion,  such  as  fright  or  terror. 

The  pathological  variations  in  the  pupil  iiiii\-  ))e  classilied  as  follows  : — 

1.  Loss  of  the  I'njiillari/  Li<^ltl  Ue/lcr.  cidier  with  or  without  constriction  of  the  pupil, 
but  with  persistence  of  tlie  reaction  to  acconiniodal  ion,  constitutes  the  Argyll  Kobertson 
pupil.  It  never  oceurs  in  healthy  individuals,  Iml  has  been  observed  most  fre(|uently  in 
tahes  florsalis.  to  an  extent  varying  accordinu  lo  diirerent  observers  from  70  to  !)(>  per  ceni 
of  all  the  cases.  The  condition  is  usually  permanent.  It  also  oceurs  in  general  paralt/sis 
of  tlie  insane.  The  pupil  is  constricted  in  nearly  all  tabetic  eases,  and  the  aireetion  is  nu)st 
{■ommonly  bilateral. 

•.i.  Loss  of  Coiit'crgent  .tccomniorlalioii  Jiefle.v  anil  lietentiou'itf  the  Light  lie/lex. — This 
eoiidilioii  is  extremely  rare,  but  has  been  observed  in  sjipliiUs.  basal  meningitis,  mi/clitis. 
atui  tumour  of  the  corpora  iiuailrigemina. 

:t.  Loss  of  the  Convergence  I'u/iillari/  llejler  may  be  unilateral  or  bilalcnil.  II  oeciirs, 
rarely,  in  tabes  ilorsalis.  and  after  some  cases  of  iliplillicria  and  iilriiholic  iiilii.ricalion . 

V.  Loss  of  all  Heller  Movements  of  the  I'lipil.  -In  this  condition  Ihere  is  paralysis  of  the 
siihineter  of  llie  pupil  and  of  the  eihary  unisele.  Ilie  exlrinsic  nuiseles  of  Ihe  <•>(■  being 
uiKincclcd  ((,plilliahiio(ilcgia  intciiia).      The    site  of   llic  l.sion  nnisl    l)e    in    Ihelhird    nerve 


552  PUPIL.     ABNOK.^IALITIES    OF    THE 

niielciis,  and  it  is  most  frequently  unilateral,  though  occasionally  bilateral.  Syphilis  is 
the  most  frequent  cause.  It  may  also  occur  after  dipliDieria,  ittjini/,  or  in  some  intracranial 
diseases. 

5.  In  the  condition  in  which  there  is  a  lesion  of  the  optic  nerve  on  one  side,  between  the 
chiasnia  and  the  globe,  there  will  be,  as  a  result,  a  loss  of  direct  lioht  reflex  in  that  eye,  and 
of  the  consensual  light  reHex  in  the  opposite  eye. 

6.  Loss  of  Sensory  or  Psychic  Reflex  occurs  in  lesions  of  the  dilatator  pupillary  tract, 
such  as  jjuralysis  of  the  cervical  sympathetic  :  in  which  condition  it  is  associated  with 
slight  ptosis  of  the  up])cr  lid,  enojihthalmos,  and  diminished  tension  of  the  globe. 

7.  Abnormal  Constriction  of  ii  Pupil.  Kith  Retention  of  the  Light  and  Convergent  Reflexes, 
may  occur  from  abnormal  stimuli  of  the  sphincter,  or  paralysis  of  the  dilatator  pupillse  as 
the  result  of  acute  encephalitis,  intracranial  abscess,  or  groivth,  in  which  the  lesiqn  irritates 
but  does  not  destroy  the  centre  for  con\ergence.  In  all  cases  of  brain  disease  the  constriction 
is  ultimately  replaced  by  dilatation. 

8.  Abnormal  Dilatation  of  the  Pupil,  -vith  Retention  of  the  Light  and  Convergent  Reflexes, 
is  met  with  in  cases  of  stimulation  of  the  cervical  sympathetic,  for  instance  by  an  aortic 
aneurysm.  It  may  also  be  observed  in  certain  mental  states,  such  as  epilepsy,  acute  mania, 
or  catalepsy. 

9.  Inequality  in  the  size  of  the  Pupils  is  observed  frequently,  and  may  have  no  patho- 
logical significance  ;  but  pronounced  difference  in  the  size  of  the  ])upils  is  nearly  always 
symptomatic  of  some  organic  lesion.  In  cases  where  the  abnormal  pupil  is  the  smaller, 
the  condition  is  usually  due  to  hyperflpmia  of  the  iris,  such  as  occurs  in  iritis  ;  paralysis  of 
the  cervical  sympathetic  :  or  the  use  of  a  myotic  drug  such  as  physosiigminc.  In  cases 
where  the  abnormal  pu])il  is  the  larger,  the  dilatation  is  usually  due  to  stimulation  of  the 
sympathetic,  the  use  of  a  mydriatic,  paralysis  of  the  fibres  of  the  third  nerve,  or  increased 
ocular  tension,  such  as  may  occur  in  glaucoma. 

In  cases  of  inequality  of  the  pupils  one  may  suspect  tabes,  general  paralysis  of  the 
insane,  a  unilateral  lesion  of  the  third  nerve  or  cervical  sympathetic,  trigeminal  neuralgia, 
carotid  or  aortic  aneurysm,  a  unilateral  intracranial  lesion,  or  glaucoma. 

10.  Irregularities  in  the  shape  of  the  pupils  other  than  those  mentioned  above  may 
occur  in  tabes  and  various  cases  of  insanity.  There  is  no  marked  or  sharp  irregularity,  it 
only  being  noticed  that  the  pupil  is  not  circular  owing  to  paralysis  of  certain  fibres  of  the  iris. 

11.  Ilippus. — This  term  is  .applied  to  a  condition  in  which,  when  both  eyes  are  shaded, 
and  then  illuminated,  the  pupils  will  alternately  dilate  and  contract.  It  is  sometimes  associ- 
ated with  nystagmus,  and  occurs  also  in  disseminated  sclerosis,  and  in  some  cases  oi  brain 
tumour.  It  is  obser\ed  most  frequently  when  there  is  a  central  scotoma  in  the  field  of 
vision,  with  some  injury  to  the  macular  or  axial  fibres  of  the  optic  nerve.  It  is  also  common 
in  alcoholic  subjects. 

12.  Paradoxical  I'upillary  Reflex  :  pupils  dilating  under  the  stimulus  of  light.  This 
condition  is  extremely  rare,  and  has  only  been  observed  in  patients  affected  with  grave 
lesions  of  the  central  nervous  system,  usually  tabes  dorsalis. 

VS.  Ilemianopic  Pupillary  Reflex  :  lesions  of  the  brain  situated  in  the  ojitie  tract  above 
the  corpora  quadrigemina  may  give  rise  to  partial  loss  of  vision,  but  will  not  affect  the 
pupil-reflex  arc.  For  example,  a  lesion  in  the  right  occi|)ital  cortex  may  give  rise  to  a  left 
homonymous  hemianojisia,  but  the  pupil  will  react  even  when  a  light  is  thrown  on  the  blind 
side  of  the  retina  (see  IIe:\ii.vnopsia.  p.  300).  In  cases,  however,  where  the  lesion  is  situated 
in  the  optic  tract  below  the  corpora  quadrigemina,  hemianopsia  may  also  occur,  but  under 
these  circumstances  no  pupillary  reflex  for  light  can  be  obtained  on  stimulus  of  the  blind 
side  of  the  retina,  the  pupil  reacting  to  light  when  the  opposite  side  of  the  retina  is  stimu- 
lated. This  reaction  is  termed  the  liemiopic  pujiillary  reflex,  and  is  of  great  value  in  the 
localization  of  intracranial  lesions.  Herbert  L.  Eason. 

PURPURA  signifies  haemorrhage  into  the  skin,  and,  according  to  the  size  of  the 
extravasatifm  of  blood,  the  lesions  are  spoken  of  as  puncta  or  s[)ots,  vibices  or  lines,  pete- 
chia" or  small  patches,  ecchymoses  or  bruises.  The  lesions  cannot  be  obliterated  by  pres- 
sure with  the  finger,  which  distinguishes  the  effused  blood  from  mere  congestion.  The 
diagnosis  of  the  actual  fact  of  purjmra  is  seldom  difhcult  :  the  persistence  of  the  discolora- 
tion under  pressure  differentiates  it  from  erythematous  lesions,  and  the  colour  generally 


PURPURA  553 

serves  to  distinguish  it  from  pigmentation  of  the  skin  other  than  that  (hie  to  hipmorrhage. 
In  a  case  of  doubt,  the  fact  tliat  the  lesions  presently  alter  in  colour  and  then  disappear 
serves  to  distinguish  purpura  from  ca|)illary  na?vi  or  from  pigmentation  of  the  skin,  which 
persist.  It  may  be  more  dilficuit.  however,  to  decide  what  is  the  nature  of  the  purpura  in 
any  given  ease  ;    the  following  is  a  list  of  its  better-recognized  causes  : — 


Causes  of  Purpura. 

1. — Due  to  Local  Injuries: 

Flea-bite  j     Blows 

Pediculosis  I     .Sprains 

Leech-bite  1     Rupture   of  a   muscle 

•2. — The  Effect  of  Drugs  and  Poisons  : 


.Antip\  rin 

Iodoform 

Iodide    of   Potassium 

.Sulphonal 

Copaiba 

Belladonna 

Chloral 

-In  Fevers  : 

Typhus    lc\er 
Cerebrospinal  fever 
Small-pox 
Pyaemia 
.Septica-mia 
Fungating     endocar- 
ditis 


Clilonil   liydrute 

Butyl-chloral  hydrate 

^'eronal 

.Mercury 

.\rsenic 

Quinine 

Ergot 


General   tuberculosis 

Dysentery 

Cholera 

Yellow    fever 

Weil's     disease,     or     bilious 

typhoid 
I'lajiue 


Rupture  of  a   vein,   especially 
a  \'aricose  vein. 


Salicylic   acid 
Potassium   chlorate 
Diphtheritic  antitoxin 
Ptomaine 
Snake-bite  poison. 


Remittent   fever 
Severe  malarial  fever 
Blackwater  fever 
Measles 
Diphtheria 
Typhoid  fever 
Scarlet  fever. 


4  — -In  association  with  Jaundice  from  whatever  cause  (see  J.vundice,  p.  324). 
5. — Bright's  Disease. 
G. — Chronic  Alcoholism  : 

Cirrliosis  (if  thr   liver        IVriplu-ral    MfiuiHs 

7. — The  so-called  Blood  Diseases  : 

Splciioiucdullary   leu-        PcrriicioMs  an  iiiiia  Barlow  s  disease. 

kainia  .Splenic  an.'cmia  Haniopliilia 

l.ympliatlc  Icukiemia       Pseudo-leuka'inia  iiilatituin 
Lyiiipliadenoma  !    Scurvy 

8. — In  cases  of  generalized  Malignant  Disease,  cspcciall\   : 


Sarcfunaffisis 

Peliosis  Rheumatica. 
Henoch's  Purpura. 
Purpura  Simplex. 

Mcillllls    riKMIlloMlsnC 

WcrllM.r 


I       CIlloIdllKl 


I'lirptira    lurindrrliaiiica 


Purpura   riilmiuaiis. 


A  nund)cr  of  the  above  conditions  rccpiire  but  little  iliseussion.  for  if  they  are  oidy 
borne  in  mind  their  diagnosis  will  gcfierally  be  easy. 

Fleri-hitrs  are  by  far  the  commonest  cause  of  purpura  in  the  <iMl-paticnl  (li'partmcnt 
of  a  hospital,  and  they  may  sometimes  be  .so  numerous  as  to  raise  a  misleading  suspicion 
thai  the  ])atient  is  sidTcring  from  some  serious  disease.  The  relatively  small  lucmorrhagie 
foci,  and  their  prevalence  on  the  parts  covered  by  the  clothes  rather  than  upon  the  hands, 
face,  or  exposed  parts  of  the  legs,  serve  to  indieale  Uie  diagnosis,  even  in  a  severe  case. 

The  commonest  variety  of  pcdinilosis  to  produce  juirpura  is  /'.  inr/ioris  or  vrslinifn- 
toriim  :  the  eireumstanees  of  the  case  and  the  distribution  of  llic  puipura  itself  and  of  the 
marks  of  scratching,  particularly  in  the  regions  where  j'ollars  and  oilier  constrictions  in  the 
dress  occur,  would  indicate  the  diagnosis. 

The  lucmorrhagc  around  a  leccli-bite  is  so  characteristic  Ihat.  once  seen,  it  camiot  be 
mistaken  for  aii\  thing  <-lsc. 

liliins  anil  sjiniiiis.  if  sullicienlly  severe,  produce  purpura  even  In  I  he  licailhy,  in  whom 


554  PURPURA 

tlio  history  gives  the  diagnosis  ;  it  is  important  to  bear  in  mind,  however,  that  some  normal 
individuals  bruise  with  such  ease  that  there  may  be  no  clear  evidence  of  injury  unless  care- 
ful inquiry  is  made,  when  some  trivial  stumble  or  knock  may  be  recalled  to  mind  by  the 
patient.  Such  easy  bruising  may  also  occur  in  any  of  the  blood  diseases.  A  case  of 
epilepsy  may  sometimes  come  under  observation  for  multiple  bruises  simulating  some 
other  kind  of  purpura,  but  due  to  injuries  produced  during  the  attacks,  which  may  them- 
selves be  unsuspected  if  they  occur  during  the  night.  Very  extensive  purpura  on  the  legs 
or  other  parts  has  sometimes  been  produced  by  multiple  self-injury  in  girls  suffering  from 
hysierin  or  by  malingerers  :  serious  organic  disease  may  be  feared  unless  other  factors  in 
the  case  or  the  distribution  of  the  purpura  suggests  an  artificial  origin  ;  the  h;emorrhagic 
spots  and  blotches  may  be  abundant  on  the  fronts  and  sides  of  the  legs,  for  instance,  and 
not  down  the  backs  of  them  ;    no  known  organic  purpura  has  so  selective  a  distribution. 

Spontaneous  rupture  of  a  muscle  leads  to  extensive  purpuric  extravasation  of  blood, 
but  the  diagnosis  is  not  diliicult  if  the  history  is  clear,  and  one  can  often  feel  the  place 
where  the  muscle  has  given  way  unless  it  is  too  deep-seated  to  palpate,  as  in  the  case  of  the 
plantaris  longus,  which  is  apt  to  rupture  during  sudden  efforts  such  as  may  be  made  in 
playing  tennis  or  the  organ. 

The  purpuric  discoloration  of  the  skin  around  vuricose  veins  in  tlie  legs,  together  wit!> 
its  resultant  dark-brown  pigmentation,  is  familiar  to  all. 

As  regards  drugs,  the  list  above  indicates  that  there  are  many  which  may  sometimes 
produce  purpura  ;  it  may  be  said  at  once,  however,  that  none  do  so  at  all  commonly. 
Nevertheless  the  possibility  should  be  borne  in  mind,  and  inquiry  made  as  to  the  remedies 
the  patient  may  have  been  taking.  Antidiphtheritic  serum  and  ptomnines  merit  particular 
attention.  The  commonest  eruption  resulting  from  anti-diphtheritic  serum,  or  from 
other  forms  of  antitoxic  horse-serum  administered  hypoderniieally,  is  in-ticaria  ;  purpura 
is  relatively  rare  ;  either  form  occurs  as  a  rule  about  nine  or  ten  days  after  the  serum  has 
been  given,  and  is  generally  associated  with  lassitude,  muscular  and  joint  pains,  anorexia, 
and  more  or  less  pyrexia,  lasting  from  a  few  hours  to  two  or  three  days.  Ptomaine  poison- 
ing is  often  difficult  to  recognize  with  certainty  unless  it  occurs  in  epidemic  form.  It  is  due 
in  most  cases  to  the  products  of  Gaertner's  bacillus,  and  seeing  that  the  blood-serum  of 
patients  affected  by  this  bacterium  develops  agglutinating  powers  against  it  similar  to 
Widal's  reaction  for  typhoid  fever,  this  serum  test  should  not  be  omitted  ;  if  it  provis 
positive  the  diagnosis  is  clear  ;  a  negative  result,  however,  does  not  exclude  ptomaine 
poisoning. 

In  the  majority  of  acute  fevers,  the  occurrence  of  ])urpura  is  of  prognostic  rather  than 
of  diagnostic  value  :  in  di])htheria,  for  example,  even  a  single  well-defined  purpuric  spot 
is  a  sign  of  grave  omen,  but  it  does  not  assist  at  all  in  the  diagnosis  of  the  disease,  which 
has  to  be  recognized  upon  other  grounds.  The  same  apijlies  to  measles,  scarlet  fever,  and 
so  on  ;  indeed,  the  only  two  fevers  in  which  purpura  is  of  essentially  diagnostic  value  are 
typhus  and  cerebrospinal  fever.  The  former  is  now  very  rare  in  Great  Britain,  but  when 
it  was  common  and  typhoid  fever  began  to  be  differentiated  from  it,  the  point  upon  which 
greatest  stress  was  laid  was  that  in  true  typhus  or  gaol  fever  there  is  always  more  or  less 
purpura,  whereas  in  typhoid  fever  all  the  red  spots  fade  upon  pressure.  It  happens  occa- 
sionally, even  yet,  that  typhus  fever  develops  in  the  poeirest  jjarts  of  cities,  and  this  point 
is  most  useful  in  distinguishing  it  from  typhoid.  In  the  latter,  if  tlea-bites  are  excluded, 
purpuric  spots  are  exceedingly  rare.  Cerebrospinal  fever  presents  many  characters  that 
are  common  to  it  and  to  other  forms  of  acute  meningitis  ;  but  if  with  these  there  is  a  pur- 
puric eruption,  it  is  at  once  differentiated  from  the  others,  though  the  absence  of  purpura 
does  not  exclude  the  disease.  So  characteristic  is  the  purpura  in  some  cases  that  the 
malady  lias  earned  the  title  of  spotted  fever,  which  used  to  occur  in  widespread  epidemics, 
and  still  does  in  smaller  ones  from  time  to  time.  The  diagnosis  may  be  clinched  by 
bacteriological  examination  of  the  cerebrospinal  Huid  obtained  by  lumbar  puncture. 

Smull-pox  may  jjresent  cutaneous  haemorrhages  of  three  different  kinds  ;  there  may 
be  luemorrliage  iuto  the  pustules  in  a  late  stage,  when  the  diagnosis  has  already  been  made 
and  when  the  prognosis  is  not  thereby  made  wor.se  ;  there  may  be  ha-morrhage  bctiveen 
the  pustules,  vesicles,  or  papules,  the  diagnosis  haviiig  already  been  made,  in  which  case 
the  prognosis  is  not  good  ;  and  there  may  be  a  hoemorrhagic  eru])tion  either  all  over  the 
body  or  in  the  bathing-drawers  regit)n  in  the  prodromal  stage  of  the  disease,  in  which  case 


PURPURA 


the  ))iitient  will  almost  certainly  die  before  the  true  sniall-pox  eruption  develops,  so  that 
if  there  is  not  an  epidemic  at  the  time  the  diagnosis  may  be  exceedingly  difficult. 

Almost  any  condition  in  which  there  are  pyogenic  micro-organisms  or  their  toxins 
circulating  in  the  blood-stream  may  be  associated  with  extensive  purpura,  and  this  applies 
to  ////(pntia  and  septicwmia  in  general.  The  diagnosis  will  be  confirmed  best  by  obtaining 
cultivations  from  the  blood,  though  should  blood-cultures  prove  negative  septicaemia  will 
not  be  excluded  necessarily  :  there  will  very  likely  have  been  rigors,  pyrexia,  and  other  sym- 
ptoms pointing  to  the  nature  of  the  case.  Fiuigaliiig  endocarditis  is  only  a  variety  of 
pj'.T-mia  or  septicemia,  .'•'eeing  that  it  is  very  rare  to  get  purpura  in  association  with 
chronic  valvular  disease  of  the  heart  if  both  purpiu'a  rheumatica  and  infective  endocarditis 
can  be  excluded,  the  occurrence  of  purpura  in  a  heart  case  (Fig.  236)  may  be  one  of  the 
main  sym|)toms  indicating  that  fungating  endocarditis  has  supervened.  So  indefinite  is 
the  nomenclature  in  regard  to  this  disease,  that  the  terms  malignant,  ulcerative,  fimgating, 
infected,  and  infective  endocarditis  are  used  indiscriminately  by  different  observers  to 
denote  the  same  condition.  The  disease  may  be  further  indicated  by  symptoms  described 
on  ]).  34.  Pi/f/nlirin  alvcolaris  is  another  .sejitic  infection  which  leads  occasionally  to  exten- 
sive |)ur])ura  and  other  haemorrhages. 

(k'licral  tuberculosis  is  not  a  common  cause  of  purpura,  and  yet  in  a  few  instances 
extensive  purpura  has 
been  the  first,  and  for 
the  time  being  the  only, 
symptom  of  an  obscure 
illness  which  has  ulti- 
mately turned  out  to  ]>i- 
general  tuberculosis. 
The  patient  has  gencrall\ 
been  a  child,  and  the 
diagnosis  has  only  been 
possible  when  the  course 
of  the  case  has  been 
watched.  The  same  may 
be  said  of  sarenmiitosis 
in  certain  cases,  though 
this  has  been  included 
tinder  a  different  heading 
in  the  above  list. 

Jfiiiiidice  should  be 
borne  in  mind  as  a  caiiM- 
of  purpura,  for  allhougli 
the     occurrence     of    the  ;  „  ,;; ,   _,  ,„„ ,„„„,,,„,,,  ,|,„„i,„,  „^,,„,w„  ,„„.|„„,,  i„  „  „,,o  of  f,n«atinu  cn.i,,- 

latter   does    not     assist     in  '■"■Ims.     The  lln.l.s  were  all,vt,-,l  uuinMhai,  tl.c  trunk.    From  the  same  cMse  as  ft.,.  L'70, 

I>.   (Ml). 

differentiating    one    kind 

of  jaundice  from  another,  one  might  be  misled  into  fliagnosing  something  more  serious  than 
is  necessary  if  one  did  not  bear  in  mind  that  any  kind  of  jaimdice  may  produce  ])urpura. 
Moreover,  some  of  these  patients  may  seem  to  have  been  grossly  ill-treated  if  one  were  to 
judge  only  b>-  the  degree  of  bruisingthat  m;i>-  result  from  ordinary  pidpatioii  :  the  danger 
of  fatal  oozing  after  operation  is  always  to  be  rememhered  when  surgical  measures  art- 
thought  of  in  a  jaundiced  subject.  Spontaneous  hicmorrhage  into  the  skin  is  less  conuiicni 
here  than  is  lucmorrhagc  from  what  otherwise  would  be  trivial  causes. 

lirighl's  diseiisv.  particularly  the  chronic  varieties,  may  produce  luemorrhage  any- 
where in  the  body.  I'lupuni  is  not  a  very  common  form  of  such  luemorrhage.  but  when 
it  does  occur  it  may  be  extensive.       'I'he  diagnosis   is  discussed  under  Ai.bimini  ui.v  (p.  (i). 

Chronic  alcoholism,  especially  if  it  has  already  led  to  either  cirrhosis  of  the  liver  or  to 
peripheral  neuritis,  is  occasionally  a  <-ause  of  considerable  purpura,  though  the  latter  is 
gen<Tally  confined  to  the  legs,  piirticularly  to  the  parts  below  the  knees.  In  many  instances 
the  diagnosis  is  easy,  even  if  the  history  is  not  given  with  perfect  honesty  :  but  consider- 
able iliHicidly  sometimes  arises  in  the  case  of  ladi<s  who  lia\c  contracted  the  habit  of 
secret  diiiikiiit;.  Ilicii-  nlalivis  ami  friends  li.in;;  fiilinK    iiiiaware  of  it. 


556  PURPURA 

Any  of  the  so-called  Mood  diseases  may  present  purpura  as  a  prominent  symptom, 
and  in  some  cases,  particularly  in  lymphaiic  leiikcemia  in  children,  extensive  purpura  may 
be  the  first  symptom  that  anything  is  wrong.  More  often,  however,  the  disease  has 
already  given  rise  to  anaemia  or  to  enlargement  of  the  spleen  or  lymphatic  glands,  or  to 
some  other  prominent  haemorrhage,  and  the  diagnosis  has  already  been  made  by  the  time 
the  purp>ira  su])ervenes.  (See  An.«mia,  p.  20  ;  Spleen,  Enlargement  of  the,  p.  628  : 
and  Lymphatic  Gland  Enlargement,  p.  376.) 

Scurvy  in  an  adult  is  relatively  rare,  but  is  sometimes  met  with  in  those  who  have 
been  obliged  by  poverty  to  live  upon  a  diet  containing  no  fresh  vegetables  ;  a  man  may 
try  to  live  for  a  month  or  more  on  plain  bread,  in  which  case  typical  scurvy  may  develop 
in  him,  with  the  spongy  heaping  up  of  the  gums  both  inside  and  outside  the  teeth,  and 
with  the  knotty  haemorrhagic  swellings  in  the  muscles  of  the  calves,  as  well  as  purpura. 
Children  who  are  fed  upon  jjatent  foods  without  sullicient  fresh  milk,  or  vegetable  food,  or 
fresh  meat,  not  infrequently  develop  a  milder  form  of  scurvy,  with  marked  tenderness  of 
the  periosteum  of  the  long  bones,  pasty  pallor,  mouth  bleeding  from  spongy  gums,  and 
possibly  pur]>ura  ;  this  is  infdnlile  scuny,  or  Barlozv's  disease,  which  should  not  be 
confused,  as  it  is  apt  to  be.  witli  rickets. 

Hwmopliiliii  is  miierally  indicateil  at  once  by  the  history  of  persistent  oozing  from 
slight  cuts  and  scratches,  and  also  by  the  fact  that  other  members  of  the  family,  especially 
males,  have  suffered  in  a  similar  way. 

Chloromn  is  a  very  rare  disease,  in  some  ways  related  to  sareomatosis.  and  in  others 
to  lymphatic  leukaemia  ;  it  produces  swellings  in  connection  with  the  bones,  especially  of 
the  head,  together  with  enlargement  of  the  lymphatic,  lachrymal  and  salivary  glands  ;  it 
develops  in  early  life,  proves  slowly  fatal,  and  the  diagnosis  is  confirmed  by  the  green 
colour  of  the  new-formed  tissue — "  green  cancer."     The  blood  changes  are  negative. 

Peliosis  Theumnlica.  or  purpura  rlieumalica,  or  Schonlein's  disease,  was  formerly 
regarded  as  related  to  acute  rheiunatism  ;  but  it  is  exceedingly  rare  for  a  patient  affected 
by  it  to  present  immistakable  signs  of  valvular  heart  disease,  although  there  may  be  a  local 
systolic  bruit  at  the  impulse.  The  reason  why  it  is  thought  to  be  related  to  acute  rheuma- 
tism is,  that  in  addition  to  the  extensixe  purpura,  whioli  comes  out  in  successive  crops  and 
may  affect  any  part  of  the  body,  though  it  is  conunoner  upon  the  lower  limbs  than  else- 
where, there  is  considerable  pain,  redness,  and  swelling  of  many  joints,  which  may  become 
affected  successively  ;  the  temperature  rises  during  an  attack  to  103^  F.  or  104.°  F.,  the 
throat  generally  being  sore  at  the  same  time.  It  is  not  imjjossible  that  the  purpura  is  due 
to  the  absorption  of  microbes  or  their  toxins  from  the  acute  tonsillitis  :  but  be  this  as  it 
may,  the  diagnosis  is  not  dilfieult  when  the  j)urpura.  the  joint  pains,  and  the  pyrexia  are 
present  together.  The  disease  is  little  influenced  by  sodium  salicylate  ;  it  may  be  associ- 
ated with  more  or  less  erythema  as  well  as  piu-pura  :  the  malady  afi'ects  yoimg  persons, 
especially  between  the  ages  of  ten  and  thirty,  of  either  se.-;. 

Henoch's  purpura  is  met  with  chiefly  in  children  (Fig.  157,  p.  345).  and  the  same 
patient  may  sutler  from  recurrent  attacks,  which  usually  cease  at  or  before  puberty.  In 
addition  to  haemorrhages  beneath  the  skin,  there  is  generally  some  tendency  to  joint  pains 
not  unlike  those  of  peliosis  rheumatica.  but  in  addition  to  this  the  child  is  seized  with  more 
or  less  severe  acute  abdominal  symptoms,  varying  from  simple  vomiting  and  stomach-ache 
to  severe  prostration  with  agonizing  cramp-like  attacks  of  colic,  some  of  which  may  be  fol- 
lowed by  the  jiassage  of  blood  and  mucus  per  rectum  to  such  an  extent  as  to  simulate  acute 
intussusception  ;  the  abdominal  attacks  are  probably  the  result  of  submucous  intestinal 
ha'morrhages.  There  is  every  degree  of  the  affection,  from  mild  to  very  severe,  but  the 
association  of  the  purpura  with  the  abdominal  attacks  in  childhood  suggests  the  diagnosis 
at  once,  especially  if  there  has  been  a  similar  attack  previously.  The  chief  error  to  avoid 
is  mistaking  for  Henoch's  purpura  that  which  is  really  an  acute  nephritis  :  the  urine 
should  be  examined  periodically  for  albumin  and  renal  tube-casts,  even  if  there  is  no 
oedema,  though  the  occurrence  of  blood  alone  would  not  be  sufficient  to  indicate  acute 
nephritis,  seeing  that  haemorrhage  from  the  kidney  may  be  due  to  Henoch's  purpura  itself. 

It  is  only  when  every  precaution  has  been  taken  to  exclude  all  the  above  causes  of 
purpura  that  one  can  be  satisfied  with  any  of  the  remaining  three  diagnoses,  namely  pur- 
pura simplex  (morbus  ruacidosus  of  Werlhof),  purpura  hiemorrhagica,  or  purpura  fulminans. 
These  differ  from  each  other  only  in  degree  ;    broadly  speaking,  purpura  simplex  signifies 


PrSTl'LES  557 

hsemorrhasc  into  the  skin  only  :  juiipura  lia>niorrhagica  has,  in  addition,  liacmonhages 
from  the  mucous  membranes,  particularly  of  the  mouth,  nose,  and  bowel,  less  commonly 
of  the  urinary  passages  ;  whilst  purpura  fulminans  is  the  term  used  to  denote  a  condition 
in  which  a  person  may  seem  perfectly  healthy  to-day,  may  be  seized  with  acute  purpura 
and  be  dead  before  to-morrow,  without  develo))ino'  any  other  symptoms  to  indicate  the 
nature  of  the  complaint.  These  kinds  of  purpura  have  sometimes  been  spoken  of  as  idio- 
pathic, but  they  must  have  some  underlying  cause,  if  only  it  can  be  found.  It  is  better 
probably  to  label  them  cases  of  pur]5ura  of  which  the  exact  cause  is  not  yet  known,  than 
to  be  content  M'itli  such  a  term  as  purpura  simplex,  and  it  is  probable  that  if  bacterio- 
logical examinations  were  made,  a  bacterial  cause  would  be  discovered,  jiarticularly  in 
connection  with  the  tonsils,  the  gums  in  states  of  septic  gingivitis  or  inorrhrea  alveolaris, 
the  uterus,  the  bowel,  or  the  circidating  blood  itself.  Herbert  Freneli. 

PUS    IN   THE    CHEST.— (See  Chest.  Pls  in,  p,  103.) 

PUS  IN  THE  STOOLS  in  sullicient  amount  to  be  recognizable  by  the  naked  eye, 
indicates  the  rupture  of  an  abscess  into  the  intestinal  tract.  The  symptom  is  rare,  how- 
ever, for  even  when  a  large  appendicular  abscess  perforates  into  the  ca'cum,  the  pus  either 
becomes  indistinguishable  when  mixed  with  the  fieces,  or  unrecognizable  on  account  of 
digestion  and  decomposition.  The  less  the  pus  is  mixed  with  other  intestinal  contents, 
the  nearer  to  the  anus  has  the  site  of  rupture  been  ;  but  the  diagnosis  of  the  source  of  the 
abscess  needs  to  be  determined  upon  other  grounds,  particularly  the  history,  and  the 
results  of  general  physical  examination,  including  that  of  the  reetimi  and  vagina. 
Abscesses  most  apt  to  cause  a  discharge  of  pus  with  the  stools  are  of  the  appendicular, 
cholecystic,  perinephric,  psoas,  pelvic,  perigastric,  or  other  local  peritoneal  types,  and 
pyosalpinx. 

Microscopical  quantities  of  pus  in  the  stools  may  be  due  to  any  of  tlie  causes  already 
mentioned  :  they  may  also  be  derived,  not  from  lesions  outside  the  intestines,  but  from 
affections  of  the  mucous  membrane  itself:  acute  or  chronic  colitis,  with  or  without  ulcera- 
tion ;  dysentery  ;  cholera  ;  dengue  ;  mucous  or  mucomembranous  colitis  :  tuberculous, 
typhoidal,  malignant,  or  venereal  ulceration  of  the  bowel.  The  pus  corpuscles  may  be 
recognizable  as  such  imder  the  microscope  :  but  it  is  difficult  to  determine  when  the 
leucocytes  derived  from  the  intestinal  catarrh  are  merely  leucocytes  in  excess,  and  when 
their  numbers  become  sullicicnt  to  merit  the  term  actual  pus.  Examination  with  the 
sigmoidoscope  is  sometimes  in\aluable  when  the  diagnosis  has  not  been  decided  by  other 
methods.  Herbert  Freneli. 

PUSTULES. — The  pustule,  one  of  the  primary  cutaneous  lesions,  is  an  epidermic 
elevation,  citiur  unilocular  or  multiloeular,  containing  a  purulent  liquid,  and  differing 
from  a  vesicle  or  a  bulla  only  in  the  character  of  its  contents.  .Always  a  product  of  in- 
llammation,  it  may  originate  as  a  pustule  or  may  develop  from  a  papule,  hut  much  more 
often  it  is  a  transformed  vesicle  ;  if  the  metamorphosis  is  imperfect  the  lesion  is  styled  a 
papulo-pustule  or  a  vcsico-])ustule.  Frequently  the  transformation  from  a  papule  or  a 
vesicle  is  so  swift  that  the  true  origin  of  the  lesion  may  escape  notice  ;  but  in  such  cases  it 
is  usual  to  fmd  jiapules  or  vesicles  intermingled  with  the  pustules.  The  pustular  cavity 
may  be  situated  in  the  epidermis,  in  4he  derma,  or  in  a  follicle  ;  a  purulent  aecunndation 
beneath  the  derma  is  either  an  iibscess  or  a  gumma.  Kj>ideruiie  pustules  may  be  su|)er- 
ficial,  as  in  inqjctigo,  or  deep,  as  in  the  condition  known  as  ecthyma,  which  I  regard  as  hut 
a  severe  form  of  impetigo.  Deritiie  pustules,  such  as  the  miliary  absces.scs  of  new-born 
children,  are  seldom  met  with,  while  {(illicuUir  pustules,  such  as  those  of  sycosis,  are  com- 
mon. In  colour,  pustules  are  usually  yellowish  or  greyish,  with  a  red  areola  ;  but  when 
the  contents  are  mixed  with  blood,  the  yellow  may  be  tinged  with  red  or  brown.  If  a  pus- 
tule is  pimetured  or  ruptured,  the  lii|uiil  is  seen  to  be  tiiore  or  less  turhid  and  yellowish  ; 
under  the  microscope  it  is  found  to  consist  largely  of  leucocytes  and  serum  as  well  as  cocci. 
Pustules  vary  greatly  in  size  :  small  ones  may  iciTiain  of  inconsiderable  dimensions,  or 
may  become  large  by  excentrie  extension.  'I  lie  prevalent  shape  is  roundish  or  convex,  as 
in  furuncle  and  acne  :  but  it  may  be  aeuminale,  as  is  fre(|ueMl  in  sycosis  and  eczema,  or 
flat  and  irregular,  as  in   impetigo  and   syphilis,   while   in   rare   instances,  as  sometimes  in 


558  PUSTULES 

scabies,  it  may  be  oblong,  with  a  tendency  to  the  linear  form.  In  variola  and  the  varioli- 
form syphilide,  the  pustules  may  be  flattened  or  concave,  either  because  the  fluid  may  not 
fully  distend  the  cleft  in  which  it  lies,  or  from  flaccidity  of  the  sac  due  to  commencing 
absorption.  Pustules  may  develop  slowly,  as  sometimes  occurs  in  impetigo  and  in  the 
pustular  syphiloderm  ;  but  as  a  rule  they  run  a  rapid  course,  and  terminate  either  by  rup- 
ture— much  more  often  accidental  than  spontaneous — or  by  desiccation.  In  either  case, 
a  yellow,  brown,  or  blackish  crust,  more  or  less  thick  and  irregular,  is  formed  :  but  if  the 
termination  is  by  desiccation,  the  crust  has  a  less  jironounced  coloration,  and  is  friable 
instead  of  firm. 

A  cutaneous  affection  in  which  the  pustule  plays  a  leading  part  is  impetigo  vulgaris 
sell  contagiosa  ;  usually  following  slight  febrile  disturbance,  small  erythematous  spots 
a])pear,  on  which  form  vesicles  containing  a  turbid  fluid  that  quickly  becomes  jjurulent  ; 
when  the  pustules  break,  as  they  soon  do,  they  discharge  a  fluid  tliat  dries  up  quickly 
into  scabs  that  are  at  first  yellowish,  and  afterwards  green.  Dotted  about  among  the 
scabs  are  pustules,  which  may  coalesce  so  as  to  form,  on  rupture,  crusts  of  considerable 
size.  The  eruption  may  be  limited  to  a  few  discrete  lesions,  or  may  extend  over  large 
areas  of  the  body.  In  parts  where  the  pustules  are  exposed  to  friction,  as  on  the  limbs, 
they  are  generally  ruptured  at  an  early  stage,  and  a  flat  irregular  scab,  surrounded  by  an 
areola,  forms  over  them — the  condition  known  as  ecthyma.  Sometimes  the  distribution 
is  annular  (impetigo  circinntn  or  gi/ratrt).  In  the  condition  known  as  impetigo  bullosa  the 
lesions  are  much  larger,  and  are  not  always  transformed  into  true  pustules.  With  impeti- 
ginous eruptions,  though  not  with  these  alone,  cutaneous  (liphtheria  is  sometimes  associ- 
ated, especially  in  children.  The  most  typical  form  of  this  affection  has  the  appearance  of 
an  im])etiginous  eczema,  associated  with  conjunctivitis,  and  occasionally  with  otorrhoea 
and  rhinitis.  No  diphtheritic  membrane  may  be  present,  and  if  cutaneous  diphtheria  is 
suspected,  the  Klebs-Loffler  bacillus  should  be  sought  for  bacteriologically.  Staphylococci, 
or  streptococci  and  staphylococci  together,  are  the  organisms  generally  found  in  simple 
impetigo,  but  occasionally  other  germs  ])roduce  a  precisely  similar  eruption — the  Bacillus 
coll  coiinniinis  for  example,  or  the  linriUun  pi/oci/ancus. 

The  differences  between  im])etiji(>  \  ulgaris  and  follicular  impetigo  are  well  marked. 
The  latter  is  pustular  from  the  beginning,  and  always  situated  around  a  hair-follicle.  It 
starts  as  a  round  pustule,  often  pierced  by  a  long  or  coarse  hair,  and  it  may  be  quite  small, 
or  as  large  as  a  pea  ;  the  pus  collects  under  the  horny  layer,  which  it  distends  and  raises. 
The  eruption,  usually  multi|)le,  has  no  sites  of  election,  but  ajipears  wherever  a  breach  in 
the  liorny  layer  affords  entrance  to  the  pyogenic  organism.  The  pustules  are  more  resist- 
ant than  those  of  impetigo  contagiosa,  and  are  less  quick  to  break.  When  they  rupture, 
yellow  crusts,  smaller  and  thinner  than  those  of  impetigo  vulgaris,  arc  formed.  The 
|)ustules  of  follicular  im])etigo  can  hardly  be  mistaken  for  those  of  any  other  affection. 
The  other  form  of  impetigo,  however,  has  in  rare  cases  to  be  diagnosed  from  pemphigus. 
In  the  latter  the  lesions  start,  not  as  small  vesicles  but  as  bulla;,  and  the  fluid  they  contain 
is  only  sometimes  inoculable.  Usually,  too,  there  is  marked  systemic  disturbance.  But 
it  is  with  pustular  eczema  that  impetigo  vulgaris  is  most  likely  to  be  confused,  especially 
when  the  pustules  of  the  latter  condition  have  run  together  into  a  ])atch.  In  eczema, 
however,  the  pustules  are  smaller,  there  are  severe  itching  and  burning,  there  is  an  in- 
flammatory areola  aroimd  the  crusts,  which  is  seldom  the  case  in  impetigo  vulgaris,  and 
other  definitely  eczematous  lesions  will  usually  be  found  if  sought  for  carefully,  including 
infiltration  and  thickening  of  the  integument. 

Like  follicular  impetigo,  sycosis  vulgaris  is  a  staphylococcic  infection.  The  lesions 
begin  as  papules,  or  as  nodules  which  form  round  the  hairs — usually  of  the  face,  and  espe- 
cially of  the  chin,  but  sometimes  attacking  the  eyebrows,  eyelashes,  and  the  axillary  and 
pubic  regions — and  presently  develop  into  pustules,  each  of  them  pierced  by  a  hair.  As 
the  result  of  suppuration,  the  hairs  are  loosened,  and  if  one  is  pulled  out,  a  drop  or  two  of 
pus  usually  exudes.  In  severe  cases  the  pustules  may  be  jsacked  so  closely  together  as  to 
form  infiltrations,  which  may  fungate.  The  chief  diagnostic  features  of  the  affection  are 
its  inflammatory  character,  its  origin  in  the  hair-follicles,  and  its  limitation  to  the  hairy 
parts,  usually  of  the  face.  The  differential  diagnosis  from  tinea  sycosis  has  been  given 
under  Fungous  Affections  of  the  Skin  (p.  246).  Eczema  is  not  limited  to  the  hairy 
parts,  and  if  the  follicles  are  involved  it  is  only  secondarily,  nor,  as  a  rule,  is  the  inflammation 


1 


PLSTULES  5r,o 

so  severe  as  in  sycosis  vulgaris.  Of  sycosis  Niilgaris  again,  intense  itcliing  is  not  a 
feature.  Sometimes,  when  the  sycosis  is  widely  difiused.  the  crusts  may  have  to  be 
removed  to  clear  up  the  diagnosis :  when  this  is  done,  the  follicular  implication  will  soon  be 
perceived.  Tertiary  syphilitic  ulceration  is  not  restricted  to  the  follicles,  and  behind  it 
there  lies  a  history  of  earlier  sijccific  lesions,  as  well  as  of  the  ])rimary  infection,  unless 
this  should  have  escaped  notice.     AVassermann's  serum  test  may  be  ap])lied. 

If  there  is  ever  any  doubt  as  between  sycosis  vulgaris  and  acne  vulgaris,  the  presence 
of  the  latter  on  non-hairy  parts  should  of  itself  suffice  to  decide  the  question.  The  pustules 
of  ncne  vulgaris  can  scarcely,  indeed,  be  confounded  with  those  of  any  other  affection, 
except  with  the  lesions  of  small-pox  (see  below)  and  those  of  bromide  and  iodide  eruptions. 
In  these  drug  eruptions,  however,  comedones  are  absent,  the  lesions  occur  on  any  part  of 
the  body,  and  are  generally  a  brighter  red,  while  the  fluid  they  contain  is  rather  thinner. 
Drug  eruptions,  again,  occur  at  any  time  of  life,  whereas  acne  vulgaris  is  essentially  a  disease 
of  puberty.  Pustular  syphilides  may  attack  any  part  of  the  body,  and  are  generally 
grouped,  whicli  is  never  the  case  with  the  pustules  of  acne. 

A  furuncle  is  so  characteristic  that  the  only  lesion  from  which  it  can  ever  rKjuire 
to  be  differentiated  is  a  carbuncle.  The  pathological  ])r(icess  is  the  same  in  both  :  but 
while  in  furuncle  there  is  but  one  point  of  suppuration  and  opening,  in  carbuncle  there 
are  several.  The  only  condition  from  which  a  carbuncle  has  in  turn  to  be  diagnosed, 
except  a  furuncle  and  malignant  pustule,  is  diffuse  cellulitis,  in  which  there  is  no  circum- 
scribed outline. 

In  malignanl  pustule  (anthrax),  following  itching  and  l)urning  at  the  site  of  inoculation, 
a  livid  red  papule  appears,  on  which  a  bulla  or  pustule  forms  (piickly  and  breaks,  drying 
up  into  a  black  gangrenous  eschar.  This  is  fringed  with  tiny  vesicles  or  pustules,  and 
surrounded  by  a  broad  areola  of  solid  cedematous  infiltration,  the  skin  over  which  is  ten.sc 
and  violaceous.  There  are  constitutional  symptoms,  with  septic  fever.  The  diagnosis 
rests  mainly  upon  the  presence  of  a  gangrenous  ])atch  surrounded  by  infiltration  in  a 
j)atient  whose  occupation  exposes  him  to  infection  with  the  anthrax  bacillus,  especially 
from  cattle,  hides,  or  wool.  The  organism  (Plate  Willi,  p.  01  t)  may  be  detected  without 
difliculty  under  the  microscojie.  It  is  a  relatively  large  bacillus  which  gener  Uly  forms  long 
chains  and  is  gram-positive.  It  is  only  at  the  outset  that  the  lesion  can  be  mistaken  for  a 
carbuncle.  The  primary  lesion  of  syphilis  can  be  excluded  by  its  indolence,  and  by  the 
absence  of  gangrene  and  of  febrile  symptoms. 

In  glauiler.s.  the  cutaneous  lesions  begin  as  red  spots,  which  pass  through  the  papular 
and  vesicular  or  bullous  stage  into  pustules  that  give  rise  to  widespread  ulceration.  The 
coiidilion.  with  its  severe  constitutional  <listurl)ance  and.  except  in  some  chronic  cases, 
the  peculiar  discharge  from  the  nostrils,  is  usually  easy  of  recognition  :  and  m  exceptional 
cases  in  which  the  diagnosis  is  in  douI)t,  recourse  should  be  had  to  the  mallcin  injection 
test,  or  the  Itaeillus  mallei  may  be  isolated  from  the  lesions. 

In  scriifuliidcruiia  (tuberculides),  usually  an  affection  of  childhood  and  adolescence, 
pusluiar  lesions  lake  the  form  which  has  been  styled  liy  Diihring  the  large  Hat  pustular, 
and  the  small  pustular  serofuloderm.  Tlie  former  begins  as  one  or  more  superficial 
indurations  which,  becoming  pu.stular,  extend  peripherally  and  form  a  flat,  yellowish, 
I  crusted  pustule  of  considerable  size,  surrounded  by  a  violaceous  areola.  Neighbouring 
pustules  may  coalesce.  When  the  crust  is  removed,  a  gramdar  scrofulous  ulcer  is  seen. 
The  small  pustular  serofuloderm  is  usually  a  papulo-pustule  rather  than  a  fully-developed 
pustule,  the  pus  being  frequently  limited  to  the  central  i)art  of  the  sununit,  while  the  outer 
part  of  the  lesion  riiuains  hard.  'I'lie  crusting  is  sometimes  a  slow  process,  which  may 
occupy  several  weeks,  and  when  the  crust  drops  off  it  lea\cs  indelible  sears  not  utilike 
those  of  variola.  'I'he  oidy  diseases  with  whicli  serofulodermia  generally  can  be  coidused 
are  lupus  and  syphilis.  Tlie  absence  of  '  ai)ple-jelly "  nodules  and  of  infiltration  will 
distinguish  it  from  lupus,  though  the  two  conditions  may  co-exist.  The  syphilitic  ulcer 
is  met  with  in  adults,  and  is  usually  a  nuieh  more  active  process  than  senifuloderniia,  nor 
has  the  lesion  the  undermined  horder  which  is  characteristic  of  the  latter  alTci-tion. 
Concomitant  syphilitic  signs  will  usually  be  present,  .just  as  in  .serofulodermia  there  will 
generally  be  other  tubercular  symptoms  ;    \Vas.sermann"s  serum  reaction  should  be  tested. 

In  sjii>liiliH  the  pustule  is  a  much  less  frequent  lesion  than  the  jjapule  (p.  K(()),  and  is 
generally  found  in  association  with  a  cachectic  state  of  health.     It  appears  in  two  dilTcrcnt 


560  PUSTULES 

forms,  the  acuminate  anrl  tlic  flat  pustular  syphilide,  and  in  l)oth  the  lesion  may  be  either 
small  or  large.  The  small  acuminate  or  miliary  syphilide.  not  usually  much  larger  than  a 
pinhead,  in  most  instances  begins  as  a  papule,  and  papules  will  generally  be  found 
intermingled  with  the  pustules.  Wlien  the  crusts  into  which  the  pustules  dry  are 
detached,  there  may  be  some  scarring,  or  the  lesions  may  leave  no  trace  except  stains, 
which  presently  disappear. 

The  diagnosis  of  these  small  acuminate  pustules  seldom  jjresents  any  difficulty  ;  but 
it  is  not  so  with  the  large  acuminate  pustules,  the  acneiform  syphilides,  which  may  be 
mistaken  not  only  for  acne,  but  also  for  variola  and  iodide  eruptions.  Appearing  on  a 
base  which  may  at  first  be  pink,  and  afterwards  copper,  they  may  be  jiustular  from  the 
beginning,  or  may  start  as  vesicles  or  as  papules  ;  they  are  more  or  less  generalized,  about 
the  size  of  a  pea,  disseminated,  or  grouped  irregularly,  and  while  they  are  predominantly 
acuminate,  some  of  them  may  be  rounded.  Some  of  the  pustules  may  be  dimpled,  and  occa- 
sionally the  majority  of  them  display  this  character.  When  the  crusts  fall  off,  brownish 
stains  are  seen,  and  there  may  be  slight  scarring,  which,  however,  is  seldom  permanent. 
The  grouping  which  is  characteristic  of  these  pustidar  syiihilides.  and  the  drying-up  of 
the  pus  into  scabs,  are  important  points  in  differentiating  them  from  the  lesions  of  acne, 
which,  further,  instead  of  being  generalized,  seldom  affect  parts  other  than  the  face,  the 
back  of  the  neck,  the  chest,  and  the  back  between  the  shoulders.  The  comedones  of  acne 
are  another  distinguishing  feature,  the  eruption  is  of  a  more  sluggish  and  chronic  character, 
and  there  is  no  cachexia.  The  diagnosis  as  between  pustular  syphilides  and  variola  is 
given  below.  The  pustules  met  with  in  iodic  eruptions  are  seldom  either  generalized  or 
profuse. 

Small  flat  pustular  syphilides  ('  impetiginous  syphilides  ")  may  begin  as  such,  or  may 
develop  from  maeides  or  papules.  They  are  discrete  ;  but  in  such  regions  as  the  face  and 
scalp  may  run  together.  The  eruption  is  of  a  generalized  character,  with  a  preference  for 
the  genitals,  the  scalp,  and  the  face.  The  crusts  into  which  the  pustules  quickly  dry  are 
frequently  adherent  ;  beneath  them  there  is  superficial  idceration  ;  occasionally  they  are 
surrounded  by  an  areola  of  the  characteristic  raw-ham  colour.  When  the  eruption  is 
extensive,  the  patient  is  often  an;emic  and  cachectic.  The  affections  from  which  these 
syphilides  have  to  be  differentiated  are  pustular  eczema  and  impetigo.  The  ulceration 
which  underlies  the  crusts  in  the  syphilides  is  not  found  in  either  of  those  conditions,  nor  is 
itching  present  as  in  eczema.  In  impetigo,  the  pustules  most  fre(|uently  affect  the  face  and 
hands,  and  are  superficial  ;   and  the  eruption  is  mild  in  character  and  of  shorter  duration. 

The  large  flat  pustular  syphilides  ("  ecthymatous  syphilides  ")  differ  little  from  the 
small  ones  except  in  size,  and  the  only  lesions  with  which  they  are  likely  to  be  confused 
are  those  of  severe  impetigo  vidgaris.  The  diagnosis  from  that  condition  must  rest  upon 
the  slow  development,  the  greater  niunber  of  the  jjustules,  the  coppery  areola  and  base, 
the  accomiianying  cachexia,  and  the  pigmented  scars.  But  it  should  be  remembered — 
and  this  applies  not  to  pustular  syphilides  only,  but  to  syphilis  generally — that  in  most 
cases  a  sure  diagnosis  of  syphilis  can  be  made  only  when  all  the  factors  of  the  case  are  taken 
into  account  :  the  history,  character,  course  and  termination  of  the  lesions,  and  their 
reaction  to  salvarsan,  mercury,  or  ar.senic  and  the  iodides.  The  distinctive  characters  of 
secondary  lesions  generally  are  their  symmetry,  their  coppery  colour,  the  positions  in 
which  they  occur,  their  polymorphism,  and  the  absence  of  itching,  together  with  enlarged 
glands,  sore  throat  or  tongue.  In  (i(iul)tlul  cases  the  whole  cutaneous  surface  should 
be  examined  for  characteristic  marks  or  lesions.  If  the  diagnosis  is  still  uncertain,  the 
Wassermann  test  should  be  applied. 

Of  all  diseases  of  which  the  pustule  is  one  of  the  manifestations,  small-pox  is  that 
which  presents  the  greatest  difficulty  in  diagnosis.  The  lesion,  occasionally  jjreceded  by  a 
roseolar  rash  not  luilike  that  of  scarlatina,  begins  as  a  mere  fleck,  of  pin-head  size,  flush 
with  the  surface  and  impalpable.  In  the  course  of  a  few  hours  it  swells  up  into  a  pink 
papule,  which  can  be  felt  embedded  in  the  skin  like  a  small  shot.  In  a  few  days, 
the  papule  undergoes  vacuolation,  at  the  same  time  getting  bigger,  and  becoming  grey  and 
translucent.  So  the  papule  passes  into  the  vesicle,  which  is  loculated,  so  that  if  it  is 
punctured  the  contained  fluid  is  not  entirely  discharged.  As  a  rule,  the  smaller  vesicles 
are  hemispherical,  the  larger  flat-topped,  and  occasionally  the  crown  is  indented.  After 
about  twenty-four  hours  the  contents  become  turbid  and  the  covering  dull  and  whitish. 


PUSTULES 


561 


. — DisL-rete  small-pox 
S.  Daeies,  J/.O  //.    Bristol.) 


and  so  the  pustular  stage  is  entered  upon.  While  the  lesion  is  undergoing  this  transition, 
the  grey  translucent  centre  is  encircled  at  the  periphery  of  the  crown  by  a  white  or  yellow 
ring.  By  the  sixth  day  from  its  birth,  the  lesion  has  become  yellow  throughout  and  the 
crown  dome-shaped  ;  the  pustule  so  attains  maturity,  and  if  of  full  size  measures  about 
three-eighths  of  an  inch  across.  Even  in  unmodified  small-pox,  however,  the  lesions  often 
fail  to  reach  those  dimensions.  As  the  pustule  develops,  the  er>i:hematous  zone,  the  areola, 
which  encircled  the  papule  and  was  biggest  and  brightest  in  the  vesicular  stage,  begins  to 
wane,  and  has  disai>peared  by  the  time  the  pustule  reaches  maturity.  This  occurs  about 
the  ninth  day.  As  the  pustules  dry  up 
or  burst,  scabs  are  formed,  which  on 
separation  leave  dark  stains,  scars  and 
■pits,"  the  number  and  depth  of  the 
pits  usually  being  determined  by  the 
severity  of  the  disease.  In  mild  attacks 
the  pustules  remain  discrete,  in  severe 
cases  they  run  together,  confluent  small- 
pox {Figs.  2.37,  238).  In  bad  cases, 
hsemorrhage  takes  place  into  the  skin 
and  the  interior  of  the  pustules.  The 
mucous  membranes  of  the  air-passages 
may  be  invaded,  the  extent  to  which 
they  are  involved  being  determined  by 
their  susceptibility  rather  than  by  the 
severity  of  the  attack.  In  modihed  small-pox  the  eruption  may  resemble  that  of  the 
unmodified  disease,  as  here  described,  the  difference  being  that  the  lesions  are  less  abundant 
and  are  seldom  confluent. 

It  has  been  usual  in  the  diagnosis  of  small-pox  to  lay  the  chief  stress  upon  the  solidity 
and  hardness  of  the  j)a])ule,  the  umbilication  of  the  vesicle,  and  the  loculation  of  its  cavity  ; 
but  in  his  masterly  monograph  ("The  Diagnosis  of  Small-pox"),  to  which  I  owe  the 
following  description,  Ricketts  has  shown  that  the  distribution  of  the  lesions  is  of  more 
diagnostic  value  than  their  character,  as  also  is  it  moi-e  easily  observed.  The  parts  most 
liable  to  the  eruption  are  the  face  and  hands  ;  and  of  the  two.  the  face  is  more  liable  than 
the  hands.  Xext  to  the  hands  in  susceptibility  come  the  ujjper  limbs,  then  the  tnmk, 
then  the  lower  limbs.  .\s  to  the  trunk,  the  rash  is  thicker  behind  than  in  front,  and  thickest 
on  the  shoulders.  'I"he  incidence  is  smallest  on  the  great  flexures  of  the  body,  while  the 
extensor  surfaces  of  the  limbs,  and  especially  the  elbow,  receive  a  disproportionate  share 
of  the  rash.     The  neck  fares  better  than  either  the  head  or  the  shoulders  ;    the  back  of  it 

suffers  more  than  the  front.  On  the 
Ihiiik  the  rash  is  less  profuse  than  on 
tlic  adjoining  parts  of  the  chest-wall, 
eitlur  In  front  or  behind.  On  the  foot, 
I  lie  distribution  is  marked  by  great 
inconstancy.  Usually  the  back  of  the 
loot  receives  more  altenliiin  than  the 
sole  :  belween  the  toes,  and  in  the  folds 
licncath  Ihc  Iocs,  there  is  comparative 
iiiiiiiiinit\-  ;  and  the  parts  for  which  the 
ciuplion  shows  most  ])refercnce  are  the 
iiislep.  especially  the  tendinous  ridges 
and  the  bony  eniinenccs,  the  tendo 
.\cliillis.  the  balls  of  the  toes,  the  toe- 
pads,  and  the  heels.  In  the  hand,  the 
palm,  and  especially  the  hollow  of  it,  suffers  little,  and  the  brunt  of  the  attack  is  borne 
by  the  extensor  surface  :  the  rash  is  thickest  on  the  back  of  the  wrist  and  hand,  and  over 
the  heads  of  llie  iiielacarpals.  'i"o  these  usual  characters  the  distribution  olTcrs  exceptions, 
some  of  them  <linieiiil  of  explanalion;  but  lliey  are  luitlur  so  niinicrous  nor  so  ciin- 
siderahlc   as    materially    lo    lessen    its   diagnostic   iniportancc. 

The  diagnosis  of  siMall-|io\   lioiii  (•lii<k(  ii-|)iix      the  disease  with  which  it   is  most  often 

1)  ae 


(/■/.'. 


56-2 


PUSTULES 


confused — and  from  vaccinia,  has  been  set  out  under  Vesicles  (p.  757).  The  eruptions 
of  measles  and  of  German  measles  differ  from  that  of  small-pox  in  that,  instead  of  being 
papular,  they  are  macular,  and  that  they  never  pass  into  a  vesicular  or  a  pustular  stage. 
In  German  measles,  further,  there  is  enlargement  of  the  jjosterior  cervical  glands,  which 
is  never  the  case  in  small-pox  at  an  early  stage.  In  scarlatina,  the  '  strawberry  tongue  ' 
is  a  sign  which  is  quite  different  from  the  condition  of  the  tongue  in  small-pox.  The  rose- 
red  lenticular  spots  which  make  up  the  rash  of  enteric  fever  are  neither  so  hard  nor  so 
prominent  as  the  ]3apules  of  small-pox,  and  they  appear  chiefly  on  the  trunk,  and  elect 
the  abdomen  and  chest  rather  than  the  back  ;  the  arms  and  legs,  and  especially  the  face, 
almost  always  escape. 

If  the  pink,  slightly  elevated  macules  of  simple  purpura  are  mistaken  for  the  eruption 
of  small-pox,  the  error  is  soon  corrected  by  the  deeper  colour  which  the  macules  take  on  ; 
nor,  even  though  the  macules  may  become  papules,  have  the  lesions  the  characteristic 
hardness  of  variolous  papules.  Another  point  of  difference  between  simple  purpura  and 
small-pox  is.  that  in  the  former  affection  the  face  and  trunk  are  seldom  attacked,  the  sites 
of  election  being  the  limbs.  In  erythema  multiforme,  although  the  rash  makes  its  chief 
attack  upon  the  limbs,  it  may  be  widely  diffused  and  may  even  invade  the  face.     In  such 

cases,  however,  the  diffusion  will 
usually  be  less  general  than  that  of 
I  lie  variolous  eruption,  nor  is  the  order 
of  incidence  the  same.  With  the 
involution  which  the  erythematous 
lesions  undergo,  the  resemblance  to 
small-pox  ceases.  Even  in  cases  of 
acute  febrile  erythema,  in  which  the 
whole  cutaneous  surface  is  covered 
by  a  profuse  eruption,  the  distribution 
is  (|uite  different  from  that  of  the 
small-|)ox  eruption. 

Confusion  between  small-pox  and 
syphilis  is  much  more  likely  to  arise 
when  the  syphilide  is  pustular  than 
when  it  is  vesicular  or  papular.  The 
erroneous  diagnosis  may  be  assisted 
l)y  the  fe\er  and  aching  symptoms 
wliich  may  precede  pustular  syphilides, 
and  by  the  fact  that  the  lesions  may 
begin  as  papules.  In  syphilis,  how- 
e\er,  the  constitutional  symptoms  are 
less  severe,  the  eruption  runs  a  more 
indolent  course,  and  appears  in  suc- 
cessive crops,  whilst  the  vesicles  which 
form  on  the  summits  of  the  papules  have  an  indurated  base.  Sometimes,  too,  the  syphilitic 
eruption  is  indifferent  in  distribution,  and  often  it  comprises  various  types  of  lesions,  even 
when  it  is  not  distinctly  ijolymorjihic,  whereas  in  small-pox  the  departure  from  homo- 
geneity is  much  more  limited. 

Occasionally,  impetigo  vidgaris  is  mistaken  for  mild  modified  small-pox  {Fig.  239), 
but  attention  to  the  points  which  mark  off  the  former  affection  from  pustular  eczema 
(see  abo\e)  shoidd  prevent  the  mistake.  Further  differentiating  features  as  between 
impetigo  vulgaris  and  small-pox  are,  that  in  impetigo  there  is  no  fever,  and  that  the  lesions 
begin  as  vesicles  or  bulls  and  dry  up  into  flat  yellowish  crusts.  In  those  cases  of  sudden 
and  acute  eczema  which  may  mimic  small-pox,  guidance  is  to  be  found  in  the  small  size 
and  superliciality  of  the  eczematous  lesions,  and  the  a?dema  and  infiltration  of  the  imder- 
lyinii  skin.  In  scabies,  again,  the  vesicles  are  superficial,  burrows  will  generally  be  found, 
and  the  heterogeneity  of  the  secondary  lesions  will  aid  the  diagnosis.  In  all  these  affections, 
the  distribution  is  quite  different  from  that  of  small-pox,  the  incidence  being  partial  or 
patchy.  Thus,  in  impetigo  the  lesions  are  frequently  confined  to  the  face  and  extremities, 
and  if  the  trunk  is  invaded,  it  is  the  front  more  than  the  back,  the  lower  part  more  than 


{Pholu  by  Dr.  b.  .5.  Danes,  M.U.H.,  Uristai.) 


PYREXIA.     PROLOXGEI)  563 

the  upper.  In  scabies,  except  in  children,  the  face  escapes,  and  the  commonest  sites  are 
tiie  hands  and  fingers,  buttoclvs,  and  feet. 

In  Ricketts'  experience,  no  affection,  except  cliiclven-pox,  is  so  frequently  confused 
with  small-pox  as  acne  vulgaris,  in  spite  of  its  chronic,  afebrile  character,  and  the  absence 
of  subjective  symptoms.  If,  however,  the  rash  is  limited  to  the  upper  part  of  the  body 
and  a  few  characteristic  acne  lesions  such  as  comedones  are  found,  small-pox  may  be 
excluded. 

I  have  seen  copaiba  eruption  mistaken  for  small-pox.  The  absence  of  constitutional 
symptoms  such  as  pain  in  the  lumbar  region  and  fever,  the  mixed  character  of  the  lesions, 
and  the  history  are  the  chief  points  in  the  diagnosis. 

It  is  seldom  that  bromide  or  iodide  eruptions  are  mistaken  for  the  rash  of  small-pox. 
In  doubtful  cases,  attention  must  be  paid  to  the  larger  size  of  the  pustules,  as  compared 
with  those  of  small-pox,  and  to  the  symmetrical  or  patchy  distribution.      Malcolm  Morris. 

PYREXIA,  PROLONGED.— A  pyrexia  may  be  considered  prolonged  if  it  lasts  more 
than  ten  days.  In  most  cases,  no  doubt,  there  are  signs  and  symptoms,  or  facts  in  the 
history,  which  enable  one  to  make  a  diagnosis  before  this  ;  but  difficulties  often  arise  from 
the  absence  of  the  distinctive  characters  of  any  one  of  the  diseases  commonly  accompanied 
by  such  pyrexia.  In  most  cases  such  a  prolonged  pyrexia  is  the  result  of  one  of  the 
infectious  diseases,  and  it  is  by  a  careful  consideration  of  the  more  probable  among  these 
that  one  may  often  arrive  at  a  definite  opinion.  The  g,ener(il  infections  most  likely  to  give 
rise  to  a  long-lasting  fever  are  : — 

Typhus  fever  Meninjjiitis  Malaria 

Typhoid  fever  Malignant  endocarditis  Syphilis 

Paratyphoid  fever  Septiciemia  from  deep-seated    |      Bacilluria 

Mediterranean  fever  ■  foci  of  disease,   such  as  :    '      Bronchopneumonia. 

Influenza  !  Empyema,     Cerebral     ab- 

Tuberculosis  j  scess.      Pylephlebitis,      or 

otlier  form  of  suppuration 

A  high  temperature  of  very  long  duration  occurs  often  in  connection  with  diseases 
of  the  blood  and  blood-forming  organs,  such  as  : — 

AddisDn's  aiueinia  |       Leukieniia  |       Ilodgkin's  disease. 

It  also  occurs  much  more  often  than  has  been  commonly  supposed  in  sarcoma  and 
carcinoma  of  different  organs,  and  has  been  observed  in  cirrhosis  of  the  liver.  There  are 
two  other  forms  of  pyrexia  which  should  be  borne  in  mind,  namely,  a  prolonged  purexia 
occurring  in  children,  often  very  difficult  to  explain  :    and  so-called  neurotic  pi/re.rias. 

Modern  research  has  a  tendency  to  rely  upon  its  own  methods  alone,  and  to  ignore 
the  older  clinical  dilferences.  Hut  this  involves  a  separate  irnestigation  for  each  disease  as 
it  conies  to  be  considered  ;  and  thus  it  may  ha])|)en  that  one  patient  may  have  to  undergo, 
in  addition  to  a  thorough  bedside  examination  of  all  his  organs,  a  lumbar  pimcture,  and 
the  removal  of  blood  for  the  Widal  test  or  for  the  cultivation  of  organisms  ;  and  these 
may  have  to  be  repeated.  A  full  knowledge  of  the  history  of  the  illness,  of  exposure  to 
infection,  and  of  the  clinical  changes  as  far  as  they  are  manifested,  is  desirable  in  order 
that  the  researches  of  the  bacteriologist  may  be  directed  as  early  as  possible  into  the  right 
path. 

'I'llldiiis.  -On  the  score  of  prolonged  pyrexia  (/•'/<,'.  2()S,  p.  (i:{H,  and  /''/•,'.  ^(ilt.  p.  (i:!!»)  little 
need  be  said  of  this  fever.  The  eruption  is  generally  distiiu'tivc,  and  shows  itself  belore  the 
fever  has  attaine<l  any  duration  :  but  it  is  capable  <>(  being  t'onfounded  with  typhoid  fever, 
and  even  with  malignant  endocarditis.  The  distinction  from  typhoid  fever  is  given  else- 
where ;  and  a  cordiision  with  malignant  eixlocardilis  is  only  possible  if  the  latter  should 
produce  a  very  uniformly  distributed  petechial  eruption  over  the  skin  while  the  cardiac 
nuirmur  is  of  slight  intensity  :  or  if  a  person  already  the  subject  of  cardiac  nnirnun-  shoulil 
contract  typhus,  and  have  an  ill-delincd  eruption.  In  either  case,  if  the  pyrexia  were 
prolonucd  beyond  the  tw<-lfth  or  fourlicidh  day.  lyphns  wonlil  be  unlikely. 

Injlucnzd.  In  most  cases  of  inllucn/.a  uiK'omplicaled  by  dclinilc  \isccral  changes, 
such  as  pneumonia  or  gastro-enlerit  is  the  fever  is  of  short  duralion.  but  it  is  often  as  long 
as  a  week  or  ten  days,  and  sometimes  three  weeks  or  more  (Fig.  210).      The  longer  |>erio(l. 


564 


PYREXIA,     PROLONGED 


accompanied  as  the  fever  is  by  few  distinctive  signs,  is  sufficient  to  lead  to  a  confusion  witli 
typhoid  fever,  tuberculosis,  or  malignant  endocarditis,  either  of  which  may  proceed  for 
two  or  three  weeks,  and  the  last  two  for  many  more  weeks,  without  distinctive  clinical 
signs.  The  constant  presence  of  influenza  amongst  us,  and  the  great  variety  in  the 
characters  it  assimies,  make  it  very  difficult  to  exclude  it  until  positive  signs  of  another 
complaint  have  manifested  themselves.  Equally  difficult,  however,  is  it  to  prove  the 
existence  of  the  disease,  since  the  organism,  Pfeiffer's  bacillus,  is  not  found  easily  in  the 
blood  ;  and  in  the  prolonged  cases,  the  rather  striking  peculiarities  of  the  intense  acute 
attacks,  such  as  severe  pain  in  the  head  and  back  of  the  eye,  and  in  the  lumbar  region, 
may  be  absent.  The  diagnosis  can  often  be  made  positively  only  ina  exclusionis,  when  the 
bacteriological  tests  of  typhoid  fever  and  tuberculosis  have  failed,  and  if  there  is  an  entire 
absence  of  rose  spots,  diarrhoea,  or  enlarged  spleen  on  the  one  hand,  or  of  pidmonary 
symptoms  on  the  other.  Especially  must  we  bear  in  mind  that  an  apparent  attack  of 
influenza  may  only  be  the  pyrexial  equivalent  of  early  tuberculous  infection,  and  if  at  any 
time  in  the  course  of  the  illness  .sputum  is  available,  it  should  be  examined  for  tubercle  bacilli. 


Fir/.  240. — Temperature  chart 
diagnosis  was  confirmed  by  bar 
by  influenzal  otitis  media,  and  ti 


of  influenza  in  whicll  the  pyrexia  lasted  a  month ;    the 
of  Pfeiffer's  influenza  bacilli.     The  case  was  complicated 


Typhoid  Fcvtr  should  be  comparatively  easy  to  diagnose  in  the  present  day.  A  fever 
commencing  with  frontal  headache,  perhaps  with  diarrhoi'a,  generally  compelling  the 
patient  to  lie  up  in  bed  by  the  end  of  the  first  week,  and  showing  within  the  first  ten  days 
rose  spots  on  the  abdomen  and  a  slight  enlargement  of  the  .spleen,  while  at  that  time  the 
temperature  is  101°  F.  or  102'  F.  in  the  morning,  and  103'  F.  or  more  in  the  evening,  and 
the  pulse  is  relatively  slow,  namely  from  80  to  100  in  the  minute,  should  be  typhoid  fever. 
The  Widal  reaction,  that  is,  the  agglutination  of  typhoid  bacilli  by  the  ]iatienfs  blood 
serum,  becomes  positive  about  the  tenth  or  twelfth  day.  All  these  signs  may  fail  for  a 
time  :  spots  may  be  absent,  the  bowels  may  be  persistently  constipated,  enlargement  of 
the  spleen  may  be  difficult  to  prove,  the  Widal  test  may  and  often  does  fail.  Examinations 
of  the  fa'ces  for  Eberth's  bacillus  are  not  easy  ;  but  cultivation  of  the  bacillus  from  the 
blood  taken  from  the  patient's  vein  may  yield  the  bacillus,  and  this  at  an  earlier  date  than 
the  Widal  reaction  can  be  obtained.  Apart  from  such  cultivation,  the  appearance  of  rose 
spots  from  the  sixth  to  the  tenth  day,  with  additions  to  their  number  every  day  for  five 
or  six  days,  forms  jjerluips  the  most  conclusive  evidence  of  typhoid  fever  ;  and  the 
diagnosis  based  on  these  grounds  should  not  be  upset  by  one  or  two  failures  to  get  a 
positive  reaction  with  the  AVidal  test.  This  test  may  require  to  be  made  with  two  or  more 
strains  of  Eberth's  bacillus,  and  failing  them,  paratyphoid  bacilli  should  be  used.  A 
positive  Widal  reaction  in  a  case  otherwise  imlike  typhoid  fever  must  be  accepted  with 
caution.  If  a  case  is  devoid  of  spots,  and  gives  no  Widal  reaction,  the  probability  of  its 
being  ty])hoid  fever  might  be  asserted  from  its  mode  of  onset,  a  characteristic  chart  of 
temperature  (Fig.  241),  with  high  readings  morning  and  evening  in  the  middle  of  the  second 
week,  and  ending  in  twenty  to  twenty-five  days  after  wide  oscillations :  and  finally,  a  pulse 
always  under  100.  On  the  other  hand,  a  pulse  of  more  than  100  does  not  exclude  typhoid, 
as  it  is  conunon  enough  in  the  severe  adynamic  forms.     Typhoid  fever  may  be  confounded 


PYREXIA.     PROLONGED 


565 


witli  many  acute  diseases  ;  as  a  prolonged  pyrexia  it  is  especially  pulmonary  tuberculosis, 
malignant  endocarditis,  a  long-lasting  influenza,  septica;niic  processes,  and  occasionally 
tuberculous  meningitis  which  will  give  dilliculty. 


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Fig.  ■J41. — Temperature  chart  of  '■ 


I  of  typliokl  fever. 


I'ardli/phoiil  Fever. — Of  this  it  need  only  be  said  that  it  presents  the  features  of  a 
benign  typhoid  fever,  in  which  all  the  distinctive  characters  are  less  marked.  Like 
typhoid,  it  may  !><■  confounded  witli  a  mild  long  inllucn/.a,  or  with  early  tuberculosis.  Its 
recognition  depends  ultimately  upon  the  agglutination  of  paratyphoid  bacilli  by  the 
patiiiifs  blood  serum. 


Fiy.  242. — Temperature  chart  of  a  caae  of  Mediterranean  fever  of  unduliint  type. 


Mrditirriiiirdii  Frvrr  is  unr  ul'  llii-  iikisI  pmlnngcil  ol'llic  fevers  due  to  one  recognized 
micro-organism;  for  in  the  uriduhinl  ruriii  ol'  (lie  disease  successive  exacerbations  of 
pyrexia    may    curry    on    the    illiuss    into    the    lillcciith    or   si\lccntli   week   (/'"/t'-   -I-)-       It 


566 


PYREXIA.     PROLONGED 


resembles  typlioid  lever  elosely.  inclufling  tlie  enlargement  of  the  spleen,  but  is  proved  to 
be  due  to  inleetion  with  Micrococcus  melitensis,  conveyed,  almost  invariably,  in  goat's  milk. 
In  British  jtraetice  its  occurrence  is  unlikely,  except  in  one  who  has  been  in  the  parts  of  the 
world  where  it  is  rife — namely,  the  Mediterranean  coast  and  islands,  whence  it  has  foimd 
its  way  into  Spain,  Portugal,  and  other  countries,  and  even  to  such  distant  parts  as  South 
Africa.  It  differs  from  typhoid  fever  in  the  absence  of  spots  and  of  characteristic  diarrhoea, 
but  as  these  often  fail  in  typhoid  fever  the  distinction  is  not  always  available.  However, 
the  diagnosis  can  generally  be  made  by  the  Widal  test,  since  the  blood  serum  will  agglu- 
tinate the  Micrococcus  mcUtcusis  as  early  as  tlie  fifth  day  of  the  disease. 

Tuberculosis. — The  onset  of  general  miliary  tuberculosis,  or  of  miliary  tuberculosis 
of  the  limg.  has  often  for  its  only  symptom  a  moderate  pyrexia,  with  accompanying 
physical  weakness  and  anorexia.  Such  a  condition  may  cozitinue  for  weeks  without  any 
other  sign  ;  the  breathing  need  not  be  quickened,  and  there  may  be  an  entire  absence  of 
abnormal  signs  in  the  limgs.  The  morning  temperature  is  frequently  near  the  normal, 
while  the  evening  temperature  alone  is  high  :  and  it  does  not  as  a  rule  increase  to  a 
maximum  and  subsequently  fall,  so  as  to  form  the  curve  whicli  is  characteristic  of  typhoid, 
but  continues  nearly  at  the  same  level  for  long  periods.  In  the  absence  of  sputum  the 
detection  of  tubercle  bacilli  is  not  available.  Tuberculin  tests  may,  however,  be  tried, 
and  will  probably  give  positive  results.  Of  these  the  most  suitable  is  the  cutaneous  tuber- 
culin test  of  von  Pirquet  (Plate  XXXVII,  p.  770).  Tuberculous  infection  in  other  localities 
may  equally,  when  not  accompanied  by  striking  local  signs,  and  only  jjresenting  the  pyrexia, 
be  taken  for  typhoid  fever  :  for  instance,  tuberculous  disease  of  the  kidney,  or  pyelitis,  and 
especially  tuberculous  meningitis.  Headache  and  fever  occur  both  in  this  and  in  typhoid 
and  may  be  for  a  time  the  only  facts  in  the  case,  until  in  the  one  case  spots  or  loose  motions 
assert  themselves,  or,  in  the  other,  optic  neuritis,  convulsions,  paralysis,  or  retracted 
abdomen  point  to  a  cerebral  localization. 

Meningitis. — The  duration  of  a  tuberculous  meningitis  is  often  three  or  four  weeks, 
during  wliich  there  is  pyrexia  of  moderate,  or  occasionally  of  severe  type.  In  the  sporadic, 
infantile  form  of  cerebrospinal  meningitis,  first  described  as  posterior  basal  meningitis,  the 
fever  is  often  prolonged  for  five,  six,  or  more  weeks.  The  continuous  temperature  is  not 
generally  very  high,  but  in  some  cases  there  are  sudden  rises  to  103^  and  104\  followed 
by  a  fall  to  the  normal  within  a  few  hours  (Fig.  253,  p.  591).  These  rises  of  temperature  may 
occur  daily,  or  every  other  day.  or  more  frequently.  As,  in  meningitis,  by  the  time  the 
pyrexia  has  become  prolonged  the  cerebral  symjitoms,  such  as  drowsiness,  coma,  and  re- 
tracted head,  are  usually  pronounced,  there  is  not  much  difficulty  in  locating  the  disease  in 
the  meninges.  To  determine  whether  the  inflammation  is  tuberculous  or  meningococcal  or 
of  other  bacterial  origin  may  require  a  lumbar  puncture  (p.  304)  or  blood  culture. 

Infective  or  Malignant  Endocarditis  may  be  mentioned  next  because  for  days,  weeks, 
or  months  the  only  prominent  feature  may  be  a  continuous  pyrexia  with  evening  rises  to 
101  F.,  falling  in  the  morning  to  99'  or  98-4"  F.  (Fig.  243).  In  most  cases  a  cardiac  murmur 
is  present,  and  then  one  may,  after  a  certain  lapse  of  time,  such  as  fourteen  days,  -and 


Fig.  '2^Z. — Temperature  chart  of  a 


excluding  the  possibility  of  typhoid  fever,  often  make  a  diagnosis  with  confidence.  This 
is  confirmed  by  the  occurrence  of  other  symptoms  mentioned  on  p.  34.  An  attempt 
should  be  made  to  obtain  an  organism  from  the  blood  by  cultivation,  but  it  is  not  always 
successful.  In  the  early  stages  the  difficulty  is  not  uncommonly  increased  by  the  fact 
that  no  murmur  can  be  heard,  in  spite  of  the  fact  that  endocardial  changes  are  present. 
The  course  of  some  of  these  cases  of  infective  endocarditis,  which  may  be  called  chronic, 


PYREXIA,     PROLONGED  ,,67 

is  remarkably  prolonged,  sometimes  for  six,  eight,  or  twelve  months,  with  little  variations 
in  the  accompanying  conditions.  Long  before  that,  of  course,  typhoid  fever  and  tuber- 
culosis would  have  been  excluded  ;  and  after  eight  or  ten  weeks  the  co-existence  of  cardiac 
murmur,  with  uniform  prolonged  pyrexia,  would  make  the  diagnosis  certain.  Cases  in 
which  the  brunt  of  the  disease  falls  upon  the  brain  may  actually  have  meningitis,  as  in 
pneumococcal  cases  ;  or  they  inay  be  mistaken  for  meningitis,  or  for  typhoid  fever,  or,  if 
petechiae  are  present,  for  typhus.  But  in  such  instances  the  illness  is  generally  a  short 
one,  and  it  would  scarcely  come  into  the  present  category. 

Septicemia. — In  any  prolonged  pyrexia  the  possibility  of  a  focus  of  deep-seated 
suppuration  should  be  considered.  In  many  situations  the  focus  causes  pain  which  at 
once  directs  attention  to  the  origin  of  the  trouble  ;  but  in  some  cases  pain  is  absent,  ami 
foci  in  some  situations  are  habitually  painless.  The  disorders  to  be  thought  of  are  otitis, 
abscesses  in  the  tliroat.  a  small  empyema,  cerebral  abscess,  deep-seated  glandular  suppuration, 
suppurative  pi/leplilebitis.  (ippciidicitis,  pelvic  suppurations  in  women,  and  umbilical  lesions 
in  the  new-born  infant.  If  the  blood  shows  a  leucocytosis  this  will  be  in  favour  of  a 
suppurating  centre.  .At  any  rate,  it  will  exclude  typhoid  and  miliary  tuberculosis.  Each 
possible  centre  of  infection  must  be  called  to  mind,  and  the  locality  concerned  must  be 


Fi'j.  'l\\.  -'J'cnipomture  cliart  of  n  ca-^e  of  pymmia,  secondary  to  otitis  meiiiii  and 
liiteral  sinus  thrombosis.    There  was  a  rigor  almost  daily. 


iiivcsligalcd.  Suppurative  |)ylc phlebitis,  in  spite  of  the  extent  of  the  lesions  and  the  size 
nf  the  organ  ((iticcrncd,  has  fre(|ucntly  been  overlooked,  and  has  been  mistaken  for  typhoid 
f<\(T,  |)neiunotiia,  peritonitis,  or  api)ciidicitis.  It  is  relatively  rare,  but  it  is  a  sequel  of 
other  sup|)urativc  lesions  in  the  abdomen,  and  should  therefore"  be  thought  of  when 
apjx-ndicitis  or  other  similar  affection  has  been  under  treatment.  Higors  are  very 
inconstant  in  tliseases  of  this  class  ;  if  they  occur  they  compel  altcnlion  to  tlic  piissibility 
of  i)yogenetie  centres  (/''(X'-  -It)  ;  but  their  absence  must  not  be  allowed  to  iiitluinee  one 
in  the  contrary  sense.  'I'hey  are  most  constant  in  visceral  pya-mia,  but  this  illness  is  not 
gciieially  prolonged.  In  some  cases  the  organism  is  only  discovered  after  repeated  cultural 
examination  of  the  blood,  the  urine,  or  even  the  cerebrospinal  fluid,  and  it  may  be  found 
(i)  lie  some  rarity  such  as  the  glanders  bacillus  or  a  Icjitollirix  bacillus. 

ICrjisijiclas.  though  generally  of  short  dunitioii.  sonulimes  causes  pyrexia  lasting  more 
lli:ni  a   fortnight  (Fig.  •1\-,). 

Sfiiiliilis.  XAkc  other  infections,  this  has  its  lexers.  I)i)lli  in  the  seciindary  stage, — ■ 
thai    is   the  stage  of  gencrali/al  inn   of  the   inliction      and   in   tlic   lale  stages  accompanying 


568  PYREXIA.     PROLONGED 

gumniata  and  other  local  processes.  The  secondary  fever  is  certainly  not  present  to  a 
marked  degree  in  most  cases  ;  a  little  feverishness  there  may  be.  but  it  scarcely  requires 
special  mention.  Only  occasionally  is  there  a  really  prolonged  pyrexia,  with  decided 
evening  elevations  of  temperature.  The  diagnosis  is  rarely  in  question  because  the  fever 
only  accompanies  the  rash  and  sore  throat  ;  and  the  origin  in  a  local  infection  is  generally 
well  known.  The  same  help  may  be  with  us  in  the  fever  attending  gumma-formation  ;  but 
if  the  gumma  is  deep-seated  in  a  viscus  such  as  the  liver,  even  though  it  should  be  painful, 
and  recognized  by  palpation  as  an  abnormal  enlargement  or  thickening,  some  hesitation 
may  be  felt  as  to  the  diagnosis  unless  it  is  remembered  that  such  pyrexia  may  be  present. 
Moreover,  a  jnrexia  of  this  kind  has  occurred  in  connection  witli  the  lesions  of  the  inherited 
disease.  Syphilitic  pyrexia  is  frequently  of  decided  character,  with  evening  elevations 
to  103°  F.  or  more,  and  morning  falls  nearly  to  normal,  until  stopped,  as  it  may  be  at  once, 
by  the  administration  of  potassium  iodide.  In  both  these  cases  the  ^Vassermann  reaction 
is  available  to  make  certain  the  nature  of  the  infection. 

Rronchopneumonia. — This  may  be  mentioned  because  it  has  sometimes  a  duration 
of  many  weeks,  and  during  the  whole  time  an  oscillating  temperature  is  present.  The 
local  signs  are,  however,  sullicient  to  explain  the  presence  of  fever,  and  the  difficulty  lies 
only  in  the  fact  that  a  general  pulmonary  tuberculosis  may  resemble  almost  exactly  the 
more  curable  bronchopneimionia  of  pneiunococcal  or  streptococcal  origin. 


Fig.  24.*>. — Temperature  chart  of  a  case  of  facial  erysipelas  following  a  septic  scratch. 


Malaria. — Important  as  is  this  disease,  its  diagnosis  may  be  dealt  with  briefly  here. 
The  non-malignant  cpiartan  and  tertian  fevers  produce  isolated  pyrexias  of  short  duration 
{Fig.  fi,  p.  28,  and  Fig.  7,  p.  29)  which  do  not  come  within  the  scope  of  this  paper.  It  is 
only  the  malignant  or  subtertian  fevers,  which  do  not  ari.se  in  this  country,  and  are  little  likely 
to  be  seen  in  other  than  regions  known  to  be  malarious,  which  cause  prolonged  continuous 
pyrexia  (Fig.  11,  p.  31).  The  diagnosis  is  based  upon  a  consideration  of  the  symptoms, 
upon  the  discovery  of  the  parasite,  and  upon  the  results  of  treatment  with  quinine.  The 
symptoms  chill,  fever,  and  sweating  have  less  value  in  a  continuous  pyrexia  than  in  the 
sim))le  tertian  and  quartan  fevers,  and  in  a  quotidian  fever  the  resemblance  to  septic  poison- 
ing is  well  recognized.  An  enlarged  spleen  is  present  in  malaria,  but  also  commonly  in 
typhoid  fever.  Most  reliance  is  to  be  placed  upon  a  microscoiiical  examination  of  blood- 
films  coloured  with  Romanowsky's  or  Leishman's  stain  ;  for  in  eases  of  pernicious  malaria, 
it  is  rarely  that  the  organisms  (Plate  XXVIII.  Fig.  E.  p.  614)  fail  to  be  discovered  by  this 
means.  Absence  of  leucocytosis  and  an  increase  of  the  large  mononuclears  to  15  per  cent  in  a 
diffei'cntial  count  of  the  leucocytes  in  the  blood,  are  also  in  favour  of  malaria,  at  least  in  the 
first  two  weeks  ;  after  which  the  results  may  be  very  similar  in  typhoid  fever.  The  third  test 
is  the  administration  of  quinine,  which,  given  in  sufficient  quantity,  will  stop  malaria  ;  and 


PYREXIA.     PROLONGED 


569 


on  tlic  other  hand,  if  the  fever  continues  in  spite  of  it,  malaria  is  exehided.  An  adequate 
dose  for  this  purpose  is  3  or  4  gr.  every  three  hours,  day  and  night,  for  two  or  three  days. 

Bncilluria. — This  is  usually  due  to  infection  of  the  urinary  passages  with  Bacillus  coli 
comnninis.  The  synijitonis  may  be  slight  or  they  may  be  those  of  cystitis  or  pyelitis  in  a 
marked  degree  (see  Bactkriiria,  p.  69)  ;  with  these  there  is  a  more  or  less  continuous 
pyrexia  (Fig.  193.  ]).  456).  Es])eeially  in  infants  they  may  be  few,  or  none  at  all  other  than 
the  j)yrexia.  which  is  variable  in  degree,  generally  irregular  from  day  to  dav.  may  he  accom- 
panied by  chills  and  sweating,  and  may  last  several  weeks.  Hence  in  an  obscure  fever  in 
infants  the  urine  should  be  examined  carefully. 

Anfpmia. — The  several  forms  of  pernicious,  idiopathic,  or  .Addisonian  an;cmia  are 
frequently  accompanied  by  a  moderate  degree  of  pyrexia,  which  may  persist  for  many 
weeks  (Fig.  246).  Such  an  auicmia  might  be  the  manifestation  of  tuberculosis,  of  infective, 
endocarditis,  or  of  malignant  growths  ;  but  an  examination  of  the  blood  with  the  discovery 
of  poikilocytosis,  of  a  colour-index  above  unity,  the  lemon-yellow  tint  of  the  skin  in  some 


T-^^ 


^^^h^^ 


':.<>.>..-?-. 


fv 


f^   -\ 

aAP^ 

r^ 

\     *            V     - 

V 

: 

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-^"7^^        -T,  ^-^ 

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7-lMP^^A.M^;/^, 


Fi-j.  21(;.— CliE 


A!teriitic  te;npcrature  cliart  of  it  ease  of  pi 


cases,  and  the  history,  will  generally  determine  the  diagnosis,  though  the  differentiation 
of  the  ])articular  form  of  an:i-mia  may  still  remain  to  be  considered  (see  .An/Kmia,  p.  20). 
Ilddghiii's  Dixeasc.  In  some.  bMt  by  no  means  all,  cases  of  this  disease,  a  very 
rcnijirkablc  form  of  pyrexia  occurs.  It  consists  of  alternating  periods  of  pyrexia  and 
apMcxia,  each  of  eight,  ten.  or  twelve  days"  duration,  lasting  in  all  for  six,  nine,  or  twelve 
mouths.  During  llic  p\  nxial  period  the  tcnipeiatun-.  Ii<giiniing  near  the  normal,  becomes 
d;iy  by  day  higher  and  higher,  till  on  the  fourth  or  tifth  evening  it  reaches  102  E.  or  103°  P., 
its  highest  jioint  ;  it  gradually  declines  during  the  next  four  or  live  days  to  the  normal  ; 
and  then  for  three  or  four  days  it  becomes  increasingly  subnormal  till  a  mininunn  is  reached, 
and  from  this  point  there  is  a  gradual  return  to  the  normal,  when  a  second  pyrexial  curve 
begins  (Fig.  2t7).  If  the  cervical,  axillary,  or  inguinal  lymph-glands,  apart  from  or  in 
company  with  the  spleen,  are  enlarged,  and  the  con<lition  of  the  blood  is  normal,  or 
of  the  simple  chlorotic  t>pe.  the  diagnosis  of  Ilodgkin's  disease  is  safely  made.  If  such  a 
temperMlure  is  <)bser\<'d  without  any  i-nlargement  of  the  spleen  or  of  the  external  glands,  a 
lyniphadc  iKinialous   enlargenienl    of  the   intern.al   glands.    Iironeliial   cir   mediastin;il,    should 


570 


PYREXIA.     PROLONGED 


be  suspected,  and  endeavours  should  be  made  to  demonstrate  them  by  palpation, 
percussion,  or  a-rays.  Leueocytosis  should  be  absent  :  but  its  occurrence  in  a  late  stage 
of  the  pyrexia  would  not  militate  against  the  diagnosis. 


3.  JUIY          lO       «UCUSr.3    ,»„UCUST      TO      AUGUST    27    !6    AUGUST    TO    St^TEMBL,.  I.SC^nBEI.    TO  SEI^EMSEJ.» 

lOS- 

>m- 

lira-    J 

!■"■■  t     --           -4]}             "  J} 

\  __          kh          ::^i\r    "    -4 

^"-  t  -             4            ^  n          4 

■--i s^--- :^ii--\—J^ 

:::■  \]ul^      -  Ia,^^^^        hr^^ 

\j  J                      "■       fry                                r~     " 

t  I 

r59'f 


-F/f/.  ■247. — Temperature  cliart  of  a  case  of  Hodgkiii's  disea.se. 

Leukaemia. — Pyrexia  is  a  common  occurrence  in  the  different  forms  of  leukaemias 
As  a  rule  the  great  size  of  the  spleen  in  one  group  of  cases  leads  to  an  easy  diagnosis,  am 
in  another  group  the  glands  are  manifestly  enlarged,  though  acute  cases  occur  in  which 
these  changes  do  not  appear  early  ;  in  all  these  forms  an  examination  of  the  blood  will 
show  the  excessive  number  of  leucocytes,  of  one  or  other  variety  (p.  24),  a  sutficient 
explanation  of  the  occurrence  of  pyrexia. 


I 


Fi(j.  i-lS. — Temperature  chart  of  a  t 


■  the  neck  and  mediastinum. 


New  Growths. — Xew  growths  are  not  accompanied  by  pyrexia  as  a  rule  ;  but  many 
exceptions  have  been  recorded,  in  regard  both  to  sarcoma  and  to  carcinoma.  A  case  of 
sarcoma  of  the  neck  and  mediastininn  was  accompanied  for  the  four  months  preceding 
death  by  a  pyrexia  resembling  in  its  variations  from  week  to  week  that  of  Hodgkin's  disease  i 
(Fig.  248),  and  carcinoma  has  now  frequently  been  known  to  be  accompanied  for  weeks! 
or  months  by  fever,  especially  where  there  are  secondary  deposits  in  the  liver  (p.  326). 
The  diagnosis  is  not  generally  difficult  :  the  tumour  is  in  evidence.  A  point  of  importance! 
is  that  the  pyrexia  does  not  help  to  distinguish  between  syphilis  and  cancer. 

Cirrhosis  of  the  Liver. — The  diagnostic  relations  of  pyrexia  in  cirrhosis  of  the  live 
are  on  the  same  footing.  It  occurs  in  .some  cases  (Fig.  167,  p.  371)  and  is  apparently  due  t^ 
cirrhosis  ;  perhaps  because  it  is  an  inflammatory  process,  or  because  the  cirrhosis  is  due  to ' 
a  toxaemia  which  may  raise  the  temperature.  The  fact  is  of  interest  when  we  consider  that 
ascites  due  to  hepatic  cirrhosis  has  often  been  mistaken  for  tuberculous  peritonitis,  and, 
perhaps  less  often,  tuberculous  peritonitis  for  cirrhosis.  The  absence  of  pyrexia  might 
possibly  be  held  to  exclude  tuberculous  peritonitis,  but  its  presence  would  leave  the  diagnosis 
open,  since  it  might  be  due  to  either. 

The  curious  pyrexial  outbiu-sts  in  rat-bite  fever  are  described  on  p.  598,  and  the  longJ 
continued  low  fever  of  pellagra  on  p.  225. 

Neurotic  Pyrexia. — This  term  may  be  applied  to  two  classes  of  case  :  in  one  thd 
mercury  is  found  at  extraordinarily  high  levels  at  irregular  intervals,  often  at  differenj 
levels  in  different  parts  of  the  body,  and  falling  again  rapidly  to  the  normal.  This  maj 
be  repeated  many  days,  but  hardly  constitutes  prolonged  pyrexia.  In  the  second  varietj 
the  j5atient  has  a  genuine  pyrexia,  lasting  two,  three,  or  more  weeks,  irregular  in  thi 
elevations  reached  on  successive  days,  but  on  the  whole  resembling  the  pyrexia  of  sepsis 


PYREXIA    ^VITHOL'T    OBVIOUS    CAUSE  571 

These  cases  are  more  often  females,  and  the  fever  may  be  associated  with  symptoms  refer- 
able to  the  pelvic  organs,  or  may  persist  after  the  entire  subsidence  of  such  symptoms,  so 
that  skilled  obstetric  physicians  Iiave  been  unable  to  find  any  active  local  lesion.  The 
neurotic  origin  of  such  cases  may  be  open  to  doubt,  but  it  is  supported  by  the  variability 
of  the  pyrexia,  and  by  its  occasional  rapid  cessation  without  adequate  explanation,  and 
without  any  local  change.  The  diagnosis  can  only  be  made  as  a  rule  via  exclnsionis.  and 
must  always  be  considered  provisional  as  long  as  there  is  any  probability  of  an  adequate 
cause  being  found. 

The  Unexplained  Pyrexia  of  Children. — This  form  of  pyrexia  is  in  a  somewhat  similar 
position  to  the  above.  All  students  of  disease  in  children  are  familiar  with  the  fact  that 
in  patients  under  nine  or  ten  years  of  age  a  mild  pyrexia  may  occur,  lasting  two,  three,  or 
four  months,  for  which  no  explanation  can  be  foimd.  Since  it  arises  in  quite  young  subjects, 
a  neurotic  origin  is  not  so  readily  suggested,  nor  so  likely,  as  in  the  adult  female,  and 
yet  it  is  possible  that  some  cases  are  of  this  nature.  Tuberculosis  should  be  considered 
carefully,  but  is  often  safely  and  rightly  excluded.  Gastro-intestinal  disturbance,  such 
as  constipation  :  the  unsuitable  nature  of  the  food  ;  and  acute  intoxication  from  the 
alimentary  canal,  are  other  possible  explanations  of  some  cases.  Since  the  prognosis  is 
good,  it  is  satisfactory  to  be  able  to  recognize  the  clinical  condition,  even  though  the  causa- 
tion is  obscure  ;  but  the  diagnosis  can  only  be  established  after  careful  exclusion  of  typhoid 
fever,  tuberculosis,  and  local  inflammatory  conditions  such  as  otitis,  bacilluria,  and  other 
definite  lesions  or  infections.  Freilerick  Taijlor. 

PYREXIA  WITHOUT  OBVIOUS  CAUSE.— From  researches  carried  out  in  trying 
to  ascertain  the  mechanism  by  which  the  body  maintains  in  health  an  average  temperature 
(practically  constant)  of  98-4°  F.,  and  the  factors  that  le.id  in  disease,  and  also  even  in 
health,  to  a  departure  from  that  temperature,  a  rumiber  of  general  principles  have  been 
established,  and  these  must  be  grasped  before  we  can  form  a  just  estimate  of  the  value  of 
the  reading  of  the  thermometer  in  diagnosis.  We  must  briefly  state  the  more  important 
of  these  without  discussion. 

1.  Sources  of  the  Actual  Produclion  of  Ileal  in  Health  in  order  of  importance  : 
(a)  Muscles  at  work  ;  (6)  Glands  at  work  ;  (c)  All  minor  tissues  in  which  katabolie  changes 
are  proceeding. 

2.  Provisions  for  the  Escape  of  Heat. — (a)  Temperature  changes  in  the  air,  especially 
that  expired  ;  (b)  Escape  by  the  skin,  radiation,  and  evaporation  of  sweat  ;  (c)  Escape 
by  urine  and  faeces  ;    (d)  Warming  of  food,  and  anabolic  tissue  changes. 

3.  Mechanisms  for  liegulaling  the  Distribution  of  Heat  "t'nerated  Loc(dln. — («)  A 
main  centre  for  regulating  the  distribution  of  the  bloo<l.  situated  in  the  medulla  :  (b) 
Subsidiary  centres  for  the  same  purpose  situated  in  the  cord  and  ('.')  elsewhere  :  (c)  The 
physical  jiropcrties  of  the  blood,  lymph,  and  tissue  juices  as  regards  their  circulatory 
movements  and  their  capacity  for  absorbing  and  retaining  heat. 

These  three  belong  to  the  province  of  ])ure  experimental  |)hysiology  and  |)liysics  ; 
wc  have,  then,  the  further  observations  shared  by  jjliysiology  and  clinical  medicine  : 

-I-.  That  the  temperature  in  perfect  health  can  be  raised  considerably  (at  least  to  102"  F. 
• — Hill)  by  strenuous  physical  exertion  ;  such  elevations  disappear  very  rapidly,  possibly 
with  small  oseillatiims. 

5.  That  in  exhaustion  from  violent  eliorl  or  <\p(isurc  (generally  both,  as  in  shipwrecks 
and  similar  accidents)  the  temperature  can  be,  an<l  is,  very  dangerously  depressed,  this 
being  |)ossibly  the  sole  cause  of  death. 

(i.  'J'hat  in  every  form  of  mierobic  invasion  oT  the  body,  the  Iciiipcralurc  may  be 
altered.  This  alteration  may  be  produced  in  several  eoueeivabic  ways,  e.g.,  by  the  direct 
action  of  the  microbes  or  their  poisons  on  the  seats  of  the  production  of  heat  or  on  the 
centres  regulating  its  distribution,  or  again  by  the  action  of  the  same  poisons  or  microbes 
on  the  in:iin  sniincs  of  loss  of  heat.  The  exact  and  precise  cause  is  very  obscure,  though 
extreiuily  inlvnsliug  to  llie  pathologist. 

Lastly,  as  punl\    cliiiieal  ol)s(rvations  we  have  learnt  : 

7.  That  in  order  llial  \aiialioiis  in  teniperature  may  kill,  or  indeed  of  liieMisclvcs  be 
of  very  serious  import.  Ilicy  need  to  be  \-ery  extreme  (say  <«  or  7  degrees  al>ij\c  or  below 
normal)  or  else  very  prolonged.  Ilie  necessary  <liiral  ion  \ar\ing  witli  the  degree  ol' departure 
from  the  normal. 


572  PYREXIA    WITHOTT    OBVIOUS    CAUSE 

8.  That  in  the  wards  of  a  liospital  where  the  temperatures  are  taken  and  charted  at 
regular  intervals,  it  is  scarcely  jjossible  to  find  a  chart  of  chronic  disease  which  does  not 
show  some  oscillations  in  temperature,  the  causes  of  which  are  obscure  or  overlooked. 

From  these  general  propositions  we  may  pass  to  the  practical  value  of  thermometric 
observations  in  diagnosis.  We  may  again  generalize,  and  say,  that  standing  alone  as  a 
primary  and  isolated  observation,  the  fact  of  a  disturbance  in  temperature  is  of  little  use  : 
but  when  this  observation  is  controlled  by  other  factors  in  diagnosis,  and  we  have  made  a 
complete  diagnosis  of  a  given  disease,  we  are  then  in  the  position  of  knowing  by  experience 
approximately  the  course  of  the  temperature  for  that  disease,  and  we  shall  get  many  useful 
hints  from  the  thermometer  as  to  complications  or  the  severity  of  the  attack  :  a  point  to 
which  we  shall  refer  presently.  Hence,  it  is  useful  in  our  present  discussion  to  divide  all 
patients  into  two  main  groujss  :  (1)  Those  tvlio  are  well  enough  to  visit  their  doctor,  and 
(2)  Those  ivho  are  too  ill  to  do  so. 

Patients  who  are  well  enough  to  visit  their  doctor. — I'nless  some  special  com- 
plaint or  physical  sign  soon  leads  to  satisfaetiirv  diagnosis,  let  it  be  an  accepted  rule  to 
take  the  temperature  ;  by  doing  so  we  shall  not  infreiiuently  discover,  early,  a  disease 
which  we  might  otherwise  have  overlooked  until  something  or  some  one  else  had  drawn 
attention  to  it,  greatly  to  our  discomfiture  and  loss  of  credit.  The  three  most  typical 
illustrations  of  this  position  are  perhaps  typhoid,  phthisis,  and  a  condition  which  in  our 
haste  we  label  '  Influenza: 

A  headache  lasting  four  or  five  days  and  associated  with  some  degree  of  pyrexia,  is, 
even  standing  alone,  so  suspicious  of  the  first,  that  the  patient  must  be  ordered  to  bed  to 
be  watched.  A  nasty  dry  cough,  with  general  anaemia,  weakness,  tiredness,  and  malaise, 
makes  us  very  suspicious  of  the  second,  especially  if  there  is  also  the  slightest  alteration  in 
the  breath  sounds  anywhere.  The  third  is  the  recently  developed  refuge  of  the 
diagnostically  destitute  ;  it  leads  to  much  mortification  when  suppurating  gums  or  tonsils, 
gonococcal  discharges,  decomposing  urine,  or  other  critical  points  are  discovered  later  :  a 
position  which  may  be  avoided  by  examining  all  easily  accessible  orifices,  and  if  the  mouth, 
throat,  and  nose  all  seem  healthy,  by  labelling  the  trouble  fever  of  uncertain  origin,  and 
ordering  the  patient  to  bed.  In  fact,  ;/  on  examining  the  patient  in  the  eonsulting-room 
no  cause  for  the  pyrexia  is  apparent,  I  would  lay  down  as  a  golden  rule — Remove  the  patient 
at  once  from  Group  1,  and  place  him  in  Group  2  for  further  critical  examination  of  his  or 
her  person,  blood,  and  excreta. 

Patients  who  request  their  doctor  to  visit  them. — It  must  be  admitted  that  in 
this  group  also,  pyrexia  by  itself  is  not  a  very  strong  diagnostic  point,  for  ex  hypothesi 
the  other  symptoms  are  of  considerable  severity  and  imjjortanee,  and  therefore  point  pretty 
strongly  in  some  diagnostic  direction.  Our  residuum  from  Group  1,  with  a  certain 
proportion  of  individuals  originally  in  Group  2,  will,  however,  together  make  up  a  by  no 
means  negligible  number  of  patients  in  whom  the  cause  of  pyrexia  is  obscure  to  an  ordinary 
examination.  Here  it  is  the  first  rule  to  examine  systematically  every  orifice  of  the  body 
for  a  possible  source  of  trouble  ;  gums,  and  especially  the  roots  of  the  teeth  for  pyorrhoea, 
ears,  nose,  throat,  vagina,  rectum,  and  urethra  ;  should  all  these  prove  healthy,  the  fingers 
and  toes  must  be  inspected  for  overlooked  sores  ;  and  the  bones  near  joints  investigated 
for  a  possible  osteomyelitis. 

The  Blood. — It  is  by  now  almost  certain  that  some  clue  will  have  been  obtained, 
but  should  none  have  appeared  (in  some  cases  even  when  a  complete  diagnosis  has  been 
made)  we  must  now  proceed  to  have  the  blood  examined  by  the  best  available  scientific 
methods  ;  we  may  by  this  means  prove  that  the  blood  itself  is  at  fault,  or  that  it  contains 
some  microbes,  thus  : — 

1 .  Leucocytosis  suggests  leucocj^tha^mia  perhaps,  in  which  disease  outbreaks  of  pyrexia 
are  not  uncommon  ;  or  some  obscure  focus  of  suppuration  ;  or  perhaps  it  proves  that  an 
obvious  focus  requires  the  surgeon's  assistance  :  or  per  contra,  it  provides  a  slight  argument 
against  typhoid  or  tubercle,  and  in  favour  of  gross  parasitic  worms. 

2.  Poihilocytosis  suggests  a  severe  anaemia,  which,  like  leucocythajmia,  is  known  to 
have  pyrexial  periods, 

3.  IVidal's  Test,  if  positive,  practically  proves  the  presence  of  typhoid. 

4.  Cultivation  of  it  may  prove  a  microbic  invasion,  the  name  and  nature  of  the  invader, 
and  possibly  the  point  of  invasion. 


PYREXIA     WITHOUT    OBVIOUS    CAUSE  578 

5.  Microparasites  of  protozoal  form  (malarial  or  other)  may  be  recognized  in  the  blood 
under  the  microscope. 

The  Urine  may  be  found  to  be  thick  or  decomposed,  and  thus  give  a  clue  to  tubercle 
of  the  genito-urinary  tract,  to  calculous  trouble,  or  to  B.  coli  communis  invasion.  It  is 
well  to  remember  that  B.  coli  may  exist  in  what  otherwise  appears  to  be  a  healthy  urine 
(p.  12). 

The  Faeces  may  yield  information  :  melaena,  fatty  stools,  gall-stones,  or  even  eggs 
of  parasites  may  be  found,  thus  clearing  up  the  cause  of  an  obscure  pyrexia. 

Tests  such  as  C'almette"s  or  von  Pirquefs  may  be  tried  for  Intent  tubercle,  but  the 
dropping  of  tuberculin  into  an  eye  is  not  without  its  own  risks,  and  in  my  opinion  had 
better  be  avoided,  especially  as  by  the  time  tubercle  has  caused  pyrexia  it  has  probably 
advanced  so  far  as  to  be  discoverable  by  careful  physical  examination  of  the  chest. 
Moreover,  the  test  is  alleged  to  be  so  delicate  as  to  discover  obsolete  tubercle,  which  is  not 
the  cause  of  the  pyrexia,  and  so  may  lead  one  astray. 

When  physical  examination,  clinical  methods  of  investigating  secretions  and  excre- 
tions, and  bacteriological  aids  have  thus  all  been  exhausted,  there  will  still  remain 
a  few  rare  cases  in  which  the  cause  of  the  pyrexia  is  undiscoverable.  These  are  chiefly 
abdominal  :  thus  gall-stones  and  their  complications,  pylephlebitis,  ovarian  abscess, 
and  deep-seated  phlebitis  have  all  presented  instances  to  the  writer  ;  but  he  knows  of 
no  rules  by  which  such  cases  can  be  discovered  :  time  or  an  autopsy  can  alone  clear  them 
up.  Apart,  however,  from  such  obscurities,  there  still  remain  some  interesting  and  useful 
observations  to  be  made  on  certain  clinical  thennometric  measurements. 

PYREXIA    OR    SUBNORMAL    TEMPERATURES    IN    CHILDREN. 

In  children  we  know  that  the  heat-regulating,  like  other  nervous  mechanisms,  takes 
time  to  develop  proper  and  complete  eoimections  with,  and  control  over,  subordinate 
centres  of  regulation,  whether  these  be  foci  of  production  or  surfaces  of  loss  ;  hence  we  are 
not  surprised,  still  less  alarmed,  at  temperatures  above  normal  in  children,  which  in  adults 
may  have  a  very  different  significance.  It  is  rather  the  reverse  with  those  below  normal, 
because  we  know  that  the  growing  child  requires  very  large  supplies  of  heat  to  carry  on 
the  anabolic  functions  of  growth  and  development. 

Subnormal  Temperature. — Suppose  we  find  a  child  in  this  condition,  the  immediate 
diagnosis  is  great  exhaustion  ;  such  temperatures  are  generally  found  in  marasmic  children 
who  have  been  starved,  or  its  equivalent,  i.e.,  badly  fed,  or  exposed.  Subnormal  tempera- 
tures are  also  found  in  summer  diarrhoea,  or  sometimes  in  conditions  associated  with 
intense  pain  ;  also,  at  an  interval  after  convulsions  (not  immediately),  and  in  many  other 
conditions,  the  differential  diagnosis  of  which  will  generally  be  obvious. 

Pyrexia,  on  the  other  hand,  owns  an  infinity  of  causes,  of  which  we  can  only  glance 
at  a  few  which  may  give  rise  to  trouble  in  diagnosis. 

Excitement. — In  children's  wards,  visiting  day  almost  invariably  causes  a  plentiful 
crop  of  high  temperatures,  even  as  much  as  103  F.,  and  the  private  practitioner  has  to 
remember  this  when  a  loving  aunt  or  an  injudicious  visitor  of  any  sort  has  come  in  contact 
with  his  little  pallciit  ;it  home.  A  had  night  mav  casilv  send  the  temperature  up  to  any 
height. 

FehricuUi.-  This  is  merely  n  I-atin  name  for  the  fad  of  pyrexia,  but  before  using  the 
term  let  every  system  be  examined  (;arefully  for  signs  of  disease.  It  may  be  that  there  is 
absolutely  nothing  else  wrong.  The  following  is  a  useful  and  ordinary  average  cMnical  rule  : 
for  each  1  \'.  the  temperature  rises  we  may  expect  the  pulse  to  increase  in  fr(i(ueney  10 
beats  (or  in  eliildnn  1"))  per  miiuile.  and  the  rcspirulions  2  to  .'J  per  miniilc.  and  if  this  ratio 
is  maintained  it  is  lairly  safe  to  say  that  heart  and  lungs  arc  neither  of  them  specially  threat- 
ened, and  hence,  ;/  there  he  notliinfi  clue  to  iittract  attention,  it  is  safe  to  say  that  the  child  is 
certainly  feverish,  and  we  must  nurse  and  watch  it.  I  have  known  a  delicate  boy  of  9  or  10 
tlnis  to  have  a  temperature  of  ^^)•>•^>  to  10;!-5°  for  three  or  four  days  at  a  time  for  no  reason 
that  I  could  e\-er  detect  ;  he  ate  well,  slept  well,  and  felt  well  ;  and  this  aspect  of  affairs 
should  he  remembered.  On  the  other  hand,  such  temporary  attacks  of  pyrexia  may  be 
aroused  by  the  presence  of  some  miero-organisms  which  lia\-e  hitherto  escaped  deteetion. 
but  (/»«  the  pyrexia  in  itself  nothing  more  can  be  said.  Deep-seated  tubercle,  perhaps  in 
internal  lymphatic  glands,  ma\'  be  suspected,  but  il  will  often  be  exeeedingly  diflieult  to 
settle  the  diagnosis. 


r,74  PYREXIA    WITHOUT    OBVIOUS    CAUSE 

Convulsions. — These  must  be  remembered  as  a  possible  cause  of  a  temperature  of  even 
103'  F.  if  tlie  thermometer  be  used  at  once. 

Specific  Zymotic  Diseases. — On  discovering  a  child  witli  fever,  suspicion  will  naturally 
be  aroused  that  one  of  these  troubles  is  at  hand.  The  only  thing  to  be  said  here  is  :  Do 
not  attempt  to  give  a  diagnosis  on  the  thermometer  alone  ;  the  temperature  is  raised  long 
before  a  diagnosis  is  possible.  It  is  well  to  note  that  a  temperature  of  102'  F.  only,  or 
less,  is  a  point  in  favour  of  diphtheria  against  a  tonsillitis  of  other  causation,  which  frequently 
has  a  pyrexia  of  104'  F.  or  105°  F.  Slight  pyrexia,  with  headache  and  \omiting,  makes 
us  suspect  tuberculous  meningitis,  whereas  a  temperature  of  103'  F.  or  104'  F.  with  similar 
associations  renders  pneumonia  j)r(>l)al)le, 

IN    CHILDREN    AND    ADULTS. 

Here  we  may  draw  attention  to  some  of  those  cases  in  which  the  fever  of  known 
a^'erage  departs  fron\  its  usual  course. 

Empyema. — Suggested  by  the  crisis  of  a  pneimioiiia,  followed  in  a  few  days  by  inter- 
mittent or  remittent  fever  {Fig.  71,  p.  160). 

Endocarditis. — Suggested  in  rheumatism  by  a  temperature  of  100'  F.  to  100'5°  F.  or 
101'  F.  following  the  initial  lull  from  the  administration  of  salicylates  ;  though  the  absence 
of  such  pyrexia  does  not  exclude  the  existence  either  of  endocarditis  or  of  pericarditis. 

Hyperpyrexia. — Met  with  in  rheumatism,  typhoid,  and  other  septic  conditions  ;  its 
onset  is  easy  to  detect  in  the  latter  conditions  :  in  the  former,  restlessness  with  less  com- 
plaint of  pain  may  cause  suspicion.  The  diagnosis  must  be  confirmed  by  a  frequency  of 
registration  proportionate  to  the  severity  of  the  initial  observation  ;  two-hourly,  hourly, 
or  e\en  quarter-hourly  observations  may  be  necessary,  that  treatment  may  be  controlled. 

In  addition  to  such  obvious  causes,  it  must  be  rememl)cred  that  in  cerebral  diseases 
and  injuries  of  almost  any  kind,  the  temperature  may  rise  to  most  unusual  heights  :  one 
over  106°  F.  almost  certainly  heralds  a  fatal  event :  the  same  is  sometimes  found  in  unemia. 

Attention  may  be  drawn  to  the  fact  that  malaria  is  not  quite  extinct  in  England,  and 
a  regular  succession  of  pyrexial  attacks  at  the  same  time  of  day  suggests  this  cause. 

Sudden  Drops  in  Temperature. — These  are  met  with  in  many  diseases  at  times, 
e.g.,  typhoid,  and  the  jjatient  must  be  examined  carefully  for  other  suggestive  factors — 
blanching,  severe  abdominal  pain,  etc.,  indicative  of  haemorrhage,  perforation,  or  other 
complication.  Do  not  forget  that  the  crisis  in  pneumonia  is  a  great  deal  more  of  a  crisis 
for  the  patient  than  it  is  for  his  microbes,  and  be  ready  with  the  appropriate  stimulants. 

Pyrexia  and  Malignant  Disease. — When  the  nature  of  a  swelling  in  the  liver  or 
elsewhere  is  being  considered,  the  discovery  of  a  temperature  hovering  about  101°  F.,  or 
even  higher,  does  not  militate  against  a  malignant  growth,  for  these  frequently  give  rise 
to  pyrexia  {Fig.  145,  p.  326),  and  so,  too,  but  more  rarely,  mav  cirrhosis  of  the  liver 
(F/g."l67,  p.  371). 

In  the  differential  diagnosis  of  cerebral  al/scess  from  tunuiur  it  must  not  be  overlooked 
that  a  subnormal  tem])erature,  contrary  to  the  usual  rule  of  suppuration,  suggests  an  abscess 
rather  than  timiour. 

It  is  well  to  bear  in  mind  that  after  an  operation,  a  few  degrees  of  pyrexia,  even  for 
forty-eight  hours,  are  not  a  conclusive  proof  of  infection  of  the  wound. 

When  the  source  of  a  continued  pyrexia  is  being  sought  for,  the  heart  must  be 
examined  carefully  every  day,  or  even  more  frequently,  for  infected  endocarditis  is  by  no 
means  an  infrequent  result  of  gonococcal  and  other  microbic  invasions  which  may  be  most 
difficult  to  detect.  Fred.  .J.  Smith. 

PYROSIS.— (See  Heartburn,  p.  296.) 

PYURIA. — Pus  appears  in  the  urine  in  all  suppurative  conditions  affecting  the 
urinary  tract,  and  occasionally  from  the  rupture  of  an  extra-urinary  abscess  into  the 
urinary  apparatus.  It  may  be  present  in  large  or  in  microscopic  quantities  ;  when  in 
bulk  it  forms  a  thick,  greyish,  tenacious  sediment,  which  must  be  distinguished  from 
phosphates  and  from  urates ;  urates  are  of  a  pinkish  colour,  and  will  be  cleared  by  heating 
the  specimen  ;  phosphates  will  be  dissolved  by  the  addition  of  acid,  whereas  pus  will 
remain  unaltered  by  either  test. 


PYURIA 


575 


In  alkaline  urine,  the  pus  cells  tend  to  run  together  into  a  dense  viscid  deposit,  leaving 
the  upper  layers  of  the  urine  slightly  turbid.  Microscopically  each  pus  cell  is  niultinuclear 
rounded,  and  about  twice  the  size  of  a  red  blood-disc.  The  contents  are  granular,  but  the 
addition  of  acid  clears  the  cell  and  makes  the  nucleus  stand  out  more  distinctly.  Urine 
containing  pus  will  always  contain  at  least  some  albumin  and  frequently  epithelial  cells 
from  some  part  of  the  urinary  tract.  If  the  s])ecimen  containing  pus  be  shaken  gently 
with  ozonic  ether,  a  slight  effervescence  will  be  produced,  or  if  mixed  with  liquor  potassre, 
a  ropy  precipitation  occurs. 

The  following  is  a  classified  list  of  the  causes  of  pyuria  : — 

(.4).  From  Diseases  of  the  Urinary  Organs. 


Renal : 

y.   We.sicil  .■ 

4. 

Prostatic  : 

Pyelitis 

Cystitis                   [clironic 

Prostatitis,    acute    or 

Pyelonephritis 

Tuberculosis,     acute     or 

chronic. 

Renal  abscess 

Calculus 

5. 

Urethral  : 

Pyonephrosis 

Ulcer — Simple,  Epithelio- 

Urethritis   —   Gonor- 

Tuherculosis 

matous 

rheal,  Septic,  Gouty 

Calculus. 

Tumour — Sloughin<;    pa- 

Stricture. 

Ureteric  : 

pilloma,  Villus-covered 

Calculus. 

carcinoma 
Billiarzia  ha?niatobia. 

(B).  From  Diseases  outside  tlie  Urinary  Organs. 


Lcucorrhcea. 
Balanitis  with  phimosis. 
From   the   extension   of   inflammatory 
processes    to    the    bladder,    or    the 
rupture  into  the  bladder  or  urethra 
of  an  abscess  such  as  : — 
Prostatic  abscess 
Appendicular  abscess 


Iliac  or  pelvic  abscess 

Psoas  abscess 

Pyosalpinx 

Carcinoma  of  the  uterus,  rectum, 

ca;eum,  sigmoid,  or  pelvic  colon 
Ulceration  of  the  small  intestine — 

— tuberculous  or  dvsenteric. 


It  is  impossible  to  determine  the  lesion  producing  pus  in  the  urine  simply  by  the 
examination  of  the  latter.  Due  consideration  nuist  be  given  to  the  history  and  the  other 
symptoms  of  any  case,  and  particular  care  be  taken  not  to  lay  too  much  emphasis  upon 
any  symptom  which  may  point  to  a  vesical  lesion  when  in  reality  the  trouble  is  in  the 
kidney.  This  is  perhaps  most  likely  to  occur  in  a  ha?matogenous  infection  of  the  kidney 
by  micro-organisms,  in  which  increased  frequency  of  micturition  is  a  marked  sympcom, 
whilst  the  bladder  remains  quite  free  from  disease.  Occasionally,  after  pus  has  been 
prcserd  continuously  in  the  urine  for  some  time,  it  may  disappear  entirely,  the  change  being 
accompanied  by  increase  of  pain  in  the  side,  by  an  cle\ation  of  temperature,  or  enlarge- 
ment of  the  kidney  in  a  case  of  py()nc]jhrosis,  when  the  obstruction  to  the  How  of  urine 
from  that  side  has  become  temporarily  complete.  Very  little  hclj)  is  derived  from  the 
character  of  epithelial  cells  accompanying  pus  in  the  urine.  The  shapes  of  the  cells  of  the 
renal  pelvis,  ureter,  and  deeper  layers  of  the  bladder  are  s( 
impossible  to  difiVrentiatc  them. 

Some  assistance  in   the  determination  of  the  origin  of 
gained  by  inslnimcntal  exaniinaiion  : 

Hi/  ('(ithclrr.  If  a  catheter  be  passed  and  llic  bladder 
of  boric  acid,  it  will  be  found  that  tiie  medium  is  soon  rendered  clear  if  the  pyuria  is  of 
renal  origin,  but  that  it  is  much  more  didicult  to  obtain  a  perfectly  dear  nicdium  if  the 
bladder  is  the  scat  of  llic  suppuration.  If  Ihe  mcdiuni  is  cleared  quickly,  bill  yel,  after 
some  ten  mimihs'  iclciil  ion  in  the  bladder  is  again  roNnd  to  be  turbifl,  the  pus  is  almost 
certainly  descending  I'nim  the  kidney. 

The  Ci/sloncope.  .Much  more  certain  evitlence  is  gained,  however,  by  a  careful  cysto- 
scopic  examination.  Hy  this  means  it  can  be  determined  in  the  great  majority  of  cases 
if  the  bladder  is  infeelcd  or  if  any  ulceration  is  present.  In  a  few  eases  the  bladder  may 
be  so  aHectcd  that  only  a  small  dilatalion  is  allowed,  or  bleeding  is  |)roflueed  so  easily  that 
cystoscopy  is  rendered  futile  :  in  lliese  cases  there  will -be  little  need  for  an  inspection  of 
tlic  bladder.  If  the  bladder  be  fouiwl  to  be  normal,  evidence  of  a  suppurative  lesion  in  Ihe 
kidney  may  be  oblaiiied  from  Ihe  appearance  of  the  ureteric  orifices  or  by  Ihe  \ariali()ns 
ill   llie  cliaraclci-  of  llic   iiriiiarv    cllliix   Cidrii   llicm.      Instead  of  llie   niiriiial   Inicible   Mow  of 


much  alike,  that  it  is  usually 
the   pus  in   the  urine   mav  be 


hcd 


vitli  clear  solution 


576  PYURIA 

clear  urine  from  each  orifice,  mixing  with  the  medium  in  the  bladder  in  a  characteristic 
swirl,  urine  containing  pus  may  be  seen  emitted,  appearing  in  the  field  as  a  small  smoky 
puff  from  the  orifice  {Plate  X^'.  Fig.  B.  p.  282);  pieces  of  muco-pus  may  be  seen  to  pass 
from  the  orifice,  or  the  turbid  urine  may  be  seen  to  leave  the  orifice  in  a  gentle  trickle 
instead  of  a  jet  if  the  renal  secreting  function  is  impaired  or  if  renal  dilatation  is  present. 
Apart  from  the  alterations  in  the  urinary  efflux  from  an  orifice,  the  actual  appearance 
of  the  orifice  may  show  changes  which  indicate  renal  disease.  Thus,  in  pyelitis,  the  margins 
of  the  orifice  are  slightly  oedematous  and  congested,  and  apjjear  to  pout  into  the  bladder 
(Plate  X\',  Fig.  C.  p.  282) :  the  mucous  membrane  of  the  bladder,  immediately  below  and 
internal  to  the  orifice,  is  frequently  congested  or  granular  from  the  effect  of  the  altered 
urinary  flow  upon  it.  If  the  renal  pelvis  and  ureter  are  dilated,  the  orifice  is  usually 
elongated  and  patulous,  whilst  in  tubercle  or  in  diseases  in  which  the  ureter  is  thickened, 
the  whole  ureteric  orifice  is  drawn  upwards  and  outwards  from  its  normal  situation  {Plate. 
XV,  Fig.  D.  p.  282),  and  is  seen  at  the  apex  of  a  conical  retracted  area  in  the  bladder  base. 

PYURIA    CAUSED    BY    DISEASES    OF    THE    URINARY    ORGANS. 

Renal  Disease.      Diseases  of  inflammatory  origin. 

PiieliliK  and  pyelonephritis  may  arise  as  an  ascending  infection  from  the  lower  urinary 
tract,  especially  when  there  is  some  obstruction  to  the  normal  passage  of  urine.  Thus  it 
is  common  in  cases  of  prostatic  enlargement  and  stricture.  When  cystitis  is  present,  it  is 
usually  bilateral,  although  one  kidney  may  show  much  more  advanced  disease  than  the 
other.  Any  growth  or  lesion  in  the  bladder  which  is  accompanied  by  suppurative  infection, 
and  which  involves  the  ureteric  orifice,  such  as  vesical  epithelioma,  or  the  direct  involve- 
ment of  one  or  both  ureters  in  the  spread  of  uterine  cancer,  may  set  up  pyelitis  in  the  kidney, 
the  infection  ascending  either  by  the  ureter  or  by  the  peri-ureteric  lymphatics. 

In  this  group  of  cases  the  primary  cause  of  the  disease  has  usually  advanced  to  a 
sufficiently  late  stage  to  be  obvious,  and  the  symptoms  of  suppurative  ascending  infection 
of  the  renal  pelvis  or  renal  tissues  are  usually  overshadowed  by  the  symptoms  of  the  disease 
causing  the  obstruction.  Aching  in  the  loin,  rigors  or  raised  temperature,  tenderness  on 
deep  palpation  in  the  renal  area,  or  actual  renal  enlargement,  are  usually  indicative  of  renal 
infection.  The  urine  is  often  increased  in  quantity,  of  low  specific  gravity,  and  the  daily 
excretion  of  solids  is  lessened  ;    the  skin  is  dry  and  harsh  and  the  tongue  glazed. 

Pyelitis  and  pyelonephritis  may  also  arise  as  an  infection  of  the  kidney  apart  from 
any  other  disease  in  the  genito-urinary  organs.  Infection  is  conveyed  to  the  kidney  by 
the  blood-stream  (ha>matogenous  form),  and  is  not  uncommon  in  acute  fevers,  or  with 
mild  forms  of  sup])uration  in  other  parts  of  the  body,  or  in  association  with  pregnancy. 
In  the  less  acute  forms  a  pyelitis  may  result,  as  in  typhoid  fever,  but  in  most  cases  the 
ha-matogenous  infection  produces  first  a  suppurative  process  in  the  renal  parenchyma, 
from  which  infection  spreads  to  the  calices  and  pelvis.  This  form  of  disease  has  been 
shown  by  recent  work  to  be  due  most  frequently  to  the  colon  bacillus  in  association  with 
affections  of  the  intestinal  canal,  less  frequently  to  the  staphylococcus,  strei^tococeus, 
pneumococcus,  typhoid  or  bacillus  proteus.  The  renal  pyelitis  which  ensues  when  a 
calculus  has  ulcerated  into  the  renal  pelvis  is  truly  a  hicmatogenous  infection. 

Acute  haematogenous  infection  of  the  renal  pelvis  without  involvement  of  the  renal 
parencyhma  usually  begins  with  slight  rigors,  tenderness  in  the  loin,  and  increased  frequency 
of  micturition.  The  urine  is  faintly  turbid  and  opalescent,  does  not  settle  to  a  pronounced 
sediment,  but  remains  of  a  sheeny  appearance.  It  contains  numerous  bacteria,  a  little 
pus,  and  a  little  albumin.  When  the  infection  first  attacks  the  renal  parenchyma  as  well 
as  the  pelvis,  the  symptoms  are  much  more  severe,  and  the  patient  may  become  uraemic 
rapidly.  In  the  less  acute  cases,  small  foci  of  suppuration  occur,  which  coalesce  to  form 
an  abscess,  with  the  general  syni])tonis  of  sup]3uration.  Renal  abscess  may  also  result 
from  injury  when  an  effusion  of  blood  in  the  renal  tissues  becomes  infected  by  pyogenic 
micro-organisms,  or  by  the  breaking  down  of  a  renal  infarct. 

Pyonephrosis — or  dilatation   of  the  pelvis  and  calices  of  the   kidney  with   pus    andl 
urine — is  caused  when  suppuration  has  occurred  in  a  kidney  which  is  at  the  same  time 
subjected  to  some  form  of  obstruction  to  the  normal  passage  of  urine.     Pyonei)hrosis 
caused  most  commonly  by  renal  calculus  or  tuberculosis,  but  is  by  no  means  uncommon 
with  a  chronic  cystitis,   complicating  urinary  obstruction  from  an  enlarged  prostate  oi' 


PYURIA  577 

stricture.  Carcinomatous  ulceration  affecting  a  ureteric  orifice,  either  primary  in  the 
bladder  or  by  direct  extension  of  uterine  cancer,  is  also  a' comparatively  common  cause  of 
pyonephrosis,  In  contradistinction  to  suppurative  pyelonei)hritis,  the  symptoms  of  pyo- 
nephrosis are  less  severe  ;  at  first  they  are  those  of  the  obstructive  lesion  causing  the  disease, 
to  which  are  added  the  general  symptoms  of  suppuration.  Pyonephrosis  causes  a  renal 
tumour  of  variable  size,  whilst  in  the  same  patient  distinct  intermittenee  in  size  may  be 
observed,  a  decrease  being  associated  with  the  discharge  of  a  larger  amount  of  pus  in  the 
urine.  In  pyonephrosis  due  to  calculous  disease  the  urine  may  contain  a  large  amount  of  pus, 
but  there  may  be  no  limibar  pain  suggesting  a  renal  stone.  In  these  cases  a  large  calculus  will 
usually  be  found  in  the  renal  pelvis,  and  will  be  shown  on  a'-ray  examination  {Fig.  13;5,  p.  279). 
The  urine  in  suppurative  disease  of  the  kidney  and  its  pelvis  requires  careful  examina- 
tion. It  may  be  normal  with  a  localized  cortical  renal  abscess  or  with  closed  jnoneijlirosis  ; 
in  all  other  lesions  it  contains  pus  and  micro-organisms.  If  the  i)us-cclls  are  found  in  the 
form  of  easts  of  the  renal  tubules,  infection  of  the  renal  parenchyma  is  ])resent,  whilst  in 
this  latter  the  albumin  in  the  urine  is  in  excess  of  that  due  to  the  pus  present.  Polyuria, 
with  a  diminution  of  the  total  solids  of  the  urine  in  a  daily  examination,  is  commonly 
present  in  inflammatory  lesions  of  the  renal  tissue. 

Renal  Tuberculosis. — The  miliary  form  of  tuberculosis  occurs  in  cliildrcn  as  part  of 
a  general  dissemination  of  tubercle,  and  causes  no  urinary  symptoms.  The  kidney  is, 
however,  attacked  not  infrequently  by  primary  tuberculous  infection,  beginning  as  a 
unilateral  deposit  of  small  tubercidous  nodules.  These  enlarge  and  coalesce  to  form  a 
caseating  area,  which  eventually  opens  into  the  renal  pelvis  by  direct  ulceration  of  a  calyx 
to  discharge  its  contents  by  the  urine,  when  the  lining  membrane  of  the  renal  pelvis  and 
ureter  become  infected  with  tubercle  and  thickened  by  subnuicoiis  infiltration.  At  first, 
before  ulceration  into  the  renal  pelvis  has  occurred,  the  symptoms  of  the  disease  are  very 
slight  ;  there  may  be  aching  pain  in  the  loin  and  slight  albuminuria,  but  as  soon  as  the 
renal  pelvis  is  involved,  more  marked  symptoms  occur — including  persistent  pyuria, 
lumbar  aching,  increased  frequency  of  micturition,  and  polyuria.  The  urine  is  pale,  of 
low  specific  gravity,  and  of  opalescent  turbidity  :  by  careful  examination  after  centri- 
fuging,  the  tubercle  bacillus  is  usually  found.  A  small  amount  of  blood  is  generall\' 
present.  The  increased  frctjuency  of  micturition  occurs  before  any  descending  vesiciil 
infection  has  occurred,  and  this  symptom,  accompanied  by  jjyuria,  has  fre(|uently  given 
rise  to  a  diagnosis  of  vesical  disease.  The  occurrence  in  a  young  adult  jjaticnt  of  persisteiil 
pyuria  which  is  not  due  to  gonorrha-a,  injury,  or  stone,  should  always  be  looked  upon  with 
grave  suspicion,  and  a  careful  search  made  for  the  tubercle  bacillus  :  should  this  not  be 
found  by  the  microscope,  inoculation  experiments  into  guinea-|)igs  should  be  conducted. 
A  careful  examination  of  the  bladder  sliouM  also  be  made  by  tlie  c^stoseope,  when  early 
vesical  tuberculosis  may  be  seen  (Pliitc  A'l',  Fig.  K.  p.  282),  or  the  characteristic  changes 
in  the  ureteric  orifice  may  show  the  presence  of  renal  infection  (Plate  A'l',  Fig.  D).  \i\ 
digital  examinatif)n  [ler  rectum,  the  lower  end  of  the  ureter  may  be  felt  to  be  thickened 
and  rigid  in  renal  tuberculosis. 

Uenal  tuberculosis  is  often  confonncicd  with  /(•//(//  siiiue.  and  tlie  colic  which  is  usually 
associated  with  stone  may  be  present  in  luhi  iculosis  if  a  ])icce  of  caseous  (l(l)ris  be  passed 
down  the  ureter.  .\  skiagra|)hic  shadow  of  a  calculus  shows  wcll-dclincd  margins  (Fig.  i:i;i. 
p.  27!)),  wliereas  a  tuberculous  focus  ivi  the  kidney  may  give  rise  to  a  faint,  bhnicd,  indistinct 
shadow  in  the  renal  area  (Fig.  l;5t,  j).  280).  The  i)resence  of  tubercle  bacilli  will,  however, 
determine  the  existence  of  tuberculosis,  whilst  tuberculous  lesions  elsewhcn-  in  the  body, 
most  frcqucnlly  in  llic  trslcs.  proslalr,  or  \csicula'  scniiiiulcs.  may  also  s<'i\('  lo  conlirm 
llic  dia;;iiosis. 

The  symptoms  of  iiii:il  ciilciiiiis  vary  with  Ihc  position  of  the  stone  and  the  changes 
lliat  have  taken  place  in  Ihc  kiilncv  in  conse(iuence  of  its  presence.  It  may  be  silualecl 
in  the  renal  paren<-hyma.  and  <ansc  no  symptoms  beyond  lumbar  aching  :  or  in  Ihc  renal 
pelvis,  when,  if  movable,  it  may  cause  acute  renal  colic,  due  either  to  the  attempted  passage 
of  the  stone  by  the  pelvic  outlet  or  to  the  increased  intrarenal  pressure  from  blockage  of 
the  ureter.  .So  long  as  the  kidney  remains  aseptic  the  urine  contains  only  a  microscopic 
trace  of  bloo<l  ;  but  if  it  becomes  irdccted  with  mi<'ni-organisms,  ))yelitis.  pyelonephrilis, 
or  pyone|)hrosis  may  result,  with  their  allcndani  symptoms.  I'us  only  occurs  in  tiic  urine 
in  a  case  of  renal  slonr  when   infcclion  (jf  Ihc  Uidncv  has  occurred. 

I)  37 


578  PYURIA 

Ureteric  Calculus. — A  small  renal  calculus  may  become  impacted  during  its  passage 
along  the  ureter,  and  may  cause  some  diflieulty  in  diagnosis.  The  usual  situations  of  the 
obstructed  calcidus  are  in  the  upper  few  inches  of  the  ureter,  at  the  i^elvic  brim,  or  at  the 
vesical  end  of  the  tube  ;  in  most  cases  the  previous  history  of  renal  colic  and  symptoms 
of  renal  stone  will  be  sufficient  to  indicate  its  partial  ureteric  descent.  A  calculus  may, 
however,  be  present  in  the  upper  end  of  the  ureter  or  at  the  pelvic  brim,  and  give  very  few 
symptoms  beyond  a  fixed  pain  in  the  course  of  the  ureter  :  in  the  latter  situation  it  has 
frequently  been  mistaken  for  ovarian  pain  or  for  chronic  appendicitis.  If  the  stone  blocks 
the  ureter  completely,  the  kidney  of  the  same  side — in  the  absence  of  septic  infection — 
becomes  funetionless  and  atrophies  ;  but  if  the  calculus  only  partially  occludes  the  lumen 
of  the  tube,  renal  distention  will  occur,  with  resulting  uro-  or  pyo-ne])hrosis.  If,  however, 
the  calculus  becomes  impacted  in  the  vesical  segment  of  the  ureter,  a  train  of  symptoms 
occurs  simulating  vesical  stone  or  vesical  tuberculosis  ;  namely,  increased  frequency  of 
micturition,  penile  pain  following  micturition,  and  often  a  small  amount  of  blood  and  pus 
in  the  urine,  in  addition  to  the  acliing  ])ain  in  the  loin.  A  ureteric  calculus  impacted  in 
this  situation  may  often  be  felt  in  the  ureter  upon  a  rectal  or  vaginal  examination  ;  it  may 
be  demonstrated  by  the  a;-rays  {Fig.  192,  p.  455)  ;  whilst  the  changes  seen  around  the 
ureteric  orifice,  and  the  absence  of  a  vesical  lesion  on  cystoscopic  examination,  will  confirm 
the  diagnosis. 

Vesical  Diseases. — Pyuria  may  occur  in  any  lesion  of  the  bladder  which  is  associated 
with  inflammatory  changes.  The  fact  that  urine  is  retained  in  the  bladder  renders  the 
latter  much  more  liable  to  septic  infection,  so  that  cystitis  is  common  with  urethral  stricture 
or  prostatic  obstruction.  Any  ulceration  of  the  bladder,  tuberculous  or  malignant,  is 
also  accompanied  by  inflammatory  changes,  when  pus  will  be  present  in  the  urine. 

Cystitis  may  be  acute  or  chronic,  and  the  essential  factor  of  either  form  is  the  infection 
of  the  bladder  by  some  micro-organism  ;  any  agent  which  produces  either  congestion  of 
the  bladder  or  retention  of  urine,  acts  as  a  predisposing  cause. 

^Vith  acute  cystitis  the  mucous  membrane  of  the  bladder  becomes  cedematous  and 
highly  congested,  and  epithelial  desquamation  and  formation  of  pus  rapidly  follow. 
Ha-morrhage  may  occur  from  the  congested  mucosa,  or  small  abscesses  develop  in  it  and 
rupture  into  the  bladder,  to  leave  small  areas  of  ulceration.  In  severe  cases,  patches  of 
the  mucous  membrane  may  become  gangrenous.  The  symptoms  of  acute  cystitis  are 
usually  distinctive  :  frequent  and  painful  micturition,  elevation  of  temperature,  pain  in 
the  i)erineum  and  suprapubic  area,  with  the  presence  of  pus  and  blood  in  the  urine,  which 
is  commonly  of  an  acid  reaction.  Usuallj'*  some  distinct  cause  for  the  onset  of  acute 
cystitis  is  apparent,  such  as  some  form  of  acute  urethritis  or  of  previous  instriunentation, 
and  there  is  little  difficulty  in  the  diagnosis.  The  same  symptoms  are,  however,  produced 
by  an  acute  inflanmiation  of  the  prostate  which,  in  nearly  all  cases,  is  preceded  by  acute 
urethritis  ;  the  presence  of  swelling  of  the  gland,  and  acute  pain  on  rectal  palpation,  will 
determine  the  presence  of  prostatic  inflammation. 

Ciironic  cystitis  may  succeed  acute.  The  symptoms  are  less  marked,  but  increased 
frequency  of  micturition  is  always  present.  The  urine  is  alkaline,  contains  pus  and  mucus, 
and  the  disease  is  commonly  associated  with  some  form  of  urinary  obstruction,  or  with 
retention  or  incontinence  due  to  some  nervous  disease,  such  as  tabes  dorsalis  or  transverse 
myelitis.  The  possibility  of  retroversion  of  a  gravid  uterus  should  not  be  overlooked. 
The  association  of  ]3yuria  and  increased  frequency  of  micturition,  which  is  present  in  chronic 
cystitis,  must  be  distinguished  carefully  from  that  due  to  pyelitis  or  pyelonephritis,  for 
increased  frequency  of  micturition  may  be  present  without  any  \esical  infection.  In  renal 
pyelitis,  the  urine  is  usually  acid  in  reaction,  pale  in  colour,  and  shows  a  general  turbidity, 
with  little  inclination  towards  a  deposit  at  the  bottom  of  a  specimen.  The  urine  of  chronic 
cystitis  is  alkaline,  and  rapidly  deposits  a  greyish  sediment  of  pus.  In  pyelitis  and 
pyelonephritis,  the  urine  contains  more  albumin  than  the  pus  would  account  for,  and  on^ 
microscopic  examination  renal  or  pus  casts  are  frequently  found,  whereas  in  cystitis  thd 
albimiin  is  less,  and  vesical  cellular  elements  are  present,  without  casts  unless  the  kidney! 
are  affected  also.  Further  evidence  may  be  obtained  by  the  use  of  the  cystoscope.  In 
cystitis  the  bladder  wall  is  trabeculated  and  the  mucous  membrane  thickened  ;  it  has  losi 
the  normal  iridescent  appearance,  and  the  vessels  of  the  mucous  membrane  are  obscuredl 
With  pyelitis,  the  bladder  wall  is  normal,  but  the  ureteric  orifice  of  the  affected  side  shows 


PYURIA  579 

the  tliickencd  or  pouting  Ii|)s  and  slightly  raised  area  of  thickened  niueous  membrane, 
whilst  the  urine  flowing  from  the  orifice  may  be  seen  to  be  turbid  or  to  contain  small 
particles  of  muco-pus. 

Chronic  cystitis  may  be  simulated  by  an  inflammation  of  the  posterior  urethra.  In 
such  a  case  there  is  almost  always  a  history  of  urethral  infection,  and  the  diagnosis  can  be 
made  by  urethral  irrigation.  The  jiatient  is  directed  to  retain  his  urine  for  some  three 
hours,  and  after  irrigating  the  anterior  urethra  as  far  as  the  compressor  muscle  with  sterile 
water  or  boric  acid  lotion,  the  urine  is  passed  into  two  glasses.  With  posterior  urethritis, 
the  urine  contained  in  the  first  specimen  will  contain  shreds  of  muco-pus,  whilst  that  of  the 
second  specimen  is  clear  :  whereas,  with  cystitis,  the  second  specimen  will  be  as  turbid  as, 
or  even  more  turbid  than,  the  first. 

Tuberculous  cystitis  occurs  usually  in  young  adults.  The  characteristic  symptoms 
are  increased  frequency  of  micturition  during  both  day  and  night,  pyuria,  with  pricking 
pain  in  the  glans  penis  at  the  end  of  micturition,  and  the  appearance  of  a  few  drops  of  blood 
in  the  last  drops  of  urine.  The  same  symptoms  are  often  present  with  vesical  calculus 
and  with  vesical  epithelioma,  when  ulceration  has  taken  place.  Vesica!  calculus  is  usually 
present  in  older  patients,  and  during  the  early  part  of  the  illness,  before  cystitis  has  set 
in,  the  calculus  only  gives  rise  to  penile  pain  and  desire  to  micturate  during  movement. 
When  cystitis  supervenes,  the  frequency  of  micturition  will  be  marked  during  both  day 
and  night.  I'esical  epithelioma  also  occin"S  in  older  patients,  and  when  ulcerated  may 
cause  ha-maturia  :  fre<}uently  the  diagnosis  may  be  made  by  palpation  per  rectinn  of  an 
indurated  area  in  the  bladder  base,  or  of  some  enlarged  glands  in  the  pelvic  lymiihatic 
space.  Tuberculous  cystitis  in  the  early  stages,  when  the  disease  is  characterized  by  the 
deposition  of  greyish  tubercles  in  the  submucous  coat  of  the  bladder,  may  give  rise  to 
increased  frequency  of  micturition  without  other  symptoms,  but  in  the  progressive  advance 
of  the  disease  the  tubercles  enlarge,  coalesce,  and  ulcerate  on  the  surface,  by  which  time 
pus  and  blood  will  be  ])resent  in  the  urine,  and  tubercle  bacilli  should  l)c  found.  It  may  be 
taken  as  a  general  rule  that  in  any  patient  of  young  adult  life  with  increased  frequency  of 
micturition  and  pyuria,  a  careful  search  should  be  made  for  tubercle  bacilli  in  the  urine, 
and  for  other  tuberculous  lesions,  especially  in  the  testes,  prostate,  or  vesicute  seminales. 
Tuberculous  cystitis  is  much  less  often  a  primary  disease  than  secondary  to  other 
lesions  in  the  genito-urinary  apjjaratus — most  commonly  to  tuberculous  disease  of  one 
kidney,  when,  after  the  primary  focus  has  ruptured  into  the  renal  pelvis,  the  lining  mem- 
branes of  the  latter,  of  the  ureter  and  of  the  bladder  become  affected  successixely.  The 
diagnosis  between  |)rimary  renal  and  primary  vesical  tuberculosis  is  very  often  dillicult, 
for  when  the  renal  focus  has  ulcerated  into  the  pelvis,  and  descending  infection  has  com- 
menced, the  symptoms  of  the  two  affections  are  very  similar.  Thus,  with  renal  disease, 
persistent  pyuria,  increased  freciuency  of  micturition,  and  penile  i>ain  at  the  termination 
of  urination,  may  be  present  hcl'ore  the  bladder  sliows  any  sign  of  disease  ;  blood  is  usually 
present  in  small  (|uantity  in  the  urine,  but  its  amount  is  not  so  definitely  greater  in  the 
urine  passed  at  the  end  of  micturition  as  is  the  case  in  vesical  disease.  In  renal  tuberculosis 
there  may  be  tenderness  in  the  loin,  the  kidney  is  usually  enlarged,  and  the  lower  end  of 
the  ureter  can  he  felt  distinctly  thickened  upon  rectal  or  vaginal  examination.  The  two 
conditions  can  usually  he  diagnosed  by  a  careful  cystoscopic  examinatii)n.  In  vesicral 
tuberculosis  the  deposition  of  submucous  tubercles,  together  with  the  shallow  ulceration 
in  the  bladder  mucous  membrane,  may  be  seen  (I'tate  AC.  Fii<.  K.  |).  2H2),  wliilst  in  renal 
tuberculosis,  changes  may  be  seen  in  the  ureteric  orifice  of  the  alTected  side  {Plate  A'l',  Fig. 
I)).  At  first  the  orifice  becomes  thickened,  (edematous,  and  slightly  patulous  :  but  later  it  is 
rigid  and  patent,  or  drawn  U|)  by  the  shortening  of  the  ureter  to  occupy  a  position  above 
and  outside  the  normal  situation  in  the  trigonal  area  of  the  bladder,  or  drawn  up  to  the  apex 
of  a  conical  r(tra<-tion  of  the  bladder  bas<-.  When  tuberculous  cystitis  is  secondary  to  lesions 
in  the  testes,  prostate,  or  vesicles,  the  disease  conunord\-  begins  in  the  e|)i<lidymis  of  one  side, 
and  spreads  to  the  vesicle  or  i)rostate,  whence  a  focus  may  directly  ulcerate  into  the  bladder. 
The  patient  will  first  notice  increased  fre(|uency  of  micturition  and  vesical  pain,  followed 
by  an  attack  of  ha'maturia  when  actual  ulceration  into  the  bladder  base  occurs  ;  the 
formation  of  a  tuberculous  idcer  in  the  bladder  leads  to  ]nuria  and  the  other  symptoms 
mentioned  abovi-.  This 'se(|uence  is  by  no  means  uncoiniuon  :  the  history  of  testicular 
disease  and  the  e\  idcnce  obtained  l)y  rectal  examination  will  s(r\e  to  indicate  llu'  nature 
of  the  condition. 


580  PYURIA 

Vesical  calculus  may  give  rise  to  |nuria  when  it  is  accompanied  l)y  cystitis,  but  may 
be  present  a  long  time  before  any  inflamniatcirv  infection  occurs.  When  cystitis  is  present, 
the  urine  shows  no  features  which  will  distinuuish  it  from  that  of  patients  suffering  from 
some  other  form  of  cystitis,  except  that  there  may  be  a  constant  presence  of  crystals,  or  an 
increased  amount  of  blood  after  exercise.  Tlie  constant  symptoms  of  vesical  calculus  are 
vesical  irritability  during  the  day  time,  penile  pain  after  micturition,  and  haematuria, 
especially  after  any  exercise.  If  a  calculus  in  the  bladder  is  suspected,  examination  by 
the  ,r-rays  {Fig.  135,  p.  "282),  a  sound,  or  the  cystoscope,  will  reveal  it  ;  the  cystoscope  may 
detect  a  stone  that  is  in  a  diverticulum,  partially  encysted  or  lying  in  the  pouch  behind  an 
enlarged  prostate,  where  it  may  easily  be  overlooked  in  searching  the  interior  of  the  bladder 
with  a  sound. 

Ulceration  of  the  bladder,  apart  from  tuberculosis  and  epithelioma,  may  occur  as  a 
simislc  vilcer,  consecutive  to  chronic  cystitis,  or  as  the  result  of  injury.  A  single  non-tuber- 
culous ulcer,  similar  to  gastric  ulcer,  has  been  described  as  occurring  in  young  adults  in 
the  neighbourhood  of  the  ureteric  orifices,  causing  haematuria  and  painful  frequent 
micturition.  Later,  the  surface  of  the  ulcer  becomes  encrusted  with  phosphatic  material, 
when  the  urine  contains  miico-pus,  and  often  small  flakes  of  phosphatic  debris  from  the 
surface  of  the  ulcer.  This  single  ulcer  is  rare,  and  can  only  be  diagnosed  by  the  use  of  the 
cystoscope.  Ulceration  may  also  occur  in  the  bladder  as  a  result  of  severe  cystitis,  when 
necrosis  has  occurred  in  the  mucous  membrane.  This  condition  is  present  occasionally  in 
a  case  of  obstinate  cystitis,  giving  rise  to  painful  and  frequent  micturition,  and  may  be 
diagnosed  by  means  of  the  cystoscope.  Both  the  simple  and  the  consecutive  ulcer  must 
be  dilferentiated  from  tuberculous  ulceration  of  the  bladder  :  in  the  latter,  hajmorrhage  is 
usually  slight,  and  occurs  at  the  termination  of  mictiu-ition  ;  tubercle  bacilli  may  be  found 
in  the  urine,  or  other  deposits  of  tubercle  found  in  the  epididymis,  jirostate,  or  .seminal 
vesicles.  The  cystoscopic  ai)pearance  of  tuberculous  disease,  and  its  more  generalized 
distribution  in  the  \esical  wall,  will  afford  the  strongest  evidence  in  the  diagnosis. 

Maligiianl  ulceratiari  of  the  bladder  occurs  in  two  distinct  forms  :  (a)  The  infiltrating 
epithelioma  ;    (b)  The  villus-covered  carcinoma. 

(a).  The  infiltrating  variety  occurs  as  an  ulcer,  with  raised  edges  and  imexen  necrotic 
surface,  usually  at  the  base  of  the  bladder.  It  is  usually  met  witli  in  men  over  fifty  years 
of  age,  causing  increased  frequency  in  micturition,  |):iin  at  the  glans  penis  following 
micturition,  with  blood  and  pus  in  the  urine.  The  bladder-wall  in  the  vicinitj-  of  the 
ulcer  is  densely  infiltrated,  and  frequently  can  be  felt  on  digital  examination  per  rectum, 
whilst  at  the  same  time  the  lymphatic  glands  in  the  pelvic  space  may  be  felt  to  be 
enlarged. 

{b).  The  villus-covered  carcinoma  of  the  bladder  is  not  uncommon,  and  gives  rise  to 
ii  regular  profuse  ha-morrhages.  The  tiunour  is  attached  to  the  bladder  by  a  broad  pedicle, 
or  may  be  entirely  sessile  and  covered  by  blunt  villi,  presenting  a  coarsely  mammillated 
surface.  It  occurs  in  elderly  patients,  and  the  tumours  are  frequently  multiple.  The 
surface  is  often  necrotic,  giving  rise  to  pyuria.  The  diagnosis  is  not  difficult,  the  frequently 
recurring  hfemorrhages  in  the  urine,  associated  with  increased  frequency  of  micturition, 
l)ain,  and  pyuria  in  an  elderly  patient,  being  fairly  distinctive.  Xot  uncommonly  there  is 
unilateral  renal  aching  from  the  interference,  by  the  position  of  the  growth,  with  the  flow 
of  urine  from  one  ureteric  orifice,  so  that  renal  disease  may  be  suspected  :  but  in  all  cases 
a  careful  cystoscopic  examination  will  show  the  nature  of  the  disease.  Difficulty  may  be 
experienced  in  obtaining  a  satisfactorily  clear  mediimi  for  a  cystoscopic  view,  but  in  most 
cases  this  can  be  accomplished  by  gentle  manipulations,  or  by  the  use  of  a  styptic  such  as 
adrenalin  1-1000,  or  silver  nitrate  1-1000.  Difficulty  may  be  found  in  distinguishing 
cystoscopically  between  a  benign  jiapilloma  and  villus-covered  pedimculated  carcinoma  : 
but  the  broad  attachment  of  the  latter  to  the  bladder,  the. stunted  villi  covering  it,  and 
the  multiplicity  of  the  tumours,  will  be  signs  of  malignant  disease  {Plate  AT/,  Fig.  F,  p.  2S4). 
In  rare  instances  a  benign  papilloma  may  begin  to  slough  on  the  surface,  or  may  be  accom- 
panied by  cystitis,  when  jjyuria  will  be  present.  A  cystoscopic  examination  will  reveal 
the  diagnosis.  Microscopical  examination  of  the  urinary  deposit  may  show  distinctive 
fragments  of  new  growth. 

Bilharzia  hamatobia  may  cause  pus  in  the  urine  in  advanced  cases.  When  the  small 
nodules  in  the  submucous  tissues  {Plate  XVI,  Fig.  K.  p.  284)  of  the  bladder  ulcerate,  sma!L 


PYURIA  581 

fungating  masses  are  found  in  tlie  bladder.  The  typical  ova  in  the  urine  (Fig.  26,  p.  79), 
in  addition  to  pus  and  blood,  will  be  found  on  microscopical  examination  of  the  urinary 
sediment. 

Urethral  Causes. — Any  condition  which  sets  up  a  purulent  urethritis  will  cause 
pyuria.  If  the  urethritis  is  recent  or  profuse,  the  local  condition  will  be  enough  to  indicate 
the  diagnosis,  but  it  must  be  remembered  that  cystitis  may  complicate  a  case  of  urethritis 
by  direct  backward  infection.  If,  in  addition  to  urethral  discharge,  there  is  increased 
desire  to  urinate,  suprapubic  jjain,  or  hicmaturia,  acute  cystitis  is  probably  present.  Tlic 
anterior  urethra  should  be  irrigated  well  with  sterile  water  or  boric  acid  lotion,  and  the 
patient  then  directed  to  pass  urine  into  two  glasses.  If  the  first  portion  ])assed  contains 
pus  and  the  second  is  clear,  infection  is  present  in  the  posterior  urethra  and  not  in  the 
bladder,  but  if  both  specimens  are  turbid  with  pus,  cystitis  is  present. 

The  onset  of  acute  prostatitis  com])Iicating  urethritis  gives  rise  to  increased  desire 
to  micturate,  and  perineal  and  suprapubic  pain,  in  addition  to  pyuria,  or  may  cause 
retention  of  urine.  Digital  examination  of  the  pro.state,  per  rectum,  will  show  the  prostate 
to  be  enlarged,  and  very  painful. 

A  small  amoimt  of  pus  may  be  present  in  the  urine  in  cases  of  chronic  urethritis  which 
is  not  sufficient  to  cause  any  visible  discharge  from  the  meatus.  The  anterior  urethra 
should  be  irrigated  well,  and  the  urine  again  passed  into  two  separate  glasses,  when,  if  the 
first  washings  from  the  urethra  contain  pus.  there  is  infection  in  the  anterior  urethra  ;  if 
the  first  specimen  of  urine  contains  pus  but  the  second  is  clear,  there  is  infection  in  the 
posterior  urethra  ;  whilst  if  both  contain  pus,  cystitis  is  jjresent.  In  any  case  of  urethral 
discharge,  a  bacteriological  examination  should  be  made  for  the  organism  causing  the 
infection,  for  it  is  far  from  uncommon  to  find  that  an  a])parent  gonorrlifcal  urethritis  is  in 
reality  due  to  sta|)hylococcal  infection. 

Pyuria  is  commonly  ])rcsent  in  cases  of  stricture  of  the  urethra,  from  the  co-existing 
urethritis  or  cystitis. 

PYURIA    CAUSED    BY    DISEASE    OUTSIDE    THE    URINARY    ORGANS. 

Pus  may  lie  |)resenl  in  the  urine,  apart  from  any  disease  in  llie  urin;iry  a|)paratus, 
either  by  accidental  contamination  of  the  urine,  or  by  the  direct  spread  of  inflammatory 
or  carcinomatous  processes  from  neighbouring  organs  to  the  urethra,  the  bladder,  or  more 
rarely  the  ureter.  In  the  male,  tlic  accumulation  of  pus  behind  a  phimosin  may  account 
for  pyuria,  or  in  the  female  a  leuriirrliifdl  (lisrlnirac  may  contaminate  the  urine.  In  the 
latter  case  the  vulva  should  be  cleansed  well  with  an  antisci)tie,  and  a  catheter  passed 
111   obtain  a  s|)ecimen   for  examination. 

The  spread  of  iidlanniiatory  processes,  or  the  actual  rupture  of  an  abscess  into  any 
pail  of  the  urinary  tract,  will  cause  pytnia.  and  may  create  coiisidcrahU'  dillieulty  in 
diagnosis.  If  symptoms  pointing  to  urinar\-  trouble,  such  as  markedly  increased  frc(iuency 
of  micturition  or  slight  ha-inatiuia,  be  followed  by  the  sudden  ap|)earanee  of  a  <|uantity  of 
pus  in  the  urine,  there  is  strong  [)r()bability  of  the  riiptitic  of  an  e.vlia-iiiiiifinf  abscess  into 
the  lilailder  or  lu-ethra,  jirovidcd  that  the  sudden  emptying  of  a  renal  abscess  or  a 
pyonephrosis  can  be  eliminated.  Kre((ticntly  the  history  of  any  case  will  give  some  indication 
of  the  primary  trouble,  of  which  the  most  fretiuent  are  prostatic  abscess,  ai)pen(lical  abscess, 
pMisalpinx,  psoas,  iliac,  or  pelvic  abscess. 

I'riisliitic  ahsrcss  is  most  frei|uen1ly  a  sequela  of  an  acute  inctliril  is  which  has  infected 
the  poNlciior  urethra  and  caused  an  .icutc  prostatitis.  It  niiy  be  due  to  a  gonorrlueal  or 
to  a  scplic  xcriinij  inrcci  i:in,  (ii-  riciy  result  Iniiii  septic  instrumcntalioii  in  the  urethra. 
All  acute  |irii^lal  il  is  is  \er\  pniiie  lo  iisiill  ill  I  he  liiiiiial  ion  of  an  abscess  which  may  rupture 
into  the  urethra,  bladder,  or  rccluni.  unless  appropriate  surgical  measures  be  undertaken. 
The  onset  of  leiite  prostatitis  is  marked  by  inercasiug  desire  t<i  miclurale.  piin  in  the 
periiKMun  and  hypogastric  areas,  and  raised  temperature,  whilst,  per  rectum,  the  prostate 
is  lell  to  be  uniformly  enlarged  and  very  leiulcr.  If  an  iibsccss  result .  there  may  be  rigors 
and  increased  dillieulty  in  micturition,  even  retention  of  urine,  wliilsl  a  soil  area  may  be 
lell  ill  till-  prostate  from  the  rectal  aspect.  .\  prostatic  abscess  may  occur  more  rarely  in 
<diiiieel  idii  with  a  /iriislalif  calciiliis:  or  may  be  present  in  advanced  •ictiiln-Kriiiiiri/  tiilivr- 
iiiliisis.  wlicii  a  priislalic  focus  may  caseale  and  ulecrtitc  Into  the  trigonal  area  ol'lhc  bladder, 
a  eoMililioii  which  is  usually  aeeoiiipaiiied  by  a  sharp  allaeU  of  li:ciiialuiia.      A  lulicrculous 


582  PYURIA 

focus  in  the  prostate  is  conmionly  a  comparatively  late  feature  in  the  disease,  and  the 
presence  of  nodules  in  the  epididymis  or  seminal  vesicles,  or  the  jjrevious  knowledge  of 
vesical  tuberculosis,  will  assist  \ery  largely  in  the  diagnosis. 

Pyuria  in  Inflammation  of  the  J'ermiform  Appendix. — In  the  usual  position  of  the 
appendix  the  bladder  is  commonly  not  affected  :  but  if  the  appendix  passes  downwards 
across  the  pelvic  brim,  it  is  not  uncommon  to  find  that  should  it  become  inflamed,  the 
patient  complains  of  frequent  and  painful  micturition.  The  a])pendix  may  be  adherent 
to  the  bladder,  when  the  latter  will  show  on  eystoscoiiic  exaniination  u  localized  area  of 
acute  congestion  on  the  right  lateral  wall,  and  both  pus  and  blood  may  be  present  in  the 
urine  ;  further,  a  small  abscess  may  be  formed  in  the  adhesions  between  the  appendix 
and  the  bladder,  ulcerating  into  the  latter  and  giving  rise  to  pyuria.  Two  such  cases  have 
come  under  the  care  of  the  writer,  when  the  association  of  frequently  recurring  attacks  of 
pain  low  down  in  the  right  side  of  the  ])elvis,  with  increased  fre<|ueney  of  micturition  and 
pyuria,  had  given  rise  to  the  suspicion  of  ureteral  calculus.  In  each  case  a  cystoscopic 
examination  showed  a  normal  ureter,  and  a  small  ulcer  in  the  right  lateral  wall  of  the 
bladder,  surrounded  by  an  area  of  acute  cystitis.  The  diagnosis  of  these  cases  is  by  no 
means  easy  ;  in  the  first  place  the  situation  of  the  pain  is  lower  in  the  pelvis  than  is  usual 
with  appendicitis,  whilst  the  association  with  urinary  symptoms  rather  points  to  vesical 
disease  ;  but  the  character  of  the  onset  of  the  trouble,  with  elevation  of  temperature  and 
pulse-rate,  and  right-sided  abdominal  rigidity,  will  j^iiiit  to  an  acute  intra-abdominal 
lesion.  In  other  ca.ses,  again,  an  abscess  resulting  from  a])|)endicular  suppuration  may 
track  down  into  the  pelvis  and,  if  unopened,  may  rupture  into  the  bladder.  In  these  cases, 
there  will  be  the  usual  history  of  acute  appendicitis,  followed  by  a  tumour  in  the  right 
iliac  fossa  or  pelvic  space,  with  a  continuance  of  pyrexia,  or  even  rigors,  which  subside  on 
the  appearance  of  a  large  tiuantity  of  pus  in  tlie  urine. 

A  pyosalpinx  may  rupture  into  the  bladder  or  cause  cystitis  from  direct  spread  of 
tlie  inflammatory  process  to  the  bladder.  There  will  usually  be  a  history  of  leucorrhcea, 
with  constant  aching  or  dragging  pains  in  the  huiibo-sacral  region,  witli  more  severe  attacks 
of  pain  and  malaise  at  intervals.  The  periods  may  be  profuse  and  associated  with  more 
pain  than  usual,  and  on  vaginal  examination  a  distinct  fullness  or  tumour  may  be  felt  in 
one  or  both  fornices. 

Psoas  or  iliac  abscess  may  rupture  into  the  bladder,  and  a  psoas  abscess  has  been  known 
to  open  into  a  ureter  ;  but  the  swelling  in  the  iliac  fossa  or  inguinal  region,  together  with 
signs  of  spinal  caries,  will  point  to  the  condition. 

Carcinoma  of  the  neighbouring  organs  in  the  pelvis  frequently  attacks  the  bladder  by 
direct  spread  of  the  growth.  This  is  most  common  in  carcinoma  of  the  uterine  cervix  and 
of  the  rectum,  but  may  result  from  cancer  of  the  pelvic  colon,  sigmoid,  or  ca?cuni.  In  any 
case,  the  spread  of  the  disease  to  the  bladder  occurs  late  in  the  disease,  so  that  symptoms 
of  the  initial  trouble  are  sufficiently  manifest  to  point  to  the  diagnosis.  The  implication 
of  the  bladder  is  shown  first  by  an  increased  desire  to  pass  urine,  and  by  pain  during  the 
act  ;  later,  when  the  gro\vth  has  actually  infiltrated  the  vesical  mucous  membrane,  ulcera- 
tion into  the  bladder  occurs,  with  the  passage  of  pus  and  blood  in  the  urine.  If  the  growth! 
has  extended  from  the  uterus  or  vagina,  there  may  be  a  leakage  of  urine  into  the  latter  ;| 
or  if  from  the  rectimi  or  colon,  some  fseces  or  flatus  may  be  passed  per  urethram. 

Tuberculous  or  dt/senteric  ulcers  of  the  small  intestine  ha\e  in  some  instances  become| 
adherent  to  the  bladder  wall,  and  caused  cystitis  by  direct  spread,  or  have  even  perforated 
into  the  bladder.  n.  //.  Jocelyn  Szcan^ 

RAINBOW  VISION.— (See  Visiox.  Defects  of,  ]).  76-2.) 

RASHES. — (See  Krvtukma.  ]).  222;    Pustules.  ]j.  5.57:    Vesici.es,  p.   753.  Etc.) 

REACTION    OF     DEGENERATION.— In    testing     nnisdes    and    nerves    electrically,  I 
two  different    kinds  of  eunctit   are  ciniiloyed.  namely:    fiiradic.  in  which  there  is  a  very] 
rapid  alternate  making  and  breaking  of  the  current,  and  the  galvanic,  in  which  the  current 
flows  continuously  until  it  is  voluntarily  interrupted  by  the  operator.     The  faradic  current 
excites  the  nerve  and  muscle  continuously  all  the  time  it  flows  :    the  galvanic  current  only 
excites  when  it  is  made  and  when  it  is  broken  :    not  whilst  it  is  flowing.     In  the  case  of 


REACTION     OF     DEGEXKHATION  583 

the  faradic  current  there  is  no  difference  between  tlie  poles,  each  being  alternately  an  anode 
and  a  kathode  many  times  a  minute  ;  in  the  galvanic  current,  on  the  other  hand,  the  pole 
connected  to  the  zinc  of  the  battery  is  known  as  the  kathode,  and  it  is  by  this  that  the 
current  leaves  the  body,  whilst  the  other  pole  is  known  as  the  anode,  and  bv  it  the  current 
enters  the  body.  ^Vllcn  testing  muscles  or  nerves,  it  is  usual  to  have  one  pole  in  contact 
with  an  indifferent  i)art,  such  as  the  spine,  and  the  other  over  the  motor  point  of  the  muscle 
or  nerve  to  be  tested.  Broadly  speaking,  the  best  spot  for  stimulating  a  nerve  is  the  place 
where  it  is  most  superficial,  and  for  a  muscle,  over  the  site  of  entry  of  its  motor  nerve.  It 
is  important  to  have  the  skin  well  wetted,  to  minimize  its  resistance  to  electrical  conduction  ; 
and  the  strengths  of  current  required  to  produce  contractions  should  be  measured  by  a 
galvanometer,  without  which  the  relative  excitabilities  of  the  nerves  and  muscles  of  the 
two  sides  of  the  body  cannot  be  compared. 

Under  normal  conditions,  both  faradic  and  galvanic  currents  produce  brisk  contrac- 
tions of  a  nuiscle  when  ajiplied  either  to  it  or  to  its  nerve  ;  and  with  galvanism  it  is  found 
that  a  weaker  current  will  sulFice  to  evoke  a  contraction  on  making  the  circuit  when  the 
kathode  is  on  the  muscle  or  nerve  than  when  the  anode  is  similarly  employed.  This  is 
usually  summarized  by  the  formula  K.C.C.  >  .A.C'.C,  which  means  "  the  kathodal  closure 
contraction  is  more  easily  obtained  than  is  the  anodal  closure  contraction.""  AVhtii  the 
nerve  is  degenerated,  however,  there  is  a  change  in  these  electrical  reactions,  and  when  there 
is  complete  reaction  of  degeneration — often  written  and  spoken  of  as  R.D. — stimulation 
of  the  nerve  itself  evokes  no  nuiscular  contractions  whether  the  faradic  or  the  galvanic 
current  is  employed,  stimulation  of  the  muscle  evokes  no  contraction  when  the  faradic 
current  is  used,  whilst  with  galvanism  the  muscle  can  still  be  made  to  contract,  though  its 
method  of  response  differs  from  the  normal  in  the  following  rcsjjects  : — 

1.  It  may  be  evoked  by  a  strength  of  current  less  than  the  healthy  minimum. 

2.  The  twitch  of  the  contraction  is  slow  and  sluggish,  instead  of  brisk  and  quick. 

3.  It  may  be  evoked  at  least  as  readily  when  the  pole  upon  the  muscle  is  the  anode 
as  when  it  is  the  kathode  ;  this  is  expressed  by  the  formula-  A.C.C.  =  K.C.C.,  or  A.C.C. 
>  K.C.C.  the  latter  meaning  that  the  anodal  closure  contraction  is  obtained  from  a  smaller 
current  than  the  minimum  re()uired  for  the  kathodal  closure  contraction. 

In  this  connection,  however,  two  considerations  require  to  be  understood  clearly. 
In  the  first  place,  if  a  given  nerve  were  cut  across  with  a  knife,  there  would  be  no  immediate 
K.D.  ;  it  takes  a  week  or  more  for  the  process  of  nerve  degeneration  to  reach  the  stage 
that  produces  K.D.  :  it  then  depends  upon  what  happens  to  the  nerve  how  long  the  K.D. 
persists  :  if  regeneration  occurs,  it  takes  from  twelve  weeks  onwards  to  complete  itself, 
and  K.D.  will  be  found  all  that  time  :  if  the  nerve  does  not  regenerate,  then  K.D.  may 
jiersist  for  two  or  three  years  or  more,  provided  that  the  muscle  fibres  are  ke|)t.  by  massage 
and  electrical  treatment,  from  becoming  mere  stran<ls  of  fibrous  tissue.  Should  the  latter 
change  ensue,  there  will  be  no  more  electrical  response  in  the  fibrous  tissue  that  used  to  be 
muscle  than  there  would  be  in  any  other  fibrous  tissue. 

In  the  second  place,  it  happens,  as  often  as  not,  that  when  some  fibres  in  a  nerve  trunk 
degenerate,  others  do  not,  and  the  same  applies  to  the  corresponding  muscle  fibres.  It 
follows  that  there  will  then  be  a  mixed  reaction,  the  normal  fibres  giving  a  normal  response, 
the  degenerated  fibres  giving  K.D.  :  the  greater  the  proportion  of  degenerated  fibres,  the 
nearer  will  the  reactions  obtained  approach  to  complete  K.D..  and  vice  versa.  The  result 
is  sj>okcn  of  as  jiitrtial  H.I).  ;  some'excitability  both  of  the  nerves  and  of  the  nuiscles  to 
faradism  remains,  but  it  is  less  than  normal  ;  the  nerve  res|)onds  to  gahanism.  but  not 
so  readily  as  does  the  nniscle  when  the  latter  is  stimulated  directly  ;  the  response  of  the 
muscle  will  be  less  brisk  than  normal,  and  yet  K.C.C.  may  slill  be  more  easily  obtained 
than  .\.C.C.  It  is  by  no  means  e-isy  to  be  sure  of  the  interpretation  of  a  partial  ICI)..  but 
Iiarlial  is  cm cricr  than  (•(iriiplclc  IM). 

The  cliii  r  use  (jI  H.I),  is  in  ilisi  injiuishing  inuscniar  alr(i|ili\  due  lo  orgMuie  changes 
in  the  lower  neuron  IVomi  other  eases  of  atnpph\-.  especially  when  the  latter  is  due  lo  general 
wasting  from  cachexia,  or  to  arthritis,  or  disuse,  or  a  priroMry  muscular  dystrophy.  When 
K.D.  is  present  there  is  a  lesion  in  the  lower  neuron,  either  in  the  anterior  cornual  cells, 
in  the  anterior  nerve  roots,  or  in  the  peripheral  motor  nerve  fibres.  The  differential 
diagnosis  of  the  various  afl'eclions  of  these  parts  is  discussed  under  .Vrnoi'nv,  .Mr.scii.Ait 
(p.  r,!»). 


,'584  REACTION    OF    DEGENERATION 

It  remains  to  add  that  there  are  a  few  maladies  in  which  tlie  electrical  reactions  are 
peculiar,  though  they  do  not  present  R.D.  In  tetany,  for  instance,  Erh  has  shown  that 
A.C.C.  is  often  greater  than  K.t'.C'..  although  in  other  respects  the  reactions  are  normal  In 
Thomsen's  disease  there  is  variability  in  the  polar  responses,  the  original  contraction  produced 
on  closure  lasting  a  long  while,  and  sometimes  developing  into  a  series  of  wave-like  move- 
ments during  the  continuance  of  the  passage  of  the  constant  current  ;  but  excitability  to 
faradism  remains.  It  is  a  rare  malady,  but  one  so  characteristic  that  it  is  recognized  easily  : 
the  chief  feature  of  it  is  slowness  of  the  relaxation  of  the  muscles  when  they  are  first  used 
after  a  period  of  rest.  When  the  jiatient  starts  to  rise  from  a  chair,  for  example,  he  does  sn 
very  slowly  and  as  though  he  were  stiff :  the  muscles  are  unduly  rigid,  and  the  first  few  steps 
he  takes  are  consequently  awkward  and  very  slow  :  after  a  few  seconds  the  jjcculiar  delay  in 
relaxation  passes  off  and  ordinary  walking  becomes  possible.  After  sitting  down  again  for 
a  while,  the  same  difficulty  of  rising  and  starting  to  walk  ensues ;  and  the  trouble  is  gener- 
ally- jiersistent.  There  is  no  pain  as  a  rule,  which  distinguishes  the  condition  from  true 
stiffness,  ankylosis,  or  rhemnatoid  arthritis,  which  might  otherwise  be  diagnosed  in  error. 
The  legs  are  nearly  alwa>s  alTected  more  than  other  parts,  and  the  main  complaint  is  that  ol 
dilliculty  in  starting  to  walk  or  otherwise  use  the  legs,  this  difficulty  jjassing  off  after  a  few 
seconds  or  minutes. 

In  .some  cases  of  Haynaud"s  disease,  and  in  angio-neurotic  (edema  and  allied  vaso- 
motor neuroses,  there  may  be  variations  from  the  normal  galvanic  reactions.  In  my- 
asthenia gravis  {Figs.  Ill,  112,  p.  235)  it  is  characteristic  that,  whereas  the  affected  nuiscles 
respond  readily  to  the  first  few  faradic  stimuli,  the  contractions  diminish  rapidly  in  size 
and  cease  after  a  few  minutes,  notwithstanding  the  continuance  of  stimulation.  After  a 
l)eriod  of  rest  this  myasthenic  reaction  is  obtainable  again,  and  so  on.  This  type  of  electrical 
response  corresponds  precisely  to  the  rapid  fatigue  of  the  voluntary  muscle  movements, 
and  the  diagnosis  is  not  dilTieult,  though  the  disease  is  rare.  Herbert  French. 

RECTUM,    ABNORMALITIES    FELT    PER. 

Method  of  E.vamiiKitioii.  The  jiatieiit  sliould  Ije  jjhieed  in  a  good  liglit  on  a  couch  of 
convenient  height.  AVith  male  subjects  the  best  position  is  the  knee-elbow,  with  females 
the  right  lateral  with  the  knees  flexed  and  the  right  arm  behind  the  back.  The  examina- 
tion should  be  made  with  the  left  hand,  leaving  the  right  free  for  manipulations.  Most 
diseases  of  the  rectum  are  situated  within  two  inches  of  the  anus.  It  is  advisable,  therefore, 
that  to  begin  with  the  finger  should  be  inserted  as  far  as  the  first  joint  only,  and  the  lower 
inch  of  the  bowel  examined  thoroughly.  The  examination  must  not  be  concluded  vmtil 
the  finger  has  been  passed  up  as  high  as  possible  and  the  whole  of  the  rectum  within  reach 
explored,  as  well  as  the  coccyx,  sacrum,  ischio-rectal  fossic,  and  adjoining  viscera.  The 
rectal  speeidum  and  the  sigmoidoscope  may  also  be  needed  to  complete  the  examination. 

If  any  abnormality  be  felt,  the  first  tiling  to  ascertain  is  (1)  Whether  it  lies  free  in  the 
liiDirii  or  is  attached  to  the  icall  of  the  reetiini  :  (2)  Wlicther  it  is  some  (ilnioniiiditii  of  tin  adjoin- 
iiig  straeliirc  or  viseiis  tliat  can  lie  felt  through  the  reelnni. 

I.  ABNORMALITIES  LYING  FREE  IN  THE  LUMEN  OR  ATTACHED  TO  THE 
WALL  OF  THE  RECTUM. 
Foreign  Bodies. — Though  fa>ces  can  hardly  be  considered  as  foreign  to  the  rectum, 
yet  a  hai-d.  scybalous  mass,  enterolith,  or  hair-ball  may  amoimt  to  an  abnormality.  True 
foreign  bodies  include  those  that  have  been  introduced  through  the  anus,  and  those  that 
have  been  swallowed.  Exam])les  of  the  first  class  are  seldom  met  with,  and  then  are 
generally  in  persons  of  weak  intellect.  Thieves  sometimes  emjiloy  the  rectum  as  a  hiding- 
place  for  stolen  goods.  The  majority  of  foreign  bodies-felt  per  rectum  have  been  swallowec 
— for  instance,  fishbones,  pins,  needles,  or  splinters  of  wood.  Their  importance  lies  in  ih{ 
fact  that  they  may  cause  a  rectal  or  ischio-rectal  abscess,  and  in  treating  such  a  case  theii 
discovery  and  removal  is  essential  for  a  comjilete  cure. 

Swellings  of  the  Rectum  projecting  into  the  Lumen : 

Internal  Ilwmorrhoid.s  are  rarely  |ialpal)le  to  the  finger  imless  chronically  inflamedj 
thrombosed,  or  gangrenous.  If  palpable,  they  will  be  felt  immediately  inside  the  anua 
and  can  be  hooked  out  with  the  finger  and  made  to  protrude  through  the  anal  orifice  foi 
inspection.  The  existence  of  ])iles  having  been  diagnosed,  an  effort  should  be  made  tc 
see  if  there  is  any  causative  condition,  sucli  as  a  carcinoma  in  the  Ijowel  above. 


RECTUM.     ABNORMALITIES    FELT    PER  585 

.Abscess  (svihiuucous)  gives  rise  to  a  more  or  less  elongated,  smooth,  elastic  swelling 
in  the  rectal  wall.  It  is  intensely  tender,  the  slightest  pressure  causing  great  pain.  The 
mucous  membrane  may  feel  hot,  and  ])it  on  pressure.  If  the  abscess  has  burst  or  bursts 
during  examination,  the  finger  on  withdrawal  will  be  covered  with  pus.  An  abscess  that 
has  already  emptied  itself  feels  like  a  small  pea  or  bean  in  the  submucous  tissue. 

Polypus  is  a  term  used  to  designate,  without  reference  to  its  histological  characteristics, 
any  benign  tiunour  that  is  pedunculated.  Almost  all  innocent  tumours  in  this  position, 
even  if  sessile  at  the  beginning,  become  ])edimculate(l  owing  to  tlie  downward  ])ressure 
of  the  faices.  The  passage  of  blood  and  mucus,  combined  with  the  absence  of  piles  and 
carcinoma,  shoidd  lead  one  to  suspect  the  presence  of  a  polypus.  It  may  not  be  easy  to 
feel,  because  its  consistency  is  much  the  same  as  tliat  of  the  mucous  membrane,  and  further, 
its  pedimcle  may  allow  such  free  movement  that  it  may  easily  be  mistaken  for  a  small  mass 
of  fjpces.  The  best  way  of  fixing  these  growths  is  to  sweep  the  finger  round  and  round  the 
whole  circumference  of  the  rectum  u|i  to  the  highest  point  attainable.  The  growth  is  then 
arrested  by  the  ))cdiclc.  and  the  finger  can  he  hooked  round  it.  so  that  the  growth  is  drawn 
down  and,  if  possible,  made  to  jjrotriide  through  the  anus.  If  the  ])oIypus  is  large,  a  rectal 
speculum  may  be  of  service.     It  is  to  be  remembered  that  ])olypi  are  often  multiple. 

Ulcers,  unless  malignant  or  chronically  inflamed,  can  rarely  be  felt  with  the  finger  ; 
tlie\  nuist  be  exposed  to  view  with  the  speculum.  They  may  be  tuberculous,  gummatous, 
traumatic,  or  due  to  ulcerative  colitis  or  dysentery. 

('(irciiiiitna  occurs  usually  in  peojjle  over  forty.  Its  conmionest  site  is  within  the  four 
terminal  inches  of  the  bowel.  It  is  generally  hard,  fixed,  irregular,  and  nodular.  Its  extent 
^■aries  with  its  stage  ;  it  may  involve  only  part  of  the  circumference  of  the  bowel,  or  may 
extend  right  round  so  as  to  occlude  the  lumen  and  cause  a  stricture.  The  surface  is  usually 
ulcerating,  so  that  it  is  friable  and  bleeds  easily.  There  is  nearly  always  a  belt  of  normal 
mucosa  between  the  internal  sphincter  and  the  neoplasm.  Not  only  the  lateral  but  the 
upper  limit  of  the  growth  may  sometimes  he  ascertained  by  inserting  the  finger  to  its 
extreme  limit,  care  being  taken  not  to  sjjlit  the  mass.  .Another  point  to  be  gauged  by  a 
rectal  examination  is  the  degree  of  infiltration  as  measured  by  the  fixity  of  the  tumour 
to  tlie  neighbouring  structures,  e.g.,  sacrum  and  coccyx.  Following  the  rectal  examination, 
the  abdomen  is  to  be  |)alpated  for  evidence  of  infection  of  the  inguinal,  pelvic,  or  lumbar 
glands,  and  the  existence  of  secondary  dejjosits  in  the  liver. 

The  clinical  symi)toms  of  carcinoma  of  the  rectum  are  very  suggestive.  The  patient 
generally  comi)lains  of  diarrlura.  the  bowels  being  open  five  to  twenty  times  a  day,  and 
this  may  have  followed  on  a  ])eriod  of  consti])ation.  Notwithstanding  the  apparent 
diarrhfra  the  total  amount  of  ik-ces  passed  is  very  small,  and  no  sen.se  of  satisfaction  is 
obtained  by  the  patient  after  stool.  The  evacuation  may  be  so  rapid  as  to  merit  the  des- 
cription ■  explosive  diarrlKca."  Ihcmorrhagc  from  the  bowel  is  conmion,  and  in  the  later 
.st<iges  there  is  a  discharge  of  mucus.  I'ain  is  complained  of — a  dull  aching  ])ain  in  tlie 
rectum  and  at  llie  l)ollom  of  the  back,  which  is  not  made  much  worse  l)y  the  passage  of 
a  tiioliiiu,  i|iiiti-  unlike  I  he  sharp  temporary  excruciating  pain  associateil  wilh  an  anal  fissure 
or  ulcer.  iMiiariiliiin  is  rapid,  and  a  history  of  wasting  and  diairlKci  in  a  middle-aged 
palicnl  should  always  lead  to  a  careful  exaininatlon  of  the  reetiuu,  and  if  nothing  Is  to  be 
felt  with  the  linger,  a  sigiiioidoscope  should  be  used.  A  carcinoma  is  likely  to  be  over- 
looked from  carelessness  and  from  nol  making  an  examination.  .Alistakes  may,  however, 
arise  between  carcinoma  and  an  adc'^iomatous  polypus  or  ulceration,  cither  traumatic  or 
tubcreidous.  around  which  much  long-st  inding  liillanunatlon  has  caused  thickening.  The 
facts  that  a  carcinoma  is  hud,  tlie  surface  often  excavateii.  .iiul  I  lie  edges  nodular  and 
everted,  arc  generally  suniciriil.  IT  real  doubt  exists,  a  piece  of  tlu'  ulcer  mi\  be  removed 
for  microscopic  report. 

//)/».v.s(/.v(r/(//o//.-  Occasionally  a  piice  of  intussuscepted  bowel  may  ciiinr  down  so 
far  as  to  be  felt  per  rectum.  This  coriditioii  is  associated  with  the  prissage  (if  blood  and 
mucus,  anil  IIk  iclun-  iiiiL;lit  be  mistaken  for  a  <llscasc  of  the  iccluiii  proper.  The  fact 
that  iiiliissiis((|it  ion  occurs  nearly  always  In  children,  especially  at  the  igr  ■il'  nine  months 
<ir  llicrcaliniils,  Mud  causes  inlesliiial  iibst  met  inn.  sIkiuM  make  siieli  a  iiiislaUc  easily 
av.iidablc. 

Stricture  due  to  a  <'arcinoina  is  dcall  with  aliu\c.  but  a  lew  rein  irks  remain  In  be  made 
about    llbrous  stricture.      This  may   be  prisenl   at    tin-  anal  orilic<-.  at    IIk'  le\<l  of  the  upper 


586 


RECTUM.     ABNORMALITIES     FELT    PER 


border  of  the  internal  sphincter,  or  tliree  to  four  inches  up  the  rectum.  It  may  be  annular 
or  tubular.  The  finger  meets  with  a  firm  cord-like  constriction,  which  perhaps  will  not 
allow  the  entrance  of  more  tlian  its  tip  :  there  will  be  no  bleeding  unless  the  finger  is  forced 
through  the  stenosis  and  the  mucous  membrane  torn. 

Fistulae,  either  recto-vaginal  or  recto-vesical.  whether  congenital  or  acquired,  may  be  felt 
with  the  finger.    The  passing  of  urine  or  fseces  by  abnormal  passages  indicates  the  complaint. 

Malformations  of  the  Rectum. — Some  children  are  born  without  an  anus,  or  without 
the  lower  portion  of  tlie  rectum,  or  tlie  finger  introduced  may  be  stopped  by  a  membrane 
separating  the  upper  from  the  lower  portion  of  the 
bowel.  The  diagnosis  is  obvious.  The  usual  types 
of  abnormalities  are  shown  on  the  accompanying 
diagrams.  Figs.  '24f)-'252,  reproduced  from  the 
Medical  Annual,  1910  :  the  figures  are  a  summary 
by  Dr.  A,  Keith,  of  a  series  of  54  cases  in  male, 
and  .52  cases  in  female,  children. 


Fit.    950.— Diaffra 
rees    of   imperfentic 

eptum  is  shaded ;  the  various  do^rr 
lake  up  a  scries  between  the  pioctodait 
lid  ba^e  of  the  prostate. 


Fig    'ol  — sagitt  il  lectio     of  tl  e  j  le  Fig.  'Ib2. — Diagram  illustrating  the  I'om- 

infant    showing  the  i«ctum  opening  n  mon    varieties    of    malformation    in     the 

fossa  of  the  vulva      A    I  ladder      B  -  female ;    the  various  degrees    make   up    a 

uterii  e  fold      0  svmphv  is   \  ubi=5      E  F  series  between  the   proctodaium    and    the 

cervi'^      G   pro  todpum  (rirelv  pre  e  t    i  tl  t  ni  recto-uterine  fold, 
ope  IS    into    tie    \uha}        H    urettli       I    elit  rs        K 
hymen 

II.  ABNORMALITIES    OF    NEIGHBOURING    STRUCTURES    FELT    PER    RECTUM. 

It  does  not  lie  witliin  tlie  scojie  of  this  article  to  give  the  differential  diagnosis  of  all 
the  morbid  conditions  that  can  be  felt  through  the  rectum  ;   it  sullices  to  take  the  structures 


REDUPLICATION    OF    HEART    SOUND  587 

within  reacli  of  the  finger,  and  indicate  the  varying  conditions  in  whicli  a  diagnosis  may 
be  aided  by  a  rectal  examination. 

On  the  Anterior  Wall  tlie  structures  that  can  normally  be  felt  are  the  prostate  in 
the  male,  and  the  uterus  in  the  female. 

Prostate. — Any  enlargement  is  easily  felt.  An  adenoma  is  the  commonest  form.  This 
is  soft,  elastic,  and  has  a  groove  in  the  middle  line.  A  carcinoma  or  sarcoma  is  hard  and 
fixed,  and  the  outlines  are  blurred.  A  prostatic  abscess  causes  a  marked  painful  protrusion 
into  the  rectum. 

The  Vesiculie  Seminales  are  not  palpable  normally.  The  fact  that  they  can  be  felt 
is  almost  sufficient  to  declare  them  diseased.  They  are  most  commonly  affected  in 
connection  with  tuberculosis  of  the  testes  or  from  present  or  past  gonococcal  vesiculitis. 

The  Bladder  is  not  felt  if  healthy.  If  greatly  distended  it  may  form  a  tense  resistance 
in  the  anterior  wall  of  the  rectum.  Rarely,  a  large  stone  or  a  malignant  growth  of  the 
floor  may  be  felt. 

The  Uterus  is  easily  palpable.  Enlargement  or  retro\ersion  can  be  recognized  ;  the 
pressure  of  a  fa?tal  head  may  occlude  the  rectiun. 

The  f'agina  cannot  be  felt  unless  it  is  occujiied  by  a  foreign  body  such  as  a  pessary, 
or  is  the  seat  of  a  growth. 

The  Ovaries,  if  enlarged  by  cystic  disease  or  by  new  growth,  may  come  within  reach 
of  the  finger  :  pi/osalpin.t  is  often  a  bilateral  affection  in  which  the  inflammatory  masses 
can  be  felt  per  rectuin  in  Douglas's  pouch  ;  they  can  be  detected  more  readily  by  vaginal 
examination,  hnwcvcr.  wluii  this  route  is  permissible. 

Through  the  Posterior  Wall  the  only  structures  that  can  be  recognized  are  the  coccyx 
and  sacrum. 

The  Cocci/x  may  be  found  bent  in  and  ])ressing  cm  the  rectum.  In  coeeydynia  any 
movement  of  the  coccyx  may  cause  great  pain. 

The  Sacrum  may  be  the  seat  of  cither  a  growth  or  an  abscess,  which  will  cause  ;i  bulging 
into  the  posterior  wall. 

On  the  two  Lateral  Surfaces  no  structures  are  normally  recognized.  The  ischio- 
rectal fossa-  are  common  sites  for  aliscesses,  and  these  can  be  felt  as  tense  swellings  pushing 
in  the  wall.  Rarely  an  aiiciiri/sDi  of  the  internal  iliac  artery  or  a  stone  in  tin-  lowest  portion 
of  the  ureter  may  be  felt. 

If  anything  is  felt  with  the  tip  of  the  finger  through  the  up])er  portion  of  the  rectum, 
it  will  usually  he  soniething  (list<iuling  Douglas's  pouch.  This  may  be  blood  coming  from 
a  ruptured  or  leaking  ectopic  gestation,  or  a  localized  abscess,  either  |)arametric  or  arising 
from  a  septic  Fallopian  tube  or  the  vermiform  appendix.  Some  surgeons  state  that  they 
are  able  to  detect  the  ap|)endix  if  it  is  hanging  over  the  brim  of  the  pelvis,  but  to  do  this 
the  finger  must  be  long  and  the  senses  very  acute. 

.Sometimes,  when  there  is  doubt  as  to  whether  symptoms  arising  in  eoimeetioii  witli 
a  more  distant  organ,  e.g..  the  stomach  or  the  gall-bladder,  are  due  to  nuilignant  disease 
or  not,  rectal  examination  affords  valuable  evidence  of  malignancy  even  when  there  are 
no  pelvic  symptoms  at  all.  When  secondary  deposits  have  arisen,  they  develop  not 
infrequently  in  the  pelvic  peritoneum,  ])resimiably  as  the  result  of  gravitation  of  malignant 
particles  into  Douglas's  pouch.  These  latent  secondary  deposits  can  sometimes  be  felt 
very  definitely  as  a  firm  band  or  shelf  the  '  rectal  shelf  if  the  observer's  index  finger 
is  a  fairly  long  one.  Rectal  examinalion  is  sometiniis  ni'  \ahic  also  in  \erifying  the 
existence  of  free  iluid  in  the  peritoneal  cavity.  (in,r<ii-  E.  (iosl:. 

RECTUM,    BLOOD    PER.      (See  Mi.ood  i'i:n  Anim.  p.  T.j  :    and  .Mki.kn A.  j).  ;tK.-..) 

REDUPLICATION    OF  HEART  SOUND,      ll    sel< i    liappcns    thai    Ihe  .liagii,,sis  in 

a  l)articular  ease  is  itillucneed  lo  any  niarkeil  degree  by  llie  presence  or  al)senee  of  redupli- 
cation of  cither  heart  sound  :  nevertheless,  Ihe  reduplication  is  sometimes  so  delinile  thai 
it  attracts  s|)ceial  attention  and  needs  intcrprelal  ion.  It  has  lo  be  dislinguished  from 
other  triple  sounds,  particularly  from  Ihe  eanler-riiythin  Ihal  oetius  most  commonly,  with 
acute  i)erieardilis.  and  less  ol'len  with  dilatation  ol  Ihe  hcinl  rnim  ImIIv  change,  especially 
in  pernicious  ananiia  and  nlhiv  eondilions  nf  oligochromieiiiia  ;  and  Iniin  Ihe  beginning 
of  a  mid-diastolic  bi  uil  ;il  I  In-  iin|iulsc  in  a  ease  of  acute  rheurnal  ic  iriiiiieiiniil  is  dl  I  he  mil  ral 


588  REDUPLICATION    OF    HEART    SOUND 

valves.  One  can  lay  down  no  rules  as  to  how  these  various  sounds  are  to  be  distinguished  ; 
it  can  only  be  done  by  having  heard  them  in  other  cases  ;  sometimes,  indeed,  opinions 
differ  as  to  whether  the  sounds  heard  in  a  given  patient  are  due  to  a  bruit  or  to  a  redupli- 
cation. 

Reduplication  of  the  first  sound  is  rare,  and  to  all  intents  and  purposes  it  never  occurs 
except  at  or  near  the  impulse  ;  it  indicates  some  abnormality,  but  does  not  specify  exactly 
what  that  abnormality  may  be.  If  there  is  no  bruit,  the  commonest  cause  is  great 
hyjK'rtrophy  of  the  left  ventricle  from  granular  kidney  or  arterio-sclerosis,  indicated  by 
the  big  heart,  high  blood-pressure,  urinary  and  retinal  changes. 

Reduplication  of  the  second  sound  is  common,  especially  in  the  pulmonary  area  (second 
left  intercostal  space  close  to  the  sternum).  It  generally  indicates  great  relative  increase 
in  the  intrapulmonary  blood-pressure,  so  that  the  pulmonary  valves  close  a  fraction  sooner 
than  the  aortic  ;  the  reduplication  may  alternate  with  simple  accentuation  (see  p.  1),  the 
commonest  cause  being  mitral  disease,  especially  mitral  stenosis.  Similar  reduplication 
of  the  second  sound  may  be  heard  at  the  impulse  also  in  these  cases,  though  more  often 
the  second  sound  here  is  weak  or  inaudible.  The  commonest  cause  for  reduplication  of 
the  second  sound  at  tlie  impulse  is  great  relative  increase  in  the  systemic  blood-pressure — 
especially  in  cases  of  arteriosclerosis  or  granular  kidney.  The  second  sound  in  the  aortic 
area  (second  right  intercostal  space  close  to  the  sternum)  is  generally  very  loud  and  ringing, 
or  even  reduplicated  at  the  same  time.  There  are  no  other  really  important  causes  of 
reduplication  of  either  of  the  heart  sounds.  Ilcrherl  French. 

REFLEX,    PLANTAR.— (See  B.vbinski-.s  Sign.  p.  68.) 

REFLEX,  PUPILLARY.— (See  Pupil,  Abnormalities  ok.  p.  5.51.) 

REGURGITATION  OF  FOOD  THROUGH  THE  NOSE  may  be  but  a  temporary 
accident,  tlic  result  nf  an  unsuccessful  attempt  t(i  stave  oil  a  sneeze,  a  cough,  or  a  burst 
of  laughter  when  the  mouth  is  full  of  food  or  fluid  :  or  it  may  result  from  an  explosive 
return  of  gas  from  the  stomach  or  oesophagus,  particularly  after  drinking  gassy  fluid  such 
as  soda-water,  champagne,  ginger-beer,  cider,  or  beer.  In  such  eases  the  diagnosis  is 
generally  obvious.  Pathological  regurgitation  of  food  through  the  nose  results  from  two 
main  groups  of  causes,  namely  : — 

A.  Structural  Imperfections  of  the  Palate  : — 

(a)  Congenital  :   cleft  palate  {b)   Acciuiicd  perforation  :    (i)  traumatic, 

(ii)      syphilitic,     (iii)      malignant, 
(iv)  tuberculous. 

B.  Paresis  or  Paralysis  of  the  Soft  Palate  or  of  the  Pharynx  : — 

(a)   I'dst-dii.lithentic  i  (rf)   The  result  ofbulliar  paralysis 

{b)   J'ost-operative  (p)   Tlie  result  of  pseudo-bulbar  jjaralysis 

(c)  Syphilitic  I  (/)   Cases  of  undetermined  cause. 

Simjjle  inspection  of  the  roof  of  the  mouth  is  generally  sufficient  to  decide  whether 
tlie  cause  Ixlongs  to  group  A  or  to  group  B.  The  median  and  symmetrical  imperfection 
of  a  congenital  cleft  palate  is  obvious,  and  there  is  the  history  of  the  trouble  dating  from 
birth.  There  may  be  a  harelip  or  other  congenital  abnormality  at  the  same  time.  When 
an  ulcerative  process  is  .still  in  ])rogress  there  may  for  a  time  be  some  doubt  as  to  whether 
it  is  syphilitic,  malignant,  or  tuberculous.  The  history  may  help,  or  the  healing  of  the 
ulcer  uiKler  the  influence  of  mercury  or  iodide  of  ]5otassium  or  salvarsan  may  indicate  its 
syphilitic  nature.  If  it  is  important  to  arrive  at  the  correct  diagnosis  as  early  as  possible, 
a  small  portion  of  the  pathological  tissue  may  be  excised  and  examined  microscopically, 
or  Wassermann's  serum  test  applied,  or  scra])ings  from  the  ulcer  examined  directly  for 
the  Nj)irocli(Pla  pallida  or  for  tubercle  bacilli.  Tuberculous  ulceration  of  the  jjalate  is  very 
rare,  and  is  generally  associated  either  with  lupus  or  with  definite  phthisis,  A  new  growth 
of  the  palate  may  be  cither  epithelioma,  endothelioma,  or  .sarcoma,  the  distinction  between 
these  depending  mainly  on  the  microscope. 

Diphtheria. — If  there  is  no  structural  defect  of  the  palate,  the  regurgitation  of  food 
through  the  nose  being  due  to  paralysis,  by  far  tlie  most  likely  cause  is  previous  diphtheria. 


RETRACTION     OF     THE     HEAD  589 

The  existence  of  the  latter  may  liave  been  reeofinized  at  the  time,  but  (juite  often  the 
diphtherial  attack  has  been  so  sliiiht  as  eitlier  to  have  caused  no  definite  illness,  or  else  to 
have  been  regarded  as  simple  sore  throat.  The  palate  alone  may  be  paralyzed,  givinj; 
rise  to  a  nasal  alteration  in  the  character  of  the  voice  as  well  as  to  the  regurgitation  ;  or 
there  may  be  paresis  of  the  ciliary  muscles  and  the  eyes  as  well,  causing  difficulty  in  reading  : 
less  commonly,  there  is  further  evidence  of  peripheral  neuritis  affecting  the  limbs  and  heart. 
The  trouble  may  not  come  on  for  three  or  four  weeks  after  the  di])htherial  attack,  and  there- 
fore it  may  no  longer  be  possible  to  detect  Klebs-LofHer  bacilli  in  swabbings  from  the  tonsils 
or  fauces  :  but  in  every  such  case  it  is  important  to  look  for  them,  both  directly  and  by 
means  of  cultures.  Probably  not  a  few  cases  ascribed  to  "  influenza."  or  to  undetermined 
causes,  are  really  ))ost-di])htheritie.  The  paresis  recovers  in  time,  sometimes  quickly, 
l)ut  often  iiiit  until  three  months  or  more  have  elapsed. 

Post-operative  Cases. — The  history  in  these  cases  will  point  to  the  diagnosis  ;  the 
accident  is  rare,  and  as  a  rule  the  effects  are  temporary  ;  it  may  happen  during  the  removal 
of  tonsils  and  adenoids. 

Syphilitic  Paralysis  of  the  Palate  is  not  common,  and  it  hardly  ever  occurs  by  itself. 
It  is  a  general  rule  that  luetic  affections  of  cranial  nerves  are  multiple  and  often  asym- 
metrical :  thus  there  may  be  strabismus,  or  a  laryngeal  paresis,  in  addition  to  that  of  the 
palate  :    or  there  may  be  a  history  or  other  evidence  of  syphilis. 

Bulbar  Paralysis. — When  this  affects  the  palate  and  causes  regurgitation  of  food 
through  the  nose,  there  have  generally  been  other  symptoms  for  some  time.  The 
malady  is  slowly  progressive,  and  starts  with  jiaresis  of  the  lips  and  tongue  ;  swallowing 
is  dillieult,  not  so  much  because  of  the  regurgitation  as  because  the  tongue  is  unable  to 
thrust  the  bolus  back  between  the  fauces.  The  constant  dribbling  of  saliva  from  the 
angles  of  the  mouth  is  characteristic  of  some  cases.  The  title  labio-glosso-pharyngo- 
laryngeal  ])aralysis  indicates  the  usual  sequence  of  events.  Bulbar  paralysis  may  be 
associated  with  progressive  muscular  atrophy  (p.  61),  and  it  may  be  distinguished 
from  pseudo-bulbar  paralysis  by  the  atrophy  of  the  tongue,  which  occurs  in  the  former 
but  not  in  the  latter.  Bulbar  paralysis  is  due  to  a  lesion  in  the  medulla  oblongata,  whereas 
pseudo-bulbar  paralysis  has  very  similar  symptoms  due  to  bilateral  cortical  softening.  In 
either  case  tlir  patients  are  generally  elderly. 

Undetermined  Causes. — As  regards  such  cases,  it  may  be  repeated  that  the  majority 
iire  doubtless  post-di|)htheritie,  so  that  it  is  imjjortant  to  examine  swabbings  from  the 
throat  of  all  such  i)aticnts  for  the  Klebs-LolHer  bacillus.  The  symptom  is  very  rarely 
hysterical.  Herbert  French. 

RETENTION    OF    URINE.— (Sec  ^liCTrrnnoN.  Ai!N()HMAI.itii-.s  oi'.  p.  .-{iJIJ.) 

RETRACTION   OF   THE  ABDOMEN.     iSee  Ki(;ii)itv  of  tuh  Abdomkn.  p.  5!C2.) 

RETRACTION  OF  THE  GUMS  is  occasionally  a  symptom  which  troubles  jiatients 
very  much,  hut  In  ilsclt  it  seldom  indicates  more  than  a  local  affection.  In  a  mild  degree 
it  may  be  due  to  excessive  use  of  a  hard  tooth-brush  ;  in  most  cases  it  results  from 
a  local  infective  process,  especially  tartar,  caries  of  the  teeth,  or  pyorrluea  alveolaris. 
These  conditions  are  discussed  under  the  heading  of  Bi.ki.dinc;  (Jims  (p.  72).  though  very 
olli-n  r(ira<-tiiin  max    be-  prcsi-Ml.  cm'?!  In  an  cxlrernc  (k'i;rce.  wilhiuit  actual  lik'cding. 

Ilnherl   Fnnrli. 

RETRACTION    OF    THE    HEAD    may     be    a    maikcd    symplom    in    the    following 
conditions  ; 

Acute   iiicniiiL'itis  :  .Siipetior  l(>ii^itudiri:il  sinus  .Sti ycliiiiiic   pnisDiiing 

1.  Sii()[Hii"ilivc  llirornhosis  |       TcImmms 

2.  Tulicri  iiluus  (hasalj  .\(iilc  <-iicepli;ilitis  Hyilni|ilinlii;i 
;S.   .Meiiiiiyococeal       (pos-  UnpMeli(ipiieiirniiiiia  with              CalalciP'.y 

terior  liasal)         p^-  i  partial   aspliyxia  I  Spiisiiiiiijic   InrI  irdllis 

I.  .MciiiiigocDeea!       (epi-  Laryiijjcal  iiiisliMctioii,  rspc-  I  I'aramyiicldiiiis   multiplex 

(liiiiic  ecrelprospinal)  eially  iliplitlieiia  in  <liil-  |  Hysteria       and      liystero- 

teiehclliir  or  other  siibten-  dreti  |  epilepsy, 

torial  tiiinotir  or  abscess  \  ! 

In  arrixing  at  a  diagnosi-,  in  any  given  case,  the  probabilily  is  that  slri/iliiiiiir  pnisDiiing, 


590  RETRACTION     OF     TUV.     UKAI) 

tetanus,  and  lii/dioplnibia  will  cither  suggest  tliemselves  at  once  on  accoimt  of  otlicr  circum- 
stances in  the  case,  or  else  will  not  need  to  be  discussed  at  all.  Ili/sieiifi  can  only  be  dia- 
gnosed when  all  other  possibilities  have  been  excluded,  and  jjrobably  not  imtil  the  case  has 
been  watched  anxiously  for  a  time  ;  there  may  be  other  functional  symptoms  in  the  case 
(p.  4(i,5)  :  the  patient  is  generally  a  young  adult,  more  often  female  than  male.  Catalepsij 
and  hf/steio-eitHepsy  will  be  suggested  by  the  mental  symptoms,  or  obvious  insanity. 

These  things  being  excluded,  the  first  thought  that  marked  and  maintained  retraction 
of  the  head  arouses  is  that  the  patient  has  some  serious  intracranial  lesion,  probablv 
meningitis.  Before  coming  to  this  conclusion,  however,  it  is  important  not  to  forget  that 
extreme  dyspnoea  in  children  sometimes  produces  considerable  head  retraction,  so  that 
the  physical  signs  in  the  lungs  and  heart  should  be  noted  carefully,  bronchopnenmonia  and 
capillary  bronchitis  being  kept  specially  in  mind,  and  any  signs  of  laryngeal  obstruction 
looked  for,  especially  stridor  and  spasmodic  up-and-down  movements  of  the  thyroid 
cartilage,  with  sucking  in  of  the  thorax  above  and  below  the  clavicles,  along  the  attach- 
ments of  the  diaphragm,  and  in  the  intercostal  spaces.  Diphtlieria.  foreign  body  in  the 
larynx,  and  relriipliaryngeal  abscess  have  all  been  mistaken  for  meningitis. 

If  there  is  no  evidence  of  sufficient  throat  or  lung  trouble  to  account  for  the  symptom, 
an  intracranial  lesion  is  probable  ;  and  by  far  the  most  likely,  especially  in  a  child,  is  acute 
meningitis,  either  tuberculous  or  posterior  basal.  Symptoms  common  to  all  the  intra- 
cranial affections  are  headache,  vomiting,  and  giddiness  ;  pyrexia,  generalized  convulsions, 
coma,  incontinence  of  urine  and  faeces,  retraction  of  the  head,  and  optic  neuritis  ;  or  even 
local  sym])tonis,  especially  twitchings,  convulsions,  or  paralysis  of  individ\ial  limbs  or 
parts  of  limbs,  according  as  one  part  of  the  brain  or  another  is  more  irritated  or  softened 
than  the  rest.  If  there  is  an  obvious  source  of  sepsis  in  connection  with  the  cranium,  such 
as  otitis  media,  mastoid  abscess,  facial  erysipelas,  a  septic  scalp  wound,  boils,  ]jediculi 
with  sores,  suppuration  in  the  orbit,  nose,  antrum  of  Highmore,  frontal,  ethmoidal,  or 
sphenoidal  air-cells,  or  naso])harynx,  the  probability  is  that  any  acute  meningitic  symptoms 
are  due  to  staphylococcal  or  streptococcal  suppurative  meningitis  ;  pneumococcal  meningitis 
may  occur  without  local  sepsis,  either  alone  or  as  part  of  a  general  pneumococcal 
septicaemia  ;  suppurative  meningitis  due  to  the  Bacillus  diphtheriw.  the  typhoid  bacillus, 
influenza  bacillus,  or  the  Bacillus  coli  communis  may  occur,  but  it  is  decidedly  uncommon 
and  clinically  indistinguishable  from  other  forms  of  suppurative  meningitis,  in  all  of  which 
marked  pyrexia  and  a  fatal  ending  in  two  or  three  days  are  the  rule.  Tuberculous  menin- 
gitis is  much  commoner  in  childhood  than  it  is  at  any  other  age  ;  it  is  always  part  of  a 
general  tuberculosis,  and  it  is  very  rare  in  adult  life.  At  first  there  may  be  no  pyrexia, 
though  this  depends  on  the  caseous  glands  and  tuberculous  lesions  in  the  lungs  and  else- 
where more  than  upon  the  meningitis.  The  early  diagnosis  is  apt  to  be  uncertain,  but 
as  the  days  go  by  the  serious  nature  of  the  complaint  generally  becomes  ob\'ious  ;  the 
effortless  vomiting,  the  irregular  pyrexia,  severe  headache,  optic  neuritis,  retracted  head, 
possibly  choroidal  tubercles  {Plate  XX.  Fig.  u\  p.  418)  or  evidence  of  tuberculous  foci  else- 
where, serve  to  clinch  the  diagnosis.  The  chief  difliculty,  after  the  stage  of  retraction 
has  been  reached,  is  to  decide  between  tuberculous  meningitis  on  the  one  hand  and 
meningococcal  (posterior  basal)  meningitis  on  the  other.  The  duration  of  the  disease  is 
often  of  assistance  in  this  respect — suppurative  meningitis  kills  in  two  or  three  days,  tuber- 
culous meningitis  in  two  or  three  weeks,  whilst  posterior  basal  meningitis  ends  in  recovery 
in  a  variable  percentage  of  cases,  even  after  continuing  for  two  or  three  months.  The 
tendency  to  head  retraction  is  greatest  with  the  posterior  basal,  least  with  the  suppurative 
forms.  Optic  neuritis  barely  has  time  to  develop  in  suppurative  meningitis,  but  it  is  present 
more  often  than  not  in  both  basal  and  posterior  basal  meningitis.  The  way  in  which  the 
heels  touch  the  occiput  in  some  cases  of  the  latter  may  by  itself  decide  the  diagnosis. 
Another  point  in  favour  of  meningococcal  meningitis,  is  the  occurrence  of  periodic  spike- 
like rises  of  the  temperature  chart — pyrexial  '  crises  '  lasting  twenty-four  hours  or  less 
(Fig.  253),  and  superposed  upon  what  is  otherwise  a  chart  of  but  moderate  type. 
When  doubt  remains  as  to  the  fact  of  meningitis  or  as  to  its  nature,  microscopical  and 
bacteriological  examinations  of  the  cerebrospinal  fluid  obtained  by  lumbar  puncture  will 
often  serve  to  establish  the  diagnosis  (p.  304).  Bacteriologically,  tubercle  bacilli  are  the 
least  easy  to  find.  The  Gram-negative  meningococci  (Diplococci  intraeellulares  meningitidis 
Weichselbauinii)  (Plate  XXJ'III,  Fig.  A',  p.  614)  are  characterized  by  their  occurrence  within 


RETRACTION    OF    TIIK     HEAD 


591 


tho  leucocytes  in  jjairs,  like  gonococci,  but  without  the  reniform  shape  of  the  latter.  The 
organisms  of  supj)urative  meningitis  may  be  discovered  on  direct  staining,  but  more  often 
cultural  methods  are  required. 

Where  posterior  basal  meningitis  ends  and  epidemic  cerebrospinal  meningitis  begins, 
it  is  difficult  to  say  ;  they  are  both  meningococcal,  and  probably  they  are  only  different 
types  of  the  same  malady,  connected  together  by  sporadic  cases  in  which  posterior  basal 
meningitis  is  associated  with  more  or  less  severe  spinal  symptoms.  The  way  in  which 
the  least  touch  or  movement  causes  the  patient  to  cry  out  with  pain  sometimes  indicates 
how  inflamed  the  coverings  of  the  posterior  nerve-roots  are,  besides  which,  the  erythe- 
matous, vesicular,  or  purpuric  skin  eruptions  that  may  accf)mpany  it  often  suggest  the 
diagnosis.  There  is  less  difliculty  during  an  epidemic  :  it  is  the  sporadic  case  that  may 
Ik-  missed.  The  clinching  point  in  tlie  diagnosis  is  l)acteriological  investigation  after  lumbar 
puncture,  assisted  perhaps  by  the  henelicial  eUVcts  of  the  specific  antimeningococcal  serum. 


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Superior  lo)ii<ilii(liii<il  sinus  Ihroniliosis  ni\i\  <i<iili'  piiliD-iiiiiitlKilHis  arc  liolh  nearly 
always  diagnosed  as  acute  meningitis  in  the  fusl  instance.  It  is  when  a  case  that  has 
simulated  acute  and  .severe  meningitis,  willi  cunia  anil  apparently  impending  death,  gets 
rapidl\-  better  after  a  few  days  and  ends  in  speedy  recovery,  with  or  without  some  impair- 
ment of  local  or  general  brain  fimclions.  in  a  child  or  \()img  person,  that  one  changes  one's 
(liagiiosis  of  meiiingilis  to  polio-encephalitis.  tlious.;li  i\cn  then  it  remains  one  of  opinion 
chielly.  .Almost  the  same  ap])lies  to  superior  longitudinal  simis  thrombosis  ;  though,  if 
acute  cerebral  symptoms  in  a  previously  healthy  child  end  in  a  gradual  and  but  partial 
recovery,  accompanied  by  permanent  sjiaslic  j)aralysis  of  the  legs,  without  niueh  alTcction 


59'2  RETRACTION    OF    THE    HEAD 

of  the  arms,  it  is  very  possible  tliat  the  lesion  has  been  thrombosis  of  the  superior  longi- 
tudinal sinus,  with  softening  of  the  leg  areas  of  cortex  on  either  side  of  it. 

Cerebellar  or  other  subtentorial  tumours  or  abscesses  generally  cause  a  much  more 
gradual  onset  of  sym]jtoms  than  do  any  of  the  above.  Head  retraction  is  not  present 
until  the  later  stages.  The  diagnosis  of  tuniiiur  will  rest  on  the  slow  increase  in  the  signs 
of  raised  intracranial  pressure,  with  nystagmus,  optic  neuritis  going  on  to  optic  atrophy, 
and  a  tendency  to  fall  always  in  one  definite  direction — forwards  or  backwards  if  the  tumour 
is  in  the  vermis,  to  the  right  or  to  the  left  according  as  it  is  in  the  right  or  left  hemisphere. 
There  is  often  marked  ataxy,  with  exaggeration  of  the  tendon  reflexes,  particularly  on 
the  same  side  as  the  tumour.  If  nystagmus  is  well  marked  this  serves  as  a  point  of  some 
value  in  distinguishing  a  cerebellar  from  a  cerebral  tumour.  Abscess  is  distinguished 
from  tumour  chiefly  by  the  existence  of  some  obvious  cause  for  intracranial  abscess, 
especially  otitis  media  on  the  one  hand,  bronchiectasis  upon  the  other.  Cerebellar  abscess 
may  give  rise  to  no  pyrexia  and  no  leucocytosis  ;  but  whether  the  temperature  is  raised 
or  not,  the  pulse-rate  is  often  absolutely  slowed.  Herbert  French 

RIGIDITY  OF  THE  ABDOMEN  is  a  sign  not  to  be  regarded  lightly,  and  one  to 
find  tlie  true  siijniliciince  of  which  may  call  for  the  greatest  care  and  skill.  The  patient 
should  be  examined  lying  on  the  back  with  the  whole  of  the  abdomen  and  lower  thorax 
exposed.  The  observer,  seated  on  a  level  with  the  patient,  should  watch  the  abdomen 
for  a  minute  or  so  and  see  whether  it  moves  or  not  with  respiration,  and  whether  one  part 
moves  more  than  another. 

It  should  be  remembered  that  some  patients,  whether  from  modesty  or  timidity,  hold 
their  abdomens  intensely  rigid  in  a  wholly  unnecessary  way,  a  tendency  which  may  create 
a  false  impression.  This  can  be  avoided  by  engaging  them  in  conversation  for  a  minute 
or  two,  by  asking  them  to  take  a  few  deep  breaths,  or  by  making  them  draw  their  knees 
up  and  kee])  their  mouths  open,  when  the  normal  abdominal  walls  will  generally  relax. 

Tliere  are  varying  degrees  of  rigidity.  The  whole  abdomen  may  be  rigid,  the  upper 
or  lower  part  only,  or  one  side,  as  in  the  presence  of  a  localized  appendicular  abscess. 
Again,  one  part  or  one  rectus  muscle  may  be  put,  as  it  is  termed,  '  on  guard,"  whenever 
the  patient  thinks  a  tender  spot  is  about  to  be  touched.  The  rigidity  over  an  inflamed 
gall-bladder,  or  a  gastric  or  duodenal  ulcer,  are  instances  of  this. 

The  most  im])ortant  cause  of  viniversal  rigidity  is  septic  infection  of  tlie  peritoneum. 
which  may  follow  external  wounds,  abdominal  operations,  childbirth,  abortion,  endometritis, 
parametritis,  extension  of  inflammation  from  or  perforation  of  the  appendix,  ulcer  of  the 
stomach,  duodenum,  or  bowels,  perforation  of  the  gall-bladder,  suppurating  Fallopian 
tube,  or  abscess  of  the  liver,  spleen  or  kidney  ;  or  which  may  be  primary,  as  in  sonic 
pneumococcal  cases.  It  is  a  safe  rule  to  believe  there  is  peritonitis  until  the  contrary  is 
proved.  As  in  the  case  of  other  disease,  diagnosis  must  not  be  based  on  one  clinical  sign, 
and  the  jiatient  must  be  examined  for  the  other  signs  of  peritonitis. 

The  history  of  the  onset  is  important.  In  perforative  cases,  the  beginning  is  marked 
by  intense  abdominal  pain.  This  may  be  general  and  continuous,  or  by  being  referred  to 
the  stomach  or  appendix  region  give  an  indication  of  the  primary  seat  of  the  mischief.  The 
position  taken  up  is  on  the  back,  sometimes  with  the  knees  drawn  up  to  relieve  abdominal 
tension,  and  the  patient  generally  lies  still,  for  any  movement  causes  increase  of  pain.  In 
colic,  on  the  contrary,  whether  intestinal,  biliary,  or  renal,  the  patient  rolls  about  during 
the  spasms.  It  is  painful  to  use  tlie  diaphragm  :  therefore,  respiration  is  superficial  and 
costal  in  type.  The  abdomen  gradually  becomes  distended,  tense,  and  tympanitic  ;  the 
liver  dullness  which  was  previously  present  may  disappear,  and  in  some  forms  of  peritonitis 
fluid  ma^-  accumulate  in  the  abdomen  and  be  detected  by  the  signs  of  shifting  dullness  in 
the  flanks.  The  pulse  is  small  and  rajiid.  100  to  150,  and  has  the  tendency  to  quicken.  A 
friction  rub  may  be  heard  over  the  liver  or  the  spleen  when  the  patient  breathes. 
Borborygmi  will  generally  be  absent.  Vomiting  is  an  early,  prominent,  and  almost  con- 
stant feature.  The  contents  of  the  stomach  are  ejected  first,  then  bile-stained  fluid,  and 
later  green  or  brownish  fluid  with  a  slight  fjecal  odour.  The  vomiting  is  often  of  a  peculiar 
'  pumping  '  character.  The  bowels  may  be  loose  at  first  and  then  constipation  follows, 
but  is  not  complete  as  in  intestinal  obstruction.  Micturition  may  be  frequent,  or  there 
may  be  retention  when  the  pelvic  peritoneum  is  acutely  inflamed.    When  the  disease  is  well 


RIGIDITY    OF    THE     ABDOMEN  593 

developed  the  appearance  of  the  patient  is  very  characteristic,  exhibiting  the  '  Hippoerafic 
facies.'     The  pulse  is  often  of  great  assistance  in  arriving  at  a  diagnosis  of  the  need  to  j« 
operate  urgently  in  these  cases  ;    it  should  be  counted  every  ten  minutes  :    if  its  rate  falls 
or  does  not  rise  at  successive  counts,  peritonitis  is  less  probably  present  than  when  the 
pulse-rate  is  found  to  be  rising  each  time. 

In  suppurative  peritonitis  leucocytosis,  though  it  may  not  occur  at  all,  is  often  marked 
(15,000  to  30.000  per  c.nnn.). 

It  docs  not  necessarily  follow,  because  the  whole  abdomen  is  rigid,  that  the  peritonitis 
is  general.  For  instance,  in  cases  of  perforative  appendicitis  it  has  been  shown  by  opera- 
tion that  pus  was  only  to  be  found  around  the  cfecuni.  and  yet  there  was  general  rigidity. 
Without  operating,  it  is  often  imiiossible  to  tell.  The  best  way  of  finding  out  whether 
there  is  pus  in  the  abdomen,  and  the  method  to  be  employed  at  once  if  there  is  any  doubt, 
is  to  open  the  abdomen  and  see. 

Other   CoN'niTiONS   associ.\ted   with   Abdominal   Rigidity   which    may   be 

JIISTAKEN    FOR    PERITONITIS. 

Piieiiitioiiid  or  Didpliidiimatic  Pleurisy. — In  the  early  stages  here,  before  the  onset  of 
dullness  in  the  lungs  and  other  ])hysieal  signs  in  the  chest,  the  most  prominent  features 
may  be  abdominal  pain  and  rigidity.  Laparotomy  has  often  been  performed  on  the 
mistaken  diagnosis  of  peritonitis.  If,  however,  the  examination  is  thorough,  signs  pointing 
to  implication  of  the  lungs  will  usually  be  found.  Rajjidity  of  respiration,  working  of  the 
nares,  and  blueness  of  the  lips  .should  receive  particular  attention.  Examination  of  the 
blood  may  reveal  a  high  leucocytosis  (30.000  to  40,000)  :  in  supinirative  peritonitis  the 
mimbers  are  rarely  so  high. 

Colic.  The  suddenness  of  the  onset  of  pain,  its  intense  character  and  the  abdominal 
rigidity,  may  render  this  condition  extremely  dillicult  to  differentiate  from  peritonitis  due 
to  perforation  of  some  viscus.  Collapse  may  be  marked,  and  the  effect  on  the  pulse  is 
considerable  ;  vomiting  is  common  also.  The  temperature  is  raised  slightly  but  rarely 
exceeds  100  F.,  and  the  pulse,  though  it  may  be  rapid,  does  not  tend  to  quicken 
progressively.  The  pain  is  spasmodic,  not  continuous  as  in  peritonitis,  and  is  generally 
relieved  in  a  few  hours.  Biliary  and  renal  colic  are  fairly  characteristic,  but  that  due  to 
lea<l,  the  crises  of  tabes  dorsalis,  or  gastro-intestinal  disturbances  may  easily  be  mistaken. 
The  gums  arc  to  be  examined  for  a  blue  line,  the  knee-jerks  and  pupils  tested,  and  a  blood- 
eount  made.  In  uncomplicated  colic  there  is  no  leucocytosis.  In  cases  of  extreme 
dilliculty  the  abdomen  may  have  to  be  opened.  The  persistence  of  borborygmi  is  in  favour 
of  colic  rather  than  of  general  peritonitis. 

IiilcsliiKil  Ohslnirlioii. — The  vomiting  and  constipation  here  ])resent  may  lead  one  to 
think  of  peritonitis,  and  indeed  the  two  conditions  may  l)e  present  at  the  same  time,  as  in 
the  ease  of  an  ulcerating  earciiioina  of  tlie  l)owel.  I'sually  the  rigidity  is  not  well  marked, 
and  the  constipation,  which  is  not  absolute  in  peritonitis,  is  liere  complete. 

Injuries  (if  the  Abdomen.-  — 

I.  Contusion  of  the  abdominal  wall,  with  laceration  of  muscle:  Particularly  in 
|)afi(Mts  who  have  been  run  over  across  the  abdomen,  rigidity  is  a  marked  feature,  and 
there  nuist  always  be  a  doidit  at  first  as  to  whether  any  of  the  viscera  have  been  torn  and 
are  bleeding,  or  whether  the  escii|)e  of  their  contents  is  setting  up  peritonitis.  In  the  ease 
of  mere  contusion,  if  the  patient  is  pirt  to  bed  and  kept  warm,  collapse  will  soon  disappear, 
the  abdomen  will  become  less  rigid,  and  the  ])ulse-rale  will  fall. 

"i.  Contusion  of  the  abdominal  wall  with  injury  of  viscera  :  i'lie  sigtis  lure  will  be  more 
marked,  and  instead  of  tending  to  diminish  rapidly  will  become  worse.  If  tliere  is  internal 
bleeding  the  mucous  surfaces  will  be  pale,  the  skin  cold  and  elanuny.  and  llie  pulse  small 
anil  lre(|ueiil .  If  the  contents  of  a  \iscus  have  esi'aped,  tlie  signs  of  peritonilis  will  de-  <lop 
rapidly.      In  all  cases  of  <loul)t  an  exploratory  laparotomy  should  not   l>e  delaNcd. 

I{i(jilun</  Tiilitil  dcsldliiiii.  This  may  simulate  general  peritonitis.  Tlie  Mlnioiiiinal 
rigidity  here  is  not  well  marked,  and  the  signs  of  bleeding  are.  .V  moderate  degree  of 
leucocytosis  is  present  (10.000  to  l."..00()),  but  the  number  of  red  cells  is  nuich  diniinishe<l. 
If  the  patient  is  a  woman  of  llie  eliild-l)earing  age,  known  to  be  a  week  or  more  overdue 
as  to  monlhly  period,  and  has  begim  to  lose  blood  per  vaginam  synchronously  with 
the  onset  of  acute  abdominal  pain  and  jiallor,  the  <liagnosis  will  suggest  itself  at  once. 

D  38 


,094  RIGIDITY     OF    THE    ABDOMEN 

Acute  Hcemorrhagic  Paiicreiilitis  is  usually  diagnosed  as  intestinal  obstruction  or  acute 
perforative  peritonitis.  The  attack  sets  in  with  intense  pain,  usually  in  the  upper  and 
left  part  of  the  abdomen.  Vomiting,  constipation,  and  tympanitic  distention  are  present. 
The  condition  is  so  rare,  and  the  signs  are  so  unreliable,  that  an  exploratory  laparotomy 
should  be  made,  and  the  nature  of  the  case  becomes  obvious  directly  the  characteristic 
opaque  yellow  patches  of  fat-necrosis  are  seen  in  the  omentum. 

Rupliire  of  an  .Ibdoniiniil  Arieiiri/sni.  Dissecling  Aortic  Aneurysm,  Embolism  of  the 
Superior  Mcseiileric  Artert/.  may  simulate  jteritonitis.  and  so  also  may  Acute  Thrombosis 
of  the  Inferior  i'ena  Cava  :  but  all  these  conditions  are  rare,  and  they  will  be  very  dillicult 
of  diagnosis  unless  the  existence  of  some  cause  for  them,  such  as  aortic  aneurysm  (jr 
fungating  endocarditis,  is  already  known. 

Acute  Suppurative  Xephritis  sometimes  gives  abdominal  rigidity,  and  is  associated 
with  fever  and  vomiting.  There  is  always  marked  tenderness  in  the  loin  on  the  affected 
side,  and  the  urine  will  contain  albumin,  pus.  blood,  casts,  and  bacteria.  The  milder  types 
of  the  infection  (see  Bacteriuri.v.  p.  C9)  may  be  mistaken  for  acute  appendicitis,  or  for 
general  peritf)nitis,  imless  the  centrifugalized  deposit  from  the  urine  is  examined  micro- 
scO]}ically  for  pus,  George  E.  G'nsA-. 

RIGORS,  or  CHILLS,  are  common  at  the  onset  of  the  most  various  acute  febrile 
disorders,  and  may  occur  at  regular  or  irregular  intervals  in  the  course  of  many  of  the  more 
severe  of  them.  The  chief  sign  of  a  rigor  is  shivering,  the  chief  symptom  a  feeling  of  cold 
and  general  wretchedness.  At  its  beginning,  the  patient  looks  chilly,  pinched,  and  blue, 
and  sits  or  lies  huddled  up.  complaining  of  the  cold  :  his  arteries  are  contracted,  the  pulse 
is  rapid,  small,  and  of  raised  tension  :  the  extremities  are  chilled  superlicially,  but  the 
internal  temperatm'e  is  above  the  normal.  Very  soon  the  sensation  of  cold  induces 
involuntary  shivering  ;  the  patient  shakes  all  over,  sometimes  so  violently  that  the 
chair  or  bed  is  thrown  into  noisy  vibration  ;  the  teeth  chatter,  and  even  the  muscles 
of  the  face  twitch  involuntarily.  This  shivering  lasts  for  minutes,  or  even  for  an  hour, 
dying  away  gradually  as  the  patient  feels  himself  to  be  warmed  up.  Thus  the  initial  stage 
of  the  fever  passes  into  the  second  stage  or  fastigium,  in  which  the  complaint  is  of  sweating, 
thirst,  and  undue  heat,  and  the  body  temperature  rises  still  further.  In  children,  general 
convulsions,  with  ]«irtial  or  complete  coma,  may  occur  at  the  onset  of  an  acute  infection, 
in  conditions  that  would  give  rise  to  a  rigor  in  adults.  In  adults,  convulsions  are  not  known 
to  take  the  place  of  rigors.  Cases  may  arise,  however,  particularly  when  only  an  imperfect 
history  can  be  obtained,  in  which  it  may  be  hard  to  say  whether  a  patient  has  had  a  rigor, 
or  an  epileptiform,  hysterical,  or  epileptic  fit.  Should  the  patient  have  lost  consciousness 
during  the  shivering,  or  have  fallen  down,  bitten  his  tongue,  or  passed  his  water  during 
the  attack,  or  should  he  give  a  history  of  similar  attacks  on  previous  occasions,  the  diagnosis 
of  epilepsy  would  be  more  than  probable.  Epileptiform  fits  that  unskilled  observers  might 
confuse  with  rigors  may  occur  in  uremic  or  eclamptic  patients  ;  the  hi.story  of  the  case, 
and  the  discovery  of  albumin  in  the  patienfs  water,  together  with  other  evidences  of  acute 
or  chronic  renal  disease,  should  make  the  diagnosis  clear.  Fits  indistinguishable  from 
rigors  to  the  untrained  eye  may  occur  in  hysteria  ;  in  these,  however,  the  shivering  patient 
would  be  red  in  the  face,  or  at  least  would  not  present  the  slightly  livid  and  shrunken  facial 
appearance  characteristic  of  a  rigor,  the  temperature  woidd  not  be  raised,  and  the  signs  or  a 
history  of  other  hysterical  phenomena  should  be  obtainable. 

For  their  further  consideration  it  is  convenient  to  classify  rigors  according  as  they  are 
single  or  multiple. 

1.  Single  Rigors. — The  occurrence  of  a  single  rigor  at  the  outset  of  an  acute  infectious 
disorder  is  extremely  common,  and  may  be  taken  as  evidence  of  the  severity  of  the 
infection  to  some  extent  ;  in  lobar  pneumonia  this  initial  rigor  is  often  particularly  long 
and  severe.  No  exhaustive  list  of  the  disorders  that  may  be  thus  ushered  in  can  be  given  ; 
but  it  may  be  stated  generally  that  an  initial  rigor  is  common  in  : — 

Lobar  pneumonia  i  l^neunionic  tuberculosis  JIaiaria 

Small-pox  Typluis  Yellow  fever 

Influenza  Relapsing  fever  ,  Weil's  disease 

Severe  feverish  colds  Krysipelas  i  After  catheterization. 

Septica-mia  Cercljrosjjinal  fever 

Pyaemia  |  Acute  polioniyelitis 


RIGORS,     OR    CHILLS 


It  is  less  often  seen  in  : — 

Scarlet   fever 
Measles 
Diphtheria 
Tonsillitis 
Hheuniatie  fever 

And  is  comparatively  rare  in  : 

Enteric  fever 
(Jerman   measles 
Mumps 
lioiit 


Tetanus 

Miliary  tuberecilosis 

Sapr;cmia 

Glanders 

Sick  headache 


Anthrax 
Hvdrophobia 
Cliolera 
Playue 


Acute  siastro-intestinal 

disorders 
Xcphritis 
Cholelithiasis 
Renal  calculus. 


Dysentery 
.Alalta  fever 
Beri-beri. 


The  diagnosis  of  all  these  different  morbid  conditions  must  naturally  be  made  from 
the  history  of  exposure  to  infection,  and  from  the  subsequent  signs  and  symptoms.  It  is 
clear  that  the  occurrence  or  non-occurrence  of  an  initial  rigor  will  rarely  be  of  much  practical 
assistance  in  determining  the  nature  of  the  disorder  from  which  any  given  patient  is 
suffering. 

A  rigor  after  catheterization  is  not  rare,  whether  the  kidneys  be  soimd  or  no.  and  in 
some  cases  is  due  to  septic  infection  of  the  urethra  or  bladder.  In  others,  however,  it 
ensues  when  no  infection  has  taken  place,  and  is  not  followed  by  any  evidences  of  urinary 
sepsis  :  in  these  instances  the  rigor  nnist  be  referred  vaguely  to  nervous  shock,  and  need 
not  give  rise  to  ahum. 

2.  A  Second  Rigor  coming  on  in  the  course  of  any  of  these  disorders,  or  a  rigor 
occurring  unex|K(tedly  for  the  lirst  time  when  the  disease  is  well  established  or  derlining, 
is  often  evidence  of  the  spread  t)f  the  infection,  or  of  the  oceurrcncc  of  some  coniplicatiim. 
For  example,  a  second  rigor  occurring  in  the  course  of  lobar  pneumonia  may  coincide  with 
the  appearance  of  signs  indicating  the  spread  of  the  disease  to  the  second  and  iireviously 
sound  lung  ;  a  second  rigor  ha])pening  after  the  crisis  may  indicate  an  empyema.  In 
enteric  fever  a  rigor  is  rare  though  it  may  be  due  to  such  complications  as  perforation  of  the 
intestine,  acute  ])eritonitis,  ))leurisy.  pneinuonia.  middle-ear  disease,  periostitis,  and  so 
forth  :  but  there  is  an  abnormal  type  of  enteric  fever  in  which  rigors  occur  for  no  ai)parent 
reason,  followed  by  heavy  sweats  ;  and  rigors  may  be  observed  in  cases  with  constipation, 
or  during  defervescence,  or  in  enteric  patients  who  have  been  treated  with  anti-pyretic 
drugs. 

3.  Recurring  Rigors.  The  occurrence  of  a  .src/c.v  of  riiior.s  often  gi\cs  information  of 
more  definite  value,  for  they  are  seen  in  but  a  liniiled  number  of  local  or  general  infections, 
most  of  which  have  some  eharaeleristic  or  localizing  siotis.  In  themsehes  these  rigors 
are  no  more  than  evidence  of  the  severity  of  Hie   inrcelioii.  and  of  the  extent   to  which 

bacterial  toxins  have  been  absorbed  into  the  hi 1.     The  following  are  Ihc  chief  disorders 

cliaracterized  bv  a  series  of  rigors  : 


.Malaria  tertian,  (pjailaii 
a'slivo-autiMiiiial  nr  iiiali:^' 
nant 

Itclapsini;   lever 

A(iil<-   leukaiuia 


.Acute   inllaniiMafions.   e.g.  :- 
I'velitis 
I'velonephrilis 
(  vstilis 
Ciioleeystitis 
I'^iiipyeni.i 
Inleelive  sinus  thrombosis 


.\eute  blodd-inlietiou: 
eluding' 

I'ortal   pyaiiiia 
I'va-mia 
Septi<()-pya'inia 
Septiciemia 

Abscess  formation  :  — 
Hepatic  (tropical) 
Appendi<ular 
Subphrenic 
I'erincphric 
Prostatic 
Cerebral. 


Special  I'orius  of  these 
may  be  known  as  puerperal 
fever.  maliyiiaut  endo- 
carditis:, acute  inrective 
osleomvelitis,  suppurative 
pylephlebitis,  etc. 

Pulmonary   I uliereulosis 

Hroriehiectasis. 

I'aiterie  (ever 

l')rvsipelas. 

Hal -bite  lever 

liillu(']i/.a. 


.\  very  lliiiroiigh  physical  examination  ulaiiN  patient  presenting  multiple  rigors  should 
be  made  ;  the  condition  is  always  serious,  and  ina\  be  due  to  septic  absorption  from  .some 
(U'cp-sealed  abscess  thai  prodne<'s  only  the  seanliesi  of  physical  signs.  When  no  abnormal 
physical  signs  can  be  Inniid  bacterial  enlliircs  should  be  made  from  the  circulating  blood, 
care  being  taken  In  drau  cill  a  sMllieicnl  (pi,inlit\  of  blood  .">  to  10  I'.e.  and  lo  repeal 
the  cultivation  several   times  befiuc  it    is  ilecidcd   that    I  Ik-  hi l-slriam   is  sterile. 


596  RIGORS.     OR     CHILLS 

In  mnhiriii  the  rigors  tend  to  recur  at  regular  intervals  of  forty-eiglit  (Fig.  6,  p.  28)  or 
seventy-two  hours  (Fig.  7.  p.  29)  in  the  benign  tertian  and  quartan  infections,  at  shorter 
intervals  if  the  infection  is  mixed.  In  the  a-stivo-autumnal  form  the  rigors  and  also  the 
course  of  the  fever  are  much  less  regular  {Fig.  lo,  p.  31).  The  jiarasite  {Plate  VI,  p.  32) 
may  be  found  in  the  circulating  blood,  and  the  patient,  if  not  in  extremis,  is  cured  by 
quinine  :    there  is  no  leucocytosis,  bvit  a  relative  increase  in  large  lymphocytes  occurs. 

In  relapsing  fever  the  onset  is  acute,  with  a  rigor  or  a  series  of  rigors.  A  fortnight 
later,  when  the  patient  has  been  convalescing  for  a  week  or  ten  days.  rela])se  and  a  second 
rigor  or  series  of  rigors  occurs  {Fig.  5.  p.  27).  A  second  relapse  may  be  noted  at  the 
end  of  the  third  week,  and  in  a  very  few  cases  a  third  relapse.  Relapsing  fever  has 
practically  died  out  of  the  United  Kingdom,  but  it  is  met  with  in  Egyi)t.  India,  and  other 
countries.  It  occurs  in  epidemics,  and  Obermeier"s  .spirochaete  {Plate  XXVIII.  Fig.  I, 
p.  614)  can  be  foimd  in  the  patient's  blood  while  he  is  feverish. 

Multiple  rigors  occur  exceptionally  in  the  course  of  acute  blood-diseases,  such  as  acute 
Icuksemia.  pernicious  anaemia,  or  Hodgkin's  disease.  Severe  and  progressive  anaemia, 
wasting,  fever,  heavy  sweats,  and  hicmorrhage  from  the  mucous  membranes,  are  likely  to 
occur  in  these  cases,  with  characteristic  changes  in  the  microscopical  ap])earances  presented 
by  the  blood  (p.  24). 

Multiple  rigors  are  commonest  in  the  various  forms  of  acute  blooil-infections  ;  special 
forms  of  these  have  received  particular  names.  Tlius  puerperal  fever  occurs  after  delivery, 
and  is  due  to  bacterial  infection  of  the  uterus  and  its  spread  thence  to  the  blood  ;  the  patient 
will  probably  have  a  sanious  or  offensive  vaginal  discharge  as  well  as  the  evidences  of 
septicaemia  or  pyaemia.  In  malignant  endocardUis.  attention  is  directed  mainly  to  the 
condition  of  the  heart,  the  presence  of  valvular  murmurs  and  the  signs  given  on  p.  34. 
In  acute  infective  osteomyelitis  the  first  conijilaint  arises  from  the  acute  inflammation  occur- 
ring in  the  marrow  of  one  of  the  bones.  Portal  pycrmia  or  sup]iurative  pylephlebitis 
is  seen  in  patients  with  various  acute  inflammatory  intra-abdominal  lesions,  and  is  due  to 
the  spread  of  bacterial  infection  to  the  portal  vein.  The  commonest  precursor  is  mild 
appendicitis.  The  blood  in  the  portal  vein  clots,  the  clot  is  infected  with  microbes,  softens, 
and  breaks  up.  to  be  dispersed  throughout  the  liver  in  the  form  of  infective  emboli.  Multiple 
hepatic  abscesses  result,  with  pain,  swelling,  and  tenderness  in  the  hepatic  region  :  jaundice 
is  present  in  less  than  half  the  cases,  with  more  or  less  coloured  stools,  vomiting  and 
diarrhcca  are  frequent,  and  there  is  hectic  fever.  Pyceinia  is  characterized  by  the  formation 
of  metastatic  abscesses  in  any  of  the  tissues  or  organs,  oftenest  in  the  lungs,  in  consequence 
of  the  lodgement  there  of  multiple  infected  emboli.  Before  the  days  of  antiseptic  or 
aseptic  surgery,  pyaemia  was  the  common  outcome  of  serious  surgical  operations  or  severe 
wounds.  Nowadays  it  is  comparatively  infrequent,  and  when  it  does  occur  is  secondary 
to  a  severe  infected  wound,  to  ulcerations  of  the  mucous  surfaces,  or  to  deeply-seated 
abscesses  that  are  not  amenable  to  surgical  treatment.  Occasionally  it  seems  to  be  idio- 
pathic, or  due  to  some  infective  lesion  that  escapes  discovery.  Pya"mia  oftenest  begins 
suddenly  :  the  main  symptoms  are  hectic  fever,  rigors,  leucocytosis,  diarrhoea  and  \oniit- 
ing,  heavy  sweats,  prostration,  and  the  formation  of  secondary  abscesses  due  to  the  arrest 
of  septic  emboli.  When  the  lungs  become  the  seat  of  multi))le  abscesses,  the  breathing 
becomes  rapid,  and  signs  of  bronchitis,  pleurisy,  or  pulmonary  consolidation  ai)])ear. 
Abscesses  in  the  more  superficial  tissues  or  joints  make  their  jjresenee  known  by  the  local 
evidences  of  [jain.  swelling,  redness,  and  heat  ;  in  the  deeper  parts  or  organs,  by  pain  and 
disturbance  of  function.  The  development  of  secondary  subcutaneous  abscesses  is  common 
in  the  less  acute  cases  ;  abscess-formation  in  the  heart,  and  suppurative  pericarditis,  are 
prone  io  occur  when  the  primary  lesion  is  a  ])eriostitis  or  an  acute  necrosis  of  bone. 
Pyaemia  may  be  distinguished  from  enteric  fever  only  with  great  difficulty  if  evidences  of 
abscess-formation  or  some  source  of  primary  infection  are  not  forthcoming,  especially  as 
the  typhoid  state  is  common  in  the  later  stages  of  both  diseases  ;  the  occurrence  of  multiple 
rigors  is  rare  in  enteric  fever,  common  in  ]]yaeniia  :  ^Vida^s  reaction  should  be  tested  for. 
From  malaria,  pyemia  is  distinguished  by  not  reacting  to  quinine  ;  malarial  parasites  will 
not  be  found  in  the  circulating  blood.  Pain  and  inflammation  in  the  joints  after  childbirth 
or  a  miscarriage  may  be  diagnosed  as  rheumatism  wlieu  the  condition  is  really  one  of 
pyaemia  or  puerperal  fever. 

The  precise  diagnosis  between  pyaemia  and  septic;emia  is  often  impossible,  and  is, 


RIGORS.     OR     IHILLS  597 

indeed,  of  academic  ratlier  than  clinical  intej-est.  Tiie  necessity  for  it  is  in  ])art  avoided 
by  the  use  of  the  term  seplicopy(e»iia.  tlie  evidences  of  which  are  much  tlie  same  as  those 
of  pyaemia  :  all  three  conditions  may  arise  from  identical  causes,  and  bacteria  (streptococci, 
staphylococci,  gonococci.  pneumococci,  B.  coli  communis.  li.  typliosiis.  B.  iiifliienzce, 
B.  pi/ocyaneus.  etc.),  may  be  cultivated  from  the  circulating;'  blood  in  any  of  tliem.  Multiple 
rigors  are  far  commoner  in  pyicmia — where  se\eral  may  occur  daily — than  they  are  in 
septicemia  due  to  the  growth  of  microbes  in  the  blood  without  the  formation  of  metastatic 
abscesses  ;  it  originates  in  lesions  very  similar  to  those  that  underlie  pyaMiiia,  or  results 
from  infected  but  apparently  trifling  cuts  or  injuries,  or  even  from  neglected  chronic 
suppuration  about  the  teeth.  Its  main  symptoms  are  ])yrexia.  debility,  ana?mia  ;  in  severe 
cases  rigors  occur,  and  the  patient  may  fall  into  the  typhoid  state.  The  bacteria  causing 
it  can  be  cultivated  from  the  circulating  blood  ;  septic  rashes  are  often  seen  in  both  pyaemia 
and  .septica-mia.  but  they  are  not  seen  in  enteric  fever.  It  should  be  noted  that,  at  the 
best,  a  deal  of  looseness  attaches  to  the  meaning  of  the  term  septiciemia  :  for  in  lobar 
pneumonia,  enteric  fever,  Malta  fever,  and  many  other  acute  febrile  disorders,  the  specific 
microbes  can  habitually  be  cultivated  from  the  circulating  blood.  Technically  speaking, 
therefore,  these  are  all  instances  of  septicicmia.  Two  new  terms  have  recently  come  into 
vogue  in  this  connection,  namely,  hacillivmiii  and  Ixicterifemia. 

Multijtle  rigors  may  result  from  acute  localized  inflammaton/  infectious  if  the  inflam- 
mation is  sufliciently  extensive  and  the  infecting  micro-organism  virulent.  It  is  often 
impossible  to  say  how  far  such  rigors  are  evidence  of  the  absorption  of  toxins,  and  how 
far  they  indicate  that  living  bacteria  have  gained  access  to  the  blood-stream.  Situated  in 
the  genito-urinary  tract,  these  inflammations  are  often  associated  with  a  history  of  gonor- 
r/i(ra.  renal  calculus,  or  gout,  and  produce  characteristic  pathological  changes  (ha^maturia, 
pyuria,  albuminuria)  in  the  urine,  or  difficulties  in  micturition.  If  the  gall-bladder  or 
bile-ducts  are  the  seat  of  the  inflammation,  jaundice,  and  pain  in  the  hepatic  region  will 
probably  be  observed  with  the  fever  and  rigors,  and  a  history  of  gall-stone  colic  may  be 
given,  suppurative  cliolecfi.-^titis  or  suppurative  cholangitis  having  supervened  ;  the  gall- 
bladder will  be  tender  and  i)r(>bably  enlarged  from  the  former,  the  whole  liver  swollen 
and  possibly  tender  from  the  latter  ;  t'harcofs  hejtatic  intermittent  fever  is  due  to  chronic 
cholangitis,  with  intermittent  biliary  obstruction  due  to  a  ball-valve  stone  often  lying 
in  the  ampulla  of  Vater.  The  occurrence  of  rigors  in  a  child  convalescing  from  pneu- 
monia, measles,  scarlet  fever,  or  pleurisy,  may  lead  to  the  discovery  of  an  imsuspected 
empyema.  Infective  sinus  thrombosis  occurs  mainly  in  patients  with  otorrhoea,  and 
indicates  that  the  bacterial  infection  has  spread  from  the  ear  to  one  of  the  cranial  venous 
sinuses.  Its  symptoms  are  general — those  of  septiciemia  or  pyaemia,  often  with  an  initial 
rigor  and  vomiting  followed  by  high  fever,  more  rigors  {Fig.  21.4,  p.  .567),  and  sweating  ; 
and  local —very  severe  pain  alinut  the  ear,  excruciating  headache,  and  venous  congestion 
(if  the  optic  disc,  with  others  that  vary  with  the  site  of  the  thrombosis.  If  the 
sigmoid  sinus  is  throiTiboscd.  u'dema  and  tenderness  over  the  mastoid  a|)])ear.  and 
should  the  cldtting  spread  downwarils  a  throml)Us  may  be  felt  in  the  intcrnaf  jugular 
vein.  Thrombosis  of  the  cavernous  sinus  is  accompanied  by  scpiinf,  cxophthalmt>s,  and 
oedema  of  the  ortiits  and  eyelids.  Thrombosis  of  the  superior  longitudinal  sinus  may  .set 
up  tt'dcma  of  tlie  scalp  near  the  .sagittal  suture.  The  diagnosis  must  fie  made  from  cerebral 
or  cerebellar  abscess,  in  which  repeated  vomiting  is  likely  to  occur,  and  the  localizing  signs 
and  symptoms  will  suggest  brain-disease  :  and  from  meningilis.  in  which  rigors  are  rare. 
In  other  patients,  some  acute  inflammatory  disordi-r  may  result  in  delinilc  al/sccss  formation, 
when  rigors  may  develop  from  toxic  or  septic  alisorption  :  here  again,  the  \iriilenee  of  the 
particular  microbe  causiuL;  the  inllammation  will  be  the  chief  factor  in  determining  whether 
rigors  occur  or  nol .  In  many  cases  the  rigors  will  really  be  due  to  a  seenndary  and 
probably  terininal  s(|>|ie:iniia   or  pya-mia. 

Troiiicat  alisccss  of  the  liver,  usually  single,  occurs  in  patients  who  ha\c  Ix-en  abroad 
and  have  had  d\senlery,  whetlier  aniubic  or  ba<'terial.  The  early  symptoms  of  liver 
abscess  are  oflen  obscure,  malaise,  fever,  sweating,  rigors,  and  gastro-inteslinal  disturbances 
occurring,  or  a  pleural  effusion  secondary  to  spread  of  infection  through  the  diaphragm, 
■while  nothing  particularly  suggests  implication  of  the  liver.  .Vs  a  rule,  complaint  of  dull 
pain  in  the  right  hypochondriiim.  axill.i.  or  shoulder  will  be  made.  The  diagnosis  of  this 
and  (it  licr  forms  of  suppuration  In  tin-  li\  ir  is  discussed  on  p.  .'Jiilt. 


598 


RIGORS.     OR    CHILLS 


Multiple  rifjors  may  occur  from  septic  absorption  in  various  diseases  of  the  lungs,  the 
most  im])ortant  of  wliich  are  bronchiertasis,  and  advanced  pubnonary  tuberculosis  with 
secondary  pyogenic  infection  of  the  bronchi  or  tuberculous  cavities.  In  either  case  the 
sputiuii  will  be  abundant,  and  will  probably  contain  fragments  of  clastic  tissue  ;  it  is  sure 
to  be  offensive  in  bronchiectasis. 

High  or  irregular  fever  with  recurring  rigors  has  been  recorded  in  a  few  unusual  cases 
of  enteric  fever  {Fig.  241,  p.  565)  and  of  influenza  free  from  any  comiilication.  and  in 
erifsipclns  (Fig.  245.  p.  568). 

Only  about  a  dozen  cases  of  rat-bite  fever  have  been  recorded  in  Great  Britain  so  far. 
l)ut  it  is  probably  commoner  than  it  would  appear  to  be,  and  habitually  unrecognized. 
It  occurs  in  persons  who  have  been  bitten  by  rats,  or  by  ferrets,  cats,  or  weasels  that  have 
killed  rats  recently  :  the  rat-bite  heals  slowly,  and  after  an  incubation  period  of  from  two  to 
four  weeks  the  patient  begins  to  suffer  from  a  series  of  acute  febrile  attacks  at  fairly  regular 
intervals  of  a  few  days.  These  attacks  recur  for  from  two  to  ten  months  in  different 
instances  (Fig.  254).   The  onset  of  each  is  abrupt,  with  headache,  fever  up  to  102'-106°  F., 


Fitj.  2.JJ. — Temperatu 


L'luirt  in  a  severe  case  of  rat-bite  fever  ;  only  part  of  the  cliart  is  s 
attacks  extended  over  a  period  of  four  montlis. 


1 ;  tlie  recurrent   , 


malaise,  pains  all  over,  often  a  rigor,  severe  i)ain  and  swelling  in  some  of  the  muscles, 
recurrence  of  inflanmiatory  ])heii(inHna.  rarely  suppurative,  about  the  original  wound,  and 
urticarial,  measly,  patchy  erythcmalous  rashes  on  the  face,  limbs,  and  trunk.  Each  attack 
lasts  for  a  day  or  two,  the  j)atient  being  fairly  well  in  the  intervals  ;  during  the  attack 
a  varying  leucocytosis  is  common.  Rat-bite  fever  is  not  fatal  :  the  infecting  agent, 
though  often  looked  for.  remains  unknown.  .j.  j.  Jcx-Blake. 

RINGWORM.  -(See  FiNGOis  .-Vfkections  of  tue  .Skiv,  p.  246.) 

RISUS  SARDONICUS  is  the  fixed  unmirthful  grin  that  results  from  spasm  of  the 
nuiselcs  of  l)()tli  sides  iil  tlie  face.  The  angles  of  the  mouth  are  drawn  outwards  and  the 
eyelids  raised  l)y  tonic  contraction  of  the  same  muscles  as  produce  the  facial  expression 
of  smiling,  but  the  sj)asm  is  maintained  in  a  way  that  at  once  excludes  natural  smiling. 
The  chief  causes  of  the  condition  are  tetanus,  strychnine  poisoning,  malingering,  hysteria, 
catalepsy. 

Catalepsy. — The  differential  diagnosis  is  not,  as  a  rule,  dilTicult.  A  cataleptic  case 
is  chronic  ;  the  facies  is  by  no  means  always  that  of  smiling,  but  if  it  should  be,  then  the 
smile  is  a  fixed  one  ;  the  chief  characteristic  of  the  condition  is  the  maintenance  for  hours 
at  a  stretch  of  some  attitude  that  would  rapidly  fatigue  an  ordinary  person  :  the  history 
and  the  associated  mental  s\niptoms  of  melancholia  or  dementia  point  to  the  diagnosis, 
and  tetanus  and  strychnine  poisoning  would  be  excluded  by  the  absence  of  tetanic  spasms. 

Hysteria  sometimes  takes  a  form  that  may  for  a  while  raise  doubts  as  to  strychnine 
having  been  taken,  but,  as  a  rule,  the  nuiltiformity  of  the  contortions  points  to  the  correct 
diagnosis.  The  features  may  be  kept  fixed  for  a  time,  but  sooner  or  later  they  become 
twisted  into  all  sorts  of  shapes,  and  the  tonic  and  clonic  spasms  of  the  body  and  limbs  are 
not  in  any  way  regular,  as  they  arc  apt  to  be  in  strychnine  poisoning  and  tetanus.  The 
patient  is  likely  to  be  a  woman,  and  there  may  be  a  liislmy  of  previous  hysteria  (p.  465). 


PLATE     XXIII 


INTESTINAL      SAND 


1.  Microscopical  !i|.|ic:iraMi'C  of  Inio  intestinal  saiul. 
2.   Microscopical  ajipearancc  of  false  intestinal  sand,  following  the  iiigcslioii  of  pt 
Jhj  j„'rmi<.ii:,ii  Irmn  '  Tin-  /'Vr/M  in  Childrm  iiiiil  Ailiills:     /'.  ./,  Cimmiihjr. 


ISDKX      111-'     Ji|Ai;N()SI.S-7'u   hicr  „.  5118 


SCABS  599 

During  a  quiescent  interval  it  may  be  founii  possible  to  stroke  or  touch  the  patient  without 
bringintr  on  a  convulsion,  whereas  in  strychnine  poisonin<;  and  in  tetanus  the  slightest 
touch  is  a|)t  to  evoke  a  violent  and  generalized  spasm,  even  opisthotonos. 

Malingering  may  take  the  form  of  imitated  convulsions,  during  which  the  features 
may  be  kept  fixed  in  one  position  or  another,  sometimes  in  that  of  smiling.  The  fixed 
voluntary  contractions  cannot  be  maintained  long,  however,  on  account  of  fatigue,  so  that 
although  there  may  be  some  doubt  at  first,  this  generally  disappears  soon.  The  patient 
is  usually  a  man  who  has  something  to  gain  by  malingering  :  a  night's  lodging  in  a 
hospital,  for  instance. 

Strychnine  Poisoning  and  Tetanus  arc  the  two  chief  causes  of  typical  risus  sardonicus. 
The  main  point  to  rely  on  in  distinguishing  tlic  two  is  the  history,  if  it  is  obtainable — the 
injection  of  an  overdose  of  strychnine  hy])odermically,  or  the  taking  of  a  rat-paste,  on  the 
one  hand,  or  the  occurrence  of  some  small  but  penetrating  wound  by  a  rusty  nail  or  earth- 
soiled  knife  or  stick  during  the  fortnight  preceding  the  symptoms,  on  the  other.  The 
absence  of  any  known  wound,  however,  does  not  exclude  tetanus.  If  lock-jaw  and  stiffness 
of  the  neck  are  ])rominent  features,  tetanus  is  more  probable  than  strychnine  poisoning, 
and  vice  versa.  In  strychnine  cases,  the  patient  will  either  die  quickly,  or  the  symptoms 
will  subside  rapidly,  whereas  in  tetanus  they  may  persi-st  unabated  for  several  days.  In  a 
few  instances  the  diagnosis  may  only  be  settled  by  the  discovery  of  strychnine  in  the  gastric 
contents,  or  of  tetanus  bacilli  (Plate  XXVIII,  Fig.  T,  p.  614)  in  anaerobic  cultivations 
from  the  infected  woimd. 

It  only  remains  to  add  that  a  few  eases  of  facial  sclerodermia  may  simulate  risus 
sardonicus,  though  more  often  there  is  complete  smoothness  of  the  features  and  lack  of 
expression.  There  are  no  spasmodic  contractions,  the  condition  comes  on  gradually,  is 
permanent,  and  the  diagnosis  becomes  obvious  at  once  when  the  hard  smooth  skin  is 
palpated,  for  one  cannot  pick  it  up  between  one's  fingers.  Herbert  French. 

RUMINATION.     (Sec  .AIkkvcism,  p.  888.) 

RUPIA.— (See  Scars,   below.) 

SALIVARY   GLANDS.     (Sec  Swf.i.i.jnc  of  Tin;  Sm.ivahv  (ii.ANDs,  p    0!»k) 

SALIVATION,   UNDUE.  H-"it'e  I'tvai.ism,  p.  542.) 

SAND,  INTESTINAL.  -This  is  seen  in  the  motions,  especially  when  they  are  fluid 
and  the  piilicnl  has  imiiibranous  colitis.  It  is  like  the  finest  sea-sand  :  its  colour  varies 
owing  lo  \aryiiig  (kgnes  of  imbibition  of  fa-cal  pigment.  I"sually  it  is  red.  looking  some- 
thing like  line  uric  acid,  and  it  varies  from  this  to  a  jjale  dirty  yellow.  It  is  seen 
best  showing  up  against  the  white  of  the  bed-pan  in  which  it  lies.  Analysis  shows  that  it 
consists  of  fro7ii  ;5()  to  70  per  cent  of  organic  matter,  doubtless  all  d(ii\:(l  IVom  the  fa-ces. 
The  inorganic  matter  is  invariiibly  nearly  all  calcium  phosphate,  wilh  Iniccs  of  calcium 
oxalate.  iii:igriesiinu.  iron,  and  perha|)s  silica.  The  amount  of  sand  passed  in  a  day  may 
be  four  teaspoonfuls,  but  usually  it  is  nnich  less.  .Many  patients  pass  it  I'oi-  years,  but  not 
always  constantly  even  then  :  it  may  be  passed  daily  for  weeks,  and  then  for  weeks  none 
is  passed.  It  is  far  commoner  in  those  who  have  membranous  colitis  than  in  other  patients, 
but  it  has  been  seen  with  malignant  disease  of  the  large  intestine  :  it  always  indicates  some 
organic  disease  of  the  colon.  It  must  be  distinguished  from  false  intestinal  sand,  which 
looks  very  like  it  and  may  be  found  in  the  motions  of  those  who  have  eaten  largely  of  pears. 
This  is  entirely  \(i;rtal)lc.  .-ind  can  be  distinguished  easily  frorti  true  intestinal  sand  by 
rnicrnsci.piiMl   (  \:iiiiiii.it  inn   ll'late   Will).  If.  Ihile  While 

SCABS.  The  scab,  or  crust,  one  nf  the  sciundarN  cutaneous  lesions,  is  a  more  or  less 
irregular,  dried-up  mass  of  exudation  on  llu-  surl'air  (jI  the  skin.  It  may  be  produced  by 
the  desiccation  of  senun.  pus.  or  blood,  or  of  a  mixture  of  these  lluids.  and  conuningliiig 
with  these  substances  there  may  be  epithelial  debris,  or  fat.  or  fungous  elements.  Seal)s 
form  on  matured  \csieles.  Iiulhe  and  pustules,  on  ul<'erat  ions,  erosions,  and  on  every  kind 
of  exi'orialinn.  pal  lioiiijijcal  m-  trauma  tie.      It  I  lie  i  xudaticiii  i^  thin,  as  sdmrlimcs  in  ec/.ema, 


€00  SCABS 

thev  are  soft  and  friable  :  if  it  is  thick,  they  may  be  tougher  and  more  adherent,  and 
successive  layers  may  be  formed,  as  in  the  rupial  crusts  of  syphilis.  Scabs  composed  largely 
of  fimgous  elements  are  more  or  less  friable,  and  these,  like  those  resulting  from  the  sebor- 
rhoeic  process,  may  partake  of  the  character  of  scales  as  well  as  of  scabs.  Such  formations, 
however,  as  for  example  the  '  crusts  "  of  favus,  are  in  the  nature  of  scales  rather  than 
of  scabs,  and  are  noticed  elsewhere.  (See  Scaly  Eruptions,  p.  601  ;  and  Fungous 
Affections  of  the  Skin,  p.  246.) 

Scabs  vary  greatly,  not  only  in  consistence,  thickness,  and  adhesiveness,  but  also  in 
colour  and  in  form  ;  and  by  attention  to  these  differences  the  diagnosis  of  the  affections 
in  which  they  occur  may  be  assisted.  Some  guidance  may  also  be  obtained  from  the  con- 
dition of  the  surface  from  which  the  scab  has  been  removed  ;  it  may  be  dry  when  the  scab 
has  been  long  adherent,  as  in  some  cases  of  impetigo,  excoriated  as  in  eczema,  or  ulcerated 
as  in  rupia.  But  the  clinician  will  be  guided  much  more  by  the  primary  than  by  any 
secondary  lesion  :  and  for  the  decisive  diagnostic  features  of  the  diseases  about  to  be 
mentioned,  the  reader  is  referred  to  the  articles  Macules  (p.  382)  ;  Vesicles  (p.  753)  ; 
BuLL.F.  (p.  96)  ;   Papules  (p.  487)  ;   Nodules  (p.  402)  ;   and  Pustules  (p.  357.) 

In  irritatwe  herpes  the  vesicles  on  the  skin  shrivel  up  and  form  yellowish-brown  crusts, 
wliieh  after  a  few  days  become  detached,  as  a  rule  leaving  no  scar,  but  only  a  brownish 
stain,  which  slowly  fades  away.  In  herpes  zoster  most  of  the  vesicles  which  do  not  abort 
reach  tlie  same  termination  ;  but  others,  instiad  of  drying  up,  may  burst  and  discharge  a 
fluid,  which  then  forms  yellowish  or  brownish  crusts.  In  zoster  a  scar  is  produced  some- 
times. In  erythema  multiforme  there  is  often  considerable  scabbing,  as  is  mentioned  under 
Vesicles  (p.  753).  In  eczema  the  lesions  may  dry  up  either  into  scales  or  into  crusts. 
Crustation  is  usually  the  third  stage  in  the  evolution  of  the  disease,  the  discharge  from  the 
vesicles  drying  into  greyish-yellow  scabs  of  varying  thickness,  which  become  detached  and 
are  succeeded  by  others  until  the  '  weeping  "  ceases.  When  the  lips  are  attacked,  they 
may  become  so  stiffened  imder  layers  of  crusts  superimposed  one  upon  another  that  the 
patient  can  hardly  move  his  lips  without  fissuring  the  skin.  In  the  male,  the  '  bathing- 
drawers  '  area  may  be  so  covered  with  crusts  that  the  patient  cannot  walk  or  sit  down 
without  breaking  them.  In  the  same  region  in  the  female  the  inflammation  and  crusta- 
tion may  be  even  more  severe,  and  the  scabs  may  be  marked  by  much  foulness.  One  of 
the  characteristic  features  of  what  is  called  papular  eczema  is  tlie  ajipearance  of  a  tiny  dome 
of  blood-crust  on  the  papules,  due  to  scratching.  In  seborrha'ic  cczemii  there  may  either 
be  scaling,  or  the  squames  may  be  massed  into  fatty  crusts  (see  Scaly  Eruptions,  p.  601). 
The  scabs  in  eczema  ruhrum  are  extremely  thin,  like  goldbeater's  skin  ;  when  they  are  torn 
off,  a  red,  wet,  raw,  tender  surface  is  laid  bare.  The  crusts  of  scabies  may  be  distinguished 
from  those  of  eczema  by  their  being  isolated  and  distributed  irregularly,  instead  of  being 
grouped,  and  by  the  multiformity  of  the  lesions  with  which  they  are  mixed — vesicles, 
bulla',  pustules,  ha^morrhagic  scabs,  etc.  In  most  itching  diseases  there  will  be  found 
blood-scabs,  resulting  from  the  scratching  to  which  the  patient  is  provoked. 

In  cliei ropompholyx  the  bullae  into  which  the  little  sago-grain  vesicles  run  dry  up  into 
crusts,  the  remo^•al  of  which  reveals  a  surface  that  is  red  and  exquisitely  tender.  The 
appearance  and  sensitiveness  of  the  underlying  skin,  together  with  the  limitation  to  the 
hands  and  feet,  and  often  to  tlie  hands  alone,  will  help  the  diagnosis.  The  crusts  of  sycosis 
vulgaris  also  have  a  limited  distribution  :  they  may  be  confined  to  the  upper  lip.  and  in 
any  ease  they  do  not  extend  beyond  the  hairy  parts  of  the  face.  They  arc  brown  or  yellow 
in  colour,  thin,  and  distinctly  adherent. 

In  impetigo  contagiosa  the  scabs  which  are  formed  from  the  dried-up  fluid  discharged 
by  the  pustules  on  rupture  are  yellowish  ;  in  uncleanly  persons  they  are  brown,  or  even 
black.  A  characteristic  feature  is  that  they  have  aroimd  them  no  hypera'mic  halo,  but 
look  as  if  they  might  have  been  stuck  on  artificially.  In  the  severe  form  of  the  disease 
styled  ecthyma,  however,  the  flat  irregular  scab  formed  from  the  ruptured  vesicles  is 
surrounded  by  a  more  or  less  pronounced  areola.  At  first  loosely  attached,  the  scabs  in 
impetigo  contagiosa  afterwards  become  so  firmly  adherent  that  their  removal  requires 
some  force  and  gives  rise  to  a  little  bleeding.  In  this  affection  there  is  what  may  be  called 
a  secondary  scab,  formed  by  the  drying-up  of  the  thick,  purulent  discharge — honey-like 
in  consistence  and  appearance — from  the  surface  left  raw  by  the  removal  of  the  earlier 
erusts.     The    reddish    stain    that    ai)])ears   when    the   lesion    heals    is   not    permanent.     In 


SCALY    ERUPTIONS  601 

pemphigus  vulgaris  the  crusts  into  which  the  bullae  shrink  arc  brownish-yellow  ;  and  when 
they  fall  off  spontaneously  the  surface  beneath  is  not  raw,  as  in  impetigo,  but  is  found  to 
be  covered  with  ncwly-fornied  epidermis,  at  first  purple,  afterwards  turning  brown,  and 
gradually  becoming  normal  in  colour.  ^Vhen  the  area  covered  by  the  scabs  is  extensive 
there  is  an  unpleasant  sense  of  tension,  and  if  they  are  removed  prematurely,  excoriation 
may  be  caused.  In  the  more  serious  affection  known  as  pemphigus  foliaceus.  the  crusts 
are  yellowish,  and  as  the  disease  proceeds,  large  scales  are  formed.  In  pempliigus  I'egelnns 
the  foul-smelling  secretion  from  the  patches  of  affected  skin  forms  a  thin  crust,  which  can 
easily  be  stripped  off,  when  a  papillary  excrescence,  partly  covered  with  a  thin  stratum  of 
epidermis,  is  revealed.  The  process  usually  ends  in  gangrene  and  death.  The  excrescences 
are  distinguishable  from  the  condylomata  of  syphilis  by  always  being  surrounded  by  a 
zone  of  bulla',  while  condylomata  have  an  infiltrated  border. 

In  )ienY  Icprosii  tlic  bulUe.  wliich  have  the  same  characters  as  those  of  pemphigus 
vulgaris,  form,  on  rupture,  a  large  crust,  the  removal  of  which  exposes  a  grey  surface  con- 
sisting of  altered  rete,  the  epidermis  being  cast  off  by  suppuration.  In  this  way  a  succession 
of  yellow  scabs  or  crusts  may  be  formed  and  fall  off,  lea\ing  at  last  a  granulating  surface, 
which  ultimately  is  converted  into  a  white  scar.  If  the  bulla;  abort,  they  are  followed  by 
a  parchment -like  scale  instead  of  a  crust,  and  this  in  turn  gives  place  to  a  hypersesthetic 
ulcer.  The  scabs  of  nerve  lejjrosy  have  some  resemblance  to  the  rupial  crusts  of  secondary 
syphilis,  but  there  is  little  danger  of  confusion  between  the  two.  The  rupial  crusts,  greenish 
or  blackish,  consist  of  several  successive  layers,  each  smaller  than  the  one  immediately 
below  it,  so  that  a  jjyramidal  structure  is  formed,  somewhat  resembling  the  .shell  of  a  limpet. 
This  very  characteristic  crust,  which  can  scarcely  be  mistaken  for  that  of  any  other  con- 
dition, and  distinguishable  from  the  psoriasis  rupioides  of  M-Call  .Vuderson  by  the  base 
being  ulcerated,  is  formed  from  pustules  usually,  but  may  follow  also  on  tlu-  drying  up 
of  bulhe.  The  scabs  in  scaiudarij  i/incs  form  upon  the  yellow  heads  of  large  papules,  and 
beneath  them  are  found  reddish  ras])berry-like  granulations  which  secrete  a  little  pus,  and 
after  a  time  become  pale  or  even  vvliite.  Healing  usually  takes  place  beneath  the  scabs, 
which  fall  off  about  the  end  of  the  second  month  from  the  onset  of  the  secondary  rash. 
The  raspbcrry-iike  granulations,  the  characteristic  lesion  of  yaws,  will  obviate  confusion 
between  tliese  crusts  and  those  of  any  other  alieetion.  The  crusts  of  lujius  vulgaris  are 
greenish-black,  like  rupial  crusts.  l)ut  they  do  not  consist  of  layers  superimposed  upiin 
each  other,  and  dotted  around  the  ragged  edge  will  be  seen  the  "  a])plc-jelly  '  nodules 
which  are  the  "  note  "  of  lupus. 

In  smalt-po.r  the  formation  of  scabs  on  the  pustvilts  begins  in  the  centre  and  causes  a 
secondary  '  umhilic'ation  "  :  it  is  generally  attended  by  intense  itching.  In  from  three 
to  four  weeks  from  tluir  appearance  the  crusts  fnll  off.  leaving  a  reddened  surface,  made 
uneven  by  sears  or  '  ])its."  The  true  iiatinc  of  the  (hsease  will  have  been  discovered, 
even  in  doubtful  cases,  before  the  crust  stage  is  reached.  (For  the  differential  diagnosis, 
see  under  Pisici.ks,  p.  .5.57).  In  the  diagnosis  of  utrrrs.  as  in  that  of  small-pox.  the  crust 
is  of  liltle  imporlancc.  These  are  dealt  witli  under  1 'i.ci'.haiion  ok  i  hi;  1<"a<  i;  (p.  T.'f.i)  and 
ri.(i;K.\rioN  oi   TUK  Foot  (p.  785).  Malrohii  Morris. 

SCALY  ERUPTIONS,  The  Miuanic.  or  s<a!c.  one  of  the  secondary  cutaneous 
lesions,  is  a  dry,  ami  as  a  rule  laniimitrd.  cxinljalion  of  Ihr  epidermis.  Disregarding  the 
slight,  inipereeptible  d;s(|uamation  which  is  a  purely  physiological  ])roeess,  scales  may  be 
said  to  result  either  from  inflanunation.  as  in  psoriasis  and  pityriasis  rubra  pilaris  ;  from  an 
abnormal  dryness  of  the  skin,  as  in  <lry  seborrho'a  and  keratosis  pilaris  ;  or  from  an  earlier 
acute  hyperainia,  as  in  scarlatina  and  other  ervlliematous  eruptions.  The  |)rocess  m:iy 
consist  in  an  over-multiplication  of  the  epidermic  cells  or  in  interference  with  the  normal 
horny  transformation.  In  colour,  scales  are  ordinarily  white  or  grey,  cither  dull  and 
lustreless,  as  in  seborrhcea,  or  silvery,  as  in  psoriasis  ;  but  they  are  sometimes  a  dirty 
yellow,  as  in  some  dry  syphilides,  or  even  reddish-brown,  as  in  oily  seborrlxi'a.  They  may 
be  large  and  thin,  as  in  ()ityriasis  rubra,  or  small  and  branny,  as  in  tinea  versicolor  :  even 
HI  the  same  alieetion  (e.g..  pityriasis  rubra)  they  may  vary  greatly  in  size  in  different 
regions.  They  may  consist  of  a  singU-  layer,  as  in  scpiaiiious  eczema,  or  of  several  ailherent 
strata,  as  in  psoriasis.  In  (piarility  I  hey  m;iy  be  inconsiderable,  as  in  tinea  \  crsiiMilor, 
or  must   profuse,  as  In  psciriasis  and  pityriasis  rubra,      fsualiy  I  hey  are  dry  and  trialilc,  iiul 


602  SCALY    ERUPTIONS 

if  mixed  with  an  oily  secretion,  as  in  seborrhoea,  or  with  a  serous  or  seropuriilent  discharge, 
as  in  eczema,  they  may  partake  of  the  nature  of  both  scales  and  crusts. 

A  brief  description  of  the  scales  met  with  in  various  affections  may  be  given  here  : 
but  except  in  a  few  diseases  of  which  they  form  a  highly  characteristic  manifestation,  such 
as  seborrhoea,  psoriasis,  and  pityriasis  rubra,  they  have  little  diagnostic  value,  and,  as  I 
have  said  elsewhere  of  scabs,  diagnosis  must  usually  rest  u])on  ijrimary  rather  than  upon 
secondary  lesions. 

Sometimes  there  is  scale-formation  in  eruptions  due  to  the  internal  administration  of 
such  drugs  as  quinine  or  belladonna,  or  to  the  external  application  of  carbolic  acid,  iodine, 
etc.  :  but  it  has  no  significance  in  diagnosis.  In  keralosis  pilan's  (xeroderma)  and  other 
forms  of  iciitlnjosis,  there  is  always  more  or  less  dcsiiuamation  of  the  dry  and  roughened 
and  sometimes  warty  skin  ;  but  here  also  it  is  without  diagnostic  import.  Of  the  scales  of 
scarlet  fever,  measles,  German  measles,  and  other  htfectious  fevers,  again,  nothing  need  be 
said,  for  the  diagnosis  ought  to  have  been  settled  before  they  appear.  Nor  need  I  speak 
of  the  scaliness  of  tinea  tonsurans,  tinea  versicolor,  and  other  fungous  affections,  for  the 
(iilierential  diagnosis  of  these  diseases  has  been  given  under  Fcngous  Diseases  (p.  '246). 
The  scales  of  papular  syphilides.  again,  have  been  described  under  Papules  (p.  487),  and 
the  diagnosis  of  the  lesions,  both  primary  and  secondary,  from  tliose  of  psoriasis  will  be 
found  in  that  article.  In  the  unusual  instances  of  urticaria  in  which  desquamation  is 
])resent,  it  is  so  slight  as  to  be  negligible.  In  most  forms  of  erythema,  scales  occur  ;  but 
here  again  they  have  little  significance  for  the  diagnostician,  and  it  will  be  sufficient  to 
say  that  in  erythema  simplex  the  des(|uamation  is  slight,  and  that  in  erythema 
scarlatiniforme  it  is  more  considerable.  In  lupus  eri/theniatosus  the  central  scar-like 
depression  of  the  primary  eruptive  lesions  may  be  covered  either  with  thin,  papery,  greyish 
scales,  or  with  a  firmly  adherent  scab.  In  parts  furnished  with  sebaceous  glands,  the 
skin  will  usually  be  covered  with  small  adherent  .scales  of  sebum,  which  at  the  margin  of 
the  patch  plug  the  dilated  orifices  of  the  glands,  so  that  numerous  comedones  are  formed. 
From  other  forms  of  erythema,  as  also  from  ringworm,  lupus  erythematosus  may  be  dis- 
tinguished by  the  slowness  and  persistence  of  the  process.  The  lesion  itself,  atrophic  in 
the  centre,  with  a  well-defined  red  border,  and  studded  with  plugs,  can  scarcely  be  mistaken 
when  it  ap])cars  on  its  site  of  election,  the  face.  When,  however,  it  occurs  on  the  hands, 
it  may  mimic  chilblains  so  closely  that  only  the  lapse  of  time  can  make  the  diagnosis 
certain,  lupus  erythematosus  being  much  more  obdurate  to  treatment,  and  not  disappear- 
ing in  the  summer.  For  the  diagnosis  between  lupus  erythematosus  and  psoriasis,  see 
below  ;  for  that  between  lupus  ervthematosus  and  lupus  vulgaris,  .see  under  Nodules 
(p.  102.) 

We  now  come  to  affections  in  which  scales  play  a  more  imj)ortant  part.  In  seborrhoea 
sicca  there  is  an  excess  of  the  solid  fatty  constituents  of  the  sebum,  and  the  excreted 
material  takes  the  form  of  scaly  but  usually  somewhat  greasy  masses.  In  seborrhea 
oleosa  there  is  an  abnormal  predominance  of  the  oily  part  of  the  sebaceous  secretion, 
which  dries  into  yellowish  or  reddish-brown  cakes  of  greasy  scales,  often  with  a  hyper- 
aniie  base  and  a  fringe  of  papules  about  the  edge.  In  the  face,  oily  seborrhoea  is  more 
often  met  with  than  the  dry  form  ;  but  seborrhoea  generally,  though  it  may  occur  on 
the  trunk  and  limbs,  almost  invariably  begins  on  the  scalp.  When  not  limited  to  the 
seal]),  as  usually  it  is.  it  .spreads  downwards  to  the  face,  round  the  neck,  the  chest,  the  centre 
of  the  back,  and  the  limbs.  In  the  light  of  this  preference  for  the  scalp,  and  the  downward 
extension  when  the  affection  is  not  confined  to  that  part,  a  typical  case  of  seborrhoea  is 
unmistakable.  In  cases  of  seborrhoea  which  resemble  psoriasis,  guidance  may  be  found 
in  the  scales,  which  in  the  latter  affection  are  silvery,  and  harder.  The  respective  starting- 
points  of  the  eruptions,  however,  furnish  a  safer  indication,  psoriasis  almost  always 
ap|)earing  first  on  the  elbows  and  knees  and  spreading  upwards. 

In  typical  eczema,  scaling  forms  the  final  stage  of  the  pathological  process.  After 
the  initial  erythema  comes  the  exudation,  then  the  crustation  (see  Sc.VBS,  p.  599).  next 
the  dry  stage,  and  lastly  the  desquamation,  the  epidermis  being  shed  in  scales  that  become 
progressively  thinner  and  smaller  until  only  a  brownish  stain  is  left  to  mark  the  site.  All 
the  stages  are  often  present  at  once  in  a  given  case.  Scaling  is  frequently  a  noticeable 
feature  when  there  is  a  predominance  of  erythematous  lesions,  as  it  is  also  in  eczema  follicu- 
lorum.     But  it  is  in  seborrheic  eczema  that  this  phenomenon  is  most  ])rominent.  the  latent 


SCALY     ERUPTIONS  003 

catarrh  with  which  the  affection  begins  being  followed  by  tlie  agglutination  of  epidermic 
scales  which  are  thrown  off  in  the  form  of  large  lamelte.  In  some  cases  the  scales  may 
increase  in  quantity,  in  others,  as  is  mentioned  under  Scabs  (p.  .599),  they  may  become 
massed  into  fatty  crusts  among  the  hairs.  The  differential  diagnosis  of  eczema  has  been 
set  out  in  the  articles  on  the  primary  lesions.  The  secondary  lesions  in  this  affection  may 
indeed  be  rather  a  hindrance  than  a  help  in  determining  its  true  nature,  and  in  doubtful 
cases  the  first  thing  to  do  is  to  remove  both  scales  and  crusts  in  order  that  the  under- 
lying lesion  may  be  examined  carefully.  As  between  eczema  and  psoriasis,  however,  just 
as  between  eczema  and  seborrhcca,  the  scales  afford  guidance  in  the  diagnosis  ;  while  in 
psoriasis  the  lower  layers  of  scales  are  whitish  or  silvery  and  hard,  in  eczema  they  are 
yellowish,  dull,  and  friable. 

In  psoriasis  the  scale  has  distinct  diagnostic  value.  It  enters,  indeed,  into  the  defin- 
ition of  the  disease  as  an  affection  of  the  skin,  characterized  by  fiat,  dry  patches  of  varying 
extent,  covered  with  whitish,  silver-grey,  or  asbestos-like  scales.  The  scaliness  may  vary 
from  a  thin  film  to  a  dense,  heaped-up  mass.  If  the  scales  are  removed,  a  smooth,  dry, 
shining  hypencmic  surface  is  seen,  studded  with  spots  that  show  various  gradations  of  colour, 
from  a  deep  to  a  bright  red,  the  bright-red  points  being  the  tops  of  inflamed  pa])illa».  The 
eruption  appears  as  pajjules  of  jjin-head  size,  at  first  red.  but  becoming  white  as  the  scales 
form.  S]>reading  ccntrifugally,  the  papules  form  patches,  generally  roundish  or  oval  when 
small,  and  becoming  more  irregular  as  they  grow  larger.  They  may  remain  stationary  for 
a  long  time,  and  slowly  disappear,  or,  continuing  to  spread,  may  become  confluent.  While 
the  disease  is  active  the  individual  patch  is  encircled  by  a  narrow  zone  of  redness,  but 
when  it  is  not  spreading  this  fades  away.  Sooner  or  later  involution  takes  place,  and  the 
redness  whicii  the  lesions  leave  behind  them  soon  disappears,  though  in  protracted  cases  a 
brown  .stain  may  persist,  and  in  rare  instances  there  may  be  superficial  atrophy.  The 
malady  may  come  and  go.  recrudescing  after  nearly  disappearing,  for  the  greater  part  of  a 
patient's  life.  It  is  often  most  abundant  when  the  patient  is  in  the  best  health,  and  may 
almost  or  quite  disajipear  <luring  serious  illness.  In  distribution.  ])soriasis  is  almost  invari- 
ably symmetrical.  Like  small-pox,  it  shows  a  marked  jiredilection  for  surfaces  that  are 
exposed  to  friction.  .\Imost  always  it  starts  on  the  tips  of  the  elbows  and  the  fronts  of  the 
knees,  .\fter  the  extensor  aspects  of  the  limbs,  its  favourite  site  is  the  hairy  scalp,  and 
then  the  trunk,  especially  over  the  lumlKir  region.  In  typical  cases  the  clinical  picture — 
the  patches  with  sharply  defined  border,  covered  witii  hard,  shiny  scales  ;  the  hyper;cmic 
surface  beneath,  dotted  with  red  |)oints  ;  the  distribution  as  just  deseribcd  ;  the  unim- 
paired health,,  the  natural  complexion,  the  |)roneness  to  attack  blue-eyed  fair-haired  persons, 
and  the  absence  of  exudation — scarcely  admit  of  misinterpretation.  In  all  these  particulars, 
except  the  unimi)aired  health,  psoriasis  differs  from  eczema,  as  well  as  in  the  less  intense 
and  less  constant  itching  by  which  it  is  attended.  On  the  seal]),  while  jjsoriasis  usually 
occurs  in  patches  and  ends  abruptly  at  or  only  Just  beyond  the  m;irgin  of  the  hair, 
.seborrlui'ie  eczema  almost  invariably  extends  over  the  whole  surface,  and  often  involves 
the  face  and  the  neck.  Almost  always,  too.  psoriasis  spreads  upwards  from  its  sites  of 
election,  seborrlm-ic  eczema  downwards  from  the  head.  In  xcry  chronic  forms  of  eczema, 
in  which  there  may  be  no  history  of  "  weeping,"  the  diagnosis  from  psoriasis  may  be 
dillicult.  In  all  doMbtful  itistances.  gentle  seratching  on  the  affected  surface  will  bring 
out  the  silvery  scales,  if  the  ease  is^one  of  psoriasis. 

The  papular  stage  of  lirlicn  i>liiiiiis  may  be  mistaken  for  psoriasis.  In  lichen  planus. 
Iiiiwever.  the  eruption  shows  a  preference  for  the  llexor  aspects  of  the  wri^K  .iiiil  knees  : 
il  consists  of  shining-smooth  papules,  without  scales  ;  the  ground-tint  is  bluish-red  or 
\  iolet  ;  and  the  patches  are  formed  by  the  a'.;grcgation  of  a  nundjcr  of  |)apiiles  insteail 
(<(  by  centrifugal  extension.  In  doubtful  cases  the  whole  body  must  be  searched  for  the 
typical  lesions  of  lillicr  disease. 

Lii/iiis  (■ri/lhcwiiltisii.s  .lillers  from  psoriasis  in  llinl,  in  llic  r.irrncr  rondiliMii,  llic  scales 
are  not  Ml)iin<l:inl.  llic  ciliic  of  llic  p;itili  is  more  clcvaliil.  llic  checks  arc  iisiialjv  allarkcd, 
as  they  arc  not  in  psnriasis.  and  llicrc  arc  llic  dislinrti\c  pliius  In  llic  cirili-cs  (if  the 
.sebaceous  duels,  as  described  earlier  in  this  arlicle.  Scarriicj,  too,  nia\  lie  fniiul  in  llie 
Jjateh.  and   there  may   be  atrophy  of  tli<'  ears. 

,\s  bctwc<-n  psoriasis  and  ixtjiiiliir  si/iiliiliilrs.  llic  diagnosis  is  ui\cii  under  I'm'i  i.i'.s 
(p.    I-HT).      The   licapcd-up  crusts  of  the  condil  ion   which   has  been   styled  psoriasis  nipioiiles 


604  SCALY    ERUPTIONS 

can  be  rlistinguished  from  the  rupial  lesions  of  syphilis  by  the  base  being  ulcerated  in  the 
latter  disease  :  but  syphilis  mimics  everything,  and  cases  sometimes  occur  in  which  it  can 
be  distinguished  even  from  so  distinctive  an  affection  as  psoriasis  only  by  attention  to  the 
history,  and  by  the  discovery  of  other  lesions,  the  ]iresence  of  cachexia,  the  influence  of 
salvarsan,  iodides,  and  mercury,  or  by  the  Wassermann  serum  test. 

In  pityriams  rubra  the  whole  cutaneous  surface  is  always  inflamed  and  reddened, 
without  infiltration  or  thickening,  but  accompanied  by  profuse  desquamation  (Plate  XXIV). 
branny  on  the  head,  larger  Hakes  from  the  trunk,  huge  scales  from  the  hands  and  feet. 
Pityriasis  rubra  may  occur  as  an  indejiendent  disease — an  extremely  rare  event — or  may 
follow  in  the  wake  of  erythema  multiforme,  eczema,  psoriasis,  lichen  planus,  dermatitis 
herpetiformis,  and  certain  drug  eruptions.  Its  most  frequent  precursor  is  psoriasis.  The 
constant  and  jji-ofuse  desquamation,  the  papery  scales  and  sheets  in  which  the  epidermis 
is  shed,  are  important  diagnostic  signs  ;  others  are  the  vivid  redness  of  the  eruption,  the 
rapidity  with  which  it  is  diffused,  its  universality,  the  serious  impairment  of  health — some- 
times issuing  in  death — and  the  frequent  absence  of  itching.  From  eczema  it  is  distinguished 
by  the  absence  of  exudation  and  of  crusts  ;  from  psoriasis  by  its  rapid  spread  and  imiversal 
diffusion  ;  from  pemphigus  foliaceus  by  the  absence  of  loose  bulla;  and  of  foul-smelling 
discharge,  the  less  severe  general  symptoms,  and  the  greater  amenability  to  treatment  ; 
from  lichen  ruber  ])lanus  by  the  absence  of  papules,  as  well  as  by  its  rapid  extension  and 
involvement  of  the  whole  area  of  the  body. 

The  essential  lesions  of  pityriasis  rosea  are  patches  or  circles,  very  slightly  raised  and 
thinly  covered  with  small  scales.  The  eruption  usually  shows  itself  first  on  the  abdomen, 
though  it  may  begin  on  the  chest,  the  face,  or  the  arms.  It  spreads  less  rapidly  than 
pityriasis  rubra,  but  in  two  or  three  weeks  the  trunk,  the  face,  and  the  limbs  may  be 
covered,  and  though  occasionally  it  is  universal,  it  seldom  extends  below  the  elbow  or  the 
knee.  The  diagnosis  is  seldom  in  doubt,  the  characteristic  "  herald  patch  "  with  which 
the  rasli  begins,  the  pale-red  tint,  the  slight  elevation  of  the  patches,  the  mingling  of 
maculate  and  circinate  lesions,  the  slight  degree  of  scaliness,  and  the  spontaneous  involu- 
tion, forming  a  distinctive  ensemble.  The  differences  it  presents  from  pityriasis  rubra  have 
been  indicated  above.  From  psoriasis  it  is  differentiated  by  its  less  inflammatory  character, 
the  more  rapid  onset,  the  .slight  scaliness,  its  neglect  of  the  situations  most  vulnerable  to 
psoriasitic  attack,  and  the  absence  of  hy|>(ianiic  spots  on  tlie  surface  beneath  the  scales. 
From  seborrhoca  corporis,  by  the  dryness  of  the  scales,  its  nuich  less  chronic  character,  the 
lesions  disappearing  spontaneously  in  a  few  weeks.  From  tinea  circinata,  by  the  large 
number  and  wide  distribution  of  the  lesions,  and  the  absence  of  the  fungus  which  is  the 
cause  of  cutaneous  ringworm.  From  the  maculo-pa))ular  syphilide.  by  the  absence  of 
infiltration,  the  lighter  colour,  the  fact  that  the  palms  of  the  hands  are  usually  spared, 
and  the  lack  of  concomitant  syphilitic  signs. 

Pityriasis  rubra  pilaris  may  appear  in  the  form  of  scaly  patches,  resembling  psoriasis, 
on  the  palms  and  soles,  or  as  a  dry  eruption,  covered  with  eczematous-looking  crusts  ;  but 
the  ])apule  which  soon  appears  is  a  more  characteristic  lesion,  and  the  diagnosis  of  the 
condition  from  psoriasis  and  other  affections  will  be  found  under  Papules  (p.  488). 

.Malcolm   Morris. 

SCLEROTICS,   BLUE.     (See  FiiACTrm;.  Spontankois.  p    24'J.) 
SCOLIOSIS. — (See  Curvature,  Spinal,  p.  153.) 
SCOTOMATA.— (See  Vision-,  Defects  of.  ],.  737.) 

SENSATION,  SOME  ABNORMALITIES  OF.— The  abnormalities  of  sensation 
met  with  in  disease  are  as  mimerous  as  they  are  important  for  the  purpose  of  diagnosis. 
Under  Pain  in  the  Face  (\>.  t4<i)  :  1'ain  in  the  Upper  Extrejiitv  (p.  442)  ;  and  Pain  in 
THE  Lower  Extremity  (p.  438),  the  question  of  subjective  pain  in  relationship  to  diagnosis 
has  been  discussed,  and  reference  will  be  foimd  to  another  subjective  abnormality  of  sensa- 
tion, to  which  the  term  '  acroparfesthesia  "  is  applied  on  p,  4i4. 

Wherever  sensory  loss  occurs,  it  should  assist  in  forming  a  conclusion  as  to  the  site  of 
disease,  even  if  it  does  not  indicate  clearly  anything  with  regard  to  its  nature.  In  order 
that  the  sensory  loss  may  give  the  necessary  information,  it  is  absolutely  necessary  that  the 


PLATE     XXIV 


PITYRIASIS      RUBRA 


From  •  Diseaxa  oj  Ihc  Skin; 

hy  kind  pcrmimon  of  Sir  Malcolm  Morris,  K.C.V.O. 


SENSATION.   Some   abnormalties   of 


605 


physician  should  ascertain  both  the  Hniit  and  the  nature  of  the  loss.  He  will  be  able  to 
judge  from  the  shape  and  locality  of  the  antesthetic  area  whether  it  conforms  to  a  lesion  of 
a  peripheral  nerve,  a  spinal  root,  or  some  part  of  the  central  nervous  system.  Analysis 
to  show  whether  the  loss  is  uniform  to  all  forms  of  sensory  stimuli,  or  whether  it  is  limited 
to  one  or  two  forms  only,  will  provide  additional  information  for  diagnosing  the  situation 
of  the  lesion.  ^In  order  to  utilize  the  information  provided  by  the  shape  and  size  of  the 


SOUV    NKKVrs    IN   THK   SK 


area  of  an;fstlicsi:i,  il  is  ncrcssMr\-  to  krinw  what  arc  Hit-  aicas  on  the  surl'ai-c  of  Ihc  body 
which  correspond  to  the  distrihiil  icjii  nl'  p(ri|iliii:il  nerves  on  the  one  hand,  and  of  spinal 
segments  or  spinal  roots  on  Ihr  nlhii,  'I'lic  aicmnpanying  diagnuns  (l''if>.  2.5.5  and  I'lalc 
A'AT.  p.  (i(IH)  supply  this  inliirrnalion  lo  some  cxlent.  but  in  order  that  il  may  be  used 
to  the  best  advanlage.  il  is  necessary  to  say  a  few  words  about  various  forms  of  sensory 
loss  due  lo  lesions  in  dilTerenl  parts  of  the  nervous  system.  n<'l'ore  entering  upon  this 
part  of  the  subject,  we  may  explain  the  way  in  which  we  propose  to  use  the  terms 
ana-sthesia.  analgesia,  and  thermo-aniesthesla. 

.liKi-sthrsiit   denotes    impairment    or    loss   iil'   llic    ciilaiiicius    s<'iisil)ilil  y    Id   cot  tiiM-\v<iiil 


606 


S?]NSATION.     SOME    ABNOR.MALITIKS    OF 


toucli.  and  it  is  important  to  remember  that  ])arts  whieli  are  hairless  should  be  chosen  for 

accurate  examination. 

Analgesia  refers  to  impairment  or  loss  of  pain-sense,  the  adjective  '  superficial  '  being 

applied  when  the  surface  pain  produced  by  the  prick  of  a  pin  is  interfered  with,  and  the 

adjective  '  deep  "  when  the  pain  usually  associated  with  pinching  or  scjueezing  the  nniscles 

and  deeper  tissues  is  no  longer  appreciated. 

'riicrriio-atMi'sthcsia  indicates  loss  of  appreciation  of  lieat  and  cold  :    hut  the  inability 

to  distinguish  between  things  which  are  warm  and 
cool  is  not  always  associated  with  eiiual  loss  of 
sensibility  in  distinguishing  between  objects  which 
are  ice-cold  and  really  hot. 

Disturbances  of  Sensation  in  Peripheral 
Nerve  Lesions.  The  aflcnnt  mechanisni  of  the 
]jeripheral  nervous  system  consists  of  the  following 
three  sub-systems  : — 

1.  Deep  Sensibility. — This  conveys  impulses 
excited  by  pressure  and  by  all  movements  of 
joints,  tendons,  and  muscles.  Painful  impulses 
(lerixed  from  excessive  jjressure  are  also  carried 
by  this  sub-system.  By  its  means  a  healthy 
])crson  is  able  to  recognize  not  only  movements 
(if  joints,  but  also  the  locality  of  the  stimulus  and 
the  direction  of  the  movement.  The  fibres  which 
conduct  these  sensory  impulses  run  mainly  with 
the  muscular  nerves,  and  are  not  destroyed  by 
division  of  the  sensory  nerves  to  the  skin. 

2.  Pnilopatliic  Seiisibility. — This  sub-system 
responds  to  painful  cutaneous  stimuli  (pinpricks) 
and  to  the  more  extreme  degrees  of  heat  and  cold. 
The  appreciation  of  these  stimuli  is  vague  and 
inexact  as  to  the  locality  of  the  spot  stimulated. 

sub-system  is  due  the  jjowcr  of  perceiving  and 
locating  light  touches  (cotton-wool),  of  discriminating  between  two  points  applied 
simultaneously  to  the  surface,  and  of  recognizing  the  finer  grades  of  temperature  called 
cool  and  warm. 

It  has  been  shown  that  w-hen  a  peripheral  eutuncoHS  7ierve  is  divided  the  area  of 
epicritic  loss  is  greater  than  that  of  protopathic  loss  ;  in  other  words,  there  is  more  over- 
lapping of  j)rotopathic  sensibility  than  of  epicritic 
sensibility  between  neighbouring  nerve  distributions. 
Thus,  if  the  ulnar  nerve  is  divided  near  the  wrist, 
there  is  complete  loss  to  touch,  superficial  pain, 
heat,  and  cold,  over  an  area  including  the  little 
finger  and  part  of  the  inner  edge  of  the  palm  of  the 
hand.  This  is  the  area  of  epicritic  and  ])rotopathic 
loss.  But  epicritic  loss  extends  over  a  wider  area 
which  includes  half  the  ring  finger  and  more  of  the 
hand  {Fig.  257).  In  this  area  of  epicritic  loss  pain 
can  be  recognized  but  cannot  be  localized  exactly, 
while  light  touch  is  not  appreciated,  and  the  dis- 
crimination between  cool  and  warm  is  absent. 

Consideration  of  the  above  points  shows  how  important  it  is  to  define  accurately  the 
exact  nature  of  any  sensory  loss,  and  to  be  careful  that  the  appreciation  of  pressure  is  not 
mistaken  for  the  appreciation  of  light  touch.  If  tactile  sensibility  is  tested  by  the 
observer's  finger  or  with  the  head  of  a  pin,  the  results  will  be  vitiated,  because  pressure 
sensibility  is  at  once  brought  into  action. 

Another  important  diagnostic  point  depends  on  the  fact  that  protopathic  sensibility 
returns  some  months  before  e])icritic  sensibility  in  the  process  of  regeneration  after  the 
division  of  a  peri])heral  nerve.     During  the  stage  of  protopathic  repair  there  is  often  a 


Fig.  "JSd. —  Peripheral  neuritis.  '  Glove  aiul 
stockii%'  aiijostbesiu.'  Cotton-wo'ol  and  pinprick 
sensibility  impaired  or  lost  over  the  dotted  areas. 
This  is  assoeiated  with  hyperalgesia  of^^^the  under- 
lying muscles. 


:!.   Kpieritic    Scnsihilitii.     To    this 


Fig.  25.'.— Division  of  ulnar  nerve  at  the  wrist. 
The  dark  area  represents  loss  of  epicritic  and  proto- 
pathic sensibility.  The  line  indicates  the  liniits_of 
epicriticjoss.    (Afler  Head  and  Sherren.) 


SKXSATIOX.     SOME     ABNORMALITIKS     OF 


607 


considerable  degree  of  hyperalgesia  in  the  affected  area  ;    that  is  to  say.  the  pain  iiroduecd 
by  a  pin-])riek  or  a  scratch  is  out  of  all  proportion  to  the  nature  of  the  stimulus. 

So  far  we  have  dealt  with  the  disturbance  of  sensibility  produced  by  the  disease  or 
injury  of  a  single  nerve.  In  the  disease  known  as  peripheral  ncnrilis  the  sensory  disturb- 
ances are  very  characteristic,  and  consist  of  pain,  tingling,  tenderness,  and  cutaneous 
ansesthesia.  Spontaneous  pain  in  the  limbs  is  often  com])lained  of.  but  more  important  is 
the  intense  suffering  produced  by  movements,  and  especially  by  handling  the  limbs  or  by 
squeezing  the  muscles.  At  the  same  time  cotton-wool  touch  is  often  unpcrceived  on  the 
peripheral  parts  of  the  lind)s.  particularly  in  what  are  known  as  the  glove  and  stocking 
areas.  This  combination  of  deep  liyperalgesia  and  cutaneous  ana-sthesia  constitutes  an 
important  differentiil  sign  between  ]jeri|)lieral  neuritis  and  tabes  dorsalis.  in  which  super- 
ficial and  dee])  analgesia  are  nearly  always  associated. 

Disturbances  of  Sensation  in  Lesions  of  the  Cord. — The  imiiulses  of  the  three 
peripheral  sub-systems — deep,  epicritic,  and  protopathic — combine  in  new  groups  soon 
after  they  enter  the  spinal  cord.     Some   impulses  cross  to 

the  ojjposite  side  immediately,  others  cross  after  running  a  -c  •      ^  a 

short   course  on  the  same  side,  and  others    ascend    to    the       ^  I  •=  ■=  ^       »  I 

upjier  extremity  of  the    cord  entirely  on  the   side  of  their       E^  ^aoj'*       "~ 

entry.     This     rearrangement     may    be    summarized    l)rielly       gj  ~^S3S       i~ 

thus  : — 

1.  Impulses  of  pain,  whether  excited  by  cutaneous 
stimuli  or  by  excessive  pressure,  run  together  in  the  spinal 
cord,  and  cross,  probably  soon,  to  the  opposite  side, 

2.  Impulses  of  temperature  of  fill  degrees  cross  to  the 
opposite  side  and  are  closely  associated,  but  not  intcr- 
niingled,  with  those  of  pain  :  the  impulses  of  heat  are 
also  separated  from  those  of  cold. 

8.  Impulses  excited  by  light  toueli  and  by  ])ressure. 
and  those  which  subserve  their  localization,  accompany 
each  other,  cross  to  the  op|josite  side,  probably  less  rapidly 
than  those  of  pain  and  tem|)eiature.  and  ascend  in  a  path 
which  is  distinct  from  that  of  the  latter. 

4.  Impulses  subserving  tlic  senses  of  passive  position 
and  movement  arc  associated  uitli  tliose  of  tactile  dis- 
crimination     (compass 

Pressure  and  its  localization 
Deep. 


1^? 


I  Pressure  and  it. 
J  lYessure  Pain-- 

'  tendons,  their  e 


(rat'dltr  Discriminaiii 


Epicritic.  -.Ltght  touch  and  its  localization. -"^ 

i  Temperatures  {2S°-£0°C-)  — 

J  Temperatures  {below  20" and  above  iS^C.) 
sjxiin. ■ 


■iuhe 


Central, 
(Sitinal  Chord) 


spinal  conl.      (Fi 


points)  in  their  ascent 
of  the  cord  on  the  .same 
side  as  their  entry. 
These  impulses  |)ass  up 
the  posterior  columns. 

'I'he  accompanying 
diagram  reprcsenis  tliis  Pro^opaf/iicJ^""^'^'^ 
rearrangement     of    iiii 
))Ulses  aixl   their  course 
in  the  spinal  cord.  /••»/.  'j.-.s. -Diu-r.i 

I  ni    (OKI   poHils  oi        .1/,  ,;,>,,„■,  vol.  vii.) 
praitieal  importance  in 

clinical  work  to  be  deducted  IVoni  Ibc  ;ilio\c  considerations  are  as  follows:  In  (he  lirsl 
place,  analgesia  resulting  from  a  cord  lesion  always  includes  deep  as  well  as  supeiTK-ial 
pain,  and  so  differs  from  the  analgesia  produced  by  a  peripheral  nerve  lesion  in  which,  as 
we  have  seen,  superlicial  analgesia  may  be  associated  with  deep  hyperalgesia.  Sei'on<lly, 
a  lesion  of  the  spinal  cord  may  abolish  the  appreeialion  of  thermal  stimuli,  but.  if  it  does 
so,  the  discrimination  between  all  degrees  of  heat  and  cold  will  be  lost.  This  again  dilfers 
I'rom  the  eHeet  of  some  peripheral  lesions.  In  the  third  place,  a  lesion  of  the  posterior 
cohnmis  niMV  produce  loss  of  the  sense  of  passive  position  and  mov'iniiil  without  any 
loss  of  tact  ilc.  paiid'ul.  or  Ihcrnial  stimuli,  a  eond)ination  wliieli  does  not  olilain  as  the 
result  (if  a  lesion  liinile<l  to  t  lie  peripheral  nervous  system. 

In  all  diseases  or  injuries  ol  the  spinal  cord,  the  (h'gree  of  sensory  loss  depends,  of  course 


608 


SENSATION,     SOME    ABNORMALITIES     OF 


upon  the  severity  of  the  lesion.  On  the  other  hand,  the  distribution  of  the  sensory  loss  is 
of  the  greatest  iniportanee  for  the  diagnosis  of  the  level  of  the  lesion.  The  distribution 
must  be  mapped  out  carefully,  and  then  compared  with  the  accompanying  diagram  (Plate 
XXV),  which  shows  the  sensory  areas  corresponding  to  the  different  spinal  segments. 

In  a  case  of  myeUtis,  for  instance,  it  may  be  found  that 
sensation  is  perfect  above  the  level  of  the  umbilicus,  and 
impaired  on  the  trunk  and  legs  below  that  level  (Fig.  "200).  We 
shall  be  justified  in  concluding  that  the  highest  point  of  the 
disease  corresponds  to  the  9th  dorsal  segment  of  the  cord. 
Take  another  example  :  fracture  dislocation  of  the  vertebrce  is 
common  in  the  cervical  region,  and  may  crush  the  spinal  cord 
at  the  level  of  the  7th  cervical  segment.  The  resulting  sensory 
loss  is  represented   in  the  accompanying  chart   (Fig.  261). 

In  testing  the  sensibility  of  the  skin  it  is  always  advisable 
to  work  from  the  aniesthetic  area  towards  the  normal,  and  to 
note  not  only  complete  anaesthesia,  but  all  modifications  of 
sensation.  For  instance,  bordering  on  the  region  of  complete 
ansesthesia  there  may  be  an  area  in  which  the  jjatient  is  able  to 
appreciate  a  touch  or  a  pin-prick,  but  in  which  he  describes  the 
sensation  produced  as  differing  from  the  natural  sensation 
elicited  by  these  stimuli.  Such  modifications  should  be  taken 
into  account  in  diagnosing  the  level  of  the  lesion. 

As  a  result  of  disease  or  injury  of  one  side  of  the  spinal 
cord,  a  symptom-complex  called  liroivn-Sequard  paralysis  is  met 
with.  This  is  discussed  on  p.  496.  Fig.  204  (p.  497),  illustrates 
the  sensory  loss  in  a  case  of  this  kind. 

Syringoniyelia  and  li(ematomyelia  are  other  conditions  in 
which  dissociative  anaesthesia  is  common  (Fig.  262).  In  the 
former  disease  thermo-aufcsthesia  and  analgesia  are  usually  found  first  in  the  arms  and 
thorax,  and  they  tend  to  spread  all  over  the  body.  In  rare  instances  they  begin  in  the 
legs  or  on  the  face.  Their  distribution  is  nearly  always  asymmetrical.  The  borders  of 
the  cutaneous  loss  are  not  sharj)  but  sliaded  off,  and  correspond  to  the  limits  of  spinal-root 


ited  frac- 
ture of  the  sac-rum,  witli  injury 
to  the  3rd,  4th,  and  5th  sacral 
roots.  Complete  loss  of  sensi- 
bility to  touch,  superficial  Jtain, 
heat  and  cold. 


0\\ 


::    \i> 


Fitj.  '_'(in. —  noi"sal  myelitis  affectuii?  the  cord 
a«  hi2:h  :is  the  9th  dorsal  segment.  Tlie  shaded 
parts  are  insensitive  to  touch,  deep  and  super- 
ficial pain,  and  all  degrees  of  temperature. 


Fi{_7.    '-^''.1 .— Fr.irtiire-ilislocatio] 
vical   spine.     The   shaded    area    represotits   the 
loss  of  sensibility  to  touch,  pain,  he:it  and  cold. 


areas.     On  the  other  hand,  charts  sometimes  show  regions  of  dissociative  aniesthesia  which| 
correspond  laterally  to  one  or  more  root  areas,  but  do  not  cover  their  longitudinal  extent. 
For  instance,  the  sensory  loss  in  one   hand  mav  be  limited  above  bv  a  line  encircling  the] 


PLATE     XXV. 


DIAGRAM       SHOWING       THE       RADICULAR       SENSORY      AREAS      OF 
THE       HUMAN       BODY 


Copyri'jhr 


Farqiihar  Bu:z< 


This  (llagi-am  has  been  compiled  by  the  writer  from  a  study  oE  ^irnihir  diagrams  published  by  others, 
and  modified  in  accordance  with  his  own  experience. 

Aithouph  the  various  areas  depicted  in  the  diagram  are  essentially  Root  Area?,  the  information  thoy 
supply  can  be  used  clinically  for  the  purpose  of  localizing  both  radicular  and  intramedullary  lesions.  It 
must  bo  remembered,  however,  that  the  deductions  in  the  one  case  are  dilTeroiit  from  those  in  the  other. 
My  for  instance,  the  character  of  the  sensory  change  in  one  of  those  areas  is  of  the  peripheral  tyjie,  a 
radicular  lesion  of  the  corresponding  seiL'mental  level  may  be  diaifnosed ;  if,  on  the  other  hand,  the  sensory 
loss  Ls  of  the  central  type  in  a  particular  skhi  area,  the  spinal  lesion  must  be  sought  at  a  level  several 
segments  hitrher  than  that  which  corresponds  to  the  sensory  area. 

Kor  pnictical  purposes  it  is  im])ortant  to  remember  that  the  ui)permost  level  of  sensory  change  (not  the 
upper  level  of  total  analgesia)  should  bo  conii)ared  with  the  nearest  corresporuiing  line  on  this  diagram. 

If  employed  with  an  intelligent  appreciation  of  these  points,  the  diagram  is  of  much  clinical  importancn, 
but  it  should  not  be  exploited  blindly  ns  a  mechanical  calculator.  Individual  variutions  alone  ai-.'  sulllcicnt 
lo  di'inand  a  considerable  margin  of  error. 


INDKX     or     IHACNOSIS     -To  face   p.   G08. 


SENSATION,     SOME    ABNORMALITIES    OF 


609 


forearm,  so  as  to  give  it  the  appearance  of  a  glove  distribution.  Similarly,  on  the  face  a 
central  area,  includinw  the  nose,  month,  and  eyes,  may  preserve  its  sensibility  intact,  while 
the  surrounding  regions  are  completely  insensitive  to  painful  and  thermal  stimuli.  Thermo- 
anaesthesia  and  analgesia  are  sometimes,  but  not  always,  co-extensive.  Tactile  loss  also 
occurs,  but  usually  supervenes  in  the  later  stages  of  the  disease.  Subjective  sensations 
may  form  the  initial  evidence  of  the  disease,  and  may  be  thermal,  painful,  or  tactile. 
Lancinating  pains  and  cramps  are  described.  More  curious  are  the  subjective  sensations 
of  drenching  sweat  in  a  part  which  is  dry,  or  of  cold  in  a  part  which  is  quite  normal  in 
temperature. 

In  tabes  dorstiUs  the  disturbances  of  sensation  are  numerous  and  characteristic.  Light- 
ning and  dull  boring  pains,  tingling,  numbness,  girdle  sensations,  and  various  painful 
crises  are  among  the  subjective  abnormalities.  Impairment  or  loss  of  deep  and  super- 
ficial pain  sensibility  in  various  parts  of  the  body  is  one  of  the  earliest  and  most  important 
physical  signs  for  the  purpose  of  diagnosis.  The  cutaneous  analgesia  is  generally  found 
on  the  legs,  and  often  also  in  the  root  areas  on  the  arms  and  thorax  corresponding  to  the 
C  8  to  D  5  segments  (Fig.  2(53).     Deep  analgesia  is  nearly  always  present  in  the  calf  muscles. 


Fig.  2H-i. — Syringomyelia.  The  sliaded  parts 
show  tlie  areas  of  dissociative  ariaisthesii,  i.e.,  of 
thermo-aruTwthesia  and  analgesia.  Tliiti  \va,s  associ- 
ated witii  atrophic  palsy  of  the  upper  extremities. 


Fig.  -HM. — Early  tabes  dorsalis.  The  dotted 
areas  represent  a  characteristic  distribution  of  sen- 
sory disturbance.  Tlie  loss  is  chielly  to  painful 
stimuli,  and  the  superficial  analgesia  is  almost 
always  associated  with  deep  analgesia. 


Superficial  nerves  such  as  the  ulnar  may  often  be  found  insensitive  to  rolling  or  pinching. 
Delayed  sensibility  is  another  phenomenon  very  characteristic  of  some  cases  of  tabes 
dorsalis.  lly penes! licsia  may  be  present,  especially  in  bands  around  the  abdomen,  when 
gastric  or  intcslinal  crises  form  part  of  the  clinical  picture.  Intolerance  of  hot  or  cold 
water  on  any  part  of  the  skin  is  descriljcd  by  sonic  jiaticnts  suffering  from  severe  forms  of 
the  disease.  .Vlloeliciria,  or  reference  of  a  sensory  stimulus  lo  llic  opposite  side  of  the  body, 
has  also  been  observed.  The  sense  of  position  and  movcmeni  is  nearly  always  disturbed 
in  locomotor  ataxy,  and  this  results  in  varying  degrees  of  inco-ordination  and  in  the  pro- 
duction of  Komlterg's  sign.  Astereognosis,  or  the  inability  to  gauge  iipproximately  the 
size  and  shape  of  objects  ])laeed  in  the  paticufs  hand,  is  another  common  sensory  defect. 

In  ilissciiiiiialfil  .sc/cTO.s/.v.  sensory  troubles  do  not  as  a  rule  constitute  so  prominent  a 
feature  as  do  the  motor  disabilities,  but  subjective  and  objective  changes  arc  by  no  means 
uncommon.  Numbness  of  one  limb  lasting  a  few  weeks  or  months,  girdle  sensations,  and 
even  pains  of  a  neuralgic  type,  arc  sometimes  complained  of.  I  have  known  transient 
hemianiestlicsia  to  be  an  initiid  symptom  in  one  case,  and  astereognosis  with  loss  of  sense 
of  position  on  one  side,  to  be  the  earliest  signs  of  disease  in  two  or  three  cases.  From  the 
diagnostic  st:indpoint  these  are  important  facts,  because  it  is  very  tempting  to  assume, 
erroneously,  that   siicli  sensory  |ilienomena,  occurring  alone  without   any  reflex  or  motor 

D  39 


610 


SENSATION.     SOME    ABNORMALITIES    OF 


signs  of  organic  disease,  are  hysterical  in  origin.     Tliey  are  doubtless  due  to  patches  of 
disease  near  the  internal  capsule. 

This  brings  us  to  the  consideration  of  the  Abnormalities  of  Sensation  resulting  from 
Disease  of  the  Higher  Parts  of  the  Nervous  System.  Ileiniaiia'Sthesia  is  a  common 
result  of  the  \arious  vascular  accidents  responsible  for  apoplexy  and  hemiplegia.  It  may 
be  present  with  or  without  motor  paralysis  and  with  or  without  heniianopia  ;  sometimes 
all  three  |)henomena  are  associated  in  the  case  of  severe  lesions  of  the  internal  capsule 
and  optic  radiations.  In  most  cases  of  apoplexy  hemiansesthesia  is  slight  and  transient. 
Tactile  and  pain  sensibility  may  be  impaired,  usually  more  so  on  the  limbs  than  on  the 
trunk,  and  more  especially  in  the  distal  portions  of  the  arm  and  leg.  Even  when  touches 
are  perceived  they  are  localized  badly  by  the  patient.  In  lesions  of  the  optie  thaUimiis  the 
opposite  side  of  the  body  may  be  the  site  of  a  curious  sensory  disturbance  which  consists 
in  part  of  a  lowered  sensibility  to  painful  stimuli  and  in  part  of  a  great  exaggeration  of  the 
disagreeable  effects  produced  by  such  stimuli  when  they  are  perceived.  For  instance,  the 
patient  may  fail  to  recognize  a  light  pin-prick  so  well  on  the  affected  as  on  the  sound  side, 
but  a  scratch  may  produce  an  intensely  painful  sensation  referred  to  a  very  wide  area  and 

not  localized  to  the  spot  stimulated.  In  such 
cases  the  patient  often  complains  also  of  parox- 
ysms of  severe  pain  in  the  affected  limbs. 

The  heminncestliesia  of  hysteria  is  usually  far 
more  complete  to  all  forms  of  stimulation  than 
any  hemianaesthesia  due  to  organic  disease  of  the 
brain.  The  hysterical  patient  is  foimd  to  have 
lost  taste,  smell,  and  sometimes  even  hearing,  on 
the  ana\sthetic  side.  The  visual  defect,  instead  of 
being  hemianopic  as  in  the  organic  cases,  is 
generally  a  marked  contraction  of  the  visual  fields, 
sometimes  amounting  to  blindness,  especially  in 
the  eye  corresponding  to  the  other  sensory  defects. 
Lesions  of  the  brain-stem  may  also  be  re- 
sponsible for  extensive  loss  of  sensation.  For 
instance,  thrombosis  of  the  posterior  inferior 
cerebellar  artery  gives  rise  to  a  localized  softening 
on  one  side  of  the  medulla,  which  produces 
thermo-anaesthesia  and  analgesia  on  the  same  side 
of  the  face,  and  on  the  trunk  and  limbs  of  the 
opposite  side  (Fig.  •2iil).  This  sensory  disturb- 
ance is  sometimes  complicated  by  homolateral 
cerebellar  ataxy  and  cranial  nerve  palsies. 
So  far  we  have  dealt  chiefly  with  the  various  forms  of  lowered  sensibility,  and  ha\e 
given  little  attention  to  perversions  of  sensation,  such  as  are  indicated  by  the  terms  hyper- 
cesthesia  and  j^arcvstliesia. 

Hypercesthesia  is  observed  in  cases  of  tabes  dorsalis  and  i)eri])heral  nerve  lesions  as 
described  above,  but  it  is  also  met  with  in  other  conditions  of  organic  as  well  as  functional 
disease.  It  is  found,  for  instance,  in  root  areas  in  cases  of  vertebral  and  intravertebral 
disease.  In  spinal  earies  and  in  tumours  of  the  spinal  meninges,  a  zone  of  hypenesthesia 
may  be  detected  just  above  the  area  of  anaesthesia  produced  by  the  compression  of  the 
cord,  or  it  may  precede  the  appearance  of  compression  signs.  The  increased  sensibility  is 
probably  caused  by  pressure  on,  or  irritation  of,  the  jjosterior  root  fibres.  A  similar 
phenomenon  is  a  frequent  accompaniment  and  sequel  of  an  attack  of  lierpes  zoster. 
The  shape  and  situation  of  such  hyperaesthetic  zones  afford  a  clue  to  the  site  of  the  lesion. 
Hyperaesthesia  as  well  as  paraesthesia  are  among  the  earliest  signs  of  subacute  combined 
degeneration  of  the  cord,  and  are  referred  by  the  patient  to  peripheral.parts  of  his  four  extre- 
mities. They  may  precede  by  many  weeks  or  months  the  appearance  of  ataxic  or  spastic 
paraplegia  and  definite  areas  of  sensory  loss.  Similar  symptoms  are  also  complained  of  in 
not  a  few  cases  of  pernicious  anaemia  and  other  severe  blood  diseases,  probably  on  account 
of  scattered  degenerations  in  the  nervous  system  as  the  result  of  the  An.emi.v  (p.  '20). 

Neurasthenic  and  hysterical  states  are  responsible  for  hyperaesthetic  areas  which  ha\e 


Fig.  2fi4.— Thrombosis  of  left  postei 
cerebellar  artery.  The  dotted  areas 
regions    of    dissociative    anesthesia, 


or    inferior 

show    the 

loss    of 


iibility  to  pain  and  temperature  of  all  degrees. 


PLATE     XXVJ. 


SORE       THROATS 


I,  OrJiniiry  liyiicr.cmic  sore  tliroat.      M.  Milil  (ollicular  tonsillilb.      III.  Scvrcrer  fullicul  ir    tuM^illili! 
IV.  LcIt-3iUcd  qulnsi".     v.  Syphilitic  sore  tlirout. 


ISDKX     Ol'     DIAONOSIS  — y«  /arr  p.   ClU. 


SKODAIC     RESOXANCE  611 

no  relation  to  central  or  periplieral  innervation.  In  neurasthenia,  especially  the  traumatic 
variety,  the  patches  are  usually  found  on  and  around  the  spine  and  over  the  scalp.  In 
hysterica!  conditions  similar  patches  may  be  detected  in  the  mammary  and  ovarian  regions. 

Hyperresthesia  in  connection  with  viscernl  disense  has  been  referred  to  in  other  articles, 
such  as  those  on  Pain  ix  the  Face  (p.  446)  ;    Paix  in  the  Uppeh  Extremity  (p.  442) ;  etc. 

A  very  special  peculiarity  of  sensation,  known  as  Magnan's  sign,  is  met  with  in  sufferers 
from  the  cocaine  habit  ;  it  consists  in  a  subjective  feeling  as  of  multiple  small  worms  cree])ing 
about  under  the  skin,  though  in  some  cases  the  iiatient  compares  his  sensation  to  tliat  of  fine 
sand  under  his  skin.  e.  Farqiilinr  Buzzard. 

SHIVERING    FITS.— (See  Kigors.   p.  594.) 

SHORTNESS    OF    BREATH.— (See  Breath,  Shortness  of,  p.  87.) 

SKIN  ERUPTIONS.     (.See  .-Macules,  p.  382  ;   Papules,  p.  487.  Etc.) 

SKIN,    PIGMENTATION  OF.--(See  Pigment.vtion  of  the  Skin,  |).   527.) 

SKODAIC  RESONANCE.— When  there  is  a  basal  and  unilateral  pleuritic  effusion 
of  medium  degree,  the  pitch  of  the  percussion  note  over  the  upper  part  of  the  thorax  in 
front  is  often  higher  on  that  side  of  the  chest  on  which  the  effusion  is  than  on  the  other.  It 
is  not  a  question  either  of  impairment  of  resonance  or  of  hyper-resonance,  but  merely  of 
pitch.  This  higher  pitch  of  the  jiercussion  note  over  the  upper  lobe,  when  the  lower  lobe 
is  compressed  by  an  effusion,  is  named  "  .Skodaic  resonance."  after  the  observer  who  first 
drew  attention  to  it.  Its  importance  is  mainly  twofold  :  in  the  first  place  it  does  not  indi- 
cate disease  of  that  part  of  the  lung  which  affords  the  sign — for  instance,  the  fact  that,  in 
a  case  of  right-sided  effusion,  the  right  upper  lobe  gives  a  higher-pitched  percussion  note 
than  does  the  left  cannot  be  taken  as  evidence  that  there  is  a  lesion,  perhaps  tuljerculoiis, 
at  the  right  apex  ;  in  the  second  iilace,  it  is  erroneous  to  suppose  that  skodaie  resonance  is 
obtained  <jnly  in  cases  of  effusion  ;  its  occurrence  cannot  be  taken  as  proof  that  dullness  at 
the  base  is  due  to  fluid  there.  It  is  true  that  pleural  effusion  gives  it  not  only  in  most 
marked  degree,  but  also  most  commonly  ;  nevertheless  it  may  also  be  observed  in  some 
cases  of  btisdl  pneiiiiinnid  without  effusion,  or  as  the  result  of  compression  of  a  lower  lobe 
by  such  causes  as  subilitijihrafiiiifilie  or  Iwpatic  fibscess,  hepatic  masses  such  as  carcinoma, 
gumma  or  lii/iliilitl  ri/st,  f>reat  enlargements  of  the  spleen  such  as  occur  in  leukaemia,  a  big 
heart,  a  peril nrdiiil  effusion,  or  a  niediiistinal  or  jiulnioniir!/  nezv  groivlh. 

The  cause  of  skodaic  resonance  has  never  been  (piite  decided,  and  many  theories  have 
been  propounded  about  it  :  clinically,  the  most  serviceable  view  is  that  anything  that 
lessens  the  degree  to  which  the  upper  lobe  is  stretched,  yet  without  actually  compressing 
it.  may  ])rodiiee  a  rise  in  the  pitch  of  its  percussion  note.  Hilateral  com|)ression  of  the 
bases  of  the  lungs  by  such  lesions  as  ascites,  presumably  causes  bilateral  Skodaic 
resonance,  but  this  is  dillieult  to  determine,  because  the  latter  is  recognizable  only  when 
there  is  a  difference  of  pitch  between  the  two  sides. 

Skodaic  resonance  over  an  upper  lobe  when  there  is  some  lesion  affecting  the  lower 
lobe  on  the  same  side,  should  not  be  confused  with  the  tympanic  note  that  may  sometimes 
be  heard  over  the  other  parts  of  the  thorax.  Stomach  tympany  is  heard  normally  external 
to  and  below  the  precordial  region  over  an  area  known  as  Traube's  space,  which  is  bounded 
above  by  the  precordial  dullness,  behind  by  the  splenic  dullness,  and  below  l)y  the  rib 
margin.  When  the  stomach  is  dilated  there  may  be  an  abiKunial  extent  of  this  gastric 
tympany  in  the  thorax.  When  the  transverse  colon  is  distended  with  gas,  or  when  it  is 
pushed  upwards  by  something  intra-abdominal,  it  may  produce  abnormal  areas  of  thoracic 
tympany,  particularly  in  the  lower  steriud  region  or  on  eilher  side  of  this.  Such  condi- 
tions can  scarcely  be  mistaken  for  skodaic  resonance,  for  Die  latter  concerns  the  upper 
lobe,  and  is  not  a  delinile  tympany,  but  ratlicr  a  moderate  rise  in  the  pitch  of  the  (udinary 
percussion  note,  not  as  a  rule  obvious  till  llie  Iwo  sides  are  eonlrasled.  llcrl>i-rl  Frenrb. 

SLEEPLESSNESS.     (S.-e  issoNrsiA,  p.  :!2().) 

SMELL,  ABNORMALITIES  OF.  .Ahnormalilies  of  Ihe  sense  of  smell  fall  into 
three  main  categories,  namely:  -(1)   'I'oo  lirenl  seusilivi'ness  to  smells  -.vhieli  nrluidhi  exist. 


612  SMELL,     ABNORMALITIES    OF 

(2)  Deficient  sensitiveness  to  smells  xvhich  actuaUi)  exist  ;  (3)  Subjective  sensations  of 
smells  which  do  not  exist. 

Too  great  sensitiveness  to  existing  smells  is  sometimes  a  nuisance  to  tiie  individual, 
but  is  seldom  a  sign  of  disease.  There  are  great  differences  in  the  powers  of  perception 
of  different  sensations  in  different  persons,  and  just  as  some  can  ajjpreciate  very  slight 
differences  in  soimds  more  than  others,  so  can  some  detect  smells  that  are  indiscernible 
by  others.     This  is  natural  idiosyncrasy. 

Deficient  sensitiveness  to  actual  smells  is  often  but  the  obverse  of  the  above,  and 
no  sign  of  disease,  although  it  may  be  a  detriment  to  the  individual,  especially  in  certain 
commercial  pursuits  in  which  the  varying  qualities  of  products  are  judged  partly  by  smell. 
When  the  power  of  smell,  having  been  normal,  becomes  deficient  or  totally  absent,  the 
change  may  affect  one  nostril  only,  or  both.  The  condition  may  be  transient  or  persis- 
tent. The  commonest  cause  of  transient  anosmia  is  acute  nasal  catarrh,  whether  the  result 
of  an  ordinary  cold,  or  of  other  affections  such  as  hay  fever  (coryza  e  feno),  oncoming 
measles,  or  the  effects  of  drugs  such  as  iodide  of  potassium  or  arsenic. 

Persistent  anosmia  may  be  due  to  : — 

(a).  IriabilUjj  to  get  air  freely,  or  at  all,  through  the  nostril,  as  the  result  of  : — 

Adenoids  Hypertrophic  rhinitis 

Polypi  Syphilis 

Disiocated  nasal  septum  Necrosis  of  bones  in  the  nares 

Nasal  septal  spur  I       Occluded  anterior  or  posterior  nares. 

(b).  Alteration  in    the    olfactory    mucous    membrane,  so    that    it    no    longer    transmits 
impulses  to  the  endings  of  the  olfactory  nerve,  although  the  airway  is  free  : — 

Atrophic  rhinitis  j        Paralysis  of  the  fifth  nerve,  leading  to 

I  undue  dryness  of  the  mucosa. 

(c).  Abnormalities  of  the  olfactory  nerves. 

Congenital  absence  noxious  vapours,  ammonia,  or  snuff ; 

Hydrocephalus  or  part  of  a  general  peripheral  neuritis 

Olfactory   neuritis,   either   the   result   of  !  Post-influenzal  changes, 
overstimulaticn      locally      by      strong 

(d.  Cranial  lesions,  especially  haemorrhage,  thrombosis,   embolism,   softening,   injury, 

or  tumour  of  the  uncinate  gyrus,  which  is  the  centre  for  smell, 
(e).  General  nerve  diseases,  especially  : — 

General  paralysis  of  the  insane  [      Tabes  dorsalis 

(/■).  Hysteria. 

There  is  little  need  to  discuss  the  above  table  in  detail,  for  each  heading  speaks  for 
itself.  When  a  case  is  being  investigated,  the  history  is  very  important  :  it  is  next  neces- 
sary to  examine  the  nose  carefully  through  a  speculimi,  and  to  test  the  air-way  through 
each  nostril  ;  if  there  is  any  local  lesion  it  will  generally  be  obvious,  and  only  after  local 
affections  have  been  excluded  should  conditions  in  groups  c,  d,  e,  and  f  be  discussed. 
Anosmia  will  seldom  if  ever  be  a  prominent  symptom,  except  in  connection  with  local 
affections  of  the  nose  ;  when  due  to  any  other  cause  there  will  nearly  always  be  some 
other  symptoms  which  will  attract  attention  more  than  the  anosmia  itself. 

Subjective  sensations  of  smells  whicb  do  not  exist  externally  may  be  due  to  : — 
(a).  Offensive  or  purulent  inflammations  of  the  nose  or  of  the  air-cells  communicating 
with  it,  especially  empyema  of  the  antrum  of  Highmore,  or  of  a  frontal  sinus. 
(b).  Local  thickening  of  the  meninges,  tumour  of  the  brain,  or  interference  with  the 

vascular  sup])ly,  causing  irritation  of  the  hippocampal  region. 
(c).  An  aura  preceding  an  epileptic  seizure, 
(rf).  Hysteria. 
(e).   Insanity. 
In  arriving   at  a  diagnosis,  it   is    chiefly   important   to    exclude  purulent    affections 
discharging  into  the  nose  ;    if  it   is   possible   to   state   with    certainty    that   the  abnormal 
sensations  have  no  such  organic  basis,  it  is  not  difficult  as  a  rule  to   decide  between  the 


PLATE     XXill. 


SORE       TH  ROATS 


'\-...y 


VI.  .VlliJ  diphthcrin,  simulnting  folliculiir  lorislilitls.      VII.  Diplitlieritic  sore  (liroat,  o(  medium  severity. 

VIII.  Diphtheritic  8orc  Ihrofit  of  severe  type,   showirijj  spread    of   tlio    moinbrnltous   e.\udule    to    the   j)iilato. 

IX.  I'hlet'monous  diphllicriii.     X.   Vincent's  iinu-inii. 

IN'IIK.V     OF     DIAIiXOSIS— rn  fiirf  /..  111'.'. 


SORE    THROAT 


613 


other  causes.  It  is  a  curious  fact  that  subjective  abnormalities  of  smell  are  apt  to  be 
associated  with  delusional  insanity  concerning  the  genital  organs,  in  which  the  prognosis 
is  not  free  from  acute  dangers.  Ilerberl  French. 

SNORING  may  be  a  very  troublesome  symptom  in  some  patients,  particularly  to 
those  who  have  to  sleep  in  the  same  room  with  them  ;  but  it  is  often  less  an  indication  of 
disease  than  niercly  a  bad  habit.  Most  snorers  sleep  with  their  mouths  ojjen,  and  breathe 
partly  through  the  nose  and  partly  through  the  mouth  ;  but  it  is  possible  for  snoring  to 
occur  with  the  mouth  completely  shut,  and  nothing  the  matter  with  the  nasal  ])assages. 
The  tendency  is  increased,  however,  by  any  obstruction  of  the  nasal  airway,  so  that 
particular  examination  should  be  made  for  such  lesions  as  undue  smallness  of  the  nares 
or  a  tendency  for  the  soft  parts  of  the  nostrils  to  collapse  on  inspiration,  deflected 
septum,  hypertrophic  rhinitis,  polypi,  adenoids,  acute  or  chronic  nasal  catarrh,  inflamma- 
tion of  the  accessory  sinuses  or  of  the  pharyngeal  tonsils,  or  even  a  fibrosarcoma  or  other 
neoplasm  of  the  nasopharynx.  Herbert  French. 


SORE   THROATmay  be  due  to  one  or  other  of  many  different  causes  :- 
1.  Affections  of  the  Tonsils  : — 

Quinsy. 

Acute  Tonsillitis. 

(a).  With  reddening  and  swelling  only  : 
Acute  inflammation  due  to  various 

micro-organisms,    especially    to 

streptococci  ;        staphylocofci  ; 

pneumocoeci  ;      pneuniobaeilli  ; 

diphtheria   bacilli  ;     Hofmann's 

bacilli  :     Vincent's   spirilla  and 

fusiform    bacilli  ;        spirocliicta 

(treponema)  pallida  ;  micrococci 

catarrhales  ;     bacilli   influenza'  ; 

tubercle     bacilli.       The    sore 

throats  of  scarlet   fever,    rheu- 
matic   fever,    German    measles, 

and  measles   are   probably   not 

due  to  specific  micro-organisms, 

but   to   streptococci,  or   others 

of  the  bacteria  just  enumerated. 


(0- 


(b).   With  redness,  swelling,  and  exuda- 
tion : 
Follicular  tonsillitis  due  to  strepto- 
cocci, etc.,  as  above 
Diphtheria 
Vincent's  angina 
Syphilis 

Kirkland's  disease,  or  epidemic  cer- 
vical adenitis. 
With  ulceration  : 
Phlegmonous     tonsillitis     due     to 

streptococci,  etc.,  as  above 
Syphilis 

Vincent's  angina. 
Chronic  Affections  of  the  Tonsils  : — ■ 

Recurrent   inflammation   often   associ- 
ated with  adenoids,  or  tonsillar  hy- 
pertrophy, especially  in  children 
Primary  or  secondary  syphilis 
Vincent's  angina  |lioma) 

Squamous-celled      carcinoma     (epithe- 
.Sarcoma  (Junima         Tubercle. 


2.  Inflammation  of  the  Soft  Palate,  Uvula,  and  Fauces  : — 


Catarrh,  occurring  either  by  itself  or 
associated  with  any  of  the  varieties 
111'  loiisillitis  cnunierated  above 

;j.  Affections  of  the  Pharynx  : — 

Acute  catarilial  phaivMgitis  due  ti>  any 
1)1'  tlic  niicrd-iiiganiMus  nicnliiincil 
under  the  heading  iil' acute  toiisillltis 

C'lirimlc  granular  pharyngitis*  due  to 
smoking  in  excess  ;  or  to  over-use, 
as  ui  clergvMian's.  cnstermongcr's,  or 
slciikl)rok('-r's   sore   Ihniaf 


Gumma 

Squamous-eelled  eareuKinia 
Tubercle. 


.Scpiamous-cclled     carcinoni; 

pharynx 
I'ost-pharyngeal  abscess 
Varieilla  " 
Nariola. 


•i.  Laryngeal  Conditions,  especially  :^ 

,\cutc  catarrhal   laryngitis  due  to  any  Carcinoma  laryngitis 

of  the  organisms     mentioned   abo%'e  Acute   perichondritis  of  the  arytenoid 

Trdierculous   laryngitis  thyroid,  or  erieoiil  cartilages. 

.Sy|ihililie   laryngitis 

r>.  Sore  Throats  the  result  of  the  Swallowing  or  Inhalation  of  Irritants  : 

Corrosives,    such    as   alkalies   or   strong  Arnnionia   vapour,  eliloririe   I'lunes 

acids  Mot   steam. 

(>.  Mumps. 

7.  Acute  and  Subacute  Adenitis  of  the  lymphalic  glands  in  the  neck. 


614  SORE    THROAT 

Notwithstanding  the  length  of  the  above  list  the  differential  diagnosis  of  a  sore  throat 
in  practice  is  not  difficult  as  a  rule.  Inquiry  into  the  history  and  inspection  of  the  parts 
locally  in  a  good  light  will  generally  serve  to  give  one  a  shrewd  notion  of  the  nature  of  the 
coni])laint.  The  chief  ]3oint  in  jiractice  is  to  determine  as  soon  as  possible  whether  the 
Klebs-Loffler  bacilli  of  diphtheria  are  present  or  not,  for  it  has  been  established  that  there 
is  no  kind  of  sore  throat  which  can  be  recognized  clinically  as  non-diphtheritic.  It  is  impor- 
tant that  swabbings  should  be  taken  from  the  inflamed  parts  and  examined  by  a  bacterio- 
logist both  directly  in  films  stained  by  Neisser's  method  or  one  of  its  modifications,  and  by 
means  of  cultures.  Similar  bacteriological  investigations  will  serve  to  determine  which  of 
the  organisms  mentioned  above  is  responsible  for  an  acute  or  follicular  or  ulcerative  sore 
throat  other  than  diphtheritic,  it  being  borne  in  mind,  however,  that  the  organism  should 
be  foimd  in  fairly  pure  cultures  if  it  is  to  be  regarded  as  causative  and  not  merely  as  a 
secondary  or  even  casual  infection. 

Affections  of  the  Tonsils. 

Qiiinsi/  is  practically  always  asynuuetrical,  one  tonsil  being  very  nuich  more  bulged 
than  the  other  ;  the  surface  is  reddened,  generally  without  follicular  suppuration,  and  the 
diagnosis  is  ultimately  confirmed  by  the  bursting  of  the  abscess. 

The  presence  of  Klebs-Loffler  bacilli  in  association  with  a  sore  throat  may  be  regarded 
as  conclusive  proof  that  the  lesion  is  (liphllicria.  even  though  there  may  be  no  typical  diph- 
theritic exudate.  Diphtheria  having  been  excluded,  the  diagnosis  of  one  of  the  other 
varieties  of  acute  tonsillitis  is  rendered  ])ossible.  The  frequency  with  which  acute  rheuma- 
tism is  associated  with  recurrent  tonsillitis,  especially  in  young  people  between  the  ages  of 
five  and  twenty,  shoidd  always  be  borne  in  mind  ;  the  patient  may  or  may  not  ha\'e 
suffered  from  other  effects  of  acute  rheumatism,  such  as  joint  pains,  endocarditis  (evidenced 
by  tile  bruits),  pericarditis,  iileurisy,  erythema  nodosum,  chorea  :  or  a  history  of  such 
rheumatic  affections  may  be  obtained  in  other  memfjers  of  the  same  family.  The  tonsilhtis 
is  benefited  by  sodium  salicylate,  but  by  no  means  to  the  same  extent  as  are  the  joint 
pains,  so  that  the  effect  of  treatment  is  not  by  itself  conclusive  evidence  of  the  nature  of 
the  complaint. 

\Vhen  acute  rheumatism  gives  rise  simultaneously  to  generalized  erythema  and  to 
tonsillitis,  there  will  be  very  considerable  difficulty  in  excluding  scarlet  fever,  especially  if 
there  has  been  considerable  nausea  or  actual  vomiting  :  in  some  such  cases  the  diagnosis 
will  be  one  of  opinion  only  :  that  which  was  regarded  at  first  as  acute  rheiuiiatic  tonsillitis 
and  erythema  may  prove  to  have  been  scarlatina  after  all,  should  the  jiatient  presently 
develop  acute  nephritis,  or  if  other  members  of  the  family  dexelop  typical  scarlatina  ; 
the  occurrence  of  extensive  iieeling  of  the  skin  is  not  conclusive  evidence  of  scarlatinal 
erythema  and  sore  throat.  If  the  patient  is  known  to  have  had  scarlet  fever  formerly, 
the  rheumatic  natiu'c  of  the  case  is  more  likely. 

FoUicnlar  tonsillitis  is  not  a  final  diagnosis,  for  it  may  be  due  to  various  different 
micro-organisms,  and  there  is  no  doubt  that  the  diphtheria  bacillus  may  produce  that 
which  to  ins])ection  ])rcsents  nniltiple  foci  of  j)us  in  the  different  tonsillar  crypts  formerly 
regarded  as  characteristic  of  follicular  as  distinct  from  diphtheritic  tonsillitis.  The  only 
conclusive  jjroof  that  a  com])aratively  simple  follicular  tonsillitis  is  not  diphtheritic  is 
bacteriological  examination.  If  clinical  points  alone  have  to  be  relied  on,  one  would  say 
that  the  higher  the  temperature,  the  greater  the  constitutional  disturbances,  and  the  more 
sudden  the  onset,  the  more  likely  is  it  not  to  be  diphtheria. 

i'incent's  angina  has  been  differentiated  bacteriologically,  cases  of  this  kind  having 
formerly  been  regarded  either  as  diphtheria  or  as  follicular  tonsillitis.  The  characteristic 
micro-organisms  present  are  elongated  fusiform  bacilli  symbiotic  with  spirilla  (Plate 
XXVIII,  Fig.  M).  The  disease  is,  as  a  rule,  more  resistant  to  treatment  than  are  other 
forms  of  acute  sore  throat,  .so  that  what  has  originally  been  a  tonsillitis  with  exudation 
presently  becomes  an  ulceration  associated  with  remarkable  foetor  of  the  breath,  but 
without  that  tendency  to  fatal  termination  presented  by  most  other  varieties  of  acute 
idcerative  or  phlegmonous  sore  throat.  The  disease  cannot  be  recognized  without  the 
aid  of  the  bacteriologist. 

Syphilis  may  cause 'acute  soreness  of  the  throat  in  its  secondary  stages,  and  unless 
that  possibility  is  borne  in  mind,  one  may  diagnose  as  acute  simple  or  acute  follicular  ton- 
sillitis that  which  is  really  syphilitic.     There  is  more  or  less  pyrexia,  and  in  most  cases 


PLATE     XXJIII 


BACTERIA,      AND      BLOOD      PARASITES 
As  spen  under  the  ,^tli-inch  oil-immersion  lens. 


A,  Miiliiriii,  early  rint?  form;    B.  Mahiriii,  ordinary  ring  form;    C,  Mai; 
roadv'tosporulate;    g,  Malaria,  crcscciitic;    F,    Filaria  embryo ;    G.    I'ryii 
bodies,  olilaincd  by  siilonie  laincturc ;    I.  Spirocluuta  Obcrmoieri  of  rclapsinw  fever; 
K    Tubercle  bacilli  and  pus  cells;    L.  Diplitberia  bacilli:    M.  Vincent's  angina,  Spirill: 


goco 
ccIIh;    R. 


.thin  a  le 


icytc; 


{Thr  tttaijniflmthn  oj  F  ttn'l  S 

111'      l>IAi:.V()i'I»— '/'(I   /nrr  /'.    I'll  I 


1  pus  cells;    P,  Staphylococci  and  II 
S,  Aciinoniyccs;    T.  Tetanus  bac 


nni'li  Irm  than  that  of  the  remaimter ;  the  rrhtii 
1/  the  relative  sizeg  of  the  white  corpiiitclen.) 


Jt.  Ford,  del. 


.... .  tertain;  D.  Malaria,  tertnin, 
mbionse;  H.  Lei-ilmiann-tlonovjin 
J  Splroehirta  pallida  of  syphilis; 
I  lirul  Fusiform  bacilli:  N.  Menin- 
lus  cells  ;  Q,  Streptococci  ami  pus 
illi. 


SORE    THROAT 


615 


there  will  be  tenderness  of  the  sealp  and  <)f  the  bones,  together  with  the  well-known 
roseolous  eruption  upon  the  skin  and  the  '  snail-track  '  ulcers  upon  the  pharynx.  The 
diagnosis  may  be  more  dilficult  in  women  than  in  men,  for  in  the  latter  the  remains  of  the 
chancre  may  still  be  obvious.  Wassermann's  serum  test  may  assist  materially  in  the 
diagnosis  of  doubtful  cases. 

Chrnnic  affections  of  the  tonsils  in  children  are  nearly  always  the  result  of  recurrent 
acute  attacks  of  non-diphtheritic  tonsillitis,  generally  in  association  with  adenoids,  both 
affections  arising  from  the  hal)it  of  mouth  breathing.  Inspection  of  the  bulging  hyper- 
trophied  tonsils,  with  or  without  digital  examination  of  the  posterior  nasal  fossae,  will 
indicate  the  diagnosis.  In  an  older  person,  simple  hypertroplw  from  recurrent  tonsillitis 
becomes  progressively  less  common.  Chronic  tonsillitis  in  a  young  adult  may  be  di|jh- 
theritic,  syphilitic,  or  due  to  Vincent's  angina,  the  diagnosis  between  these  being  arrived 
at  in  the  way  described  above.  It  may  be  mentioned  that  in  very  rare  instances  an  actual 
chancre  appears  ujjon  one  tonsil,  giving  rise,  unless  secondary  symptoms  are  present,  to 
much  dilTiculty  in  diagnosis  until  the  case  has  been  watched.  Malignant  disease  of  the 
tonsils,  whether  squomous-celled  carcinoma,  or  sarcoma,  is  fortunately  not  very  common  ; 
when  it  does  develop,  its  comparatively  non-acute  course  and  its  unilateral  distribution 
with  progressive  ulceration  of  the  central  parts  and  overgrowth  of  the  edges  of  the  neo- 
plasm will  point  to  the  diagnosis.  A  gumma  of  the  tonsil  is  rare,  but  may  at  first  simulate 
squamous-celled  carcinoma  :  in  case  of  doubt  a  small  portion  of  the  suspicious  mass 
might  be  excised,  and  examined  microscopically  ;  or  if  operative  measures  were  not  to  be 
adopted  at  once,  potassiiun  iodide  or  salvarsan  might  be  administered,  and  the  lesion  would 
be  shown  to  be  gummatous  if  it  were  thereby  relieved  or  cured.  Tuberculous  ulceration  of 
the  tonsils  is  imcommon,  practically  never  primary,  but  nearly  always  preceded  by  both 
phthisis  and  tuberculosis  of  the  larynx.  The  diagnosis  will  be  indicated  by  the  discovery 
of  tubercle  bacilli  in  the  sputvun.  though  it  should  not  be  forgotten  that  carcinoma  or 
guiHina  niighi   affect  the  lonsil  in  a  person  wlu)  has  phthisis. 

Inflammation  of  the  Soft  Palate,  Uvula,  and  Fauces. 

This  may  be  seen  in  many  cases  of  common  cold  ;  in  association  with  acute  rheuma- 
lisin  ;  in  persons  who  have  recently  returned  to  town  from  a  holiday  ;  in  patients  who  have 
been  subjected  to  the  influence  of  motor-car  dust  stirred  up  from  the  roads  after  the  latter 
have  been  dry  for  about  three  days — a 
longer  period  of  dryness  seems  to  lead 
to  relative  tlisinfection  of  the  dust, 
wliilst  rain  keeps  the  dust  from  rising, 
so  that  either  continuance  of  fine 
weather  or  a  return  to  wet  leads  to  a 
disappearance  of  the  sore  throats :  or 
in  those  who  are  suljjectcd  to  the 
iiilluencc  of  relatively  concentrated 
microbes,  as  in  the  air  of  old-fashioned 
hospital  wards,  of  ill-vcntilaterl  much- 
inhabited  rooms,  of  sewers,  and  the 
like.  Often  a  rim  of  acute  reddening  is 
to  be  seen  all  along  the  edge  of  the 
anterior  pillars  of  the  fauces,  and 
affecting  nuich  of  the  uvula  and  of  the 
soft  palate,  proilucing,  as  a  rule,  but 
little  pyrexia,  though  much  discomfort 
in    swallowing,   and    a   raspy   feeling  at 

the  back  of  the  mouth  on  lirst  waking  in  the  morning.  This  inllammation  of  the  palate 
and  fauces  may  or  may  not  be  associiited  with  tonsillitis,  pharyngitis,  or  laryngitis  ;  it 
is  clearly  microbial  ;  and  doubtless  more  than  one  of  the  varieties  of  bacteria  mentioneil 
above  may  produce  the  lesion.  The  diagnosis  of  the  fact  of  inllammation  is  obvious  on 
inspection  :  lliat  uf  the  naturr  of  llic  micni-drgaiiisiii  rc(|uires  skilli'd  bacteriological 
assistance. 

During  llic  last  few  years  a  new  and  <'()iimi<in  disease,  epidiiiiic  in  <'liai-act(r.  and  with 
acute    sore    throat,    fever,    and    cnlargenient    ol    the    upper    ccrN  ieal     glands    as    its    main 


Fill.  "I'< 

dwcnse  in  whic-li  the  sore  throat  a 
were  more  pronounced  than  the  cerv 
case  the  t^mjierature  l-ist.4  le^d  than  j 


severe  case  of  Kirkhind's 
(I  constitutional  symptoms 
'al  adenitis.     In  an  average 


616  SORK    THROAT 

symptoms,  has  been  described  by  Kirkland,  of  Cheltenham  ;  it  is  spoken  of  variously  as 
Kirkland's  disease,  the  Clieltenliain  disease,  or  epidemic  cervical  adenitis.  In  some  respects 
it  resembles  diphtheria,  in  some  rheumatic  fever,  and  in  some  atypical  scarlatina  without 
rash,  but  it  differs  from  all  these  according  to  most  observers,  and  it  is  now  regarded  as  a 
specific  malady.  It  affects  young  and  old  alike,  is  very  infectious,  generally  occurs  in 
epidemic  form,  may  be  mild,  medium,  or  very  severe,  but  generally  ends  in  recovery. 
Starting  with  sore  throat  and  a  rise  of  temperature  to  102^  F.  or  higher,  the  patient  soon 
complains  mainly  of  extreme  tenderness  of  the  neck,  and  on  palpation  acute  tender  swelling 
of  the  parotid,  submaxillary,  and  jugulo-facial  glands  is  found  ;  the  swelling  may  be  very 
considerable,  but  it  generally  resolves  without  suppuration.  Fever  may  last  only  a  day 
or  two,  but  in  severe  cases  it  may  persist  for  a  fortnight,  especially  if  the  malady  relapses 
after  a  period  of  improvement  as  it  is  apt  to  do  {Fig.  26.5).  Tlie  tonsils,  uvula,  fauces,  and 
pharynx  may  be  merely  red  and  injected  ;  or  on  the  other  hand  there  may  be  an  exudation 
simulating  diphtheria.  On  cultivation  of  swabbings  from  the  throat  no  Klebs-Loffler  bacilli 
can  be  found,  but  as  a  rule  streptococci  in  abimdance.  What  is  very  remarkable  is  that  in 
most  of  the  cases  the  heart  is  affected  during  the  illness,  but  without  producing  permanent 
valvular  changes  like  those  of  rheumatic  fever  ;  the  impulse  becomes  diffuse,  the  heart 
dilates,  there  is  often  a  local  systolic  mitral  or  aortic  bruit,  or  both,  and  the  pulse  may  be 
both  feeble  and  intermittent.  There  is  seldom  albuminuria,  but  the  general  toxaemia  in 
severe  cases  may  be  enough  to  cause  deliriimi  and  temporary  coma.  There  are  no  definite 
joint  pains,  though  the  patient  aches  all  over.  Convalescence  is  generally  slow  at  first, 
two  or  three  weeks  elapsing  before  the  patient  begins  to  feel  anything  like  well  ;  but 
complete  recovery  soon  takes  place  after  this. 

Gumma,  squamous-celled  carcinoma,  and  tuberculous  affections  of  the  fauces,  soft 
palate,  and  uvula  are  relativelN  vmeommon  :  they  are  differentiated  in  the  same  way  as  has 
been  described  in  connection  with  tonsillitis. 

Affections  of  the  Pharynx. 

Acute  pharyngitis  may  occur  by  itself,  or  in  association  with  acute  tonsillitis  or  acute 
laryngitis,  and  in  either  case  it  may  be  due  to  any  of  the  micro-organisms  mentioned  above. 
The  differential  diagnosis  of  the  micro-organisms  is  carried  out  in  the  bacteriological 
laboratory.  The  fact  of  acute  pharyngitis  is  determined  by  careful  inspection  of  the 
structures  at  the  back  of  the  mouth. 

Chronic  pharyngitis  is  generally  the  result  of  excessive  smoking,  or  of  the  imdue  use 
of  the  voice,  in  which  latter  case  it  may  be  associated  with  hoarseness  or  ready  tiring  of 
the  voice,  as  in  those  who  have  to  declaim  loud  and  long — clergymen,  stockbrokers,  coster- 
mongers,  public  orators,  and  others.  The  history  will  generally  point  to  the  nature  of  such 
a  case,  but  one  should  examine  the  sputimi  and  the  lungs  for  evidence  of  tuberculosis,  and 
also  look  for  signs  of  syphilis  or  new  growth,  in  order  to  exclude  these  possible  alternatives. 

Posl-pharyngeal  abscess  is  a  cause  of  acute  dyspnoea  rather  than  of  soreness  of  the 
throat  ;  it  is  almost  confined  to  infancy  ;  after  three  or  four  years  of  age  the  disease 
becomes  almo.st  unknown.  It  might  be  simulated  by  spinal  caries,  in  which,  long  before 
there  is  soreness  of  the  throat,  there  is  severe  pain  in  the  cervical  region  of  the  spine, 
especially  on  movement. 

Chiclxcii-pox  and  small-})ox  may  each  produce  its  characteristic  eruption  in  the  mouth, 
pharynx,  and  cesophagus,  and  thus  give  rise  to  sore  throat  ;  but  the  latter  symptom  will 
never  be  present  by  itself,  and  the  presence  of  the  cutaneous  papules,  vesicles,  or  pustules, 
will  indicate  the  diagnosis,  especially  if  there  have  been  other  similar  cases  in  the  neigh- 
bourhood. 

Laryngeal    Conditions. 

Acute  laryngitis  may  be  due  to  the  same  micro-organisms  as  acute  tonsillitis  ;  soreness 
of  the  throat  is  generally  less  complained  of  than  is  huskiness,  or  weakness,  or  loss  of  voice. 
The  nature  of  the  inflammation  is  determined  baeteriologically.  One  variety  of  acute 
non-diphtheritic  laryngitis  that  merits  special  mention  is  that  due  to  pyogenic  cocci — 
pneumococci,  streptococci,  staphylococci — which  in  a  few  cases,  in  addition  to  producing 
acute  superficial  inflammation,  also  lead  to  rapid  and  extreme  oedema  of  the  larynx,  with 
death  from  asphyxia  unless  tracheotomy  be  performed  speedily.  These  cases  have  been 
spoken  of  as  acute  suffocative  cedema  of  the  larynx. 

Tuberculous,  syphilitic,  and  carcinomatous  lesions  of  the  larynx  are  less  acute,  though 


SORES.     PENILE  617 

they  may  have  relatively  acute  exacerbations  or  become  secondarily  infected  with  pyogenic 
cocci  ;  their  diagnosis  depends  partly  upon  laryngoscopie  inspection — tuberculosis  and 
syphilis  being  bilateral,  whilst  new  growth  is  generally  unilateral  ;  upon  examination  of 
the  sputum  for  tubercle  bacilli,  and  of  the  lungs  for  apical  physical  signs  of  phthisis  ;  upon 
the  beneficial  influence  of  potassium  iodide,  mercury,  or  salvarsan  ;  upon  Wassermann's 
syphilitic  serum  test  ;  upon  microscopic  examination  of  small  excised  portions  ;  or  upon 
the  course  of  the  disease. 

Sore  Throats  the  Result  of  the  Swallowing  or  Inhalation  of  Irritants  and 
Corrosives,  are  <!iagnosed  as  a  rule  by  tlie  history  :  in((uirv  will  generallv  sullicc  to 
indicate  that  some  irritant  has  been  taken,  or  there  may  be  direct  evidence  of  it  in  the  form 
of  eschars  on  the  lips  or  the  buccal  mucosa  :  there  may  be  vomiting  and  ha-matemesis  : 
analysis  of  tlie  gastric  contents  may  indicate  the  nature  of  the  ])oison  taken  :  ammonia 
may  be  detected  by  the  smell. 

Mumps  and  Acute  Adenitis  of  the  Cervical  Lymphatic  Glands  may  each  ])roduce 
marked  soreness  of  the  throat  in  addition  to  dysphagia,  stiflness,  discomfort,  and  pain. 
Mumps  is  not  dillicult  to  diagnose  unless  its  possibility  is  forgotten,  in  which  case  it  might 
be  mistaken  for  acute  oedema  of  the  neck  or  other  similar  lesions.  The  way  in  which  the 
swelling  is  located  in  the  salivary  glands,  starting  on  one  side  and  spreading  to  both,  is 
often  pathognomonic.  Cervical  adenitis  might  simulate  nnmips,  but  careful  palpation 
will  generally  enable  one  to  determine  that  the  swelling  is  not  in  the  salivary  but  in  the 
lymphatic  glands,  and  it  will  only  remain  to  decide  what  has  been  the  source  of  the  infec- 
tion. '  This  will  probably  have  been  from  some  inflammatory,  ulcerative,  or  malignant 
focus  in  connection  with  tlie  shoulders,  neck,  liead.  face,  lips,  cheeks,  gums,  teeth,  tongue, 
fauces,  uvula,  palate,  tonsils,  pharynx,  or  nares  :  the  differential  diagnosis  will  be  based 
upon  inspection  and  palpation  of  the  parts,  together  with  bacteriological  examination. 

It  only  remains  to  add  that  scarlet  fever  is  at  the  present  time  so  atypical  that  acute 
cervical  adenitis  may  really  be  of  scarlatinal  origin  without  any  .scarlatinifor.m  rash  having 
been  observed  upon  the  skin.  One  would  naturally  look  for  evidence  of  desquamation, 
sore  throat,  bald  tongue,  albuminuria,  nephritis,  perhaps  otitis  media  :  but  there  is  no 
doubt  that  some  cases  of  acute  cervical  adenitis  are  really  scarlatinal,  without  there  having 
been  any  other  sign  of  this  disease  except  pyrexia  and  sore  throat.  .\  few  such  cases  jjrove 
rapidly  fatal,  and  they  have  recently  been  recorded  as  examples  of  acute  and  fatal  .sore 
throat  corresponding  to  one  form  of  the  angina  maligna  of  the  eighteenth  century. 

Herbert  French. 

SORES,  PENILE.  Sores  (111  the  penis  may  be  ])reseiit  on  the  thin  mucous  covering 
of  the  glans  or  pie|)uee.  or  on  the  cutaneous  surface  of  the  body  of  tlie  |)enis  :  they  ,ire 
more  common  in  the  former  situation. 

I'Iceration  in  the  neighbourhood  of  the  glans  penis  may  be  due  to  : — 

1.  Balanitis  i.  t'liaiuTe  7.   Tuh(  rciiloiis   iileenilioii. 

2.  Herfies   |)n);.'cnitiilis  .">.   I^pithclionia 

:',.  Sdl't   scin-  (i.   (Jiinimatous  ulceration 

Balanitis.  If  inllammatdiy  proees.ses  have  been  allowed  to  continue  beneath  the 
prepuce,  iiiecialioii  anil  exeoiialioii  of  the  mucous  membrane  covering  the  glans  jicnis  or 
lining  the  prepuce  will  occui'.  The  siirface  of  the  glans  will  be  denuded  of  epithelium, 
and  the  process  will  be  aeeompaiiicd'by  a  stinking,  purulent  discharge.  Mulliple  shallow 
ulcers  are  formed,  rapidly  eoalesejng  and  causing  considerable  discomfort.  The  prepuce 
often  becomes  swollen  and  (edematous,  preventing  retraction,  so  that  a  condition  of 
phimosis  occurs:  care  must  then  be  exercised  in  diagnosing  a  simple  balanitis  from  one 
accompanying  acute  gonorrlural  urethritis  or  an  underlying  syphilitic  or  soft  chancre. 
With  an  acute  urethritis,  there  will  be  a  history  of  infection,  pain  along  the  course  of  the 
urethra  during  micturition,  and  perhaps  chordee  ;  further,  the  intracellular  gonococcus 
may  be  identified  in  a  stained  smear  of  the  discharge  (I'liite  Wl'lll.  Fig.  l\.  p.  01  1). 

If  a  chancre  exist  under  the  swollen  phimoscd  prepuce,  there  is  often  a  tender  spot 
about  the  corona  or  at  the  Ineiium.  With  a  soft  sore,  coiisceutive  sores  m;iy  appear  about 
the  orilice  (if  the  pn  |iiiee.  whilst  the  inguinal  glands  arc  riuicli  iikiic  lil<el\  Id  lie  iiillamed 
<ir  to  Mippiirate  than  with  simple  balanitis.  V  sypliililic  chaiierc  dbscurcd  li\  :i  phimosis 
can   iisiiall\    he   fell    (lisliriclly   under   the   skin,   and   causes  a   eom|iaralivel\    sni.ill   amount 


61.S  SORES,    PENILE 

of  discharge,  whilst  the  inguinal  glands  become  enlarged  but  do  not  suppurate.  The  history 
of  the  date  of  infection,  Wassermann's  reaction,  or  the  subsequent  appearance  of  secondary 
symptoms,  will  hcl])  materially  in  the  diagnosis.  Spirocha'tes  may  be  found  in  the 
discharge. 

A  form  of  balanitis  which  is  frequently  very  obstinate  to  treatment  may  occur  in 
patients  the  subjects  of  gout  or  diabetes  mellitus. 

Herpes  Progenitalis. — Herpes  may  attack  the  genital  organs  as  part  of  a  herpes 
zoster  in  which  the  cutaneous  eruption  depends  upon  some  lesion  of  the  central  nervous 
system,  or  as  a  local  affection,  the  so-called  catarrhal  herpes.  The  disease  begins  as  a 
patch  of  erythema  on  the  inner  surface  of  the  prepuce  or  on  the  glans  penis,  followed  by 
the  appearance  of  vesicles  and  jjustules  ;  the  latter  become  rubbed  by  the  clothes,  and 
form  small  ulcers.  Herpes  of  the  genital  organs  tends  to  recur,  so  that  a  previous  history 
of  a  similar  attack  is  often  forthcoming.  If  seen  during  the  vesicular  stage,  no  difficulty 
will  be  met  with  in  the  diagnosis  :  but  if  suppuration  has  followed,  it  must  be  diagnosed 
from  a  venereal  sore.  Soft  chancres  are  usually  deeper,  with  marked  edges  ;  their  base 
is  sloughing,  and  they  are  usually  accompanied  by  a  bubo,  which  is  exceptional  with  herpes. 
A  syphilitic  chancre  is  usually  single,  indurated  and  raised,  and  is  accomjianied  by  the 
typical,  multiple,  discrete,  amygdaloid  glands  in  the  inguinal  region.  It  should  be  remem- 
bered that  syphilis  may  become  inoculated  upon  a  herpetic  patch,  or  that  herpes  may 
appear  in  an  area  previously  inoculated  with  the  syphilitic  virus. 

Soft  Sores  or  Chancroids  of  the  penis  occur  almost  invariably  from  infection  during 
sexual  connection.  The  incubation  period  is  short,  a  vesicle  occurs  in  two  days,  and  this 
breaks  down  rapidly  to  form  a  rounded  or  oval  ulcer  with  sharply  defined  edges,  and  a 
yellowish  sloughing  base.  The  ulcers  appear  usually  on  the  mucous  surface  of  the  glans, 
fraenum,  or  corona,  and  are  most  often  multiple,  direct  inoculation  occurring  from  an  ulcer 
to  the  contiguous  part.  They  may  cause  rajjid  destruction  of  tissue,  perforating  the 
fra-num  or  spreading  over  the  surface  of  the  glans.  The  soft  sore  must  be  differentiated 
from  others  occurring  on  the  glans,  and  above  all  from  a  syphilitic  chancre.  .\t  the  same 
time  it  must  be  remembered  that  besides  the  infection  with  chancroid,  a  simultaneous 
infection  with  syphilis  may  have  taken  place,  so  that  a  soft  sore  may  idtimately  become 
indurated  and  assume  the  character  of  a  primary  syphilitic  lesion.  The  chancroids  are 
multiple,  are  accompanied  by  a  good  deal  of  thin,  purulent  discharge,  and  by  a  painful 
swelling  of  the  inguinal  glands,  usually  of  one  side,  which  have  a  marked  tendency  to 
suppurate.  On  the  other  hand,  a  syphilitic  chancre  is  nearly  always  single,  is  raised  and 
indurated,  has  little  discharge,  and  is  accompanied  by  enlarged,  but  firm  and  indolent, 
glands  in  both  inguinal  regions  ;  the  incvibation  period  of  a  syphilitic  chancre  is  from 
twenty-one  to  twenty-eight  days. 

The  multiple  ulcerations  caused  by  herpes  are  more  superficial,  and  rarely  cause  a 
bubo. 

Chancre — the  initial  lesion  of  syphilis — generally  appears  on  the  ])enis,  and  is  most 
common  in  the  neighbourhood  of  the  fra-num  or  coronary  sulcus.  .\  chancre  appears 
about  twenty-five  days  after  infection,  as  a  reddened  ])atch,  which  becomes  raised  above 
the  surface  of  the  mucous  membrane,  with  distinctly  indurated  margins.  The  central 
part  breaks  down  into  an  ulcer,  discharging  a  thin^  purulent  fluid,  and  at  the  same  time 
the  inguinal  glands  of  both  sides  become  palpable,  slightly  enlarged,  but  discrete,  and  with 
no  tendency  to  suppurate.  The  chancre  increases  but  slowly  in  size,  or  may  occasionally 
become  smaller  without  any  treatment,  and  after  a  further  lapse  of  from  four  to  six  weeks 
the  typical  secondary  symptoms  make  their  appearance  ;  namely,  a  roseolar  rash  on  the 
chest,  abdomen,  face,  and  thighs,  general  adenitis,  and  mucous  patches  about  the  faucial 
pillars  and  tonsils.  The  diagnosis  of  the  primary  lesion  of  syphilis  frequently  presents 
no  difficulties,  the  indurated  character  of  the  sore,  the  date  o'f  its  appearance  after  infection, 
and  the  presence  of  firm,  indurated  glands  in  the  inguinal  region,  being  distinctive.  In 
other  cases  the  character  of  the  sore  is  by  no  means  distinctive,  and  it  is  necessary  to 
differentiate  it  from  other  lesions  of  the  penis.  If  the  sore  be  syphilitic,  the  secondary 
manifestations  of  the  disease  will  follow,  provided  that  the  doubtful  ulcer  is  not  treated 
as  a  chancre.  Thus,  in  any  case  in  which  syphilis  is  suspected,  but  not  wholly  certain, 
it  is  advisable  to  withhold  any  specific  treatment  for  syphilis  until  such  time  as  secondary 
symptoms   appear,    so   that    a  jiatient    may   not    be  ct)ndemned   to  the  lengthy  process  of 


SORES,     PERINEAL  619 

treatment  for  syphilis  until  the  diagnosis  is  absohitely  certain.  The  Spiroclueta  pallida 
should  be  looked  for  in  scrapings  from  the  affected  parts,  but  too  much  reliance  should  not 
be  placed  upon  a  negative  Wassermann  blood-reaction  in  the  early  stages  of  the  disease. 

A  chancre  may  be  simulated  by  an  inflamed  soft  sore,  especially  if  the  latter  has  under- 
gone cauterization.  Soft  sores  are,  however,  frequently  nuiltiple,  appear  within  a  few 
days  of  infection,  and  are  accompanied  by  painful  enlargement  of  the  inguinal  lymphatic 
glands,  which  are  particularly  prone  to  suppurate.  It  must  not  be  forgotten  that  a  double 
infection  may  have  occurred,  so  that  a  soft  sore  may  show  little  inclination  to  heal  or, 
becoming  indurated,  may  present  the  features  of  a  chancre  after  about  three  weeks,  and 
later,  the  symptoms  of  constitutional  syphilis. 

Epithelioma  of  the  penis  in  the  early  stage  may  be  confused  with  syphilitic  cliaucre. 
In  epithelioma  there  is  no  history  of  infection  :  it  occurs  only  in  elderly  patients,  and  there 
is  frequently  a  greater  destruction  of  tissue  than  in  syjjhilis.  The  inguinal  glands  are  not 
enlarged  until  the  sore  has  been  present  for  some  weeks,  and  there  are  no  secondary  lesions 
such  as  the  faucial  ulceration  and  cutaneous  rash.  If  any  doubt  exists,  a  small  piece  may 
be  removed  from  the  edge  of  the  ulcer  for  microscopical  examination. 

Perhajjs  the  greatest  diflieulty  in  the  diagnosis  of  a  chancre  is  experienced  when  the 
latter  is  hidden  beneath  an  inllanud  an  1  [)!iiinosed  prepuce.  There  is  a  ]niruleiit  and  foul 
discliarge  from  beneath  the  U'dematous  and  swollen  prepuce  :  the  inguinal  glands  are 
enlarged  from  the  associated  sepsis.  If  a  chancre  is  present,  it  can  frequently  be  felt  as 
an  indurated  area  under  the  prepuce,  whilst  if  it  has  been  present  for  some  time,  the 
secondary  lesions  of  syphilis  may  be  jjresent.  If  any  doubt  exists  in  an  elderly  patient 
as  to  whether  an  indurated  subprepucial  area  be  an  early  epithelioma  or  a  syphilitic  sore, 
the  prepuce  should  be  split  u])  along  the  dorsal  aspect  under  an;esthesia.  the  ulceration 
inspecteii,  and  a  small  |)iecc  submitted  to  microseo|)ieal  examination  if  necessary. 

Epithelioma  (siiuauious-eelled  carcinoma)  is  the  most  common  form  of  malignant 
growth  of  the  penis.  It  arises  most  frequently  from  the  inner  aspect  of  the  jirepuce,  or 
from  the  mucous  membrane  of  the  glans,  as  a  small,  raised  ulcer,  with  friable,  irregular 
edges.  It  is  rarely  present  before  the  age  of  forty,  and  fre(|uently  occurs  on  the  site  of 
l)revious  ulceration  or  long-standing  irritation.  .\n  cpitheliomatous  ulcer  increases 
gradually  in  size,  in  spite  of  various  forms  of  treatment,  and  with  it  is  frequently  associated 
glandular  enlargement  in  the  inguinal  area.  .\t  first  the  glands  may  be  enlarged  from 
se|)tic  infection,  but  later  from  malignant  infiltration.  An  cpitheliomatous  ulcer  may 
in  some  cases  be  confused  with  a  chancre  ;  but  the  friable,  irregular  edges  of  the  former, 
the  liability  to  bleed,  and  the  gradual  progressive  increase  in  size  in  spite  of  treatment  in 
an  elderly  patient,  should  give  rise  to  grave  suspicion  of  malignant  disease.  .Microscopical 
examination  of  a  small  pii-cc  renioxiil  from  the  edge  of  the  ulcer  will  give  direct  evidence 
of  epithelioma. 

Gummatous  Ulceration  ol'  ihc  |)(nis  occurs  occasionally,  resulting  from  the  disin- 
tegration of  a  smail  gmimia  of  Ihc  glans  or  piepuce,  frequently  in  the  position  of  an  old 
scar.  .\  gunuiia  <-ommences  as  a  small,  elevated  nodule,  which,  if  lefl  untreated,  softens 
and  discharges  its  contents,  leaving  an  ulcer  bounded  by  thin  edges  and  with  a  yellowish, 
sloughy  base.  A  gununatous  ulcer  has  been  mistaken  for  a  primary  lesion  of  sy|)hilis  ; 
but  the  absence  of  induration,  the  history  of  the  onset  and  of  a  previous  infection  with 
syphilis,  would  be  points  against  a  chancre.  .\  second  infection  with  syphilis  is  by  no 
means  unknown,  especially  in  those  jivlio  lia\c  li;id  salvarsan  alon<'  in  the  treatment  of 
the  first  attack,  but  it  is  raii'.  Occasionally  the  base  of  a  gummatous  uliir  proliferates 
into  a  papillary  tumour  and  has  given  rise  to  a  suspicion  of  <-iniiioina  :  the  diagnosis 
will  he  eonlirm<(l  by  the  behaviour  of  the  lesion  iniilci-  potassiuiii  ioclidc.  wluii  a  tertiary 
syphilitic  allVction  will  clear  up  rapidly. 

Tuberculous  oi'  Lupoid  Ulceration  of  the  penis  is  rare,  and  is  generally  associated 
with  achanccil  lulicic  iilous  inliltralion  elsewhere.  Tuberculous  ulcers  are  usually  shallow, 
with  thill  oMihaiiging  erlges,  painful  and  multiple.  Ihc  iiifcclion  has  icsiilliil  IVom  the 
rile  of  iiil'aiil  ilc  circumcision   by   the  .Jewish   incthoil.  ir  II .  .Innliiii  .S:i.(iii. 

SORES,    PERINEAL,      riccralion  may  lie  present   in  the  perineum  as  the  lesiill  of:  — 

1.  CiilMiicoiis  iiillaiiiiiiiilioMs  III'  iiiiiirv         I        t.   .Svpliilis 

2.  I  rellii'iil    li'.liila'    or   mi|i|iiii'iiI  ion    '  .',.    lO'iill  lielionia. 

:i.     I'r.isllltie    sll|,|,llialinll  I 


620  SORES,    PERINEAL 

Cutaneous  Inflammation  or  Injury. — An  ulcer  in  the  perineum  may  result  from 
direct  injuTfj  to  tlu'  area,  or  Iriim  iiitiammatory  Infection  of  the  sebaceous  of  hair  follicles 
of  the  cutaneous  covering.  An  ulcer  from  these  causes  may  be  placed  at  the  centre  or 
to  one  side  of  tlie  ])erineum,  is  movable  on  the  deeper  parts,  and  shows  no  track  into  which 
a  probe  can  be  passed.  In  women,  ulceration  of  the  perineal  area  may  be  associated  with 
goiionlHcal  or  septic  'vaginal  (lischdrac 

Urethral  Suppurations  or  Fistulae. — During  the  progress  of  an  acute  urethritis,  a 
glandular  follicle  frequently  becomes  infected.  The  suppurative  process  leading  from 
this  in  the  Ijulbous  urethra  may  extend  towards  the  perineimi  and  open  externally,  leaving 
a  small  fistula  which  may  or  may  nor  discharge  urine  during  the  act  of  micturition.  In 
a  similar  manner,  urinary  Astute  may  result  from  inflanunatory  processes  behind  a  urethral 
stricture,  and  in  an  old-standing  case  it  is  not  uncommon  to  find  a  urinary  calcidus  in  the 
dilated  portion  of  the  urethra  behind  the  stricture.  When  the  urethral  suppuration  is 
acute  and  an  abscess  bursts  in  the  ])erineiun.  the  diagnosis  will  be  quite  obvious,  and  the 
ordinary  treatment  for  an  abscess,  in  addition  to  that  of  the  acute  urethritis,  will  usually 
suffice  to  cure  the  condition. 

If,  however,  the  perineal  woimd  discharges  urine,  it  will  be  found  that  this  occurs 
as  a  rule  only  during  the  act  of  micturition,  as  there  is  no  interference  with  the  vesical 
sphincter.  In  nearly  all  cases,  however,  a  stricture  of  the  urethra  will  be  found,  though 
not  necessarily  one  of  suflicient  degree  to  cause  severe  interference  with  micturition. 
Endoscopic  examination  will  show  the  presence  of  a  urethral  stricture,  whilst  behind  it 
can  be  seen  frequently  the  sloughy  granulations  denoting  the  jjosition  of  the  urethral 
opening  of  the  fistida.  Occasionally  urine  drains  from  a  perineal  fistula  continuously, 
and  not  only  during  the  act  of  micturition.  In  these  cases  there  is  constant  soaking  of 
the  perineal  skin,  and  frequently  excoriation.  That  urine  should  leak  constantly  from 
the  fistula  denotes  interference  with  the  vesical  .sphincter,  either  by  dilatation  behind  a 
tight  urethral  stricture,  by  the  presence  of  a  calculus  in  the  prostatic  or  membranous 
urethra,  or  by  actual  division  of  the  vesical  sphincter  following  some  operation,  such  as 
perineal  prostatectoniy  or  perineal  lithotomy. 

Diseases  of  the  Prostate. — .\n  abscess  or  tuberculous  focus  in  the  prostate  may 
occasionally  disehiirge  in  the  perineimi,  and  remain  as  a  sinus.  .\n  abscess  in  the  prostate 
arises  practically  always  from  some  infection  in  the  jiosterior  urethra,  from  venereal  causes, 
or  after  septic  instriuiientation.  It  is  accompanied  by  urethral  discharge,  or  there  is  a 
history  of  a  recent  infection,  whilst  i)er  rectum  the  prostate  may  be  felt  to  be  inflamed, 
or  scarred  from  the  shrinkage  of  the  abscess  cavity. 

When  a  tuberculous  ca\'ity  in  the  prostate  opens  in  the  perineum  there  is  advanced 
tuberculous  disease,  so  that  little  difficulty  will  be  found  in  arriving  at  a  diagnosis.  .A. 
tuberculous  prostate  is  very  rarely  a  primary  condition,  but  in  most  cases  is  secondary 
to  disease  in  the  testis  or  bladder,  so  that  examination  of  these  organs  will  in  nearly  all 
cases  give  evidence  of  tuberculous  disease  and  indicate  the  nature  of  the  perineal  ftstida. 
Palpation  of  the  prostate  per  rectum  may  reveal  the  rounded  nodular  deposit  of  tubercle 
in  the  gland. 

Syphilis  may  cause  ulceration  on  the  perineum  either  as  a  chancre  or  as  mucous 
tubercles.  A  chancre  on  the  perineiun  is  rare.  It  forms  a  small  ulcer  with  slightly  indurated 
borders,  indolent  in  character,  and  accompanied  by  slight  enlargement  of  the  inguinal 
lymphatic  glands.  A  chancre  of  the  skin  does  not  possess  the  usual  features  of  a  genital 
chancre,  and  is  not  usually  diagnosed  with  certainty  until  the  secondary  lesions  of  syphilis 
become  apparent  ;  but  an  ulcer  with  raised,  infiltrated  edges,  which  shows  no  tendency 
to  heal  imder  aseptic  precautions,  should  always  give  rise  to  a  suspicion  of  syphilis.  The 
Spirocliceta  pallida  may  be  looked  for,  and  Wassermann's  serum  test  tried. 

Condifloniata  may  be  present  about  the  perineimi  in  association  with  active  syphilis 
They  may  extend  from  the  anal  or  vulval  orifice,  and  form  oval  or  rounded,  flat-lopped, 
sessile  masses,  co\ered  by  macerated,  greyish  epithelium,  or  they  maj-  be  ulcerated  on 
the  surface.     The  accompanying  signs  of  syphilis  will  indicate  the  diagnosis. 

Epitheliomatous  Ulceration  of  the  perineum  is  practically  only  seen  as  a  direct  spread 
of  a  growth  of  the  anus  or  vulval  area,  when  the  diagnosis  presents  no  difficulty.  An 
epithelioma  may  develop  in  the  scar  of  some  former  cutaneous  affection,  in  which  case 
an  ulceration  may  exist,   showing  the  usual  characteristics  of  a  cutaneous  epitheliom,^, 


SORES,    SCROTAL  621 

namely,  gradual  progressive  increase  in  size,  raised,  friable  edges,  and  tendency  to  slight 
haemorrhages.  The  inguinal  glands  may  be  enlarged  early  from  inflammatory  absorption, 
or  later  by  infection  with  malignant  disease.  In  case  of  doubt  a  fragment  may  be  removed 
for  microscopical  examination.  r_  //.  Jocelyn  Swan. 

SORES,    SCROTAL. — t'lccration  of  the  scrotum  occurs  in  association  with  : — 

1.  New  growth  :  3.  .Sypliilis.  Syphilitic. 

Epithelioma  4.  Testicular  disease  :  5.  Suppurating  cysts. 

Papilloma.  Inflammatory  | 

2.  Fistula'.  I  Tuberculous 

Epithelioma  of  the  Scrotum,  commonly  known  as  '  chimney-sweep's  cancer.'  is 
by  no  means  limited  to  this  avocation,  but  is  certainly  more  common  in  men  engaged  in 
work  in  which  they  are  exposed  to  much  irritation  from  solid  particles  or  from  noxious 
fiunes.  Hence  the  disease  is  most  commonly  seen  amongst  chimney-sweeps,  em])loyees  in 
gas-works,  parailin  and  chemical  works,  and  coal-mines.  It  often  begins  as  a  small  sub- 
cutaneous nodule,  over  which  the  skin  is  thinned  and  adherent  ;  the  nodule  enlarges  slowlv, 
and  the  thinned  covering  gives  way,  to  form  an  ulcer  with  thickened,  irregular  edges  and 
a  tendency  to  bleed  on  slight  injury.  The  ulcerated  area  extends  both  radially  and  into 
the  tissues  of  the  scrotum,  later  involving  the  testes.  The  inguinal  lymphatic  glands 
become  enlarged  soon  after  active  idceration  commences,  at  first  from  inflammatory  causes, 
later  from  malignant  infiltration.  In  other  cases  a  scrotal  epithelioma  begins  in  a  wart 
or  papilloma,  which  may  have  been  present  for  years  with  only  slight  increase  in  growth. 
These  soft  papilloniata  are  not  unusually  the  starting-point  of  malignant  change,  when 
they  become  more  vascular,  whilst  the  surface  cpithdimn  becomes  thinned  and  easily 
excoriated.  A  small  amount  of  foul  discharge  is  present.  ofUii  encrusted  into  a  scab, 
which  on  removal  leaves  an  ulcer  with  indurated,  everted  edges,  with  the  gradual  progress 
of  a  cutaneous  epithelioma.  Any  ulcer  on  the  scrotum,  especially  if  indurated  or  readilv 
caused  to  bleed,  must  be  looked  upon  with  extreme  suspicion,  and  when  it  does  not 
improve  with  ordinary  antisc|)tic  medication,  should  be  widely  removed  without  waiting 
for  glandular  enlargement. 

Epithelioma  may  occur  in  the  scrotal  area  as  a  localized  recurrence  after  removal 
of  a  malignant  growth  of  the  penis  or  testicle.  Knowledge  of  the  previous  condition  for 
which  operation  has  been  performed  would  give  the  diagnosis. 

Fistulae  may  occur  in  the  scrotum  and  cause  ulceration.  They  are  most  common  in 
as.sociation  wilh  tuberculous  or  syphilitic  disease  of  the  testes  (see  below),  but  occasionally 
they  occur  from  urethral  extravasation,  or  burrowing  from  rectal  suppuration.  An  abscess 
may  form  and  open  through  the  scrotal  skin  from  a  iHri-urcthral  al)scess  accompanving 
an  acute  urethritis  or  formed  by  septic  infection  behind  a  urethral  stricture.  In  cither 
case  a  small  amount  of  urine  may  leak  through  the  opening  during  micturition,  whilst 
the  history  of  urethral  discharge,  tir  of  difficulty  in  micturition  and  other  symptoms  of 
stricture,  will  point   lo  tlic  diagnosis. 

Syphilis  of  the  Scrotum  may  be  present  cither  as  a  primary  chancre  or  as  a  mucous 
tubercle.  .\  /iiittiain  iIkiucic  in  tliis  situation  is  by  no  means  easy  to  recognize  unless  other 
signs  of  syphilis  are  i)rescnt  :  but  the  presence  of  a  cutaneous  sore  which  does  not  show 
much  inclination  to  heal  under  non-jiiercurial  antiseptic  dressings  should  always  give  a 
suspicion  of  syphilis.  There  is  often  only  slight  induration  of  the  ulcer  compared  with 
that  of  a  penile  chancre^  but  the  edge  is  raised  and  of  a  rolled  appearance.  The  inguiruil 
lymphatic  glands  arc  enlarged  and  discrete,  and  some  five  to  six  weeks  al'ler  the  conunencc- 
ment  of  the  ulcer  the  usual  secondary  syniptoms  of  sypliilis  become  nianifcsl. 

Miiniiis  tithvriivs  may  be  present  on  the  scrolum,  usually  on  the  I'cnioral  aspect.  They 
may  extend  directly  from  the  anal  area.  No  dillieuKy  will  be  met  willi  in  the  diagnosis, 
as  other  signs  of  syphilis  are  obvious. 

Testicular  Disease.-  in  some  cases  extension  of  disease  in  the  testicle  may  involve 
the  coverings  of  the  s<rotiun.  and  may  even  perforate  them  to  form  a  scrotal  sore.  This 
sequence  occasionally  occurs  with  :  (I)  A  testicular  abscess  ;  (•!)  Tuberculosis  of  the  testis  ; 
(8)  Gumma  of  the  testis. 

A  lestirular  ahsress  is  somewhat  unconmion.  but  may  arise  from  direct  extension  from 
the  urethra  \  ia  the  vesicuia-  scminali's  and  vasa  deferent ia  or  by  a  li:cmatogenous  iuh-etion 


6-2-2  SORES.     SCROTAL 

during  the  course  of  a  specific  fever,  sucli  as  scarlet  fever,  mumps,  or  enterica.  It  may 
also  follow  chronic  torsio  testis.  With  urethral  disease,  the  primary  trouble  may  be  due 
to  gonorrhoea,  or  more  frequently  to  a  septic  urethritis  from  the  introduction  of  infected 
instruments,  and  is  thus  not  infrequent  in  cases  of  prostatic  enlargement  in  which  the 
patient  is  passing  his  own  catheter.  In  cases  in  which  the  infective  process  extends  from 
the  urethra,  the  epididymis  is  affected  first,  whilst  in  the  metastatic  cases  the  body  of  the 
testis  usually  shows  the  first  sign  of  enlargement.  These  acute  inflammations  of  the  testis 
occasionally  suppurate,  when  the  scrotal  tunics  become  inflamed  and  adherent,  whilst 
softening  occurs  later,  and  unless  surgically  relieved,  the  abscess  opens  through  the  skin 
leaving  an  ulcer,  and  a  sinus  discharging  pus. 

Tuberculosis  of  the  testicle  may  occur  as  a  primary  disease  or  as  a  secondary  deposit  in 
association  with  tuberculosis  elsewhere  in  the  genito-urinary  tract.  Testicular  tubercle 
almost  always  begins  as  a  nodule  in  the  epididymis,  but  in  the  later  progress  of  the  disease 
may  extend  into  the  testicle  proper.  If  the  tuliereulous  nodule  progresses  rather  than 
undergoes  cure,  the  scrotal  skin  becomes  adherent,  thinneil.  and  finally  perforated,  leaving 
a  shallow  ulcer  with  thin,  undermined  edges,  and  discharging  thin  pus.  Occasionally 
the  necrotic  tubules  of  the  epididymis  fungate  through  the  opening  in  th  escrotum,  appear- 
ing as  a  greyish,  sloughy  projection  from  the  cutaneous  opening — the  so-called  '  hernia 
testis." 

A  gumma  <if  the  testis  causes  a  swelling  in  the  body  of  the  testis  rather  than  in  the 
epididymis.  A  gmnma  which  remains  imrecognized  or  untreated  may  soften  and  ulcerate 
through  the  scrotal  skin  in  a  manner  similar  to  tuberculous  disease,  leaving  a  clearly-defined 
ulcerated  area  with  sharply-cut  margins,  and  a  wash-leather-like  sloughy  base.  The 
gummatous  granulation  tissue  may  fungate  through  the  scrotal  aperture,  forming  a 
yellowish  necrotic  mass. 

The  diagnosis  of  these  three  conditions  may  produce  some  difliculty  in  the  earlier 
stages  (see  Swelling.  Scrotal,  p.  696).  but  in  the  advanced  stage  now  under  consideration. 
when  an  open  scrotal  sore  is  present,  the  diagnosis  is  easier.  The  opening  of  a  testicular 
abscess  on  the  scrotum  leaves  a  small  sinus  discharging  pus  and  accompanied  by  a  general 
enlargement  of  the  organ.  Preceding  the  rupture  of  the  abscess  there  is  acute  pain  in 
the  testicle,  with  rise  of  temperature,  rigors,  and  general  signs  of  suppuration,  which  are 
much  diminished  as  soon  as  the  abscess  is  allowed  to  burst.  There  is  often  a  urethral  dis- 
charge, which,  however,  is  often  much  lessened  with  the  onset  of  the  acute  epididymitis, 
with  distinct  thickening  of  the  cord  and  aching  pain  in  the  neighbourhood  of  the  external 
abdominal  ring,  or  in  metastatic  cases  the  abscess  occurs  during  the  progress  of  an  acute 
fever.  The  general  history  is  one  of  acute  pain  commencing  in  the  testicle,  with  rapid  and 
extremely  tender  swelling  of  the  organ,  followed  by  abscess-formation. 

In  tuberculosis  of  the  testis  the  ])rogress  is  much  more  gradual.  A  nodule  may  have 
been  jiresent  in  the  epididymis  for  some  time,  gradually  enlarging,  but  causing  very  little 
pain  ;  in  some  cases  a  nodule  may  have  been  present  for  months  without  any  apparent 
change,  and  then  it  may  enlarge  suddenly,  involve  the  scrotal  tunics,  and  discharge  its 
contents.  By  the  time  the  disease  has  reached  this  stage,  it  is  probable  that  evidence  of 
tuberculous  trouble  will  be  found  in  other  organs,  particularly  the  other  testis,  prostate, 
seminal  vesicles,  or  bladder.  The  affected  testicle  usually  presents  several  nodules  in 
the  epididymis,  tender  on  pressure,  whilst  small  nodules  may  also  be  felt  in  the  vas 
deferens. 

The  opening  remaining  from  the  discharge  of  a  gummatous  orchitis  is  usually  a  rounded 
ulcer  with  sharply-cut  edges  and  yellowish  base.  The  whole  testis  is  enlarged,  practically 
painless,  and  feels  heavy.  The  cord  is  not  thickened,  and  there  is  no  evidence  of  disease 
in  the  other  testicle,  prostate,  or  seminal  vesicles.  There  is  probably  a  history  of  syphilis, 
and  other  tertiary  syphilitic  lesions  may  be  present  elsewhere,  such  as  gummatous  peri- 
ostitis. Strong  evidence  of  the  syphilitic  nature  of  the  disease  is  often  obtained  by  the 
result  of  treatment  with  large  doses  of  potassium  iodide,  alone  or  in  combination  with 
mercury  or  with  salvarsan,  when  a  gumma  diminishes  in  size  with  marked  rapidity.  It 
should  be  remarked,  however,  that,  as  in  two  cases  under  the  writer's  care,  testes  which 
are  subsequently  removed  and  foimd  to  contain  large  gimimata,  may  show  no  improvement 
before  operation,  even  under  large  doses  of  iodides,  though  the  Wassermann  test  may 
be  positive.  M 


SPEECH.     ABNORMALITIES     OF  623 

A  hernial  protrusion  of  necrotic  testicular  tissue  may  be  present  either  with  tuber- 
culous disease  or  from  a  gumma.  In  tuberculosis  the  mass  is  greyish  and  necrotic,  dis- 
charging thin  pus.  and  there  will  be  sulUcient  evidence  of  tuberculous  disease  in  the  under- 
lying testis  and  other  genital  organs.  Tubercle  bacilli  may  be  found  in  the  discharge.  A 
distinctive  feature  of  tlie  gummatous  hernia  testis  is  found  in  the  appearance  of  the  cutan- 
eous o))ening  :  if  the  fungating  mass  be  pushed  aside,  the  opening  in  the  scrotal  skin  will  be 
seen  to  he  cleanly  cut  and  to  encircle  the  protruding  tissue  tightly.  The  fungating  hernia 
testis  of  tubercle  or  syphilis  must  also  be  diagnosed  from  other  conditions  producing  a 
raised  tumour  on  the  scrotum.  An  epithelioma  of  the  scrotum  has  raised  borders,  but  the 
centre  is  excavated,  and  there  is  rarely  any  enlargement  of  the  testis.  A  sloughing  papil- 
loma of  the  scrotmn  may  more  nearly  reproduce  the  appearance,  but  the  tumour  and  the 
skin  arc  freely  movable  on  the  underlying  testis,  whilst  in  hernia  testis  the  mass  is  connected 
with  the  testicle,  and  the  tubular  structure  of  the  latter  is  often  ajiparent  on  i>ieking  up  a 
small  fragment  of  the  fungating  tumour. 

Cysts  of  the  Scrotum. — -As  an  exceptional  occurrence,  a  sebaceous  cyst  may  develop 
in  the  scrotal  skin,  supjjurate.  and  leave  an  open  sore.  The  areas  remaining  present  raised 
borders,  and  are  easily  mistaken  for  an  early  epithelioma.  An  accurate  history  of 
the  i>revious  swelling  in  the  skin  is  of  little  assistance  in  these  cases,  but  microscopical 
examination  of  a  piece  removed  from  the  margin  of  the  ulcer  will  exclude  malignancy. 
A  suppurating  cyst  in  the  scrotum  is  more  uncommon  than  epithelioma. 

I{.  II.  Joct'lf/ii  Sican. 

SPASTICITY.     (Sec  (;\iT.  Ai!norm.vlities  ok.  p.  251.) 

SPEECH,  ABNORMALITIES  OF.— Abnormalities  of  speech  are  numerous,  varying 
from  comiilete  mutism  to  slight  defects  in  articulation,  and  dependent  on  disturbances, 
functional  or  organic,  in  some  |)art  of  the  complex  mechanism  which  is  responsible  for 
the  production  of  intelligible  language.  This  article  is  intended  to  expose  the  broad 
principles  by  which  various  abnormalities  of  speech  can  be  detected  and  used  for  the 
purposes  of  diagnosis  ;  it  docs  not  embrace  a  discussion  of  the  controversial  views  which 
are  held  concerning  their  exact  production. 

The  amount  of  investigation  required  for  making  a  diagnosis  in  cases  of  speech 
abnormality  varies  within  wide  limits.  Great  care  is  called  for  in  examining  cases  of 
aphasia  which  result  from  disturbance  in  the  function  of  the  cerebral  speech  centres  or 
their  dependent  paths  of  connniuiication  ;  the  defective  articulation  of  a  patient  suffering 
from  cleft  palate  n(<(Is  only  a  comparatively  superficial  examination  in  order  to  arrive 
at  a  correct  diagnosis. 

It  will  be  convenient  to  consider  the  various  abnormalities  of  speech  under  the 
following  heads:  (1)  Mental  defects:  (2)  .tphiisiii  :  (3)  Deiif  mutism;  (4)  Dijsartliria  ; 
(5)  Fiinrliiiniil  (lisnrilers — stammering,  lalling,  idioghtssiii. 

Mental  Defects.  — '1  he  acquirement  of  the  power  of  speech  may  be  delayed  in  children 
who  are  menially  <lefective.  and  in  some  forms  of  idiocy  may  be  suspciulcd  altogether. 
Uel'orc  making  a  diagnosis  of  m<ntal  deliciencv  in  a  child  who  appears  lo  be  dilatorv  in 
talking,  it  is  well  to  remember  that  tlie  age  at  which  speech  is  ae(|uired  is  very  variable, 
and  that  the  delay  may  be  considerable  where  no  mental  impairment  is  present.  In  such 
cases  the  diagnosis  nnist  depend  on  a  consideration  of  other  points  in  the  child's  develop- 
ment. In()uiry  should  be  made  as  to  whether  he  is  clean  in  his  habits,  whether  lie  is 
destructive,  whether  he  plays  with  toys  or  with  other  children  in  a  naturil  manner,  and 
whether  he  displays  abnormally  bad  temper  or  irritability.  In  some  eases  the  delay  in 
ipeakiiig  may  be  due  to  a  defect  in  hearing  which  has  been  imsuspected  by  the  parents. 
Phis  point  is  especially  apt  to  arise  in  respecl  lo  children  who  have  begun  to  talk  at  the 
normal  age.  and  who  have  lost  wlial  little  tluv  hail  learned  of  I  he  art  in  the  sc(|uel  of  some 
icute    illness. 

In  adults.  loss  of  speech  may  !«■  due  lo  many  forms  of  mental  deliiiency  of  a  temporary 
or  permanent  nature.  .\  familiar  example  of  temporary  loss  of  speech  is  that  degree  of 
alcoholic  intoxication  lo  which  the  term  '  speechless  "  is  vulgarly  applied.  .Similarly,  the 
intoxication  of  the  higher  meiita!  faculties  associated  with  organic  poisons,  such  as  those  of 
pneumonia  or  typhoid  fever,  may  be  n'sponsible  for  temporary  loss  of  speech.  Complete 
mutism   (hie   to   dlNcase   of  the   lii"her   inlcllert nal   eenlres   is  eonunon    In    various   forms  of 


624 


SPEECH.     ABNORMALITIES    OP 


dementia,  and  is  proved  to  be  no  aphasic  defect  by  the  sudden  and  complete  restoration 
of  speech  which  may  take  jilace  after  montlis  or  even  years  of  silence.  The  speechlessness 
of  a  melancholic  patient  or  of  one  who  is  suffering  from  paralytic  dementia  is  further 
differentiated  from  true  aphasia  by  the  fact  that  the  latter  is  associated  with  attempts 
at  communication,  while  the  former  is  not.  On  the  other  hand,  general  paralysis  of  the 
insane  is  a  disease  in  which  temporary  aphasia  is  by  no  means  uncommon,  especially  in 
connection  with  tlie  transient  hemiplegia  following  '  congestive  "  attacks. 

Aphasia.  -A  definition  of  aphasia  is  difheult  to  supply  in  a  few  words.  The  term 
is  used  to  denote  that  loss  of  speech  which  does  not  depend  on  mental  deficiency,  nor  upon 
paralysis  of  the  motor  mechanism  of  articulation.  Such  a  negative  description  requires, 
liowever,  some  modification,  because  a]>hasia  is  frequently  associated  with  some  impair- 
ment of  intelligence  resulting  from  disturbance  of  internal  language,  which  plays  an 
important  part  in  all  intellectual  processes,  and  any  lesion  of  the  cerebral  centres  connected 
with  it  must  necessarily  interfere  with  the  higher  mental  activities.  This  is  particularly 
the  case  in  what  is  called  sensory  aphasia,  that  variety  which  depends  upon  a  lesion  of  the 
auditory  and  visual  word  centres  situated  in  the  cortex  near  the  posterior  part  of  the  left 
Sylvian  fissure  of  the  brain. 

In  riglit-handed  persons  the  chief  speech  centres  are  placed  in  the  left  cerebral  hemi- 
sphere (Fig.  206),  and  it  is  customary  to  consider  them  as  being  three  in  number.     The 


Cheiro-kinaistlietic 


Visual   word   centr 


Fig.  206. — Left  cerebral  hemisphere,  with  speech  centres. 


posterior  part  of  the  first  temporal  convolution  is  regarded  as  the  area  in  which  the  auditory 
memories  of  spoken  words  are  stored  and  recalled.  It  plays  an  important  part  in  the 
development  of  speech,  because  it  is  largely  through  tlie  sense  of  hearing  that  the  child 
first  learns  to  associate  objects  with  their  names  and  expressions  with  their  meaning.  The 
cortex  in  the  angular  gyrus  has  a  similar  special  function  in  regard  to  the  storage  of  visual 
word  memories,  a  function  which  bears  the  same  relationship  to  written  language  as  the 
auditory  word  centre  has  to  spoken  language.  These  two  portions  of  the  cortex  constitute 
the  sensory  speech  centres.  A  third  important  centre  is  called  the  motor,  or,  better,  the 
higher  kina?sthetic  centre,  and  this  is  located  in  Broca's  area,  or  the  posterior  part  of  the 
third  frontal  convolution.  In  this  situation  are  stored  the  memories  of  afferent  impulses 
excited  by  the  motor  activities  employed  in  speech.  Unless  this  centre  is  intact,  the 
conversion  of  internal  into  external  language  is  imperfect  or  impossible.  In  the  opinion 
of  some  authorities,  there  is  a  similar  kinsesthetic  centre  in  the  posterior  part  of  the  left 
second  frontal  convolution,  which  plays  a  ]3art  in  connection  with  written  language 
comparable  to  the  part  played  by  Broca"s  area  in  relation  to  spoken  language. 

With  these  physiological  and  anatomical  data  as  a  basis,  we  can  proceed  to  consider 
the  chief  varieties  of  aphasia  and  the  points  in  their  differential  diagnosis.  Before  doing 
so,  it  is  well  to  sound  a  note  of  warning  with  regard  to  the  complications  which  are  con- 
stantly being  met  with  by  the  clinician  in  attempting  to  analyse  cases  of  aphasia.  In  the 
first  place,  a  diagrammatic  anatomical  definition  of  the  cerebral  centres  is  liable  to  give 


SPEECH.     ABNORMALITIES    OF  625 

a  wrong  impression.  These  centres  are  more  diffuse  in  tlieir  function  than  they  appear 
to  be  on  a  map  of  the  brain,  and  they  are  much  more  interdependent  tlian  their  topography 
would  suggest.  C'ommimicating  nervous  tracts  bind  them  togetlier  in  such  a  way  that 
a  destructive  lesion  of  one  must  necessarily  upset  the  function  of  another,  and  so  modifv 
profoundly  the  clinical  picture  of  any  particular  case.  In  the  second  place,  aphasia  is,  in 
most  instances,  the  result  of  a  vascular  lesion,  and  all  the  centres  referred  to  lie  in  the  area 
supplied  by  one  artery — the  middle  cerebral.  Consequently  even  when  the  main  brunt 
of  a  vascular  disturbance  falls  on  one  of  the  special  speech  centres,  the  others  may  also 
suffer  more  or  less,  temporarily  or  permanently,  from  disturbances  of  nutrition.  In  any 
case  of  aphasia,  therefore,  we  may  have  to  be  satisfied  if  we  can  arrive  at  a  conclusion  as 
to  the  site  of  the  chief  defect,  without  being  able  to  define  the  exact  limits  of  the  loss  or 
impairment  of  cerebral  function.  In  the  third  place,  due  allowance  must  be  made  for 
the  fact  that  the  right  cerebral  hemisphere  may  gradually  acquire  some  degree  of  speech 
activity,  especially  in  cases  of  aphasia  occurring  during  the  earlier  years  of  life,  and  may 
tend  to  replace  the  loss  caused  by  the  defective  action  of  the  left. 

Word-deafness  is  the  result  either  of  a  lesion  of  the  au<litory  word  centre  in  the 
temporal  cortex,  or  of  one  which  isolates  that  centre  from  the  periphery  :  that  is  to  saj-, 
of  a  sub-cortical  lesion  cutting  off  the  centre  from  auditory  impulses.  In  either  case  the 
patient  who  is  word-deaf  is  unable  to  recognize  the  meaning  of  spoken  language,  although 
he  may  hear  perfectly  the  sounds  by  which  it  is  conveyed.  lie  fails  to  understand  anything 
which  is  said  to  him.  and  does  not  obey  simjile  commands  so  long  as  they  are  not  accom- 
panied by  gestures  suggestive  of  their  meaning.  If  the  visual  word  centre  has  not  been 
affected  at  the  same  time,  he  will  still  be  able  to  read  and  to  understand  wliat  is  written. 
He  will  depend  upon  writing  and  reading  for  his  means  of  communication  with  others. 
The  amount  of  interference  with  spontaneous  speech  will  depend  upon  whether  the  lesion 
is  cortical  or  sub-cortical.  If  the  latter  the  integrity  of  the  auditory  word  centre  ])reserves 
internal  speech,  and  so  permits  the  patient  to  s])eak  spontaneously  with  fluency  and  probably 
with  accuracy,  and  his  power  of  writing  will  be  equally  unimpaired.  When  the  corlica! 
centre  is  itself  destroye<l,  internal  language  is  thoroughly  disorganized,  and  although  some 
spontaneous  speech  may  be  possible,  it  is  certain  to  be  more  or  less  unintelligible.  .Accord- 
ing to  the  extent  of  the  lesion,  it  will  vary  between  a  speech  containing  inaccuracies  of 
minor  importance,  and  one  which  is  a  jargon  incapable  of  interpretation.  Characteristic 
of  this  defect  is  the  fact  that  the  patient  himself  does  not  appreciate  the  mistakes  he  makes. 
His  written  language  is  likely  to  be  more  accurate  and  more  intelligible  than  his  spoken 
language,  but  it  will  probably  not  reach  a  very  high  standard.  lie  may  copy  with  accuracy, 
but  is  quite  unable  to  write  from  dictation.  Such  are  the  usual  chief  attributes  of 
word-deafness  in  its  ])ure  form.  Clinically,  word-deafness  is  usually  accompanied  by 
word-blindness,  to  a  greater  or  less  e.xtenl. 

Word-blindness,  or  Alexin,  is  produced  by  a  lesion  of  the  left  angular  gyrus.  an<l  may  \ 
or  may  not  be  accompanied  by  defective  \isioii.  .Vs  in  the  ease  of  word-dcafncss.  it  may 
result  from  a  corlicMl  or  inim  a  sub-cortical  lesion,  and  it  is  in  assiiciation  willi  the  latter 
class  of  ease  that  I  Ii;\n  ANoesrA  (p.  ;{()())  is  most  conmion.  In  <<irliial  word-blindness  the^l 
patient  is  unable  to  read,  alllioiigh  lie  sees  the  letters  clearly  and  iiias  (•\en  be  able  to  copy  ' 
them  in  the  same  way  as  a  chihl  eopits  lellers  when  learning  the  alphalx-t.  Writing  conveys 
no  meaning  to  his  mind,  although  in  the  less  severe  cases  the  patient  may  still  recognize 
familiar  words,  such  as  his  name,  'i'liere  are,  in  fact,  varying  degrees  of  word-blindness, 
some  of  which  are  dillicult  to  understand  and  to  analyze.  The  wor(l-blin<l  patient  suffers 
in  his  spontaneous  speech  to  a  greater  or  less  extent  according  to  whether  he  uses  his  visual 
or  his  auditory  memories  cliiclly  In  the  piocess  of  internal  language  Slmulil  lie  be  a 
'visual"  his  spontaneous  spccili  will  sutler  riiucli  more  tlmri  if  he  is  an  "  inidil  i\  r.'  'I'lie 
terms  'visual'  and  "audilixc"  are  used  to  ilisi  inguisli  two  classes  of  peisons,  the  tirst 
(h'pending  more  on  their  visual  memories  of  words,  and  the  second  more  on  their  auditory 
memories  of  words  in  tlie  course  of  reviving  them  for  the  purposes  of  int<-rual  thought  and 
speech.  Spontaneous  writing  is  likely  to  be  lost  completely,  but  writing  from  dictation 
may  be  carried  out  with  more  or  less  accuracy.  In  word-blindness  due  to  a  sub-cortical 
lesion,  although  h<-mianopia  is  almost  certain  to  be  present,  spontaneous  speech  and  spon- 
taneous writing  arc  preserxcil  perfectly,  altliougli  the  power  of  reading  and  of  copying 
hand-written  sentences  into  printed  capitals  is  entirely  in  abeyance. 

t>  40 


026  SPEECH,     ABNORMALITIES    OF 

When  word-blindness  and  word-deafness  coexist,  the  condition  is  called  sensory  aphasia, 
and  is  one  to  which  some  authorities  belie\e  that  the  term  aphasia  should  be  limited.  It 
is,  however,  usual  to  describe  a  motor  aphasia  which  may  be  dependent  upon  a  cortical 
or  sub-cortical  lesion. 

Cortical  motor  aphasia  results  from  a  destructive  lesion  of  Broca's  area,  the  part  of 
the  cortex  which  stores  memories  of  the  afferent  impulses  excited  by  speech,  and  in. which 
such  memories  must  be  revived  if  spontaneous  speech  is  to  be  carried  out  perfectly.  This 
form  of  motor  aphasia  may  be  present  without  any  paralysis,  but  it  is  usually  accompanied 
by  some  disturbances  of  internal  speech,  and  perhaps  even  by  some  defective  understanding 
of  spoken  and  written  language,  which.  howe\er.  never  amounts  to  true  sensory  aphasia. 
Much  more  common  is  the  sub-cortical  motor  aphasia,  which  is  due  to  a  lesion  cutting 
off  Broca's  cortical  area  from  the  motor  mechanism  connected  with  articulation.  In  this 
form  intellectual  processes  and  internal  language  may  be  perfectly  intact,  but  in  most 
cases  the  inability  to  speak  is  associated  with  right  hemiplegia  in  right-handed  persons, 
or  with  left  hemiplegia  in  left-handed  individuals.  The  im[)erfect  speech  of  the  patient 
who  is  jjartly  aphasic  from  a  sub-cortical  motor  lesion  may  resemble  to  some  extent  that 
of  the  patient  who  is  word-deaf  ;  but  the  former  is  conscious  of  his  mistakes  and  the  latter 
is  not.  Sub-cortical  motor  aphasia  may  perhaps  be  described  better  as  an  articulatory 
rather  than  a  speech  defect  :  as  an  anarthria  rather  than  an  aphasia.  All  the  attributes 
for  speech  are  preserved,  but  its  emission  is  impossible. 

Agraphia  results  usually  from  a  lesion  of  the  visual  word-centre,  or  perhaps  in  some 
cases  from  a  lesion  of  the  posterior  part  of  the  left  second  frontal  convolution.  In  the 
former  case  the  power  of  wTiting  may  be  lost,  although  there  is  no  paralysis  of  the  arm 
or  hand.  In  the  latter  case  the  agraphia  is  usually  associated  with  right  hemiplegia,  and 
in  order  to  test  whether  the  power  of  communicating  thoughts  by  written  language  is 
preserved,  the  patient  must  be  asked  to  use  the  left  hand  for  the  purpose.  There  is  some 
doubt  as  to  whether  pure  motor  agraphia  occurs,  and  some  doubt  as  to  the  lesion  upon 
which  it  may  depend.  I  have  had  experience  of  the  clinical  occurrence  of  pure  motor 
agraphia  without  being  able  to  correlate  the  phenomenon  with  its  anatomical  basis. 

We  have  now  considered  the  various  forms  of  aphasia  and  have  indicated  their  points 
of  distinction.  This  will  serve  as  a  basis  for  diagnosing  the  site  of  the  lesion  responsible 
for  the  speech  defect,  but  the  nature  of  the  lesion  must  be  determined  from  other  considera- 
tions. Vascular  lesions,  for  instance,  are  usually  acute  in  their  onset,  sudden  in  the  case 
of  embolism,  less  ]3recipitate  as  a  rule  in  cases  of  hunnorrhage  or  thrombosis.  In  cerebral 
tumour  or  abscess  the  onset  of  symptoms  is  more  gradual,  and  local  troubles  such  as  that 
of  aphasia  are  generally  accompanied  or  preceded  by  the  symptoms  of  increased  intra- 
cranial pressure  in  the  form  of  headache,  vomiting,  and  ojatic  neuritis.  But  aphasia  is  , 
not  always  the  result  of  a  gross  and  permanent  lesion.  Transitory  aphasia  may  be  I 
observed  in  the  sequel  of  epileptiform  convulsions,  or  may  be  in  itself  an  epileptic  equivalent^ 
— a  form  oX  petit  mat  in  an  epileptic  subject.  Temporary  aphasia -occurs  also  in  connection 
with  migraine,  and  I  have  known  it  to  occur  at  intervals  during  a  period  of  thirty  years  iii 
a  woman  who  was  perfectly  healthy  in  every  respect,  and  who  showed  no  other  sym- 
ptoms suggestive  of  either  epilepsy  or  migraine. 

Dysarthria,  or  in  its  extreme  form  "  anartliria.'  is  the  term  used  to  describe  defective 
articulation  as  op]K)sed  to  defective  speech.  Articulation  is  carried  on  by  certain  muscles 
of  the  larynx,  i)harynx,  palate,  tongue,  and  lips  which  are  innervated  by  the  bulbar  nuclei, 
and  the  latter  are  set  into  action  by  voluntary  impulses  coming  from  the  motor  cortex  of 
both  cerebral  hemispheres  via  the  pyramidal  tracts.  The  articulatory  movements,  there- 
fore, are  represented  bilaterally  in  the  brain,  and,  like  other  bilaterally  represented  move- 
ments of  the  body,  are  not  disorganized  by  unilateral  lesions  of  the  pyramidal  system. 
Thus,  in. cases  of  hemiplegia  without  aphasia,  there  is  little  or  no  defect  in  articulation, 
and  the  examination  of  such  a  patient  shows  that  both  vocal  cords,  both  sides  of  the  palate, 
and  the  tongue,  retain  their  power  of  voluntary  movement  almost,  if  not  quite,  to  perfection. 
Suprabulbar  dysarthria  is  induced,  however,  in  cases  of  double  hemiplegia,  when  the 
fibres  from  both  hemispheres  to  the  bulbar  nuclei  are  interfered  with  by  destructive  lesions. 
When  a  right-sided  stroke  is  followed  by  a  left-sided  stroke,  or  when  double  hemiplegia 
results  from  a  lesion  in  the  pons,  dysarthria  results.  In  such  cases  the  power  of  speech 
may  be  perfect,  but  the  ability  to  articulate  naturally  and  clearly  is  disturbed.     The  patient 


SPEECH.     ABNORMALITIES    OF  627 

is  not  aphasic  but  dysarthric.  Articulation  is  usually  slow,  spastic,  and  indistinct,  if  it 
is  not  altogether  unintelligible.  These  cases  are  differentiated  from  cases  of  dysarthria 
due  to  lesions  of  the  bulbar  nuclei  or  of  the  cranial  nerves,  not  only  by  the  presence 
of  other  hemiplegic  signs  in  the  limbs  and  trunk,  but  by  the  fact  that  the  tongue  retains 
its  shape,  nutrition,  and  normal  electrical  reactions,  and  the  palate  its  natural  reflex.  This 
condition  of  pseudo-hiilbnr  palsy,  as  it  is  sometimes  called,  is  further  distinguished  by  facial 
starchine.ss  or  spasticity,  and  by  the  patient's  inability  to  control  the  expression  of  his 
emotions. 

Dysarthria  of  similar  origin,  but  generally  of  less  degree,  may  be  observed  in  cases 
of  oeneral  paralysis  of  the  insane,  in  cerebral  diplegia,  and  in  disseminated  sclerosis.  In  the 
latter  disease  the  terms  "  staccato  "  or  •  scanning  '  are  applied  to  describe  the  articulatory 
defect.  Some  cases  of  Friedreicli's  ataxy  exhibit  a  form  of  articulation  which  is  slow  and 
jerky,  not  unlike  that  of  disseminated  sclerosis.  Probably  some  degree  of  inco-ordination 
enters  into  the  production  of  this  peculiar  utterance.  In  all  these  diseases  the  diagnosis 
of  the  condition  depends  upon  the  presence  of  other  symptoms  and  physical  signs,  and  can 
rarely  be  deduced  from  the  articulation  alone. 

Dysarthria  also  arises  from  disease  of  the  bulbar  nuclei,  or  of  the  nerves  arising  from 
the  latter  which  supply  the  muscles  of  the  larynx,  pharynx,  tongue,  and  lips.  In  true 
bulbar  palsy,  which  is  a  disease  depending  on  a  slowly  progressive  degeneration  of  these 
motor  nuclei,  articulatory  defects  are  often  among  the  earliest  symptoms.  The  diagnosis 
of  these  cases  is  based  on  the  fact  that  the  symptoms  begin  insidiously  and  progress 
gradually,  that  the  paresis  affects  the  muscles  of  both  sides  more  or  less  symmetrically, 
and  that  it  is  an  atrophic  form  of  paralysis.  The  atrophy  is  seen  best  in  the  tongue  muscles, 
and  is  usually  associated  with  a  certain  amount  of  fibrillation,  and  with  diminution  of  their 
electrical  excitability.  The  palatal  reflex  is  also  impaired,  and  examination  of  the  vocal 
cords  shows  that  they  too  are  the  seat  of  a  progressive  palsy.  The  dysarthria  is  always 
accomijanied,  sooner  or  later,  by  some  degree  of  dysphagia,  and  also  by  some  weakness 
and  atrophy  of  the  muscles  of  mastication.  Atrophic  palsy  may  also  be  observed  in  the 
small  muscles  of  the  hands,  and  there  is  a  tendency  to  exaggeration  of  all  the  tendon  reflexes 
in  the  limbs.  A  similar  clinical  picture  may  develop  in  cases  of  gross  disease  of  the  bulb, 
due  either  to  local  softening  or  hicmorrhage,  or  in  rarer  cases  to  the  gradual  growth  of  a 
tumour  in  that  region.  Such  cases  can  be  differentiated  from  true  bulbar  palsy,  partly 
by  the  more  acute  onset  of  symptoms  in  the  case  of  the  vascular  lesions,  and  partly  by  the 
asymmetrical  distribution  of  the  muscular  atrophy  and  paresis  when  a  lunionr  forms  the 
basis  of  the  disease,  (inmmatous  meningitis  at  the  base  of  the  brain  may  involve  the  cranial 
nerves  close  to  their  exit  from  the  bulb,  and  so  produce  a  dysarthria  of  a  somewhat  similar 
character.  When  tumour  or  meningitis  are  the  cause  of  dysarthria,  symptoms  of  increased 
intracranial  pressure  are  likely  to  be  observed. 

Another  form  of  bulbar  palsy  Is  seen  in  cases  of  myasthenia  gravis.  In  this  condition 
there  is  little  or  no  atrophy  of  the  articulatory  muscles,  although  .some  thinning  of  the 
tongue  Is  observed  sometimes.  'I'he  rllstlnguisliing  characteristics  of  this  dysarthria  are 
first  of  all  its  marked  variability,  and  secondly  the  eliect  produced  by  fatigue.  .V  myasthenic 
patient  may  begin  a  eon\ersation,  or  may  begin  to  read  aloud  from  a  book,  without  sliowing 
nuich  difliculty  In  his  utterance,  but.  as  he  progresses,  liis  articulation  becomes  more  and 
more  defective  and  more  dlllicult  to  understand.  I'sually  tlu-  palate  fails  (juickly,  and 
a  nasal  (piallty  Is  given  to  the  voice.  If  he  Is  asked  to  repeat  the  word  •  rub  "  many  times, 
the  termitiiil  "  b  "  becomes  an  '  m,"  and  he  ends  by  saying  "  rum  "  Instead  of  '  rub.' 
-Most  cases  of  myasthenia  gravis  exhibit  snnllar  fatigue  phenomena  in  relation  to  other 
parts  of  the  musculature  (sec  Fig.  Ill,  |).  2:iii).  and  in  particular  show  varying  degrees  of 
ocular  palsy,  which,  like  the  dysarthria.  Is  at  one  time  more  marked  than  at  another,  and 
is  inueli  Inllueiiced  by  rest  and  exercise. 

.Some  articulatory  defect  Is  |)r<)duced  by  bihiliral  pcriphi  lal  palsy  ol  Ih'  palalc.  whicli 
most  often  results  from  the  elTeets  ol'  the  iliphlliiria  iinisiiii.  Tlu-  voice  is  nasal,  and  the 
promuiclatloii  of  certain  consonants  Ikiihtms  inipussihlc.  ■  |{  "  Incomes  "  ni,'  "d"  becomes 
'  n,"  and  "  k  "  sounds  like  '  ng." 

liilatend  facial  palsy  Interferes  with  that  part  of  articulation  which  de|)ends  upon 
the  labial  muscles,  and  so  renders  speech  Indistinct,  although  not  unintelligible.  Facial 
palsy  of  tills  kind  (l-'ig.  'iOI,   p.    f!);i)   is  met    with   in  some  eases  of  pcriplicral   neiuitis  and 


628  SPEECH.     ABNORMALITIES     OF 

also  in  some  cases  of  myopathy,  especially  that  form  to  whicli  the  name  Landouzy-Dejerine 
is  applied. 

I'nilaleral  bulbar  pnlsi/  may  exist  without  much  interference  with  articulation  or 
phonation.  There  may  be  considerable  palsy  of  one  vocal  cord  due  to  a  lesion  of 
one  recurrent  laryngeal  nerve,  without  a  recognizable  alteration  in  the  character  of  the 
voice.  .\  bilateral  laryngeal  palsy,  when  complete,  leads  to  aphonia.  Similarly,  unilateral 
palsy  of  the  palate  or  of  one-half  of  the  tongue  may  exist  without  articulatory  defect, 
especially  after  the  patient  has  become  accustomed  to  the  altered  conditions. 

Functional  Disorders  of  Speech. — In  cases  of  hysteria,  a  functional  aphonia  is  by 
no  means  unconuiion.  and  in  many  cases  can  be  distinguished  from  aphonia  due  to  organic 
disease  only  by  an  examination  of  the  larynx.  Hysterical  aphonia  may  be  complete  ; 
in  other  cases  the  voice  is  reduced  to  a  whisper,  and  yet  the  patient  is  able  to  adduct  the 
cords  properly  in  coughing.  This  is  sometimes  a  recurrent  malady,  and  the  suddenness 
of  its  onset,  as  well  as  the  suddenness  with  which  it  is  often  cured,  are  characteristic. 

Stammering  is  another  type  of  functional  dysarthria  and  presents  a  large  variety  of 
forms.  There  is  little  difficulty  in  their  recognition,  because  in  all  cases  when  once  the 
articulatory  flow  is  established  the  utterance  is  perfectly  normal.  The  difficulty  generally 
arises  either  in  commencing  a  word  or  a  sentence,  or  in  connection  with  certain  consonants. 
Some  of  the  cases  depend  on  an  initial  spasm  of  the  articulatory  muscles,  and  others  upon 
an  ineo-ordination  between  the  action  of  the  respiratory  muscles  and  those  which  have 
to  do  with  phonation  and  articulation.  The  complete  absence  of  physical  signs  of  disease, 
and  the  history  of  the  case,  make  the  diagnosis  easy.  On  the  other  hand,  stammering  is 
occasionally  an  early  symptom  of  progressive  degenerative  conditions  of  the  central  nervous 
system,  especially  of  general  paralysis  of  the  insane. 

The  term  '  killing  '  is  applied  to  a  defective  form  of  articulation  met  with  chiefly  in 
persons  who  are  more  or  less  mentally  feeble.  It  is  characterized  by  what  appears  to  be 
an  imperfect  pronunciation  of  certain  consonants.  In  more  severe  cases  one  consonant 
is  consistently  replaced  by  another,  such  as  •  r  "  by  ■  w."  These  mistakes  in  pronun- 
ciation are  common  enough  in  normal  children  when  learning  to  speak,  but  the  endurance 
of  the  defect  after  the  learning  age  is  passed  generally  indicates  some  permanent  mental 
deficiency.  A  temporary  perversion  of  speech  is  seen  occasionally  in  children  before  they 
learn  the  proper  use  of  language.  They  may  talk  glibly  and  fluently  in  a  language  which 
they  appear  to  understand  themselves  but  which  is  unintelligible  to  their  neighbours.  In 
this  condition,  to  which  the  term  •  idioglossia  '  is  generally  given,  the  prognosis  may  be 
regarded  as  favourable.  JC.  Farquhar  Buzzuril. 

SPINAL  CURVATURE.~(See  Curvatlkk.  Spinal,  p.  153.) 

SPLEEN,    ENLARGEMENT    OF    THE. 

The  Physical  Signs  of  Enlargement  of  the  Spleen. — If  the  organ  is  only  slightly 
or  moderately  enlarged,  there  is  no  alteration  in  the  size  or  shape  of  the  abdomen  ; 
if  it  is  considerably  or  enormously  enlarged,  the  abdomen  may  be  much  distended,  and 
at  a  first  glance  this  distention  may  appear  to  be  uniform,  as  though  due  to  ascites.  Closer 
inspection  may  show  tliat  it  is  by  no  means  uniform,  there  being  distinct  bulging  of  the 
left  side,  especially  in  tlic  left  hypochondrium,  the  left  lumbar,  and  the  left  half  of  the 
umbilical  regions.  The  inner  border  of  the  sjjleen  may  be  tilted  forward  in  some  cases, 
so  that  a  distinct  edge  or  ridge  may  be  seen  j)ushing  the  abdominal  wall  forward,  this  ridge 
running  downwards  and  inwards  from  the  left  costal  margin  near  the  anterior  axillary 
line  towards  the  umbilicus  ;  in  a  few  cases  a  distinct  notch  can  be  seen  in  this  edge  or  ridge. 
When  the  patient  takes  a  deep  breath,  the  prominence  may  be  seen  to  move  distinctly 
downwards,  though  occasionally  the  spleen  may  be  so  enormously  enlarged  that  its  lower 
end  becomes  impacted  in  the  jjclvis,  when  no  downward  movement  is  possible. 

Palpation  is  the  best  means  of  detecting  splenic  enlargement.  If  the  organ  is  but 
little  enlarged,  it  may  not  be  felt  until  the  observer,  standing  upon  the  left-hand  side  of 
the  recumbent  jsatient,  and  supporting  the  lower  left  ribs  posteriorly  with  his  right  hand, 
steadily  but  firmly  presses  the  fingers  of  his  left  hand  under  the  left  costal  margin  just  in 
front  of  the  anterior  axillary  line  ;  when  the  patient  now  takes  a  deep  breath,  a  definite 
sense  of  increased  resistance  may  reveal  splenic  enlargement  when  the  organ  is  comparatively 


SPLEEN'.     ENLARGEMENT    OP    THE  629 

soft,  as  in  niaiiy  cases  of  typhoid  fever  for  example,  or  a  hard  mass  with  a  distinct  edge 
may  be  felt  in  more  obvious  cases.  When  the  enlargement  is  moderate  or  considerable, 
the  splenic  tumour  will  be  felt  coming  down  from  beneath  the  left  ribs  close  behind  the 
abdominal  wall  :  and  unless  there  is  a  very  large  liver  at  the  same  time,  or  some  other 
cause  preventing  the  viscus  from  following  its  natural  direction  as  it  enlarges,  it  tends  to 
reach  and  ultimately  cross  the  middle  line  at  or  just  below  the  level  of  the  umbilicus.  It 
is  generally  smooth  and  firm,  and  the  characteristic  notch  or  notches  can  be  felt  in  its 
anterior  border.  Except  in  those  rare  eases  in  which  the  whole  spleen  is  dislocated,  it  will 
not  be  possible  to  insert  a  hand  between  it  and  the  left  costal  margin,  or  to  define  its  upjier 
limit  by  palpation.  The  lower  pole  can  be  felt  to  move  decidedly  downwards  on  inspira- 
tion, unless  the  enlargement  is  very  great.  On  bimanual  palpation,  the  loin  is  not  tilled 
out  as  it  would  be  by  a  renal  tumour,  and  the  mass  cannot  be  pushed  back  into  the  loin 
so  as  to  be  felt  by  the  posterior  hand  as  readily  as  it  is  by  the  hand  on  the  anterior 
abdominal  wall. 

Percussion  yields  a  dull  note  over  the  mass,  the  dullness  being  directly  continuous 
with  an  increased  area  of  dullness  in  the  thorax  extending  upwards  as  high  as  the  seventh 
rib  in  the  mid-axillary  line,  the  sixth  rib  in  the  nipple  line,  or  even  higher,  and  including  the 
ordinary  area  of  splenic  impairment  of  resonance  behind.  Percussion  of  the  left  loin  may 
elicit  resonance  here,  indicating  that  the  colon  is  not  displaced  as  it'  would  have  been  by 
a  renal  tumour  :    no  intestines  can  be  felt  or  percussed  over  the  front  of  the  spleen. 

-Auscultation  seldom  affords  much  evidence  of  value  in  these  cases,  but  sometimes 
when  the  splenic  enlargement  is  associated  with  local  jieritonitis,  as  in  cases  of  infarction 
for  example,  a  loud  rub  may  be  heard  over  the  mass  when  the  patient  takes  a  particularly 
deep  breath  ;  and  sometimes,  especially  if  the  enlargement  is  as.sociated  with  venous 
engorgement,  a  well-marked  continuous  humming  bruit  may  be  heard. 

Distinction  between  an  Enlarged  Spleen  and  other  Tumours  wliich  may  simulate 
it.  —  .-\n  enlarged  spleen  has  to  be  distinguished  from  other  tumours  which  may  arise 
in  the  left  liypoehondriac  region,  especially  from:— (1)  Kidney  tumours  or  perinephric 
inflammation  or  abscess  :  (2)  Suprarenal  tumours  ;  (3)  Carcinoma  of  the  splenic  flexure 
of  the  colon  ;  (4)  Pancreatic  lumoius.  especially  cyst  or  carcinoma  :  (.5)  Malignant  growth 
of  the  stomach  :  ((i)  Ovarian  tinnour  :  (7)  Tuberculous  peritonitis  ;  (8)  Pascal  accmnula- 
tion  in  the  colon. 

Disliiicliijii  frimi  ti  lientil  Tuinour. —  It  may  be  dillicult  to  <listinguish  an  enlarged 
s|)leeii  from  a  ki<liiey  in  some  cases.  Both  conditions  may  cause  local  |)rominence  or 
bulging  of  the  left  side  of  the  abdomen  :  in  the  case  of  splenic  enlargement  the  bulging  is 
more  forward  and  inward,  whereas  in  a  kidney  enlargement  the  loin  is  more  likely  to  be 
bulged.  No  distinct  edge  or  notch  can  be  seen  or  felt  in  the  case  of  most  renal  enlargements, 
a  point  the  significance  of  which  cannot  be  over-estimated.  Either  tumour  may  move 
downwards  when  the  patient  takes  a  deep  breath  :  but  the  spleen,  being  in  closer  contact 
with  the  imder  surface  of  the  diajjhragm.  moves  the  more  markedly  of  the  two.  .\  renal 
tumour  being  more  ileeply  silualcd  in  the  abdomen  seldom  ajjproximates  closely  to  the 
anterior  iibdomina!  wall  unless  flic  cnlargemcnl  is  very  great,  in  which  case  the  loin  will 
be  filled  out  and  feel  very  firm  and  resistant  on  bimanual  examination.  .V  renal  tumour 
generally  slopes  away  as  it  approaches  the  ribs,  so  that  it  is  less  didicull  to  get  one's  hand 
between  its  upper  pole  and  the  eostaV  margin  than  is  the  case  with  the  undislocated  spleen. 
The  colon  may  be  seen  or  felt  over  the  anicrior  smface  of  a  renal  tumour,  which  is  ne\cr 
the  ease  with  splenic  enlargement  ;  and  percussion  may  yield  a  resonant  note  in  front,  or 
in  typical  cases  a  vertical  band  of  colonic  resonance  down  the  centre  of  an  otherwise  dull 
mass,  the  loin  jiosteriorly  being  dull  ;  whereas  with  a  splenic  tumour  the  loin  may  be 
resonant,  and  the  anterior  aspect  of  the  mass  quite  dull.  The  presence  of  a  local  l)ruit 
or  rub  would  make  renal  tumour  unlikely.  The  occurrence  of  II.iCMArrniA  (p.  27.5). 
PviuiA  (p.  .■)7t).  or  .Ai.niMiNiiUA  (p.  4).  would  suggest  renal  enl:irgement.  whilst  the 
contlitions  of  the  l)!oo(l  miglit  be  such  as  to  suggest  splenic-. 

Not  withstanding  ;'.ll  these  points,  to  distinguish  between  splenic  and  renal  masses  is 
sometimes  by  no  means  easy  :  anil  it  is  only  bv  paying  careful  attention  to  the  history 
and  the  patient's  own  sensations,  as  well  as  tn  the  physical  signs  and  the  changes  in  the 
blood  and  urine,  that  a  correct  di;vgno-;is  can  be  made. 

MalitliKinl    Dinrnsc   (if   llic    Left    Siiprdiciial    (ihnid  may   eausr  a  large  mass  which   is 


630  SPLEEN,     ENLARGEMENT    OF    THE 

sometimes  particularly  difficult  to  distinguish,  either  from  a  splenic  or  from  a  renal  enlarge- 
ment. Owing  to  the  close  proximity  of  the  suprarenal  capsule  to  the  kidney,  and  the 
liability  for  the  capsule  of  the  latter  to  become  infiltrated  by  growth  of  the  former,  the 
physical  signs  of  a  suprarenal  are  practically  the  same  as  those  of  a  renal  tumour,  except 
that  it  may  be  more  difficult  to  pass  the  hand  between  the  mass  and  the  costal  margin. 
Haematuria  and  other  urinary  changes  may  result  from  spread  of  the  disease  to  the  kidney  ; 
affection  of  one  suprarenal  gland  alone  does  not  produce  Addison's  disease,  and  it  may  be 
impossible  to  arrive  at  a  correct  diagnosis  without  laparotomy.  A  peculiar  affection  of 
chil(h-en  deserves  special  mention  :  at  a  comparatively  early  age  tliere  may  be  an  abnormal 
development  of  the  pubic  and  axillary  hair  and  of  the  genital  organs  (see  Figs.  174.  175. 
p.  408).  with  premature  puberty,  associated  with  overgrowth  of  suprarenal  rests  in  the 
kidney,  the  resultant  tumour  being  spoken  of  as  a  hypernephroma. 

Carcinoma  of  the  Splenic  Flexure  of  the  colon  is  usually  annular,  giving  rise  to  no 
definite  tumour,  but  rather  to  symptoms  of  chronic,  followed  by  acute,  intestinal  obstruc- 
tion. Occasionally,  however,  the  growth  may  be  more  voluminous,  or  it  may  have  caused 
leakage  and  inflammatory  matting  from  local  perforation  through  or  above  the  growth, 
with  the  residt  that  a  fairly  large  tumour  may  be  felt  in  and  below  the  left  hypochondrium. 
This  mass  is  generally  resonant  to  percu.ssion,  has  no  well-defined  edge  or  notch,  and  may 
vary  somewhat  in  position  from  day  to  day  :  it  will  usually  be  associated  with  intestinal 
symptoms,  especially  constipation  alternating  with  diarrhoea,  and  the  passage  of  mucus, 
and  occasionally  blood,  per  rectum.  Sometimes  there  are  obvious  secondary  deposits  in 
the  liver  or  in  the  lef!  su])raclavicular  glands. 

Pancreatic  Tumoars  are  usually  situated  more  in  the  median  line  of  the  abdomen  than 
is  a  spleen,  between  the  ensiform  cartilage  and  the  umbilicus  ;  sometimes,  however,  a  very 
large  cyst,  such  as  may  nearly  fill  the  abdominal  cavity,  may  cause  considerable  difficulty 
in  the  diagnosis.  One  very  important  point  is  that  no  definite  edge  and  no  notch  can  be 
felt.  The  stomach  generally  lies  in  front  of  a  pancreatic  cyst  :  or,  if  the  latter  pushes  its 
way  forward  so  as  to  displace  the  stomach  upwards  and  tlie  transverse  colon  downwards, 
it  may  be  possible  to  define  its  relationship  to  the  stomach  by  inflating  the  latter  with  gas. 
A  splenic  tumour  rarely  extends  to  the  right  of  the  middle  line  unless  the  enlargement  is 
great,  and  then  it  crosses  at  or  below  the  umbilicus,  whereas  a  pancreatic  cyst  reaches 
across  to  the  right  of  the  middle  line  above  the  navel.  Pancreatic  new  growth  has  a  similar 
position  ;  but  the  outline  of  the  mass,  if  any  can  be  felt  at  all.  is  more  nodular  ;  there  will 
generally  be  jaundice  and  a  palpable  gall-bladder,  and  the  urine  may  yield  Cammidge's 
pancreatic  reaction  (p.  100). 

Malignant  Growth  of  the  Stomach  may  be  mistaken  for  enlargement  of  the  spleen, 
especially  gastric  sarcoma,  which,  though  very  much  rarer  than  carcinoma,  is  more  likely 
to  involve  the  whole  of  the  stomach  and  give  rise  to  a  very  large  tumour  occupying  chiefly 
the  up]jer  part  of  the  left  side  of  the  abdomen.  The  following  changes  will  serve  to 
distinguish  a  gastric  new  growth  from  enlargement  of  the  sjjleen  :  the  mass  is  apt  to  shift 
its  position  during  the  course  of  an  examination  or  from  day  to  day  ;  it  does  not  present  a 
well-defined  edge  with  definite  notch  or  notches  :  it  may  extend  a  considerable  distance 
to  the  right  of  the  middle  line,  although  its  lower  limit  may  not  be  below  the  level  of  the 
lunbilicus  ;  it  is  likely  to  be  resonant  in  front,  though  the  percussion  note  over  it  may  be 
impaired  ;  there  may  be  anaemia  and  leucocytosis,  but  the  blood-changes  would  not  be 
cluuiictcristic  of  any  positive  blood  disease  ;  the  taking  of  food  may  cause  an  increase  in 
the  gastric  pain  ;  vomiting  will  generally  be  a  prominent  symptom  ;  the  vomit  may 
contain  blood,  obvious  or  occult  ;  free  hydrochloric  acid  may  be  deficient  or  absent  ; 
sarciuie  ventriculi  may  be  found  {Fig.  121,  p.  241)  ;  and  there  may  be  secondary  deposits, 
especially  in  the  liver  or  in  the  left  supra-clavicular  glands.  Examination  of  the  stomach 
with  the  a'-rays  after  a  bismuth  or  barium  meal  may  also  assist  the  diagnosis  (Fig. 
131,  p.  270). 

Ovarian  Tumours  have  been  mistaken  for  enlargement  of  the  spleen,  and  vice  versa, 
the  differential  diagnosis  being  particularly  difficult  in  cases  in  which  the  spleen  has  become 
dislocated,  or  is  so  large  as  to  reach  down  as  far  as  the  uterus.  The  organ  has  sometimes 
been  found  so  dislocated  as  to  lie  wholly  within  the  pelvis.  The  differential  diagnosis 
depends  in  most  cases  on  the  following  points  :  an  ovarian  tumour  rarely  extends  upwards 
to  such  an  extent  that  its  u])|)er  limit  comes  into  actual  contact  with  the  left  costal  margin 


SPLEEN.     ENLARGE3IENT    OF    THE  631 

so  that  the  liand  cannot  be  placed  between  it  and  the  iil)s  ;  it  does  not  move  much 
downwards  durinj;-  deep  inspiration  :  it  extends  npwards  from  the  |)el\  is.  whence  it  may  be 
felt  definitely  to  arise,  the  lower  part  of  the  abdomen  being  more  prominent  than  the  upper  : 
it  is  usually  more  globular  than  a  splenic  tumour,  and  has  no  sharj).  well-d<'fuied  edge  with 
notches  in  it,  even  when  covered  with  projecting  bosses  of  simple  or  malignant  new  growth  ; 
it  usually  extends  more  to  the  right  of  the  middle  line  than  an  enlarged  spleen  ;  and  it  is 
more  apt  to  transmit  aortic  pulsations  ;  a  vaginal  examination  may  determine  that  the 
mass  is  attached  to  one  or  other  of  the  broad  ligaments,  and  that  the  cervix  and  the  body 
of  the  uterus  are  drawn  upwards  :  there  will  probably  be  no  distinctive  blood-changes, 
but  very  likely  amenorrlKca. 

Tubercidoiis  Peritonitis  may  cause  various  abdominal  tumours  (see  p.  48),  and  some- 
times gives  rise  to  a  mass  occupying  the  left  hypochondriac  region,  the  result  of  matting 
together  of  the  intestines,  thickening  of  the  omentum,  or  thickening  and  infiltration  of  the 
peritoneum  attached  to  the  abdominal  wall  here.  The  tumour  does  not  generally  extend 
close  up  under  the  ribs,  so  that  the  li:ind  may  be  placed  between  it  and  the  costal  margin, 
and  altliough  it  may  feel  somewhat  rounded,  with  a  more  or  less  well-defined  edge,  there  is 
no  definite  notch  to  be  felt  :  sometimes,  however,  when  there  are  two,  three,  or  more 
separate  masses  united  together,  a  notch  may  be  simulated  to  some  extent.  The  mass 
itself  may  be  dull,  but  there  is  generally  resonance  between  it  and  the  normal  splenic  dull- 
ness. Ascites  is  often  present,  and  there  may  be  palpable  Iumi)s  in  other  parts  of  the 
abdomen,  or  perhaps  redness  and  oedema  of  the  abdominal  wall,  or  a  purident  or  faecal 
discharge  from  the  umbilicus.  Indeed,  tubercidous  peritonitis  is  the  conuiioncst  cause  of 
acquired  imibilical  fistula,  the  next  commonest  cause  of  the  latter  being  pneumococcal 
peritonitis  which  has  recovered  slowly,  either  without  or  with  operation.  There  may  be 
signs  of  tuberculosis  elsewhere,  for  instance  in  joints,  or  lymphatic  glands.  ('almctte"s  or 
von  Pirquet's  tuberculin  reactions  may  be  positive.  The  patient  will  generally  be  young, 
and  have  consumcrl  unsterili/erl  cow's  milk.  I'vrexia  may  be  present  or  absent,  either  with 
tuberculous  peritonitis  or  with  splenic  aliections,  so  that  its  occurrence  does  not  assist  the 
diagno.sis  much,  except  perhaps  that  if  the  chart  exhibits  marked  evening  pyrexia  in  a  young 
subject,  with  a  sub-normal  temjieraturc  in  the  morning,  it  is  an  additional  argument  in 
favour  of  tubercle.  The  reverse  type  of  pyrexia — morning  rise  and  evening  fall — has  been 
spoken  of  as  characteiistic  of  tubercle,  but  it  is  seldom  met  with. 

Fa'cnl  Acciiniiilfitioii  in  tlie  Splenic  Flexure  or  adjacent  parts  of  the  transverse  or 
<lescending  colon  may  be  mistaken  for  an  enlarged  si)leen  upon  a  first  examination  ;  but 
this  source  of  error  is  usually  removed  when  the  patient  is  re-examined  after  an  action  of 
the  bowels  has  taken  place.  The  condition  is  found  most  fretiuently  in  women  if  the  age 
is  not  great,  or  in  elderly  people  of  cither  .sex.  There  is  generally  a  history  of  severe 
obstipation,  and  jiossibly  atlacks  of  temporary  obstruction.  The  mass  is  generally  irregular, 
more  or  less  cylindrical,  and  in  thin  persons  il  may  be  possible  actually  to  alter  its  shape  by 
manipulation  with  the  hand.  The  best  test  oC  the  condition,  however,  is  the  eirccf  of 
copious  enemata  upon  the  mass. 

II(emiit(mi(i  due  to  lAdkasle  from  an  .Mi(l(iinin<tl  .intiiriism  is  by  no  means  always  easil\ 
recognized.  i>.nd  it  may  be  mistaken  for  an  enlargement  either  of  the  spleen  or  of  the  kidney, 
unless  the  aneurysm  itself  can  be  felt  pulsating  ;  or  unless  there  is  a  history  or  an  acute 
I  xaccrbatioii  of  intra-abdominal  pain,  accompanied  by  blanching  due  to  the  amoimt  of 
blood    losl. 

Cm  si:s    oi-    Sei,r;NK'     I'Xi.Aruii'.Mi'.Ni'. 

Having  coMcluilcd  tli;il  llic  spleen  is  enlarged.  Ilie  ne\l  step  is  to  dceide  llii-  cause  of 
I  lie  etilargcMK'rit.  Tliere  ;irc  \;iiious  ways  in  which  the  diMercnl  causes  may  be  classified, 
l)Ml    from  a  diagnoslic  poiril  of  \  iew  Ihc  following  is  ser\iceable  :  — 

I.  Chronic  Enlargement  of  the  Spleen. 

(«).    On/  great  enlargement  : 
S|)leiMiiiie<lullarv  leukicniiu 
l-ynipliiilic  leiik;i-mia 
Mixed   leuku'inia 
Chronic  malaria 
Kala-.i/.ar 

SpleiiDinegalie   pdlycytlueniia 
SplcnoMie^alie  cinliosis 


.Spleni.-   MM.e 
INeiiilo-UiiUi 

'iiii; 

ill 

alltl 

(iauilier's  <li 
SI  ill's   (liseas 

M'M' 

Kainillal   aeh 

iliir 

>■  ,i- 

imkI 

ICjixptiMri   sp 

eiicpr 

!> 

632  SPLEEN.     ENLARGEMENT    OF    THE 

(h).  Motkratc  enlargement. — All  conditions  mentioned  in  <;rou|)  (n)  will  at  some  stage 
exhibit  a  spleen  that  has  not  yet  become  enormous  ;  and  besides  these,  chronic  and  moderate 
enlargement  of  the  spleen  may  be  exhibited  in  eases  of  : — 

Pernicious  anieniia  ;  Thrombosis  of  tlie  portal  vein 
Rickets  Pressure  on  the  portal  vein  by 
Congenital  syphilis  I  enlarged  lym])hatic  glands  or  by 
Hodgkin's  disease  I  adjacent  tumour  of  the  gall- 
Cirrhosis  of  the  liver  ;  bladder,  liver,  pancreas,  stomach, 
Lardaceous  disease  etc. 

II.  Acute  Enlargement  of  the  Spleen,  the  enlargement  as  a  rule  being  slight. 

(a).  Acute  infective  fevers  : 

Especially — 

Tvphoid   fever  Malaria 

l'Miiity|)h()id   fever  .Alalta   fever 

He!aiisinf>    fever  Erysipelas 

Typhus  fever  Septiea-iuia.  • 

Less  often  in — 

Pneumonia  Klieunvitic  fever 

Diphtheria  I  Influenza 

Scarlet   fever  General  tuberculosis. 

Sniall-pox 

(b).  Embolism,  especially  in  cases  of  fungating  endocarditis. 

(c).   Injiirt). 

(d).  Sirangnlntio))  by  twisting  of  the  pedicle. 

It  will  be  noted  that  no  mention  is  made  of  abscess,  gunnna,  carcinoma  (whether 
primary  or  secondary),  sarcoma  (primary  or  secondary),  or  hydatifi  cyst  of  the  spleen,  for 
these  are  all  so  exceedingly  rare  they  are  very  unlikely  to  be  met  with.  It  will  also  be  noted 
that  no  mention  is  made  of  backward  pressure,  whether  due  to  chronic  valvular  disease 
(if  the  heart  with  failing  compensation,  or  to  obstruction  to  the  inferior  vena  cava  above 
the  hepatic  veins,  such  as  may  result  from  thrombosis  or  from  pressure  uijon  the  veins  by 
mediastinal  fibrosis  or  new  growth  ;  these  conditions  are  omitted  purposely,  for  it  i.s  quite 
exceptional  for  ordinary  backward  pressure  to  produce  enlargement  of  the  spleen.  So 
true  is  this  that  in  a  case  of  chronic  valvular  heart-disease  with  failing  compensation  the 
existence  of  a  definitely  palpable  spleen  is  evidence  of  there  being  more  than  mere 
mechanical  heart-failure — probably  .superposed  fungating  endocarditis.  The  chief  excep- 
tions to  this  occur  in  childhood,  where  the  spleen  becomes  palpable  more  easily  than  in 
adults,  so  that  with  heart-failure  in  a  child  enlargement  of  the  spleen  is  less  good  evidence 
of  fungating  enilocarditis  than  it  is  in  a  gniwn-up  |xrsr)n. 

I.  CHRONIC  ENLARGEMENT  OF  THE  SPLEEN. 
Chronic  and  very  great  Enlargement  of  the  Spleen. — When  the  spleen  is  so  large 
as  to  occujjy  half  the  abdomen  or  more,  the  diagnosis  is  generally  easy.  The  largest  of  all 
spleens  are  those  due  to  splenomeduUary  leulnemia.  The  first  step  is  tp  make  a  full  examina- 
tion of  the  blood,  including  particularly  total  and  differential  leucocyte  counts.  If  there 
is  an  extreme  degree  of  leucocytosis,  up  to  anything  between  50,000  and  1.. 500,000  per 
e.nim.  for  example,  the  diagnosis  is  almost  certainly  leuka-mia,  and  if  in  the  differential 
leucocyte  count  there  are  from  20  per  cent  to  50  per  cent  of  myelocytes,  it  is  of  the  spleno- 
meduUary type,  whilst  if  the  lymphocytes  amount  to  90  per  cent  or  more,  the  disease  is  of 
the  h/mpliatic  form,  in  which  the  lymphatic  glands  are  almost  certain  to  be  enlarged  as  well 
as  the  spleen  ;  in  some  ca.ses  of  lymphatic  leukiemia  the  latter  may  be  scarcely  enlarged 
at  all,  but  in  others  it  may  be  almost  if  not  quite  as  large  as  in  the  splenomeduUary  type 
of  the  di.sease.  For  mixed  leuka?mia,  see  .\n.e.mia  (p.  25).  In  the  absence  of  any  marked 
leucocytosis,  or  of  characteristic  differential  leucocyte  counts  (see  also  An.emia),  the 
diagnosis  of  the  nature  of  a  very  large  spleen  will  depend  in  the  first  place  upon  whether 
there  has  or  has  not  been  residence  in  a  nudarial  region — the  fen  districts  of  Great  Britain, 
the  tropics,  or  certain  parts  of  Europe,  particularly  Italy.  The  ague-cake  spleen  of  the 
fens  is  now  very  rare  ;  it  is  more  often  found  in  chronic  cases  of  tropical  malaria,  when 
the  history  may  indicate  its  nature,  and  if  the  ]xiticnt  is  having  febrile  attacks,  the  parasites 


SPLEEN.     ENLARGEMENT    OF    THE 


633 


iPldte  XWIII.  Fias.  A.  B.  C.  D,  E  p.  614)  may  be  found  in  the  blood.  Recent  investi- 
gations have  shown  that  some,  at  least,  of  the  enlarged  spleens  formerly  attributed  to 
malaria,  are  due  to  other  infections.  One  of  these  has  been  differentiated  clearly  from 
the  rest,  namely  Kald-azar.  which  occurs  in  India,  iiarticularly  in  Assam,  in  Africa,  and 
in  Sicily,  and  is  diagnosed  chiefly  by  the  discovery  of  the  Leishman-Donovan  bodies  in  the 
fluid  obtained  by  splenic  puncture  (Plate  XXl'III.  Fig.  II,  p.  614). 

Splenoimgalic  poli/ct/tlHPmia  is  a  rare  affection  of  adults,  characterized  by  more  or  less 
cyanosis  (Philc  XXIX,  p.  634)  and  symptoms  which  might  suggest  a  cardiac  lesion,  together 
with  more  or  less  enlargement  of  the  spleen,  and  polycythiemia  amounting  perhaps  to  six, 
seven,  ten,  or  even  twelve  million  red  corpuscles  per  c. mm.  The  malady  is  generally  chronic, 
extending  over  years  :  with  an  insidious  onset  and  slow  progress.  The  first  symptoms  are 
vague,  with  progressive  loss  of  working  power,  and  some  shortness  of  breath  on  exertion. 
Ha»morrhages  may  occur  early,  or  at  any  stage  of  the  malady  ;  especially  bleeding  from 
the  mouth,  epistaxis.  haemoptysis,  hsematemesis,  haematuria,  or  melaena.  Purpura  is 
not  common.  The  patient's  heart  is  generally  hypertrophied  and  dilated  to  some  extent, 
with  or  without  a  systolic  apical  bruit  ;  and  the  blood-pressure  is  above  the  normal — it 
may  be  anything  between  150  and  "250  mm.  Hg.  The  patient  does  not  usually  waste. 
He  may  develop  effusion  into  any  of  the  serous  cavities.  The  diagnosis  is  arrived  at  when 
polycythemia  and  enlargement  of  the  spleen 
occur  in  the  absence  of  any  definite  cause. 

SplenomegaUc  cirrhosis  is  an  affection 
of  children  and  young  adults,  in  whom 
there  are  likely  to  be  more  or  less  jaundice, 
anccmia.  lack  of  development,  and  ultimately 
ascites,  as  well  as  considerable  enlargement 
of  the  spleen.  There  is  a  tendency  for  this 
malady  to  affect  more  than  one  member  of 
a  family,  and  this  sometimes  gives  the  clur 
to  the  diagnosis.  Wlien  diatli  ultiniatclv 
ensues,  in  addition  to  the  great  enlargenuni 
of  tlie  spleen  these  cases  exhibit  more  or  less 
fibrosis  or  cirrhosis  of  the  liver,  and  .some- 
times the  liver  is  indistinguishable  from 
that  of  ordinary  alcoholic  cirrhosis.  Wli  it 
relationship  this  malady  has  to  ordinary 
alcoholic  cirrhosis  of  the  liver  on  the  one 
hand,  and  to  splenic  ananii.i  or  IJantis 
disease  upon  I  lie  other,  is  not  clear  ;  but 
owing  to  the  cnlMrgenient  of  the  spleen,  it 
is  dilicR'ntiatcd  as  splcnoniegalic  cirrhosis. 
Ha-morrhages.  partieiilarl\'  haniatcinesis. 
are  not  infre(|tieiit  in  this  as  in  other  forms 
of  cirrhosis  of  the  liver.  The  blood-changes 
are     merely     those    of    a    simple    chlorolic 

ana-mia.  The  diagnosis  is  aliorded  chiefly  by  the  age  of  the  patient,  by  the  size  of  the 
spleen,  and  by  the  absence  of  any  positive  blood-changes,  particularly  if  more  than  one 
member  of  thi'  finiily  is  alTeeterl  in  the  same  way.  The  patient  often  lives  for  a  number 
of  years,  and  is  able  to  work  in  spile  oC  I  he  cuniplaiiil .  urilil  Mscites  supervenes.  The 
fingers  may  be  clubbed. 

S/ilciiii-  (iiKfiiiid  has  been  discussed  undei-  .\\.i;\ii\  (p.  ;17|.  The  spleen  is  not  as 
a  rule  \(i\  uiiall\  enlarged,  though  sometimes  it  iii;iy  be  enonniiiis  (/•'/;;.  -.'(iT).  'I'he  blood 
changes  are  simply  those  of  progressive  and  se\cr<'  anamia  of  a  elilorolie  type:  even 
though  there  ma\  really  be  a  disease  meriting  the  distineti\c  teiin.  "splenic  ana'inia.' 
not  a  few  cases  diagnosed  as  such  on  aeeouni  of  the  co-existence  of  splenic  enlargement 
with  simple  aiKcniia.  nllini;!lel\  turn  nut  to  be  cirrhosis  of  llie  liscr.  Whin  llial  which  is 
re;illy  cirrhosis  of  the  li\cr  is  diaynosed  in  its  early  stages  as  splenic  ananiia.  I  he  condition 
is  leinierl  /liiidi's  ili.^irisr.  One  pailieiijiir  variety  ul  l.'iiiiilial  splc-nie  :iii;eiiiia  ol  yoiHlg 
l)ersons  lias  lic'ii   disi  ingiiislieil    IViiiii   llir   rest   .-is  (idiiclicr' s  disiiisc.      II    runs  a  course  very 


Jul  ^ 

..7.    -.-^pleni 
f   the   Splcoi 

iiiiatniiti :  pliutO!,'raph  showing  thr- 
.     TherG  was  sc-vitl-  chiorotie  juimini-i 

without 
here  was 

(Micucylosis 

;  the  patiout  liiLMt,  ami  al  the  autopsy 
s  of  the  Uver. 

634  SPLEEN.     ENLARGEMENT    OP    THE 

similar  to  that  of  familial  acholuric  jaundice  (see  below),  but  is  distinguished  during  life  by 
the  occurrence  of  a  peculiar  fat-like  deposit  under  the  exposed  part  of  the  conjunctiva 
external  to  the  cornea  ;  and  after  death  by  the  presence  of  special  Gaucher  cells  in  the 
spleen  and  liver.     It  is  rare. 

Pseudo-leiikccmia  infantum  (von  .Jaksch's  Disease)  was  until  recently  regarded  as, 
apart  from  true  leukicniia.  almost  the  only  cause  of  very  great  enlargement  of  the  spleen  in 
young  children  {Fis-  13.  p.  37).  It  is  diagnosed  by  the  severity  of  the  an.xmia,  which  is  of 
the  indeterminate  chlorotic  tyjie  without  great  leucocytosis.  but  with  all  the  changes  that 
are  to  be  expected  in  any  severe  anaemia  (pp.  21,  22)  developing  in  an  infant  of  a  year  old 
or  less,  running  a  chronic  course,  but  sometimes  resulting  in  complete  recovery.  It  is  prob- 
able that  von  Jaksch's  disease  (splenomegaly  and  anaemia  in  a  child)  is  not  a  disease  but  a 
syndrome,  and  that  it  includes  cases  in  which  these  symptoms  are  due  ti>  different  causes  ; 
in  some  this  is  congenital  syphilis,  as  proved  by  VVassermann's  test  :  others  with  a  negative 
Wassermann  reaction  are  probably  related  to  the  splenic  anaemia  of  adults  :  others  are 
familial  acholuric  jaundice  :  others,  Gaucher's  disease  :  while  some  are  due  to  obscure 
causes  not  yet  elucidated. 

One  clinical  point  of  interest  which  may  assist  some  day  in  separating  these  cases 
into  more  definite  groups  is  that  some  show  undue  fragility  of  the  red  corpuscles  and  others 
do  not  ;  this  fragility  is  tested  by  putting  a  drop  or  two  of  the  patient's  blood  into  succes- 
sively weaker  solutions  of  salt  until  the  point  at  which  laking  occurs  is  found  :  the  nearer 
to  normal  saline  this  point  is,  the  greater  the  fragility  of  the  cells.  In  one  group,  with 
normal  fragility  undue  destruction  by  some  toxic  agent  in  the  patient  is  taking  place  ; 
in  another,  the  fragility  of  the  corpuscles  is  a  main  cause  of  the  anaemia. 

Slill's  Disease  is  really  subacute  generalized  rheumatoid  arthritis  of  children  (Fig. 
169,  p.  377)  associated  with  wasting,  moderate  enlargement  of  most  of  the  superficial 
lymphatic  glands,  and  in  some  cases  considerable  enlargement  of  the  spleen.  The  latter 
is  not  essential,  however,  and  in  any  case  it  is  the  affection  of  the  joints  that  attracts  chief 
attention.     The  patient  may  be  completely  crippled. 

Familial  Acholuric  Jaundice  is  in  many  respects  similar  to  splenomegalic  cirrhosis 
of  children,  described  above  ;  without  laparotomy,  or  post-mortem  examination,  it  may 
be  impossible  to  be  certain  whether  the  enlarged  spleen  is  accompanied  by  cirrhosis  or  not. 
The  disease  affects  se\eral  children  in  the  same  family  as  a  rule,  runs  a  chronic  course, 
beginning  soon  after  birth  but  permitting  of  survival  for  many  years.  The  patient  might 
be  described  as  delicate  rather  than  ill,  with  more  or  less  ana-mia  of  chlorotic  type,  a  facies 
reminiscent  of  that  of  pernicious  anaemia,  no  great  wasting,  a  distinctly  icteric  tinge 
of  the  skin  and  conjunctivae,  without  any  bile-staining  of  the  urine,  which  remains  of  a 
normal  colour  ;  considerable  enlargement  of  the  spleen  and  often  of  the  liver  also  :  some 
of  these  cases  give  a  positive  Wassermann  reaction,  others  do  not  ;  the  congenital  syphilitic 
type  is  held  by  some  to  be  quite  distinct  from  true  familial  acholuric  jaundice.  Splenec- 
tomy has  cured  a  certain  number  of  these  eases. 

Egyptian  Syjleninnai<dti  is  a  disease  affecting  natives  in  Egypt,  clinically  very  similar  to 
splenic  anaemia,  l)ut  thought  to  be  due  to  infection  by  a  jirotozoon  not  yet  discovered, 
though  perhaps  related  to  either  malaria  on  the  one  hand  or  to  trypanosomiasis  upon  the 
other.  It  runs  a  chronic  course  for  some  years,  but  ends  like  cirrhosis  of  the  liver  with 
ascites,  pyrexia,  and  cachexia.     The  spleen  may  be  enormous. 

Chronic  Enlargement  of  the  Spleen,  the  enlargement  being  of  moderate  size. 

It  is  clear  that   cunditions  which   may    sometimes  jiroduce  great  enlargement   of   the 
spleen  must  go  through  a  jihase  in  which  the  spleen  is  not  yet  enormous,  and  at  this  stage  all 
those  diseases  that  have  just  been  discussed  will  come  into  the  present  group.     The  remarks 
already  made  need  not  be  repeated  here,  however,  for  the  diagnosis  at  the  stage  in  which 
the  spleen  is  yet  only  moderately  big  is  arrived  at  in  the  way  already  described.     A  blood-J 
count  is  essential  in  order  to  exclude  or  diagnose  leukaemia  :    parasites  may  be  discovered 
to  account  for  malaria  or  kala-azar  :    and  so  on.     The  spleen  is  palpable  in  a  considerablej 
proportion    of  cases    of  pernicious    ana'min,   but  it  is    seldom   greatly   enlarged,  and    the  j 
diagnosis    is    arrived    at    by  finding  the  blood-changes  described   under  An.e.mia  (p.   24-). 
In   none  of  the  other  diseases  mentioned   in  the   list  above  are  the   blood-changes  them- 
selves pathognomonic. 

The  spleen  of  a  small  child  is  often  just  ])alpable  without  there  being  any  disease  atj 


PI.  ATE     XXIX 


SPLE  NOW  EG  ALIO      P  O  L  Y  C  Y  T  H /E  M  I  A 


The  cliaracteriKtJc  fnci(?s  ol  s-iilotionii-triilir  pnlyoylli 


INt)l'.X     OF     liIAONnsii — 7'o  /or/-  IK  (i34 


SPLEEN.     ENLARGEMENT    OF    THE  635 

all  :  if  it  is  more  deciderily  enlarged,  the  first  suspicion  will  be  that  it  is  due  to  rich'els  or 
congenita!  si/philis.  The  bony  changes,  quadrate  head,  beaded  ribs,  large  epiphyses, 
exaggerated  curves  of  the  long  bones,  particularly  of  the  legs,  delay  in  the  closure  of  the 
fontanelles,  and  the  pot-belly,  will  suggest  rickets  :  it  should  be  added,  however,  that 
owing  to  the  eversion  of  the  lower  ribs  along  a  line  corresponding  with  the  attachment  of 
the  diaphragm,  and  known  as  Harrison's  sulcus,  the  spleen  often  becomes  unduly  palpable 
in  rickety  children  without  being  necessarily  enlarged.  Congenital  syphilis  may  be 
suggested  by  a  knowledge  of  the  family  history,  by  the  occurrence  of  snuffles,  of  specific 
skin  eruptions,  and  so  forth  :  but  in  many  cases  the  diagnosis  will  l)e  one  of  surmise  only, 
unless  it  can  be  confirmed  by  the  specific  serum  reaction  of  Wassermann.  Pseiido-leitkinniri 
infantum  has  been  discussed  above  ;  by  some  it  has  been  regarded  as  in  some  way  associ- 
ated either  or  with  rickets,  with  congenital  syphilis,  or  both  ;  but  the  most  recent  view  is 
that  it  is  due  to  some  cause  other  than  these,  of  a  nature  not  yet  known. 

Ilodgkin's  Disease,  when  it  is  typical,  is  associated  with  considerable  and  progressive 
Lymphatic  Gland  Enlakgejient  (p.  376).  especially  those  of  the  neck,  and  later  those  of 
the  axillie  and  groins,  thorax  and  abdomen,  together  with  moderate  but  seldom  very  great 
enlargement  of  the  spleen  :  without  any  ana-mia  to  begin  with,  but  later  with  a  progressive 
and  ultimately  severe  ana'mia  of  the  chlorotic  type,  with  all  the  changes  mentioned  on 
pp.  21,  22  ;  without  leucocytosis,  and  with  nothing  characteristic  about  the  differential 
leucocyte  count,  except  that  an  occasional  basophile  cell  or  myelocyte  may  be  seen. 
Ilodgkin  himself  laid  particular  stress  upon  the  changes  in  the  spleen  in  this  disease,  but 
there  can  be  little  doubt  that  there  are  cases  of  a  precisely  similar  nature  in  which  there  is 
much  lymphatic  glandular  enlargement  without  enlargement  of  the  spleen.  An  attempt 
is  sometimes  made  to  distinguish  this  type  from  that  with  splenic  enlargement,  by  styling 
it  lyniphadenoma  ;  but  where  lymphadenoma  ends  and  Hodgkin's  disease  begins,  and 
vice  versa,  is  by  no  means  settled.  It  would  seem  much  more  likely  that  there  is  every 
degree  of  acuteness  and  severity  between  extremes  that  are  wide  apart,  those  eases  which 
have  lymphatic  glandular  enlargement  and  a  rapidly  fatal  ending  without  leucocytosis  as 
their  most  ])rominent  feature  being  styled  lym])hosarcoma  ;  similar  cases  with  the  addition 
of  enlargement  of  the  spleen,  but  a  fairly  rajjid  fatal  ending,  being  termed  acute  Hodgkin's 
disease  :  others  again,  with  enlargement  of  the  glands  without  enlargement  of  the  spleen 
and  with  rather  greater  duration,  being  termed  lymphadenoma  :  whilst  precisely  similar 
cases  with  enlargement  of  both  spleen  and  glands,  and  a  duration  of  anything  between 
several  niontlis  and  several  years,  are  termed  ordinary  Ilodgkin's  disease.  One  very 
important  point  to  be  realized  about  this  disease  is  that  the  blood-changes  in  it  are  not 
pathognomonic  even  when  they  are  severe. 

Cirrhosis  of  the  Liver,  by  the  time  it  has  ended  fatally,  is  nearly  always  associated 
with  a  spleen  that  is  bigger  than  normal  as  judged  by  post-mortem  weights.  Clinically, 
however,  this  enlargement  can  be  made  out  only  in  a  small  pro])ortion  of  the  cases,  and 
even  in  these  the  enlargement  is  seldom  great.  When,  however,  there  is  doubt  as  to  the 
diagnosis,  and  cirrhosis  of  the  liver  seems  to  be  a  jjossible  cause  for  other  sym])tonis.  such 
as  II.KMATEMESis  (p.  2(i5).  .AsciTES  (p.  48).  .IacnduI';  (]).  ;!2t),  the  i)resence  of  chronic 
but  not  very  great  enlargement  of  the  spleen,  without  aflVction  of  the  lymphatic  glands 
and  without  pathognomonic  blood-changes,  is  an  additional  argmnent  in  favour  of  the 
diagnosis.  On  llic  other  hand,  sph'nic  eidargeineni  is  a  very  prominent  and  r<lali\cly 
early  feature  in  a  few  c'ases.  as  in  the  splcnomcgalic  cirrhosis  of  children  (p.  'M'-i)  and  young 
adults  :  whilst  in  some  older  patients,  long  before  the  hepatic  changes  themselves  attract 
attention,  the  case  may  come  under  observation  for  aiucmia.  with  or  without  ha-morrhage, 
such  as  purpura.  e[)istaxis,  ha'matemcsis.  or  the  passage  of  blood  per  rectum  ;  and  a  con- 
siderable enlargem<'nt  of  the  spleen  may  lie  found.  The  blood-changes  may  be  merely 
chlorotic.  and  in  the  absenc'c  of  other  definite  signs  or  symptoms  the  diagnosis  of  s])lenic 
ana-mia.  thai  is  to  say  of  simple  ana'inia  associated  with  an  erdarged  spleen,  may  be  made  ; 
riiMiiy  such  cases  ullirnatcly  turn  out  to  be  examples  of  cirrhosis  of  the  li\er      Manti's  disease. 

I.arildiidiis  Disriise.  A  lardaccous  spleen  is  not  always  largt'.  but  is  frecpiently  big 
(iKMigli  1(1  be  palp.dile.  and  llic  li\cr  is  generally  enlarged  at  the  same  lime.  The  con- 
ililicin  risulls  rniiii  loni;  roni  inncd  sup|juration.  discharging  sinuses  Trom  em[)vema  or 
spinal  caiiis.  puriilchl  (avilics  In  phthisis  or  bronchieclasis.  or  from  tertiary  syphilis.  If 
eoiisidcralili-  cnlMrLiiriirnl    ol'  tli<-   spleen   is  assoeiate<l  with  an\    ol'llicsc  it    is  probably  ilue 


636  SPLEEN.     ENLARGE:MENT    OF    THE 

to  lardaceous  disease.  There  is  generally  diarrlura  on  aceount  of  affection  of  the  intes- 
tines ;  and  polyuria  and  albuminuria  owing  to  renal  changes.  The  patient  is  weak,  frail- 
looking,  and  bloodless.  Blood-counts  exclude  leukiemia,  and  indicate  more  or  less  anaemia 
of  the  chlorotic  type.  The  disease  is  very  much  less  common  than  formerly,  because 
modern  surgical  methods  have  done  away  with  nmch  of  the  persistent  suppuration  that 
was  formerly  common  ;  for  the  most  part  it  is  diagnosed  by  reason  of  there  being  obvious 
cause  for  it,  especially  prolonged  sepsis  or  tertiary  .syphilis. 

Tlirombosis  of  the  Portal  Vein  as  a  cause  for  splenic  enlargement  can  seldom  be  more 
than  guessed  at  (see  Ascites,  p.  51). 

I'teaaure  on  tlie  Portal  Vein  by  enlarged  lymphatic  glands  or  by  adjacent  tumours, 
will  almost  certainly  be  associated  with  obstruction  to  the  bile-duct  at  the  same  time,  so 
that  there  will  be  jaundice,  and  probably  also  ascites,  in  addition  to  any  splenic  enlarge- 
ment ;    the  latter  will  be  slight. 

II.  ACUTE    ENLARGEMENT    OF    THE    SPLEEN. 
Acute  Infectious  Fevers. 

Tijiiliiiid  Fever  is  the  licst-known  febrile  disease  in  which  moderate  enlargement  of  the 
spleen  occurs.  Tlic  organ  is  usually  soft,  so  that  in  many  cases  only  an  increased  sense  of 
resistance  is  noticed  on  palpating  close  imder  the  left  ribs.  The  enlargement  may  be  so 
slight  that  the  organ  may  be  felt  only  when  the  patient  takes  a  deep  breath,  so  as  to  push 
it  down  from  imder  the  ribs  ;  or  it  may  be  so  big  that  its  lower  border  reaches  to  the  level 
of  the  umbilicus.  If,  in  a  case  of  obscure  fever  in  which  a  continued  pyrexia  (Fig.  "241, 
p.  565)  is  associated  with  a  relatively  slow  pulse-rate,  the  spleen  is  found  to  be  enlarged, 
the  diagnosis  of  typhoid  fever  is  very  likely  ;  especially  if  there  is  a  history  of  gradual  onset 
with  anorexia  and  lassitude,  accompanied  by  headache  and  sometimes  epistaxis,  a  gradual 
rise  of  temperature  which,  if  it  has  been  observed  from  the  first,  is  seen  to  go  up  about  two 
degrees  every  night,  with  a  fall  of  one  degree  the  following  morning,  until  step  by  step  it 
reaches  103°  F.  or  104°  F.,  or  even  higher  ;  and  perhaps  no  definite  abnormal  physical 
signs  whatever  except  as  regards  the  spleen,  or  a  few  rhimclii  in  the  chest.  The  character- 
istic rash  does  not  appear  until  the  sixth  day  or  later,  when  it  comes  out  on  the  abdomen, 
sometimes  also  upon  the  chest  and  back,  in  the  form  of  small,  rosy-red,  flattened  papules 
which  fade  on  pressure,  come  out  in  successive  crops,  and  are  seldom  present  to  the 
extent  of  more  than  half  a  dozen  or  a  dozen  at  a  time.  Widal's  agglutinating  serum 
reaction  should  ultimately  be  positive  in  a  dilution  of  1  in  200  in  half  an  hour,  but  it  is 
generally  the  second  week  before  this  test  is  positive.  Earlier  confirmation  of  the  nature 
of  the  fever  may  be  obtained  by  the  blood-count,  there  being  no  leucocytosis — indeed, 
sometimes  Leucopenia  (p.  361) — whilst,  unlike  many  febrile  illnesses,  typhoid  fever  pro- 
duces a  relative  increase,  not  in  the  polymorphonuclear  cells,  but  in  the  small  lymphocytes. 
.Such  blood-changes  are  in  themselves  almost  pathognomonic,  and  they  ai'c  obtainable 
before  WidaKs  reaction  is  to  be  expected,  though  the  latter  is  the  ultimate  test  of  the  fever. 
Typhoid  bacilli  may  be  recovered  from  the  blood  on  special  cultivation  qviite  early  in  the 
attack,  but  this  method  of  diagnosis  is  not  resorted  to  often.  When  neither  blood-count 
nor  serum-test  is  possible,  the  diagnosis  may  not  be  cleared  up  until  the  third  week  or  later, 
when  sloughs  from  Peyer"s  patches  can  be  discovered  in  the  stools.  The  ratio  of  the  pulse- 
rate  and  temperature  is  of  considerable  value  in  the  diagnosis,  for  in  most  cases  the  pulse- 
ratio  is  very  low  ;  for  instance,  with  a  temperature  of  104°  F..  tlic  ])ulse-rate  may  be  only 
90  or  100  per  minute,  when  the  physiological  ratio  for  this  temperature  is  120.  Pneu- 
monia in  its  earlier  stages  may  also  produce  a  low  pulse-ratio  ;  but  the  respiration-ratio 
is  here  increased,  which  is  not  the  case  in  typhoid  fever.  The  following  figures  illustrate 
these  points  : — 

T.  P.  R. 

Physiological   ratio            .  .               . .               . .          104"  F.  . .  12,3  . .  32 

Tyijhoid  fever   .  .               .  .               . .               .  .          104°  V.  .  .  90  . .  30 

Pneumonia         .  .               .  .               .  .               . .          104"  F.  . .  100  .  .  40 

General  tuberculosis  may  simulate  typhoid  fever  in  this  respect  also,  and  sometimes 
it  is  not  pos.sible  to  decide  between  the  two  until  the  case  has  been  watched  for  some  time. 

Paratyphoid  Fever  is  closely  related  to  typhoid  fever,  and  the  clinical  symptoms  are 
very  similar  ;    the  importance  of  distinguishino;  between  the  two  lies  chiefly  in  the  carrying 


SPLEEN.     ENLARGEMENT    OP    THE  6:!7 

out  of  WidaPs  agglutinating  serum  reaction.  •  It  sonietinu-s  hajjpens  that  in  a  case  which, 
from  a  clinical  point  of  view,  is  almost  certainly  typhoid  fever,  the  serum  will  not  cause 
clumping  of  Kberth"s  typhoid  bacilli  :  and  so  far  as  the  bacteriological  test  goes,  the 
diagnosis  might  remain  altogether  obscure  unless  the  serum  were  tested  also  against  the 
Bacillus  paratijpliosiis  A  and  the  B.  paralyphosiis  B.  In  a  certain  proportion  of  cases 
clumping  will  be  obtained  with  one  or  other  of  these,  the  diagnosis  of  paratyphoid  fever 
being  based  ujjon  bacteriological  rather  than  upon  clinical  conditions.  The  spleen  is 
enlarged  in  paratyphoid  fever  to  about  the  same  extent  as  in  typhoid. 

Relapsing  Fever  is  associated  with  considerable  enlargement  of  the  spleen.  The 
disease  is  contagious,  but  nowadays  rare,  developing  only  under  conditions  of  filth  and 
famine.  It  is  characterized  by  an  acute  onset,  with  chills,  pains  in  the  back,  and  a  sudden 
rise  of  temperature.  The  latter  remains  high  for  six  or  seven  days,  and  then  falls  by  crisis. 
For  about  a  week  the  temperature  remains  normal,  and  then  it  rises  again  as  before,  several 
such  remissions  and  relap.ses  succeeding  each  other  and  being  pathognomonic  of  the  disease 
(Fig.  5.  p.  "27).  The  pulse  is  rapid,  and  there  is  profuse  sweating.  Enlargement  of  the 
spleen  is  detected  early.  It  is  most  conclusively  distinguished  from  other  diseases  by 
examination  of  blood-liltns  in  which  the  Spirorlitrlii  ohcniivicri  {I'hdc  XXl'III.  Fig.  I, 
p.  614),  will  be  found. 

Mallfi  Fever  is  discussed  on  |).  563  ;  the  splenic  enlargement  is  similar  to  that  of  tJ^lhoid 
fever. 

Malaria. — Apart  from  the  chronic  enlargement  of  the  spleen  due  to  recurrent  attacks 
of  malaria,  the  spleen  becomes  enlarged  and  soft  as  the  result  of  active  hyperiemia  during 
acute  attacks.  Even  when  no  splenic  enlargement  can  be  detected  in  the  intervals,  during 
the  paroxysms  the  viscus  can  usually  be  felt  projecting  below  the  costal  margin,  presenting 
a  soft  and  indefinite  lower  border.  When  the  patient  has  more  or  less  chronic  enlargement 
of  the  spleen  as  the  result  of  preceding  attacks,  each  acute  febrile  paroxysm  is  associated  as 
a  rule  with  an  additional  swelling  which  passes  off  after  the  attack.  For  the  characters 
of  the  fever,  see  pp.  29-32.  The  nature  of  the  malady  will  be  suggested  by  geographical 
considerations,  or  by  the  influence  of  quinine  ;  but  the  only  conclusive  proof  is  the 
discovery  in  stained  blood-films  of  the  malaria  parasites  {Plate  XXVIII.  Figs.  A.  B,  C.  D. 
p.  614).  There  is  often  marked  anremia.  especially  in  cases  of  recurrent  malaria,  the  red 
corpuscles  and  haemoglobin  bcc'oming  reduced  as  in  chlorosis  ;  the  leucocytes  arc  also 
diminished,  and  the  dilTcrential  leucocyte  count  shows  a  relative  increase  in  the  large 
iiyaline  lymphocytes  up  to  even  1.5  or  20  per  cent. 

Erifsipelas  is  often  associated  with  moderate  enlargement  of  the  spleen  :  but  the  fever, 
rigors  (Fig.  245,  p.  568).  and  slightly-raised  red  spreading  infection  of  the  skin  are  sulli- 
ciently  characteristic  to  indicate  the  diagnosis. 

Seplicrrniid  may  be  less  easy  to  diagnose  unless  there  is  some  obvious  source  of  sepsis 
ill  the  first  instance,  such  as  infection  of  the  uterus  after  childbirth,  sepsis  in  connection 
with  the  general  peritoneal  cavity,  joints,  wounds,  and  so  forth.  The  cliicf  diihculty  arises 
ill  those  cases  in  which  the  source  of  the  sepsis  is  not  obvious,  being  due  to  absorption  from 
such  lesions  as  pyorrhtra  alveol.aris.  whitlows,  acne,  or  other  comparatively  small  super- 
licial  affections  :  or  to  dccp-scitcd  suppuration,  such  as  a  hidden  cmpyciiia.  infective 
pylephlebitis.  iiifecli\<'  cholaiigilis.  pyosalpinx.  and  so  forth.  In  some  cases  of  chronic  or 
subacute  scpl  iciemia,  enlargement  <if  the  spleen  may  be  considerable,  and  the  diagnosis 
111  inle(ti\c  ciidocarditis  will  very  likely  suggest  itself.  Whether  or  not  the  heart  valves 
arc  anVclcd  in  I  he.se  cases,  the  ultimate  diagnosis  will  depend  upon  discovery  of  infective 
oryaiiisnis  in  cultures  obtained  by  venepimcture. 

Diplilhcria.  I'lieiiinonia.  Sctirtel  Fever,  and  Stiuill-iiur  seldom  gi\r  rise  to  very 
priiiiiiiunl  splenic  enlargement,  and  the  only  importance  of  it  is  that  In  the  early  stages 
(il  llic  malady  detection  of  a  spleen  that  is  just  palpable  may  temporarily  arouse  a  suspicion 
llial  the  patient  may  be  sutiering  from  typhoid  fever.  The  course  of  the  disease,  bacterio- 
logical examination  of  swabbings  from  the  throat,  the  physical  signs  in  the  lungs,  and 
characters  of  the  sputum  and  the  skin  rash,  will  serve  to  point  to  the  correct  diagnosis. 

Ti/pliiis  Fever  is  fortunately  very  rare  now,  although  there  are  small  outbreaks  of  it 
in  the  poorer  parts  of  large  <il  ies  from  time  to  time  :  the  spleen  becomes  soft  and  moderately 
enlarged,  but  less  eoiistaiitly  so  than  in  typhoid  fever.  The  disease  sets  in  more  acutely 
llian   enteric,    with   eliills     early    pnisl  rat  ion,   and   a    lii^;li    liinperal  lire   which   ends   by   less 


638 


SPLEEN.     ENLARGEMENT    OF    THE 


marked  lysis  (Fig.  268)  than  does  that  of  typhoid  fever  (Fig.  241.  p.  565)  :  and  sometimes 
ahnost  by  crisis  at  tlie  end  of  the  second  week  (Fig.  269).  The  rash  differs  from  that  of 
typhoid  fever,  in  that  it  appears  on  the  tifth  day,  and  consists  of  )5etecliiac  and  of  dark-red 
groups  of  subcutaneous  macules  in  addition  to  rosy-red  papules  on  the  surface.  Nervous 
symptoms  become  very  marked,  especially  at  the  end  of  the  first  week,  the  so-called  typhoid 


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Fiy.  26S. — Temperiiture  chart  from  a  typical  case  of  typhus  fever  ending  by  lysis  ratlier  than  by  crisis. 

{Chan  kindly  supplied  by  Dr.  Turner,  Med.  Supt.  of  the  South  Eastern  Fever  Hosp.,  London.) 


state  being  an  expression  used  to  denote,  not  the  condition  that  occurs  in  typhoid  fever,  but 
that  which  develops  in  typhus.  There  may  be  severe  vomiting,  and  retention  of  urine, 
important  symptoms  that  are  rare  in  typhoid  fever.  There  should  be  no  positive  Widal's 
reaction,  and  no  sloughs  in  the  stools. 

Influenza  is  a  diagnosis  which  should  never  be  made  except  with  very  good  cause,  for 
many  febrile  illnesses  in  which  the  real  cause  escapes  recognition  receive  the  label  influenza. 


SPLEEX.     ENLARGEMENT    OF    THE 


639 


It  is  easiest  to  diagnose  correctly  in  times  of  spvere  epidemic,  and  tlien  slight  enlargement 
of  the  spleen  may  occur  in  a  few  cases.  This  in  itself  is  not  important  if  influenza  can  be 
diagnosed  with  certainty  on  other  grounds  ;  but  until  the  nature  of  the  fever  becomes 
obvious,  it  is  important  in  that  it  may  suggest  typhoid  when  none  exists.     The  sudden 


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riff.  ■iGl). — Ciisc  of  typhus  fever,  sliowinc  termination  by  crisis  at  the  eiitl  of  the  S' 
oases  exhibit  a  less  abrupt  crKltiit;  to  the  pyre.xia  perhaps,  but  tlie  above  type  is  chi 

irl„irl  kuii/lii  Mii,i,li,il  hy  Dr.  Tiirmr,  M,d.  Kiijit.  nf  ilu-  Snuih  AViW- 


:oiiU  week.    The  majority  of  the 
iructcristie  in  some  epidemics. 
T/i  h'rrrr  lliisiiiliil.  I.,imlnn.\ 


oUMl.  cxIriMic  pnislratiou.  high  pulsc-ralc  us  well  as  tempt  ralurc.  initial  chill,  profuse 
sweating  which  comes  on  when  the  patient  begins  to  improve,  aiul  the  fall  of  the  temi)cra- 
ture  after  an  illness  lasting  from  twenty-four  hours  to  three  or  four  days  or  a  week,  would 
all    piiiiil     (o    iiilliii  ii/.a.       It    may.    however,    he    iiupossihlc    to    distinguish    iiilluciiza    from 


640 


SPLEEN.     ENLARGEMENT    OF    THE 


typhoid  fever  until  the  course  of  the  pyrexia  has  been  watched,  or  luiless  typical  Bacilli 
iiiflitetizce  are  recovered  in  nearly  pure  culture  from  some  secretion,  such  as  the  sputum. 
It  is  worthy  of  note  that  in  influenza  as  well  as  typhoid  there  is  no  leucocytosis. 

General  Tuberculosis  may  also  simulate  typhoid  fever  in  certain  cases,  and  enlargement 
of  the  spleen  may  result  from  the  development  of  tubercles  in  it.  ^Vhen  cerebral  symptoms 
predominate,  the  diagnosis  is  relatively  easy  :  the  headache  may  be  eciually  severe  in  both, 
but  with  tuberculous  meningitis  there  is  more  vomiting  and  more  retraction  of  the  head, 
whilst  it  is  probable  that  optic  neuritis,  and  perlia])s  choroidal  tubercles,  can  be  detected, 
WidaPs  test  will  remain  persistently  negative  :  there  will  be  no  rosy  rash,  probably  no 
leucocytosis,  and  no  sloughs  will  be  found  in  the  stools.  In  some  cases,  however,  general 
tuberculosis  produces  a  clinical  picture  that  may  be  very  difficult  to  distinguish  from 
typhoid  fever,     Limibar  puncture  may  decide  the  diagnosis, 

Eiubolism. — Fungating  endocarditis  is  nearly  always  associated  with  palpable  enlarge- 
ment of  the  spleen,  and  sometimes  the  organ  attains  a  considerable  size  (Fi^.  270),     As  stated 

above,  ordinary  heart-disease  with  failure 
of  compensation  does  not  give  rise  to 
splenic  enlargement  that  can  be  recog- 
nized clinically,  except  perhaps  in  chil- 
dren, notwithstanding  the  fact  that  one 
might  have  expected  the  backward  pres- 
sure to  cause  the  spleen  to  be  big  by 
being  dilated  with  blood.  Except  in 
children,  enlargement  of  the  spleen  in  a 
heart  case  should  always  arouse  serious 
suspicion  of  infective  endocarditis.  The 
enlargement  may  be  due  to  embolism 
and  infarction,  in  which  case  there  may 
have  been  a  history  of  acute  pain  low 
down  on  the  left  side  of  the  chest,  accom- 
panied by  a  definite  rub  due  to  peri- 
splenitis] over  the  infarct.  The  splenic 
enlargement  in  some  cases,  however,  is 
due  less  to  actual  infarction  than  to  the 
general  toxaemia  :  even  when  there  has 
been  an  infarct  it  is  not  always  easy  to 
be  sure  of  it,  Fungating  endocarditis 
sometimes  develops  without  there  being 
any  bruit  at  all  ;  the  diagnosis  is  then 
exceedingly  diflicult  unless  the  patient 
suffers  from  multiple  emboli — cerebral, 
renal,  intestinal,  splenic,  peripheral, 
.Sometimes  such  an  embolus  may  be 
followed  by  the  development  of  an  acute 
aneurysm — femoral,  popliteal,  cerebral 
and  so  forth,  A  cerebral  embolism  of 
this  kind  has  sometimes  resulted  in 
sudden  transient  coma  and  hemiplegia  ; 
the  patient  has  seemed  to  be  reco\ering  ; 
then  in  a  day  or  two  has  relapsed  into  coma  again,  and  died,  the  cause  of  the  relapse  and 
fatal  ending  being  the  development  of  an  acute  cerebral  aneurysm  at  the  site  of  the  em- 
bolus, rupture  of  this  aneurysm,  and  death  from  the  resultant  haemorrhage.  Progressive 
anaemia  of  the  chlorotic  type,  without  much  leucocytosis,  is  another  feature  of  these  cases. 
The  diagnosis  must  always  be  dillicult  when  there  is  no  cardiac  bruit  :  when  there  is  a 
bruit,  the  difficulty  is  to  determine  whether  the  patient  is  suffering  merely  from  mechani- 
cal heart-failure,  or  from  fungating  endocarditis  su])erposed  upon  the  chronic  heart  lesions 
(p.  34). 

Thrombotic  infarction  may  cause  acute  splenic  enlargement  in  almost  any  of  the  blood 
diseases,  particularly  in  lymphadenoma  and  leuka'mia. 


:  i-uduiLirditis  (the  same 
iri«  purpura).  Note  also 
L-ernible  in  the  left  hand. 


SPUTA     ^  641 

Neither  Injury  nor  Strangulation  of  the  spleen  by  its  becoming  tzcisted  upon  its  oivn  hilum 
is  a  very  common  event,  and  the  latter  is  nearly  always  the  result  of  injury.  A  blow  in  the 
splenic  region  may  cause  a  rupture  in  the  pulp  of  the  spleen  without  bursting  its  capsule, 
and  without  obviously  injuring  the  chest  wall  or  abdomen.  The  bleeding  that  occurs 
within  the  capsule  of  the  spleen  itself  causes  great  pain  in  the  part  and  enlargement  of  the 
organ  ;  the  diagnosis  can  seldom  be  more  than  guessed  at  unless  laparotomy  is  performed. 
Strangulation  of  the  spleen  seldom  occurs  if  the  organ  is  in  its  natural  position  ;  but  when 
there  has  been  previous  dislocation,  an  abdominal  injury,  or  sometimes  a  sudden  spon- 
taneous effort,  has  led  to  its  becoming  twisted  on  its  own  hilum,  the  symptoms  being  such 
as  to  suggest  an  acute  intra-abdominal  condition  requiring  immediate  laparotomy,  but 
seldom  pointing  to  the  actual  diagnosis  until  the  laparotomy  has  been  performed. 

Herbert  French. 

SPONGY   GUMS.— (See  Bleeding  Gums.  )>.  12.) 

SPUTA  vary  enormously  as  to  their  amount,  consistence,  colour,  and  so  forth  :  but 
by  far  the  most  important  point  about  them  in  diagnosis  is  the  determination  of  whether 
they  contain  tubercle  bacilli  or  not.  There  is  no  particular  variety  of  sputum  which  can 
be  said  to  be  characteristic  of  jjulmonary  tuberculosis,  although  stress  is  generally  laid 
upon  the  fact  that  phthisis  with  cavitation  produces  a  nummular  sputum — that  is  to  say, 
sputum  of  which  the  individual  portions  expectorated  tend,  not  to  coalesce  but  to  flatten 
out  as  separate  round  portions,  if  they  are  spat  on  to  a  flat,  dry  surface  ;  if  expectorated 
into  antiseptic  fluid,  they  remain  as  more  or  less  globular,  separate  masses.  As  a  matter 
of  fact,  however,  ordinary  bronchitis  may  jiroduce  sputum  ])ossessing  a  typical  appear- 
ance of  nummularity.  and  it  is  most  unwise  to  rely  on  the  naked-eye  appearances  of  sputum 
for  any  diagnosis  except  that  of  lobar  pneumonia,  when  it  may  be  typically  viscid  and 
rusty.  It  is  in  almost  all  cases  essential  to  make  films  of  the  sputum,  and  to  stain  these 
for  tubercle  bacilli  by  the  Ziehl-Xeelsen  method  with  carbol-fuchsin. 

The  carbol-fuchsin  solution  is  made  up  of  1  fim.  of  fuchsin.  10  c.c.  of  absolute  alcohol,  and  100  c.c. 
of  5  per  cent  solution  of  carbolic  acid  in  distilled  water.  The  slide  is  covered  by  the  stain  in  a 
suitable  receiver,  and  held  over  a  small  Bunsen  burner  or  spirit  flame  until  the  fluid  steams  briskly 
but  docs  not  actually  boil.  After  immersion  in  this  for  five  minutes  at  least,  and  it  does  not  much 
matter  if  for  longer,  the  excess  of  stain  is  poured  off,  the  film  washed  in  water,  the  excess  of  the 
latter  drained  off,  and  the  slide  immersed  in  25  per  cent  sulphuric  acid  for  about  half  a  minute  ; 
it  is  then  transferred  to  water  again,  and  recovers  more  or  less  of  the  red  tint  of  the  fuchsin  ;  if 
too  little  of  this  has  been  discharged,  the  slide  is  returned  to  the  sulphuric  acid  for  another  period, 
and  so  on  ;  when  well  decolorized,  only  the  thickest  parts  of  the  film  retain  obvious  red  ;  it  is  then 
countcrstained  hy  five  minutes'  immersion  in  carhol-methylene  blue,  the  excess  of  this  stain  being 
washed  off  with  water,  the  film  dried  in  the  air,  and  either  mounted  in  Canada  lialsam  or  else 
examined  directly  through  ee(lar-woo<i  oil  ;  the  tubercle  bacilli  {Plate  XXVIII.  Fig.  K,  p.  (iU) 
show  up  as  bright-red  rods  in  a  blue  field  under  the  oil-immersion  lens. 

The  presence  of  acid-fast  bacilli  in  an  ordinary  sputum  film  is  very  nearly  proof  posi- 
tive of  tuberculosis  of  the  lung,  the  only  source  of  fallacy  being  the  possibility  of  non- 
pathogenic acid-fast  bacilli  l)eing  deriveii  from  the  mouth.  It  is  very  milikcly  that  this 
source  of  fallacy  will  persist  from  day  to  day.  especially  if  care  be  taken  to  make  the  films 
from  the  interior  of  the  sputum  pellets.  It  should  be  rcmcndjcrcd,  of  course,  that  the 
absence  of  tubercle  bacilli,  or  rather  their  non-detection,  is  no  proof  of  the  absence  of 
pulmonary  phthisis,  and  if  there  is  tioubt,  successive  sputa  should  be  tested  in  the  .same 
way.  It  should  also  be  rerncmbered  that  a  lesion  which  may  have  been  tuberculous 
originally,  may  in  time  lose  its  tuberculous  character,  the  tubercle  bacilli  may  die  out, 
though  the  cavities  produced  by  them  still  persist  and  become  occupied  by  pyogenic 
organisms  and  their  products.  Many  of  the  symptoms  of  phthisis  itself  arc  not  due  to 
tubercle  bacilli  directly,  but  rather  to  secondary  infection  by  streptococci,  sta])hylococci, 
pneumococci,  micrococci  catarrhalcs,  and  so  forth  ;  anil  the  degree  of  this  .secondary 
infection  may  be  gauged  from  the  films  at  the  same  time  as  one  looks  for  tubercle  bacilli. 

If  is  also  important  to  realize  that  a  person  may  expectorate  sputum  containing 
tubercle  bacilli  in  abimilance  c\ery  day  for  ijionfbs,  and  yet  may  ba\c  precisely  as  much 
lung  tissue  left  by  the  end  of  that  time  as  at  the  bcgiiming  ;  this  is  due  to  the  fact  that  when 
cavities  have  been  produced  they  are  lined  by  gramdation  tissue,  and  it  is  possible  for  the 
discharge  from  the  surface  of  these  granulations  to  produce  a  continuous  supi)ly  of  sputum 
withiMil    the  cnision   of  the   lung  tissue   progressing.      One  sees  a   precisely  similar  stale  of 

11  H 


64-2 


SPUTA 


affairs  in  cases  of  some  skin  ulcers,  which  may  rtiscliarge  abimdantly  and  yet  remain  much 
the  same  size  for  months.     The  best  evidence  of  hmg  destruction  is  afforded  by  the  dis- 
coverv  of  elastic  fibres  {Fig.  271)  in  the  sputum  ;    if  these  are  present  there  must  be  some- 
thing which  is  eroding  the  lung  tissue,  and  if  tubercle  bacilli  are  present  at  the  same  time, 
the  two  together  indicate  advancing  phthisis.     The  elastic  fibres  may  be  obvious  when 
ordinary   sputum    is   examined    fresh    after    it    has    been 
pressed  out  between  cover-slip  and  slide,  but  oftener  they 
are  more  easily  detected  when  a  quantity  of  sputum   has 
been  boiled  with  strong  caustic  soda  to  destroy  pus  cells, 
nuicus,  and  so  forth,    leaving    the    very    resistant   elastic 
fibres  unaffected.     Tubercle  bacilli  are  also  very  resistant 
to  the  effect  of  strong  alkali,  and  when  they  are  suspected 
to  be  present  but  cannot  be  found  without  in  some  way 
concentrating  them,  it  is  a  useful  plan  to  boil  the  sputum 
with  an  equal  amount  of  5  per  cent  caustic  potash,  or  with 
antiformin,  to  dilute  the  result  with  water,  to  centrifugalize 
it  well,  and  make  films  from  the  deposit.    There  are  various 
other  methods  of  obtaining  concentrated  bacilli  from  the 
sputum,  but  this  is  one  of  the  simplest.     It  should  be  borne 
in  mind  that  tubercle  bacilli  may  be  found  even  when  the 
sputum  is  exceedingly   small    in    amount    and  apparently 
insignificant  and  mucoid. 
For  sputa  containing  blood,  see  Haemoptysis  (p.  285). 

Viscid,  Rusty  Sputum  is  almost  pathognomonic  of  pneumonia.  As  a  rule  the 
diagnosis  of  lobar  jmcumonia  is  fairly  clear  owing  to  the  sudden  onset  of  an  acute 
pulmonary  coin|)laint  associated  with  fine  crepitations  confined  to  one  or  more  lobes, 
followed  by  dullness,  with  bronchial  brcatliing,  bronchophony,  and  pectoriloquy  without 
riiles  ;  these  being  succeeded  by  redux  crepitations,  with  a  diminution  in  the  broncho- 
phony, pectoriloquy,  and  bronchial  breathing  until  normal  voice  and  breath  sounds  are 
restored.  Herpes  labialis  is  common.  The  patient's  temperature,  after  maintaining 
a  high  level  such  as  103"  F.  or  104-  F.  for  from  five  to  ten  or  more  days — usually  about 
seven — falls  by  crisis  {Fig.  272).  The  respiration  rate  is  very  rapid — for  example,  40  per 
minute — during  the  height  of  the  fever,  and  the  skin  is  flushed,  dry,  pungent  before  the 
crisis,  moist  from  profuse  perspiration  after  it.     The  diagnosis  is  much  more  dilficult  in 


Fi<j.  'iTI.— Elasl 
Tlie  lower  figure 
the  upper,  and  s 
nient  of  the  lii 
Medical  Laboruloi  t 


some  cases,  however  ;  there  are  not  a  few  patients  in  whom  the  consolidation  is  deep- 
seated,  so  that  it  does  not  come  to  the  surface  at  all,  and  lobar  pneinnonia  has  to  be 
diagnosed  when  there  are  no  abnormal  physical  signs  to  be  detected  in  either  side  of  the 
chest.  In  such  cases  the  general  symptoms  may  suggest  the  diagnosis,  and  the  sticky,  viscid 
sputum,  the  colour  of  which  is  generally  that  of  iron  ru.st — but  which  may  be  any  of  the 
colours   that  a  bruise  may  have,   from   bright-red  or  brown  to  greenish-brown,  greenish. 


SPUTA  64H 

yellowish,  or  even  bluish-yellow — confirms  it  even  when  the  lung  signs  remain  normal. 
Tlie  viscidity  of  the  sputum  in  these  cases  is  of  as  nuich  importance  as  the  colour.  Films  of 
it  usually  contain  numbers  of  pneumococci  {Plate  XXl'III.  Fig.  O.  p.  614) ;  in  exceptional 
instances  pneumo-bacilli.  When  lobar  pneumonia  is  due  to  the  influenza  bacillus,  the 
sputum  has  not  the  viscid,  rusty  character  as  a  rule,  but  is  more  like  that  of  ordinary  muco- 
purulent bronchitis.  The  presence  of  large  mmibers  of  ])neiunococci,  however,  or  of  any 
other  micro-organism  than  the  tubercle  bacillus,  is  l)y  itself  no  proof  that  these  are  the  cause 
of  the  lung  lesion,  for  even  in  the  sijutum  of  perfectly  normal  ])ersons  pneumococci  and  other 
bacteria  are  frequently  abimdant.  It  is  quite  ]>ossible  for  a  patient  who  is  dying  of  general 
miliary  tuberculosis  of  the  lung  to  have  no  tubercle  bacilli  in  the  sputum,  but  an  abundance 
of  capsulated  ]ineumococci  which  may  readily,  when  they  are  discovered,  lead  to  an 
erroneous  diagnosis. 

Influenza  bacilli  are  exceedingly  small  :  but  it  is  important  that  they  should  be  looked 
for,  both  directly  and  by  cultural  methods,  in  all  cases  thought  to  be  influenzal,  before  this 
diagnosis  is  regarded  as  established  :  even  when  influenza  bacilli  are  found  there  is  still 
the  possibility  that  they  may  be  an  intercurrent  infection  in  some  other  malady  ;  but  it  is 
so  tempting  to  think  of  influenza  when  no  other  obvious  cause  for  a  febrile  illness  can  be 
discovered,  that  it  should  not  be  diagnosed  until  influenza  bacilli  have  been  shown  to  be 
present. 

Abundance  of  Foul  Sputum,  especially  when  expectorated  much  at  a  time  at  com- 
paratively long  intervals,  is  sometimes  by  itself  a  .striking  symptom,  and  it  suggests  that 
the  patient  is  sulieriiig  from  one  or  other  of  the  following  : 

Uroncliicctasis  i       ,\ii  einpyeniii  ruptured  into  the  lung 

Phthisis   with   cavitation  Gangrene  of  the  lung. 

Fn'tid  bronchitis  I 

It  is  sometimes  very  easy  to  distinguish  between  these  ;  with  fibroid  lung  and  bronchi- 
erlfi.tis  the  |)atient  is  likely  to  have  had  symptoms  periodically  for  a  long  while  ;  there 
will  generally  be  Cubbed  Fingers  (p.  Ill)  ;  the  abnormal  physical  signs  are  confined 
to  one  lung  as  a  rule,  and  especially  to  the  lower  lobe,  with  displacement  of  the 
heart  towards  that  side  ;  there  will  be  deficiency  of  movement,  resonance,  and  vesicular 
murmur  in  the  affected  lower  lobe,  together  with  either  absence  of  voice  sounds  and  of 
rales,  or  scaltercd  foci  of  crackling  rales,  es|)ecially  when  the  patient  coughs,  with  broncho- 
phony. j)cctoriIo()uy,  and  bronchial  breathing.  If.  on  the  other  hand,  the  abundant  and 
foul  sputum  is  associated  with  abnormal  physical  signs  in  both  lungs,  and  if  the  upper 
lobes  are  obviously  more  affected  than  the  lower,  if  the  patient  has  a  strong  tuberculous 
family  history,  and  if  tubercle  bacilli  arc  either  now  present  in  the  s])utum,  or  are  known 
to  have  been  present  formerly, — the  diagnosis  of  chronic  j)hthisis  ivith  crlensiir  cavil/itiiin 
and  sccondari)  infccliiin  of  the  cavities  with  ))yogenic  organisms  is  obvious. 

Fu'lid  brinnliilin  is  always  a  dangerous  diagnosis  to  make,  and  the  probability  is  that 
many  cases  so  diagnosed  have  been  examples  either  of  deep-seated  bronchiectasis,  of 
phthisis  with  cavitation  and  secondary  pyoeoccic  infection,  or  of  empyema  ruptured  into 
the  lung.  Tlic  latter  is  generally  associated  with  hardly  any  abnormal  physical  signs, 
because  if  the  original  cm|)yema  had  given  rise  to  the  ordiiu'rv  signs  it  would  have  been 
diagnosed  iuid  relieved  hy  operations  an  empyema  n)ay  (le\elop  either  between  the  lobes, 
or  between  the  pericardium  and  the  lung,  or  between  the  diaphragm  and  the  lung,  in  such 
a  way  as  to  l(a\c  normal  hmg  tissue  all  round  the  surface  next  the  chest  wall,  so  that  the 
usual  evidence  of  |ius  in  the  chest  is  entirely  wanting.  Fven  if  abnormal  physical  signs 
are  [jrodueed  when  the  pus  is  kept  in  an  abnormal  position  in  this  way.  the  needle  may  have 
to  pass  through  so  much  tissue  before  the  (inpyema  cavity  is  entered,  that  the  pus  caimot 
be  located  :  in  either  of  these  cases  the  em|)yema  will,  in  the  course  of  time,  tend  to 
ulcerate  its  way  through  the  pleura  and  lead  to  theexpectoration  of  large  (puintities  of  foul 
sputiun  at  intervals  as  the  empyema  cavity  re-lills.  The  diagnosis  <le|)ends  largely  upon 
the  exclusion  of  other  causes  of  abuixlant  foul  expectoration,  and  perhaps  upon  the 
history  of  a  preceding  illness  predisposing  lo  empyema,  for  example  lobar  (nienmonia. 

(langrcnc  of  the  lung  may  be  simulated  to  some  extent  by  hronchiectasis  or  by 
enq)yema  rupturing  into  the  lung;  but  ycncrally  speaking  nothing  but  gangrene  will 
prodncc   so   inuch    stench,      foul    tliough    the   spniuui    in    bad    hiiiiichicclasis   may    hecoine, 


644  SPUTA 

it  seldom  approaclies  the  awful  foetor  of  pulmonary  gangrene.  The  history,  moreover,  is 
acute  :  there  may  be  some  obvious  cause  for  gangrene,  particularly  lobar  pneumonia  in 
a  patient  debilitated  from  some  other  cause,  such  as  diabetes,  or  inhalation  of  foul  particles 
after  immersion  in  a  dirty  river,  or  as  the  result  of  disease  of  the  mouth,  throat,  or  cesoph- 
agus,  or  septic  embolism  of  the  lung  from  lateral  sinus  thrombosis.  If  any  doubt  remains 
as  to  whether  lung  tissue  is  being  destroyed  or  not,  elastic  fibres  can  be  sought  for,  their 
presence  at  once  distinguishing  between  bronchiectasis  or  deep-seated  empyema  on  the  one 
hand  and  gangrene  on  the  other. 

AVhen  a  large  quantity  of  pus  is  expectorated  through  the  lung  in  a  person  who,  having 
been  in  the  tropics  and  having  possibly  suffered  from  dysentery,  has  since  had  symptoms 
pointing  to  hepatic  trouble,  the  possibility  that  an  amcebic  abscess  of  the  liver  may  have 
opened  its  way  through  the  diaphragm  into  the  lung  will  immediately  occur  to  one, 
especially  if  the  expectorated  pus  is  tinged  the  colour  of  anchovy  sauce.  It  might  be 
thought  that  the  Amwha  cnli  would  be  found  in  it  ;  but  this  is  not  the  case,  for  this 
protozoon  is  not  ])resent  in  the  pus  of  a  hepatic  abscess  as  a  rule,  but  only  in  the  granu- 
lations of  the  abscess  wall.     The  sputum  in  these  cases  is  not  generally  foul. 

The  other  abnormal  features  that  may  be  exhibited  by  .sputum  are  relatively  un- 
common, and  are  of  diagnostic  significance  only  in  exceptional  cases.  The  serous,  mucoid, 
muco-purulent,  or  purulent  sputum  of  the  various  stages  of  acute  and  chronic  bronchitis 
may  arouse  a  doubt  as  to  whether  the  patient  has  not  a  tuberculous  focus  :  repeated  exam- 
ination will  fail  to  reveal  either  tubercle  bacilli  or  elastic  fibres,  but  it  is  to  be  remembered 
that  a  considerable  minority  of  phthisical  subjects  seem  not  to  expectorate  the  bacilli. 
Black  sputum,  is  conunon  in  those  who  live  in  smoky  atmospheres,  particularly  in  towns, 
colliery  districts,  and  manufacturing  centres.  Other  changes  in  colour  may  be  due  to 
ha>moptysis,  pneumonia,  or  hepatic  abscess,  which  are  all  discussed  above  ;  sometimes 
infection  by  the  lidcilliis  jii/od/dncKS  may  produce  greenish  or  bluish  sputa  which  may 
alarm  the  patient,  but  which  need  not  have  any  serious  import,  and  red  sputum  simu- 
lating the  hajmoptysis  of  phthisis  may  be  due  to  infection  by  pigment-producing  bacilli 
such  as  the  Bacillus  prndigiosus  ;  phthisis  may  be  diagnosed  wrongly  in  such  a  case 
unless  the  most  careful  investigations  of  the  sputa  are  made  by  cultural  methods. 

Curschrnann^s  spirals  (p.  153)  and  Charcot-Leyden  crystals  (p.  102)  have  been  discussed 
elsewhere. 

Casts  of  the  bronchial  tubes  are  met  with  in  very  exceptional  cases,  and  they  are  of  two 
main  types — ^namely,  diphtheritic,  and  non-diplitheritic.  The  distinction  depends  on 
bacteriological  examination  ;  histologically  they  consist  of  ill-deflned  exudate  containing 
cells  irregularly  embe.lded  in  it.  Non-diphtheritic  casts  are  due  to  plastic  or  fibrinous 
bronchitis,  a  very  rare  disease  of  which  the  sputum  is  the  diagnostic  point.  Two  other 
rare  causes  for  the  expectoration  of  casts  of  the  bronchi  are  lobar 
])neumonia,  and  the  inhalation  of  blood  from  some  other  part  of 
the  lung  in  a  case  of  hicmoptysis,  and  its  subsequent  expectoration 
after  it  has  clotted. 

Now  and  again  a  cretaceous  pellet  (Fig.  278)  or  a  small 
caseous  mass  may  be  found  in  the  sputum  of  a  patient  who  either 
lias  pulmonary  phthisis,  as  evidenced  by  the  abnormal  apical 
])hysical  signs,  and  by  the  detection  of  elastic  fibres  as  well  as 
tubercle  bacilli  in  the  sputum,  or  in  children  as  the  result  of  the 
„.    ,_  ^T^^""  ulceration  of  a  caseous  bronchial  gland  into  the  trachea  or  a  main 

Ftg.'2t-^. — Calcareous  coticre-  ^ 

tions  from  piithisicai  sputum.  ;  bronchus,  and  then  expectoration  of  its  caseous  or  cretaceous 
contents. 

Another  rarity  which  has  occasionally  been  found  in  the  sputum  is  a  recognizable 
particle  of  new  growth,  the  detection  of  which  may  be  of  material  assistance  in  diagnosis. 

Chemical  analyses  are  relied  on  by  some  observers  in  distinguishing  tuberculous  from 
non-tuberculous  sputum,  it  being  stated  that  expectoration  containing  coagulable  proteid 
is  more  likely  to  be  the  result  of  tuberculous  infection  than  is  sputum  which  does 
not  coagulate  with  heat.  This  distinction,  however,  is  not  universally  accepted,  and 
microscopical  examination  for  tubercle  bacilli  is  certainly  a  more  reliable  test  in  the  great 
majority  of  cases. 


STERILITY  645 

The  rarer  bacteria  and  moulds  that  may  be  detected  in  tlie  sputum  by  special  bacterio- 
logical methods  generally  require  very  special  investigation,  including  cultural  tests  by 
skilled  bacteriologists  ;  one  need  not,  therefore,  enter  into  details  here,  though  it  may  be 
well  to  enumerate  certain  micro-organisms  which  may  be  pathogenic  in  the  lung  in  com- 
paratively rare  instances — B.  mallei,  generally  amongst  workers  in  stables  or  otherwise  in 
connection  with  horses  ;  Aspergillus  flaviis,  A.  niger.  A.  finnigntiis.  generally  amongst  those 
who  have  to  do  with  the  artificial  feeding  of  pigeons  and  other  birds  :  Actinomyces  or  the 
ray  fungus,  in  those  who  have  had  to  do  with  barley  in  some  way  or  another,  or,  as  has 
recently  been  demonstrated,  in  those  who  are  in  the  habit  of  holding  cotton  in  their  mouths, 
such  as  tailors  and  seamstresses.  Besides  these  pathogenic  micro-organisms,  not  a  few 
others  which  are  not  actually  pathogenic  are  to  be  recognized  in  the  sputum  when  it  has 
become  secondarily  infected  in  chronic  cases.  Penicillium  gldNCiim.  for  instance,  or  Oidiiim 
albicans  :  yeast  and  other  moulds  :  Micrococcus  letragenus  :  or  Oidium  iropicale.  a  micro- 
organism similar  to  but  culturally  different  from  Oidium  albicans,  which  has  recently 
been  reported  to  be  a  cause  of  lung  lesions  both  in  Europeans  and  natives  in  Ceylon,  the 
.symptoms  suggesting  phthisis,  but  the  latter  being  excluded  by  the  persistent  absence  of 
tubercle  bacilli  from  the  sputum  and  by  the  absence  of  reaction  to  tuberculin. 

Whooping-cough  is  sometimes  difficult  to  distinguish  from  other  colds  and  from 
bronchitis,  and  if  the  recent  statements  to  the  effect  that  it  is  due  to  the  minute  Bordet- 
Gengou  bacillus  prove  true,  bacteriological  examination  of  the  sputum  may  be  of  use  in 
diagnosing  this  condition  in  doubtful  cases  ;  the  patienfs  blood-serum  may  also  give  a 
positive  clumping  reaction  with  cultures  of  this  organism. 

The  lung  fluke,  Paragonimus  Westcrmani,  which  causes  haemoptysis  in  Korea,  Japan, 
and  parts  of  China,  is  to  be  diagnosed  by  the  discovery  of  its  oval,  capsulated  eggs  in  the 
sputum.  Herbert  French. 

SQUINT.— (.See  Strabismus,  p.  640  :    and  Diplopia,  p.  ITk) 

STAMMERING.  -(See  Spioecii,  Aiixou.MAHTir.s  of.  p.  023.) 

STERILITY. — The  differential  diagnosis  of  the  causes  of  sterility  is  often  difficult, 
and  although  there  are  many  well-defined  conditions  which  give  rise  to  it,  there  are  numbers 
of  cases  in  which  no  definite  cause  can  be  found.  Further,  we  must  not  overlook  the  fact 
that  the  husband  is  responsible  for  a  sterile  marriage  in  one-fourth  to  one-third  of  the  cases. 
This  is  a  fact  shown  by  many  observers,  and  too  often  forgotten  when  investigating  cases. 
Therefore,  we  must  not  consider  a  case  to  be  complete  unless  the  husband  and  his  semen 
have  been  investigated.  Many  a  woman  has  her  married  life  made  miserable,  and  is  taken 
from  doctor  to  doctor  on  account  of  sterility,  when  the  husband  really  is  to  blame. 

The  causes  of  sterility  are  shown  in  the  table  on  the  next  iiage.  From  a  study  of  it, 
it  is  clear  that  some  of  the  cau.ses  of  sterility  are  primary,  whilst  others  are  secondary. 
Thus  absence  of  the  uterus  or  infantile  uterus  means  primary  sterility,  whilst  hyperinvolu- 
tion,  carcinoma  of  the  cervix,  etc.,  may  occur  in  women  who  have  had  children,  and  only 
secondarily  become  sterile  on  account  of  these  lesions.  Further,  some  of  these  causes  are 
conunon,  or  may  be  remedied  ;  others,  on  the  other  hand,  are  rare  or  absolutejv  incurable. 
Diagnosis  is  therefore  of  great  imprfrtance,  for  it  is  far  better  to  discover  and  remedy  a 
defect  early  in  married  life,  than  to  wait  until  the  best  years  are  soured  and  embittered 
by  the  longing  for  a  child.  I'nfortunately,  many  patients,  from  various  motives,  put  off 
the  investigation  too  long. 

Congenital     Lesions.     S ■   of  the   congi'tiilal    lesions   arc   iliagnoscii    cMsily,    such   as 

closure  of  the  hi/mcii,  cibseiice  of  the  vagina,  or  closure  of  the  cervi.e.  wliilst  absence  of  the 
essential  organs  often  re(|uires  an  anaesthetic  in  order  that  a  bimanual  examination  may 
be  made  .satisfactorily.  The  infaulile  uterus  and  small  adult  ti/pe  are  very  dillieult  to  dilfer- 
cntiate  :  but  in  the  former  the  body  forms  only  one-third  of  the  total  length  of  tlii'  organ, 
whilst  in  the  latter  it  forms  two-thirds,  both  types  of  uterus  being  small  in  the  antero- 
posterior and  lateral  dimensions,  and  oidy  slightly  shortenerl  in  the  vertical.  Of  all  the 
congenital  lesions,  the  ■  coehleule  '  uterus  oi'  \'i>/./.\  is  the  commonest  cause  of  sterility,  and 
is  the  must  hopcfiil  as  regards  trealnieiit.  The  uterus  is  fell  to  be  unusu.illy  cur\ccl  ante- 
rioriw  has  a  Iniig  ciinicil  ccrxix.  and  a  small  cxlernal  (is.      In  siicli  an  cxlcnialis-  Miallnnncil 


646 


STERILITY 


uterus  as  this  it  is  possible  that  the  internal  structure  is  abnormal  :  the  endometrium, 
perhaps,  is  unduly  thin  and  fibrous,  the  nuiscle  layers  badly  developed.  The  hypothetical 
change  in  the  endometrium  may  be  the  essential  cause  of  sterility  :  hence  curettage  for  its 
complete  removal  forms  an  essential  part  of  the  treatment.  The  peculiar  shape  and  curva- 
ture have  long  been  considered  a  possible  cause,  preventing  the  entrance  of  spermatozoa 
into  the  cavity.  Pseudo-hermaphroditism  usually  shows  itself  by  shortness  of  the  vagina, 
elongation  of  the  clitoris,  and  the  presence  of  glandular  masses  in  the  groins,  which  are 
almost  always  testes,  proving  that  the  subjects  of  it  are  really  undeveloped  males. 


Lesions  of  the  Generative  Organs. 


Congenital  Lesions — 
Absence   of  uterus,    tubes, 

ovaries 
Closure    of  hymen,    vagina, 

cervix 
Pseudo-hermaphroditism 
Infantile  uterus 
Small  adult  type  of  uterus 
'  Cochleate  '   uterus 
Displacements 
Hyjjothetical    changes    in    the 

endometrium. 


Acquired  Lesions — 
Dyspareunia 
Vaginismus 
Salpingo-oophoritis 
I'terine  fibroids 
Endometritis 
Cervical  catarrh 
Polypi 

Carcinoma  of  cervix 
Carcinoma  of  fundus 
Ovarian   tumours 
Acquired  atresia  of  vagina 

„  „       cervix 

Genital  fistula- 
Hyperinvolution 
Astringent  douches 
Deficient  ovarian  activity. 

In  the  male. 
Azoospermia 
Oligospermi.a 
Neerospermia. 


General  Conditions. 


Old  age 

Obesity 

Anaemia 

Nutritional  disturbances 

Incompatibility 

Absence  of  sexual  feeling. 


Acquired  Lesions. — The  differential  diagnosis  of  the  acquired  lesions  can  only  be  made 
by  com])lete  examination  of  the  ])aticnt  l)y  ins])ection,  bimanual  examination,  and  the  use 
of  the  microscope  to  elucidate  doubtful  growths.  Dyspareunia  as  a  cause  is  dealt  with  in 
the  article  under  this  head  (p.  193).  Hyperinvolution  is  diagnosed  easily  ;  it  occurs  always 
after  a  labour,  and  strictly  means  a  continuance  and  progressive  increase  of  the  normal 
lactation  atrophy  of  the  uterus  ;  the  latter  is  felt  to  be  very  small  bimanually,  and  the 
sound  may  pass  only  \h  inches  in  a  marked  case  ;  it  is  always  associated  with  incurable 
amenorrhcea. 

Deficient  ovarian  actii'ity,  whereby  the  Graafian  follicles  do  not  ripen  or  rupture,  is  not 
to  be  diagnosed  by  any  of  the  ordinary  methods  we  can  employ,  and  it  is  doubtful  whether 
a  microscopic  examination  of  the  ovaries  themselves  would  reveal  the  true  condition. 
It  is  supposed  to  be  associated  with  scanty  menstruation  or  amenorrhcea  for  which  no 
other  definite  cause  can  be  found.  Absence  of  ovarian  activity  must  be  the  true  cause  in 
the  general  conditions  which  are  outwardly  shown  by  obesity,  ancernia,  and  disturbances  of 
nutrition  ;  and  it  is  a  fact  that  some  women  have  not  conceived  as  long  as  they  remain  too 
fat,  whilst  loss  of  weight  has  in  some  cases  been  followed  by  conception.  Incompatibility 
between  husband  and  wife  sexually  is  an  ill-defined  condition,  which,  however,  is  fully 
believed  to  be  a  cause  of  sterility.  It  is  almost  incapable  of  proof,  for  in  the  case  of  a  sterile 
widow  who  remarries  and  conceives  for  the  first  time  we  have  no  proof  that  the  former 
husband  was  capable  of  procreation.  Absence  of  sexual  feeling  or  the  sexual  orgasm,  too, 
is  not  always  a  cause  of  sterility,  for  conception  has  occurred  in  women  who  are  absolutely 
devoid  of  these  feelings.  On  the  other  hand,  most  authors  quote  the  case  of  a  woman  who 
conceived  as  a  result  of  the  only  coitus  at  which  an  orgasm  was  experienced.  The  influence 
of  age  on  child-bearing  must  not  be  forgotten,  the  liability  to  conceive  falling  rapidly  every 
year  over  thirty. 

Sterility  of  the  Male. — Finally,  the  examination  of  the  husband  and  his  seminal 
fluid  should  never  be  omitted  unless  there  is  some  quite  well-defined  cause  to  be  found  in 
the  wife.     .Assuming  that  the  penis  and  testes  are  present,  and  that  erections  render  the 


STIFF    NECK  647 

sexual  act  possible,  the  seminal  fluid  must  be  examined  carefully.  The  fluid  should  be 
collected  in  a  condom  by  means  of  a  normal  coitus,  and  should  be  examined  within  twelve 
hours.  It  must  be  spread  on  a  slide  and  examined  with  a  hioh  power  of  the  microscope. 
There  may  be  no  spermatozoa  jjresent  at  all,  the  condition  known  as  azoospermia,  in  which 
case  the  husband  is  incapable  of  procreation.  There  may  be  but  few  spermatozoa,  and 
those  exhibiting  only  feeble  powers  of  movement  :  oligospermia.  There  may  be  plenty  of 
spermatozoa  present,  but  quite  devoid  of  motility  :  necrospermia.  It  is  unnecessary  in 
this  article  to  enter  into  the  causes  of  these  conditions.  They  are  usually  incurable,  and 
consequently  further  investigation  is  unnecessary.  Thos.  G.  Stevens. 

STERTOR  is  really  another  word  for  snoring  ;  but  it  is  commonly  restricted  to  the 
heavy,  snoring  sound  accompanying  inspiration,  produced  not  in  the  nose  but  by  vibrations 
of  the  soft  palate,  generally  when  the  patient  is  in  a  state  of  profound  unconsciousness. 
It  differs  from  stridor  in  that  the  latter  is  produced  in  the  larynx.  If,  as  is  generally  the 
case,  the  patient  is  comatose,  the  presence  or  absence  of  stertor  helps  little  in  the  diagnosis, 
which  is  discussed  imder  the  heading  Co.M.v  (p.  117)  Sometimes,  however,  withiait  being 
comatose,  the  patient  may  have  stertor  during  sleep,  when  he  is  sufl'ering  from  the  effects 
of  drink  or  from  any  fif  the  following  : — 

Adenoids  i  Paralysis  of  the  soft  palate 

Hypertrophied  tonsils  Post-pharyngeal  abscess. 

Quinsy  | 

The  stertor  in  these  cases  is  closely  akin  to  snoring.  The  differential  diagnosis 
generally  becomes  manifest  when  the  interior  of  the  mouth  and  the  pharynx  are  examined. 
Possibly  the  condition  most  likely  to  be  overlooked  is  post-pharyngeal  abscess,  but  this 
should  not  be  mistaken  for  anything  else  if  a  digital  examination  of  the  back  of  the  mouth 
is  made  ;  moreover,  except  when  due  to  tuberculous  caries  of  the  cervical  vertebne,  it  is 
commonest  in  infants  and  quite  small  children,  becoming  rarer  with  each  year  of  life. 

Herbert  French. 

STIFF  NECK. — This  occurs  in  a  number  of  diseases  entirely  different  in  character, 
and  its  significance  may  be  cither  grave  or  trivial.  It  is  rarely  that  stiffness  is  the  only 
symptom,  but  it  may  be  the  first  thing  complained  of,  or  it  may  be  a  complication  arising 
in  the  course  of  a  disca.se.  It  is  not  right  to  assume  that  the  trouble  is  trivial,  or  vaguely 
to  designate  it  as  '  rheumatic,"  without  a  thorough  investigation.  It  is  necessary  first 
to  incjuire  into  the  history,  when  it  may  become  obvious  that  it  follows,  say,  an  injury, 
or  has  arisen  during  tlie  course  of  some  disease,  and  is  not  primary.  Next  examine  the 
patient  with  the  head  and  shoulders  bared,  and  see  whether  there  is  any  swelling  or 
abnormality  present,  also  the  extent  of  possible  movement,  and  whether  or  not  it  is 
the  nio\cment  that  causes  pain;  if  possible,  locate  the  seat  of  the  pain.  Many  I'mllier 
lincsligMtiiins  may  be  necessary,  e.g..  examination  of  the  tliroat  for  tonsillitis,  (he  ear  for 
suppurative  otitis  media,  etc.,  according  to  the  circumstances  of  the  case. 

ICrposiirc  to  Cold  or  Sleeping  in  a  Cramped  Posilion  may  give  rise  to  a  transient  stiff 
neck  associated  with  no  other  symptoms.  There  is  generally  a  distinct  history  of  the 
patient  waking  up  in  the  morning  with  a  stiff  neck,  and  the  diagnosis  is  made  by  exclusion. 

In/lanunrilion  of  the  Liim/ih'ilir  (Hands  and  the  cellular  tissues  of  the  neck  may  cause 
local  stillness,  whether  the  infecting  focus  lie  a  boil  or  earbimclc,  or  a  carious  tooth,  an 
inllamed  tonsil,  pediculosis  capitis,  or  other  similar  cause.  There  is  no  spasm  or  rigidity 
(if  the  muscles  here,  the  neck  ciin  be  moved  ipiite  well  :  but  it  hurts  to  do  so,  and  therefore 
it  is  held  stillly.     'I'Ik'  diagnosis  is  easy  as  a  rule. 

Torticollis  or  Wnj-nerU-  is  due  to  contraction  of  the  sl<riiuniasloi<l  nuiscje  on  onr  side, 
usually  the  result  of  an  injury  to  the  muscle  caused  b>  pulling  on  the  af'teiconiing  liiad  in 
l)icech  presentations.  The  muscle  stands  out  as  a  tight  band  in  the  iieeU,  and  its  e;>ntrae- 
lion  Iciils  to  a  eh  iractcristic  deformity.  The  head  is  pulled  down  towards  the  alleeled 
siilc.  :iii(l  I  lie  faee  and  chin  are  tilted  towards  the  opposite  shoulder.  The  nin\ cinents  of 
the  head  arc  necessarily  restrlctctl  owing  !:>  the  shortening  of  the  one  iiuiscle,  and  in  long- 
standing cases  this  leads  to  a  marked  asymmetry  of  the  f.ice.  The  conseipienccs  are  not 
limited  to  the  head  and  neck,  for  the  spine  shares  in  the  general  obli(iuity,  and  shows  marked 
laleiMl  eurx'ature  in  old  eases. 


648 


STIFF    NECK 


Spasmodic  Torticollis  is  an  unusual  form  due  to  spasms  of  the  steinomastoid  and  other 
muscles  of  the  neck.  The  spasms  are  intermittent,  coming  on  suddenly  with  great  pain, 
the  affected  muscles  relaxing  after  a  variable  time. 

Cervical  Caries. — The  greatest  care  must  be  taken  not  to  confoimd  muscular  rigidity 
with  tuberculous  disease  of  the  cervical  vertebrae.  In  the  latter,  pain  and  rigidity  are 
among  the  earliest  signs  ;  the  pain  is  increased  by  the  least  movement,  and  the  child — for 
it  is  generally  a  child  that  is  affected — takes  the  greatest  precaution  to  avoid  any  move- 
ment, even  holding  the  head  between  the  two  hands.  The  position  of  the  head  varies  ; 
it  is  most  often  held  very  stiff  and  straight,  the  natural  backward  curve  of  the  neck  being 
lost.  In  the  late  stages  there  may  be  an  angular  or  lateral  curve.  The  distaste  for  move- 
ment is  very  well  brought  out  when  the  patient  is  asked  to  look  round — the  eyes  only  are 
moved,  or  the  whole  body  is  rotated.     Bearing  the  possibility  of  this  condition  in  mind, 

there  is  not  much  dilficulty  in  diagnosis, 

but  in  doubtful  cases  a  skiagram  should 
be  taken. 

Nczv  Growth  in  one  of  the  cervical 
\ertebrae  may  cause  progressive  stiff 
neck,  and  generally  much  local  pain  on 
movement  ;  the  diagnosis  may  suggest 
itself  when  the  i)atient  is  known  to  have 
had  a  new  growth  elsewhere,  especially 
a  carcinoma  of  the  breast  or  of  the 
thyroid  gland  :  cases  of  primary  new 
ijniwtli  (if  tlic  vertebrse  are  fortunately 
rare,  but  myeloid  sarcoma  does  occur  ; 
it  can  generally  be  diagnosed  only  after 
the  patient  has  been  observed  for  a  long 
time.  The  symptoms  simulate  those  of 
caries. 

Infective  Arlhrilis  of  the  Cervical 
Vertebra-. — Following  infective  diseases 
such  as  scarlet  fever,  diphtheria  and 
tonsillitis,  especially  in  children,  there 
may  ensue  a  very  chronic  form  of 
suppurative  arthritis  affecting  one  or 
several  of  the  cervical  vertebrae,  and 
going  on  sometimes  to  complete  bony 
ankylosis.  Similar  stiffness  of  the  back 
of  the  neck,  especially  its  lower  part, 
with  i)ain  on  movement,  is  apt  to  occur 
in  suHerers  from  rheumatoid  arthiitis 
(p.  :J41):  it  is  due  to  infective  peri- 
arthritis of  the  vertebral  joints,  second- 
ary to  toxic  absorption  from  such 
sources  of  chronic  infection  as  pyorrh<ra 
alveolaris. 

Spoiifli/lilis  Deformans  causes  lix- 
ation  of  the  neck  (Fig.  274),  though  the  movements  of  nodding  "yes"  and  "no"  remain  :  the 
nature  of  the  case  is  at  once  indicated,  however,  by  the  fixation  of  the  other  regions  of  the 
spinal  column  also. 

Injuries  to  the  Neck. — A  stiff  neck  may  arise  from  some  slight  injury,  such  as  a  blow 
or  a  sudden  twist.  This  will  be  clear  from  the  history.  Severe  injuries  involving  fracture 
or  dislocation  are  almost  always  fatal :  if  not  immediately,  then  in  a  few  days.  A  rare  injury 
that  may  not  be  fatal  is  unilateral  dislocation  of  one  of  the  cervical  vertebras.  This  may 
result  from  a  fall  on  to  the  head.  From  the  start  there  are  great  pain  and  stiffness 
in  the  neck,  the  head  being  fixed  immovably  and  turned  to  the  opposite  side  to  that  of  the 
dis])lacement. 

Burns. — A  self-evident  cause  of  stiffness  is  the  cicatricial  contraction  following  a  burn 
on  the  neck. 


Fiij.  274. — Spondylitis  deformans.  The  patient  was  unable  to 
raise  tiie  hiead,  tliough  tie  could  just  nod  and  shake  it  slightly. 
I'ixcept  for  the  atlas  and  axis,  tlie  whole  vertebral  column  was 
fixed.  There  was  no  affection  of  other  joints  in  the  body,  and 
the  general  health  was  good. 


STRAXGURV  649 

Stiffness  and  retraction  of  tlie  head  are  important  indications  of  metiingitis,  but  they 
are  by  no  means  constant  ;  wlien  present  they  are  generally  accompanied  by  other  well- 
marked  signs  of  meningitis. 

Stiffness  of  the  neck  is  one  of  the  earliest  signs  of  tetanus  ;  it  is  rarely  the  only  one, 
however.  The  trouble  soon  spreads  to  the  jaw.  causing  trismus  and  other  characteristic 
symptoms  (p.  730).  Oco.  E.     Cask. 

STOMACH,    DILATATION    OF.— (See  Dilatation  of  the  Stomach,  p.  178.) 

STRABISMUS — Squints  may  be  classified,  according  to  their  direction,  into  convergent, 
divergent,  or  attitudinal  ;  according  to  their  cause,  into  paralytic  and  non-paralytic  (con- 
comitant). The  diagnosis  between  paralytic  and  non-paralytic  strabismus  is,  as  a  rule, 
easy.  In  a  paralytic  strabismus  the  con\ergence  or  divergence  of  the  two  eyes  is  not  con- 
stant in  amount  in  all  directions,  as  the  farther  the  eyes  are  moved  over  in  the  direction  of 
the  action  of  the  paralyzed  muscle  the  greater  will  be  the  deviation  from  parallelisni.  In  a 
concomitant  squint  the  eyes  always  bear  the  same  relative  jtosition  to  each  other  in  what- 
ever direction  they  are  turned. 

The  diagnosis  of  the  cause  of  a  paralytic  strabismus,  which  is  associated  with  Diplopia, 
is  discussed  under  that  heading  (p.  174).  The  causes  of  concomitant  strabismus  are  usually 
— Error  nf  refraction  :  Failure  of  binocular  vision  :  Defective  vision  in  one  eye  ;  or  the  associ- 
ation of  one  or  more  of  these  conditions.  The  cause  cannot  be  determined  accurately 
without  a  careful  examination  of  the  ocular  refraction  under  a  mydriatic.  In  general  terms 
it  may  be  stated  that  convergent  squints  are.  as  a  rule,  due  to  hypermetropia,  and  diver- 
gent squints  to  myopia.  Herbert  L.  Eason. 

STRANGURY  fliffers  somewhat  from  mere  pain  on  micturition,  in  that,  in  addition 
to  se\xrc  pain  before,  during,  or  after  the  act,  the  patient  is  troubled  constantly  by  urgent 
and  repeated  necessity  to  discharge  his  urine,  sometimes  as  often  as  every  few  minutes, 
yet  without  any  satisfactory  relief  to  his  discomfort.  The  condition  is  also  spoken  of  as 
vesical  tenesmus.  Very  little  urine  is  passed  each  time  ;  sometimes  the  desire  and  the 
necessity  are  urgent  when  there  is  no  urine  in  the  bladder  at  all.  The  causes  resolve  them- 
selves into  five  groups,  as  follows  : — 

1 .  Nervous  Conditions,  especially  : — 

Ilystcriii  ;    Irritable  bladder  ]     Tabes  dorsalis 

XciinistlK-iii:i  |        (vesical  crises) 

'Jt.  Obstruction  to  the  Urine  Outflow,  leading  to  Retention  with  Overflow  :  — 


llrctliral  stiiftiirc 

Enlari;c<l  |inistat<' 

Carcinoma  of  tin-  jjrosfatc 

Hetroverted  gravid  uterus 

Uterine  fibroid         )  ,  ... 

,,        .  .  '  Impacted  in 

Ovarian  evst  ., '         ,    . 

,.        .  •      .  ,     the   pelvis 

Ovarian  careindina  ' 


I'Wtrcmc  priilapsc  dI'  the  uterus  auil  bladder 

Calculus  iiiipaek-il  in  tlic  uretlira 

Inllanu'd  urethral  caruncle 

(ionorrlwra 

Urethritis  other  than  gonocoeeal 

Periprostatic  abscess 

Periproctal  abscess 


3.  Local  Affections  of  the  Bladder  Wall  :— 

Iiijiirv  'I'uhcrciiliius  cystitis  Inliltration  liy - 

Acuti-  cystitis  I'apiJiyiiiM  vesica-  CarciiiDina  ol'llic  iili-rus 

Chrnuic  cyslilis  Carcinoma  vesicae  Carcinoma  ol'llic  rictum. 

4.  Reflex  Conditions  : 

Inllamca  hicmorrhoids  Acute   mvelitis   |     Without   iurcctinii  ol  llic 

lujurv  to  the  hack  (  oli    liacilluria    l  liladdcr   wall. 

Tiihcrciiloiis  kidiicv,  hclori-  the  liladdcr 
is  involved 

3.  The    effects  of  certain  Drugs,  especially  : — 

Cantharidcs  I    Urotropine  Cy.stopiiriii 

Oxalic  acid  Helmitol  liexaincthx  Icik  Iclraminc. 

'I'Mrpciitiuc 

d   llic   rncllKids  of  distiiigiiisliing  between 

\.  AiiNoiniAi.i  rii.s  i)i-  (p.  :(!»;!).      Irrilablc 

III  A  (p.    I'J.'i).      Two  points  ol    iiupnitancc 


Most   , 

f  Ihc   ( 

Olldilinlls    Illcl 

liolM'd   all 

)\c,   ai 

tlu 

111.  arc  ( 

iisCIISSI 

d   ill   the  arlic 

c  on   Mr 

run  i( 

bl: 

ddcr   is 

liscuss 

■d    iu„hr   Ihc 

leading  o 

■   OXAI 

650  STRANGURY 

deserve  stress,  however,  and  chief  amonost  these  are  the  vesical  crises  of  tabes  dorsalis. 
The  patient's  sole  complaint  may  be  that  he  can  never  be  far  from  a  lavatory  because  of 
acute  and  painful  calls  to  empty  his  bladder  at  frequent  intervals  ;  sometimes  he  has 
no  sooner  passed  what  is  in  his  bladder  than  he  has  to  run  back  and  again  do  it,  though 
there  is  no  urine  whatever  to  pass  ;  and  his  vesical  pains  may  be  extreme.  From  loss  of 
sleep  his  general  health  suffers,  and  he  becomes  anaemic  and  wasted  to  such  an  extent  that 
carcinoma  of  the  bladder  or  genito-urinary  tuberculosis  are  simulated  closely,  and  in  some 
cases  acute  cystitis  is  diagnosed  erroneously  upon  the  symptoms  alone.  The  true  diagnosis 
will  be  suggested  when  it  is  discovered  that  the  knee-jerks  are  absent  and  the  pupils  give 
the  Ariivll  Hohertson  reaction:  in  some  cases,  however,  the  nature  of  the  malady  may  be 
diHicult  to  decide  for  a  time,  because  crises  of  all  kinds,  like  the  lightning  jjains,  are  apt  to 
develop  in  the  earlier  stages  of  tabes,  when  the  knee-jerks  are  not  yet  absent.  Both  jerks 
should  be  tested,  for  there  are  a  good  many  cases  in  which  one  knee-jerk  is  still  present 
when  the  other  has  disappeared.  A  thorough  examination  of  the  urine  and  bladder  should 
be  carried  out  even  if  the  patient  is  known  to  ha\e  tabes  dorsalis,  for  he  may  have  a  gross 
lesion  of  the  liladder  in  addition  to  his  nerve  disease  ;  but  this  is  unusual.  The  actual 
cystitis  resulting  from  retention  of  urine  with  overflow  is  generally  a  late  symptom,  and 
not  a  relatively  early  one  like  the  vesical  crises,  which  are  quite  distinct  phenomena.  As 
time  goes  on  the  bladder  crises  may  cease  spontaneously  just  as  the  lightning  pains,  the 
rectal  crises,  and  the  other  painful  phenomena  of  tabes  are  apt  to  do. 

The  other  jjoint  tliat  merits  attention  is  the  strangury  that  certain  drugs  produce. 
CmUliarides  is  familiar  in  this  respect,  but  more  from  its  prominence  in  text-books  upon 
forensic  medicine  than  from  its  occurrence  in  actual  practice.  The  same  applies  to  oxalic 
acid  and  to  turpentine.  It  is  less  recognized  that  certain  drugs  in  common  use  may  be 
responsible  for  very  similar  symj)toms.  in  which  respect  urntropine.  Iielmitol.  cijstopurin  and 
hexatnelln/lenelcl  rami  lie  are  important.  These  are  all  employed  in  the  treatment  of  jiyuria, 
as  well  as  for  gall-stones  and  other  conditions.  If  given  for  pyuria,  when  there  may  have 
been  frequent  and  painful  micturition  already,  before  any  treatment  is  begun,  the  increased 
frequency  and  pain  that  sometimes  ensue  when  any  of  the  above  drugs  are  administered 
are  very  apt  to  be  attributed  to  an  increase  in  the  cystitis  or  other  genito-urinary  lesion, 
and  the  dose  of  the  drug  is  increased  instead  of  diminished.  It  may  be  only  after  the 
patient  deliberately  ceases  to  take  the  medicine  that  the  fact  of  the  increase  in  the  symptom 
being  due  to  the  drug  becomes  obvious  :  some  cases  develop  strangury  e\-ery  time  they 
take  lu-otropine,  and  lose  the  symptoms  a  day  or  two  after  they  have  stopped  the  medicine. 
In  some  instances  transient  hsematuria  accompanies  the  strangury,  and  the  danger  always 
is  lest  these  symptoms  be  attributed  to  the  disease  and  not  to  the  drug.  Speaking  gener- 
ally, it  is  in  cases  in  which  the  urine  is  concentrated,  or  at  least  in  small  amount,  that 
urotropine  and  its  allies  are  most  liable  to  cause  strangury  and  hii-maturia.  If  the  patient 
drinks  excess  of  water,  so  as  to  dilute  his  urine,  these  symptoms  often  disappear.  Some- 
times the  patient  can  take  helniitol  with  ease  when  he  cannot  bear  urotropine,  and  vice 
versa.  The  important  point  is  that  urotropine  and  other  drugs  of  like  nature  may  be 
responsible  for  such  strangury  as  may  simulate  local  disease  of  the  bladder,  and  unless 
this  is  borne  in  mind  an  erroneous  diagnosis  is  liable  to  be  made.  Herbert  Freiicli. 

STRIDOR  is  a  term  used  to  denote  a  harsh,  vibrating  noise  produced  as  the  air  passes 
in  or  out  of  a  partially  obstructed  larynx  or  trachea.  It  may  be  due  to  many  different 
causes,  which  may  be  classified  as  follows  : — 

1.  Partial  Obstruction  Inside  the  Larynx  or  Trachea  : — 

Jlucus  or  miicd-pus  I        Caseous    <rland   bulgiiii;    or  rupturing   into 

Foreign   hody  I  the  trachea. 

2.  Affections  of  the  Wall  of  the  Larynx  or  Trachea  : — 

Diphtheria  |      Secondary  infection  in  cases  of  tuberculous, 
Acute  oedema  due  to —  syphilitic,  malignant,  traumatic,  or  post- 

Bright's  disease  1  typhoidal  ulceration 

Potassium  iodide  i       Stenosis  after  tracheotomy  or  cut  throat 

Irritant  vapours  such  as  ammonia  or  '       Epithelioma  of  a  vocal  cord 

chlorine  |       Fibroma  of  the  vocal  cords 
.\cute  laryngitis — streptococcal,   pneu-  Epithelioma  of  the  trachea 

mocoecal,   staphylococcal  .Syphilitic  stenosis. 


SUCCUSSIOX     SOUNDS  6r,i 

3.  Swellings  Outside  Compressing  the  Larynx  or  Trachea  : — 

Knlarfjcinciit  of  the  thyroid  gland  !  Ki)ithclioina  of  the   (esophagus  invading 

Enlargement  of  the  tliymus  gland  [  tlie  traeliea 

Thoracic  aneurysm  Malignant  glands  in  tlie  neck 

Mediastinal   new  gro\vth  Cellulitis  of  the  neck 

Post-pharyngcal  abscess  Erysipelas  of  the  throat 

I  Angina  Ludovici. 

1.  Bilateral  Abductor  Paralysis  of  the  Vocal  Cords,  generally  due  to  sy|iliilitie 
degeneration  of  the  va^'ul-nuclear  nerve  cells. 

5.  Unilateral  Vocal  Cord  Paralysis  in  a  few  eases  ;  generally  if  one  cord  remains  iiornuil 
there  is  no  stridor.     The  diagnosis  of  the  causes  is  given  on  p.  494. 

Distinction  is  sometimes  drawn  between  inspiratory  and  expiratory  stridor,  and  stridor 
which  is  both  inspiratory  and  expiratory  ;  but  in  j)raetice  such  a  distinction  is  not  helpful. 
The  main  vahie  of  stridor  as  a  symptom  is  that  it  indicates  stenosis  of  the  main  air-passages 
by  one  or  other  of  the  above  causes,  except  in  tliose  rare  cases  in  which  it  is  functional  ; 
hi/.iterical  stridor  ceases  during  sleep,  is  nearly  always  confined  to  the  female  sex,  as  a  rule 
between  the  ages  of  fifteen  and  thirty,  and  is  often  associated  with  other  functional  nervous 
symptoms,  such  as  globus  hystericus  and  functional  aphonia  (p.  494).  Stridor  should 
never  be  diagnosed  as  functional,  however,  initil  every  possible  organic  cause  has  been 
excluded.  The  differential  diagnosis  of  the  causes  of  obstruction  to  the  main  air-passages 
will  be  found  discussed  on  page  418.  Herbert  French. 

STUPOR.     (See  Coma,  p.   117.) 

STUTTERING.     (See  Speech,  Abnohmai.itiks  or.  j).  r.28.) 

SUCCUSSION  SOUNDS  may  be  heard  when  a  part  that  contains  any  considerable 
hulk  of  both  lluiil  and  gas  is  shaken  whilst  the  ear  or  the  stethoscope  is  applied  over  the 
part.  Sometimes  the  sounds  are  so  loud  that  they  can  be  lieard  at  a  considerable  distance 
from  the  |)atient.  A  very  good  example  of  sueeussion  soimd  is  often  afforded  by 
tlic  normal  stomach  after  a  quantity  of  fluid  has  just  been  swallowed.  It  is  a  mistake  to 
suppose  that  gastric  sueeussion  sounds  are  evidence  of  abnormality  ;  they  merely  prove 
that  the  viscus  contains  fluid  and  gas  at  the  same  time  ;  the  gas  may  be  due  to  fermen- 
tation, but  it  is  often  nothing  but  air  that  has  been  swallowed  during  drinking.  The  chief 
value  of  gastric  sueeussion  sounds  is  that,  according  to  the  position  in  the  abdomen  at 
which  they  can  be  heard,  they  afford  some  clue  as  to  the  jxisition.  and  (lerhaps  as  to  the 
size,  of  the  stomach.  They  shoidd  not  be  heard  lower  than  the  innhilieus  ;  if  they  arc.  the 
stomach  is  either  displaced  downwards,  or  dilated,  or  both. 

.Another  variety  of  sueeussion  sounds  may  sometimes  be  heard  in  the  chest,  especially 
in  cases  of  liiiilroj)iiei(iiiollii)ra.r  :  when  the  patient  deliberately  oscillates  his  trunk  to  and 
fro,  and  then  stops,  the  lluid  and  air  can  be  heard  making  noises  like  those  [jrodueed  when 
a  ])arlly-lilled  barrel  is  ino\cd  about.  Sometimes  the  lluid  splashes  up  on  to  the  collapsed 
lung  and  then  ilrips  olT  again  into  tlx'  pool  at  the  bottom  of  the  pleural  cavity,  each  drop 
echoing  in  the  cavity  and  producing  a  niclallic  cliid^  like  a  hriiil  d'/iiriiiii  or  coin  smmd. 
Similar  sueeussion  sounds  may  be  pnidiiccil  by  a  pyopiuumothorax  or  a  ha-mopiu  uiuo- 
thorax.  the  difTerenee  between  these  being  decided,  as  a  rule,  by  exploratory  needling. 

Sueeussion  sounds  other  than  those  due  to  the  stomach,  or  to  gas  and  lluid  in  the 
])leural  ca\  ity.  are  uncommon,  but  tlx'  following  is  a  list  of  the  chief  possible  causes  :  — 

1 .  Causes  of  Sueeussion  Sounds  in  the  Thorax  : — 

IIy(lni[)iiciiiiicilli(irax  j  with    the    liarittiis   riili   lominutiin,    and 

I'vopiiciiiniilliiirax  eiiiilaiiiiiig  gas  and  pus 

Ilii-innpiiciiinot  lior.'ix  llydi'opiietiiiioperieardinin 

I  >ia{iht':)L'irial  ie   lieriiia  I'yopneunioperieardiiini 

.Siil)cljiiplir:igMialic    alisccss    eiiniiiiiuiicat-  A  huge  phlliisieal  ea\ily  henealh  a    lhii\ 

irig  Willi  sliiiiiiicli  iir  dttiiilciiinii.  and  so  chest    wall. 

eoiilajiijiig  air  and  [ills  ;    or  <'lse  infected 


6.52  SUCCUSSION    SOUNDS 

2.  Causes  of  Succussion  Sounds  in  tbe  Abdomen  : — 

The  normal  stomacli  (vi)  Production  of  gas  by  the  Bacillus 

t        Dilatation  of  the  stomach  colt  communis,  either  in  a  local  abscess 

Enormous  dilatation  of  the  cecum  (e.g.  appendicular  or  subdiaphragmatic) 

Enormous  dilatation  of  the  sigmoid  colon  ,           or  in   the  general   peritoneum 

Enormous  dilatation  of  some  other  part  |       Subdiaphragmatic    abscess    communicat- 

of  the  colon  ing  witli  the  interior  of  stomach 

Pneumoperitoneum,  due  to  :     (i)   Perfor-  I       Air  and  urine  in  the  bladder  (see  Pneu- 

ated     gastric     nicer  :      (ii)    Perforated  |           maturia,  p.  529) 

duodenal  ulcer ;  (iii)  Perforated  typlioid  Infection    of  an    ovarian    cyst    or    other 

ulcer  of  the  intestine  ;    (iv)  Perforated  collection  of  fluid  by    a  gas-producing 

tuberculous  ulcer  of  the  intestine  ;    (v)  micro-organism. 
Perforated  malignant  ulcer  of  the  colon; 

Succussion  Sounds  in  the  Chest. — The  diagnosis  is  not  as  a  rule  diHiciilt.  It  is  very 
rare  indeed  for  a  phthisical  cavity  to  give  succussion  sounds  :  but  should  it  do  so,  the 
phenomenon  would  be  apical  rather  than  basal,  and  thus  distinguishable  from  most  cases 
of  hydro-  or  pyo-pneumothorax.  It  is  possible  for  the  latter  to  be  apical,  however,  if  old 
adhesions  prevent  the  ])arietal  and  visceral  layers  of  pleura  from  separating  in  the  lower 
part  of  the  chest,  and  then,  if  tubercle  bacilli  were  found  in  the  sputum,  it  would  become  a 
matter  of  opinion  as  to  wliether  tire  sounds  were  produced  in  the  pleural  cavity  or  in  a  huge 
vomica.  Hydro-  and  pyo-pneiimcpericardiiim  are  very  rare,  and  they  are  at  once  distin- 
guished by  the  extraordinary  churning  sounds  made  by  the  heart  beating  within  the  mixture 
of  air  and  fluid.  Survival  is  im|)robable.  The  cause  is  generally  litlicr  an  epithelioma 
of  the  oesophagus  opening  the  pericarditmi  from  behind,  a  foreign  body,  such  as  a 
tooth-plate,  ulcerating  through  from  the  oesophagus,  or  the  opening  of  an  air- 
containing  sub-diapliragmatic  abscess  through  the  diaphragm  into  the  pericardium,  or 
infection  of  the  pericardial  sac  by  a  gas-producing  organism   such   as   the   Bacitlns  coli 

COttUHHIlis. 

A  siibdi/iphragmntic  abscess  containing  air  owing  to  comminiication  with  a  hole  in  a 
gastric  or  duodenal  ulcer,  sometimes  puslies  the  diaphragm  up  so  iiigh  that  the  condition 
may  be  mistaken  for  hydro-  or  pyo-pneumothorax  ;  it  may  be  possible  to  distinguish  the 
two  by  knowing  that  the  trouble  began  witli  gastric  ulceration  :  on  the  other  hand,  it  may 
be  impossible  to  tell  which  it  is  until  the  position  of  the  diaphragm  is  ascertained,  either 
by  the  use  of  the  ,T-rays,  or  by  operation.  When  the  trouble  is  subdiaphragmatic,  the 
tendency  is  to  displace  the  heart  upwards  rather  than  towards  the  opposite  side  of  the  chest, 
whereas  the  contrary  is  true  of  pneumothorax. 

Diaphragmatic  hernia  is  very  rare  ;  it  may  be  congenital,  or  it  may  be  the  result  of 
severe  injury  to  the  abdomen  and  chest.  In  neither  case  are  the  patient's  prospects  of 
survival  good.  The  exact  diagnosis  may  not  be  arrived  at  without  operation  or  post- 
mortem examination  ;  if  the  stomacli  is  lierniated  into  the  thorax,  however,  the  effects 
of  eating  and  drinking  upon  the  physical  signs  may  point  to  the  diagnosis,  or  the  .r-rays 
may  be  used  to  demonstrate  the  gastric  shadow  after  the  administration  of  bismuth  or 
barium  salts  by  the  mouth. 

In  most  cases  of  hydropneutnothorax  there  is  little  difficulty  as  to  the  diagnosis  of  the 
condition  itself ;  it  may  be  less  easy  to  decide  what  the  hydropneumothorax  is  due  to. 
If  tlie  onset  has  been  sudden,  with  acute  pain  in  the  affected  side  of  the  chest,  cyanosis, 
and  dyspnoea,  the  commonest  cause  is  phthisis.  The  sputum  should  be  examined 
for  tubercle  bacilli.  In  some  instances  an  injury  may  have  been  the  immediate  cause,  but 
injury  will  very  seldom  produce  hydropneumothorax  unless  there  was  already  a  tuberculous 
or  other  lesion  in  the  lung  at  the  time  of  the  accident.  Hydropneumothorax  may 
result  temporarily  after  paracentesis  thoracis.  If  there  has  been  bleeding  at  the  same  time, 
hcemopneumothorax  may  be  found,  and  it  is  common  after  bullet  wounds  of  the  chest. 
Either  a  hydro-  or  a  ha?mo-pneumothorax  may  become  infected  with  pyogenetic  organisms 
and  converted  into  a  pyopneumothorax.  The  diagnosis  will  be  confirmed  by  needling  the 
chest.  Pyopneumothorax  is  apt  to  escape  detection,  however,  because  it  arises  when  the 
patient  is  too  ill  to  be  .shaken — in  cases  of  gangrene  of  the  lung  for  instance,  resulting 
perhaps  from  lobar  pneimionia,  obstruction  of  a  bronchus  by  a  foreign  body  or  a  new 
growth,  or  the  breaking  down  of  an  infective  bronchopneimionia  or  iiiilmonary  infarct. 
Generally  speaking  one  may  say  that  the  existence  of  well-marked   succussion  sounds  in 


SUCCUSSIGN    SOUNDS  653 

the  pleural  cavity  of  a  i)atient  who  has  siilflcient  vigour  to  shake  his  own  body  to  and  fro 
indicates  hydropneuniotliorax  of  plithisical  origin. 

Succussion  Sounds  in  the  Abdomen. — The  first  point  in  the  differential  diagnosis 
of  succussion  sounds  in  the  abdomen  is  to  decide  whether  the  sounds  are  gastric  or  not. 
Generally  this  is  obvious  ;  if  there  is  doubt,  the  effect  of  putting  more  gas  or  more  fluid  into 
the  stomach  by  taking  a  seidlitz  powder  in  two  halves,  or  by  drinking  a  quantity  of  water, 
will  usually  so  change  the  character  and  distribution  of  the  sounds  if  they  are  gastric,  that 
little  doubt  will  remain  ;  or  the  .r-rays  and  bismuth  method  of  demarcating  the  stomach 
may  be  employed.  As  has  been  mentioned,  the  existence  of  gastric  succussion  is  no  proof 
of  gastrectasis  :  if,  however,  the  succussion  sounds  are  audible  over  a  larger  area  than  tlie 
normal  stomach  should  occupy,  they  afford  valuable  evidence  of  gastrectasis.  and  the  next 
step  will  be  to  determine  the  cause  of  the  latter.  Dilatation  of  the  stomach  has  three  main 
causes,  namely,  atony,  non-malignant  pyloric  obstruction,  especially  by  a  healed  simple 
ulcer,  and  malignant  pyloric  obstruction  by  primary  gastric  carcinoma. 

The  presence  of  visible  peristaltic  waves,  or  the  occurrence  of  vomiting,  will  exclude 
simple  atony,  which  can  never  be  diagnosed  with  certainty  until  it  is  known  that  there  is 
no  pyloric  obstruction.  The  latter  will  be  indicated  by  the  periodicity  of  the  vomiting  ; 
by  the  abundance  of  the  fluid  vomited  being  greater  than  the  amount  taken  at  the  last 
meal  ;  by  the  presence  in  it  of  particles  of  foot!  eaten  a  day  or  more  previously — ham,  for 
instance,  vomited  on  Tuesday  when  last  partaken  of  on  Sunday  ; — by  the  visible  peristaltic 
waves  corresponding  with  the  stomach  ;  and  by  the  presence  of  sarcimc  in  the  vomit  (see 
Fig.  121,  p.  24.1).  The  most  certain  method  of  detecting  pyloric  stenosis,  however,  is  by 
means  of  bismuth  or  barium  and  the  a-rays,  especially  in  those  cases,  not  infrequent,  in 
which  vomiting  does  not  take  place  in  spite  of  great  gastrectasis. 

There  may  also  be  evidence  of  delay  in  the  absorption  of  substances  that  are 
not  dissolved  until  they  reach  the  pancreatic  juice  in  the  duodenum,  tested  for  instance 
by  giving  methylene  blue  in  kciatin-coated  capsules,  and  observing  when  the  urine  first 
begins  to  be  blue.  Keratin  is  not  dissolved  by  gastric  juice,  but  is  by  pancreatic  ;  if  there 
is  no  evidence  of  pancreatic  disease,  delay  of  more  than  one  to  two  hours  in  the  first  sign  of 
blueness  of  the  urine,  after  giving  the  capsules,  indicates  marked  delay  in  their  transit 
from  stomach  to  duodenum. 

It  is  often  a  matter  of  extreme  difficulty  to  decide  whether  pyloric  stenosis  is  simple 
or  malignant,  though  upon  the  whole  the  shorter  the  history,  the  older  the  patient,  and  the 
more  definite  the  pyloric  thickening  or  lump  the  more  likely  is  the  lesion  to  be  carcinoma- 
tous. The  latter  may  occur  in  <|uitc  young  subjects,  however,  even  between  20  and  30  ; 
and  a  long  history  does  not  exclude  carcinoma,  since  some  cases  of  simple  ulcer  idtimately 
become  malignant.  Even  when  laparatomy  is  performed  for  the  relief  of  the  condition, 
its  nature  may  not  be  obvious  :  sometimes,  indeed,  i)ost-mortem  examination  has  failed 
to  decide  whether  the  stenosed  pylorus  was  earciiioiiiatous  or  not.  until  inicroseopieal 
examinations  have  been  made.  It  has  been  stated  tliat  if  the  gastric  juice  alter  a  test 
meal  contains  a  normal  amount  of  IICI,  the  diagnosis  is  unlikely  to  be  carcinoma,  and  vice 
versa  ;   but  even  this  general  rule  has  many  exceptions  (p.  270). 

The  diagnosis  of  pyloric  stenosis  due  to  other  causes  than  adhesions,  a  healed  ulcer  or 
a  carcinoma  is  seldom  possible  without  a  laparotomy  :  occasionally  such  out-of-the-way 
tilings  as  a  (■alei(ie<l  retroperitoneal  t^sl  adherent  to  the  pylorus  and  tliought  to  have  been 
a  carcinoma  pylori  may  be  foiuid. 

If  there  are  well-marked  abdominal  succussion  sounds  llial  can  be  shown  lo  be 
definitely  not  gastric,  there  are  geiurally  oilier  wcll-mfirk(  il  signs  and  syiiiplonis  wliicli 
materially  assist  the  diagnosis. 

Succussion  sounds  in  the  geiienil  p^riloiical  cavity  arc  excessively  rare,  for  even  though 
this  cavity  slmuid  contain  both  gas  and  lluid.  lor  instance  after  perforation  of  a  typhoid 
ulcer,  the  coils  of  bowel  prevent  the  sounds  from  being  produccci  readily.  The  list  of  <'auscs 
given  above  indicates  the  conditions  tliat  may  be  present.  It  would  clearly  be  next  to 
impossible  to  diagnose  most  of  them  uidess  the  previous  state  of  the  patient  was  known 
accurately,  or  unless  exploratory  laparotomy  were  resorted  to.  It  is  important  to 
remember  that  the  liiirilliis  ciili  coiiiniiiiiis  produces  gas,  so  that  intra-abdominal  abscesses, 
appendicular  and  otherwise,  are  not  infrequently  resonant.  The  oeeinTcnee,  however,  of 
marked    non-gastric   su<-cussion   sounds   in   the   alidoiiien  of    a    patiiiit    who    is   not  acutely 


654  SUCCUSSION    SOUNDS 

ill  will  oenerally  arouse  a  suspicion  that  there  is  distention  with  gas  and  fluid  of  some 
part  of  the  large  bowel,  especially  the  csecum  or  the  sigmoid  colon.  This  distention  will 
generally  be  the  result  either  of  chronic  constipation  (see  p.  121)  or  of  some  cause  of 
intestinal  stenosis. 

In  some  eases  that  were  formerly  described  as  idiopathic  dilatation  of  the  colon,  but 
which  are  now  regarded  as  chronic  volvulus  of  the  sigmoid  colon,  the  result  of  persistent 
constipation,  the  sigmoid  dilatation  may  be  so  extreme  that  this  part  of  the  intestine  bulges 
up  as  far  as  the  diaphragm  (Hirschsprung's  disease,  see  Fig.  55.  p.  l"iT,  and  Fig.  171.  p. 
389)  :  the  occurrence  of  succussion  sounds  in  such  a  dilated  colon  might  readily  lead  to  the 
erroneous  diagnosis  of  gastrectasis  ;  the  pear-shaped  outline  of  the  dilated  viscus,  and  the 
fact  that  it  is  known  to  have  come  upwards  from  the  ijclvis,  may  indicate  the  true 
nature  of  the  case,  but  sometimes  the  fact  that  succussion  sounds  are  colonic  and  not  gastric 
can  only  be  determined  by  giving  large  doses  of  bismuth  by  the  mouth  and  then  outlining 
the  stomach  by  the  dark  sliadow  cast  by  the  bisnuith  under  the  .f-rays.  Ilcrberl  Freiu-li. 

SUGAR    IN  THE   URINE.— (See  Gi.vcosriu.v,  p.  2C0.) 

SUPPRESSION  OF   URINE      (See  Anuri.\,  p.  39.) 

SWEATING,  ABNORMALITIES  OF.— The  functional  disorders  of  the  sweat-glands, 
.■iiuldmeii  {miliaria)  and  hidroci/stoma,  are  dealt  with  from  the  diagnostic  point  of  view  in 
the  article  on  Vesicles  (p.  753).  The  other  abnormalities  retjuire  but  the  briefest  notice 
in  a  work  on  diagnosis,  for  it  is  hardly  possible  to  confuse  them  with  each  other  or  with 
any  other  conditions.  In  lii/pcridrosis  the  secretion  of  sweat  is  excessive,  either  over  the 
whole  skin  or  in  some  particular  region,  e.g.,  the  palms  and  soles,  and  especially  covered 
parts  furnished  with  large  .sweat-glands,  such  as  the  axillae  and  genital  regions.  Occasion- 
ally hyperidrosis  is  limited  to  the  area  of  distribution  of  a  particular  nerve — the  fifth,  for 
example.  In  some  cases  a  peculiar  ])ink  tint  of  the  inner  side  of  the  palm  and  the  ball  of 
tlie  little  finger  and  thumb  has  been  noticed.  In  rare  in.stances  hyperidrosis  in  delicate 
children  is  associated  with  grdiiiilosis  rubra  nasi,  a  condition  in  which  the  skin  of  the  nose 
becomes  intensely  red.  and  is  dotted  ()\er  with  minute  deep-red  S]5ecks  and  papides,  the 
papules  gradually  developing  into  pustides  which  soon  dry  up.  The  cells  around  the  .sweat- 
ducts  are  infiltrated,  and  both  ducts  and  coils,  and  also  the  blood-vessels  and  the  lymphatic 
s|)aces  of  the  corium,  are  dilated.  This  complication  is  distinguishable  from  rosacea  by 
the  age  of  the  patient  and  the  absence  of  telangiectases  and  of  change  in  the  sebaceous 
glands  ;  from  eczema,  by  the  absence  of  vesiculation  and  weeping,  and  its  obduracy  to 
local  treatment  ;  from  lupus  erythematosus,  by  the  absence  of  scales  :  and  from  lupus 
vulgaris,  by  the  absence  of  apple-jelly  nodules.  The  night  sweats  of  phthisis,  and  those 
associated  with  rickets  and  with  infantile  scurvy  (Barlow's  disease,  p.  556),  are  not,  as 
a   rule,  difficult  to  attribute  to  their  cause. 

In  itnidrosis  the  secretion  may  be  merely  diminished  or  totally  suppressed,  and  either 
the  whole  skin,  or  only  some  particular  area,  may  be  affected.  The  abnormality  is  rarely 
idiopathic,  but  is  usually  associated  with  ichthyosis,  psoriasis,  eczema,  sclerodermia.  bella- 
donna poisoning,  with  malnutrition  or  with  disordered  innervation  :  imder  the  latter 
heading  one  may  mention  in  particular  the  unilateral  sweating  of  the  face  and  head  that 
accompanies  irritation  of  the  cervical  symi)athetic  by  an  aneurysm,  thoracic  cyst,  or  new 
growth  ;  the  outbursts  of  local  perspirations,  such  as  a  band  of  .sweating  round  the  body, 
that  constitute  a  rare  symptom  of  tabes  dorsalis — a  sweating  crisis  ;  and  thV  sweating  of 
half  the  body — hemidrosis — that  may  be  purely  functional  or  hysterical  phenomenon. 

Bromidrosis.  or  foul-smelling  sweat,  sometimes  associated  with  hyperidrosis,  may 
occur  in  connection  with  such  general  affections  as  acute  rheimiatisni,  lu-irmia,  and  scurvy, 
or  following  a  serious  illness  like  pneumonia,  or  may  be  idiopathic.  Occasionally 
generalized,  it  is  much  more  frequently  limited  to  particular  parts,  such  as  the  feet,  the 
axillae,  and  the  perineum.  The  foul  smell  is  due  to  the  growth  of  the  Bacillus  fcctidus  upon 
the  .sweat  after  exudation. 

In  chromidrosis  both  sweat  and  sebum  may  be  coloured,  generally  some  shade  of  blue, 
but  occasionally  red,  green,  yellow,  violet,  and  even  black.  The  pigmentation  is  u.sually 
localized,  the  most  frequent  situations  being  the  eyelids,  cheeks,  forehead,  and  side  of  the 


SWELLING.     ABDOMINAL 


655 


nose  ;  but  occasionally  the  whole  of  the  face  and  large  jjarts  of  the  trunk  and  limbs,  and 
especially  the  axilla?  and  groins,  are  affected.  The  condition  is  often  a  neurosis,  but  it 
may  be  due  to  the  ingestion  of  copper  (green  sweat),  or  of  iron  (blue  sweat),  or  to  the  action 
of  cocci  or  the  Bacillus  pi/nci/niteus  upon  the  sweat  after  secretion.  The  chief  point  in 
diagnosis  is  the  exclusion  of  ini])osture. 

Hcematidrosis.  or  bloody  sweat,  generally  limited  to  particular  parts,  the  face,  hands, 
feet,  navel,  etc.,  may  be  a  form  of  .so-calle<l  vicarious  menstruation,  or  an  expression  of 
emotional  stress  in  highly-strung  persons  ;  it  is  sometimes  simulated  by  the  presence  in 
tlie  sweat  of  bacteria  producing  a  red  pigment,  such  as  the  BaciUun  prodisiiosiis.  Uridrosis, 
in  which  urinary  constituents  are  present  in  the  sweat  in  abnormal  (piantity,  is  not  an 
idiopathic  affection,  but  an  accompaniment  of  such  grave  conditions  as  cholera  and  ur.xmia. 
It  is  quite  unmistakable  ;  the  sweat  has  a  urinous  odour,  and  white  crystals  will  be  seen 
on  the  skin. 

It  is  worthy  of  note  that  the  sweat  may  have  peculiar  effects  when  the  patient  is  taking 
certain  drugs  ;  for  example,  persons  whose  occui)ation  it  is  to  make  polished  steel  imple- 
ments, may  be  disehaiged  from  their  employment  if  they  are  taking  merciu'v  and  iodide  of 
potassium,  because  the  articles  they  have  polished  go  dull  and  spotty  almost  at  once,  in  a 
way  which  docs  not  result  IVom  ordinary  ])crspiration.  Mciholiii  Morris. 


SWELLING,  ABDOMINAL.  This  may  be  acute  or  chronic,  general  or  local,  and 
caused  by  abdominal  accunuilations  that  are  mainly  either  gaseous,  Huid,  or  solid.  The 
posilioii,  physical  consistency,  and  duration  of  abdominal  swellings  are  their  three 
outstanding  clinical  features  for  purposes  of  diagnosis. 

CLASSIFICATION. 
I. — Swellings  in  the  Abdominal  Wall. 

II. — General  Abdominal  Swellings  : — 

yl.  Ulainly  (iiisrons — 

.Surgical   cnij)liyscma  |        Metcori-,m  (p.  .'iS8) 

B.  Mainly  Fluid— 
Ascites   (p.    l;i) 


Large  cystic  tumours 


Ilistiution  of  hollow  viscera 
Hydatid  disease 


C.  Mainly  Solid — 
Obeoity  (p.  los) 
Constipation  (p. 


•Jl) 


-Local  Abdominal  Swellings  : 

.1.    I)ur  Id  (icncrid  Causes — 
Knev-slcil   ascites 
Tuberculous   pciitduitis 
Ilydulid   iliscase 

/;.   Due  li,  I'Udar 


Innanimatory  deposits 
New  growths 


.Sid)j)hrciiic  abscess 
I'hautoui  tumours 
Knteroptosis 


enicul  iij   I'arlieiihir  Orfluus. 


I.     SWELLINGS    IN    THE    ABDOMINAL    WALL. 

Swellings  silu.ilcd  iti  the  abdominal  wall  itself  can  be  reeogni/.cd  by  their  supcrlieial 
position  ;  by  their  adherence  to  the  skiti,  muscles,  or  fascia  ;  or  by  their  luit  following  the 
movements  of  the  viscera  inunediately  underlying  the  wall  of  the  abdonu'ii,  to  which  they 
must  therefore  be  superficial.  Hut  it  may  be  impossible  to  distinguish  between  a  fatty 
tumour  in  the  deeper  part  of  the  wall,  for  example,  and  a  fatty  omental  nuiss  tiuit  has 
becf)inc  adherent  to  the  parietal  pcritoncuiii  ;uul  so  has  pr.ictieally  incorporated  itself 
with   the  alidoiiiinal   wall. 

lullanniKdary  sieelliujl  of  the  wall  may  occur  by  inl'cclion  Iniui  willioul  or,  less  dflcn, 
from  within.  Thus  .1  liycr  abscess  may  cause  extensive  redness  and  swelling  in  the  right 
hypochondriac  region  ;  inlilt  ration  of  the  abdominal  wall  is  often  met  with  in  operations 
for  appendicular  absees>,  ;  in  acute  cases  of  Ilod0cin's  disease  and  lympliosareiiina.  tumours 
suggesting  a  subacute  inllanunatoiy  process  may  oecin-  in  the  abdominal  wall,  but  they  arc 


656  SWELLING,     ABDOMINAL 

really  localized  lyniijhadenomatous  or  sarcomatous  deposits,  not  due  to  infeetiim,  and  are 
associated  with  gland  enlargement  in  other  parts  of  the  body.  Iiiflatnincitory  siviiling  about 
the  umbilicus  is  not  rare  in  newly-born  infants,  due  to  the  entrance  of  infection  by  way  of 
the  cord  ;  in  stout  imcleanly  adults  the  umbilical  fossa  may  be  the  seat  of  intertrigo,  which 
becomes  painful,  swells,  and  su]3])iirates  :  but  a  far  more  serious  umbilical  inHammation 
may  occur  in  patients,  usually  children,  with  luberculous  peritonitis  :  a  tuberculous  mass 
in  connection  with  the  round  ligament  may  break  down,  perforate  at  the  umbilicus,  set  up 
a  chronic  discharge  there,  and  ultimately  establish  a  faecal  umbilical  fistula  ;  in  rare  cases 
a  subdiaphragmatic  or  perigastric  abscess  may  cause  inflammatory  thickening  of  the  round 
ligament  and  umbilicus. 

(Edema  of  the  abdominal  wall  may  l)e  either  local  or  general  (see  Oedema,  p.  -tlO). 

Tumours  of  the  alxlominal  wall,  excluding  those  due  to  inflammation,  are  rare  except 
in  certain  situations.  I.ipouiata  and  fil/rd-lijioiiiata  may  occur  in  any  part  of  it.  and  in  the 
inguinal  or  femoral  rings  closely  imitate  omental  hernias.  Hernice  are  commoner,  particu- 
larly at  the  umbilicus  and  in  the  groins  :  there  is  little  likelihood  that  a  definite  hernial 
protrusion  in  any  part  of  the  abdominal  wall  will  be  overlooked,  but  minute  hernias  into 
the  abdominal  wall,  such  as  may  occur  along  the  linea  alba,  especially  above  the  umbilicus, 
at  the  femoral  or  inguinal  rings,  or  along  the  line;e  semilunares,  may  suffice  to  produce 
complete  intestinal  obstruction  and  yet  be  small  enough  to  demand  very  careful  paljiation 
for  their  discovery. 

In  malignant  disease  of  the  stomach,  pylorus,  or  region  of  the  portal  fissure  generally, 
small  secondary  nodules  may  appear  quite  early  at  the  umbilicus  or  in  the  roimd  ligament 
just  above  it  :  and  this  may  occur  before  the  primary  timiour  has  given  rise  to  any  definite 
signs  or  synii^toms. 

II.     GENERAL    ABDOMINAL    SWELLING. 

A.  Mainly  Gaseous.  —  In  certain  cases  of  extensive  surgical  emphifsema  the  fascia 
planes  of  the  abdominal  wall  are  invaded  and  dissected  out  by  gas.  which  imparts  to  them 
a  highly  characteristic  feathery,  crepitant,  and  crackling  feeling  on  palpation.  The  gas 
may  have  entered  from  wounds  in  the  neck,  thorax,  or  trachea,  or  it  may  have  been  gener- 
ated by  gas-producing  microbes  in  any  abscess  or  focus  of  inflammation  in  the  trunk  or 
viscera,  and  have  made  its  way  thence  into  the  abdominal  wall. 

Distention  of  the  intestines  icith  gas  is  an  event  so  common  as  to  be  familiar  to  all  ;  its 
diagnosis  is  discussed  under  Meteokism  (p.  388).  In  this  condition  the  whole  of  the 
abdomen,  or  in  special  cases  some  part  of  it  only,  is  distended,  and  on  percussion  gives  a 
highly  resonant  or  tympanitic  note.  It  often  happens  that  the  outlines  of  the  gas-distended 
viscera  can  be  seen  on  the  abdominal  wall,  particularly  when  it  is  looked  at  in  an  oblique 
illumination.  The  increased  size  of  the  inflated  intestine  is  apt  to  produce  displacement 
of  the  other  viscera  ;  the  dome  of  the  diaphragm  is  pushed  up  into  the  chest,  carrying  the 
heart  with  it  and  shifting  the  apex-beat  upwards  ;  the  liver  is  similarly  pushed  up,  and  in 
addition  it  is  often  caused  to  rotate  round  a  transverse  axis,  its  lower  anterior  edge  ascend- 
ing and  its  lower  jiosterior  edge  descending,  with  the  result  that  the  area  of  liver-didlness 
in  front  is  much  reduced,  or  even  lost  altogether  ;  but  it  is  reduced  only  a  little  in  the  mid- 
axillary  line  so  long  as  the  gas  remains  in  the  intestine  ;  and  if  the  liver-dullness  in  the 
mid-axillary  line  disappears,  the  diagnosis  of  free  gas  in  the  peritoneal  cavity  is  to  be  made. 

li.  Mainly  Fluid. — The  diagnosis  of  the  various  causes  producing  accumidations  of 
fluid  in  the  peritoneal  cavity  is  given  under  the  heading  .Ascites  (p.  43). 

C.  Mainly  Solid. — In  Obesity  (p.  408)  the  abdomen  may  swell  either  in  consequence 
of  the  deposit  of  fat  in  the  abdominal  wall  itself,  or  as  the  result  of  fatty  deposits  behind 
the  peritoneum  generally,  in  the  mesentery,  in  the  omentum  and  appendices  epiploicae. 
In  \ery  fat  patients  it  is  rarely  possible  to  diagnose  the  exact  nature  of  an  intra-abdominal 
mass  by  the  usual  methods  of  palpation  and  percussion,  and  without  having  recourse  to 
exploratory  laparotomy,  because  the  abdominal  walls  are  so  thick.  The  frequency  with 
which  inconveniently  large  fatty  accumulations  occur  in  the  abdomens  of  such  ]jersons 
must  not  be  forgotten  when  the  diagnosis  of  some  vaguely-felt  tumour  within  the  abdomen 
has  to  be  considered. 

In  severe  chronic  cases  of  Constip.\tion  (p.  121).  abdominal  distention  may  result 
from  accumulation  of  faeces  in  the  large  intestine,  particularly  when  dilatation  of  the  colon, 


SWELLING,     ABDO^nXAL  65? 

idiopathic  or  secondary,  is  ]jresent.  The  scybala  can  usually  be  felt,  perhaps  soft  and 
plastic  in  the  region  of  the  ascending  colon,  usually  hard  and  nodular  in  the  descending 
sigmoid  and  colon.  Idiopathic  dilatation  of  the  colon  (Hirschsprung's  disease)  seems  to  be 
congenital,  and  is  associated  with  much  hypertrophy  of  the  colon  (Fig.  171,  p.  389).  A 
description  of  it  will  be  found  on  p,  126.  In  older  patients  a  very  similar  dilatation  and 
hypertrophy  of  the  colon  may  come  on  as  the  result  of  chronic  obstruction  about  the  lower 
end  of  the  large  intestine.  As  much  as  47  lb.  of  f;pces  may  accumulate  in  the  intestines  of 
such  patients. 

In  rare  cases  of  chronic.  ])articularly  tuberculous,  peritonitis,  semi-solid  inflammatory 
masses  may  bring  about  a  general  swelling  of  the  abdomen  ;  the  diagnosis  is  discussed 
under  Ascites  (p.  47).  General  swelling  of  the  abdomen  may  occur  in  malignant  disease 
of  the  peritoneum,  due  in  part  to  the  growth  of  numerous  secondary  malignant  nodules, 
in  part  to  a  concomitant  ascites.  The  symptoms  are  often  vague  at  first — loss  of  weight, 
strength,  appetite,  with  indefinite  abdominal  disorders.  The  abdomen  enlarges,  and  if 
there  is  not  much  ascites  the  secondary  deposits  can  be  felt  obscurely  through  the  abdo- 
minal wall.  Occasionally  they  can  be  palpated  in  the  abdominal  wall  itself  near  the 
umbilicus,  or  in  the  round  ligament  above  it,  or  the  urachus  below,  .\s  the  case  progresses, 
emaciation  becomes  marked,  the  skin  loses  its  elasticity  and  often  develops  a  diffuse 
brownish  ijigmcntation  ;  bedsores  are  not  rare.  The  primary  growth  may  be  in  any  of  the 
thoracic,  abdominal,  or  pelvic  organs,  or  in  the  mamma  or  testis.  If  any  primary  growth 
can  be  made  out,  the  diagnosis  will  not  be  difficult,  especially  if  glandular  enlargenients 
are  found  in  the  groins  or  axilla;,  if  the  ascitic  fluid  is  hemorrhagic,  and  if  it  is  found  to 
contain  nmltlnuclcar  endothelial  cells,  and  cells  with  atypical  mitotic  figures.  Tuber- 
culous peritonitis  can  be  excluded  by  means  of  the  tut)crculin  test  and  by  the  result  of 
injecting  several  c.c.  of  the  ascitic  fluid  into  guinea-pigs. 

Hydatid  disease  of  the  ])critoneum  is  discussed  on  p.   H). 

III.      LOCAL    ABDOMINAL    SWELLING. 

-1.  Due  to  General  Causes.  -It  often  hajipcns  that  the  causes  which  produce  general 
swelling  of  Hie  ahdoiiicn  fail  to  do  so  in  p;irticular  cases,  and  give  rise  onlv  to  a 
local  swelling.  Thus  in  encysted  ascites,  left  behind  after  an  acute  diffuse  peritonitis,  or 
accompanying  a  chronic  ])eritonitis,  an  accumulation  of  lluid  bounded  by  fibrinous  or 
fibrous  adhesions  between  the  adjacent  viscera  may  be  found  in  any  part  of  the  jjeritoneal 
cavity,  but  most  often  in  the  Hanks  and  about  the  pelvis.  If  a  good  history  of  the  case 
can  l)c  obtained,  the  diagnosis  of  the  nature  of  sudi  a  cyst  will  at  least  be  suggested  ;  the 
physical  signs  will  be  those  of  a  fixed  cystic  or  scmi-s;ilid  tunniur,  and  flic  diagnosis  will 
often  be  obscure  until  laparotomy  has  been  performed. 

.Vbdominal  swellings  of  the  most  various  size  and  position  may  occur  in  tuberculous 
pcritoiiilis  (p.  \~ .  under  Ascites).  Many  of  them  arc  composed  of  the  infiltrated  and 
rolled-up  oriii  iitum.  others  of  enlarged  and  lidjcrculous  mesenteric  glands,  others  of  doughy 
masses  of  adiiercnt  intestine  and  fibrin.  The  amount  of  ascitic  lluid  varies  widely  in 
(lilfcrcnt  cases.  When  tlicrc  is  mucli.  and  the  patient  is  an  adidt,  tbe  diagnosis  of  eirrhosis 
of  the  liver  is  likely  to  be  made  :  when  the  peritonitis  is  dry  (tlie  ol)literative  form),  tlie 
abdominal  cavity  may  be  smaller  tlian  normal,  and  occupied  by  a  doughy,  rallier  lender 
mass  that  presents  areas  of  alternaljng  resonance  and  dullness.  The  physical  signs  vary 
from  day  to  day  according  to  the  amount  and  position  of  Hat  us  in  the  intestine.  The 
symptoms  of  tuberculous  peritonitis  are  very  variable:  as  a  rule  the  patient  is  thin, 
ana-mic.  seriously  ill,  with  a  drawn  aspect  :  abdominal  pain  and  tenderness  arc  usual, 
nausea  anil  constipation  with  chronic  inlcstina!  ol)struilion  aic  fici|Ucnt  :  in  ac'ute  cases 
there  is  high  I'cmt.  in  chionic  the  temperature  is  not  high,  but  irregular,  or  may  excu  be 
subnormal.  If  there  is  ulceration  of  the  large  intestine,  diarrhcea  may  ociur.  Mod  Mood 
may  be  passed  in  the  motions.  The  discovery  of  tuberculosis  In  some  othci-  pari  ol  the 
body,  or  ol  a  laniily  liislory  of  I  iilierculosis.  is  strong  argument  for  regarding  a  case  with 
such  signs  as  t  ulii  iculous.  A  gciu  raj  or  patchy  brown  pigmentation  of  the  skin  is  not 
nneonunon. 

Single  or  multiple  hydatid  cysts  may  occur  in  any  pari  of  Ihi-  .iliildiniiial  caxily. 
I'snally  they  are  single,  the  large  majority  occurring  in  the  h\(r;  more  ranIs  they  altcel 
the  splicn.  oMientuin.  mesentery,  or  peritoiienni.      The  eysl  grows  slowly     and    is   spherical 


658  SWELLING,     ABDOMLVAL 

except  in  so  far  as  it  is  moulded  by  the  pressure  of  adjacent  structures.  It  contains  a  clear 
saline  fluid,  in  vvliieh  may  l)e  found  booklets  (Fig.  18,  p.  49),  and  secondary  cysts  completely 
detaebed  from  the  walls  of  the  parent  cyst.  I'ntil  it  lias  become  large  enougb  to  cause 
niecbanical  obstruction  and  pressure-symptoms,  the  single  hydatid  cyst  gives  rise  to  little 
pam  or  complaint.  It  then  produces  a  bulging  of  the  overlying  abdominal  wall,  smooth, 
rounded,  more  or  less  tense,  dull  on  percussion  ;  if  it  is  of  a  certain  degree  of  tenseness 
it  may  yield  the  hydatid  thrill — just  as  any  other  cyst  may.  Hydatid  cysts  in  the 
mesentery,  omentum,  or  peritoneum  are  often  multiple,  and  may  be  felt  as  scattered, 
rounded  timiours  generally  accompanied  by  ascites  :  the  disease  runs  a  slower  course  than 
malignant  peritonitis,  and  eehinococcal  cysts  may  be  found  in  the  ascitic  fluid  if  it  is  tapped. 
As  a  rule,  these  are  secondary  after  rupture  (accidental  or  by  ]5aracentesis)  of  a  primary 
cyst  in  the  liver.  They  cause  a  slowly  progressive  enlargement  of  the  abdomen,  which 
appears  to  be  filled  with  a  .solid  or  semi-solid  mass  ;  if  the  individual  cysts  are  large,  they 
can  be  seen  outlined  on  the  abdominal  surface,  and  can  be  felt.  They  are  freely  movable, 
and  not  connected  with  any  particular  viscus  ;  they  do  not,  as  a  rule,  give  the  hydatid 
thrill  on  percussion.  Peritoneal  hy<latid  disease  is  rare  except  in  countries  (Iceland. 
Australia,  or  South  America)  where  the  inhabitants  live  in  close  company  with  dogs  that 
are  the  hosts  of  T(eiiia  eclihiococciis.  Eosinophilia  may  be  found,  and  when  the  cysts  are 
living  and  active  the  patient's  blood-serum  may  give  a  S])ecific  hydatid  precipitin  reaction, 
though  the  absence  of  both  this  and  eosinophilia  does  not  exclude  hydatid  disease  : 
exploratory  laparotomy  may  be  necessary  before  the  diagnosis  can  be  established. 

Any  part  of  the  abdomen  may  swell  from  the  formation  of  an  abscess  ;  several  forms 
of  which  are  more  or  less  localized,  and  are  considered  below  (see  B)  ;  others  present  more 
gctieralizcd  abdominal  signs  and  symptoms,  and  will  for  that  reason  be  considered  here. 
A  subphrenic  abscess  is  any  ab.scess  in  contact  with  the  under  surface  of  the  diaphragm 
except  those  situated  in  the  liver  or  in  the  spleen.  It  is  intraperitoneal  in  more  than  half 
the  instances  ;  it  contains  gas  in  about  half  the  cases.  The  simple  or  non-gaseniis  abscesses 
are  generally  the  result  of  appendicitis  or  of  sup])uration  in  the  liver,  and  so  are  usually  on 
the  right  side  of  the  body  :  less  often  they  are  secondary  to  gastric  or  duodenal  ulcer,  or  to 
suppuration  spreading  from  the  pancreas,  kidney.  Fallopian  tubes,  spleen,  or  thorax.  They 
are  deep-seated,  and  tend  to  j)roduce  abdominal  swelling  with  signs  and  symptoms  tliat 
are  indefinite.  The  onset  is  insidious,  often  consisting  in  nothing  more  than  failure  to 
recover  from  the  primary  disorder — ap))endicitis,  hepatic  abscess — after  it  has  been  treated 
surgically  ;  the  patient  remains  .seriously  ill,  with  fever  and  quick  jjulse,  Icucocytosis, 
and  often  a  septic  aspect.  If  the  abscess  is  at  the  back  the  signs  may  point  to  pleurisy  or 
pleural  effusion,  with  the  appropriate  pain  and  friction  sounds.  If  it  pushes  forwards 
the  hypochondrium  and  epigastrium  may  bulge  in  front  and  become  tender.  The  dia- 
gnosis of  subphrenic  abscess  may  be  very  dillicult  when  there  is  no  obvious  antecedent  to 
suggest  its  occurrence,  especially  if  the  abscess  is  behind  and  below  the  liver,  and  is 
complicated  by  pleurisy  or  empyema.  If  it  is  above  the  liver,  it  may  be  very  dillicult  to 
say  whether  the  pus  is  inside  the  liver  or  outside  it.  or  both  ;  enlargement  of  the 
liver  downwards  is  in  favour  of  intrahepatic  abscess.  Examination  with  the  a-rays  is 
often  of  great  assistance  ;  but  often  it  is  necessary  to  give  the  patient  a  general  anicsthetic 
and  insert  a  long  exploring  needle  successively  into  the  intercostal  spaces  (tenth  to  sixth) 
in  the  scapular  and  mid-axillary  lines.  It  must  be  thrust  in  dee])ly.  .-\s  viewed  by  the 
.r-rays  the  diaphragm  is  depressed  by  empyema  or  pleural  effusion,  elevated  by  subphrenic 
abscess,  and  immobilized  by  either. 

The  gas-containing  abscess  or  subphietiic  pyopneumothorax  is  commoner  in  females 
than  in  males,  and  is  usually  due  to  the  perforation  of  a  gastric,  or  less  often  a  duodenal, 
ulcer,  or  to  appendicitis  ;  in  rare  instances  it  is  secondary  to  an  ulcer  of  the  colon  or 
even  to  a  suppurating  hydatid  cyst.  It  is  usually  on  the  left  side.  When  a  gastric  ulcer 
perforates,  the  onset  is  generally  sudden,  with  acute  abdominal  pain  and  collapse  ;  but 
both  the  ulcer  and  its  perforation  may  be  latent,  and  nothing  more  than  a  history  of  chronic 
dyspepsia  may  be  obtainable.  The  abdomen  soon  becomes  distended  :  hectic  fever,  with 
rigors,  rapid  jjulse,  leucocytosis,  and  shortness  of  breath,  are  the  symptoms  likely  to 
appear.  The  physical  signs,  on  the  whole,  resemble  those  of  Pneu.mothouax  (p.  530)  ;  the 
diaphragm  is  pushed  up  into  the  thorax,  and  the  gas  in  the  abscess-cavity  below  it  causes 
the  signs  of  pneumothorax  to  develo))  in  the  upper  part  of  the  abdominal  cavity  and   the 


SWELLIXG.     ABDOMINAL 


659 


lower  part  of  the  thorax.  The  picture  is  complicated  by  the  fact  that  the  inflammatory 
process  habitually  spreads  through  the  diaphragm,  so  that  the  signs  due  to  pleurisy,  with 
or  without  effusion,  are  added.  The  diagnosis  has  to  be  made  between  this  condition  and 
true  pneumothorax.  The  points  that  serve  to  distinguish  the  two  are.  that  in  pneumo- 
thorax the  gas  seems  to  occupy  the  whole  of  one  side  of  the  thorax,  the  heart  is  pushed  or 
]>ulled  over  to  the  sound  side,  and  the  ])hysical  signs  are  limited  to  the  thorax  :  wliereas  in 
sub])hrenic  pyopneumothorax  the  signs  occur  at  the  base  of  one  or  both  lungs  but  not  at 
the  apex,  the  heart  is  displaced  ujnvards  but  not  to  either  side,  and  the  upper  part  of  the 
abdominal  cavity  is  involved  as  well  as  the  thorax.  Examination  with  the  a'-rays  is  of  the 
greatest  service,  for  it  shows  that  the  gas-containing  cavity  is  below  the  diaphragm  and 
not  above  it  ;  the  readiness  with  which  the  level  of  the  fluid  in  the  abscess  changes  as  the 
patient  alters  his  position  can  also  be  noted,  and  proves  that  the  abscess-cavity  contains 
gas  as  well  as  fluid. 

The  abdomen  is  not  infrequently  the  seat  of  jjliaiiloni  iiniKiurs.  These  are  felt  as  fixed 
and  more  or  less  rounded  smooth  swellings,  either  in  or  immediately  imderneath  the 
abdominal  wall  :  they  are  dull  on  percussion,  and  may  be  tender  on  palpation.  They  are 
caused  by  involuntary  contractions  of  the  muscles  in  the  area  in  which  they  occur  ;  they 
persist  when  the  patient's  attention  is  distracted,  and  also  during  sleep,  but  disappear 
under  a  general  anaesthetic.  Phantom  tumours  are  commoner  in  women  than  in  men, 
and  in  the  neurotic  than  in  the  stolid.  They  often  persist  for  long  periods,  but  may  vanish 
when  the  patient  believes  that  they  have  been  cured.  .\  phantom  tumour  in  the  region  of 
the  liver  may  simulate  cholecystitis,  hepatic  abscess,  or  gunuiia  ;  in  the  left  hypochon- 
drium,  gastric  carcinoma  ;  in  the  appendix  region,  an  appendicular  abscess  ;  above  the 
pubes,  pregnancy  (pseudocyesis). 

In  entcrnptosifi  (Glenard's  disease),  or  downward  displacement  of  abdominal  viscera, 
any  or  all  of  the  organs  may  slip  away  from  their  normal  position  and  attachments 
(Fig.  56,  p.  127).  The  diagnosis  must  be  made  by  the  discovery  that  one  or  more  of  the 
viscera  is  out  of  j)lace,  and  is  also  abnormally  mobile. 

B.  The  Regional  Diagnosis  of  Local  Abdominal  Swellings. — For  clinical  purposes 
the  abilcitncn  iiki\  he  sul>ili\  iili  il  into  nine  ngimis.  by  two  \<rtical  lines  drawn  through 
the  middle  of  I'oupart's  jiganunts.  and  by  two  horizontal 
lines,  one  jjassing  through  the  lowest  points  of  the  tenth 
ribs  (the  subcostal  line),  the  other  drawn  at  the  level  of 
the  highest  points  of  the  iliac  crests  (Fig.  27.5).  The 
vi.scera,  or  portions  of  viscera,  commonly  contained  in 
the  areas  thus  demarcated,  are  iii\en  in  the  table  on 
j),ige  (i(i(l. 

The  abclominai  swellings  lliat  may  be  Irit  in  and 
about  these  nine  regions  will  now  be  considered  seriatim, 
excluding    the  tumours    situated    in    the  abdominal  wall 


itself     that 
(p.  (i.",). 


been 


ibei 


1.   liifilil  Hi/jKiiliondiiac  livgiaii. 


.M<ist  luniours  in  this  area  are^comu'ctc  d  uilli  Ihi- 
liver  or  gall-bladder,  and  their  diagnosis  is  discussed 
under  Livkr.  I-;Ni.Ai{(;i;.MKNr  oi-  tiik  (p.  ;}(>()).  and  (Jai.i,- 
Ht  ADDKII    l''.NI.AU(;l-.MI-.Nr    (p.    2.12). 

To  regard  the  linn  and  rounded  swelling  pioduced  1)\ 
llir  upper  set;nicnl  of  I  he  right  rectus  abdominis  inMseIc 
a^  e\  ideiiec  ol  luinour.  ciiliiri.'ctnenl .  or  induralioii  of  lln' 
|j\cr  or  i;allbla(l(lcr.  is  ;i  niislaUe  <-asil\  and  rni|uriill\ 
iiiiidi'. 

'I'lUiiiiurs  ill  coiiMccI  ion  uilli  llir  li<iiiilic  /Iriiiif  iif 
llii  riiliiii.  cMJiKliiig  M\  bala.  are  rare.  Scybala  may  be  recognized  by  their  general  shape, 
by  llic  casr  willi  which  they  can  be  moulde<l  or  indented  by  the  pressure  of  the  lingers, 
anil  by  lliiii  liciiig  dispersed  by  a  purgative.  Careinonia  or  lubcrculosis  of  the  colon  may 
produce  a  palpable  liiiiioiir  licic  :  mmiI  so  iii:i\  .in  iiil  iissiiseepi  ion.  The  diagnosis  must 
rest    upon    llic   previous  liistoiy  and   llic  ediiise  of  lln:  disease. 


/■'w.  '.'7.1.— The 
r  the!  siu;nificaiH'< 
il)lo  on  piige  iJliit 


of  tlie  ahdomoil 


SWELLING,    ABDOMLXAL 
The  Normal  Contents  of  the  Abdominal  Regions. 


1.  Rigbt  Hypochondriac 


2.  Epigastric 


Small  intestine 
Kidneys 
Aorta 
I.ymphatic  glands 


3.   Left  Hypochondriac 


Liver 

Liver 

Liver 

Call-bladder 

Stomacli  and   pylorus 

Stomach 

Hepatic  flexure  of  colon 

Trans\crsi-  colon 

Splenic  flexure  of  colon 

Kight  kidney 

Omentum 

Spleen 

Pancreas 

Tail  of  pancreas 

Duodemun 

Left  kidney 

Kidnevs 

Suprarenal  capsules 

Aorta 

Lymphatic  glands 

4.  Bight  Lumbar 

5.   Umbilical 

6.   Left  Lumbar 

Riedel's  lobe  of  the  liver 

Stomach 

Descending  colon 

Ascending  colon 

Duodenum 

Small  inte  tine 

Small   intestine 

Transverse  colon 

Left  kidney 

Right  kidney 

Omentum 

Uraehus 

7.  Right  Inguinal 


8.  Hypogastric 


9.  Left  Inguinal 


Cjeeiini 

Vermiform  appendix 

lA'mphatic  glands 


Small    intestine 

Siirnioid    lUxurc 

Distended  bladder  j 

Uraehus 

Enlarged  uterus  and  adnexa 


Sigmoid  flexure  of  colon 
Lymphatic   glands 


Tumours  of  the  kiiliici/  or  .siiprdifiuil  aland  rarely  jiresent  tlieniselves  in  this  region 
of  the  abdomen. 

2.  Epigastric  Region. 

.llinaniKil  lobes  in  llic  liver,  luiiiours  in  either  of  its  lobes  or  in  its  falciform  or  round 
ligaments,  may  be  felt  liere. 

In  thin  people  and  children  the  curvatures  of  the  normal  stomacli  when  it  is  full  may 
often  be  seen  dimly  outlined  in  the  epig'istrium.  the  lower  omvature  habitually,  the  ujjpcr 
less  often,  and  the  gastric  succussicin-si)Iash  can  often  be  elicited  here  in  healthy  persons 
as  well  as  in  those  with  dilatation  of  the  stomach.  An  epigastric  splash  is  usually  gastric, 
but  may  be  colonic.  In  dilatation  of  the  stomach  due  to  obstruction  at  the  pylorus  (caused 
in  infants  by  spasm  or  hypertrophy  of  the  pylorus,  in  adults  by  malignant  or  cicatricial 
stenosis),  waves  of  peristalsis  travelling  from  left  to  right  may  be  seen  in  the  epigastrium. 
Similar  waves,  but  travelling  from  right  to  left,  occur  in  the  colon  of  patients  with 
obstruction  in  the  rectum  or  sigmoid  (see  below).  Tiimonrs  of  the  stomach,  usuall\ 
carcinomatous,  rarely  sarcoinatous,  or  due  to  inflanmiatorv  dejjosits  round  a  gastric  ulcer 
may  sometimes  be  felt  here,  particularly  when  the  patient  takes  a  deep  breath  and 
drifes  the  abdominal  viscera  down  from  out  the  cover  of  the  diaphragmatic  dome  ;  it 
must  not  be  forgotten  that  the  normal  pylorus  can  sometimes  be  felt  in  an  infant, 
child,  or  thin  adult,  as  a  rounded  finger-like  mass  deep  in  the  right  side  of  the  epigas- 
trium. The  connection  of  a  gastric  tumour  with  the  stomach  can  often  be  made  out  more 
clearly  if  that  organ  is  inflated  with  gas  ;  or  by  the  method,  little  used  in  this  country, 
of  gastrodiaphany.  Examination  with  the  a;-rays  after  the  administration  of  a  bismuth, 
or  a  barium  sul]3hate  meal  is  often  of  great  assistance  in  obscure  gastric  cases,  and  should 
always  be   emjjloyed. 

The  transverse  colon  goes  across  the  lower  part  of  the  epigastrium  in  some  cases,  more 
usually  across  the  upper  part  of  the  umbilical  area.  Its  sacculations  and  peristalsis  are 
often  outlined  on  the  abdominal   walls  of  pot-bellied  rickety  children  or  of  thin  adults. 


SWELLING,     ABDOMINAL  661 

particularly  whin  they  arc  flatulent  or  constipated.  In  acute  or  chronic  obstruction  the 
peristalsis  becomes  much  more  marked.  Tumours  of  the  transverse  colon  are  very  rare, 
except  the  conuiion  occurrence  of  scybala  in  it  :  a  few  cases  of  chronic  hyperplastic 
tuberculosis  of  this  part  of  the  colon  have  been  recorded,  with  great  diffuse  thickening 
of  its  wall  and  stenosis  of  its  lumen. 

Swellings  in  connection  with  the  omentum  lie  l)elow  the  colon  and  in  inuiieiliate  relation 
with  the  anterior  abdominal  wall,  in  front  of  the  mass  of  small  intestine.  In  tiiberciilotis 
peritonitis  it  often  forms  an  irregular  rope  or  mass  composed  of  inflammatory  tissue,  cheesy 
tubercle,  or  encysted  exudate,  that  may  lie  in  the  epigastrium,  or  extend  into  any  of  the 
regions  of  the  abdomen — when  the  diagnosis  of  malignant  disease  of  the  intestine  or  some 
other  viscus  may  possibly  be  made.  Similar  nodular  enlargement  and  deformity  of  the 
omentum  is  common  in  chronie  peritonitis  of  any  .sort  ;  and  it  may  become  the  seat  of  an 
abscess  in  cases  of  perforated  gastric  ulcer.  Cysts  of  the  omentum,  single  or  multiple,  are 
not  \ery  rare,  and  are  often  inflammatory  in  origin.  Tuberculous  or  inflammatory 
masses  of  omentum  often  adhere  freely  to  the  anterior  abdominal  wall  as  well  as  to  the 
neighbouring  viscera. 

Swellings  derived  from  the  panereas  push  forwards  from  the  depths  of  the  abdominal 
cavity  towards  the  epigastric  and  the  upper  part  of  the  umbilical  areas,  and  present 
themselves  as  deeply-seated  vaguely-felt  masses  on  palpation.  They  have  the  stomach, 
or  the  stomach  and  colon,  in  front  of  them,  and  are  fixed  to  the  posterior  abdominal 
wall  :  they  are  usually,  made  out  best  by  examination  under  an  anesthetic  :  they  move 
little  on  respirati(jn.  and  often  transmit  from  the  adjacent  aorta  a  non-expansile  pulsation. 
They  arc  separated  from  the  liver  and  from  the  spleen  by  areas  of  resonance.  These 
swellings  may  be  carcinomatous,  in  which  ease  wasting,  ana-mia,  and  jaundice  are  likely 
to  be  observed,  with  death  in  a  few  months'  time  :  or  due  to  chronie  pancreatitis,  when  the 
course  of  the  disease  will  be  slower  and  there  will  be  more  epigastric  tenderness  and  pain, 
with  clayey  stools  and  ])erliaps  intermittent  jaimdicc.  a  ])i)sitive  C'anmiidge"s  reaction 
(p,  lOO),  or  glycosuria.  In  acute  pancreatitis  the  swollen  pancreas  has  only  exceptionally 
been  palpated  befr)re  laparotomy  ;  the  main  symptoms  are  acute  epigastric  pain,  vomiting, 
constii)ation,  fever,  and  proneness  to  collapse,  simulating  in  part  acute  intestinal  obstruc- 
tion and  in  part  acute  peritonitis,  so  that  immediate  laparotomy  is  usually  resorted  to 
and  the  diagnosis  established  by  the  discovery  of  opaque  yellow  patches  of  acute  fat  necrosis 
in  the  omcntimi  and  elsewhere  within  the  abdomen. 

I'ancrcatic  cysts,  so-called,  are  often  cysts  not  in  the  pancreas  but  in  its  neighbour- 
hoiid,  and  therefore  better  called  pcri|)ancreatic  cysts.  Pancreatic  cysts  ])ropcr  are  single 
or  nnilti[)le  retention-cysts,  usually  the  result  of  chronic  pancreatitis  ;  they  form  deeply- 
seated,  smooth,  rounded  tumours,  possibly  giving  a  feeling  of  lluctuation.  .\t  first  they 
occupy  the  lower  epigastric  or  hypochondriac  regions  ;  but  if  they  enlarge  nuicli  tliey 
may  fill  the  whole  upper  part  of  the  al)domen.  or  extend  down  to  the  pubic  sytnphysis 
or  flanks.  The  symptoms  of  chronic  pancreatic  disease  should  be  present — chronic 
indigestion,  the  passage  of  pale  and  bulky  stools,  glycosuria,  pcrha)>s  jaundice  from  time 
to  time  if  iiancreatic  calculus  is  present.  Peripnnrrentic  or  retroperilnnrtil  ei/sls.  due  to 
accurmil-ilii)iis  in  llic  lesser  sic  of  Ihc  pciildiienrn.  or  to  growths  originating  in  residues 
of  the  Wolllliii  horiy  Ixliliid  the  pcriloiiiuin.  in  i\  produce  apparently  identical  cysts; 
the  evidences  of  clironie  |)arieicitic' iliscase  should  be  absent  i[i  these  enses.  hut  the 
diagnosis  may  be  impossible  until  laparotomy  has  been  performed,  t  aininidge's  urinary 
reactinn  (p.  lOf))  is  said  to  he  (if  assistance    in  <liagnosing  these  cases. 

Sucllings  in  cunri'clidii  uilli  Ihc  iliKiilciiiim  are  felt  in  the  right  side  of  the  epigiistric 
and  umbilical  areas,  and  arc  usm;iII\  due  to  primary  malignant  disease.  In  many  cases 
they  escape  palpalinn  because  they  arc  so  deeply  placed,  and  they  usually  have  to  be 
diagnosed  from  such  conditions  as  cancer  of  the  sfoniach,  pylorus,  pancreas.  bile-<lucts, 
and  portal  (issure  generally,  not  by  their  physical  signs  but  by  the  general  syinploins  and 
progress  of  the  disease.  A  L;rii«ih  in  the  first  part  of  the  duodenum  produces  symptoms 
like  those  of  cancer  of  the  py  lor  iis  wastiu'i.  anemia,  progressive  dilatat  ion  of  tin-  stomach 
with  visible  peristalsis,  allnks  ol  <  iipioiis  xdioitiTig,  and  occasional  lia'matcmcsis  perhaps  ; 
the  motions  contain  bile,  but  llic  mhiiII  does  not  :  jaundice  is  absent  uidcss  there  are 
secondary  growths  in  the  poilal  llssuir.  Malignant  disease  of  Ihc  second  part  of  the 
duodi  num.    in    or    inMiKiuL;    I  he    l)iliar\     papilla,    sociii    produces   olist  ru<-l  i\  e   jaundice    and 


662  SWELLING.     ABUOMLXAL 

distention  of  the  gall-bladdev.  and  often  leads  to  suppurative  cholangitis,  whereas  cancer 
in  the  head  of  the  pancreas  or  bile-ducts  produces  steady  jaundice  and  is  not  followed  by 
suppuration  in  the  bile-passages.  Cancer  in  the  third  ))art  of  the  duodenum  or  below  the 
bile  papilla  produces  duodenal  stenosis,  with  dilatation  of  tlie  duodenum  and  stomach 
and  frequent  vomiting  ;  but  in  this  case  the  vomit  is  habitually  bilious  and  contains  the 
pancreatic  ferments.  If  there  is  no  stenosis,  the  bilious  vomiting  will  be  less,  and  the  case 
may  be  indistinguishable  from  one  of  cancer  of  the  stomach.  In  most  of  these  cases  the 
exact  diagnosis  is  more  often  made  |)OSt  mortem  than  ante  mortem. 

Swellings  in  connection  with  the  hiditeys  and  suprareittil  capsules  occur  in  the 
epigastrium  only  after  they  have  reached  a  considerable  size.  They  rise  up  out  of  the 
loin  and  flanks,  and  their  diagnosis  is  considered  below. 

Enlargement  of  the  spleen  may  bring  its  blunt  anterior  end  or  its  notched  upper  edge 
into  the  e])iaastrie  area.  The  splenic  swelling  always  lies  in  contact  with  the  anterior  wall 
of  the  abdomen,  with  the  stomach  above  and  behind  it  (see  Splekn,  Enlargemknt 
OF  THE.  p.  628). 

In  every  region  of  the  abdomen  li/niphatic  glands  abound,  and  any  of  these  may  become 
palpable  in  cases  of  Ilodgkin's  disease,  tuberculous  peritonitis,  or  malignant  disease.  The 
enlarged  glands  are  felt  as  nodulated  chains  or  masses,  usually  hard  and  rounded,  but 
softer  and  even  cystic  if  their  contents  caseate  or  break  down  into  pus  ;  they  may  also 
calcify,  when  they  become  hard  and  stony.  The  enlarged  glands  that  will  be  felt  in  the 
epigastric  area  are  those  connected  with  the  stomach,  liver,  and  mesentery  :  the  diagnosis 
must  be  made  on  general  and  anatomical  lines  (see  Lymphatic  Gland  Enlargement, 
p.  376). 

3.  Left  Hijpoehondn'fic  Region. 

An  abniirnially  lobulated  liver  may  make  a  superficial  tumovu-  in  this  area  continuous 
with  the  main  mass  of  the  liver  in  the  epigastric  region.  In  the  same  way,  a  tumour  in 
the  left  lobe  of  the  liver  may  project  superficially  into  the  left  hypochondrium. 

Part  of  the  stomaeli  lies  in  this  region  normally  ;  the  diagnosis  of  gastric  swellings 
has  been  considered  above.  .\  gastric  tumour  may  often  be  differentiated  from  a 
tuiuour  of  the  adjoining  spleen  by  the  fact  that  while  the  spleen  is  anchored  at  its  hilum, 
and  so  is  capable  of  but  little  movement,  the  stomach  is  highly  mobile,  changing  its  position 
with  the  position  of  the  patient,  and  also  in  accordance  with  its  fullness  and  distention. 

The  diagnosis  of  a  tumour  of  the  splenic  flexure  of  the  eolon — scybalous,  tuberculous, 
or  malignant—  is  considered  above  (see  1  and  2). 

The  diagnosis  of  the  various  causes  of  enlargement  of  the  spleen  is  discussed  imder 
Spleen,  Enlargement  of  the  (p.  631).  The  tumour  is  usually  to  be  recognized  by  the 
fact  that  it  comes  down  from  under  the  left  costal  margin  in  direct  contact  with  the  anterior 
abdominal  wall,  descends  on  inspiration,  has  a  smooth  surface,  and  a  notched  upper  and 
inner  margin.  In  exceptional  cases,  however,  the  enlarged  spleen  seems  to  ado])t  a  more 
compact  and  cubical  form  in  place  of  its  usual  elongated  prismatic  shape,  and  al.so  to  lie 
back  in  the  loin  and  left  lumbar  region  instead  of  occupying  the  anterior  and  upper  part 
of  the  abdominal  cavity  ;  it  then  simulates  a  tumour  of  the  left  kidney  or  suprarenal  body, 
and  unless  the  blood  and  leucocyte  count  give  a  definite  lead  the  diagnosis  may  be  settled 
only  by  a  laparotomy.  Conversely,  a  spleen-shaped  hypernephroma  or  suprarenal  tumour, 
or  a  calculous  and  cystic  kidney,  may  easily  be  mistaken  in  an  ana-mic  patient  for  an 
enlarged  spleen,  unless  the  possibility  of  the  error  be  kept  in  mind. 

Tumours  of  the  pancreas  and  retroperitoneal  cysts  may  project  into  the  left  hypochon- 
drium (see  2  above).  i 

Tumours  of  the  left  Ixidnefj  and  suprnrenal  body  rarely  appear  in  the  left  hypochon-l 
drium  unless  they  are  very  large  (see  6  below).  Unless  very  large,  they  have  the  stomach 
or  the  stomach  and  colon  in  front  of  them,  and  so  are  variably  resonant  on  percussion — 
according  to  the  amount  of  gas  in  those  viscera — and  are  also  less  distinctly  palpable  than 
tumours  arising  from  the  spleen,  stomach,  colon,  or  omentum,  that  may  be  felt  in  the  same 
situation. 

4.   Rigid   Lumbar  Region. 
AVhen  the  liver  is  abnormally  lobulated.  cither  congenitally  or  as  the  result  of  tight 
lacing,  a  thin  flange  of  liver-tissue,  known  as  Riedel's  lobe,  may  be  met  with  as  a  superficia) 


SWELLING.     ABDOMLXAL  663 

tumour,  continuous  with  the  liver  above  it.  in  this  region.     Sometimes  it  is  freely  movable, 
and  then  may  be  mistaken  for  a  movable  kidney  or  for  a  dilated  gall-bladder. 

The  ascetitliiig  colon  can  usually  be  palpated  and  rolled  imder  the  fingers  as  a  tube- 
like structure  at  the  confines  of  this  and  the  umbilical  region  :  when  empty  and  contracted 
it  may  feel  almost  rod-like.  Its  contents  are  usually  fluid,  but  it  may  contain  semi-solid 
or  solid  faical  masses  that  can  be  moidded  by  pressure,  in  constipated  patients.  In  patients 
with  obstruction  lower  down,  it  may  be  greatly  distended,  and  show  sacculation  and  visible 
peristalsis.  It  may  become  much  thickened  with  intlammatory  tissue,  or  even  come  to 
lie  in  an  abscess  of  its  own  production,  in  pericolitis,  perityphlitis,  typhlitis,  appendicitis, 
and  hyperplastic  tuberculosis  of  the  colon,  forming  a  thickened  and  tender  mass  immedi- 
ately under  the  abdominal  wall  :  the  patient  will  be  more  or  less  acutely  ill.  with  local  pain 
and  tenderness,  constiijation.  often  vomiting.  In  the  more  chronic  of  these  cases,  the 
diagnosis  of  malignant  disease  of  the  colon  will  often  be  suggested. 

General  thickening  of  the  ascending  colon,  with  tenderness  and  characteristic  mucous 
or  blood-streaked  stools,  is  conunon  in  muco-membranous  colitis,  in  dysentery,  aad  in 
ulcerative  colitis.  The  first  of  these  is  met  with  in  nervous  constipated  women  ;  dy-sentery. 
amcebic  or  bacterial,  is  caught  abroad,  and  is  commoner  in  men  than  women  :  while  ulcera- 
tive colitis,  whether  it  be  dysenteric  or  no.  is  a  severe  and  progressive  painful  diarrhtea. 
often  associated  with  vomiting  and  irregular  fever,  that  commonly  leads  to  emaciation 
and  death  from  exhaustion  or  intestinal  haemorrhage  in  a  few  weeks  or  months. 

The  ascending  colon  can  be  felt  as  a  sausage-shaped  tumour  in  acute,  subacute,  and 
chronic  ileoea-cal  and  ileocolic  intiissiificeptinii  :  at  first  in  the  right  flank,  then  extending 
across  the  abdomen  above  the  uml)ilicus.  and  finally  down  the  left  flank  and  into  the  f>elvis. 
The  chief  symptoms  are  spasmodic  abdominal  pain,  vomiting,  the  |)assage  of  blood  and 
mucus  by  the  rectum,  and  tenesmus  ;  the  ])alpahility  and  consistency  of  the  elongated 
tinnour  vary  according  to  the  degree  of  muscular  spasm  in  it. 

The  small  hitesline  is  but  rarely  the  cause  of  abilominal  swelling  in  this  region. 
excepting  when  it  becomes  the  seat  of  enteric  iiitussuseeption. 

Tumours  in  connection  with  the  rigid  hiilnci/  and  suprarenal  hodt/  usually  make  their 
first  ajjpearanee  deep  down  in  this  region,  having  the  ascending  colon  and  small  intestine 
in  front  of  them.  They  can  be  lifted  forwards  en  masse  from  behind  by  a  hand  placed  at 
the  back  of  the  loin.  For  their  diagnosis  see  Kidney,  En-l.^kgement  oe  (p.  8,52.)  The 
lower  pole  of  the  right  kidney  can  be  felt  in  normal  persons  on  deep  abdominal  palpation  ; 
l)ut  when  the  kidney  is  abnormally  mobile,  the  whole  of  it  may  be  felt,  and  in  rare  cases  it 
may  be  found  in  any  of  the  adjuiiiiuL;  abdi>minal  areas.  The  shajjc  and  consistence  of  the 
movable  kidney  are  eharaeteristic,  anil  the  patient  complains  of  a  ))ecnliar  sickening  sensa- 
tion when  it  is  grasped  bimaiuially  :  in  tlie  lesser  degrees  of  mobility  it  disapj)ears  readily 
into  its  normal  position  under  cover  of  the  diaphragm,  and  ceases  to  be  palpable  imtil  the 
patient  drives  it  down  again  by  a  deep  inspiration.  .\s  regards  its  diagnosis,  the  movable 
right  kidney  will  hardly  be  mistaken  for  anything  else  in  this  region  :  on  the  other  hand, 
Kieders  lobe  of  the  liver,  the  enlarged  gall-bladder,  ftecal  accumulations  or  a  cancer  of  the 
ascending  colon,  and  omental  masses,  have  all  been  mistaken  for  it,  although  they  are 
all  superficial  to  the  kidney,  and  lie  in  contact  with  the  anterior  abilominal  wall.  Other 
wandering  tumours,  e.g..  of  the  ovjiry.  Kallopiau  liil)e.  mesentery,  hydatid  disease,  may 
give  rise  to  the  same  error  if  reiiil'oini. 

.-..    riir    Iwhilinil    Uciiiiiii. 

Kxaminatioii  with  the  .i-rays  alter  a  bismuth-iueal  lias  slmwii  llial  the  Udnnal  sloinarli 
is  a  far  more  mobile  organ  than  was  formerly  supiufseil.  ami  that  in  health  its  lower  margin 
(irien  descends  even  below  the  level  of  the  uinbilieus  :  l)ul  if  much  of  it  habitually  occupies 
the  mubilieal  region,  it  is  [jrobably  dilated  to  a  pathological  degree,  either  from  atony  or 
fiijiii  p\  lorie  obslrnetion  (Fif!.  27(i). 

Tumours  in  (•onneelion  with  the  fraii^virsc  laliiii  lia\e  been  ennsidireil  under  the  head- 
ings 1  and   !■  abiivr. 

Tumours   in   e(]niiiiliiiii    wifli    Mir  Dtiiriiliini   ai'c  r ninii    in    this   iigion  :     lliose  arising 

from  the  siiiiill  iiitrslinr  arc  rare.  linlli  arc  siipcrlicial.  and  llicir  diagnosis  has  been  given 
above  (see  2). 

.Abdominal  swellings  in  eoimeetion  with  the  iinichiis.  which  runs  rroin  the  muhilicus 
to  the  bladder,  arc  considered  below  (see  S). 


664 


SWELLING.    ABDOMLVAL 


Swellings  arising  from  the  (liindenuni.  /.idiici/s.  aiiprnremils.  jnincreas,  and  mesenterij. 
may  all  present  themselves  in  the  deeper  ])arts  of  the  imibilieal  region,  usually  as  more  or 
less  fixed  masses  arising  from  or  connected  with  some  dehnite  part  of  the  posterior  wall  of 
the  abdomen.  Their  diagnosis  will  depend  mainly  upon  the  success  with  which  the  origin 
and  connections  of  the  tumour  can  be  made  out  ;  if  the  patient  is  fat,  or  if  relaxation  of 
the  abdomen  cannot  be  obtained,  palpation  under  a  general  anaesthetic  may  be  desirable. 
Consideration  must  also  be  given  to  any  general  symptoms  such  as  may  point  to  renal 
calculus,  hydronephrosis,  pancreatitis,  for  example. 

The  (lortn  bifurcates  half  an  inch  below  and  just  to  the  left  of  the  umbilicus.  In  thin, 
nervous,  and  excited  patients,  particularly  young  women,  great  pulsation  of  the  aorta 
can  often  be  felt  in  the  umbilical  and  lower  epigastric  areas,  and  may  lead  to  the  wrong 
diagnosis  of  abdominal   aneurysm.     Careful   examination  will   almost   always   show   that 

this  pulsation  is  no  more  than  a  throbbing,  an 
up-and-down  movement  as  the  patient  lies, 
without  lateral  expansile  jnilsation.  Aneurysm 
of  the  abdominal  aorta  is  very  rare  ;  it  is 
seen  in  patients  who  have  had  syphilis,  and  is 
commoner  in  men  than  in  women.  The  aneu- 
rysmal sac  is  distinctly  larger  than  the  normal 
aorta,  and  presents  diagnostic  expansile  lateral 
pulsation  met  with  in  no  other  condition.  These 
abdominal  aneurysms  often  leak  into  the  retro- 
peritoneal tissues  :  large  irregular  clots  of  blood, 
weighing  several  pounds  and  of  the  most  varied 
extent  and  distribution,  may  form  gradually  in 
the  flanks,  pelvis,  and  back  of  the  abdomen 
generally,  causing  the  patient  great  ]>ain  l)y  tlieir 
situation  and  rendering  him  anicmic  anfl  breath- 
less. The  abdominal  aneinysm  also  causes  pain 
and  stiffness  in  the  back  by  eroding  the  bodies 
of  the  vertebra?  upon  which  it*])resses. 

C.  Left  Lumbar  Region. 

The  enlarged  spleen  (see  3)  may  intrude 
into  this  area  ;  it  forms  a  firm  mass,  dull 
on  percussion,  and  is  in  contact  with  the  ab- 
dominal wall,  driving  the  splenic  flexure  of  the 
colon  inwards  or  downwards  before  it.  The 
spleen,  wlien  enlarged,  comes  down  into  the 
abdomen  in  front  of  all  the  other  structures  in 
the  left  side,  and  its  abdominal  dullness  is  con- 
tinuous with  its  thoracic  dullness,  which  extends  back  and  up  into  the  axilla  along  the 
line  of  the  ninth  or  tenth  ribs.  Tumours  of  the  stomach,  omentum,  suprarenal,  kidney, 
or  descending  colon,  may  all  be  in  contact  with  the  anterior  abdominal  wall,  and  though 
usually  nodular  and  irregular,  ma\-  present  a  smooth  and  spleen-like  surface  on  palpation. 
They  may  be  distinguished  from  the  enlarged  spleen  by  the  fact  that  they  produce  no  such 
typical  area  of  thoracic  dullness  in  continuity  with  the  dullness  of  abdominal  tumour  : 
while  the  renal  and  suprarenal  tumours  may  in  addition  be  shown  to  occupy  the  back  of 
the  loin,  so  that  they  can  be  tilted  forwards  by  the  fingers  placed  behind  just  outside  the 
edge  of  the  erector  spina;  muscles,  and  so  pushed  against  the  other  hand,  which  is  placed 
on  the  anterior  surface  of  the  loin.  A  suprarenal  tumour  may  be  associated  with  sexual 
precocity  (see  Figs.  174,  175,  p.  -408). 

The  diagnosis  of  tumours  of  the  smtill  iiilestine.  hidiieij.  and  suprarenal  glaiul  in  this 
region  has  been  given  alreadv. 


Ftj7.  "2711.— Idiopathic  dilatation  of  the  stomach. 
The^organ  post  mortem  almost  filled  the  abdominal 
cavit.v. — IntmductioH  lo  Simjcnj  (Rutherford  llurison). 


7.  Right  Inguinal  Region  and  Right  Iliac  Fossa. 
Abdominal  swellings  in  the  right  inguinal  region  are  rarely  confined  to  it.  and  usually 
extend  into  the  outer  part  of  the  hypogastric  region,  occupying  what  may  be  describeil 
somewhat  indefinitely  as  the  right  iliac  fossa. 


SWELLIXG,     ABDOMINAL 


663 


New  growths,  inflammatory  tliickcninjis,  and  abscesses  in  eonnection  witli  the  i(ecum 
and  appendix  may  all  extend  into  this  region  of  tlie  abdomen,  giving  rise  to  more  or  less 
acute  and  severe  abdominal  symptoms — pain,  fever,  vomiting,  constipation,  with  a  tumour 
in  the  right  iliac  fossa.  The  physical  signs  are  very  variable,  depending  on  the  extent 
and  acuteness  of  the  process,  the  degree  to  which  the  abdominal  wall  can  be  relaxed,  the 
exact  position  of  the  tumour — an  abscess  to  the  inner  side  of  and  behind  the  caecum  and 
appendix  may  lie  too  deeply  to  be  felt  per  abdomen.  The  rare  condition  of  sarcoma  or 
lymphosarcoma  of  the  csecum  may  be  associated  with  fever  :  the  tumour  is  soft,  and  the 
diagnosis  of  some  chronic  inflammatory  condition  will  probably  be  made.  X  caecal  car- 
cinoma is  usually  a  harder  mass  and  of  slower  growth  :  it  tends  to  constrict  the  bowel,  with 
the  result  that  faecal  accumulation  occurs  behind  it,  and  so  the  new  growth  may  be  over- 
looked when  the  hard  mass  of  ini])aeted  fa?ces  is  discovered.  The  diagnosis  of  appendicular 
abscess  has  been  made  in  patients  with  movable  right  kidney  during  a  DietTs  crisis  :  fever 
is  usually  absent  in  the  latter  :  careful  examination  will  generally  show  that  the  tumour 
in  the  right  iliac  fossa  is  an  enlarged  and  movable  kidney,  and  a  history  pointing  to  inter- 
mittent hydronephrosis,  with  polyuria  after  the  acute  attacks,  should  be  obtainable. 
Inflammation  of  the  right  ovary  or  tube,  or  ovarian  neuralgia  occurring  with  the  catamenia, 
may  all  give  ri.se  to  symptoms  in  nervous  patients  that  closely  simulate  those  of  appen- 
dicitis:  and  if  scybala  are  present  in  the  caecum,  vaguely  fel; 
as  a  tumour  through  the  rigid  abdominal  wall,  the  mistake  i 
diagnosis  of  appendicitis  may  easily  be  made  :  but  as  a  rule 
pelvic  symptoms  and  signs  will  be  found,  and  ])ain  be  felt  in  the 
jjclvie  region  and  the  lower  part  of  tlie  back  ;  the  diagnosis  will 
be  cleared  up  by  a  vaginal  or  rectal  examination — which, 
indeed,  should  never  l)e  omitted  when  there  is  any  douljt  as  to 
the  exact  causation  of  an  inllammatory  swelling  in  the  iliac 
fossa — and  by  the  previous  history  of  the  case. 

Inflammatory  swellings  and  abscesses  in  the  right  iliac  fossa 
may  arise  in  connection  with  psoas  abscess,  abscess  originating 
in  the  sacro-iliac  joint.  Iiip-joint,  or  ilium,  and  from  thc_swelling 
or  breaking  (lov/n-<)(  li/niphatic  glands  (the  external  iliac)  infected 
IVom  some  jjcrhaps  trivial  wound  in  the  leg  or  perineum.  The 
sym))toms  of  bony  disease  about  the  hip  or  the  i)elvic  girdle  will 
be  ))resent  :  the  leg  will  be  held  more  or  less  stiffly  in  some 
abnormal  attitude  of  flexi(m  and  inversion  to  relieve  the  pain. 
and  movement  of  the  leg  will  be  jiainful.  Unless  local  jjcri- 
tonitis  is  |)resent.  there  will  be  none  of  the  special  symptoms 
that  point  to  appendicular  or  Ciccal  disease. 

S.  lli/pogastric  Region. 

In  rare  instances,  tumours  arising  in  IIjc  small  iiilcslinc.  ami 
more  often  (he  sausage-like  swelling  of  an  enteric  inliissus 
ception,  may  be  felt  in  the  hypogastric  area  (see  4).  Tumours 
extending  into  it  from  the  iliac  W)ssa'  are  described  under 
headings  7  abo\c'  and  !)   below. 

In   inl'aids,   the  blaililer    re-iches    lialf    \\a\    lo   llic  uiiibiliins 

when  moderately  full,  and  does  not    fall   below   llic  pubic  s\ni-  ,  ,,,  i i,i,i 

physis  when  empty.      In   the  adult,  the  disleridcd    hlailder  is  a        "',„''"„, ','.'"Vi'.'.  ,■   !!i'    ,''''A 'lil! 

common     hypogastric    swelling,     particuhiriy     in    rcniales    with        n m  ,i|.un- n,..  i,.»,-,  |.iir( 

relroverteil   gravid    iileras.    or    in     males    of    abmil     si\l\     with        '.bury'.T;/' (Uu'i'lre^^^^ 
enlargonenl    of    tlie    /irostale  :    it    may    reach     up    as    an    oxciid 

elastic  mass  arising  from  the  front  of  the  pelvis  almosi  lo  lljc  umbilicus  under  conditions 
that  are  in  no  way  patliological.  as  well  as  when  the  retention  is  due  to  some  pathological 
cause.  Such  a  distended  bladd<r  (Fig.  277)  has  been  lapped  as  aseiles.  opiialed  upon 
as  o\;nian  or  uiMclial  eysl.  an<l  diagnosed  as  llic  prci^iianl  ulii'us  :  inislaki-s  llial  mic  nnl 
likely  lo  occiu'  if  I  liesc  possibilities  be  remeinlicicd.  and  arc  pul  mil  of  coiirl  by  iiiici  iirilioii 
or  the  use  of  a  calliilcr  bclorc  llic  diagnosis  is  made. 

The  iirnclins  is  a   libnnis  cdid   iimiiinii   in   I'idiil   of  llic  pciiliiiicimi   fniiii   llic  lop  ol    I  he 


666  SWELLING.     AXILLARY 

bladder  to  the  umbilicus,  in  the  middle  line  :  it  sometimes  becomes  the  seat  of  cyst-forma- 
tion, more  often  in  women  than  in  men.  The  urachal  cyst  is  a  rounded  tumour  lying 
between  the  umbilicus  and  pubcs,  soft  or  firm  according  to  the  tension  of  its  contents  ; 
it  may  produce  hypogastric  pain.  It  must  be  distinguished  from  encysted  tuberculous 
peritonitis,  from  ovarian  cystadennma.  and  from  the  distended  bladder. 

Abdominal  swellings  arising  from  the  iilcrus.  ovaries,  tubes,  and  uterine  ligaments  may 
all  rise  up  out  of  tlie  pelvis  and  present  themselves  as  swellings  in  this  region,  and,  as  they 
grow  larger,  may  spread  into  the  whole  or  any  part  of  the  abdomen.  While  they  are 
comparatively  small  and  manifestly  connected  with  some  intrapelvic  organ,  their  origin  is 
not  difficult  to  determine  :  their  diagnosis  is  considered  vnukr  Swuli.ini;.  Pelvic  (p.  688). 
But  wlien  they  have  grown  u])  into  the  abdomen,  or  h:i\e  aii|uire(l  a  long  pedicle,  or  have 
become  lixed  by  adlicsions  to  some  distant  part  of  tlie  al)(loniinal  wall  or  to  some  other 
viscus,  perhaps  causing  it  to  become  inflamed  and  impairing  its  functional  activity,  these 
pelvic  timiours  may  give  rise  to  signs  and  symptoms  suggesting  any  disease  rather  than 
one  that  is  pelvic,  and  the  true  diagnosis  may  be  very  difficult  tii  make.  The  possibility 
of  ])regnancy  in  the  female  should  always  be  remembered. 

!).  Left  Inguinal  Region  and  Left  Iliac  Fossa  (see  7  above). 

Tlie  sigmoid  flexure  of  the  colon  can  be  felt  normally  as  a  tube-like  cord  passing  from 
the  left  linnbar  region  down  into  the  pelvis,  and  rolled  under  the  fingers.  It  very  frequently 
contains  hard  ovoid  scybalous  masses.  In  rare  instances  it  may  be  uniformly  thickened 
and  tender  in  consequence  of  chronic  inflammation,  tuberculous  or  otherwise.  It  is 
occasionally  the  seat  of  cancerous  new  growth,  when  the  patient  will  complain  of  chronic 
intestinal  obstruction,  with  cachexia,  tenesmus,  and  the  ])assage  of  blood-stained  stools, 
phenomena  that  may  also  be  met  with  in  hyperplastic  or  stenotic  tuberculosis  of  the  sigmoid. 

The  left  iliac  fossa  may  be  the  seat  of  abscess  or  inflanuuations  similar  to  those 
described  imder  7  above.  In  addition,  suppuration  around  an  exaggerated  colonic  diverti- 
culum, with  symptoms  not  unlike  those  of  appendicitis  on  the  wrong  side,  has  been  known 
to  occur  :    such  a  condition  has  been  spoken  of  as  acute  diverticulitis  of  the  colon. 

A.J.Je.r  Blake. 

SWELLING,  AXILLARY.— Swelling  in  the  axilla  is  due  in  the  great  majority  of 
cases  to  enlargement,  from  one  cause  or  other,  of  the  lymphatic  glands  :  a  subsequent 
abscess,  either  acute  or  chronic,  is  frequent.  Any  other  form  of  tumour  is  distinctly  rare. 
In  examining  a  ease,  therefore,  these  two  causes  should  be  uppermost  in  the  mind,  and 
indeed,  on  inspection  only,  the  diagnosis  may  be  obvious,  e.g.  : — 

Acute  Abscess  may  be  recognized  at  once  by  the  well-marked  signs  of  local  inflam- 
mation and  the  general  febrile  disturbance.  There  is  one  form  of  acute  abscess  that  may 
not  be  obvious,  namely,  one  situated  in  the  upper  part  of  the  axilla  and  covered  by  the 
pectoral  muscles.  On  account  of  its  distance  from  the  surface  the  local  signs  of  inflam- 
mation may  not  be  great,  though  the  general  signs  are  marked.  There  will  be  great 
disinclination  to  move  the  arm  on  account  of  pain,  and  there  is  usually  some  cause,  such 
as  a  whitlow  on  the  finger,  to  account  for  the  trouble.  It  must  be  remembered,  however, 
that  the  abscess  may  be  "  residual " ;  that  is  to  say,  the  original  source  of  infection,  such 
as  the  whitlow,  may  have  healed  completely  two.  three,  or  even  more  weeks  before  the 
axillary  abscess  declares  itself.  Occasionally  an  empyema  points  in  the  axilla  ;  there 
are  generally,  but  not  always,  abnormal  lung  signs  to  suggest  the  diagnosis. 

Chronic  or  Tuberculous  Abscess  forms  a  single  fluctuating  swelling  which,  if  large, 
may  extend  upwards  under  the  pectoralis  major.  Owing  to  the  fact  that  few.  if  any.  of 
the  local  signs  of  inflammation  may  be  present,  difficulty  arises  in  distinguishing  this  form 
of  abscess  from  a  soft  lipoma.  The  duration  and  the  rapidity  of  growth  of  the  swelling 
are  a  good  guide,  for  though  the  duration  of  a  chronic  abscess  may  run  into  months,  it 
does  not  exist   for  years,  as  dues  a  liponia. 

Enlargement  of  the  Lymphatic  Glands.  -  Next,  supposing  that  examination  proves 
that  the  swelling  is  not  an  abscess,  attention  should  be  directed  to  ascertain  whether  it 
is  glandular,  and  it  is  therefore  necessary  to  recall  the  anatomical  position  of  the  glands. 
The  axillary  lymphatic  glands  are  ten  to  twelve  in  number,  and  are  arranged  in  three  .sets. 
One  chain  surroimds  the  axillary  vessels  and  receives  the  lymphatics  from  the  arm  ;  a 
small  chain   runs  along  the  lower  border  of  the  pectoralis  major  as  far  as  the  mammary 


SWELLING    ON    A    BONE  mi 

gland,  receiving  the  lymphatics  from  the  front  of  the  chest  and  the  breast  ;  the  third  chain 
is  placed  along  the  lower  margin  of  the  posterior  wall,  to  receive  lymphatics  from  the 
integuments  of  the  back.  If  the  glands  are  affected  in  any  way.  all  need  not  necessarily 
be  enlarged,  but  it  would  be  extremely  unusual  if  only  one  were  picked  out,  and  commonly 
two  or  three,  or  one  entire  group,  are  affected.  Therefore  axillary  swellings  due  to  glandular 
enlargement  are  almost  always  multiple,  and  are  situated  in  the  part  of  the  axilla  where 
glands  are  normally  present.  This  may  not  be  quite  accurate  when  much  inflammation 
has  occurred  around  the  glands  and  they  are  matted  together,  as  happens  with  tuberculous 
infection  :  but  even  then  the  mass  may  be  felt  to  be  made  up  of  many  glands.  For  the 
differentiiil  diagnosis  of  glandular  swellings,  see  Lymph.\tic  Gland  E.nlargkmknt  (p.  3T0). 

Primary  Tumours  of  the  Axilla  are  distinctly  rare. 

Lijioitifi  IS  tlic  most  ciiminon.  It  may  attain  a  large  size  and  extend  up  under  the 
])ectoral  inusck-s.  It  should  be  diagnosed  by  its  long  history,  slow  growth,  definite  outline, 
and  free  mobility.  When  very  soft,  the  tumour  may  give  the  feeling  of  fluctuation,  and 
so  be  mistaken  for  a  chronic  tuberculous  abscess.  Tlie  skin  wrinkles  when  one  attempts 
to  raise  it  away  from  the  tumour. 

('t/slif  IIiigriwKi  of  the  axilla  is  very  rare.  It  is  usually  congenital.  It  forms  a  soft. 
Iluetnating.  painless  swelling,  which  sometimes  grows  rajiidly.  It  may  easily  be  mistaken 
for  a   lipoma. 

I'linKiit/  MdUgiKitit  Tumours  may  arise,  but  are  of  extreme  rarity. 

.luiiiii/sm  of  the  Axillririj  Arteri/  does  occur,  but  is  uncommon.  It  is  easily  recognized. 
because  it  is  comparatively  superficial  and  it  gives  an  expansile  pulsation,  synchronous 
with  the  heart's  beat  ;  the  veins  of  the  forearm  may  be  distended  on  account  of  pressure 
on  the  axillary  vein,  and  the  radial  |)ulse  on  the  affected  side  is  diminished  in  size  and 
<lelayed.  There  may  be  a  <lelinite  history  of  local  injury,  or  in  eases  of  apparently 
spontaneous  aneurysm  tliere  may  be  signs  or  symptoms  of  fungating  endocarditis  (p.  ;J4). 

(leorge  E.  GuKk. 

SWELLING  ON  A  BONE.^It  is  presumed  that  the  swelling  has  been  ascertained 
to  be  of  the  bone,  inirnovahle  apart  fro  ii  it.  and  tliat  it  is  not  merely  some  tumour  lying 
close  to  it. 

The  following  method  of  examination  should  be  adopted:  (1)  In(|uirv  into  the 
elinieal  history,  mode  of  onset,  duration  ;  (2)  Seareli  for  the  signs  of  inllanunation  : 
('A)  Kvidenee  as  to  whether  the  swelling  is  a  localized  projection  or  involves  the  whole 
circumference  of  the  bone  :  (4)  Investigation  for  involvement  of  other  bones  or  further 
signs  of  disease,  e.g.,  tuhereidosjs,  syphilis,  rickets,  etc.  ;  (.5)  .\  skiagram  should  always  be 
taken  if  possible  ;  (0)  If  a  discharge  is  present,  a  bacteriological  examination  should  be  made. 

The   various  swellings   may   be  classified   under   the   following   headings  : 

(I.)  IiijiiTii  :  (II.)  Infective  Di.ifiiscfi  :  (III.)  (leiwrdl  Dinriiscn.  not  liniilcil  to  one 
bone:     (IN.)    Tiiiiiuiirs  ■    (\'.)    Ci/sls. 

I.      INJURY. 

A  blow  or  kick  may  gi\'e  rise  to  a  swelling  ihie  to  (■.tirdX'iisiilioii  o{  hloiid  ur  serous  fluid 
under  the  periosteum.  This  disappears  r:ipidly,  but  m;iy  le:i\e  a  small  ijernianent  thick- 
ening or  node.  .Such  a  node  is  f'ojmd  not  inl're(|uently  on  the  shins  of  football  players. 
A  Iraelure  of  bone  is  followed  by  the  fmiirilion  iit'  ciilliit.  which  forms  a  large  swelling  if 
tin-  broUeii  ends  do  nut  ||i'  in  aeeurale  :ipposition.  or  if  there  is  too  much  inii\ cincnl 
iKlwi-en  Ihcin.  Alter  loMi-  to  six  weeks  the  callus  begins  to  be  absorbed,  and  il  ina\ 
<lisii,|)pear  entirely  :  in  most  eases  a  small  perm:in<'nt  swelling  indicates  the  site  of  fracture. 
.\  green-sliek  fracture  may  not  show  any  swelling  at  lirsl.  and  may  be  oNcrlooUed  on  this 
account,  being  discovered  only  when  the  loiination  of  callus  draws  attention  to  it. 

II.     INFECTIVE    DISEASES. 

Thc'se  gi\c  rise  to  inflannna lory  elianucs  in  liiine.  lie'  sinus  of  wliieli  are  more  or  less 
ohvions,  according  to  111.-  rialinr  and  \  iiiiliiiic  of  tin-  inlcclion.  Tlusi-  clianges  have 
iisnall\  been  named  according  to  the  cliier  starling-point  (periostitis,  osteomx clilis,  etc.). 
Iliongli  lliey  seldom  remain  eonfineil  to  one  pirlieular  pari  of  the  bone.  In  this  article 
the  elassiliealion  will  be  made  :u'Conling  to  the  nature  of  the  irdeetirig  organism,  \i/., 
pyogenic  (slapliyloeoi'ei  :iiiil  si  ri  |)toei>eci).  luherch',  syphilis,  etc. 


668 


SWELLING    ON     A     BONE 


A.  With  Pyogenic  Organisms. 

Acute  iiifcrliiiii  may  oofur  tlirough  wouniis  or  injuries,  or  via  tlie  bloofi-streani.  The 
resulting  swelling  is  due  to  the  formation  of  pus  between  the  periosteum  and  the  bone  ; 
this  may  be  a  localized  abscess,  or  the  whole  of  the  periosteum  may  be  stripped  off  and 
the  bone  lie  bare  in  a  bag  of  pus.  The  disease  usually  occurs  in  young  people,  and  the 
intimate  attachment  of  the  periosteum  at  tlie  epiphyseal  lines  limits  the  spread  of  suppura- 
tion :  in  long-standing  cases  the  pus  may  burrow  farther  and  even  burst  into  the  joint. 
Su|)puration  is  rarely  limited  to  the  surface  of  the  bone,  but  spreads  into  the  marrow, 
causing  osteomyelitis  :  lymphatic  absorption  and  septic  embolism  are  liable  to  give  rise 
to  a  general  blood-infection  and  |)y;eniia. 

The  signs  of  inflanuiiation  are  al)undant  :  the  swelling  is  acutely  painful  and  tender, 
the  skin  over  it  red  and  (jedematous,  and  the  constitutional  signs  of  fever  are  marked.  If 
the  blood  is  examined,  a  high  leucocytosis  will  be  found. 

It  is  important  nnt  to  mistake  eri/thema  nodosum  for  this  affection  ;  in  erythema 
nodosum  the  red  swellings  are  generally  multiple, 
bilateral,  and  confined  to  the  shins  ;  it  is  rare  for 
acute  osteomyelitis  to  Ije  bilateral  and  symmetrical, 
and  confined  to  the  parts  between  the  knees  and 
the  ankles. 

Chronic  infection. — .Such  a  condition  as  detailed 
al)(ive  may  often  become  chronic  and  cause  a  swell- 
ing which  may  last  for  months,  years,  or  through 
life.  If  the  pus  formed  imder  the  periosteum 
escapes,  either  by  bursting  or  through  an  incision, 
sinuses  form,  and  the  periosteum,  in  the  process  of 
repair,  becomes  thickened.  If  during  the  height  ol' 
Ihe  inflammation,  a  portion  of  the  bone  has  died — 
necrosis — this  acts  as  a  foreign  body,  keeps  up 
inflanuiiation  and  sup])uration,  and  great  thicken- 
ing of  all  the  constituent  jiarts  of  the  bone  results 
(Fig.  278).  Usually  the  diagnosis  can  be  arrived  at 
without  difficulty.  Occasionally,  if  the  inflamma- 
lory  changes  have  not  been  great,  and  the  amount 
of  necrosis  is  small  and  deeply-seated  (central 
necrosis),  a  condition  resembling  a  slow-growing 
sarcoma  may  result.  If  a  skiagram  is  taken  it 
will  be  observed  that  the  chronic  inflammatory 
])criosteal  thickening  is  added  on  to  or  "  applied  ' 
to  the  original  compact  layer  of  bone,  whereas  in 
the  case  of  sarcoma,  though  there  may  be  thicken- 
ing and  formation  of  bony  or  calcareous  spicules  in 
tlie  growth,  the  compact  layer  is  eaten  away  (Figs. 
■_>8a.  286,  287,  pp.  671.  673).  However,  this  may  be 
somewhat  slender  evidence  on  which  to  base  the  dia- 
gnosis between  so  important  a  condition  as  sarcoma 
and  inflammation,  and  if  doubt  arises  an  incision 
should  be  made  into  the  tumour,  so  that  a  portion 
may  be  removed  for  pathological  investigation. 

B.  Tuberculous  Disease  usually  starts  in  the  cancellous  tissue  of  the  small  bones 
of  the  car])us,  tarsus,  and  i)halanges,  and  at  the  ends  of  long  bones.  The  inflammatory 
changes,  which  are  slight,  give  rise  to  caries  of  the  affected  bone  :  the  external  signs  of 
inflammation  are  little  marked,  and  it  is  comparatively  rare  for  any  swelling  of  the  bone 
to  result,  though  the  soft  parts  around  the  bone  may  be  swollen  considerably. 

Tuberculous  dactylitis  (Fig.  279)  furnishes  an  instance  in  which  the  disease  forms  a 
periosteal  swelling.  It  is  found  most  often  in  quite  young  children,  and  the  bones 
commonly  affected  are  the  metacarpal  bones  and  phalanges  of  the  hand.  The  affected 
digit  exhibits  a  fusiform  enlargement,  slightly  tender,  which  on  rest  tends  to  diminish. 
Tuberculous  jieriostitis  may  develop  in  any  long  bone,  on  the  ribs  and  the  humerus  most 
commonly,  and  it  then  has  to  be  differentiated  from  syphilis. 


b ^1  i     1  mi 

fr  M     1                  t    .-linn 

of  thp  111  11 

1  1"  to  no  eiiiL  iiilectio 

(SX   ijr.m 

'  /  Iir   Hugh  H  uisham.i 

SWELLING    ON    A    BONE 


669 


Chronic  tuberculous  abscess  of  bone  occurs  most  frequently  in  the  young  adult,  ami 
nearly  always  in  the  articular  extremity  of  a  long  bone,  by  preference  in  the  upper  end 
of  the  tibia.  Enlargement  of  the  bone  is  found  only  when  the  abscess  approaches  the 
surface  and  involves  the  periosteum.  The  skin  then  becomes  a  little  red  and  oedematous, 
and  there  is  generally  a  small  spot  that  is  exquisitely 
tender  on  firm  pressure.  It  is  to  be  noted  that 
when  secondary  infection  with  pyogenic  organisms 
occurs — a  not  infrequent  event — all  the  swellings 
described  under  "  acute  infection  "  may  result.  -\ 
skiagram  will  generally  reveal  the  true  condition  : 
if  not.  a  diagnostic  injection  of  Koeh"s  old  tuber- 
culin may  be  made,  or  von  Pirquefs  skin  reaction 
tested. 

C.   Syphilis   in  the  ac(|uired  I'orni  may  lead  to 
periosteal    thickenings   in  the   secondary   stage  and 


-Skiagram  shoninc;  ty|iicnl  sypliilillc  dtoeiiBc  of 
tlic  aijpcnniriccs  are  diagnostic  of  tiiis  conili- 
lilTia  is  iiorniul, 

{Skimjmm  hij  llr.  C,  Tlmrslan  /MItiml.) 


(Sl.;a, 


hij  llr.  Hiiijh    ^ynl.1lmm.) 


tlli( 

bun 


con/feuiln!    sfntliiU. 
ings  of  the   iiuiics 
nalilnrin    skull  : 


<r  till' 
(//)     li 


to  gurnniiita  in  the  Iciliary.  The  fiinncr  gi\e 
lise  |<>  excessively  terwler  swellings  (in  the 
siirl'aee  (if  the  tibia?,  clavicles,  sternum,  ribs,  or 
skull.  They  are  generally  multiple,  two  or 
three  (iften  being  Ibimd  on  the  sanu'  bone.  The 
])alieiit  complains  of  pain,  particularly  in  bed, 
when  the  extra  warmth  causes  further  dilata- 
tion (if  already  inflamed  vessels.  Helief  is 
gixcri  almost  at  once  by  potassium  iodide. 
Sdmclinus  one  of  these  swellings  is  followed 
by  the  liirmal  inn  of  compact  periosteal  bone. 
gi\  iiig  rise  to  a  node  which  fades  gradually  into 
the  surrounding  parts,  like  a  hill  risim.;  gently 
fnim  a  plain. 

(liitiiuiiilii  may   form   Idcali/.ed  swellings,   or 

may  iri\ade  the  whole   substance   of  the    bone, 

causing   osteomyelitis    and    gene?al     thiekening 

{Fi<<.    •_'«(•).      The   condition     has    to    be    disllii- 

guished     from     tulxTCulosis,     chronic    pvdgenic 

inlcelidM.    and    sarcoma;    such    rei'ognition    is 

arrixcd   at   by  means  of  the  Wassermarui   t<'sl. 

and   the  fact   that   antisyphilitie  renu'dies  cause 

a   marked    and    rapid    improvement.      Diagnosis 

by  incision  has  rarely  to  be  resorted  to. 

(if    lidM\-    swelling    are    common  :    («)     I'eriostcal 

dl    the   skull,   called    Parrot's  nodes     the  hot-cross 

lidrn     iiilarils,    i  piplix  sit  is    and    scparalion    (if    the 


(370 


SWELLING    ON    A    BONE 


epiphyses.     So   painful   is  a   limb   thus  affected   that   it   is   kept   motionless,   and   may   he 
thought   to  be  ])aralyzed. 

I)  Typhoid  Fever. —  In  the  course  of  this  disease  a  periosteal  node  or  abscess  may 
form.  From  the  fluid  a  ])ure  culture  of  typhoid  bacilli  may  be  obtained  perhaps  for  a 
long  time  after  the  fever.     Tin-  nodes  by  no  means  always  break  down  into  pus. 

III.      GENERAL    DISEASES    NOT    LIMITED    TO    ONE    BONE. 

nickels. — The  ordinary  form  is  well  known,  and  can  hardly  be  confused  with  any 
other  disease. 

Scurvij-tickets  is  quite  distinct  from  rickets.  It  arises  generally  in  infants  under 
twelve  months  old,  who  have  been  fed  too  exclusively  on  artificial  foods  or  preserved  milk. 
The  disease  therefore  is  more  common  among  the  children  of  the  rich  than  the  poor.  The 
child  is  often  brought  to  the  doctor  on  account  of  the  sudden  appearance  of  an  exceedingly 
painful  swelling  of  a  long  bone,  such  as  the  femur.     The  swelling  may  fluctuate,  and  yield 

on  aspiration  blood-stained  fluid.  Spon- 
taneous fracture  is  liable  to  occur.  The 
diagnosis  is  indicated  by  the  fact  that  the 
child  is  anaemic,  and  has  spongy  gums  and 
hiemorrhages  from  the  mucous  membranes. 
The  condition  is  most  likely  to  be  confused 
with  acute  suppurative  periostitis  and  trau- 
matic fracture. 

Osteitis  DefoniKins  (see  Figs.  0.3,  64,  p. 
iri.5)  is  a  senile  disease,  very  chronic,  and 
characterized  by  thickening,  lengthening, 
and  bending  of  the  bones.  The  whole 
osseous  system  may  be  affected,  but  atten- 
tion is  first  drawn  to  the  disease  by  thicken- 
ing of  the  tibiic  and  forward  bending  of  the 
knees,  and  by  enlargement  of  the  head.  In 
the  rare  event  of  one  bone  only  being 
ari'ccted,  it  may  be  confused  with  syphilitic 
osteitis,  and  only  be  recognized  on  the 
failure  of  antisyphilitic  remedies  and  by  the 
subsequent  involvement  of  other  bones.  The 
IKitient  suffers  from  neuralgic  pains,  and  in 
the  later  stages  from  dyspnoea.  In  such 
cases  death  sometimes  occurs  from  the 
development  of  multiple  sarcomata  of  the 
bones. 

Acrnmegnl/j  {Fig.  116,  p.  237)  is  described 
on  pp.  237. 
LconUasis  Ossea. — In  this  disease  there  is  general  overgrowth  of  the  cranial  and  facial 
bones,  and  one  of  the  chief  symptoms  may  be  the  fact  that  the  |)aticnt  has  to  get  progres- 
sively increasing  sizes  of  hats. 

Swellings  of  bones  associated  with  diseases  of  joints  may  be  found  in  gout,  osteo- 
arthritis, and  pubnortary  hypertrophic  osteo-arthropathy.  (See  Joints,  Affections  of, 
p.  351.) 

IV.      TLMOURS. 

These  are  innocent  and  malignant.  Innocent  tumours  as  a  whole  are  characterized 
by  their  long  history,  slow  growth,  localized  projection,  and  the  absence  of  all  signs  of 
inflammation. 

Varieties  of  Innocent  Tumours. 

Ostcomri  or  exostosis  is  the  commonest  form  (Fig.  2!S1).  The  usual  site  is  in  the 
neighbourhood  of  the  epiphyseal  line  of  a  long  bone,  particularly  the  lower  end  of  the 
femur  ;  the  tumour  is  capped  with  cartilage,  and  often  surmounted  by  an  adventitious 
bursa  containing  fluid. 


Fig.  !iSl.— Skinnram  of   a  common   varklj-   of  cancellous 
exo^to^^is  of  the  femur. 

{Skiagram  by  Dr.  Hihih   Wiihlinn 


SWELLING    ON     A     BONE 


671 


r|.:.l 


Fihroniiild    ifrow    IVoni    the    fil)n 


SJ 

■isii,  "ST. 

lOin'lit.ri.imma  iiiul  sar- 

" 

lot  .ippcu- 
(Skiniiratn 

Tiiliki"  ill  skinqrains. 

Ivi  llr.   Iluijli    W'alsimm) 

The  lingual  phalanx  of  the  great  toe  is  another  eonininn  site  for  a  similar  tuinnur, 

wliich  pushes  up  the  nail  and  may  be  very  painful  if  ordinary  boots  are  wt>rn.     Multiple 

exostoses  are  not  uncommon,  and  they  may  be  heredi- 
tary.    Diagnosis  can  be  made  at  once  by   means  of  a 

skiagram,  and  with  this  aid  it    can    be    seen    that    the 

swelling  is  composed  of  cancellous    tissue    continuous 

with  that  of  the  bone.     .\  spurious  osteoma  may  arise 

by  ossification   of  a  tendon   or  by  an  extension  of  the 

ridge  into  which  the  tendon  is  inserted,  the  condition 

being  generally  consequent  on  some  injury  or  repeated 

strain,  as  in  the  case  of  horse  riders,  who  are  aj)t  to 

develop   one  on  the  inner  aspect  of  the  knee  ;  another 

example  is  the  spur  that   is  apt  to  form  on  the  imder 

surface  of  the  os  calcis  at  the  posterior  end  of  the  long 

])lantar   ligament,   giving  rise  to  much  discomfort  and 

even  acute  pain  below  the  heel  in  walking.     .V  skiagram 

may    be    required    in    establishing   the    diagnosis    with 

certainty  (Fig.  18.5.  p.  440). 

Ivory  exostoses  may  be  found  on  the  flat  bones  of 

the  skidl.  or  in  the  auditory  meatus  growing  from  tlie 

petrous  bone,    or   causing    tmilateral    exo])hthalmos    if 

.springing  from  the  orbital  plate  of  the  frontal  bone  or 

the  walls  of  the  frontal  sinus. 

Cliontlromalii  may  grow  from  any  bone.     'rhe_\'  aie 

most  commonly  multiple,  affecting  the  phalanges  and 

mclaearpal   bones  of  the  hand   (Fig.  282).     The   result 

is  increasing  deformity,  with  [lain  and  iileeration  of  the 

skin. 

ti.ssue  of  the 
perio.steum.  but  are  rare  except  in  the  form  of 
an  epulis  of  the  jaw.  (.See  Swki.i.in(;  oi'  tue 
.1  AW.  I,owi:u.  p.  683.) 

Lipiiinrilfi  are  extremely  rare.  They  grow 
friiiii   llie  onlcr  layer  of  the  periosteum. 

Malignant  Tumours  may  occur  either  pri- 
niaiily  (sarcoma),  or  secondarily  by  metastasis 
or  by  invasion  (sarcoma  and  carcinoma). 

I'crioslcnl  sriiciiiiifilfi  aif  of  so  many  types 
and  of  such  \arying  degrees  of  ni.alignaney,  that 
il  is  a  (lillicull  task  to  lay  down  any  rule  as  to 
Iheh-  charaeteristi(  s.  The  softer  their  con- 
sislency  and  the  nearer  they  approach  to  the 
embryonic  type  of  the  tissue,  the  more  malig- 
nant they  are  :  the  nearer  they  reach  the  fully- 
formed  lissucs  and  contain  cartilage,  bone,  or 
lllirous  tissue,  Ihe  slower  growing  and  less 
niaiigiianl  lluy  aie,  .\  tspical  case  may  be 
re|)rc,sented  as  a  i';ipidl\  growing  tinnour. 
generally  about  the  end  nf  a  lung  bone  (Fig. 
28.-!).  It  is  iiol  usually  painful,  and  the  signs  of 
local  iiiMiunnialion  and  general  fe\cr  are  little 
marked,  or  absent.  The  patient  is  eonuuonly  a 
\oinig  achill.  who  (iricn  gives  a  liistory  of  injury 
hi  IIk-  part,  and  ma\-  lose  weight  and  strength 
lie  Idle  actual  euehexia  sets  in.  The  veins  o\ir 
I  Ik    swelling  bet'ome    prominent.    Ihe  lymphatic 

-l.i,i.i,.i..  ,,1  ,.  |.,  n,,,-i,;,i  „, I  i;hirids  enlarged,    and    metastases   by    the   biiiod- 

(.'iUa(,,'im  )',.','' Or  //mjl,  llnWmm.)  stream   occur  <arly.   especially    in  I  lie   lungs.      It 


672 


SWELLING    ON    A    BONE 


lias  to  be 
a  |)it'oe  o 
])re])arecl 


distinguished  from  chronic  and  syphilitic  periostitis.     If  a  skiagram  is  insufficient, 

f  the  tumour  may  have  to  be  excised,  decalcified,  and  a  microscopic  section  from  it 

This  form  of  sarcoma  is  the  worst  possible,  and  seeing  that  amputation  does 

not  cure  and  often  does  not  prolong  life, 
this  extreme  resource  may  be  delayed 
where  either  gumma  or  chronic  perios- 
titis is  still  a  possible  diagnosis. 

Eiiilostriil  or  iiii/ejoul  sarcomata  are 
(if  much  slower  growth  ;  so  slow  are 
they  that  some  pathologists  are  inclined 
to  denote  them  as  benign  tumours. 
They  are  prone  to  affect  the  ends  of 
tlie  long  bones,  particularly  the  lower 
end  of  the  femur,  the  upper  end  of  the 
tibia,  the  upper  end  of  the  humerus,  the 
lower  end  of  the  radius  (Figs.  284,  286, 
287),  the  sternal  end  of  the  clavicle, 
and  the  upper  jaw  (malignant  epulis). 
Attention  is  first  called  to  the  part  by 
|i:iin  :    llicti     a     more     or     less     imiform 


rm  -M  — ^Kn  nm 
end  ot  tlie  richu&  I 
compaicd  ^itli  Ftfj  . 
sarconid  ire  not  dibtinq 


oiTKi  of  tlie  lower 
(i.  287  should  bo 
crichondronia  and 

Jliiijh    IViilsliniii.) 


swelling  appears.  This  is  at  first  bony  hard,  and  only 
as  the  shell  of  bone  yields  does  softening  occur,  or 
crackling  on  pressure,  Tlie  lymphatic  glands  are  not 
enlarged,  and  metastases  do  not  occur.  In  the  early 
stages,  diagnosis  has  to  be  made  from  rheumatism  and 
chronic  abscess,  and  later  from  chronic  osteomyelitis  and 
periosteal  sarcoma  ;  it  is  easily  made  by  the  aid  of  .x'-rays 
as  a  rule,  but  it  is  most  important  not  to  mistake  the 
callus  that  is  produced  after  fracture  for  a  sarcoma  ; 
this  mistake  is  not  always  obviated  even  by  the  use  of 
the  a;-rays,  unless  the  latter  reveal  the  line  of  fracture  as 
well  as  the  callus  around  it. 

Sarcoma  may  also  invade  the  bones  from  outside, 
having  started  in  the  subcutaneous  or  deeper  soft  tissues 
outside  the  bone  {Fia.  285). 

Carcinoma  is  always  secondary  (Fig.  62,  p.  132). 
.Squamous-celled  carcinoma  may  spread  to  the  tibia  from 
an  epithelioniatous  ulcer  of  the  leg,  or  to  the  jaw  from 
the  lip  or  floor  of  the  mouth.  It  is  mostly  spheroidal- 
celled  carcinoma  which  infects  bone  by  metastatic 
growths,  particularly  from  the  breast  or  from  the  thyroid  gland.  A  swelling  of  bone  may 
be  found,  but  this  is  rarely  discovered  until  attention  is  called  to  it  by  a  spontaneous 
fracture. 


Fiff.    235. — Skiagram  of 
radius  and  ulna  :     the   gro 
the  bones  and  is  eating  into  them  ;   it  vv;f- 
not  primarily  a  bone  growth.     Male,  age  ->  - 

{Skiagram  by  Dr.  C.  T/mrstan  Holland.) 


SWELLING    OF    THE     FACE 


673 


V.  CYSTS. 

Blood  cysts  are  found  in  desienerating  sarcomata. 

Hydatid  cysts  are  nneoninion  in  this  coinitry.     They  affect  the  diaphyses  of  the  long 
bones,  converting  the  shaft  into  a  tliin-walled  tube,  which  undergoes  spontaneous  fracture. 


Fiff.   '236. — Skiagram    givitij;  the   arilero-posterior 
I  myeloid  sarcoma  of  the  lower  end  of  the  radius.     Tlie 
s  at  a  later  sta^-e  than  that  depicted  in  Fig.  2il. 


Fi(f.   '2S7   shows  the  same  growth  as  Fit/. 
ISO,  but  seen  from  the  lateral  ixspect. 

(Skia'jratns  htj  Dr.  Hugh   Walsliam.) 


Tliey   would   hardly   be   suspected    unless   there   were   known   hydatid   disease   elsewhere, 
especially  in  the  liver  (p.  375). 

Cysts  of  the  jaw,  or  dentisrrous  cysls.  arc  considered  in  the  tirticlc  on  Swki.i.ing  of 
TTiK  Lowi'.it  .Jaw  (p-  fiS'i)-  (Icorge  E.  Gask. 

SWELLING  OF  THE  FACE.-  In  litis  in-ticlc  an-  inchidcd  only  swdhngs  of  the  skin 
and  sul)cutancous  tissues.  .Malignant  and  other  discu.ses  of  the  facial  bones,  etc.,  are 
considered  under  Swellinj;  of  tur  Jaw  (p.  688),  and  Swki.ling  on  a  Bonk  (p.  667). 
SwKi.i.iNi;  Of  iin;  Saiivakv  Glands  is  discussed  on  p.  69 1.  Ciintiisions  and  injuries  to  the 
face  arc  so  ob\iinis  Ihal  (hey  nccil  no  inciilioii.  'I'lic  rciiiMiiiiiij;  swclliims  will  be  classilied 
!is  (1)  \()ii-iiijl(iiiiiiiiiliiiy  :    and  (2)  liijhniiiniildri/. 

Non-Inflammatory    Swellings. 

Iiiiiii/  anil  Citiilidr  (Kdciiiii.  W  the  whole  lace  is  piilTy  and  llic  (•> clids  iiic  (idi'iualotis. 
the  urinary  and  cardiiic  systems  :irc  to  be  cxtiniincd  for  disease.  I'or  swelling  due  to 
iilisliiiiiinn  iif  llic  sii/ii'iior  vciitt  earn  1>\  mcdiiisliriiil  librosis.  aneiwysni.  or  new  growth,  .see 
(JCi)i;ma  (p.  HI),  antl  Vi;iNs,  N'Aiiico.sr;  Tiiohacic  (p.  750). 

.liHiionciiwIic  (EdciiKi  is  a  disease  characterized  I)y  the  oiciiiicnci'.  sdimlimes 
periodical,  of  local  crdematous  swellings,  more  or  less  limited  in  exicnl  tiiid  ol  transient 
diif.ilioii.  It  is  not  conlined  to  lli<-  (ace.  hul  the  eyelid  is  a  eommoti  situtition  (/•'/,!;.  178, 
p.  tIJ).  and  also  the  lips  and  clirck.  It  may  l)c  simidiitcd  closely  by  urticaria  following 
llie  takini;  of  lish  or  pork  :  or  a  souk wlial  similar  cfTcct  produced  by  some  drugs,  notably 
by  aspirin  in  certain  patients. 

Taiiiiiiirs  are  not  common.  'I'hcy  may  be  libroma,  li]ioma.  <i)il  hclioma.  or  sebaceous 
cyst. 

D  W 


674  SWELLING    OF    THE     FACE 

Inflammatory  Swellings. — Often  the  cause  is  obvious  :  for  instance,  a  boil,  carbuncle, 
or  siippidntiiig  icoKiifl :   or  tlie  '  blubber-lips  '  that  result  from  chronic  himphangitis. 

Erysipelas  is  prone  to  occur  on  the  face.  It  is  marked  by  a  vivid  red  oedematous 
swelling,  associated  with  fever.  The  redness  tends  to  spread,  the  edges  being  raised  and 
well  defined  from  the  healthy  skin.  The  oedema  may  be  continuous,  or  it  may  disappear 
in  one  place  and  re-appear  in  another.  In  the  very  severe  eases  the  fever  is  high,  rigors 
occur  (Fig.  245,  p.  568),  the  cuticle  may  be  raised  in  blebs,  and  sloughing  may  ensue. 

Alveolar  Abscess  and  Dental  Caries  are  fertile  sources  of  facial  swelling,  also  abscess  in 
the  nasal  sinuses.     (See  Swelling  of  the  Jaw,  p.  683.) 

Anthrax  chiefly  affects  operatives  in  wool  and  horse-hair  factories  and  workers  of  raw 
hides.  The  disease  is  characterized  by  the  formation  of  a  vesicle,  which  bursts,  forms  a 
scab,  and  then  becomes  surrounded  by  a  ring  of  vesicles,  and  around  this  is  an  area  of 
oedema.  The  diagnosis  is  made  by  the  microscope.  A  drop  of  fluid  from  one  of  the  vesicles 
contains  large,  square-ended,  Gram-staining  bacilli,  which  have  a  characteristic  growth 
on  culture  media. 

Vaccinia. — An  accidental  infection  about  the  face  may  be  mistaken  for  an  anthrax 
inistule.  If  iiKHiiry  into  the  attendant  circumstances  is  not  suiricient  to  exclude  the  graver 
disorder,  a  bactevicilogical  examination  should  be  made. 

Primarij  Sjipldlitii  Sore,  if  found  on  the  face  (Fig.  23,  p.  73).  is  generally  situated  on 
the  u]3per  lip.  It  is  not  so  indurated  as  when  on  the  glans  jjenis,  but  the  surrounding 
oedema  is  more  marked,  and  the  neighbouring  lymphatic  glands  are  considerably  enlarged. 
The  condition  is  often  missed  because  it  is  not  expected.  An  absolute  diagnosis  can  be 
made  by  finding  the  spirochaHa;  in  the  serum  discharged  from  the  ulcer  (Plate  XXVIII. 
Fig.  .7.  p.  614),  and  by  Wassermann's  test. 

Insect  Biles — from  mosquitos.  gnats,  bees,  etc. — often  cause  large,  lumpy,  irritating 
swellings.  The  only  difficulty  in  diagnosis  is  when  they  become  infected  with  pyogenic 
organisms. 

The  various  skin  diseases  which  may  be  associated  with  swelling  of  the  face  are  con- 
sidered under  PrsTii.KS  (p.  557);    Vksicles  (p.  753):    AViir.ALS  (p.  771);    Etc. 

George  K.  (Sdsk. 

SWELLING,  FEMORAL.~By  the  femoral  region  is  meant  Scarpa's  triangle.  It 
is  very  easy  to  define  on  pajjer  what  is  a  femoral  swelling,  but  in  a  fat  patient  it  may  be 
very  difficult.  The  two  great  landmarks  which,  with  care,  can  always  be  made  out,  how 
ever  fat  the  patient,  are  the  spine  of  the  pubes  and  the  anterior  superior  .spine  of  the  ilium  ; 
a  line  joining  these  two  points  and  curving  slightly  downwards  separates  the  inguinal  from 
the  femoral  region,  and  indicates  Pouparfs  ligament.  Mistakes  are  often  made,  especially 
in  fat  people,  because  a  horizontal  crease  in  the  thigh  which  lies  below — sometimes  as  much 
as  two  inches  below — is  mistaken  for  the  ligament.  The  first  point  in  making  the  diagnosis 
is  to  decide  definitely  that  the  swelling  is  femoral,  and  then  to  decide  its  nature. 

It  may  be  obvious  at  once  what  the  swelling  is  :  for  instance,  a  well-marked  acute 
abscess,  with  redness  and  oedema  of  the  skin  and  an  undoubted  source  of  infection,  such 
as  a  .sore  toe  ;  or,  a  rare  occurrence,  an  aneurysm  of  the  femoral  artery,  showing  expansile 
pulsation.  Supposing,  however,  the  signs  are  not  so  clear,  the  various  conditions  may  be 
classed  broadly  under  two  heads  :  (1)  Swellings  that  are  reducible  and  give  an  impulse  on 
coughing  ;    (2)  S-aellings  that  are  irreducible  and  do  not  give  an  impulse  on  coughing. 

Reducible  Swellings  with  an  Impulse  are  :  (a)  Femoral  hernia — reducible  ; 
(h)  .Sa])hen.i  varix  :  (c)  Psoas  abscess.  All  these  give  an  ini])ulse  on  coughing  ;  are,  or  may 
be,  reducible  on  pressure  ;  may  disajipear  on  lying  down  and  reappear  on  standing.  How 
then  is  one  to  distinguish  between  them  V 

(a).  Femoral  Hernia  (reducible). — The  sex  of  the  patient  is  no  real  guide,  for  though  it 
is  more  common  to  find  a  femoral  hernia  in  a  woman  than  in  a  man,  this  is  not  sufficient 
to  base  the  diagnosis  on.  Before  puberty  it  is  rare  in  either  sex.  A  femoral  hernia  leaves 
the  abdomen  through  the  femoral  canal  and  turns  directly  forward,  forming  a  tumour  in 
the  uj)])er  and  inner  part  of  the  femoral  region  ;  then,  following  the  line  of  least  resistance, 
it  turns  upwards,  extending  often  above  Pouparfs  ligament,  thus  simulating  an  inguinal 
hernia.  More  rarely,  the  hernia  extends  downwards  along  the  femoral  vessels.  Its  course 
must  be  remembered  in  attempting  to  discover  whether  the  swelling  is  reducible.  If  it 
is  large  and  contains  intestine  it  will  be  resonant,  and  a  gurgling  mav  be  heard  or  felt  on 


SWELLING.     FEMORAL  67r> 

reduction,  distinguishing  it  at  once  from  all  otlier  femoral  swellings.  If  it  is  reduced  and 
the  finger  held  o\er  the  femoral  aperture,  the  hernia  will  be  felt  projected  forcibly  against 
the  finger  when  the  jiatient  is  asked  to  cough.  If  a  swelling  is  complained  of,  and  none  is 
found  even  on  standing  and  straining,  it  is  suggestive  of  femoral  hernia  with  only  occasional 
descent,  and  tlie  patient  should  be  examined  at  another  time  after  exercise. 

(b).  Snpliciiii  f'firi.r  is  a  localized  dilatation  of  the  saphenous  vein  at  the  saphenous 
opening,  immediately  before  it  joins  the  femoral  vein.  It  may  easily  be  confounded  with 
a  femoral  hernia,  for  it  forms  a  swelling  in  the  ordinary  position  of  a  femoral  heriiia,  it 
disajjpears  on  lying  down,  reappears  on  standing,  and  gives  an  impulse  on  coughing.  A 
little  care,  however,  should  suffice  to  distinguish  the  two.  The  impulse  is  quite  different — 
in  a  saphena  varix  it  is  more  in  the  nature  of  a  thrill,  such  as  may  be  felt  in  a  varicocele 
or  in  big  varicose  veins  in  the  leg.  If,  while  the  patient  is  standing,  a  finger  is  pressed  on 
the  swelling,  it  collapses  gradually,  and  as  the  finger  is  withdrawn  the  swelling  follows, 
regaining  its  shape  like  an  air-ball,  whereas  a  hernia  comes  out  with  a  pop.  .A  saphena 
varix  is  almost  always  associated  with  varicose  veins  in  the  leg.  though,  owing  to  the 
persistence  of  valves,  none  may  show  between  the  knee  and  Scarpa's  triangle. 

(c).  Psoas  .Ihscess. — The  need  to  differentiate  between  this  and  the  two  conditions 
mentioned  above  exists  only  when  the  abscess  has  extended  from  the  iliac  region,  has 
passed  under  Pouparfs  ligament  and  the  femoral  vessels,  and  is  pointing  in  the  inner  part 
of  Scarpa's  triangle.  There  is  an  impulse  on  coughing  and  the  swelling  is  reducible  :  but 
another  swelling  is  to  be  found  above  Poupart's  ligament,  and  fiuctuation  is  to  be  obtained 
between  the  two.  Conclusive  proof  can  be  found  by  an  examination  of  the  back.  This 
.should  be  made  with  the  patient  standing  and  the  whole  length  of  the  back  and  the  hips 
exposed.  .\n  undoubted  angular  kyi)hotic  curve  may  be  seen  at  once,  or,  if  that  is  not 
j)resent,  there  may  be  rigidity  and  impaired  movement  denoting  some  disease  on  the 
anterior  surfaces  of  the  bodies  of  the  vertebra?. 

Irreducible  Swellings  without  Impulse  :^  (a)  Femoral  hernia — irreducible  :  (h)  Lym- 
phatic glands  inllammafory  or  malignant:  (c)  Primary  tuinours  —  lipoma,  fibroma, 
sarcoma  ;    {il)  Kelopic  testis. 

(a).  Femoral  Hernia. — The  irreducibility  may  be  accounted  for  in  lour  ways  : 
(i)  Strangulation  ;  (ii)  \  |)iece  of  omentinn  adherent  to  and  plugging  the  neck  :  (iii)  .\n 
empty  sac,  but  a  mass  of  extra|)erit"neal  fat  ro\md  it  ;    (i\)  A  hydrocele  of  the  sac. 

If  strangulation  has  occurred  there  will  be  the  signs  of  intestinal  obstruction,  viz., 
vomiting  and  constipation.  It  must  be  remembered  that  the  swelling  may  be  but  a  small 
one,  and  when  the  patient  is  very  fat  it  may  be  missed. 

It  is  usual  to  find  an)Uii(l  the  sac  of  a  femoral  hernia  a  quantity  of  extraperitoneal  fat, 
even  in  a  thhi  person,  anil  it  is  quite  imi)ossible  to  sa\-  without  dissection  whether  the 
swelling  is  due  to  a  plug  of  omentum  inside  the  sac  or  to  a  collection  of  fat  outside  it. 

\  hydrocele  may  be  formed  as  a  result  of  a  long-standing  hernia  into  which  there  has 
been  no  descent  of  bowel  or  omentum,  and  in  which  the  communication  with  the  general 
peritoneal  cavity  has  become  constricted  or  closed.  The  sac  may  then  become  cystic  and 
filled  with  lluid.  The  feeling  of  Ihictuation  may  be  obtained  in  the  swelling,  though  it  is 
often  only  oti  dissection  that  the  exact  nature  of  the  condition  is  revealed.  It  is  to  be 
noted  that  in  all  cases  of  hernia  the  swelling  is  single,  and  that  though  it  may  be 
movable  in  some  tlirections.  it  is  always  tied  down  by  its  neck  to  the  aperture  of  the 
femoral  canal. 

{!)).    Kiilarilrd  (ilaiiils  may  be  :    (i)  liillarninalory  :    (ii)  .Malignant  (see   |).  liHl). 

(hronieally  iiillamcd  glands  may  be  hard  to  dincrentinte  from  a  small  irrcilueible 
femoral  hernia.  The  wlmlc  liinb  is  to  be  examined  to  sec  whether  there  is  any  possible  soinec 
of  infection,  and  the  whole  patient  to  see  whether  there  is  a  general  enlargement  of  the 
glands,  as  In  lymphadenoma.  The  chief  (listlnguishing  feature  between  the  two  conditions 
is  that  femoral  hernia  forms  only  one  swelling,  whilst  it  Is  very  rare  for  only  one  gland  in  its 
group  to  be  picked  out  by  an  infei-ting  agent,  and  not  the  others.  Thererore,  if  there  is 
more  than  one  swelling  the  chances  are  that  these  are  glands.  I'erehanei'  both  conditions 
are  present,  a  femoral  hernia  and  enlarged  glands  :  a  \-ery  dillieult  combination  unU'ss  the 
femoral  hernia  happens  to  be  reducible  or  gives  an  impulse  on  eoiigliiiig.  In  such  a  case 
an  attempt  should  be  ma<le  to  feel  the  neck  of  the  smc  running  up  to  the  femoral  <'anal. 

((■).    I'riiiKirii  .Vr;e  (Inmllis  are   ran-   in   llii--  silualimi.      Tlicy   may   be   lipmua.   fibroma. 


676  SWELLING,     FEMORAL 

or  sarcoma.     Tlie  innocent  tumours  are  noted  for  their  free  mobility  in  all  directions.     A 
primary  sarcoma  is  diagnosed  rather  by  exclusion  and  by  its  malignant  characteristics. 

(rf).  Ectopic  Testis. — One  of  the  places  into  which  a  testis  may  be  drawn  abnormally 
is  Scarpa's  triangle,  which  it  reaches  by  passing  over  Pouparfs  ligament.  The  facts  that 
the  swelling  has  the  shape  of  the  testis,  though  generally  smaller  than  normal,  and  that  the 
corresponding  half  of  the  scrotum  is  empty,  make  the  diagnosis  easy. 

Mention  may  be  made  here  of  those  swellings  which  are  neither  truly  femoral  nor  truly 
inguinal,  but  betwixt  and  between,  and  bulge  Pouparfs  ligament  forwards.  They  are 
generally  deep,  and  on  that  account  obscure.     They  may  be  due  to  : — 

1.  Distention  of  the  hip-joint,  as  in  tuberculous  disease  of  the  hip. 

2.  Distention  of  the  bursa  between  the  tendon  of  the  ilio-psoas  muscle  and  the  capsule 
of  the  hip-joint.  If  large,  the  swelling  may  be  quadrilateral  in  shape,  and  owing  to  its 
sensitiveness  to  pressure  the  leg  is  kept  in  the  position  of  greatest  ease,  i.e.,  slightly  flexed, 
abducted,  and  externally  rotated.  It  is  often  dilficult  to  distinguish  from  psoas  abscess 
or  from  distention  of  the  hip-joint,  with  which,  indeed,  it  often  communicates.  Diagnosis 
may  be  aided  by  puncturing  the  swelling  with  an  aspirating  needle. 

3.  Osteo])hytic  outgrowths  from  the  acetabulum  in  osteo-arthritis  of  the  hip-joint. 

4.  A  parametric  abscess.  George  E.  Gosk. 

SWELLING  IN  THE  ILIAC  FOSSA  (LEFT).~For  the  general  method  of  examina- 
tion, com])are  Swei.lini;  in  tiik  Ii.iac  Fossa  (Uiciit). 

Swellings   connected   with   Structures    normally    present    in    the  Left    Iliac   Fossa. 

The  Sigtnoid  FIc.rin-c  cannot  be  felt  normally.  It  becomes  paljjable  as  a  cylindrical 
swelling  if  distended  with  f;eces  ;  or  if  it  is  thickened,  as  it  may  be  in  chronic  ulcerative 
colitis  or  congenital  dilatation  of  the  colon. 

Carcinoma  of  tlie  Sigmoid. — Next  to  the  rectum  the  sigmoid  colon  is  the  most  common 
seat  of  cancer  in  the  bowel.  If  of  the  scirrhous  or  ring  tyj^e  no  lump  may  be  felt,  and  the 
condition  may  not  be  discovered  until  intestinal  obstruction  has  supervened.  When  infil- 
trating the  bowel  widely,  and  especially  when  the  tumour  is  undergoing  colloid  degeneration, 
a  swelling  forms  which  is  most  evident  on  bimanual  examination  after  the  bowels  have 
been  well  cleared  by  enemata.  If  a  lump  can  be  felt  in  the  sigmoid  flexure  of  a  middle- 
aged  patient,  the  strong  probability  is  that  it  is  a  carcinoma,  and  whether  there  are  other 
clinical  signs  or  not,  the  diagnosis  should  be  made  sure  by  actual  inspection  of  the  swelling 
by  means  of  the  sigmoidoscope,  or  even  through  an  abdominal  incision.  It  may  be  simu- 
lated by  subacute  inflammatory  changes  aroimd  an  acquired  jiouch  or  diverticulum  of 
the  colon — diverliciilitis  ;  this  sometimes  subsides  by  itself,  and  the  course  of  the  case  serves 
to  exclude  carcinoma  ;  more  often  the  symptoms  call  for  operation,  and  the  diagnosis  is 
made  by  laparotomy. 

Enlarged  Lijmphalic  Glands. — The  glands  forming  a  chain  round  the  external  iliac 
vessels  may  be  swollen  as  the  result  of  pyogenic  infection,  which  has  spread  up  through 
the  femoral  lymjjhatics  or  from  secondary  deposit  of  some  malignant  growth  starting  either 
in  the  leg,  the  external  genitals,  or  the  pelvis.  The  enlargement  is  seldom  very  great  ; 
the  source  of  infection  is  usually  obvious. 

Aneurysm  of  the  External  Iliac  Artery  is  very  rare.  It  is  recognized  at  once  by  its 
expansile  pulsations. 

Swellings  connected  with  Structures  not  normally  present  in  the  Left  Iliac  Fossa. — 
These  may  be  :  Swellings  coming  down  from  above,  extending  upwards  from  the  pelvis, 
or  pushing  forward  from  behind. 

Sioellings  coming  doivnfrom  above. — The  Spleen,  if  much  enlarged,  may  reach  even  as  far 
as  the  left  iliac  fossa.  It  is  recognized  by  its  rounded  margin,  and  the  notch  on  the  inner 
edge.  (See  Spleen,  Enlargement  of  the,  p.  628.)  A  kidney,  if  freely  movable,  may  be 
displaced  as  far  as  the  pelvis  ;    on  rare  occasions  it  becomes  fixed  there  by  inflammation. 

For  swellings  extending  up  from  the  pelvis  and  those  pushing  up  from  behind,  see 
the  article  ouSwelling  in  the  Iliac  Fossa  (Right).  George  E.  Gnsh. 

SWELLING  IN  THE  ILIAC  FOSSA  (RIGHT).— It  is  not  always  easy  to  say  whether 
there  is  or  is  not  a  definite  swelling  in  the  right  iliac  fossa,  for  it  may  be  only  small  and 


SWELLING    IN    THE    RIGHT    ILIAC    FOSSA  677 

deep,  or  be  masked  by  abdominal  rigidity  or  fat.  In  all  cases  a  careful  inspection  of  the 
abdomen  is  first  to  be  made,  the  patient  lyin<>'  on  the  back  with  the  whf)le  of  the  abdomen 
and  the  lower  thorax  exposed.  Most  mistakes  result  from  want  of  a  complete  examination, 
which  cannot  be  made  through  a  tiny  gap  in  the  clothes.  Before  even  touching  the 
abdomen,  much  may  be  made  out  by  the  use  of  the  eyes,  and  the  points  to  observe  are  : 
(1)  The  presence  or  absence  of  an  obvious  tumour  ;  (2)  Whether  the  abdominal  muscles 
move  freely  ;  (3)  The  conformation,  etc.,  of  the  tumour,  should  one  be  present,  and 
whether  it  moves  on  respiration. 

Palpation  is  then  to  be  employed,  and  this  method  will  go  a  long  way  to  elucidate 
the  complaint,  for  it  will  be  recognized  at  once  whether  there  is  a  well-defined  swelling, 
such  as  a  carcinoma  of  the  ca?cuni  ;  or  an  indefinite  swelling,  such  as  is  common  in 
appendicitis.  Distention  with  wind  or  an  accumulation  of  fajces  may  cause  a  considerable 
swelling,  but  any  doubt  as  to  these  may  be  cleared  up  by  administering  an  enema.  If 
the  swelling  persists,  the  questions  that  arise  are  :  is  it  connected  with  one  of  the  structures 
normally  present  in  the  right  iliac  fossa,  especially  the  ca-cum  or  the  appendix  ;  is  it  springing 
from  the  bone  ;  is  it  arising  from  some  organ  invading  this  space,  for  instance  tlie  uterus 
or  its  appendages,  the  right  ovary,  or  the  bladder  ;  or  from  some  structure  displaced  down- 
wards such  as  the  gall-bladder,  stomach,  or  right  kidney  ? 

A. — Swellings    Connected    with    Strltctures    Xor.mai.i.y    Present 
IN  THE  Right  Ili.vc  Foss.\. 

The  Appendix. — Appendicitis  is  so  common  that  it  is  put  first.  Most  well-marked 
attacks  of  appendicitis  are  associated  at  some  period  with  a  swelling,  though  in  the  acutest 
and  gravest  forms  the  latter  may  be  absent.  The  appendix  itself,  even  if  swollen  and 
thickened,  can  rarely  be  felt  by  palpating  the  abdomen,  and  the  swelling  is  due  to  paralytic 
distention  of  the  ca-cum,  local  oedema,  or  the  formation  of  an  abscess.  The  chief  indications 
of  appendicitis  are  :  pain,  tenderness,  local  rigidity,  and  swelling  in  the  right  iliac  fossa, 
associated  with  a  furred  tongue,  vomiting,  constipation,  an  increase  of  the  pulse-rate,  and 
a  rise  of  temperature.  Usually  there  is  also  diminished  muscular  movement  in  the  lower 
part,  or  it  may  be  over  the  whole,  of  the  abdomen.  Any  movement  is  painful,  and  in  order 
to  relax  the  tension  the  patient  lies  with  the  right  leg  drawn  up.  A  rectal  examination 
should  be  made,  for  a  bulging  abscess  may  be  felt  by  this  route.  Micturition  is  frc(iuently 
abnormal,  with  a  tendency  to  be  cither  ])ainfid  or  unduly  fre([uent.  .V  leucocyte  count 
is  of  great  service,  for  in  almf)st  every  case  of  acute  appendicitis  the  numbei-  of  white  cells 
is  increased. 

Tuberculosis  of  the  Caecum  or  of  the  Lymphatic  Glands  in  the  neighbourhood  of 
the  Caecum.  This  is  not  nearly  so  common  as  appendicitis,  l)ut  is  not  sii  rare  as  is  often 
imagined,  and  when  it  does  occur  it  is  fre<|uently  mistaken  for  appendicitis  :  it  may  be 
ordy  after  the  abdomen  has  been  o|)eiicd  that  the  mistake  is  discovered.  The  glands 
become  cidargcrl  and  painful,  and  there  may  be  some  local  peritonitis  over  them  which 
makes  the  diagnosis  very  dillicult.  I'sually  there  is  some  other  tuberculous  focus  about 
the  patient,  especially  in  the  lungs,  which  should  be  examined  with  ixirtieular  care,  the 
j-rays  and  sputum  analysis  not  beiir^  omitted.  If  doubt  exists  reeoui'se  may  be  hiid  to  a 
diagnostic  injection  of  Koch's  old  tuben'ulin,  and  the  opsonic  index  may  be  taken  both 
before  and  after  abdominal  massage.      \'on  I'irqucfs  test  is  not  very  trustworthy. 

Actinomycosis  starting  in  the  ea-cum  and  appendix  is  another  inflammatory  condition 
which  niiiN  cuiisc  a  swelling  and  give  the  signs  of  a  chronic  abscess.  The  diagnosis  can 
only  be  made  with  ccrlainlx  by  an  incision  and  the  finding  in  the  pus  of  the  characteristic 
yellowish  granides  (oce-isiunilly  black  -the  gunpowder  variety),  and  the  recognition  under 
the  ini(  luMiipc  that  these  granules  are  formerl  of  a  CJnun-staining  streplothiix  (I'ldle 
.Willi    p.  (Ji  t). 

Carcinoma  of  the  Caecum  gives  rise  to  a  swiIIImli  wliieli  (Heasiims  lew  symptoms, 
uidess  the  passage  of  I'a'ces  is  allected  and  irilesliri.il  ulisl  ruclinri  results.  II  is  important, 
however,  from  the  point  of  \  iew  of  treatment  t  liat  an  e:ir  Iv  ill  igrinsis  lie  iiiide.  The  presence 
of  a  non-inllammatorv  swelling  of  long  standing  in  the  right  iliac  fossa,  with  a  history  of 
wasting,  is  very  suggestive  of  a  carcinoma,  and  early  recourse  should  be  had  to  the  only 
sure  diagnostic   metliorl.   namely,   laparotomy.      \'erv   rai'cly   is   there   passage  of  blood  or 

niUCIls    by    the    bowil    In    help   nlle. 


678  SWELLING     L\    THE    RIGHT    ILIAC    FOSSA 

Intussusception  usually  occurs  in  children,  especially  during  the  latter  half  of  the 
first  year  of  life,  and  its  presence  is  indicated  by  the  signs  of  intestinal  obstruction,  namely, 
vomiting  and  constipation,  and  by  the  passage  of  blood  and  mucus  by  the  rectum.  The 
intussuscepted  portion  may  be  palpable,  and  in  some  cases  it  lies  in  the  right  iliac  fossa, 
though  more  frequently  in  the  right  hypochondrium.  Chronic  intussusception  may  also 
cause  a  swelling  which  generally  baffles  diagnosis,  and  is  commonly  mistaken  for  an 
enlarged  kidney. 

Aneurysm  of  the  Iliac  Arteries  is  very  rare,  but  it  is  generally  easy  of  <liagnosis  by 
reason  of  the  expansile  ])ulsation  of  the  tumour. 

B. — Swellings  Connected  with  Structures  not  Normally  Present 
IN  THE  Right  Iliac  Fossa. 

These  may  be  :  Swellings  coming  down  from  above,  swellings  extending  upwards 
from  the  pelvis,  or  swellings  jsushing  forward  from  behind. 

Swellings  coming  down  from  above. 

Tlie  lircr.  or  an  enlarged  or  abnormal  lobe  of  the  liver — Riedel's  lobe  (p.  366) — is  some- 
times very  deceptive.  The  facts  that  there  are  few  symptoms,  that  the  mass  moves  on 
respiration  and  is  continuous  with  the  liver,  and  that  there  is  no  intervening  area  of 
resonance  between  it  and  the  liver,  should  assist  the  diagnosis  ;  but  cases  are  not 
infrequently  mistaken  for  enlargement  of  the  gall-bladder.  A  suppurating  gall-bladder 
has  been  opened  in  the  right  iliac  fossa  under  the  mistaken  diagnosis  of  appendix  abscess, 
for  there  is  often  no  jaundice  in  these  cases.  Laparotomy  may  be  the  only  means  of 
certain  diagnosis. 

The  kidney,  if  unduly  movable,  may  be  displaced  and  come  to  lie  in  the  right  iliac 
fossa.  It  is  recognized  by  its  shape  and  free  mobility.  A  tumour  of  the  kidney  or  a  large 
hydro-  or  pyo-nephrosis  may  also  invade  the  upper  part  of  this  fossa. 

Carcinoma  of  the  Sto7nach — with  extreme  distention  of  the  stomach.  It  is  a  surprising 
fact  that  the  stomach  may  be  so  distended  as  to  enable  the  jjylorus  to  lie  in  the  right  iliac 
fossa.  The  history  of  copious  \(imiting.  the  wasting,  the  distention  of  the  stomach,  and 
examination  with  the  .i-rays  alter  the  administration  of  bismuth  make  the  diagnosis  easy. 

Swellings  extending  upwards  from  the  Pelvis — and  attached  to  the  uterus  and 
its  appendages,  can  usually  be  felt  dipping  into  the  pelvis  ;  vaginal  and  rectal  examinations 
Avill  assist  the  diagnosis  :  and  there  are  symptoms,  such  as  disturbances  of  menstruation, 
indicating  their  nature.  Such  swellings  might  be  a  large  fibroid  of  the  uterus,  a  laterally- 
placed  ovarian  cyst,  pregnancy,  an  abscess  extending  from  the  broad  ligament,  or  a  pouch 
of  a  bladder  distended  from  obstruction  to  the  urethra. 

It  happens  not  infrequently  that  there  may  l)e  difficulty  in  determining  between  an 
inflamed  appendix  and  an  enlarged  and  tender  ovary,  particularly  when  the  attacks  of 
pain  are  coincident  with  the  men.strual  periods.  These  generally  turn  out  to  be  due  to  the 
appendix,  though  both  may  be  implicated,  the  appendix  having  become  adherent  to  the 
ovary  or  tube. 

Pyosalpin.r  is  easily  confused  with  appendix  abscess  ;  the  fact  that  it  is  associated 
with  vaginal  discharge,  or  is  subsequent  to  parturition,  puts  one  on  the  right  track. 
Vaginal  cxainination  is  essential  in  these  cases. 

Swellings  pushing  forward  from  behind. 

These  may  be  solid,  such  as  sarcoma  or  chondroma  of  the  pelvic  bones.  Here  the  tumour 
will  be  immovable  apart  from  the  pelvis,  and  a  skiagram  makes  the  condition  clear.  If 
the  swelling  is  fluid  it  may  depend  on  suppurative  osteomyelitis  of  the  ilium  :  or  on  a  tuber- 
culous affection  of  the  ilium,  either  primary,  or  secondary  to  hip  or  sacro-iliac  joint  disease  ; 
or  on  tuberculosis,  itecrosis  or  suppuration  of  the  lumbar  vertebrir. 

If  the  swelling  cannot  be  attributed  to  any  of  the  causes  mentioned  above,  it  is  to  be 
remembered  that  a  wandering  organ,  such  as  a  spleen  or  kidney,  may  find  its  way  into  the 
right  iliac  fossa.  Rarities  such  as  hydatid  cysts  of  the  peritoneal  cavity  are  met  with  so 
seldom  that  they  merit  no  more  than  mention.  Gcorxc  E.  Gask. 

SWELLING,  INGUINAL. — A  variety  of  swellings  may  appear  in  the  groin,  and  be 
very  dillieult  to  ditferentiate.  The  following  are  some  of  the  most  important  : — 
(1)   Enlarged  glands  :    (a)  inguinal  ;    {b)  femoral  :    (c)   iliac.      (2)  Abscess,  acute  or  chronic. 


SWELLING.     INGUINAL  679 

(3)  Hernia  :  (a)  iniiiiinal  :  (b)  femoral  ;  (c)  obturator.  (4)  Retained  testicle.  (5)  Hydrocele. 
(6)  Tunidurs  of  the  cord  or  round  ligament.  (7)  Aneurysm  and  other  vascular  sicellings. 
(8)  A'fiC  groicths.     (!))  Distended  psoas  bursa  and  other  cysts. 

1.  Enlarged  Glands. — There  are  two  chief  groups  of  glands  in  the  groin.  The  most 
commonly  affected  are  the  inguinal,  which  lie  in  the  subcutaneous  tissues  about  Pouparfs 
ligament,  and  drain  the  external  genitals,  the  anus,  the  umbilicus,  the  lower  parts  of  the 
abdomen  and  back,  the  buttock  and  the  u])per  third  of  the  thigh.  The  femoral  glands 
rest  below  the  saphenous  opening  and  drain  the  lower  limb  below  the  upper  third  of  the 
thigh.  It  must  be  remembered,  however,  that  the  lymphatic  drainage  is  somewhat  erratic, 
so  that  a  sore  toe  may  sometimes  induce  enlargement  of  an  inguinal  gland  only.  The  iliac 
glands  drain  the  inguinal  and  femoral  set,  and  consequently  often  enlarge  secondarily  to 
these  ;  but  they  also  communicate  freely  with  the  abdiiminal  lymphatics  and  may  become 
infected  from  them. 

Enlarged  glands  in  the  groin  are  nearly  always  nniltiple.  and  usually  subcutaneous, 
so  that  they  are  easy  to  recognize  as  glands  ;  but  a  solitary  one  adherent  to  the  saphenous 
opening  may  be  almost  impossible  to  distinguish  from  an  irreducible  omental  femoral  hernia 
or  a  hydrocele  of  a  hernia  sac. 

The  iliac  glands  just  above  Poupart's  ligament  are  more  difficult  to  jjalpate.  because 
they  lie  deep  to  the  abdominal  muscles,  but  their  enlargement  is  generally  secondary  to 
disease  of  the  superficial  glands,  and  this  often  gives  the  key  to  the  diagnosis  of  an  obscure 
.swelling  in  this  region. 

Some  Causes  of  Enlargement  of  t)ie  Groin  Glands. — (a)  Mechanical  or  chemical  irritation  : 
{b)  Septic  infection,  for  instance  from  genital  sores  or  from  sores  on  the  toes  or  legs  ;  (c) 
Tubercle  :  (d)  Syphilis  ;  {e)  Other  specific  diseases,  such  as  rubella  and  bubonic  plague  ; 
if)  Lymphadenoma  ;  (g)  Lymphatic  leukaemia  ;  (/;)  Malignant  diseases  :  secondary 
carcinoma  :    secondary  or  primary  sarcoma. 

(a).  The  glands  become  slightly  enlarged  and  tender  as  a  result  of  the  mcchanicid 
irritation  of  a  truss,  and  more  frequently  the  bites  of  parasites  such  as  the  Pediculus  pubis. 
The  glands  generally  remain  movable,  and  they  rarely  suppurate. 

(/;).  Septic  infection  may  follow  insect  bites  ;  but  more  commonly  a  septic  sore  or 
recent  scar  can  be  discovered  upon  examination  of  the  area  drained  by  the  glands.  Septic 
glands  either  soon  subside  or  cease  to  be  tender  after  the  removal  of  the  .source  of  infection, 
or  they  enlarge  rapidly,  become  adherent,  and  suppurate  within  three  or  four  weeks  of 
their  lirst  ciilargciiKiil . 

(().  This,  and  the  arnciunt  of  inllannnation  of  tlic  sUiii  <i\cr  tlu'iii,  distinguishes  septic 
fnim  tulicrculoHs  glands  uhicli  do  not  suppurate  for  some  iiionlhs.  and  then  with  but  little 
iiillammatory  reaction.      I^pitlielioinatous  glands  may  suppurate  towards  the  end. 

(d).  The  true  syphilitic  gland  is  hard,  movable,  and  only  moderately  enlarged,  and  the 
existence  of  the  induratcfl  chancre  usually  makes  the  diagnosis  easy.  The  Spirochceta 
pallida  may  be  detected,  or  Wasscrmann's  serum  test  may  be  ])()sitive  ;  but  a  negative 
reaction  is  not  conclusive.  It  must  not  be  forgotten  that,  as  an  apparently  soft  sore  (se]>tic) 
may  later  become  hard  and  dcliiiilely  sy]>hilitic.  therefore  suppuration  of  a  bulxi  does  not 
disprove  syphilitic  iiifeclion.  Instances  of  mixed  infection  by  sepsis  and  syphilis  are  fairly 
('(itiiijion.  ' 

(  f  ).  Ill  li/ni/ihiKliiKiiiKi  Ihc  yniiii  glands  arc  rMicl\'  all'cclcd  alone,  and  the  smooth,  soft 
enlargciiu  lit  nl  iiriiiy  i;laiiils  willioiil  signs  of  iiillainiiiat  ion.  associated  with  increasing 
ana-iiiia  and  intcrniiltent  pyrexia  (Fig.  21-7.  p.  .")7()).  iiiiikes  the  diagnosis  fairly  easy. 
The   spleen    may    be   aft'ecled  at   the  same  titiie. 

ig).  Hlood  I'xaiiiinatinii  will  gi\c  patliogiioniiniic  iiMilts  in  cases  of  lynipliatic 
Icuka'mia  (p.  2.')). 

(/().  Malignant  disease  of  the  groin  glands  is  nearly  always  epitlieliomatous.  and 
secondary  to  a  primary  epithelioma  of  the  skin  or  mucous  membrane  in  the  area  drained 
by  tlic>  glanils.  The  primary  growth,  especially  at  the  amis,  may  be  very  small,  and  the 
patient  may  be  unaware  of  its  existence.  The  other  main  points  in  distinguishing  cpitlu'li- 
omatous  glands  are  their  exceeding  hardness  ;  their  progressive  but  slow  growth  ;  their 
earlv  adhesion  to  the  deep  fascia  and  skin  :  and  the  amount  of  pain  to  which  they  give 
rise  without  signs  of  inllanimation.  I.ali-  in  tin-  disease  they  may  suppurate  or  slough, 
with  severe  hicinorrhagc.  Intra-abdoniinal  J'arciiionia,  espeiially  nf  the  ovary  or  colon, 
sMinctimes  causes  enlargement  of  the  inguinal  glands. 


680  SWELLING,     INGUINAL 

Sarcoma  of  the  ">roin  glands  is  rare  ;  it  may  be  primary  or  secondary.  Usually  these 
are  not  the  only  glands  affected.  They  grow  with  great  rajjidity  and  remain  smooth  and 
fairly  soft  >intil  they  attain  a  great  size,  when  they  may  fungate  through  the  skin.  They 
are  distinguished  from  lymphadenonia  by  their  very  rajjid  growth  and  the  absence  of  pallor 
until  late  in  the  disease.  Melanotic  growths  of  the  skin  give  rise  to  rapidly  growing  smooth 
glands,  whose  pigment  may  be  visible  through  the  skin.  The  primary  growth  or  ulceration 
in  connection  witli  the  skin,  particularly  of  a  toe,  may  not  show  pigmentation,  and  its  serious 
import  may  thus  be  overlooked. 

2.  Abscess. —  (a).  Acute.  The  only  common  cause  of  acute  abscess  in  the  groin  is 
suppuration  of  the  glands,  and  a  search  must  always  be  made  for  a  ]]rimary  source  of  infection, 
especially  about  the  genitals.  A  hernia  may  occasionally  suppurate,  and  an  appenili  alar 
abscess  may  point  just  above  Poupart's  ligament  ;  but  there  is  then  a  history  of  the  charac- 
teristic syinptoms  of  appendicitis,  and  the  pus  when  released  has  the  suggestive  smell  of 
the  products  of  the  Bacilhis  colt  cnniniiniis.  Both  tuberculous  and  epitlicliomntous  glands 
may  become  acutely  inflamed  and  su|>purate. 

(h).  Chrome  obseess  here  may  be  due  to  caries  of  the  sacro-iliac  joint  or  to  hip  disease, 
or  it  may  arise  from  tubercidosis  of  the  superficial  or  dee|3  glands.  Psoas  abscess,  due  to 
caries  of  the  spine,  is  distinguished  by  fluctuation  from  the  loin  to  the  groin,  and  often 
bimanually,  above  and  below  Poujiart's  ligament,  external  to  the  femoral  ^•essels.  There 
are  also  some  tenderness  and  rigidity,  and  often  deformity  of  the  lumbar  or  lumbo-dorsal 
spine.  Iliac  abscess  does  not  extend  up  into  the  loin,  and  is  placed  farther  out  than  psoas 
abscess.  Moreover,  there  may  be  pain  and  tenderness  over  the  sacro-iliac  joint,  and  a 
limping  gait.  In  hip  disease,  especially  in  children,  the  floor  of  the  acetabulum  may  give 
way,  and  an  abscess  may  thus  enter  the  true  pelvis,  whence  it  often  ascends  and  becomes 
palpable  above  Poupart's  ligament.  The  diagnosis  of  the  cause  is  easy  from  the  well- 
marked  signs  of  hip  disease. 

3.  Hernia. — In  examining  swellings  in  the  groin,  hernia  must  always  be  considered. 
Three  chief  varieties  occur  here  :  inguinal,  femoral,  and  very  rarely  obturator  hernia.  A 
hernia  gives  an  impulse  on  coughing,  but  so  do  psoas  abscess,  psoas  bursa,  and  a  saphena 
varix.  All  these  may  also  be  reducible  like  a  hernia.  A  jjsoas  abscess  presenting  below 
Poupart's  ligament  has  been  mistaken  for  a  femoral  hernia  ;  but  it  is  distinguished  by 
its  position — external  instead  of  internal  to  the  femoral  vessels.  Moreover,  it  is  dull  on 
percussion,  whereas  a  hernia  is  resonant  except  when  it  contains  omentum  alone.  Psoas 
bursa  is  also  ])laced  outside  the  vessels.  A  saphena  varix  has  often  been  mistaken  for 
femoral  hernia  ;  but  it  can  be  distinguished  from  the  latter  easily  because  it  returns  after 
complete  reduction,  even  though  the  finger  is  kejat  pressed  against  the  femoral  canal.  It 
is  not  always  easy  to  distinguish  the  three  herni;e  which  occur  in  the  groin,  but  close  atten- 
tion to  the  following  points  usually  leads  to  a  correct  diagnosis.  An  inguinal  hernia  is 
both  seen  and  felt  to  be  nbovc  the  fold  of  the  groin  and  abcwe  Poupart's  ligament  ;  whereas 
a  femoral  hernia  is  seen  and  felt  to  be  belozv  the  fold  of  the  groin  and  beloiv  Poupart's 
ligament.  It  is  to  be  remembered  that  when  a  femoral  hernia  becomes  very  large  and 
loculated,  it  generally  extends  upwards  and  inwards  over  Pou]>art's  ligament.  Still,  the 
bulk  of  it  remains  below  the  fold  of  the  groin  in  the  upper  and  inner  part  of  the  thigh.  An 
inguinal  hernia  often  extends  into  the  scrotimi  or  labium  :  a  femoral  hernia  never  does 
this.  The  neck  of  an  inguino-scrotal  hernia  is  above  and  internal  to  the  spine  of  the 
pubis,  whereas  the  neck  of  a  femoral  hernia  is  below  and  external  to  this  bony  prominence. 
Inguinal  hernia  is  most  easily  reduced  by  pressure  directed  upwards,  backwards,  and 
outwards,  whereas  a  large  femoral  hernia  is  most  easily  reduced  by  jjressure  directed  at 
first  backwards  and  downwards,  and  then  directly  upwards.  In  didicult  cases  it  is  a 
good  plan  to  reduce  the  hernia,  then  to  get  the  patient  to  stand  up,  while  the  surgeon 
makes  firm  pressure  over  the  internal  ring  and  asks  the  jjatient  to  cough.  A  femoral 
hernia  inay  then  come  down,  but  not  an  inguinal.  Similarly,  pressm'c  can  be  made  on 
the  femoral  canal  ;  this  prevents  the  descent  of  a  femoral  hernia,  so  that  if  the  swelling 
now  returns  it  is  inguinal.  In  this  connection  it  may  be  well  to  remember  that  femoral 
hernia  is  rare  in  males,  and  also  in  all  females  under  maturity.  The  prevalent  belief  that 
femoral  hernia  is  more  common  than  inguinal  in  grown-up  women  is  wrong,  inguinal  being 
more  common  at  all  ages  and  in  both  sexes.  It  is  excessively  difficult  to  differentiate 
between  an  irreducible  femoral  hernia  containing  omentum  and  an  enlarged  gland  at  the 


SWELLING.     LXGUINAL  681 

saphenous  opening  or  in  the  femoral  canal.  A  hydrocele  of  a  hernial  sac  gives  rise  to  the 
same  difficulty,  and  sometimes  an  exploration  hecomes  necessary  on  account  of  the  danger 
of  overlooking  femoral  hernia,  and  the  risk  of  strangulation. 

The  diagnosis  between  femoral  and  obturator  hernia  is  not  very  difficult  ;  it  is  far 
more  common  to  overlook  an  obturator  hernia  altogether.  When  an  external  swelling 
is  caused  by  an  obturator  hernia,  it  is  placed  farther  inwards,  and  it  is  more  vague  than 
a  femoral  hernia.  Moreover,  there  is  pain  shooting  along  the  inner  side  of  the  thigh,  and 
generally  the  signs  and  symptoms  of  .strangulation.  Further,  a  tender  swelling  can  be 
felt  at  the  obturator  foramen  upon  vaginal  or  rectal  examination. 

The  two  chief  varieties  of  inguinal  hernia,  the  oblique  and  the  direct,  are  usually 
distinguished  quite  easily.  Direct  hernia  is  rare,  and  is  more  globular  in  shape  than  the 
indirect  or  oblique  hernia  ;  the  spermatic  cord  is  antero-external  to  it,  and  ])ostero- 
int(Tn:il  to  the  ordinary  oblique  hernia.  Direct  hernia  is  placed  a  little  farther  in  and 
higher  up  than  the  oblique.  It  is  generally  much  more  easily  reduced,  but  returns  again 
with  striking  abruptness  when  the  patient  coughs.  It  rarely  travels  into  the  scrotum, 
and  it  is  uncommon  before  the  age  of  thirty.  There  is  often  a  history  of  sudden  onset 
after  some  violent  straining  effort. 

4.  Retained  Testicle. — The  most  important  ])()ints  in  the  diagnosis  of  this  condition 
are  the  absence  of  tlie  organ  from  its  jiroper  place,  and  the  presence  of  a  swelling  about 
the  inguinal  canal.  Occasionally,  the  testicle  may  be  maldcscended,  or  after  leaving  the 
external  ring  may  have  found  its  way  into  the  upper  and  inner  part  of  the  thigh,  where  it 
simulates  a  femoral  hernia,  or  into  the  perineum.  The  swelling  in  the  groin  may  give  the 
characteristic  testicular  sensation,  or  the  condition  may  be  associated  with  attacks  of 
pain  which  luivc  been  mistaken  for  appendicitis  or  intestinal  colic.  It  is  practically 
always  accompanied  by  actual  or  potential  hernia  into  the  tunica  vaginalis,  which  is  in 
direct  comnnmieation  with  the  abdominal  cavity. 

5.  Hydrocele. — The  neck  of  the  sac  of  either  a  femoral  or  an  inguinal  hernia  may 
becoine  obstructed,  and  a  hydrocele  of  the  .sac  may  then  develop.  This  may  become 
inflamed  and  give  rise  to  considerable  difliculty  in  diagnosis.  Strangulated  or  irreducible 
omental  hernia  may  be  simulated,  and  sometimes  an  exploration  is  the  only  way  of 
settling  the  rliagnosis.  It  is  more  easily  distinguished  from  strangulated  hernia  containing 
bowel,  because  it  is  dull  on  percussion,  and  the  bowels  are  not  obstructed.  .\n  encysted 
hydrocele  of  the  cord  occupying  the  inguinal  canal  is  sometimes  dilficult  to  distinguish 
from  inguinal  hernia  ;  but  it  is  not  completely  reducible,  and  it  is  dull  on  percussion.  It 
is  not  gramdar  like  an  omental  hernia,  and  it  can  even  be  shown,  with  some  dilliculty.  to 
be  tninsliiccnt.      Like  a  hernia,  it  gi\cs  an  inipnlsc  (in  coughing. 

•  i.  Tumours  of  the  Cord  or  Round  Ligament.  The  oidy  imnniDn  tumnuis  dl' 
these  stiMK-tuics  arc  {11}  l,i|i(Miia  and  (/;)  Fibromyorna  iif  the  round  ligament.  The 
former  is  so  sod  and  displncc  able  tliat  it  gives  an  nn|iulsc  on  coughing,  and  is 
often  mistaken  I'cii'  an  iimental  hernia,  especially  in  sldul  [iilienls.  The  latter  is  hard 
and  smooth,  snniiulial  simulating  the  (i\ary  nr  a  thick-walled  hydrocele  of  the  canal  of 
Nuck.  lor  cilJiir  (if  which  it  may  be  inislakcn.  i  certain  diagnosis  only  being  possible  by 
exploration. 

7.  Aneurysm  and  other  Vascular  Swellings.  .\n(  iir\srn  dl  the  external  iliac  artery 
may  be  mistaken  for  a  \-is<'ular  sarcoma  arising  i'nini  the  pclxis.  It  can  generally  be 
recognized  by  the  classical  signs  of  aneurysm,  sueli  as  expansile  pid.sation.  bruit,  weakening 
and  delay  of  the  corresponding  femoral  pulse,  and  marked  reduction  of  the  size  of  the 
swelling  as  a  result  of  pressure  on  llic  ((iiniiion  iliac  artery.  Saphenous  \arix  has  been 
referred  to  ab(i\c. 

H.  New  Growths.  Sarcoma  of  llic  pcKic  bones  or  of  llic  soft  parts  in  this  neigh- 
bourhood is  hardly  allcrcd  in  size  b\  pressure  upiiM  the  common  iliac  artery,  nor 
does  it  give  such  a  loud  bruit  or  llic  iw/iiiiisilc  pulsation,  which  arc  characteristic  ol 
aneurysm.  The  ,i'-rays  may  give  csidcnee  whicli  is  \Mliialilc  in  disi  iiii;uisliing  aneurysm 
rrorii  sarcoma. 

!t.  Distended  Psoas  Bursa  max  give  rise  to  pulsation  commimiealed  I'nim  the 
e\l(  rual  iliac  artery.  On  carelnl  cxaminalion  it  can  be  distinguished  by  the  absence  of 
the  classical  signs  of  anenrysm  already  nieni  ioncd,  li>  its  traiislueeney  and  irredncibility. 
Thci-e   may   also   lie  signs  of  osleo-arl  lirit  is  of  llic   lijp  joinl.  /,'    /'    lliwliiiiils. 


6.S2  SWELLING.     IXGUINO-SCROTAL 

SWELLING,  INGUINO-SCROTAL.— The  most  important  swelliiifis  which  occupy 
both  the  inguinal  and  scrotal  rejiions  are  : — (1)  Hernia  :  (2)  Varicocele  :  (3)  Xeiv  grozvth  ; 
(4)  Hi/droccle  :    (5)  Lympliaiigioma. 

Hernia  is  by  far  the  most  common,  and  when  it  is  reducible  there  is  very  little 
difficulty  in  the  diagnosis.  It  gives  the  characteristic  impulse  on  coughing,  is  resonant  on 
percussion,  and  when  it  contains  bowel  it  gurgles  on  reduction.  When  it  contains  omentum 
only,  the  diagnosis  is  more  difficult.  To  distinguish  it  from  a  varicocele  it  is  only  necessary 
to  reduce  the  swelling  and  then  to  place  the  finger  firmly  upon  the  inguinal  canal  :  a 
varicocele  returns  in  a  few  seconds,  but  a  hernia  does  not.  Moreover,  an  omental  hernia 
has  a  granular  feel  which  distinguishes  it  from  varicocele.  An  irreducible  omental  hernia  is 
distinguished  from  varicocele  by  its  irreducibility  :  but  it  may  be  confused  with  a  very  rare 
condition,  lymphangioma  of  the  cord.  An  irreducible  hernia  may  be  confused  with  encysted 
hydrocele  of  the  cord.  When  a  liernia  contains  bowel  its  resonance  distinguishes  it  ;  but 
when  it  contains  omentimi  there  is  more  difficulty.  An  eneysled  hydrocele  or  a  itydrocele 
of  a  hernial  sac  is  more  even  and  elastic  than  an  omental  hernia,  which  is  usualh-  nodular. 
Moreover,  it  may  be  possible  to  show  that  a  hydrocele  is  translucent.  This  help  is  not 
available  when  the  cyst  is  deep  or  contains  blood,  which  it  occasionally  does  as  the  result 
of  injm'v  or  strangulation  of  the  omentum  at  the  neck  of  the  hernial  sac.  A  strangulated 
hernia  is  distinguished  from  an  inflamed  hydrocele  by  the  greater  severity  of  the  vomiting 
and  other  constitutional  symptoms,  and  the  completeness  of  constipation.  Moreover,  as 
stated  above,  a  strangulated  hernia  containing  bowel  is  resonant  on  percussion.  Strangu- 
lated omentum  may  be  very  difficult  to  distinguish  from  an  inflamed  hydrocele  or 
a  hydrocele  of  a  hernial  sac,  especially  as  either  of  these  may  complicate  it.  In  such  cases 
an  exploration  is  the  final  appeal.  It  should  not  be  forgotten  that  two  or  more  varieties 
of  inguino-scrotal  swellings  may  co-exist.  For  instance,  it  is  conunon  to  overlook  a  hernia 
which  may  complicate  a  varicocele,  and  this  is  especially  true  when  the  hernia  contains 
only  omentum.  Again,  it  is  quite  common  for  a  hydrocele  of  the  tunica  vaginalis  or  of 
the  lower  part  of  the  cord,  to  complicate  an  ordinary  omental  hernia.  In  such  a  case, 
a  part  of  the  swelling  may  be  reducible,  and.  imless  the  patient  is  examined  in  the  upright 
position,  the  upper  part  of  the  hernia  may  fail  to  appear  during  the  examination.  .Again, 
the  bowel  may  be  reducible,  while  the  omentum,  being  adherent,  is  not  reducible,  and 
may  be  mistaken  for  an  encysted  hydrocele  of  the  cord.  It  is  very  imi)ortant  in  all  these 
cases  to  examine  for  translucency. 

Growths  of  the  testicle  invading  the  inguinal  region  are,  as  a  rule,  easily  diagnosed, 
because  of  the  history  and  the  observed  course  of  the  disease,  and  the  general  condition 
of  the  patient  at  the  later  stages.  Groiclh  of  the  retained  testis  may  gi\e  rise  to  more 
difficulty  ;  it  may  be  confounded  at  first  with  hydrocele  of  the  tunica  vaginalis,  hydrocele 
of  the  hernial  .sac,  or  omental  hernia,  luiless  care  be  taken  to  ascertain  if  both  the  testicles 
arc  present  in  the  scrotum.  Torsion  of  a  retained  testicle  with  strangulation  of  its  vessels 
has  sometimes  given  rise  to  inguinal  or  inguino-scrotal  swelling  which  has  closely  simulated 
strangulated  hernia  :  but  although  there  may  be  much  abdominal  pain  and  local 
tenderness,  vomiting  is  rarely  so  severe  as  in  strangulated  hernia,  and  the  bowels  are  not 
really  obstructed.  Retained  testicle  is  dull  on  percussion,  and  thus  is  distinguished  from 
strangulated  hernia  containing  bowel,  and  can  only  be  confused  with  strangulation  of 
the  omentum. 

The  oblique  hernia  is  the  only  common  one  to  reach  the  scrotum.  It  may  be  acquired 
or  congenital.  In  about  one-tenth  of  the  congenital  herniae  the  bowel  and  the  testicle 
are  in  the  same  peritoneal  sac  ;  in  the  great  majority  of  congenital  herniae  the  two  sacs 
are  distinct,  the  testicle  lying  below  the  hernia.  The  same  is  true  of  acquired  inguinal 
hernia.  It  is  important  to  remember  that  nearly  all  inguinal  hernia?  descend  into 
congenital  or  pre-formed  sacs,  and  this  is  especially  true  of  herniae  appearing  apparently 
for  the  first  time  in  young  adults.  In  such  cases,  on  careful  inquiry,  it  may  be  found  that 
a  hernia  existed  and  was  apparently  cured  by  a  truss,  in  infancy,  .\gain,  it  may  be 
learned  that  the  hernia  reached  the  scrotum  on  its  first  descent,  whereas  aeciuired  inguinal 
hernia  very  gradually  develops  as  the  result  of  straining  in  men  past  middle  age.  The 
swelling  at  first  appears  only  in  the  inguinal  region,  and  there  the  swelling  increases  in 
size,  and  extends  into  the  scrotum  only  after  some  months  or  years.  Very  rarely,  a  direct 
hernia  may  reach  the  scrotum  ;    it  is  distinguished   from  oblique  hernia  by  the  fact  that 


SWELLING    OF    THE    LOWER    JAW  683 

the  cord  is  antero-external  to  it,  instead  of  postero-internal.  as  in  an  oblique  liernla.  It 
may  be  possible  in  some  cases  to  identify  the  contents  of  a  hernia.  Attention  has  been 
drawn  above  to  the  method  of  distinguishing  the  bowel  from  the  omentum.  Sometimes 
the  appendix  can  be  felt  distinctly,  especially  in  right-sided  hernia.  Occasionally  the 
bladder  may  be  identified,  as  in  Astley  Cooper's  classical  case.  When  the  patient  has 
apparently  emptied  the  bladder,  the  surgeon  reduces  the  hernia,  and  the  patient  is  imme- 
diately able  to  jjass  more  water.  /;.  p.  Itoiilimtls. 

SWELLING  OF  THE  JAW,  LOWER.  - -Swelling  of  the  lower  jaw  may  sometimes 
be  mistaken  for,  or  masked  by,  swelling  of  the  cellular  tissues  in  front  of  it.  The  real  site 
of  the  swelling  is  first  to  be  ascertained  by  opening  the  mouth  and  running  the  finger  along 
the  outer  and  inner  borders  of  the  mandible  and  comparing  the  two  sides. 

There  are  many  causes  for  enlargement,  and  they  may  be  subdivided  under  the  follow- 
ing headings  : — 

1.  Injury. 

2.  Injlammatorii  affections. 

„  I   Innocent — Fibroma,  osteoma,  and  odontoma. 

I  Malignant — Sarcoma  and  epithelioma. 
4.  Acromegaly. 

3.  Leontias's  ossea. 

InjlA'y. — .4  hcematortia  or  traumatic  periostitis  may  follow  on  a  blow.  If  the  injury 
has  been  sufRcient  to  cause  a  fracture,  the  abnormal  mobility  of  the  fragments,  the  irregu- 
larity of  the  line  of  the  teeth  and  arch  of  the  jaw,  and  the  laceration  of  the  gums,  are  suffi- 
cient to  indicate  the  injury.  The  nearer  the  line  of  fracture  is  to  the  symphysis,  the  more 
marked  is  the  mobility,  and  diagnosis  is  only  dillicult  when  the  fracture  is  of  the  ascending 
rannis  and  underneath  the  masseter  muscle.  .\  skiagram  may  then  be  needed.  Fracture 
of  the  mandible  is  commonly  compound,  and  therefore  is  often  comjilicated  by  septic 
infection.  Later,  callus  will  form  a  tumour  which  might  be  mistaken  for  one  of  some  other 
kind  imtil  the  course  of  the  case  has  been  watched. 

Inflammatory    Affections. 

.Ihratnr  Alisrrss.-  This  is  a  very  common  swelling,  associated  with  toothache.  .\n 
ordinary  gum-boil  forms  at  tlie  edge  of  the  gum.  and  is  <)uite  superficial.  \  more  trouble- 
some form  of  abscess  is  that  which  develops  at  the  root  of  a  tooth,  which,  generally  carious, 
may  yet  appear  healthy  on  the  surface.  Pus  usually  points  between  the  gum  and  the 
cheek,  but  it  may  travel  a  long  way  between  the  lionc  and  the  mucous  membrane.  an<l 
point  on  the  cheek,  in  the  submaxillary  region,  or  on  I  he  chin.  As  in  the  ease  of  injury, 
periostitis  extending  up  under  the  muscle  may  be  diMicull  to  diagnose,  and  it  is  sometimes 
mistaken  for  parotitis.  In  the  early  stages  the  only  sign  is  toolliaehe.  but  as  suppuration 
becomes  established  there  are  also  jjain,  swelling  of  the  gums,  furred  tongue,  trismus, 
enlargement  of  the  lymphatic  glands,  raised  tempcralMrc.  The  picscnce  of  a  septic  tooth 
indicates  the  diagnosis. 

Secnisis  of  the  Jazc.  often  preceded  by  an  acute  ])eriosteal  abscess,  may  follow  injury, 
aKeolar  abscess,  sypliilis,  or  mercufial  or  ])hospliorus  jioisoning,  and  in  rare  cases  acute 
exanthemata  or  typhoid  fever.  In  many  eases  it  may  be  impossible  to  say  whether  the 
bone  is  necrosed  or  not,  for  the  signs  are  much  the  same  as  in  suppuration  in  eomicction 
with  alveolar  abscess.  It  can  only  be  diagnosed  for  certain  if  a  piece  of  loose  bone  can  be 
felt  with  a  probe  or  seen  by  the  aid  of  a  skiagram.  Its  presence  may  he  iiilcrreil  by  the 
long  continuance  and  [)rofuseness  of  the  discharge. 

S///ihililic  disease  of  the  lower  jaw  is  rare,  and  if  iiresciil  will  not  usually  be  confined 
111  the  jaw.      If  tliere  is  doubt,  ii  \\ass(rmaTin"s  reaction  will   be  of  service. 

.tclinnnii/eosis.  A  long-standing  and  obstinate  su))puralion  about  the  lower  jaw. 
«  ilh  cellulitis  of  the  neck  and  formation  of  sinuses  in  the  skin,  should  lead  to  the  susjiicion 
III  the  nature  of  the  trouble.  In  the  beginning  it  gives  rise  to  inflammatory  changes  which 
simulate  ahcolar  abscess,  and  the  similarity  is  increased  by  the  presence  of  carious  teeth, 
through  wliieh  the  fungus  is  believed  to  gain  acc<'ss  to  the  jaw.  In  the  pus,  the  small  yellow 
graimlcs  arc  to  be  sought  for,  and  the  (Jram-staining  mycelium  on  mieroscopicMl  exaininalion 
(/'/(//(■   AVI///,  |).  (>l  I). 


6S4  SWELLING    OF    THE    LOWER    JAW 

Tumours. — In  many  cases  there  will  be  no  difficulty  in  deciding  whether  a  swelling 
is  inflammatory  or  a  new  growth.  In  the  early  stages — however,  and  it  is  never  to  be 
forgotten  that  an  early  diagnosis  in  the  case  of  malignant  disease  is  of  extreme  importance — 
there  may  be  grave  doubt.  Therefore,  all  possibility  of  inflammatory  mischief  should  be 
excluded  by  a  careful,  thorough  examination  of  the  mouth  and  teeth  for  any  source  of 
infection,  and  for  this  purpose  it  is  frequently  advisable  to  invite  the  co-operation  of  a 
dentist. 

Innocent  tumours  are  osteoma  and  fibroma  (more  commonly  called  a  fibrous  epulis). 
Osteoma  is  rare,  very  slow  growing,  well  defined,  bony  hard,  and  it  does  not  usually  attain 
a  very  large  size.  A  not  uncommon  place  to  find  it  is  at  the  angle  of  the  jaw,  projecting 
into  the  mouth.  It  may  be  bilateral.  Fibrous  epulis  is  common,  soft,  composed  of  fibrous 
tissue,  and  covered  by  the  mucous  membrane  of  the  gum.  It  arises  in  connection  with 
the  root  of  a  decayed  tooth,  and  if  not  treated  may  attain  a  sufficient  size  to  cause 
displacement  of  the  teeth  or  even  distortion  of  the  arch  of  the  jaw.  Sarcomata  may 
start  in  this  manner  ;  therefore  all  such  tumours  should  be  submitted  to  microscopical 
examination  before  a  definite  diagnosis  or  prognosis  is  given. 

Malignant  tumours  are  jirimnrij,  sarcomata,  and  secondnr//,  epitheliomata,  which  start 
in  the  gum  or  on  the  floor  of  the  mouth  and  invade  the  jaw  by  direct  extension. 

The  diagnosis  of  sarcomata  may  be  quite  easy,  or  attended  by  the  greatest  difficulty. 
They  occur  at  any  age.  even  in  young  infants.  They  may  be  of  rapid  growth,  associated 
with  constitutional  changes  which  simulate  inflammatory  conditions  before  a  large  size 
has  been  attained,  or  tliey  may  be  of  such  slow  development  as  to  be  confounded  with 
innocent  growths.  The  necessity  of  early  diagnosis  cannot  be  urged  too  strongly,  for  it 
is  on  this  tliat  successful  treatment  depends.  Seeing  tliat  a  growth  may  be  mistaken  for 
a  swelling  due  to  suppuration,  examination  should  first  be  directed  towards  seeing  if  any 
of  the  ordinary  signs  of  inflammation  are  present,  and  whether  there  is  an  obvious  source 
of  infection.  The  history  of  the  duration  of  the  illness  may  be  of  great  service,  and  also 
the  nature  of  the  swelling  itself.  Is  it  hard  or  soft,  is  the  bone  expanded,  are  tissues  round 
the  bone  infiltrated,  are  the  glands  enlarged  "?  Exercising  the  greatest  care,  diagnosis 
may  still  be  diflieult,  and  much  service  is  rendered  by  a  skiagram,  witii  the  aid  of  which 
one  may  determine  whether  the  swelling  is  really  bony,  or  in  the  case  of  periosteal  sarcoma 
if  the  bone  has  been  eaten  into.  If  the  diagnosis  can  be  settled  by  no  other  means,  the 
growth  should  be  cut  into  and  a  piece  removed  for  microscopical  examination,  even  if  the 
tumour  is  bony  and  a  chisel  and  mallet  be  required. 

Epithelioma— better  termed  squamous-celled  carcinoma — is  a  very  insidious  and 
dangerous  form  of  growth,  and  in  its  early  stages  very  apt  to  be  overlooked.  It  may  start 
as  a  small  ulceration  of  the  gum  about  a  decayed  tooth,  and  so  be  mistaken  for  a  simple 
ulcer,  and  it  may  not  be  until  a  large  tumour  has  formed  that  the  condition  is  recognized, 
when  most  valuable  time  will  have  been  lost  from  the  point  of  view  of  treatment.  The 
diagnosis  will  be  made  by  carefid  examination,  and  noting  that  the  ulcerated  gimi  is  hard 
and  indurated  and  does  not  heal  when  the  decayed  tooth  is  removed.  The  name  '  boring 
epithelioma  '  has  been  well  apjjlied  to  this  condition.  To  make  the  diagnosis  sure,  a  piece 
from  the  edge  of  the  ulcer  should  be  removed  for  histological  examination  at  the  earliest 
moment  that  suspicion  is  aroused  as  to  its  malignancy.  An  epithelioma  may  also  spread 
from  the  tongue  or  floor  of  the  mouth  and  cause  a  swelling  involving  the  jaw.  The  diagnosis 
lien-  is  obvious. 

Tumours  of  the  Teeth.  Odoulomata.  may  arise  from  any  portion  of  the  dental  tissue, 
lilhir  IVoni  the  tooth  germ  or  from  the  fully-formed  tooth.  Clinically  they  are  innocent, 
and  conunoner  in  young  people.  The  method  of  diagnosis  is  to  examine  the  teeth  and  find 
out  if  any  of  them  are  missing  or  abnormally  arranged.  It  is  easy  to  distinguish  them 
from  a  (jeriosteal  sarcoma,  but  confusion  may  arise  between  them  and  a  very  slow-growing 
endosteal  or  myeloid  sarcoma.  A  skiagram  will  generally  reveal  the  true  state  of  affairs, 
for  any  abnormality  or  misjilacement  of  the  teeth  is  clearly  shown.  It  is  well  to  remember 
I  he  existence  of  these  tumours,  for  unnecessarily  severe  operations  lia\e  often  been 
performed  in  ignorance. 

Two  diseases  in  which  the  mandible  becomes  enlarged,  but  in  which  the  swelling  is 
not  confined  to  the  one  bone,  and  is  only  one  of  the  manifestations  of  the  complaint,  remain 
to  be  mentioned  : — 


SWELLING.     MAMMARY  6f--5 

Acromegaly. — Tlic  lower  jaw  is  oftiii  enlarged  conspicuously  in  this  disease,  becoming 
prominent  and  m-issive  (Fig.  IKi,  p.  tiST).  There  is  hypertrophy  of  the  whole  bone  rather 
than  a  swelling  in  it.  The  other  bones  of  the  face  are  enlarged,  the  superciliary  ridges  are 
exaggerated,  and  the  general  effect  of  the  disease  is  to  give  the  patient  the  appearance  of 
a  dull,  coarse-featured  person.  In  addition,  the  hands  and  feet  become  much  enlarged  ; 
also,  in  the  late  stages  of  this  very  chronic  illness,  headache  and  muscular  debility  become 
prominent  symptoms,  and  owing  to  swelling  of  tlie  pituitary  bf)dy.  bilateral  temporal 
hemianopia  is  to  l)e  expected  (see  Fig.  1:J9,  p.  300). 

Leontiasis  Ossea  is  the  name  given  to  a  rare  disease  in  which  hyperostoses  of  the 
facial  and  cranial  bones  are  the  distinguishing  features.  It  is  not  likely  to  be  confounded 
with  any  of  the  abo\e-mentioned  swellings,  except  j)erhaps  acromegaly,  from  which  it  is 
distinguished  by  the  al)senee  of  changes  in  the  hands  and  feet.  (Irorsr  E.  Gnsk. 

SWELLING  OF  THE  JAW,  UPPER.— The  remarks  made  in  the  article  on 
Swelling  of  the  J.\w,  I>ower  (p.  683),  apply  equally  to  swellings  in  the  upper  jaw. 
Tumours  arising  in  the  antrum  of  Highmore  merit  special  mention,  however,  for  many 
cause  no  pain  or  discomfort  vmtil  the  late  stages.  Though  innocent  tumours  may  start 
in  the  antrum,  the  commonest  are  sarcoma  and  endothelioma.  Rapid  growth,  bulging 
into  and  invasion  of  surrounding  fossre,  pain,  discharge  of  blood  and  pus  from  one  nostril, 
and  invasion  of  tlie  overlying  skin,  arc  momentous  indications  of  malignant  disease.  In 
the  ease,  though,  of  slow-growing  tumours  and  in  the  early  stages,  differentiation  between 
innocent  growths  or  suppuration  is  extremely  difficult.  Transillumination  (see  P.\in  in 
THE  J.\w.  Upper,  p.  462)  is  to  be  employed  (Fig.  84,  p.  IHO).  also  puncture  of  the  antrum, 
and  if  necessary  exploration  and  histological  examination  of  the  |)arts  removed, 

(icmgc  E.  Oask. 

SWELLING  OF  THE   LEGS.— (See  Qmiema,  p.  411.) 

SWELLING,  MAMMARY. —Method  of  Kvaniiiialion.— The  clothes  should  be  removed 
to  the  waist,  so  that  a  clear  view  of  both  breasts,  the  thorax,  axillae,  and  supraclavicular 
fcs.siE  may  be  obtained.  Both  breasts  should  then  be  looked  at  to  see  whether  there  is 
any  obvious  enlargement  or  abnormality  such  as  redness  of  the  skin,  dilatation  of  \eins. 
tumour,  or  ideer.  Next,  palpation  is  to  be  emi)loyed.  using  tlie  Mat  of  the  hand  and  not 
the  tips  of  the  lingers  ;  the  surgeon  sh<juld  place  himself  in  a  convenient  position  behind 
the  patient,  using  the  right  hand  to  examine  the  right  breast  and  the  left  hand  the  left. 
The  axillary  fossa-  should  also  be  paljiated  carefully,  it  being  remembered  that  the  lym])hatic 
glands  alfected  in  diseases  of  the  breast  lie  on  the  surface  of  the  thorax  and  not  round  the 
axillary  vessels,  (See  Svveli,in(;,  .Axillary,  p.  666.)  In  cases  of  suspected  cancer  the 
examination  mi;st  not  be  eonelnded  withoid  irncsligaiion  of  the  su|)raeltnicular  fossa-  for 
111  Ml  less  or  cnjargciiicnl   of  glands,  and  of  the  I  Mora  x  and  li\-er  for  signs  of  secondary  growths. 

Swelling  in  Pregnancy  ami  Lactation  is  normal  and  physiological,  liolli  breasts 
arc  enlarged  equally,  and  feel  tense  and  nodular.  The  superlicial  veins  are  usually 
pidiiiinent,  and  on  gentle  sffueezing  a  few  drops  of  milk  are  discharged  lioiii  the  nipple. 

True  Hypertrophy  of  one  breast  is  rare.  II  may  be  found  in  nursemaids  who  have 
pill  eliilclrcn  lo  llic  breast.  The  enlargeiiienl  in  llie  majority  of  so-called  eases  of  hyper- 
trophy is  rinlly  line  lo  the  presence  of  one  or  more  libro-adenomala. 

Acute  Mastitis  occurs  usually  during  lactation,  occasionally  during  pregnancy,  and 
is  most  often  due  to  infection  with  pyogenic  organisms  which  have  gained  enlrance  through 
cracks  in  the  nipple.  .\t  the  beginning  of  the  illness  there  is  shivering,  followed  by  fever 
and  a  feeling  of  weight  and  pain  in  llic  breast;  the  pain  soon  becomes  very  acute.  In 
the  early  stages  the  swelling  is  limited  to  one  part  of  the  breast,  which  feels  more  resistant 
than  normal;  the  skin  is  not  reddened  at  lirst,  nor  are  the  lyniphalie  glands  enlarged, 
Pressure  over  the  swelling  may  cause  extrusion  of  a  drop  of  pus  from  Ihe  nipple,  and  this 
is  distinguished  from  milk  by  ils  \  iscidity  and  yellow  colour.  Later.  Miictuation  may 
become  evident.  ;iiid,  as  llic  inllaniinalion  apprf>aches  the  skin,  lliis  Incomes  red  an<l 
(I'dematous.  and  iilliiiialely  an  ahscess  may  point  and  biirsl  Ihrougli  il  :  al  llie  same  tifiie 
other  foci  of  siippiiral  ion  loriii,  imlil  the  breast  may  be  nolliing  but  a  bag  of  pus.  The 
presence  of  fever  an<l  the  intense  Icnderness  of  one  portion  of  the  breast  are  siillieient  to 
dislingiiisli  Mciile  maslilis  from  llie  pliysiologieal  engorgement. 


686  SWELLING,     MAMMARY 

It  is  not  uncommon  to  find  a  small  alveolar  abscess,  the  size  of  a  hazel-nut,  in  virgins. 

Soon  after  birth  and  at  puberty,  a  diffuse  enlargement  may  occur  in  both  sexes,  and 
a  small  quantity  of  milk  may  be  secreted.  If  the  breasts  are  handled  or  squeezed,  this 
congestive  condition  may  pass  into  true  inflammation  and  suppuration. 

Chronic  Mastitis  may  attack  numerous  lobes  of  the  breast,  so  that  the  whole  organ 
has  a  granular  feel  (chronic  lobular  mastitis),  or  the  inflammation  may  be  confined  to  one 
segment  and  form  an  inflammatory  swelling  of  considerable  size.  The  attention  of  the 
patient  is  usually  first  called  to  the  breast  by  the  presence  of  vague  pains  and  tenderness. 
If  the  lump  is  picked  up  with  the  fingers  it  is  easily  palpable,  but  if  pressed  back  against 
the  chest  wall  the  induration  is  much  less  distinct  than  is  carcinoma  or  fibro-adenoma. 
The  swelling  is  elastic,  and  its  outline  quite  diffuse,  more  so  than  in  the  case  of  carcinoma. 
The  axillary  glands  may  or  may  not  be  enlarged  ;  if  they  are.  they  are  generally  numerous, 
not  so  hard  as  in  cancer,  and  are  met  with  at  an  earlier  period  in  the  disease.  The  opposite 
breast  is  very  liable  to  be  diseased  in  a  similar  manner.  Tlu-  diagnosis  is  often  very  diffi- 
cult, ordinary  carcinoma  of  the  breast  being  confounded  with  it.  The  two  tumours  resemble 
each  other  in  that  in  both  their  outlines  are  badly  defined  and  the  axillary  glands  are 
enlarged.  In  cancer,  however,  the  tumour  is  densely  hard,  and  at  an  early  period  adhesions 
form  so  that  the  skin  puckers  on  attempting  to  move  it  over  the  swelling.  A  further 
difficulty  arises  from  the  fact  that  a  cyst  may  form  in  connection  with  chronic  mastitis. 
If  this  is  lax,  fluctuation  may  be  detected,  but  it  is  usually  so  tense  that  it  feels  hard  and 
solid.  This  again  may  be  mistaken  for  a  carcinoma  or  a  fibro-adenoma.  Where  there 
is  the  least  doubt  as  to  the  nature  of  the  swelling  and  any  possibility  of  the  presence  of  a 
carcinoma,  the  right  course  is  to  make  an  ex])loratory  incision  and  cut  microscopic  sections 
from  the  suspected  area. 

Multiple  Cystic  Disease  of  tlie  Breast. — This  condition  may  follow  on  chronic 
lobular  mastitis.  One  breast — sometimes  both — becomes  filled  with  cysts,  some  micro- 
scopic and  others  as  large  as  walnuts,  so  that  the  organ  has  a  bossy  appearance.  The 
whole  organ  is  ofteh  very  painful,  the  pain  radiating  from  the  breast  and  shooting  down 
the  arm.  There  are  epithelial  changes  in  the  lining  membrane  of  the-"C\'sts,  and  some 
authorities  think  that  these  are  ])recursory  stages  in  the  formation  of  a  cancer. 

Cysts,  miless  in  connection  with  chronic  mastitis  or  fibro-adenomata,  are  rare.  A 
simple  serous  cyst  is  described,  due  to  lymphatic  obstruction.  Galaetocele,  a  cyst  containing 
milk,  is  formed  by  dilatation  of  one  of  the  larger  lacteals  owing  to  obstruction  ;  galacto- 
eeles  occur  only  during  lactation  ;  they  form  movable,  fluctuating  swellings,  and  on  pressure 
milk  can  he  squeezed  out  of  the  nipple. 

Tuberculosis  of  tlie  Breast  is  not  so  imcommon  as  was  formerly  supposed,  and  a 
certain  number  of  cases  of  chronic  mastitis  and  chronic  abscess  are  really  tuberculous. 
The  disease  is  insidious,  starting  as  a  painless  irregular  swelling,  the  peripliery  of  which  is 
hard  and  the  centre  soft.  Later,  the  skin  becomes  reddened,  and  an  abscess  forms  which 
may  burst  and  leave  a  sinus.  It  differs  from  an  acute  abscess  in  that  the  duration  is  much 
longer,  there  is  little  or  no  pain  or  fever,  and  the  pus,  if  examined,  reveals  no  organisms. 
The  facts  that  its  history  is  a  long  one,  that  the  swelling  or  the  edges  of  it  are  hard,  and 
that  the  axillary  glands  are  enlarged,  render  this  condition  liable  to  be  confounded  with 
carcinoma,  of  the  ordinary  form,  or  one  in  which  suppuration  has  occurred.  The  various 
clinical  pathological  tests  for  tuberculous  disease  may  be  applied,  but  the  best  method  is 
to  cut  into  the  swelling  and  remove  a  portion  of  the  wall  for  histological  examination. 

Chronic  Submammary  Abscess  causes  a  projection  forward  of  the  whole  breast  ; 
it  is  due  to  tuberculosis  of  tlie  underlying  ribs,  or  in  rare  instances  to  post-typhoidal 
periostitis  which  may  have  remained  latent.  The  diagnosis  is  made  by  opening  the 
abscess  and  examining  the  pus  from  it  bacteriologically. 

Innocent  Tumours. — Pure  fibromata,  lipomala,  and  enchondromaia  are  of  rare  occur- 
rence, and  merely  call  for  mention  here.  Fibro-adenoma  is  the  only  common  innocent 
tumour,  and  though  there  are  many  pathological  varieties,  and  some  contain  cysts  and 
some  intra-eystic  growths,  for  the  purposes  of  this  article  all  may  be  classed  under  one 
heading.  A  fibro-adenoma  is  an  encapsulated  tumour,  generally  single,  sometimes  multiple, 
varying  from  the  size  of  a  nut  to  that  of  an  orange.  Because  it  is  encapsulated,  the 
surrounding  tissues  are  not  infiltrated  ;  therefore,  if  superficial,  the  outline  is  clearly  defined, 
and  the  mass  is  freely  movable  both  under  the  skin,  over  the  pectoral  muscle,  and,  most 


SWELLING.     -AL\M.\L\RY  687 

important  of  all.  in  the  breast  substance.  The  axillary  glands  are  not  enlarged.  The 
tumours  cause  no  pain,  and  arc  usually  discovered  accidentally.  Generally  they  occur  in 
women  between  the  ages  of  twenty  and  thirty.  After  attaining  a  certain  size  they  remain 
more  or  less  stationary,  unless  they  are  cystic,  when  they  may  go  on  growing  as  the  result 
of  dilatation  of  the  cyst  by  fluid.  The  diagnosis  is  generally  quite  easy,  but  if  the  breast 
is  fat  and  the  tumour  deep-seated,  it  may  not  always  be  quite  easy  to  distinguish  a 
fibro-adenoma  from  an  early  carcinoma,  without  ojieration  and  microscopical  examination. 
.\  fibro-adenoma  is  elastic  in  consistency  rather  than  hard  like  a  carcinoma.  From  chronic 
mastitis  it  is  distinguished  by  being  less  intimately  associated  with  the  breast  than  is  the 
case  with  the  inflammatory  nodules,  and  by  its  sharper  definition.  On  account  of  the 
well-known  jjossibility  of  error,  however,  no  definite  diagnosis  or  prognosis  should  be  given 
until  the  tumour  has  been  removed  and  a  pathological  report  on  its  character  received. 
Malignant  Tumours  of  the  breast  are  nearly  always  primary  ;  sarcoma  is  rare, 
carcinoma  common  :  and  the  latter  is  the  most  important  tumour  that  affects  the  breast. 
It  is  essentially  a  disease  of  the  female,  only  about  one  per  cent  of  the  cases  occurring  in 
males  ;  most  patients  have  been  married,  and  are  between  the  ages  of  thirty-five  and  sixty. 
In  advanced  cases  the  disease  is  obvious  ;  the  timiour  is  large  and  hard,  fixed  to  and  often 
fungating  through  the  skin  :  the  axillary  glands  are  enlarged  and  hard,  and  the  patient 
is  often  cachectic.  What  is  wanted  is  a  diagnosis  in  the  early  stages,  while  the  patient  still 
looks  and  feels  in  jjerfect  health,  before  secondary  deposits  are  found  in  the  axillary  glands 
and  while  successful  treatment  is  still  possible.  Too  much  insistence  cannot  be  laid  on  this. 
Usually  the  ])atient  feels  no  pain,  but  discovers  a  lump  in  the  breast  accidentally  during 
ablutions  ;  therefore  its  duration  must  generally  be  a  matter  of  doubt.  Clinically,  it  is 
felt  as  a  small  tumour  which,  unless  the  patient  is  very  fat,  can  be  palpated  easily  with 
the  flat  of  the  hand.  Its  chief  characteristic  is  that  its  outline  is  not  sharply  defined,  and 
that  it  is  hard — stony  hard.  In  the  very  early  stage  the  tumour  is  freely  movable  over 
the  pectoral  muscles  and  under  the  skin,  but  it  is  not  so  movable  in  the  breast  substance 
as  is  a  fibro-adenoma.  Very  soon  bands  of  fibrous  tissue  that  connect  the  brea.st  with 
the  skin  become  jnvolved,  and  by  their  contraction  prevent  free  movement  of  the  skin 
"over  the  swelling,  and  cause  dimpling  and  puckering.  If  the  tumour  is  situated  anywhere 
near  the  centre  of  the  breast  milk-ducts  become  involved  in  the  growth,  and  as  they 
contract  cause  retraction  of  the  nipple.  If  a  nipple,  previously  well  formed,  becomes 
retracted,  this  is  a  very  imijortant  !.ign,  though  it  is  to  be  remembered  that  nipples 
are  fiftcn  permanently  retracted.  Many  cancerous  tumours,  even  when  extensive  infil- 
tration has  occurrcfl,  cause  shrinkage,  so  that  the  affected  breast  may  a])])ear  smaller  than 
the  healthy  one,  and  in  the  atrophic  form  the  gland  may  almost  disapijcar.  In  the  ordinary 
form  (seirrhus)  it  will  be  rare  to  find  any  discharge  from  the  nipple  :  a  blood-stained 
discharge  often  indicalis  a  (lucl-eiirciiioma.  (.See  Dischakuk  i'uo.m  riiio  Xii'ri.ic.  |).  181.) 
.After  the  iliscasc  li:is  lasted  six  moiillis  the  axillary  glands  are  usually  enlarged  and  hard, 
the  first  alTeetcd  being  those  running  along  the  lower  border  of  the  pecloralis  min(jr.  Too 
much  attention  must  not  be  given  to  the  ab.sence  of  palpable  glands,  because,  first,  it  is 
hoped  that  the  diagnosis  may  be  inade  before  they  are  enlarged  ;  and  secondly,  if  the  patient 
is  at  all  fat,  it  is  exceedingly  easy  to  overlook  them.  .Attention  is  to  be  centred  on  the 
lump  itself.  Its  stony  liardncss  may  alone  be  sullicient  ground  on  which  to  base  a  dia- 
gnosis. The  two  main  conditions  which  have  to  be  distinguished  from  an  early  carcinoma 
are  libro-adcnonia  and  chrotiic  mastitis.  In  the  former,  the  swelling  is  well  defined,  clastic. 
and  freely  movable  :  in  the  latter,  a  tumour  cannot  be  fell  (listinclly  with  the  Hat  of  the 
hand  ;    it  is  soft,  and  the  whole  breast  is  often  nodular. 

The  dillicultics  in  diagnosis  are  great  and  the  sources  of  error  nuiiu  lous  ;  ikioc  of  the 
swellings  may  be  typical  :  they  may  be  obscured  by  tlie  obesity  of  the  patient,  .lud  a  tluid 
swelling  may  be  so  tense  as  to  sinuilate  a  solid  one.  This  being  so.  the  course  to  adopt, 
whencxcr  the  slightest  doubt  arises,  is  to  incise  the  swelling  and  submit  a  portion  to  micro- 
.seopieal  examination.  Seeing  the  vital  importance  of  avoiding  mistakes  in  this  connection 
there  is  a  growing  feeling  among  surgeons  that  all  tumours  of  the  breast,  whatever  the 
belief  as  to  their  character,  should  be  removed,  or  at  least  cut  into,  so  that  their  true  histo- 
logical constitution  may  be  ascertained  early  and  with  accuracy. 

Saniiimi  of  the  bnast  is  rare.  It  gcnerMlly  occurs  in  women  under  the  age  of  thirty. 
In   the  early   stage   it    i-.  not    lasily   (list  irigiiislialilc   Ironi   a    lil>nia<leMiiroa,   particularly   one 


6.SS  SWELLING.     MAMMARY 

which  is  enlarging  rapidly  on  account  of  a  cyst  or  intracystic  growth.  It  is  soft,  grows 
rapidly,  infiltrates  the  tissues,  and  forms  a  large  fungating  tumour.  It  disseminates 
rapidly,  both  via  the  lymphatics  and  by  the  blood-stream.  George  E.  Gnsl;. 

SWELLING,  PELVIC. — There  are  so  many  swellings  which  may  rise  up  out  of  the 
pelvis  info  Ihe  abdiinuii,  and  also  which  may  appear  to  be  pelvic  when  they  are  really 
primarily  abdominal,  that  a  list  in  tabulated  form  may  be  of  value  : — 

Bladder. — Simi)le  distention.    New  growth. 
Vagina. — Ha-matocolpos. 

Uterus. — Pregnancy  :    normal  or  abnormal,  or  associated  with  tumours  of  the  uterus 
or  ovary. 
New   growths  :     Fibromyoma.     Sarcoma.    Carcinoma.     Chorion-epithelioma. 
Ilsematometra. 
Ovary. — Cysts.     Solid  new  growths. 
Fallopian    Tubes. — Hydrosalpinx  Carcinoma 

Pyosalpinx  i      Tubal  gestation 

Salpingo-oophoritis  Progressive  extra-uterine  gestation. 

New  growths  ! 

Pelvic    Peritoneum. — Encysted  peritoneal  fluid 

HiEmatocelc  due  to  extra-uterine  gestation 
Haematocele  due  to  ha?morrhage  from  a  corpus  luteum 
Pelvic  abscess  |  Hydatid  cysts 

Ascites  I  Retroperitoneal  lipoma. 

Pelvic  Cellular    Tissue. — Celltditi«.     Pelvic  ha^matoma. 
Appendix  Vermiformis. — Abscess  around 

Ap])endicitis  with  pregnancy. 
Pelvic    Bones. — New  growths  of. 
Omentum. — Niw  growths  of.     Cysts  of. 
Phantom  Tumours. 
Pancreatic  Cysts. 

Kidney. — Tumours  of.     Hydronejihrosis.      Pyonephrosis. 
Gall-bladder. — Distention  of. 
Spleen. — Knlargenient  of. 
Urachus. — Cyst  of. 

It  is  oljvious  tliat  many  of  these  lesions  are  not  ))elvic  at  all  ;  but  they  ai'C  not  omitted 
from  the  list  because  they  are  liable  to  be  mistaken  for  pelvic  tumours.  Thus  pancreatif, 
renal,  splenic,  and  gall-bladder  hinmars  may  reach  the  ]iehic  brim,  but  the  history  ought 
to  show  that  they  have  grown  down  from  above,  not  u))  from  below.  Further,  renal 
tumours  may  be  associated  with  urinary  changes,  or  absence  of  iirinary  secretion  on  the 
affected  side,  as  detected  by  the  cystoscope.  Splenic  enlargements  may  be  associated  with 
blood-changes,  and  gall-bladder  distention  with  icterus.  Pancreatic  cysts  are  the  least 
likely  to  be  mistaken  for  pelvic  swellings,  but  they  have  been  difficult  to  distinguish  from 
ovarian  tumours  with  long  pedicles. 

Naturally,  the  commonest  difficulty  which  arises  in  the  diagnosis  of  pelvic  swellings 
is  to  differentiate  between  the  distended  bladder,  pregnant  titeriis,  ovarian  cyst,  and  uterine 
Jibromyiima.  and  the  commonest  mistakes  are  made  between  these  swellings.  The 
distended  bladder  is  clearly  the  easiest  to  dispose  of,  because  the  passage  of  a  catheter 
will  settle  the  question  ;  and  yet  the  neglect  of  this  simple  procedure  has  led  to  more  than 
one  abdomen  being  opened. 

The  history  is  of  value  in  differentiating  the  other  swellings,  for  amenorrhoea  is  the  j 
rule  in  pregnancy,  menorrhagia  in  fibromyoma,  and  no  change  in  menstruation  in  ovarian] 
tumours.     These    assumptions   are    correct    in   almost    99    out    of   every    100   cases,    but] 
exceptions   do   exist.     The   cardinal   point    in   diagnosis   is   not   to   think   of  the  possible 
fallacies  until  the  conunon  rule  has  been  considered  thoroughly.     Normal  menstruation 
during  pregnancy  is  almost  unknown,  but  it  is  believed  that  menstruation  is  possible  up 
to   the   third   month.     This   is   physiologically   unsound,    for   menstruation    rejjresents   the 


SWELLING.  .  MAMALIRY  689 

failure  of  the  uterus  to  receive  a  fertilized  ovum,  and  should  not  be  even  possible  if 
conception  does  occur.  That  h;emorrhages  occur  during  the  early  months  of  pregnancy 
is  true  ;  but  in  most  cases  these  hiemorrhages  represent  threatened  abortion,  and  not 
menstruation.  Further,  fibroids  are  associated  with  haemorrhages.  This  is  true  in  the 
case  of  interstitial  or  submucous  growths  ;  but  there  may  be  no  disturbance  of  menstrua- 
tion in  subperitoneal  fibroids.  Ovarian  tumours  only  disturb  menstruation  when  they 
are  double,  and  destroy  all  ovarian  tissue.  As  long  as  a  small  piece  of  ovarian 
tissue  remains  there  is  no  reason  why  menstruation  should  not  occur  normally. 

Palpation  of  these  tumours  may  be  fallacious,  although  there  is  no  difflculty  in  distin- 
guishing foetal  parts  when  the  foetus  is  big  enough.  In  the  early  months  the  jircgnant 
uterus  may  fluctuate  like  a  cyst  :  a  softened  fibroid  may  do  the  same,  whilst  on  the  other 
hand  a  tense  ovarian  cyst  may  feel  so  hard  as  to  be  mistaken  for  a  fibroid.  Whilst  the 
presence  of  the  foetal  heart  is  characteristic  of  pregnancy,  its  absence  cannot  be  taken  as 
evidence  of  a  fibroid  or  of  an  ovarian  tumour.  It  is  not  always  possible  to  hear  the  fcetal 
heart  even  in  advanced  pregnancy.  If  the  pedicle  of  a  tumour  can  be  felt  definitely 
attached  to  one  uterine  cornu  it  is  strong  presumptive  evidence  of  an  ovarian  tumour. 
It  is  useful  to  pull  down  the  uterus  with  a  tenaculum,  at  the  same  time  pushing  up  the 
tumour  so  as  to  make  tense  the  pedicle,  which  might  then  be  palpated  by  the  vaginal 
touch.  When  small  tumours  are  in  question  the  first  j^oint  which  arises  is.  Can  the  tumour 
be  separated  from  the  uterus  Ijimanually  ?  If  so,  it  can  be  neither  a  fibromyoma  of  the 
uterus  nor  a  normal  uterine  i)regnancy.  This  point  can  only  be  made  out  by  careful 
bimanual  examination,  and  undoubtedly  may  require  considerable  skill  in  some  cases. 

Early  pregnane))  in  a  retroverted  uterus  should  not  give  rise  to  diagnostic  dilliculties 
if  it  be  remembered  that  the  soft,  boggy  fundus  is  felt  through  the  posterior  fornix,  that 
the  cervix  looks  down  the  vagina  or  forwards  to  the  symphysis,  and  that  the  posterior 
mass  is  continuous  with  the  cervix.  If  the  retroverted  uterus  is  associated  with  vesical 
distention  the  picture  is  usually  clear  enough.  The  history  of  constant  dribbling  of  urine 
(distention  with  overflow),  amenorrhcca,  other  signs  of  pregnancy,  the  presence  of  two 
tumours — one  in  front,  tense  and  elastic,  the  other  behind,  soft  and  boggy — and  finally, 
the  passage  of  a  catheter,  will  settle  the  question.  The  diagnosis  of  solid  ovarian  tumours 
is  not  always  jjossible,  for  the  pedicle  is  often  short,  and  the  tumour  is  then  so  close  to  the 
uterus  that  the  two  cannot  be  separated.  They  are  therefore  likely  to  be  mistaken  for 
fibroids  of  the  uterus.  They  do  not  often  cause  menorrhagia,  however,  and  this  may  be 
remembered  as  a  cardinal  point. 

Large  tumours  arising  in  the  pelvis  arc  not  often  dillicult  to  dilTcrentiate  from  one 
another,  bearing  in  mind  that  ovarian  tumours,  uterine  fibroids,  pregnancy,  and  ascites 
are  the  common  conditions  which  are  met  with.  In  this  connection,  it  cannot  be  repeated 
too  often  that  amenorrluea  stands  for  pregnancy,  and  oeeasionally  for  ovarian  tumours 
when  doulile.  .Menorrhagia  goes  with  uterine  tibniids  except  in  the  case  of  subperitoneal 
tumours.  lOxceptions  to  these  general  statements  ari'  uncommon,  and  mistakes  in 
diagnosis  will  occur  but  seldom  if  they  are  borne  in  mind,  .\scites  has  to  be  dilTerentiated 
from  ovarian  cysts,  and  oeeasionally  from  hydramnios.  In  general,  ascites  gives  dullness 
in  the  flanks  on  percussion,  with  resonance  over  an  area  somewhere  about  the  umbilicus, 
whilst  ovarian  cysts  give  dullness  over  the  front  of  the  abdomen,  with  resonant  areas 
in  the  flanks  and  epigastric  angle.  When  ascites  exists  along  with  ovarian  tumours  the 
free  fluid  may  be  so  large  in  anmutit  that  the  tumour  camiot  he  felt  ;  as  a  rule,  however, 
it  can  be  touched  on  dipping  tludugh  the  lluiil.  Ascites  with  an  ovarian  turnour  does 
not  necessarily  rncMn  iiialignaney,  but  it  may  do  so.  Fibroma  of  the  ovary,  and  simple 
ovarian  cyst,  willi  a  twisted  pedicle,  will  always  be  accompaniefl  by  some  fluid. 

\Vheii  jiregiiiiuei/  is  assaeinted  with  lunuiurs.  the  diagnosis  may  be  of  great  didicidty. 
This  (Iocs  not  lie  in  the  recognition  of  the  pregnancy  :  anienorrhu'a,  breast  changes,  hetal 
movements,  and  the  fo-tal  heart  will  usually  make  that  clear  enough  ;  it  lies  in  deciding 
the  nature,  or  even  the  pre.sencf,  of  a  tumour  along  with  the  pregnant  uterus.  In  the 
early  months,  when  the  presence  of  two  tumours  can  be  demonstralerl,  the  diagnosis  is 
easier,  but  in  the  later  months  the  great  size  of  the  abdomen,  and  the  way  in  which  the 
swelfings  merge  into  one  another,  may  obscure  the  picture.  The  relation  to  the  uterus, 
whether  a  part  of  it.  or  attached  to  it  by  a  pedicle  :  the  fee!  of  the  tumour,  wlietlicr  solid 
or  cystic,  soft  or  lianl  :    and  tli<'  previous  liisli)r\-  :    will  alwa\s  l)c  of  assistanrc  in  making 

D  1-4 


690  SWELLING.     MAMMARY 

out  the  nature  of  the  growth.     Fibroids  are  extremely  likely  to  soften  and  degenerate 
during  pregnancy,  so  that  they  are  Hable  to  be  mistaken  for  ovarian  cysts. 

In  the  case  of  ovarian  tumours,  it  is  often  impossible  to  be  sure  of  the  exact  nature 
of  the  growth,  and  this  has  to  be  decided  microscopically  after  removal.  It  is,  however, 
important  to  distinguish  malignancy  in  growths  of  the  ovary,  and  certain  points  will  stand 
out  in  favour  of  this.  Thus,  fixation  of  the  growth  in  the  pelvis,  obvious  ascites, 
emaciation  of  the  patient,  and  rapid  growth  in  size  of  the  abdomen,  are  points  in  favour 
of  malignancy. 

In  the  case  of  definitely  uterine  tumours,  the  diagnosis  of  malignant  growths  is  not 
often  difficult,  but  may  have  to  be  settled  by  microscopic  examination  of  curetted 
fragments.  Fibroids  arQ  only  likely  to  be  mistaken  for  malignant  growths  when  they 
produce  constant  bleeding  as  a  result  of  extrusion,  infection,  and  sloughing.  Rapid  growth 
of  a  fibroid  is  more  likely  to  be  the  result  of  degenerative  changes,  such  as  formation  of 
cysts  or  necrobiosis,  than  to  the  development  of  a  sarcoma  or  other  malignant  growth 
along  with  it. 

With  small  tumours  confined  to  the  pelvis,  or  rising  only  a  little  above  the  brim, 
diagnosis  is  often  a  matter  of  extreme  difficulty.  In  practice,  however,  extra-uterine  gesta- 
tion and  its  resulting  blood-tumours  stand  out  pre-eminently  as  swellings  which  must  be 
recognized  at  once,  if  successful  treatment  is  to  be  adopted.  Before  rupture  or  abortion 
has  occurred  a  tubal  gestation  is  essentially  a  small  tumour  in  one  postero-lateral  corner 
of  the  pelvis,  attached  to  the  uterus,  indefinite  in  consistence,  and  perhaps— though  not 
always-^associated  with  amenorrhoea  of  short  duration,  and  attacks  of  pain  in  the^pelvis 
of  an  acute  nature.  Definite  signs  of  pregnancy  may  be  entirely  wanting.  It  may  be 
mistaken  for  a  chronic  salpingo-oophoritis,  a  small  cystic  ovary,  a  small  pedunculated 
fibroid,  or  a  small  ovarian  dermoid.  The  differential  diagnosis  may  be  absolutely  impos- 
sible ;  but  attacks  of  pain  unassociated  with  menstruation  are  not  likely  to  occur  in  any 
of  the  latter  conditions.  The  attacks  of  pain  are  usually  the  result  of  over-distention 
and  stretching  of  the  tube  from  hasmorrhage  into  its  wall  or  lumen  around  the  fertilized 
ovum.  When  tubal  abortion  has  occurred,  or  tubal  rupture,  the  signs  of  internal  bleeding, 
accompanied  by  sudden  pain  and  collapse,  with  ha-morrhage  from  the  uterus,  usually 
make  an  unmistakable  picture.  H.-emorrhage  is  more  conunonlv  severe  and  copious  in 
tubal  rupture  than  in  tubal  abortion.  If  the  patient  recovers  from  the  initial  bleeding  the 
clinical  picture  may  be  that  of  a  retro-uterine  hwrnatocele,  or  of  a  peritubal  hicmatocele. 
In  this  form  the  uterus  is  pushed  forwards  and  upwards  against  the  svmphysis  pubis,  and 
the  mass  of  blood-clot  can  be  felt  posteriorly  bulging  the  posterior  fornix,  and  also  the 
anterior  wall  of  the  rectum.  The  tumour  is  usually  partlv  resonant  in  front,  because 
mtestine  adheres  to  it.  Tubal  abortion  is  most  likely  to  be  mistaken  for  an  ordinary 
uterine  abortion  ;  but  the  presence  of  a  mass  on  one  side  of  the  uterus,  with  a  closed 
cervix,  and  the  absence  of  uterine  contractions  or  extrusion  of  anv  products  of  conception, 
should  make  the  case  clear. 

Progressive  extra-uterine  gestation  is  a  rare  occurrence,  and  is  the  result  of  continued 
growth  of  an  embryo  after  a  partial  separation  from  the  tube  as  a  result  of  rupture  or 
extrusion  from  the  fimbriated  end  (abortion).  The  continued  enlargement  of  a  mass 
beside  the  uterus,  with  amenorrhoea  and  progressive  signs  of  pregnancy,  are  the  most 
characteristic  pomts.  The  diagnosis,  however,  is  difficult,  because  there  is  always  some 
effused  blood  which  is  likely  to  obscure  the  outlines  of  the  uterus,  and  make  it  appear  to 
be  a  part  of  the  pelvic  mass. 

The  swellings  due  to  salpingo-oophoritis  are  usuallv  quite  easv  to  distinguish.  They 
form  fixed  masses  in  the  pelvis,  seldom  of  any  definite  shape,  but"  occasionally  presenting 
the  characteristic  retort  shape,  with  its  narrow  end  near  the  uterus,  which  the  tube  assumes 
when  distended  with  fluid.  The  history  is  usually  that  of  an  acute  illness  at  some  period, 
with  pain  in  the  pelvis,  rise  of  temperature,  and  peritoneal  irritation.  It  is  preceded, 
as  a  rule,  by  uterine  discharges  and  menorrhagia.  This  inflammatory  disturbance  in 
married  women  is  associated  with  long  periods  of  sterility,  owing  to  the  "sealing  up  of  the 
tubes.  Ihe  diagnosis  of  suppuration  with  salpingo-oophoritis  is  often  impossible,  but 
IS  always  important,  because  the  treatment  may  depend  on  it.  Constant  rises  of  tempera 
ture  ot  the  hectic  type,  wasting,  and  daily  sweating,  are  the  usual  accompaniments  oi 
suppuration  here  as  elsewhere. 


1 


SWELLING..  POPLITEAL  691 

A  large  pelvic  abscess  may  accompany  salpingo-oophoritis,  or  may  occur  alone  without 
infection  of  the  tubes,  as  we  see  occasionally  in  puerperal  septic  infections.  When  it  does 
occur,  it  is  of  course  peritoneal  ;  it  fixes  the  uterus  in  a  central  position,  bulges  into  the 
posterior  fornix  and  rectum,  tends  to  rupture  into  the  rectum,  is  acute  in  onset,  and  accom- 
panied by  signs  of  local  peritonitis.  It  is  likely  to  be  confounded  with  pelvic  cellulitis, 
in  which  the  uterus  is  fixed  in  a  laterally  displaced  position.  It  bulges  one  lateral  fornix, 
tends  to  burrow  along  tlic  round  ligament  to  the  groin,  is  slow  in  onset,  chronic,  and  not 
accompanied  by  signs  of  local  ixritoiiltis.  It  always  follows  labour,  whereas  pelvic  abscess 
of  peritoneal  origin  may  occur  with  salpingo-oophoritis  quite  apart  from  pregnancy.  Pelvic 
cellulitis  never  bears  any  relation  to  salpingo-oophoritis. 

Eiictjsled  peritoneal  fluid,  hydatid  cysts,  and  retroperitoncid  lipoma  are  generally 
diagnosed  as  ovarian  cysts,  and  their  true  nature  is  only  disco\'ered  at  operation.  There 
are  no  definite  signs  by  which  these  conditions  may  be  diagnosed,  and  as  they  all  require 
operative  treatment,  post-operative  diagnosis  meets  their  requirements. 

Distention  of  the  vagina  by  menstrual  fluid  is  not  likely  to  be  mistaken  for  anything 
else,  if  only  on  account  of  the  absolute  closure  of  the  hymen  which  gives  rise  to  it. 
Haematocolpos  is  practically  the  only  central  tumour  met  with  between  the  rectum  and 
the  bladder  reaching  from  the  hyinen  to  the  pelvic  brim.  The  uterus  can  usually  be  felt 
like  a  cork  movable  upon  its  upper  extremity. 

Urachal  cysts  occur  in  front  of  the  uterus  and  in  close  relation  to  the  bladder  ;  but 
in  spite  of  this  they  are  usually  mistaken  for  ovarian  cysts.  It  is  to  be  remembered,  how- 
ever, that  ovarian  cysts  only  get  in  front  of  and  above  the  uterus  when  they  are  large. 
Urachal  cysts  rarely  attain  a  large  size. 

Appendicitis  n'ith  pregnancy  occurs  occasionally,  and  may  be  mistaken  for  such  a 
condition  as  torsion  of  an  ovarian  pedicle.  The  swelling  due  to  appendix  inflammations 
is,  however,  in  close  relation  to  the  anterior  superior  spine  of  the  ilium,  and  apjiarently 
adherent  to  the  iliac  fossa.  The  lump  is  ill  defined,  and  rarely  Huctuates  unless  there  is 
a  large  abscess.  The  acute  onset  may  be  similar  to  that  of  torsion  of  an  ovarian  pedicle. 
There  is  usually  a  definite  fluctuating  tumour  when  an  ovarian  cyst  is  present,  and  some 
interval  between  it  and  the  iliac  crest  can  usually  be  felt. 

Phantom  tumours  are  due  to  diaphragmatic  contraction,  causing  the  abdominal  wall 
to  bulge.  TIrv  are  usually  mistaken  by  patients  for  pregnancy,  but  are  not  accompanied 
by  any  of  the  signs  of  pregnancy.  Amenorrhoca  nuist  be  excepted  from  this,  however, 
because  these  cases  usually  occur  about  the  menopause.  Their  true  nature  can  usually  be 
discovered  by  making  the  patient  breathe  normally,  relaxing  the  diaphragm  ;  but  if  any 
doubt  exists,  the  protrusion  will  disappear  under  an  ana'sthetie. 

(Inncths  of  the  jiclvic  hones  are  \ery  rare  tumours,  usually  cartilaginous  or  sarcomatous, 
'i'liey  are  only  likely  to  be  mistaken  for  adherent  inflanmiatory  masses,  due  to  salpingo- 
oophoritis.  Tlu'v  will  be  found  to  be  contimious  with  the  bones  forming  the  pelvis,  and 
when  growing  from  the  sacrtun  may  have  the  rectum  in  front  of  them  ;  all  other  tumours 
liMAi-  tlic  rcilnin  licliiiid  llicni.  They  may,  however,  l)ear  no  relation  to  the  rectum  at 
all  if  llicy  (jiciir  on  tlic  liglil  side  of  the  pelvis.  In  most  eases  of  this  nature  the  uterus 
and  ailiii-xa  r:\'.\  be  palpated  biiuaiiually,  and  shown  to  be  free  from  disease  and 
uneomiccted  with  the  mass.  When  (Mimplicated  by  the  presence  of  a  pregnani  uterus 
their  true  naluic  may  be  \cry  dillicull  to  (Iclerininc.  Mciiririg  i[i  mind  that  they  are 
absolulcly  fixed  anil  ciiril  iiiiiiiiis  willi  llii-  bones  of  tin-  pelvis.  Ilic  diagnosis  ought  not 
to  be  uiieertaiii.  Thns.  G.  Stevens. 

SWELLING,  PERINEPHRIC.     (Sre  Kh.min-.  I^ni.aiici-.mknt  or.  p.  m->.) 

SWELLING,    POPLITEAL.      Popliteal   sw.llings   may    be    divi.lc.l    into  :  - 

1.  Fluid   Swellings : 

Bursa  Varicose  veins  AiieuryMii. 

Baker's  eyst  Abscess 

2.  Solid  Swellings  not  connected  with  Bone  : 

I'^iilapf,'!  il   ylaiids  Mall^'nanl    lui irs  I     Innocent   tumours. 

3.  Solid  Swellings  connected  with  Bone  : 

Kxostosis  I'eriiistitis 

Sarcoma  .Separation  of  llie  epiphysis. 


692  SWELLING.     POPLITEAL 

FLUID    SWELLINGS. 

Bursa. — The  bursa  underneath  the  insertion  of  the  semimembranosus  muscle  into 
the  posterior  aspect  of  the  inner  tuberosity  of  the  tibia  is  often  enlarged.  When  the  leg 
is  extended  it  stands  out  as  a  tense  fluctuating  swelling  on  the  inner  side  of  the  popliteal 
space  ;  on  flexion  it  disappears  completely.  It  may  be  found  enlarged  in  young  athletes 
and  cause  no  symptoms  whatever.  On  account  of  its  frequent  comnumication  with  the 
knee-joint  it  is  often  distended  when  that  joint  is  the  seat  of  osteo-arthritis,  and  the  changes 
found  in  the  synovial  membrane  of  the  knee  are  found  also  in  the  synovial  membrane 
lining  the  bursa,  for  the  two  are  continuous.  When  much  fluid  is  present,  fluctuation 
can  be  detected  between  the  joint  and  the  bursa. 

The  bursa  under  either  of  the  two  heads  of  the  gastrocnemius  muscle  may  be  enlarged 
similiuly.  but  tliis  is  rare. 

Baker's  Cyst  occurs  in  connection  with  chronic  tuberculosis  of  the  knee-joint,  and  is 
formed  by  the  extension  of  a  chronic  abscess  which  spreads  along  a  plane  of  fascia.  Such 
an  abscess  may  present  itself  in  the  popliteal  space.  The  condition  of  the  knee-joint  will 
indicate  the  disease. 

Varicose  Veins  are  often  present ;  the  diagnosis  presents  no  diliiculties,  as  the  veins 
in  the  lower  part  of  the  leg  will  be  varicose  also. 

Acute  Abscess  is  recognized  by  the  signs  of  acute  inflammation  ;  the  skin  is  red  and 
a"dematous,  the  pulse  and  temperature  are  raised,  and  the  swelling  is  very  painful.  The 
knee  is  kept  flexed  in  order  to  minimize  the  tension  of  the  part.  The  abscess  may 
be  caused  by  suppurating  lymphatic  glands  or  by  suppurative  periostitis  or  necrosis  of 
the  lower  end  of  tlie  fenuir.  In  the  former  case  the  abscess  will  be  superficial,  and  in  the 
latter  deep  to  the  popliteal  vessels. 

Aneurysm  of  the  Popliteal  Artery  {Plate  XXX)  gives  rise  to  an  expansile  pulsating 
tiuuour,  the  pulsation  being  synchronous  with  the  heart's  beat.  Pressure  on  the  femoral 
artery  above  will  cause  a  diminution  in  size  of  the  swelling  and  cessation  of  pulsation. 
The  pulse  at  the  ankle  on  the  affected  side  may  be  smaller  than  that  on  the  opposite,  and 
delayed.  If  a  stethoscope  be  placed  over  the  swelling  a  distinct  bruit  can  be  heard.  The 
complaint  of  the  patient  will  probably  be  of  pain,  which  may  be  referred  down  the  leg  if 
either  popliteal  nerve  is  pressed  on,  or  in  the  site  of  the  swelling  if  the  bone  is  eroded. 
Varicose  veins  are  almost  always  present  also,  on  account  of  pressure  on  the  popliteal  vein. 
Owing  to  its  pulsatile  character,  an  aneurysm  is  not  often  mistaken  for  anything  else,  but 
it  must  be  remembered  that  every  swelling  that  pulsates  is  not  an  aneurysm.  A  soft 
vascular  sarcoma  growing  from  the  end  of  the  femur  may  be  pulsatile,  and  over  it  a  bruit 
may  be  heard,  but  the  tumour  is  not  as  compressible  as  an  aneurysm,  and  the  effects  on 
the  distal  pidse  are  not  so  marked.  A  skiagram  will  usually  settle  the  question  at  once. 
Distinction  must  also  be  drawn  between  a  tumour  that  pulsates  and  a  tiunour  to  which 
pulsation  is  communicated.  For  instance,  an  abscess  or  a  solid  swelling  lying  o^'er  the 
jjopliteal  artery  may  appear  to  pulsate,  but  the  movement  is  heaving  in  character  and  not 
expansile.  In  the  rare  event  of  an  aneurysm  having  become  filled  with  clot  it  might  be 
taken  for  a  solid  tiunour  growing  either  from  the  soft  parts  or  from  the  bone.  Under  this 
delusion  a  leg  has  been  amputated  for  sarcoma. 

SOLID    SWELLINGS    NOT    CONNECTED    WITH    BONE. 

Enlarged  Glands. — It  is  not  eonunon  to  find  the  popliteal  glands  enlarged  from  any 
cause.  It  is  possible  that  they  nuiy  become  infected  with  pyogenic  organisms  from  a 
.sore  on  the  back  of  the  leg. 

Tumours  are  rare.  They  may  be  innocent,  e.g.,  lipoma  ;  or  sarcomatous,  starting 
in  the  connective  tissue  of  the  popliteal  space,  or  attached  to  one  of  the  muscles.  The 
innocent  tumours  are  of  long  history  and  well  defined  ;  the  malignant,  rapidly  growing 
and  infiltrating. 

SOLID    SWELLINGS    CONNECTED    WITH    BONE. 

In  all  cases  of  bony  tumour  a  skiagram  is  of  inunense  service,  and  should  always  be 
obtained  if  possible. 

Innocent  Tumours. — Cancellous  exostoses  may  be  found,  generally  in  children  and 
young  adults,  growing  from  the  region  of  the  epiphyseal  cartilage  of  the  fenuir  {Fig.  281, 


PLATE     XXX 


POPLITEAL      ANEURYSM 


/     ^ 


y 


/ 


lirjiroduccd  by  pirmissiim  from  it  iriilir-riifitur  pninliiifj  in  the  tltinhin   Must 
i:iii/.i  iiiitiiiiiil. 


iii:x    OF    iiiai:nosi.s  — To  /««  /<.  i 


SWELLING.,  PULSATILE  693 

p.  670).  There  may  be  others  in  other  parts  of  the  skeleton,  and  sometimes  several 
members  of  the  family  are  affected  similarly.  The  swelling  is  of  slow  growth,  well  defined, 
and  rarely  gives  any  trouble.  It  is  most  often  found  at  the  inner  side  of  the  popliteal 
space.  There  is  one  thing  that  may  be  confounded  with  it,  namely,  ossiflcntion  of  the 
insertion  of  a  tendon  or  nuisele.  The  adductor  longus  muscle  is  the  one  most  commoidy 
affected. 

Malignant  Tumours  are  endosteal  and  periosteal  sarcoma.  Central  soreoma  in  its 
early  stages  resembles  chronic  osteitis  and  periostitis  so  closely  that  it  may  be  impossible 
to  come  to  a  correct  conclusion  without  the  aid  of  a  skiagram.  With  this  help  the  diffi- 
culty vanishes,  for  a  myeloid  tumour  is  seen  clearly  as  a  well-defineil  tumour  causing 
enlargement  of  the  bone  (compare  Figs.  28J-,  286,  287,  pp.  672,  673). 

Periosteal  snrcomn  causes  a  general  enlargement  of  the  whole  of  the  lower  end  of  the 
femur  or  ujjpcr  end  of  the  tibia  {Fig.  28;j,  p.  671 ),  not  swelling  in  tlie  popliteal  space  only. 
It  is  mentioned  here  because  of  its  occasional  confusion  with  periostitis  and  popliteal 
necrosis. 

Periostitis. — Popliteal  necrosis  with  abscess  formation  may  give  rise  to  a  big  swelling. 
The  signs  of  inflammation  will  usually  be  well  marked  and  accompanied  by  constitutional 
.symjjtoms  and  leucocytosis.  Chronic  ]>eriostitis,  or  chronic  abscess  of  the  bone,  or  central 
necrosis,  may  be  extremely  difhcult  to  distinguish  from  a  periosteal  sarcoma.  A  skiagram 
should  be  taken,  and  if  necessary  an  incision  made  down  to  the  timiour  for  a  piece  to  be 
removed  for  histological  examination.     (See  .Swelling  on  a  Bone,  p.  667.) 

Separation  of  the  Epiphysis. — In  the  somewhat  rare  accident  of  separation  of  the 
lower  <i)ii)hysis  of  ilie  femur,  the  lower  fragment  becomes  displaced  backwards,  forms  a 
prominciuf  in  the  jmpliteal  space,  and  j)re.sses  on  the  vessels,  sometimes  to  a  dangerous 
extent.  George  E.  Onsk. 

SWELLING,  PULSATILE.  -When  a  tumour  can  be  felt  pulsating,  the  first  point 
to  decide,  if  |)i)ssihlc.  is  wliethcr  the  pulsation  is  expansile  or  whether  it  is  merely  trans- 
mitted by  a  non-expansile  tumour  which  is  in  direct  contact  with  large  pulsating  vessels. 
The  distinction  is  sometimes  obvious,  especially  when  the  tumour  has  developed  in  a  place 
where  there  are  no  particularly  large  blood-vessels  to  transmit  jiulsation,  for  instance  in 
the  foot,  or  in  direct  connection  with  a  long  bone  at  some  spot  not  immediately  adjacent 
to  the  main  artery  of  the  limb.  The  chief  difficulty  ari.ses  when  the  mass  is  either  in  the 
root  of  the  neck  or  in  the  abdomen  and,  to  a  less  extent,  when  it  is  in  the  axilla,  the  inner 
aspect  of  the  u|)per  arm,  in  front  of  the  elbow,  in  the  groin,  or  in  the  popliteal  space, 
t'aref'ul  i)Hlpation  is  |)i'obably  the  best  means  of  determining  whether  there  is  actual  expan- 
sile pulsation  or  not  ;  in  the  case  of  the  abdomen  It  is  important  to  examine  the  patient 
not  only  when  he  lies  on  his  back,  but  also  in  tlu'  kiicc-elbow  posture,  for  sometimes  a 
tumour  which  is  in  contact  with  the  aorta  in  the  former  position  falls  away  from  it  and 
ceases  to  transmit  pulsation  in  the  latter. 

If  it  can  be  decided  dcllnitely  that  the  tumour  is  itself  pulsiiting,  most  probably  it 
is  cither  an  oneiiri/sni  of  an  artery  or  else  a  very  vascular  growth,  espeeially  osteosorcomn. 
The  existence  of  egg-shell  crackling  with  pulsation  in  a  tumour  would  be  highly  suggestive 
of  osteosarcoma,  though  it  is  conceivable  that  it  might  also  be  felt  over  an  aiieur\stn  that 
had  extensively  eroded  the  adjacent  bones,  .\ncurysm  will  be  the  probable  diagnosis 
when  the  markedly  pulsatile  swelling  occurs  directly  along  the  course  of  a  known  artery. 
Absence  of  pulsation  does  not,  however,  exclude  aneurysm,  for  the  latter  may  either  be 
situated  loo  deeply  for  the  pulsation  lo  be  fell,  or  else  the  sac  may  be  filled  parll\-  or  wholly 
by  organi/.ed   or  orguiii/ing  clot. 

Sometimes  there  may  be  doubt  as  to  whether  there  is  really  pulsation  or  not,  when 
(ligilal  examination  alone  Is  relied  upon  :  In  such  cases,  direct  application  <il'  llie  car  to 
till-  part  In  such  a  way  that  the  plima  Is  In  uniform  contact  with  the  iiallenl's  skin  will 
sometimes  briny  pulsation  lo  the  notice  very  clearly  when  Its  amount,  .•ippreclable  to  the 
membrana  tynipani.  Is  too  slight  for  the  hand  to  detect  ;  this  applies  particularly  to  deep- 
sealed   intrathoiacle  aneurysms. 

It  must  be  remembered,  on  the  oilier  hand,  that  marked  pulsation  may  suggest 
aneurysm  without  any  being  prisiiit.  particularly  at  the  root  of  the  neck  and  in  the 
abdomen  {Fig.  288)  ;    a  normal    subclavian    artery  may  sometimes  seem    to  be  abnormal 


694 


SWELLING.     PULSATILE 


particularly  if  it  is  pushed  forward  or  displaced  by  a  mass  below  or  behind  it.  for  instance 
an  accessory  cervical  rib.  Undue  pulsation  of  the  abdominal  aorta,  especially  in  women, 
is  also  to  be  remembered  as  a  possible  source  of  erroneous  diagnosis  (see  Pulsation,  Undue 
Abdominal  Aortic,  p.  543). 

It  should  also  be  remembered  that  normal  arteries  cause  very  violent  pulsation  in 
cases  of  marked  aortic  regurgitation,  and  in  severe  cases  of  exophthalmic  goitre,  in  which 
the  whole  neck,  including  the  enlarged  thyroid  gland,  may  be  seen  to  be  pulsating  vigor- 
ously. 

We  need  not  here  discuss  in  detail  the  differential  diagnosis  between  one  kind  of 
aneurysm  and  another,  thougli  one  might  mention  in  particular  the  so-called  cirsoid 
aneurysm  of  the  scalp  (Plate  XXXI),  which  is  rather  a  conglomeration  of  many  abnormally 
dilated  arteries  in  the  form  of  an  arterial  n.Tvus  than  a  true  aneurysm.  Its  position  on 
the  scalp  will  at  once  suggest  the  diagnosis. 

A   indsatile   orbital   timiour  will   generally   be   due   either  to   an   osteosarcoma,  or  to 

an  arterio-venous  aneurysmal  communication 
between  the  internal  carotid  artery  or  its 
ophthalmic  branch,  and  the  cavernous  sinus. 
The  jjresence  of  a  loud  bruit  would  be  in 
favour  of  the  latter. 

It  is  im|)()rtant  not  to  mistake  for  the 
ordinary  j5idsatile  tumours  those  which  may 
move  synchronously  with  respiration,  for 
instance  hernia  jnilmonalis,  hernia  cerebri,  and 
certain  congenital  abnormalities  of  the  brain 
and  spinal  cord,  such  as  meningomyelocele 
(Fig.  102,  p.  230). 

It  is  unlikely  that  a  pulsatile  liver  will  be 
mistaken  for  any  other  kind  of  pulsatile 
tumour.  The  cases  in  which  it  occurs  are 
those  of  chronic  failure  of  cardiac  compensa- 
tion, generally  mitral  stenosis  and  tricuspid 
stenosis  with  oedema  of  the  legs,  lividity, 
ortho)3noea,  and  perhaps  ascites,  which  have 
generally  been  present  for  some  time  before  the 
nutmeg  liver  becomes  obviously  pulsating. 

Rarely,  the  cardiac  pulsations  may  be 
transmitted  direct  to  fluid  contained  in  a 
pleural  cavity,  so  that  the  bulging  intercostal 
spaces  may  pulsate  synchronously  with  the 
radial  artery  and  simulate  some  more  serious 
pulsatile  tumour.  The  history  and  the  physical 
signs,  including  displacement  of  the  heart 
towards  the  opposite  side,  will  generally 
indicate  the  correct  diagnosis,  though  there  may  be  some  trepidation  on  the  part  of  the 
operator  who  decides  to  insert  the  exploring  needle  into  the  pulsating  swelling. 

Herbert  French. 
SWELLING  OF  THE  SALIVARY  GLANDS. 

Epidemic  Parotitis — Mumps — is  the  eonmionest  cause  of  swelling  of  the  salivary 
glands  :    it  is  discussed  on  ]).  017. 

Infective  Parotitis  is  characterized  by  a  sudden,  acute  and  generally  imilateral 
enlargement,  and  is  accompanied  often  by  a  rise  of  temperature  or  a  rigor.  It  is  not  an 
unconnnon  complication  in  certain  specific  fevers,  e.g.,  tyjihoid  fever  and  pneumonia  ;  and 
in  surgical  practice  it  may  complicate  any  septic  case,  but  especially  abdominal,  pelvic 
and  genito-urinary  oi^erations,  jiuerperal  infection,  and  pyemia.  Resolution  usually 
occurs,  but  suppuration  may  ensue. 

Salivary  Calculus. — A  calculus  may  be  found  in  Stenson's  duct,  but  is  more  common 
in  the  duct  of  the  submaxillary  gland.  In  the  early  stages  such  a  calculus  gives  rise  to 
sudden  intermittent  swelling  of  the  affected  gland  at  times  when  the  stimulus  of  food  gives 


Fit/.  28S. — Photograph  illustrating  the  difficulty 
which  may  arise  in  diagnosing  between  abdominal 
aneiu-ysm  and  carcinoma  of  the  stomach.  This 
patient  bad  :i  Ijil'i-  rmunled  epigastric  tmnom- 
(demarcated  h\  iMiniinu-  \miIi  ink  before  the  photo- 
graph was  tHkrt.i  «lii.li  imlsuted  forcibly,  and  the 
pulsation  seemed  tci  In-  expansile.  Aneurysm  of  the 
cceliac  axis  was  diagnosed,  but  post-mortem  examina- 
tion revealed  a  large  carcinoma  of  the  stomach,  and 
no  aneurysm. 


PLATE     XXXI 


CIRSOID      ANEURYSM 


J 


Itrpradui'til  bij  permb 


on  from  a  ira/rr-o/niir  piiinliiij  in  the  ihmlon   .Uiisni 
iiuij's  I/o.s/iilal. 


INDKX     OF     DrAflNOrilS— 7'o  face  p.  091 


SWELLING.     SCROTAL  695 

rise  to  active  secretion  of  saliva.  As  the  result  of  long-standinii  distention  and  chronic 
inflammation,  the  gland  may  become  permanently  swollen.  The  diagnosis  of  stone  may 
be  made  with  the  finser  in  the  mouth,  by  pricking  the  calculus  with  a  needle  through  the 
buccal  mucous  membrane,  by  i)assing  a  fine  probe  iij)  the  duct  and  feeling  the  grating  on 
the  stone,  and  by  tlie  use  of  tlie  ,i'-rays. 

Parotid  Tumours.  -Hotli  innocent  and  malignant  tumours  arise  in  the  parotid  gland. 
The  innocent  tumours  (fibromyxoma,  endothelioma,  teratoma)  are  encapsulcd,  grow 
slowly,  press  aside  the  rest  of  the  parotid  gland,  shell  out  freely,  and  if  removed  do  not 
recur.  If  left  alone  they  may  attain  a  large  size  in  the  course  of  years.  The  malignant 
tumours  (sarcoma  and  carcinoma)  grow  rapidly,  soon  affecting  the  whole  gland,  extending 
deeply  among  the  important  structures  behind  the  ramus  of  the  jaw  and  soon  involving 
the  facial  nerve,  causing  facial  i)alsy. 

The  diagnosis  has  to  be  made  from  sim])le  enlargements  of  the  gland  and  from  enlarge- 
ment of  the  pre-nuricular  lymphatic  glands  due  to  infection  with  pyogenic  organisms, 
tubercle,  or  syphilis. 

Tumours  in  the  Submaxillary  Salivary  Gland  are  similar  to  but  rarer  than  those 
whicli  occur  in  the  parotid  gland. 

Bilateral  Salivary  Swelling — Miculicz's  Syndrome. — This  condition  is  characterized  by 
a  chronic  bilateral  swelling  of  the  parotid,  submaxillary,  and  sublingual  salivary,  together 
in  many  cases  with  simultaneous  swelling  of  the  lachrymal  glands  {Fig.  3,  p.  25),  and  it  is 
sometimes  associated  with  enlargement  of  the  spleen  and  lymphatic  glands,  and  with  changes 
in  the  blood.  The  general  appearances  of  the  face  are  those  of  peisistent  nnnnps,  so  to 
speak.  The  syndrome  is  not  a  disease  in  itself,  but  results  most  often  from  hpnphadenoma 
or  li/inphntic  leiikwmia  ;  less  often  from  some  infection,  including  tiihcrcitlnsis  and 
secondary  si/pliilis.  A  few  eases  have  been  attributed  to  gaul.  Each  case  should 
be  investigated  for  any  source  of  pyogenic  infection  from  the  mouth  or  gums,  for  syphilis 
by  the  Wassermann  test,  for  leukicmia  by  blood  examination  (p.  21),  and  for  any  evidence 
elsewhere  of  tuberculosis.  (leorge  K.  Cask. 

SWELLING,  SCROTAL. -It  is  first  essential  to  prove  that  the  swelling  is  really 
limited  to  the  scrotal  region,  and  this  is  best  done  by  grasping  the  root  of  the  scrotum 
between  the  fingers  and  thumb,  and  thus  ascertaining  if  the  swelling  does  or  does  not 
extend  into  the  inguinal  region  along  the  cord.  Failure  to  take  this  obvious  precaution 
has  led  to  the  ta])ping  of  a  hernia  with  disastrous  results.  True  scrotal  swellings  may 
arise  in  any  of  the  following  tissues  :  (1)  Skin:  (2)  The  various  connective-tissue  coverings 
of  the  testicle:  (:$)  Timica  vaginalis:  ( t)  Testicle:  (5)  Epiilidymis  ;  (0)  The  lower  end 
ol  the  spermatic  cord  :    (7)   TIk'  unllira  :    (S)   'I'lie  bones  of  tlie  pubic  arch. 

1.  '1  he  nature  of  swellings  affecting  the  Skin  is  usually  obvious.  The  only  conmion 
ones  arc  :  Boils,  soft  sores  and  chancre,  sebaceous  cy.sts,  warts,  and  epithelioma. 
Tlic  latter  soon  ulcerates,  commonly  occurs  in  sweeps,  and  the  groin  glands  soon  become 
<-nlarged. 

2.  Swellings  of  the  various  Connective-tissue  Coverings  are  very  rare,  but  occasion- 
ally a  librosareoma  may  oeciu'.  These  swellings  are  movable  upon  the  leslii'lc.  The 
symmetrical  enlargement  eallcil  ilcifhiiiilidsis  si-ri)ti.  due  to  the  Filiiriii  .simgiiiiiis  liiiniinis, 
is  limited  to  the  tropics. 

:i.  The  Tunica  Vaginalis  may  become  distended  with  Ihiid.  thus  forming  the  ordinary 
vaginal  hi/drocrlc.  I^xcepl  in  late  eases  this  is  translucent,  anrl  is  thus  distinguished  from 
a  lia'matocelc  of  the  same  cavity.  It  should  not  be  forgotten  that  a  liydroccle  with  thick 
walls  may  fail  (o  gi\c  transhieeiicy.  When  pro\cd  to  be  translucent,  it  has  lo  be  distin- 
guished from  encysted  hydrocele  of  the  epididymis  and  encysted  hydrocele  of  the  cord. 
Vaginal  hydrocele  occupies  the  lower  part  of  the  scrotum  and  ciivclo/is  llic  trsliclc,  which 
cannot  be  felt  as  a  sc])aratc  ol)|ccl.  Kiic/ixlnl  hi/diorelr  of  the  rpidiiljiwis  is  placed  behind 
and  (ihovr  llic  Icsliclv,  from  which  it  is  distinet.  allliough  attached  at  the  upper  and  posterior 
part.  Moreover,  this  xariety  of  livdroeele  never  allains  a  large  size,  rarely  g<lling  larger 
than  a  tangerine  orange.  It  is  not  tightly  distended,  but  is  usually  nal)by,  and  it  eout;iins 
a  characteristic  niilUy  lluid  in  which  cholesterin  crystals  {Fig.  I2I.,  p.  251)  arc  present. 
Enci/slfd  hi/didiTlr  of  the  curd  is  plae<-d  (diiivr  Ihf  li:\tirli\  which  can  be  felt  as  a  sc|)arate 
objccl.      It    nircly  allains  a   large  si/.c,  and   is  often  elli|ilieMl   in  sliape,  exiendiiig  upwards 


696  SAVELLING.     SCROTAL 

along  the  cord.  All  the  hydroceles  fluctuate.  To  test  for  this  it  is  necessary  to  fix  the 
swelling  against  some  hard  object.  Bleeding  may  occur  into  any  of  them  as  a  result  of 
injury  or  constitutional  disease.  It  is  almost  impossible  to  distinguish  between  an  opaque 
hydrocele  and  a  hsematocele  without  tapping  the  swelling.  In  syphilitic  disease,  with 
irregular  adhesion  between  the  parietal  and  the  visceral  walls,  a  loculated  hydrocele  may 
occur. 

4.  Swellings  of  the  Body  of  the  Testicle  may  be  inflanmiatory  or  neoplastic. 
Acute  inflammatory  swellings  rarely  attain  a  large  size,  and  they  are  usually  associated 
with  enlargement  of  the  epididymis,  and  occur  as  a  part  of  acute  epididymo-orchitis  due 
to  urethritis  of  some  kind,  or  to  mumps  or  as  a  post-ti/plioiflal  phenomenon.  Chronic 
inflammatory  swellings  give  rise  to  more  difficulty.  They  are  usually  either  tuberculous  or 
syphilitic,  or  else  due  to  chronic  torsion.  In  the  former  disease,  swelling  of  the  epididymis 
is  practically  always  primary  and  more  advanced  ;  but  in  infants  the  body  of  the  testis 
becomes  involved  at  a  very  early  stage.  The  enlarged  epididymis  can  be  felt  enveloping 
the  posterior  border,  and  the  upper  and  lower  poles  of  the  testicle.  There  is  often  a  little 
hydrocele  which  may  obscure  the  shape  of  the  testicle.  If  there  is  adhesion,  with  perhaps 
an  abscess  or  a  sinus  at  the  posterior  and  lower  part  of  the  scrotum,  it  is  characteristic 
of  suppurative  disease  of  tlie  epididymis,  usually  of  a  tuberculous  nature.  Moreover,  in 
tuberculous  disease  the  vas  is  thickened,  usually  in  a  nodular  manner.  It  is  important 
to  examine  all  the  palpable  part  of  the  vas,  for  sometimes  tiie  nodules  are  limited  to  the 
inguinal  region.  Von  Pirquet's  tuberculin  reaction  is  a  valuable  aid  if  its  limitations  are 
remembered.  In  striking  contrast  with  this,  sypliihtic  enlargement  of  the  testicle  leaves 
the  e])ididymis  imaffected,  and  is  limited  to  the  testicle,  which  enlarges  unevenly,  often 
affecting  the  tunica  albuginea  and  the  tunica  vaginalis  in  a  nodular  manner.  The  syphilitic 
testicle  rarely  attains  three  times  the  natural  size.  It  is  curiously  devoid  of  pain.  The 
testicular  sensation  is  often  lost,  and  there  is  little  or  no  thickening  of  the  cord.  Its 
anterior  surface  is  uneven  and  may  become  adherent  to  the  coverings,  which  may  later 
ulcerate,  and  ultimately  give  rise  to  a  hernia  testis  on  the  front  of  the  swelling.  This 
contrasts  with  the  postero-infero-lateral  position  of  tuberculous  sinus  or  hernia  testis. 
Chronic  torsion  of  the  testis  is  generally  the  result  of  a  blow,  or  of  an  injury  in  the  saddle  ; 
the  symptoms  may  be  obscure  until  the  testicle  begins  to  swell.  Operation  is  generally 
resorted  to  with  the  idea  that  the  condition  is  tuberculous  or  malignant,  and  even  then 
the  diagnosis  may  be  in  doubt  until  microscopical  examination  of  the  organ  has  been 
made. 

It  is  often  very  difficult  to  distinguish  syphilitic  enlargement  of  the  testicle  from  that 
due  to  groivth  ;  but  a  course  of  large  doses  of  antisyphilitic  remedies  and  the  Wassermann 
reaction  may  settle  the  matter.  JMalignant  new  growth  nearly  always  grows  steadily, 
and  being  entirely  within  the  tunica  albuginea  it  maintains  the  shape  and  smooth  surface 
of  the  testicle  until  it  reaches  a  size  much  larger  than  that  of  a  syphilitic  testicle. 
Moreover,  it  causes  much  more  pain,  and  usually  some  thickening  of  the  cord,  with  later 
enlargement  of  the  glands  in  the  pelvis.  In  some  cases  the  diagnosis  between  syphilitic 
testicle,  growth,  and  hiematocele  may  be  so  ditficult  and  so  urgently  necessary  as  to 
demand  an  exploration. 

Malignant  growths  of  the  testicle  can  be  divided  into  four  varieties  :  (a)  Carcinoma  ; 
(b)  Sarcoma  ;    (c)  Embryoma  ;    (rf)  Endothelioma. 

Carcinoma  is  far  more  conmion  than  sarcoma,  although  tlie  contrary  has  been 
believed  for  many  years,  owing  to  the  fact  that  many  carcinomatous  growths  with  small 
alveoli  have  been  wrongly  labelled  sarcoma.  The  average  age  of  patients  with  carcinoma 
testis  is  43,  and  of  those  with  sarcoma  testis,  34.  The  average  duration  of  carcinoma 
before  operation  is  1|  years  ;  of  sarcoma,  11  months.  Sarcoma  advances  much  more 
rapidly  and  kills  earlier  than  carcinoma.  The  former  disseminates  through  the  veins, 
whereas  the  latter  travels  along  the  lymphatics  and  infects  the  lumbar  glands. 
Embryoma  is,  according  to  Nicholson,  "  the  commonest  new  growth  of  the  testicle,  but 
it  is  often  overlooked."  It  can  be  shown  to  contain  structures  derived  from  all  the  three 
blastodermic  layers  of  the  embryo.  The  average  age  at  the  time  of  operation  is  29,  the 
average  known  duration  before  operation  is  5^  years.  "  Although  not  necessarily 
malignant,  it  may  produce  metastases  composed  of  all  the  tissues  of  the  primary  growth, 
or  one  tissue  may  become  actively  malignant,  in  which  case  the  deposits  will  be  formed  of 


SWELLING.     SCROTAL  697 

that  tissue  alone."  It  may  spread  along  the  lymphatics  or  disseminate  thrmioh  the 
veins. 

5.  The  Epididymis  may  become  enlarged  as  the  result  of  («)  Inflammation  ;  (h)  New 
growth  ;    (c)  Cystic  degeneration. 

a.  Iiiflummatori)  sivellhigs  are  characterized  by  being  elongated  in  a  vertical  direc- 
tion ;  by  their  relation  to  the  testicle,  which  they  overlap  at  its  posterior  border,  and  its 
upper  and  lower  poles  :  and  lastly,  by  being  flattened  from  side  to  side,  so  that  the  antero- 
posterior diameter  is  greatly  increased.  Inflammatory  swellings  may  be  : — (i)  Gonor- 
rhoea! ;    (ii)  Septic,  secondary  to  some  other  form  of  urethritis  :    (iii)  Tuberculous. 

i.  The  gonnrrlioeal  variety  is  distinguished  by  its  acutencss,  great  tenderness,  the 
surrounding  oedema,  and  tlie  bacteriological  examination  of  the  urethral  discharge.  Its 
onset  is  usually  between  the  second  and  tenth  week.  Occasionally  a  subacute  form 
develops  later,  at  any  time  during  the  course  of  gleet.  Tliis  is  very  diflicult  to  distinguish 
from  the  tuberculous  variety.  Most  cases  of  tuberculous  epididymitis  end  in  suppuration, 
but  the  gonorrhtral  variety  very  rarely  breaks  down. 

ii.  The  inflammation  of  the  epididymis  following  otiier  varieties  of  urethritis  (such  as 
ulceration  near  a  stricture  or  due  to  impacted  calculus,  instrumentation,  or  prostatec- 
tomy), is  often  sufficiently  indicated  by  the  history  if  care  be  taken  to  go  into  this 
thoroughly.  Tlie  swelling  following  prostatectomy  is  apt  to  suppurate.  Some  of  these 
can  be  mistaken  very  easily  for  tuberculous  disease. 

iii.  Tuberculous  epididymitis,  as  a  rule,  is  far  more  insidious  and  painless  in  its  onset 
than  otlier  forms  of  epididymitis  :  but  it  should  not  be  forgotten  that  early  subacute  or 
even  acute  attacks  of  inflammation  may  accompany  this  disease,  and  that  these  are  often 
the  means  of  drawing  the  patient's  attention  for  tlie  first  time  to  a  disease  wliich  has  been 
going  on  insidiously  for  some  months.  It  has  frequently  been  said  that  tuberculous  nodules 
are  limited  to  the  globus  major,  and  that  those  left  after  gonorriia-al  urethritis  are  confined 
to  the  globus  minor.  It  is  more  true  to  say  that  the  latter  are  limited  to  the  globus  minor, 
whereas  tuberculous  disease  may  attack  any  part  of  the  epididymis.  Wherever  the 
tuberculous  disease  starts,  the  inflammatory  products  soon  spread  through  the  thin  fibrous 
capsule  of  the  epididymis,  and  then  gravitate  towards  the  postero-infero-latcral  corner 
of  the  scrotum,  where  adhesion  occurs,  followed  later  by  an  abscess  and  a  sinus.  In  the 
diagnosis  of  tuberculous  from  other  forms  of  epididymitis,  the  general  state  of  health, 
and  especially  the  presence  or  absence  of  other  tuberculous  lesions,  are  of  great  importance. 
Nodular  thickening  of  the  vas  deferens  and  of  the  vcsicula-  seminales  and  prostate  are  also 
valuable  signs  when  the  disease  is  well  advanced.  It  should  be  remembered  that  the 
disease  travels  upwards  along  the  vas,  so  that  in  its  early  and  hopeful  stages  tlie  upper 
part  of  the  vas  and  vesiculie  .seminales  are  not  enlarged. 

h.  I'rimarji  neiv  growth  of  the  epididymis  is  excessively  rare,  so  that  it  need  not  give 
rise  to  nmch  concern  in  diagnosis  :  it  will  generally  be  regarded  as  tubercle  until  after 
operation  and   niicroseopieal  examination  of  part  of  the  tissue  excised. 

f.  Ci/stir  disease  of  the  epididymis  may  occur  in  the  form  of:  (i)  .Solitary  cysts  (vide 
supra)  ;  (ii)  .Multiple  cysts.  The  latter  condition  rarely  occurs  except  in  men  past  middle 
age,  and  is  analogous  to  cystic  degeneration  of  the  breast.  The  condition  is  almost  painless 
and   harmless.      These  swellings  arc  "(raiishiccnl . 

•i.  Swellings  of  the  Lower  End  of  the  Cord.  'I'lic  mosl  important  swelling  of 
the  lower  part  of  the  spermatic  cord  is  viirietieele.  It  is  apt  to  be  mistaken  for  omental 
hernia,  but  the  mistake  should  never  be  made,  because  of  the  characlcristie  feel  of  the 
varicocele,  and  the  reappearance  of  the  swelling  after  it  has  been  complclely  riihieed  and 
the  linger  is  (irmly  jiresseil  on  the  external  abdominal  ring. 

T.  Urethral  Conditions.  -Occasionally  a  peri-urethral  iihscess  may  form  a  swelling 
in  the  scrotum.  Tenderness,  (rdeiiia.  and  fluctuation,  together  with  the  history  and 
evidence  of  urethral  disease,  serve  to  make  the  diagnosis  clear.  I'riuDiri/  e/iilliiliiiuKi  of 
the  urethra  is  distinguished  by  the  great   pain  and  urethral  obstruction  that   it  (•ngenders. 

M.  Diseases  of  the  Pubic  Bones.  Inflammatory  iiroducis  may  travel  into  the 
scrotum  from  disease  of  the  bones  of  the  pubic  arch,  especially  from  the  neighbourhood 
of  the  symphysis  (luhis.  Acute  necrosis  of  these  bones  is  sullieiently  indicated  by  the  grave 
constitutional  symptoms  which  always  accompany  if.  Caries  gives  rise  to  more  diflieiflty. 
The  writer  has  Uiiown  a  ease  of  luhirculous  caries  of  the  lower  part  of  the  symphysis  pubis 


Haemorrhage  with  swelling  of  tongue,  as  in 
scurv-v',  leukaemia  and  other  causes  of 
purpura  (p.  552). 


698  SWELLING.     SCROTAL 

in  which  tlie  inflammatory  products  gravitated  backwards  and  to  the  left,  so  as  to  form 
a  large  firm  swelling  in  the  left  half  of  the  scrotum,  where  it  gave  rise  to  much  difficulty 
in  diagnosis,  and  was  thought  to  be  either  a  sarcoma  arising  from  the  fibrous  covering  of 
the  crus  penis,  or  possibly  a  gummatous  mass  in  the  same  situation.  Sufficient  attention 
was  not  paid  to  the  fact  that  the  man  had  chronic  phthisis.  George  E.  Gask. 

SWELLING  OF  THE  TONGUE  is  a  condition  the  nature  of  which  is  generally 
obvious  on  inspection  and  |):il|)ati()ii.  if  the  history  is  taken  into  account  at  the  same  time, 
and  many  of  the  causes  given  in  the  following  list  need  little  detailed  discussion  : — 

1.  Causes   of  Acute    Swelling   of   the   Tongue: 

A  bite  or  sting — wasp-sting  for  example  (4).  Variola 

Injury,  for  instance  by   a  fish-bone,  or  by  (5).  Serum   injections  and   other   con- 

biting  during  an  epileptic  fit  ditions    liable    to    cause    giant 

Angina"  Ludovici  urticaria 

Corrosives  or  acute  irritant  applications  (6).  .\ngioneurotic  oedema 

.4cute  oedema,  secondary  to  : —  j  (7).  Raynaud's  disease 

(1).  Inflammatory     conditions     within 
tlie  mouth — Stomatitis  (p.  542) 
(2).  The     effects     of     certain     drugs, 

especially  mercury 
(3).  Erji;hema  bullosum  or  pemphigus   I 
(p.  98) 

2.  Causes  of  Chronic  or  Persistent  Swelling  of  the  Tongue  : 

(1).   }\'li(rc  the  s-ivelling  is  general  : — 

Macroglossia  |    Myxoedema  |    Acromegaly 

Cretinism  1    Mongolian  idiocy  |    Chronic  dyspepsia. 

(2).   }\'liere  the  swelling  is  loeal  or  asi/nnnetrieal  : — 

Irritation  by  a  tooth-  ,    Gumma  i    Ranula 

plate     or     decayed  ;    Tuberculous  infiltration  ■    Su])rahyoid  cyst 

tootfi  Actinomycosis  I    Angioma 

Epithelioma  Calculus      in      a      sublingual    ,    Sarcoma. 

Leukoplakia   (chronic  salivary  gland  j 

superfieial  glossitis)  I  I 

If  the  nature  of  the  tongue  enlargement  is  not  obvious  from  the  history  and  simple 
inspection  and  palpation,  as  will  probably  be  the  case  when  it  is  due  to  a  bite,  sting,  injury, 
corrosive  or  irritant  application,  after  the  use  of  tnercury.  serum,  or  other  drugs,  variola  or 
pemphigus — it  may  be  so  from  the  concomitant  symptoms,  as  in  the  case  of  cretinism  (p. 
234),  acromegaly  (p.  237),  mongolian  idiocy  (p.  190).  or  myxoedema  (\).  38).  The  swollen 
tongue  of  dyspepsia  is  seldom  very  large,  though  it  may  cause  the  patient  discomfort  at 
times  from  the  sense  of  its  being  too  big  for  the  mouth ;  it  is  seldom  difficult  to  recognize 
from  its  pale  flabby  look  and  its  marginal  indentation  by  the  teeth. 

Simjsle  macroglossia  is  rare  ;  when  it  does  occur,  the  history  is  that  it  dates  from  \'outh 
or  childhood,  and  the  patient  may  otherwise  be  perfectly  normal,  unless  he  also  has  some 
other  congenital  peculiarity,  such  as  macrocheilia  (blubber-lips). 

The  chronic  local  lesions  associated  M'ith  swelling  are  in  many  cases  associated  with 
superficial  ulceration,  and  the  difficulties  that  may  arise  in  distinguishing  simple,  syphilitic 
and  epitheliomatous  trouble  are  discussed  imder  Ulceration  of  the  Tongue  (p.  738). 
Tuberculous  and  actinomycotic  lingual  mischief  are  both  ^'ery  rare,  and  on  that  very  account 
may  Ije  mistaken  for  malignant  or  syphilitic  disease  imless  bacteriological  or  histological 
methods  of  diagnosis  are  resorted  to.  Ranula  and  sublingual  salivary  gland  calculus  or 
cyst  both  cause  swellings  that  are  beneath  tlie  front  part  of  the  tongue  rather  than  in  its 
substance  :  generally  bulging  up  one  .side  of  the  floor  of  the  mouth  near  the  fra'num 
linguae.  A  ranula  is  a  distended  mucous  gland,  and  after  enlarging  slowly  to  the  size  of  a 
chestnut  jjerhajis,  it  often  ceases  to  grow  further  ;  but  it  does  not  fluctuate  in  its  dimensions 
in  relationship  to  meals,  like  a  salivary  gland  swelling  often  does. 

A  suprahyoid  cyst  is  sittiated  in  the  root  of  the  tongue  posteriorly,  where  it  arises  from 
remains  of  the  obsolete  thyroglossal  duct.  It  is  seldom  large  ;  its  nature  may  be  suggested 
by  its  situation. 


SWELLING,     VULVAL  699 

An  angioma  of  the  tongue  is  rare  ;  sometimes,  however,  after  remaining  latent  for 
years,  it  grows  with  rapidity  and  necessitates  an  operation.  The  diagnosis  may  be  sugges- 
ted by  the  colour  of  the  tumour,  but  histological  examination  subsequent  to  removal  may 
be  required  before  one  can  be  sure  whether  the  tumour  is  a  simple  angioma,  or  whether 
it  has  taken  on  the  malignant  characters  of  an  angiosarcoma  or  is  a  pure  sarcoma. 

Haemorrhage  in  the  substance  of  the  tongue,  with  consequent  great  swelling  of  the 
organ  and  inability  to  use  it  for  sjjeaking  or  eating,  may  residt  from  many  of  the 
diffeiciit  blood  conditions  that  produce  purpura.  Only  in  very  exceptional  cases  would 
such  spontaneous  bleeding  be  confined  to  the  tongue,  though  conceivably  this  might  be 
the  first  symptom  in  a  case  of  acute  lymphatic  leukaMnia.  for  example,  or  of  purjaura 
haemorrhagica.  Other  haemorrhages  would  follow,  however,  and  indicate  the  need  for 
blood-co(mts  and  other  measures  that  are  discussed  under  the  heading  of  Purpura  (p.  .5.52). 

Uaiiiirmd's  disease  (p.  256)  affects  the  fingers  and  toes  more  commonly  than  any  other 
parts  :  it  may,  however,  involve  other  distal  tissues  in  a  similar  way,  including  the  jienis, 
the  ears,  the  nose  and  the  tongue.  In  the  latter  it  sometimes  produces  acute  attacks  of 
purple  or  almost  black  cyanosis,  followed  occasionally  by  local  necrosis  and  subsequent 
scarring  :  acute  swelling  of  the  tongue  may  ensue  when  the  |)aroxysm  of  vasoconstriction 
is  passing  off.  I  have  never  seen  a  case,  however,  in  which  the  tongue  alone  was  affected, 
and  when  the  fingers  and  toes  are  attacked  at  the  same  time  as  the  tongue  the  diagnosis 
is  easy. 

There  remain  for  discussion  acute  oedema  of  the  tongue  due  to  severe  stomatitis,  angio- 
neurotic rrdema  of  the  tongue,  and  angina  Liidovici.  The  latter  is  an  acute,  virulent  and 
generally  fatal  condition,  in  which  streptococci  or  other  organisms  attack  the  floor  of  the 
mouth  and  root  of  the  tongue  and  — without  producing  much  pus.  or  even  none  at  all — spread 
almost  like  wild-fire  through  the  deeper  structures  of  the  moutli.  throat,  and  neck,  and  cause 
extreme  swelling  of  all  the  tissues  in  the  neighbourhood  ;  there  is  high  fever,  often  a  severe 
rigor,  the  patient  is  soon  in  a  state  of  being  hardly  able  to  breathe,  and  extreme  oedema 
of  the  glottis  is  apt  to  cause  death  from  asphyxiation  even  when  multiple  incisions  have 
been  made  into  the  brawny  swollen  parts.  The  condition  is  almost  unmistakable  ;  fortu- 
nately it  is  r.ire.  It  may  be  simulated  by  similar  widespread  oedema  that  results  from 
infection  of  the  deeper  parts  secondarily  to  one  or  other  of  the  types  of  stomatitis  discussed 
on  p.  542  :  indeed,  such  stomatitis,  when  it  has  spread  to  the  deeper  tissues  in  this  way. 
has  virtually  led  to  a  secondary  angina  Ludovici  ;  the  latter  name,  however,  is  applied 
as  a  rule  only  to  cases  in  which  the  acute  overwhelming  infection  described  above  ari.ses 
without  any  obvious  preceding  inflammation  of  the  tongue  or  mouth. 

.Xngioncurotic  cjcdema  of  the  tongue  is  rare,  but  it  is  of  great  importance  because  it  is 
one  of  the  i)ur(ly  functional  conditions  which  may  kill  the  patient.  .Vs  a  rule  there  is  a 
history  of  similar  attacks  in  other  parts  of  the  body  i)rc\iously  [Fig.  178.  p.  412).  and  other 
members  of  the  family  will  be  familiar  with  acute  causeless  swellings  from  personal  experi- 
ence, for  it  is  a  familial  airection.  Should  it  involve  the  tongue  during  a  first  attack, 
however,  it  would  be  mistaken  for  angina  Ludovici  very  easily,  especially  as  the  patient 
may  have  pyrexia  or  a  rigor  notwithstanding  the  functional  nature  of  the  malady.  Trache- 
otomy has  been  resorted  to  as  t\\c  only  means  of  saving  the  patient's  life,  and  the  diagnosis 
has  only  beenme  clear  when  the  (ecfeina  of  the  tongue  and  adjacent  parts  has  subsided 
almost  as  rapidly  as  it  came  on,  and  the  patient  has  had  similar  neurotic  (edema,  probably 
in  other  parts,  on  s>il)sci|U<Tit  occasions.  Ihrlxil  I'niivh. 

SWELLING,  VULVAL.  The  .liMerential  diagnosis  of  vulval  tumours  must  necessarily 
ineliidr  iinl  only  trnc  sucljiritis  cif  llic  \nl\u.  but  alsii  swellings  wlii<'h  appear  al  the  \tdva 
as  a  icsnit  of  tlic  displaccimiit  of  other  structures,  such  as  occur  in  prolapse  and  eystoeeic, 
and  in  addition  lesions  like  kraurosis  vulva-,  which  are  not  strictly  swellings  at  all.  The 
lesions  of  the  vulva  may  be  tabulated  under  various  headings,  as  set  forth  in  the  following 
.scheme  : 

Inflammatory    Lesions. 

Sirri|iic    vidvifis  .Syjihilis  :  FunuKulosis 

(idhoiriiieal  vidvitls  Ilinil<ii:oi  clMiicri'  I.eukoplakie    vulvitis 

Soil   <-)ianere  ('(iM(lyliiMi:i  Kraurosis    vul\:e 

l':i|iilliiniata  'i'erliary    lesions  I'seudd-elcjihantiasis 

Tnlierculosis  ivslliionii'ne. 


700 


SWELLING,     VULVAL 


Cystic  Swellings. — 

Hydrocele     of     t 
canal  of  Nuck 

Blood  Cysts. — 

Varicocele 

New  Growths. — 

Caruncle 
Fibroma 
Lipoma 
Angioma 

Herniae. — 

Inguinal 


Sebaceous  cysts 
Mucous  cvsts 


Implantation   cysts 
Dermoid   cysts. 


I    Rupture  of  a  varicose  vein        ]    Traumatic    lucmatoma. 


Neuroma 

Fibromyoma    of   round  liga- 
ment 
Endotlu'liouia 


Posterior    labial 


Squamous-celled      carcinoma 

(epithelioma) 
Columnar-celled    carcinoma 
Sarcomata  of  various  kinds. 


I    Perineal. 


Displacement. — 

Prolapse  of  urethral 

mucous  membrane 

Prolapse   of  uterus 

Unclassified. — Simple   anasarca. 


Cystoccle 

Inversion  of  the  uterus 


Fibromvor 
wal'l. 


of    the    vaginal 


Certain  of  these  lesions  stand  out  pre-eminently  as  presenting  dilliculties  in  diagnosis. 
The  general  principles  by  which  solid  tumours  are  distinguished  from  cystic,  inflammatory 
swellings  from  new  growths,  or  new  growths  from  herniip,  need  not  be  insisted  u))on  here. 
Pcrliaps  the  commonest  difficulty  which  arises  in  practice  is  the  diagnosis  of  gonorrhcEal 
vulvitis  from  simple  vulvitis,  and  also  between  the  gonorrhoea]  soft  chancre  and  the 
syphilitic  condyloma,  the  latter  differentiation  being  of  much  more  practical  importance 
than  the  former  as  far  as  the  patient  is  concerned.  In  the  acute  stage  of  a  gonorrheal 
vulvitis  there  is  a  chance  of  recognizing  the  gonococcus  in  the  discharge,  if  films  made  from 
it  are  suitably  stained.  Practically,  all  acute  forms  of  vulvitis  appear  alike  clinically, 
so  that  the  recognition  of  the  gonococcus  becomes  a  matter  of  importance  (see  p.  185). 
In  chronic  gonorrhoeal  infections  with  vulval  swelling,  as  a  rule  the  organism  cannot  be 
found  in  the  general  vulval  discharge,  but  might  be  found  in  the  urethra  or  in  the  cervix. 
A  gonorrhoeal  infection  may  be  suspected  if  the  jjatient  gives  a  history  of  an  acute  onset, 
accompanied  by  scalding  on  micturition,  and  when  there  are  redness  of  the  orifices  of 
Bartholin's  glands,  and  much  redness  and  swelling  of  the  carunculae  myrtiformes.  Papil- 
lomata  or  warts  of  the  vulva  may  occur  also  in  chronic  gonorrhoeal  infections,  and  there 
is  no  evidence  of  a  reliable  nature  to  show  that  they  occur  in  any  other  kind  of  infection. 

The  soft  chancre  of  gonorrhcea  may  be  mistaken  for  the  condyloma  of  secondary  syphilis, 
but  as  a  rule  this  difficulty  should  not  occur.  The  soft  chancre  is  a  typical  pimched-out 
ulcer  with  a  somewhat  red  base  and  clean  edges,  discharging  pus.  The  condyloma,  on 
the  other  hand,  is  a  raised,  flat-topped  excrescence,  with  sodden,  epithelium-covered 
surface.  Soft  chancres  are  not  very  numerous,  as  a  rule,  and  are  generally  limited  to  the 
\ulva.  Condylomata  are  numerous,  and  may  occur  all  over  the  labia,  around  the  anus, 
and  even  on  the  skin  of  the  thighs  and  gluteal  region.  Condylomata  are  from  the  start, 
or  very  soon  after,  accompanied  by  a  sore  throat  and  a  typical  papular  skin  rash,  for  they 
are  secondary  syphilitic  lesions.  Soft  chancres  clear  up  with  antiseptics  ;  condylonuita 
persist  for  long  periods,  but  clear  up  in  two  or  three  weeks  as  a  rule  under  mercurial  treat- 
ment or  salvarsan.  It  must  not  be  forgotten  that  soft  sores  and  condylomata  may  occur 
together  in  the  same  patient,  in  which  case  the  diagnosis  may  be  still  more  difficult. 

Another  practical  differentiation  which  gives  rise  to  anxiety  is  that  between  the 
Hunlerian  chancre  or  primary  sj^jhilitic  sore,  and  squamous  epithelioma  of  the  vulva.  This 
is  a  question  which  is  of  vital  importance  to  the  patient  if  valuable  time  is  not  to  be  lost 
in  the  treatment  of  a  malignant  epithelioma.  The  two  lesions  look  much  alike  at  first  ; 
they  form  raised  hard  indurated  masses  in  the  skin,  which  may  ulcerate  quickly  as  a  result 
of  necrosis  of  the  superficial  portions.  Both  give  rise  to  a  thin  watery  discharge,  and  to 
enlarged  glands  in  the  inguinal  region  which  do  not  suppurate  at  first,  but  may  do  so  later 
in  the  case  of  an  epithelioma.  It  must  not  be  forgotten  that  a  primary  chancre  is  very 
seldom   seen   in   women,   whilst   squamous   epithelioma   is   relatively   conunon.     Of  course 


SWELLING.     VULVAL  701 

the  cliancre  will  lie  followed  in  due  course  by  secondary  lesions,  but  it  is  not  safe  to  wait 
for  these  to  appear  in  a  doubtful  case.  The  only  reasonable  way  to  deal  with  such  a  case 
is  to  excise  the  doubtful  swelling  at  once  and  submit  it  to  microscope  examination  by  an 
expert.  A  squamous  epithelioma  is  easily  detected  in  this  manner  in  quite  early  stages, 
and  does  not  in  the  least  resemble  a  syphilitic  lesion  microscopically.  The  Spirochceta 
pallida  may  be  recognized  in  scrapings  of  a  hard  chancre  by  the  Indian  ink  method,  or 
when  fixed  and  stained  by  Giemsa"s  or  Levaditi's  methods  {Plate  XXf'III,  Fig.  ,/.  ]i.  614). 
In  sections,  too,  the  spirocha?te  may  be  demonstrated,  but  it  must  be  remembered  that  for 
this  purpose  the  excised  growth  tnust  be  fixed  in  5  per  cent  formalin  solution.  Wasser- 
mann's  serum  test  may  assist  the  diagnosis. 

Tertiary  syphilitic  lesionn  are  by  no  means  common  on  the  vulva.  When  they  do 
occur  they  give  rise  to  spreading  ulceration  with  great  destruction  of  tissue,  and  scarring 
in  the  older  healed  portions.  Here,  the  only  likely  lesions  to  be  mistaken  are  some  forms 
of  epithelioma,  and  tubercle.  Obviously,  in  such  conditions  the  only  reliable  method  of 
diagnosis  is  to  be  found  in  excision  of  parts  of  the  lesion  and  microscopic  examination  of 
sections  made  from  them.  The  disease  known  as  esthiomene  is  probably  a  tertiary 
syphilitic  affection. 

Pseudo-elephuiitiasis  of  the  vulva  is  usually  a  syphilitic  affection  of  the  labia  minora, 
giving  rise  to  great  enlargement,  with  a  rough  and  thickened  appearance  of  the  skin.  It 
could  only  be  mistaken  for  real  elephantiasis  due  to  lymphatic  obstruction  by  the  Filaria 
sanguinis  liotninis  (Plate  XXf'III,  Fig.  F.  p.  (il4),  a  disease  which  is  practically  never 
seen  in  this  country. 

Unilateral  oedema  of  a  labium  minus  is  a  fairly  common  condition,  and  is  usually 
associated  with  an  infected  woimd  or  with  a  primary  sypliilitic  chancre.  Bilateral  oedema 
is  almost  always  associated  witli  general  anasarca,  the  result  of  renal  disease,  cardiac 
disease,  or  pressure  upon  pelvic  veins.     It  is  not  likely  to  be  mistaken  for  any  other  disease. 

Letikoplakic  vulvitis  and  kraurosis  vulvce  have  certainly  been  confounded  with  one 
another  clinically,  and  also  in  the  published  descriptions  of  the  lesions.  In  the  former 
the  labia  inajora  and  minora  and  the  prepuce  of  the  clitoris  are  affected,  whilst  the 
vestibule  always  escapes.  In  the  latter  the  lesion  affects  the  vestibule,  the  orifice  of  the 
vagina,  and  the  labia  minora.  There  is  much  greater  contraction  of  the  vaginal  orifice 
in  kraurosis.  Leukoplakia  often  precedes  a  squamous  epithelioma  ;  kraurosis  is  said 
not  to  do  so.  Leukoplakia  occurs  at  all  ages,  whilst  kraurosis  is  a  disease  of  post-menstrual 
life.  Leukoplakic  vulvitis  appears  as  a  white  sodden  hardening  of  the  skin,  with  flattening 
and  shrinkage  of  the  labia.  Kraurosis  at  first  looks  red  and  swollen,  but  later  takes  a 
yeljiiuisli  tinge.  Leukoplakia  causes  intense  itching;  kraurosis  gives  rise  to  great  pain 
and  UiKienicss,  with  a  very  severe  form  of  dysjiareunia. 

Apart  from  a  cyst  developing  in  Bartholin's  gland  or  duct,  cystic  swellings  of  the 
vulva  are  not  common.  .V  liartlwlinian  cyst  is  recognized  by  its  position  on  one  side  of 
the  vaginal  enl ranee,  distending  the  posterior  ])art  of  the  conjoined  labia,  and  also  within 
the  hymeneal  ring.  As  a  rule  the  orifice  of  the  gland  can  be  seen  on  the  inner  side  of  the 
cyst.  The  contents  of  this  form  of  cyst  may  be  glairy  nuieoid  lluid.  or  pus.  In  practice, 
a  Hartholin  cyst  is  not  likely  to  be  rTiistaken  for  anything  else  ;  but  it  is  wise  to  remember 
that  the  posterior  lahial  hernia  occurs'in  the  same  situation,  and  that  new  growths  of  the 
vulva  may  occur  there  as  elsewhere.  Hartholin  cysts  are  always  the  result  of  inlcelion, 
and  as  a  rule  a  history  of  vulval  inllannuation  can  be  obtained. 

I'aricocele  of  the  vulva  occurs  ])ractically  only  in  comicclion  with  pregnancy,  and  is 
unmistakable.  It  has  the  same  "  bag  of  worms  "  feel  as  a  varicocele  in  a  man.  and  as 
the  veins  are  close  to  the  skin  a  bluish  colour  is  always  to  be  noted.  It  is  altended  by 
much  aching  pain,  especially  on  standing.  The  veins  are  degcix  rale,  and  lialilc  to  rupture 
as  a  result  of  labour  or  traumatism. 

ll(vm<itomii  of  the  vul\a  is  recognized  as  a  blue  or  violet-coloured  swelling  co\ered 
by  tense  shiny  skin,  and  often  spreading  up  into  the  pelvis  by  the  side  of  the  vagina.  The 
history  alone  will  often  decide  tli<-  nature  of  the  swelling,  but  the  appeararu'c  is  <|uite 
typical  as  a  rule.  Ilainaloma  ol  the  \ul\a  may  occur  apart  from  pregnancy,  and  then  is 
always  traumatic. 

I'retliral  larancle  and  prolapse  of  the  urethral  tnueous  menihrune  may  be  mistaken  for 
one  another.     The  former,  however,   is  a.lways  a  pedunculated  or  sessile  new  formation, 


702  SWELLING,     VULVAL 

invariably  springing  from  tlie  posterior  wall  of  the  m-ethral  orifice.  It  bleeds  readily, 
is  often,  but  not  always,  exquisitely  painful,  and  is  usually  the  result  of  infection. 
Prolapse,  on  the  other  hand,  appears  as  a  raised  projection  with  refunded  margins,  and 
with  the  urethral  canal  in  the  centre  as  a  diniiile.  The  prolapsed  portion  may  not  neces- 
sarily include  the  whole  ring  of  the  mucous  membrane.  It  may  give  rise  to  pain,  and 
being  always  more  or  less  strangulated,  it  is  prone  to  bleed,  much  in  the  same  way  as  a 
caruncle.  It  occurs  as  a  result  of  some  straining  effort,  or  may  accompany  pelvic  floor 
prolapse  ;    it  is  not  the  result  of  infection. 

The  differential  diagnosis  of  the  new  growths  of  the  vulva  presents  no  points  of 
difference  from  their  diagnosis  in  other  parts  of  the  body.  The  only  common  benign 
tumour  is  the  pedunculated  flbroma.  or  moUuscum  fibrosum.  whilst  squamous  carcinoma 
(epitlielioma)  is  the  only  malignant  growth  which  occurs  at  all  frequently. 

If  the  general  characters  of  a  hernia  are  borne  in  mind,  there  should  be  no  risk  of  ov-er- 
looking  or  mistaking  any  of  the  varieties  which  occur  in  the  vuha.  The  resonance  on 
percussion  if  the  hernia  contains  bowel,  the  reducibility  of  the  contents,  and  the  protrusion 
through  a  pre-existing  opening,  will  usually  suffice  to  distinguish  hernia?  from  other 
swellings.  An  obstructed  or  strangulated  hernia  is  not  so  easy  to  recognize,  but  the  accom- 
panying acute  symptoms  and  the  previous  history  usually  suffice  to  make  the  case  clear. 

Hydrocele  of  the  canal  of  Nuck,  an  uncommon  condition,  may  be  mistaken  for  an 
inguinal  hernia  ;  but  as  a  rule  it  is  irreducible,  definitely  Huctuating  and  circimiscribed, 
and  has  no  obvious  neck  running  into  the  inguinal  canal.  When  the  canal  of  Nuck  has 
a  patent  peritoneal  communication  the  swelling  disappears  as  the  patient  lies  down,  but 
it  is  not  reducible  in  the  characteristic  manner  of  a  hernia.     Such  a  condition  is  very  rare. 

The  displacements  included  in  the  list  above  are  all  dealt  with  imder  the  heading  of 
Prolapse  of  the  Uterus  (p.  538).  Thos.  G.  Stevens. 

SYNCOPE.— (See  Coma,  p.  117.) 

TACHE  CEREBRALE  is  the  term  used  to  denote  that  condition  in  which, 
after  the  finger  has  been  drawn  with  moderate  firmness  across  the  patient's  skin, 
the  line  along  which  it  has  passed  becomes  of  a  bright  red  colour  from  dilatation  of  the 
superficial  arterioles  and  capillaries  ;  the  phenomenon  develops  within  thirty  seconds  or 
a  minute  of  the  finger  stroke,  and  the  red  mark  remains  evident  for  two  or  three  minutes, 
or  more.  If  letters  or  figures  are  marked  out  on  the  skin  in  this  way,  they  appear  as 
though  they  had  been  written  in  red,  so  that  the  condition  has  also  been  termed  dermato- 
graphia.  It  was  at  one  time  thouglit  to  be  a  characteristic  symptom  of  tuberculous 
meningitis,  but  not  only  is  it  sometimes  absent  in  eases  of  the  latter,  but  it  is  also  present 
in  a  very  large  number  of  other  different  conditions,  and  sometimes  in  perfectly  healthy 
people.  All  forms  of  meningitis  may  give  rise  to  it,  so  that  it  is  not  even  a  means  of  distin- 
guishing one  type  from  another.  It  is  seen  in  an  extreme  degree  in  cases  of  urticaria, 
particularly  the  factitious  variety  in  which  numerous  wheals  may  develop  as  the  result 
of  hardly  more  than  ordinary  touching  of  the  skin.  A  similar  condition  has  sometimes 
been  observed  in  the  later  stages  of  severe  febrile  illnesses  in  general.  Herbert  French. 

TACHYCARDIA,  or  abnormal  rapidity  of  the  heart's  action,  might,  strictly  speaking, 
be  held  to  include  e\ery  condition  under  which  the  pulse-rate  is  faster  than  the  normal  ; 
but  by  common  consent  it  is  restricted  for  clinical  purposes  to  cases  in  which  there  is  no 
pyrexia.  Nearly  all  fevers  produce  undue  rapidity  of  the  heart's  action,  though  some, 
such  as  typhoid  fever,  tuberculous  meningitis,  cerebral  abscess,  yellow  fever,  and  influenza, 
do  so  to  a  nuich  less  extent  than  others.  The  rapid  heart-action  of  fevers,  however,  does 
not  generally  come  into  one's  mind  when  one  uses  the  term  tachycardia  ;  indeed  the  latter 
is  chiefly  employed  for  conditions  in  which  it  is  rapid  without  there  being  anything  which 
at  first  sight  would  seem  to  be  a  sufficient  cause.  Probably  the  best  example  of  it  is  to 
be  foimd  in  cases  of  pronounced  Graves's  disease. 

The  following  is  a  list  including  this  and  some  other  causes  of  tachycardia  : — 
Graves's  disease  or  exophthalmic  goitre 
Paroxysmal  tachycardia 
Nervousness  and  excitement 


TACHYCARDIA 


Exertion,  especially  when  the  patient  is  out  of  training  or  anaemic 

Tobacco  heart 

Mitral  stenosis 

Pneumogastric  irritation  by  : — 

Caseous  glands  |  Mediastinal  fibrosis  ]  Thoracic  aneurysm  |  Thoracic  new  growth. 

Pneumogastric  '  neuritis  '  after  : — 

Diphtheria,  influenza,  and  other  microbial  affections. 

Drugs  : 

Digitalis  i  Alcohol 


Belladonna 


Thyroid  extract. 


The  four  classical  symptoms  of  Graves's  disease  are  :  .\  staring  appearance  of  the  eyes, 
generally  spoken  of  as  exophthalmos,  though  there  need  be  no  actual  protrusion  of  the 
eye-balls  (Fig.  222,  p.  527)  ;  moderate  and  almost  symmetrical  enlargement  of  the  thyroid 
gland  ;  a  pulse-rate  between  120  and  180  per  minute — usually  about  1-10  when  the  attack 
is  moderately  severe  ;  and  extreme  nervousness,  with  fine  tremor  of  the  outstretched 
fingers.  When  all  these  symptoms  are  present  at  the  same  time,  there  can  be  no  doubt 
as  to  the  diagnosis,  but  very  often  some  of  them  are  absent,  and  it  is  possible  for 
tachycardia  to  be  the  only  symptom  of  the  disease  ;  indeed,  in  a  patient,  particularly  a 
woman  between  twenty  and  forty  years  of  age,  a  persistent  pulse-rate  of  over  120  would 
arouse  serious  suspicion  that  the  case  was  really  one  of  Graves's  disease,  even  if  the  other 
three  classical  signs  were  absent. 

Paroxysmal  tacliycardia  should  be  distinguished  at  once  from  Graves's  disease  in  which 
tachycardia  alone  has  developed,  by  the  fact  that  the  tachycardia  is  not  persistent,  but 
recurs  periodically  with  intervals  of  normal  pulse-rate  :  tlie  jjaticnt  is  more  often  a  woman 
than  a  man,  and  may  have  long  periods  of  perfect  health  ;    almost  suddenly,  the  result 


Lead  2.- 
HiKht  i.ri 
to  left  let.-. 


Lead  3. — 
Left  iirm  to 
left  Ic-i;. 


/■'(;;.  *289. — Kloetroojirdio^rmm  in  a  case  of  paroxysmal  tacliycardia  in 
arm  :  Le:id  '2  from  right  arm  to  left  leg  :  JLead  3  from  left  arm  to  left  le;'. 
wave.  Time  marlciiiK  in  j^  seconds.  At  lirt^t  sight  the  tracing  looks 
considered,  it  will  be  seen  that  there  are  IG  heart-beats  in  each  'i^  on 
making  208  beats  per  minute.  The  tracing  is  from  a  young  man  seoinit 
liimself  for  examination  as  a  rc<TMJr.     it  v-i-  f.,nt!i|  thtf  vh.-n  t,<-  lit.i  u, 

pulse-rate  was  72  per  minute,  but  \\\ -  ■ ;  '^    I  ..I  !■    -  i  ;    hi 

his  toes,  or  on  walking  about,  hi- t<   '         .i      i       i  i     ' 

the  pulBc-rate  rose  to  over  2011  |i.  ]  n.,  ,   .,.:,.,■-   .,,1     1.  |.     ; 

he  was  able  to  do  ordinary  work  ,  tii.i.   u...-.  In  11.*  j.i.-..ilil. -:,ti.^- .   -iii-l  i 
'i'he  condition  appeared  to  be  one  of  simple  paroxyj^inal  tacliycardia. 


sometimes  of  a  fright  or  shock,  sometimes  without  apparent  cause,  there  is  a  sense  of  some- 
thing being  the  matter  in  the  precordial  region,  amounting  as  a  rule  to  little  more  than  a 
fluttering  or  palpitation,  together  with  a  feeling  of  liiinlncss  and  lack  of  strength,  and 
perhaps  of  ininibncss  or  of  pins-and-ncedlcs  in  the  cxlreniilics  :  when  examined  the  patient 
may  present  no  other  ahniirnuility  than  a  pulse-rale  of  perhaps  1(10  or  c\-en  200  to  the 
niimilc  i.l''iU.-  2,s!)).     The  attack  may  last  a  lew  iiiiniilcs.  or  an  Imiir  or  Iwn,  or  Inr  days,  or 


704  TACHYCARDIA 

more  rarely  for  weeks  ;  it  is  apt  to  cease  as  suddenly  as  it  began,  and  a  similar  attack  is 
almost  certain  to  recur  after  a  longer  or  shorter  interval — the  main  symjitom  of  the 
complaint  being  summarized  by  the  title  ■  paroxysmal  tachycardia." 

The  very  rapid  heart  action  that  may  be  produced  by  iienmtisness,  or  excitement,  or 
by  some  ordinary  exertion  such  as  coming  rather  rapidly  upstairs  when  one  is  out  of 
training,  or  when  the  patient  is  suffering  from  aniemia.  or  during  convalescence  after  an 
illness,  or  after  the  over-use  of  tobacco,  is  a  familiar  phenomenon  ;  the  tachycardia 
disappears  rapidly  when  the  patient  rests,  and  the  diagnosis  is  not  as  a  rule  difficult.  If 
ordinary  resting  for  a  while  does  not  cause  the  rate  of  the  heart-beat  to  return  nearly  or 
quite  to  normal,  there  may  be  doubt  as  to  the  diagnosis,  unless  the  patient  can  be 
re-examined  on  another  occasion  ;  if  there  is  persistent  tachycardia  a  suspicion  of  Graves's 
disease  will  be  aroused,  or  there  may  have  been  acute  overstrain  of  a  weakened  fatty, 
fibroid,  rheumatic,  alcoholic,  or  syphilitic  myocardium,  followed  by  long-continued  tachy- 
cardia without  bruit,  but  perhaps  with  auricular  fibrillation  ;  electrocardiograms  may  be 
required  before  an  exact  diagnosis  can  be  arrived  at  in  many  of  these  ca.ses. 

Mitral  stenosis  is  of  all  the  valvidar  lesions  of  the  heart  the  most  liable  to  lead  to 
rapidity  of  the  heart's  action  ;  but  it  seldom  happens  that  the  pulse-beat  is  fast  until  there 
has  been  other  evidence  of  failure  of  the  cardiac  compensation.  The  diagnosis  will  genei- 
ally  be  obvious  from  the  history  of  acute  rheumatism  or  chorea,  the  typical  faeies  and 
malar  flush,  and  the  cardiac  bruits. 

It  is  exceedingly  difhcult  to  be  certain  of  a  diagnosis  of  irritation  of  a  pneumognstric 
nerve  within  the  thorax  imless  the  existence  of  mediastinal  new  groivth,  aneurysm,  or  fibrosis 
is  already  known  on  account  of  the  abnormal  physical  signs,  the  a;-ray  appearances,  the 
visible  tumour,  or  the  varicose  distention  of  the  superficial  thoracic  veins  ;  if  an  intra- 
thoracic abnormalitj'  is  known  to  exist,  and  tachycardia  becomes  a  prominent  feature  of 
the  case,  it  will  probably  be  due  either  to  mechanical  interference  with  the  heart's  action 
or  to  similar  interference  with  one  or  other  vagus  nerve.  Caseous  glands  irritating  the 
pneumogastric  nerve  are  still  more  difficult  to  be  sure  of  ;  but  occasionally  one  ventures 
upon  this  diagnosis  when  a  child  who  has  been  fed  on  untested  or  unsterilized  cow's  milk, 
develops  obscure  ill-health  associated  with  persistent  tachycardia.  Such  diagnosis  would 
be  still  further  suggested  if  there  were  at  the  same  time  enlarged  glands  in  both  sides  of 
the  neck,  if  there  were  ])yrexia  without  any  obvious  explanation  of  it.  or  if  there  were  any 
evidence  of  obstruction  to  the  right  bronchus,  for  the  right  bronchial  gland  is  enlarged 
far  more  often  than  is  the  left.  An  .i-ray  examination  may  serve  to  confirm  the  suspicion 
{Fig.  61,  p.  14.9). 

Diphtheria,  influenza,  and  possibly  other  microbial  infections,  are  occasionally  followed 
by  marked  and  persistent  tachycardia  during  convalescence,  or  even  for  weeks,  months, 
or  years  afterwards.  After  diphtheria  the  condition  is  generally  fatal.  Influenza  is  always 
a  dangerous  diagnosis  because  it  is  so  difficult  to  establish,  but  in  certain  cases  in  which 
the  original  diagnosis  has  been  influenza,  tachycardia  to  the  extent  of  200  heart-beats  per 
minute  may  be  present  for  months  without  the  patient  suffering  from  any  severe  cardiac 
symptoms,  and  the  condition  ultimately  terminates  in  recovery  with  a  return  of  the  heart- 
beat to  the  normal  rate.  Precisely  what  is  the  nature  of  these  cases  it  is  impossible  to 
.say,  but  it  has  been  thought  by  some  that  the  symptom  is  due  to  inflammatory  changes 
in  the  pneumogastric  nerve,  produced  by  whatever  one  means  by  the  toxins  of  the  disease. 
Whether  this  be  so  or  not,  the  fact  that  persistent  tachycardia  may  arise  out  of  febrile 
illnesses  should  be  borne  in  mind. 

There  are  certain  drugs  which  cause  the  heart's  beat  to  be  very  rapid,  the  best  known 
perhaps  being  digitalis,  belladonna,  thyroid  extract,  and  alcoh-il.  Certain  jjatients  suffering 
from  cardiac  symptoms  seem  unable  to  bear  digitalis,  the  heart  being  driven  into  the 
condition  spoken  of  as  delirium  cordis,  though  the  reverse  effect — slowing  of  the  heart, 
bradycardia — is  to  be  expected  in  persons  who  take  digitalis  well  over  a  long 
period.  When  alcohol  is  the  cause  of  the  tachycardia,  the  fact  may  be  obvious, 
the  only  difficulty  arising  in  patients,  mainly  women,  who  may  be  regarded  by  all  as 
entirely  above  reproach,  but  who  nevertheless  may  be  addicted  to  secret  drinking. 
Belladonna  in  small  doses  slows  the  heart,  but  there  are  great  variations  in  the  degree 
to  which  different  patients  tolerate  this  remedy,  even  pharmacoepial  doses  sometimes 
producing  toxic  symptoms  of  which  tachycardia  is  one.     Widely  dilated  jjupils  and  dryness 


TASTE,     ABNORMALITIES    OF 


705 


of  the  tongue  will  help  to  point  to  the  diagnosis  in  cases  in  whieh  the  belladonna  is  taken 
otherwise  than  nicdieinally.  Tachycardia  is  the  chief  symptom  by  which  one  recognizes 
that  a  patient  for  whom  thyroid  extract  has  been  prescribed  is  receiving  too  large  a  dose. 

Herbert  Fretidi. 

TALIPES.— (See  fi.rii-FooT.  ]).   111.) 

TASTE,  ABNORMALITIES  OF.  Abnormalities  of  taste  may  be  grouped  under 
three  main  lieadinys.  luuiicly  :  (1)  Iiii/iiiirDiciit  or  loss  of  ordiiuirii  taste  sensations: 
(2)  Perverted  taste  sensations  :  (o)  Sensations  of  a  foul  lasle  in  the  mouth.  The  following 
conditions  may  produce  these  : — 


1.  Impairment  or  Loss  of  Taste  (Aiieustia)  : 
id).  Due  to  nene  lesions  : 
Paresis    or    paralysis    of    the    lingual      Glosso-pharyngcal   nerve  paralysis 


branch  of  the  fifth  nerve 


Bulbar  paralysis 


Paralysis  of  the  facial  nerve,  including      Cerebral  tumour,  especially  of  the  uncinate  gyrus 
the  chorda  tympani  Hysteria. 

(b).  Due  to  affections  either  of  the  nunttli  or  nose  : 

A  common  cold 
Hay  fevei  (coryza  e  feno) 
.Atrophic  rhinitis 
Hypertroi)liic  rhinitis 
Nasal  poly[)Us 

(e).  Fehrile  conditions,  especially  when  associated  with  coating  of  the  tongue. 
(<!}.  After  destruction  of  the  nerve  einlings  in  the  tongue  by  corrosives  taken  acci- 
dentallv  or  with  suicidal  intent. 


Adenoids 

Other  varieties  of  nasal  obstruction 

Bromism 

lodisni  [(p.  .5-1-2). 

Mercurial   and   other   varieties    of   stomatitis 


2.  Perverted  Taste  Sensations  (Paragcustia)  : 

Pregnancy  |  Hysteria  |       Epileptic  aura 

3.  Foul  Taste  in  the  Mouth  {('aeogeustia)  : 


(a).  Load  conditions  of  the  nuiuth  or  iu)se  : 


.Septic  stimips  imdcr  tooth-plate 
(Jumma  of  the  tonyuc  or  palate 
Kpithelioma  of  the  ton<;ue  or  mouth 
.Stomatitis  from  any  cause  (p.  j-t2) 
Septic  infection  of  the  antrum  of  Hiijhmore,  or 
an  cthniiiiil,  splicnoid,  or  frontal  sinus. 


Caries  of  the   teeth 

Retention    of   food    particles    between 

healthy  teeth 
Furred  tonjjue  from  any  cause 
Kxcessive  smoking 
IMnuth  breathing  at  night 
(iumhnil 

(b).  Sejvrc  fevers  associated  with  dryness  of  the  mouth  and  coating  of  the  tongue, 

especially   in  : — 
Pneumonia  |       Typhoid  lever  |       Peritonitis  |       Sejiticicmia,  etc. 

((■).  Septic  lutig  eointitions.  especially — 

I'hthisis,    with    secondary    infection   of  ;    (;ani;r<ne  of  the  luni; 

cavities 
Hroiu'hicctasis 
Unincliiolccta'Nis 
iMrtiil    broncliitis 


lOmpycma  ruptured   into  the  lung 
I.iver  aliM-css  ruptured  into  the  limtr 
Subiliiiplirai,'matie    abscess   ruptured   into 


(<l).   Ccrtoiii  druiis  or  iiinsinis.  es|)ccially 


.Mercury 

Copper 

.Arsenic 

Lead 

Iodides 


Bromides 

Sulphides 

I'araldelivde 

Asahetida 

Creosote 


(iuaiaeol 
Valerian 
Coddiver   oil 
Castor    oil. 


(r).  Certain  foods,  such  as  : — 

(iarlic  Leeks 

Oniuiis 

(/).   Ilijsteriu  aud  fun(tion(d  crnnlitioiis. 


706  TASTE.     ABNORMALITIES    OF 

From  a  diagnostic  point  of  view,  impairment  of  taste  sensations  is  of  importance  only 
in  rare  cases.  When  the  impairment  is  unilateral,  it  is  almost  certainly  due  to  a  lesion 
involving  either  some  portion  of  the  third  branch  of  the  fifth  nerve,  the  chorda  tympani. 
or  the  giosso-pharyngeal  nerve.  It  is  not  often  difficult  to  distinguish  between  these  three. 
If  the  chorda  tympani  is  involved,  it  is  almost  certain  that  the  facial  nerve  will  also  be 
affected  upon  the  same  side,  and  this  will  be  evidenced  by  paresis  or  paralysis  of  the  face 
of  the  infranuelear  type  (p.  493)  :  there  may  be  excessive  watery  secretion  from  the  sub- 
maxillary gland  upon  the  same  side  ;  the  commonest  condition  to  cause  these  symptoms 
is  disease  of  the  middle  ear  extending  to  the  Fallopian  canal.  If  it  is  found  that  taste  is 
impaired  only  in  the  posterior  third  of  the  tongue  upon  one  side,  the  lesion  probably  affects 
the  giosso-pharyngeal  nerve,  and  it  is  very  possible  that  there  may  be  paresis  of  the  same 
side  of  the  palate  or  partial  paralysis  of  the  jiharynx  at  the  same  time.  When  the  lingual 
branch  of  the  fifth  is  involved,  the  inii)urnient  of  sensation  is  in  the  anterior  two-thirds 
of  the  tongue  on  the  same  side.  The  lesion  may  be  a  tumour  or  an  injury  aflecting  the 
lingual  nerve  in  the  mouth  ;  or  it  may  be  part  of  a  more  general  affection  of  the  fifth  nerve 
of  that  side,  with  corresponding  interference  with  cutaneous  sensibility  of  more  or  less 
<if  the  skin  of  the  face,  according  to  the  extent  to  which  the  different  branches  of  the  fifth 
nerve  are  involved  ;  if  the  motor  root  is  affected,  the  fact  can  be  ascertained  by  feeling 
tlie  masseter  and  temporal  nuiscles,  which,  when  the  patient  cleziches  his  teeth,  do  not 
harden  so  much  on  the  affected  as  on  the  sound  side. 

When  sensation  on  both  sides  of  the  tongue  is  affected,  it  is  possible  that  the  lesions 
described  above  may  be  bilateral  :  but  it  is  much  more  likely  that  the  defect  is  then  not 
primarily  nervous,  unless  it  is  due  to  bulbar  paralysis,  the  progressive  labio-glosso-pharyngo- 
larvngeal  weakness  of  which  is  ]5athognomonic. 

When  the  cause  of  im])aired  sensation  is  in  the  nose,  as  in  the  case  of  coryza.  rhinitis, 
jiolypi.  or  adenoids,  it  will  be  found  that  some  substances  can  be  tasted  easily  and  others 
not  at  all  ;  this  depends  upon  the  fact  that  taste  consists  of  two  parts,  flavour  and  savour  ; 
savour  depends  upon  sensation  transmitted  by  the  olfactory  nerves — the  so-called  taste 
of  roast  beef  for  instance  :  savours  will  be  defective  when  the  nose  is  the  cause  of  abnormal 
taste-sensations  :  while  flavours  such  as  the  taste  of  sugar,  gentian,  or  salt,  which  are 
transmitted  by  the  gustatory  nerves  of  the  tongue,  will  still  be  fully  preserved. 

The  differential  diagnosis  of  the  other  conditions  enumerated  in  the  above  list  need 
not  be  detailed,  for  the  conclusion  come  to  will  depend  upon  the  result  of  careful  inquiry 
into  the  history,  investigation  of  the  abnormal  physical  signs,  and  the  other  symjitoms 
in  the  case.  One  would  only  em])hasi/c  the  possibility  of  caries,  or  decomposing  food 
between  teeth  that  superficially  look  sound,  or  septic  infection  of  the  accessory  sinuses  of 
the  nose  being  long  overlooked,  though  in  each  case  abnormal  taste  sensations  may  be 
prominent.  Herbert  French. 

TEETH,    GRINDING   OF.— (See  Grinding  of  the  Teeth,  p.  265.) 

TENDERNESS  IN  THE  CHEST  implies  that  jiain  is  felt  when  some  part  of  the 
chest  wall  is  touched  or  ]jressed  :  it  is  a  common  symptom  ;  in  some  instances  the  pain 
lelt  is  a  direct  pain,  due  to  stimulation  of  sensory  nerves  actually  in  the  diseased  area  : 
in  others — perhaps  the  majority — the  pain  is  a  referred  pain  ('  somatic  pain  '),  felt  in 
the  skin  and  subcutaneous  tissues  that  are  tender,  but  due  to  a  visceral  lesion  remote  from 
the  tender  area. 

CAUSES    OF    Tenderness    in    the    Chest. 

These  may  be  classified  according  to    he  situation  of  the  lesion  to  which  it  is  due. 

1.  Lesions  of  the  Chest-Wall:   the  pain  is  for  the  most  part  direct  : — 


Inflammations     of 
the  skin  and  un- 
derlying tissue 

Intercostal  myositis 

Myalgia 

Pleurodynia 


Atl'ections    of   the    ribs    and 

sternum 
Blood  diseases 
Intercostal   neuritis 
Injury     of     the     intercostal 

nerves 


Intercostal   neuralgia 

Hysteria 

Herpes  zoster 

Pleurisy 

Mediastinal  disease 

Pericarditis. 


TP:Xr)EKNKSS     IN"    TIIK    CHEST  707 

2.  Lesions  of  Thoracic  and  Abdominal  Viscera :  the  pain  is  usually  a  referred 
|)nin  :    felt  in  lesions  of  the — 

LunfTS  Diaphrafini  Lixcr. 

Heart  and  aorta  Stomaeh   and   a?sophagus 

Lesions  of  the  Chest-Wall. — Tenderness  in  the  chest  is  probably  the  chief  complaint 
in  superficial  infianiiriatory  lesions  of  the  chest  wall,  such  as  bruises,  burns,  cuts,  mastitis, 
and  superficial  infections  of  all  sorts,  the  diagnosis  of  which  will  probably  leap  to  the  eye, 
and  need  not  be  discussed  further. 

Pain  will  be  tlie  chief  complaint  in  iiiterenstfil  )tii/ositis.  often  vaguely  called  rheumatic, 
that  occurs  after  diill  or  strain  of  the  intercostal  muscles  :  but  the  affected  muscles  will 
also  be  tender  on  pressure,  the  tenderness  being  in  the  deeper  structures,  not  in  the  super- 
ficial tissues.  The  condition  is  also  known  as  intercostal  myalgia  or  pleurodynia  ;  it  has 
to  be  distinguished  from  pleurisy  by  the  absence  of  friction-sounds  on  auscultation  ;  and 
from  disease  of,  or  pressure  on,  the  intercostal  nerves.  No  doubt  the  tenderness  is  due 
to  irritation  of  the  sensory  fibres  in  the  intercostal  muscles.  Similar,  but  more  transient, 
])ain  and  tenderness  may  be  met  with  in  the  stitch  to  which  the  untrained  athlete  is  prone. 

Tenderness  in  the  chest  may  result  from  disease  or  injury  of  tlie  ribs  or  sternum,  when 
if  will  be  localized  to  the  injured  spot  ;  fracture,  inflammation,  or  new  growth  may  be 
the  immediate  cause.  If  fracture  is  present,  a  history  of  injury  should  be  obtainable  ; 
the  j-rays  may  show  the  fracture :  or  crepitus  between  the  fragments  on  nio\emcnt.  or 
deformity  may  be  made  out.  Sternal  or  costal  ostitis,  or  periostitis,  may  follow  injury  ;  or 
occur  in  the  course  of  such  diseases  as  enteric  fever,  tuberculosis,  pyaemia  or  septico- 
pya?mia  :  the  local  signs  of  inflammation  (jjain,  redness,  heat,  swelling)  and  the  general 
condition  of  the  patient  should  make  the  diagnosis  fairly  simple.  Tenderness  in  the 
chest  due  to  neic  growth  In  the  ribs  or  sternimi — such  as  hydatid,  sarcoma,  secondary 
deposits  from  carcinoma — is  a  rarity  that  need  only  be  mentioned.  Tenderness  of  the 
ribs  and  sternum,  as  well  as  of  the  long  bones  of  the  limbs,  is  not  uncommon  In  certain  blood 
diseases,  in  which  hyperplasia  of  the  red  marrow,  or  excessive  accunudation  of  white  cells 
in  it,  may  occur  :  such  as  pernicious  aniemia  or  leukaemia.  The  diagnosis  here  nuist  be 
made  on  the  results  of  examination  of  the  blood  (p.  24).  In  all  these  instances  the  tender- 
ness is  deep,  and  due  to  irritation  of  the  sensory  nerves  of  the  periosteum  or  bone  ;  the 
l)aln  felt  on  pressure  is  a  direct  pain. 

Tenderness  at  certain  points  of,  or  all  along,  the  course  of  an  inlercosltil  nerve  Is 
conunon  in  various  affections  of  these  structures.  The  particularly  tender  spots  arc  three 
in  number,  and  correspond  to  the  points  at  which  the  posterior  primary,  the  lateral 
cutaneous,  and  the  anterior  cutaneous  branches  are  given  off,  near  the  spinal  column,  the 
mid-axillary  line,  and  the  sternal  margin,  respectively.  Such  tenderness  may  be  marked 
in  intercostal  neuritis,  which  is  rare  ;  in  intercostal  neuralgia,  which  is  often  diagnosed  when 
some  more  serious  Intrathoracic  disorder  is  really  present,  such  as  pneumonia  or  pleurisy  : 
anil  in  eases  of  presMue  on  an  intercostal  nerxc,  such  as  may  be  set  up  by  alisress  about  the 
spinal  column,  aneurysm  of  llie  descending  aorta,  or  nnc  grrncth  Invading  the  spinal  emal. 
\Vliene\(r  a  ))ati(nt  complains  (jf  severe  or  obstinate  pain  and  tenderness  In  the  side, 
careful  and  icpcated  pliNslcal  and  ,i'-ray  examinations  should  be  made,  the  possibility 
that  some  sucli  deep-seated  disease  may  l)c  present  being  kept  In  view  before  the  diagnosis 
of  inlercoslal  neuralgia,  or  of  functional  nervous  disease  (hysteria).  Is  made.  In  cxccp- 
lional  cases  u['  hysteria,  zones  of  tenderness  In  the  chest,  |)ossibly,  too.  t'hareofs  spasmo- 
f;cnic  zones,  may  be  found. 

I'ain  and  tenderness  along  an  itilendslal  nerve  are  common  In  hir/ies  zoster,  and  may 
be  present  before,  during,  and  after  the  appearance  of  the  characteristic  rash.  The  tender- 
ness often  has  the  three  spots  of  maxunum  development  mentioned  above  :  It  is  particu- 
larly when  it  occurs  in  the  second  halfof  lile  th;it  herpes  may  be  followed  by  a  long  period 
of  pain  and  tenderness  along  tlie  course  of  tlie  alleeled  nerve.  I  lit II  the  rash  has  appeared, 
or  in  tlie  compaialixcly  inl'recpient  ease^  when  the  rash  leaves  no  scarring  behind  it.  the 
diagnosis  of  herpes  may  ln'  dillleull  :    the  r.isli.  once  seen,  can  hardly  be  mistaken. 

Lesions  of  the  Undcrlyin};  Viscera.  Tenderness  In  the  clu^st  Is  very  lrei|iieiilly 
a  symiitom  of  disease  in  llii-  imderlying  viscera,  Ihoraelc  or  abdominal,  when  Ihe  pains 
to  which  It  gives  rise  are  In  most   cases  referred  pains.       The  tenderness  is  tlieiefore  as  a 


708  TENDERNESS    IN    THE    CHEST 

rule  superficial,  confined  to  the  skin  and  subjacent  areolar  and  fatty  tissues  ;  if  tliese  can 
be  drawn  aside,  pressure  can  be  made  on  the  deeper  tissues  tliat  normally  underlie  the 
tender  area  without  provokins;  pain.  Properly  speaking-.  •  tenderness  in  the  chest  "  Ci-.n 
only  refer  to  tactile  hyperirsthesia,  or  the  eliciting  of  pain  on  pressure  whether  light  or 
heavy.  Such  tactile  hypera?sthesia.  or  the  production  of  unpleasant  sensations  or  pain 
by  the  very  lightest  touch,  is  common  in  neuralgia  and  in  neuroses,  or  in  cases  of  referred 
pain.  But  a  similar  hypera-sthesia  for  cold,  or  less  often  for  heat,  sometimes  occurs  in 
the  chest — in  tabetic  patients,  for  example  ;  this  may  perhaps  be  regarded  as  a  special 
form  of  '  tenderness."  In  the  same  way  hyperjesthesia  for  pain,  or  hyperalgesia,  in 
which  a  normally  painless  stimulus  or  impression  becomes  transformed  into  an  acutely 
painful  sensation,  is  to  be  regarded  as  a  form  of  '  tenderness  "  in  the  chest.  Further, 
perversions  of  sensation  sometimes  occur  in  organic  nervous  diseases,  such  as  syringo- 
myelia or  tabes.  Thus,  tenderness  may  be  elicited  by  the  continuous  application  of  a 
pressure  that  is  painless  if  applied  only  for  a  short  time  (summation  of  painful  stimuli)  : 
or  the  pain  may  be  first  felt  some  little  time  after  the  application  of  the  stimulus  to  the 
tender  area  (retarded  sensation). 

Tenderness  of  the  chest  is  a  common  complaint  in  pleiiiisij.  The  physical  signs  should 
sufTiee  to  make  the  diagnosis  simple  if  a  careful  physical  examination  be  made.  The 
tenderness  is  deep  as  a  rule,  and  not  in  the  skin  and  loose  subcutaneous  tissues. 

The  sternum  may  be  tender  in  the  rare  cases  of  mediastinal  inflammation  or  tumour 
that  are  met  with  from  time  to  time  ;  tenderness  and  direct  pain  may  similarly  be  caused 
l)y  the  pressure  of  aneurysms  on  the  internal  surface  of  the  chest-wall.  The  diagnosis 
in  these  cases  must  be  made  on  the  results  of  the  physical  and  .2^-ray  examination  of  the 
patients. 

Tenderness  with  ])ain  over  the  precordia  is  fairly  common  in  pericarditis,  diagnosed 
by  the  canter  rhythm  and  the  pericarditie  rub.  It  may  be  so  extreme  as  to  preclude 
percussion  or  a  satisfactory  jihysical  examination.  Similar  pain  and  tenderness  have  also 
lieen  foimd  at  the  epigastrium  and  the  upper  costal  angles  in  these  cases  ;  due,  perhai^s. 
to  involvement  of  the  diaphragm  in  the  inflammatory  process. 

Chest  tenderness  is  not  rare  in  cases  of  acute  or  chronic  disease  of  the  lungs,  particu- 
larly tuberculosis  :  in  these,  it  is  hard  to  be  sure  that  one  is  not  dealing  with  referred  pains 
due  to  old  or  recent  pleurisy  or  pleural  adhesions.  The  tenderness  may  be  either 
superficial  or  deep  ;  sometimes  it  is  so  marked  as  to  be  elicited  even  by  the  pressure  of 
the  clothes.  It  is  generally  felt  most  about  the  region  of  the  apices  of  the  lungs,  the  curve 
of  the  shoulder,  or  the  scapula.'  It  is  often  a  very  chronic  trouble,  vanishing  during 
periods  of  general  improvement,  returning  again  when  the  patienfs  health  is  low  or  the 
pulmonary  lesion  is  progressing.  Similar  tenderness  is  often  met  with  in  acute  bronchitis. 
or  with  chronic  bronchitis  and  emphysema  ;  the  diagnosis  nuist  be  made  on  general  lines. 
It  must  be  remembered  that  identical  areas  of  referred  chest -tenderness  may  be  observed 
in  disorders  of  such  various  organs  as  the  heart,  lungs,  liver,  and  stomach  ;  and  that  a 
patient  may  be  long  treated  for  "  rheumatism  '  of  the  shoulder,  for  example,  when  he  is 
really  suffering  from  such  widely  different  disorders  as  tuberculosis,  gall-stones,  gastritis, 
carcinoma  mammse,  or  coronary  artery  sclerosis. 

Direct  tenderness  about  the  precordia  is  sometimes  prominent  in  heart  disease  ;  as  a 
rule,  however,  the  tenderness  is  due  to  hyperijesthesia  of  referred  origin.  It  is  most  marked 
in  angina  pectoris,  and  often  persists  after  the  anginal  pains  have  passed  off.  Both  the  pain 
and  the  tenderness  are  felt  within  the  area  of  distribution  of  the  first  to  the  eighth  dorsal 
ner\'e-roots  ;  the  roots  usually  receiving  the  first  and  most  intense  impressions  are  the 
second  dorsal.  The  left  ventricle,  the  commonest  primary  seat  of  pain,  is  in  relation  with 
the  second  to  the  fifth  dorsal  nerve-roots  ;  the  auricle  with  the  fifth  to  the  eighth  ;  the 
ascending  aorta  with  the  third  and  fourth  cervical  and  the  first  to  the  third  dorsal.  These 
nerve-connections  explain  the  extensive  radiation  and  wide  distribution  of  the  tenderness 
and  pain  in  the  superficial  tissues  that  may  form  such  prominent  symptoms  of  heart 
disease  ;  for  the  chest,  neck,  and  arm  may  all  be  affected.  The  tenderness  of  angina 
pectoris  commonly  occupies  the  same  areas  as  the  pain,  takes  the  form  of  a  soreness, 
smarting,  or  of  hyperalgesia  to  touch,  and  may  last  for  days  after  the  pain  is  over.  In 
some  cases,  touching  or  stinmlating  the  hyperalgesic  area  on  the  chest,  arm,  or  neck, 
may  refiexly  induce  an  anginal  attack^even  the    pressure   of  a   stethoscope  applied  for 


TENDERNESS     IX    THE    CHEST  709 

Huscultation  may  suffice — wliich  is  a  stronjj  argument  for  regarding  tlie  tenderness  as  a 
viscero-sensory  reflex  or  a  referred  tenderness.  Siicii  anginal  attacks  and  tenderness  are 
commonest  in  coronary  sclerosis,  aortic  aneurysm,  aortic  reflux,  and  acute  aortitis  :  they 
may  also  be  seen  in  any  form  of  lieart-disease  in  which  liypertrophy  and  dilatation  have 
taken  place,  and  the  heart  has  to  do  more  work  than  it  can  manage,  for  example  with 
raised  blood-pressure  and  arteriosclerosis,  or  with  adherent  pericardium.  In  well-marked 
cases,  the  cardiac  origin  of  areas  of  tenderness  in  the  chest  should  not  be  dillicult  to 
diagnose,  owing  to  their  a.ssociation  with  severe  anginal  pains  on  the  one  hand,  and  with 
the  fact  that  the  pain  is  brought  on  by  exertions  or  emotions  that  increase  the  work  of 
the  heart.  Identical  areas  of  tenderness  may  be  found  in  pleurisy  or  chronic  ])ulmonarv 
tuberculosis  ;  but  here  the  pain  will  be  connected  with  respiration  or  coughing  in  an 
uiunistakable  manner,  and  there  will  be  the  history  and  signs  of  pulmonary  rather  than 
of  cardiac  disease.  Identical  areas  of  chest  tenderness  may  be  found  in  diseases  of  the 
stoniach,  in  the  areas  of  distribution  of  at  any  rate  tlie  fourth  and  fifth  dorsal  nerves  ; 
the  diagnosis  here  will  turn  on  the  liistorv  of  gastrointestinal  disorder,  and  on  the  radiation 
of  the  jiain  and  tlie  discovery  of  tenderness  in  the  epigastrium. 

Tenderness  in  the  chest  may  result  from  hijiiries  or  inflammations  of  the  diaphragm, 
the  lower  costo-chondral  margin  being  affected.  The  diaphragm  is  innervated  by  the 
phrenic  nerves  mainly,  and  so  is  connected  with  the  third,  fourth,  and  fifth  cervical  nerve- 
roots  ;  accordingly,  referred  diaphragmatic  pain  and  tenderness  may  also  be  felt  in  the 
toji  of  the  shoulder,  an  area  innervated  by  the  fourth  cervical  nerve.  In  most  cases,  the 
Icndcrness  of  these  areas  will  be  due  to  (liiijilir<i!>nialic  j>lciiiisi/. 

Di.seanes  of  the  stomach.  ]iarticularly  gastric  alccr  and  JIntalent  dyspepsia,  may  give 
rise  to  pain  and  tenderness  in  the  chest  that  may  be  very  hard  to  distinguish  from  those 
due  to  cardiac  disease.  As  a  rule,  the  history  of  gastric  disturbances  should  be  of  great 
assistance  in  coming  to  a  correct  diagnosis  ;  although  it  must  be  remembered  that 
flatulence  and  temporary  gastric  upsets  are  seen  not  infrc((uently  in  true  angina  pectoris. 
Further,  the  pain  and  tenderness  due  to  diseases  of  tlie  stomach  are  mainly  abdominal, 
are  in  the  epigastric  and  left  hypochondriac  regions,  and  in  the  lower  half  of  the  back  of 
the  chest  ;  whereas  in  cardiac  disorders  they  are  characteristically  situated  higher  up  in 
the  chest  and  bac-k.  Klectrocardiograms  may  be  reipiired  to  show  whether  the  heart 
ai'tion  is  normal  or  not. 

It  is  possible  that  disease  or  ])ainful  stimulation  (as  by  hot  drinks)  of  the  (vsopliagns 
may  |)rofl\icc  an  area  of  referred  tenflerness  in  the  chest,  over  the  lower  third  of  the  sternum 
and  in  the  middle  line,  in  correspondence  with  the  pain  that  is  felt  here  in  these  conditions. 

Tendern<ss  in  the  right  side  of  the  chest  near  the  costal  margin  is  not  rare  in  diseases 
of  tlic  liver  and  g/dl-l/ladder.  corresponding  to  the  cutaneous  distribution  of  the  seventh, 
eighth,  and  m'nih  dorsal  nerves:  for  the  most  part,  however,  the  pain  and  tenderness 
are  in  the  ejiigaslrium  and  the  right  hypoehoiidiiuMi.  The  right  phrenic  nerve  (third  to 
fifth  cervical)  sends  twigs  to  the  li\er  and  gall-bladder,  so  that  tenderness  and  i)ain  may 
also  be  felt  in  the  right  shoulder,  just  as  they  may  be  in  disorders  of  the  diaphragm.  It 
is  j)articularly  in  cases  of  gall-stone  or  biliary  colic  that  these  areas  of  tenderness  are  likely 
to  he  found.  In  jialiciils  with  hepatic  abscess,  the  sprea<l  of  inllammation  to  the  chest- 
\\:i\\  niay  give  ris<-  hi  diri-cl  pain  ;fnd  tenderness  in  the  clicsl,  with  ths  develo])mcnt  of 
characteristic  local  and  general  symptoms  and  signs  :  the  diagnosis  here  will  have  to  be 
made  from  such  things  as  axillary  abscess,  empyema  niMKing  lis  wa\  thniugh  the  chest- 
wall,  or  abscess  arising   in   llu'  chest-wall.  .1.  ./.  .le.r-liliikr. 

TENDERNESS  IN  THE  EPIGASTRIUM.  (See  I'ain  in  rni;  KiMi;.vsTiur.M,  p. 
i:!ii.) 

TENDERNESS    OF    THE    HYPOCHONDRIUM.     (S,,     Pain    in    tui     IIvkkhon- 

DIlll   \I,    p.      I.'>l».) 

TENDERNESS    IN    THE    ILIAC    FOSSA.      (.Sec  I'ain  in  tiu-.   Ii.iac  Kossa,  p.   |..-,2.) 
TENDERNESS    IN    THE    JOINTS.      (.See  .Ioints.  .Vii-i-.crioNs  oi    tiik.  p.   -.VM .) 
TENDERNESS   IN    THE    LIMBS.      (S.'.'  I'ain   in  nn;  I.imus.  (;f,ni;iiai..  p.   Kil! ;    and 

SlONSAl  ION.     Soili;    .XiSNOiiMAI.rill.s    Ol',     p.    (lOI.) 


TENDERNESS    IN    THE    SCALP 


TENDERNESS    IN    THE    SCALP  occurs  in  two  main  varieties  :— 

1.  Direct  Tenderness,  due  to  injury  or  disease,  such  as — 

Briiisiiijj;   or    infected    wounds  i  Lupus  erythematosus,  von  Recklinghausen's 

Infianiniation   or   suppuration   compli-  j  disease 

eating  pediculosis,  rinjrwornijfavus,  '  Sclerodermia,  Brocq's  "  pseudopeladc  " 

eczema,  pruritus,  aerie,  etc.  !  Diseases     of    the    sliull — rickets,    syphilis, 

Herpes    and   dermatitis    herpetiformis,  '  tumour, 

erysipelas 

2.  Referred  Tenderness,  eitlier  due  to  disease  elsewliere,  or  functional  : — 
Meningitis,  increased  intracranial  i)res-       Neuralgia,      major     and     minor,     whether 

Slue,       intracranial       tumour      or    I  primary  or  due  to  disease  of  the  eyes, 

abscess,  concussion  of  tlie   brain,  ears,  teeth,  or  viscera 

otitis  media  I  Neurasthenia  and  hysteria. 

Fig.  290  exhibits  tlie  cutaneous  nerve-supply  of  the  .scalp  and  face,  indicating  the 
areas  in  which  tenderness  and  pain  are  to  be  expected  when  disease  or  disorder  of  the 
various  nerves  is  present. 

If  tenderness  in  the  scalp  is  due  to  bruising  or  zvoiaids,  it  should  not  be  difficult  of 
diagnosis  when  the  history  has  been  obtained.  A  similar  tenderness  is  naturally  to  be 
expected  when   inflammation  or  suppuration  occurs  as  a  complication  or  later  stage  of 

any  of  the  numerous  skin  diseases  to  which  the  scalp 
is  liable,  such  as  pediculosis,  ringivorm — a  suppurating 
ringworm  is  known  as  kerinn — seborrhceic  dermatHis, 
faviis  ;  the  itching  of  eczema  or  pruritus  may  be  so 
severe  as  to  lead  to  scratching  which  breaks  the  skin, 
with  the  result  that  impetigo  ensues.  In  young  men 
and  women  acne  may  spread  back  to  the  scalp  from 
the  forehead,  face,  or  neck  :  acne  decalvans  is  a  mild 
staphylococcal  infection  of  the  hair-follicles  that 
creeps  slowly  across  the  scalp,  and  leaves  it  bald 
by  destroying  the  hair-follicles.  Furunculosis  of  the 
scalp,  and  inflammation  of  a  sebaceous  cyst,  need  only 
be  mentioned  in  this  connection. 

In  herpes  oplith(dmicus,  or    herpes   zoster   of  the 
area  supplied    by    the    ophthalmic  or  first  branch    of 
the  trigeminal  or  fifth  cranial  nerve,  extreme  tender- 
nerve's"' "v',''\      V  ,       ,:  ,,       iip'rHor      n^-''*'   over  the  affected  area  may  be  noted  while  the 

[^''''{''i.','),;  il'i'i' ,',,  i'  , ,  !i  "'!""»  ot  eruption  la.sts  :  and  after  it  has  disappeared,  tender- 
ness and  itching  may  be  left  behind  for  many  months 
or  years,  sometimes  with  abnormal  pigmentation. 
Dermatitis  herpetiformis  (p.  755)  is  a  somewhat  similar  grouped  vesicular  or  bullous 
eruption,  with,  ringed  and  other  erythematous  lesions,  but  characterized  by  a  mucli  more 
extensive  distribution  than  herpes  zoster  :  when  it  involves  the  seal])  nuich  tenderness 
may  ensue,  although  the  chief  complaint  will  be  of  itching,  and  the  course  of  the  disorder 
is  long  and  uncertain.  Erysipelas  is  common  in  the  scalp,  and  should  be  diagnosed 
readily-.  Lupus  erythematosus  of  the  scalp  may  cause  tenderness  while  progressing  actively, 
when  it  may  reseudilc  even  a  severe  persistent  erysipelas  :  as  a  rule  it  is  a  very  chronic, 
.slowly  progressive  disorder,  commoner  in  females  than  in  males,  starting  between  the 
ages  of  twenty-five  and  forty-five.  It  produces  smooth  and  depressed  areas  of  complete 
and  permanent  baldness,  reddened  by  abundant  injected  venules.  In  von  Recklinghausen's 
disease,  subcutaneous  neurofibromas  are  found  all  over  the  body,  in  association  with 
freckling  and  pigmentation  ;  occurring  on  the  scalp,  these  tumours  will  make  it  tender, 
whereas  the  tumours  of  fibroma  molluscum  {Fig.  291),  a  disorder  at  first  sight  resembling 
\-on  Recklinghausen's  disease,  are  not  sensiti\e  to  pressure.  Sclerodermia  of  the  scalp 
may  occasion  much  tenderness,  particularly  in  its  early  stages  ;  it  is  a  chronic  diffuse 
infiltration  of  the  skin  that  ends  in  atrophy,  and  by  many  is  supposed  to  include  the 
'  pseudopeladc '  of  Brocq,  an  atrophic  indurative  affection  of  the  scalp  giving  rise  to 
depressed  areas  of  absolute  and  permanent  baldness  that  adhere  to  the  underlying  skull, 
and  connected  by  Brocq  with  alopecia  areata. 


TENDERNESS    IN    THE    SCALP 


711 


Tenderness  of  the  scalp  is  common  in  rickets,  and  is  the  main  cause  of  the  head-rolling 
and  restlessness  of  the  recumbent  rickety  child.  It  is  due  to  hyperaemia  and  disordered 
growth  of  the  cranial  bones  :  and  can  often  be  dia<jnosed  at  sight  by  the  thinness  of  the 
hair  or  positive  baldness  of  the  occipital  region  to  M-hich  the  head-rolling  leads.  A  similar 
tenderness  of  the  cranial  bones  is  seen  in  congeniud  si/philis,  and  is  caused  by  the  rarefying 
(craniotabes)  or  hyperplastic  (hot-cross-bun  skull)  osteitis  present.  In  adults  with 
neglected  syphilis  the  skull  may  be  tender  from  secondary  syphilitic  periostitis  or  tertiary 
gumma  ;  besides  the  tenderness,  pain  is  present,  and  is  characteristically  worse  at  night. 
Tumour  of  the  cranial  bones  may  give  rise  to  tenderness  of  the  overlying  scalp  or 
periosteum  :  in  adults  such  tumours  are  usually  secondary  to  malignant  disease  of  the 
breast,  thyroid  glanfl.  testis,  or  prostate.  In  children  they  are  often  secondary  to  sarcoma 
of  the  suprarenal  gland,  and  may  be  the  first  clinical  evidence  that  anything  is  amiss. 

Tenderness  in  the  scalp  may  be  due  to  organic  disease  that  is  not  in  direct  connection 
with  it.  In  meningitis,  whether  syphilitic,  tuberculous,  or  due  to  pus-producing  microbes, 
local  or  general  tenderness  of  the  scalp  may  be  a  marked  feature  ;  and  the  same  is  true  in 
cases  with  increased  intracranial  pressure  due  to  any  cause  whatever.  The  chief  complaint, 
however,  will  be  of  IIkauacuk  (j).  1293).  In  intracranial  tumour  the  scalp  and  periosteum 
are   sometimes   tender   to   pressure   in   the   neisxlibourhood   of  tlie   ijrowth  :     the  associated 


signs,  such  as  vomiting  on  change  of  position,  slow  pulse,  optic  neuritis,  and  local  paresis 
or  paralysis,  should  aid  the  diagnosis.  Tenderness  of  the  scalp  in  the  occipital  region 
and  below  it  lias  often  been  noted  after  rouciissiiin  of  the  lirain.  whether  mild  in  degree  or 
severe,  and  apart  Iroiu  neurasthenia  :  llic  pain  and  liiidriricss  may  each  he  both  superficial 
antl  deep. 

Tenderness  of  the  scalp  is  dIIiii  iniikcil  in  ncundgia.  a  \ngue  terni  applied  to  any 
severe  pain  that  follows,  or  seems  to  loijou,  the  (list  libut  ion  of  a  nii\-e.  In  trigeminal 
neuralgia,  neuralgia  major,  or  tic  doulourcu.v.  the  pain  and  tenderness  often  spread  back 
to  the  vertex  and  parietal  eminence,  in  eorrespotidenee  with  the  cutaneous  distribution 
of  the  first  or  ophthalmic  branch  of  the  liftli  ner\e.  I'ressure  o\er  the  tender  area  will 
often  bring  on  a  panixysm  of  pain  :  yet  while  the  piln  Is  raging,  the  patient  often  gains 
some  relief  by  linn  pressure  n\(r  the  |ialnful  |)art.  When  the  paroxysm  is  recently  past, 
pressin-e  does  rml  have  any  (>b\  idus  elTect  in  some  eases.  Identical  neuralgic  pain  and 
tenderness  niny  be  met  with  in  llie  rare  eases  where  a  tumour  presses  on  the  trigeminal 
nerve  or  its  roots,  as  nriy  happen  In  patients  with  meningeal  n<w  growths.  Definite  loss 
of  sensation  occurs  if  the  nerve  is  inxoUcd  In  a  tumour,  whereas  in  tie  (louioincux  llieri^ 
Is  no  ana-slhesia  :    in  addition,  the  i>llii-r  slc/ns  of  IntracTaniai  lunioiir  should  l>e  looked  for. 

Ill  anolhir  i^roiip  coiiic  I  lie  (•■iscs  of  iiciiriduiii  uiiiior.  In  wlilili  |>alii  and  tenderness  in 
tlic  sc:ilp  lorin  a  xisccral  iilli\.  .•mil  arc  iliic  lo  ilisia-c  In  Hie  e\  cs.  Icelii,  ear,  and  thoracic 
oraliiloiiiiiiai  \  is  ■iia.  A  rrlcncl  \is;(ral  pain  usually  brings  uilli  ll  superlieial  leiiilerness, 
anil    liolli    Ihi-   p:iiii   ami    llir   liiiilriniss  arc    loiiiiii   o\cr    •  segiiienlal  "    areas,   or  areas  that 


TENDERNESS    IN    THE    SCALP 


The  SictiiTKN'T 


do  not  correspond  with  the  distribution  of  the  peripheral  nerves,  but  follow  a  central  distri- 
bution {Figs.  292,  293).  In  other  patients,  however,  the  same  lesions  produce  areas  of 
pain,  and  less  often  of  tenderness  also,  that  do  follow  distributions  corresponding  with 
those  of  the  periijheral  nerves  ;  and  these  are  described  as  cases  of  neuralgia  minor  proper. 
To  gi\'e  examj^les  of  reflex  neuralgia,  disease  of  the  upper  bicuspids  may  cause  pain  and 
tenderness  in  the  temporal  jregion  ;  disorders  of  the  eye,  particularly  astigmatism  and 
hypermetropia,  iritis,  and  glaucoma,  may  cause  headache  and  tenderness  spreading  from 
the  forehead  to  the  vertex  and  to  the  temporal  area  ;■  su|3puration  in  the  middle  ear  may 
make  the  whole  side  of  the  head  tender.  Certain  areas  on  the  head  are  segmentally  united 
with  other  areas  on  tlie  body  ;  the  temporal  area  of  the  scalp  is  connected  thus  with  the 
seventh  dorsal  segment,  and  so  diseases  of  the  lieart,  Inngs.  or  stomacli  may  all  bring  about 
temporal  pain  and  tenderness,  associated  with  the  segmental  area  of  cutaneous  tenderness 
about  the  level  of  the  epigastrium  that  directly  represents  the  seventh  pair  of  dorsal 
nerves.  It  is  ]jrobable  that  a  number  of  patients  with  undetected  disease  of  the  teeth, 
eyes,  ears,  or  vi.scera.  are  treated  for  '  neuralgia  '  for  long  periods,  when  a  more  careful 
examination  of  their  history  and  investigation  of  their  physical  condition  would  lead  at 
once  to  the  proper  diagnosis.  In  a  certain  number  of  cases  ))ain  and  tenderness  in  the 
scalp  are  due  to  general  diseases  such  as  diabetes  mellitus,  malaria,  and  rheumatism  :  a 
fact  that  leaves  room  for  nuich  latitude  in  diagnosis. 

In  both  neurasthenia  and 
liij.sleria  complaints  of  pains 
and  tenderness  are  common, 
and  the  scalp  may  be  affected 
u.st  as  any  other  part  of  the 
body  may.  The  neurasthenic 
often  has  occipital  tenderness, 
with  pain  referred  to  the  hair  ; 
brief  mental  effort  may  bring 
on  pain  and  tenderness  in 
the  sinciput  or  vertex.  The 
hysterical  patient  may  be 
prostrated  by  headache,  with 
extreme  tenderness  of  the 
scalp.  It  is  not  necessary  to 
say  that  the  greatest  care  to 
exclude  organic  disease  of 
every  sort  should  be  taken 
before  the  diagnosis  of  neur- 
asthenia or  hysteria  is  made  in  a  patient  ciinii)laining  of  tenderness  in  the  scalp.  It  is 
noticeable  that  any  conditions  tending  to  build  uj)  the  strength  and  improve  the  nutrition 
of  neuralgic,  neurasthenic,  or  hysterical  patients,  are  likely  to  lessen  the  pains  and  areas 
of  tenderness  of  which  they  so  often  comi)lain.  Conversely,  these  persons  are  always 
nuich  worse  when  their  healtli  is  low,  and  ])artieularly  when  they  are  anirmic. 

.1.  J.  Jcv-Blake. 
TENDERNESS  IN  THE  SPINE  occurs  in  two  <lifferent  sets  of  conditions.  In 
the  first  it  is  due  to  local  disease  of  the  skin  or  subcutaneous  tissues,  fasciae,  muscles,  bones. 
or  nerve-tissue  in  the  iinmediate  neighbourhood  of  the  spine  ;  and  the  pain  felt  when  the 
tender  spot  is  touched  is  a  direct  pain.  In  the  seeond  there  is  no  local  disease,  and 
the  pain  felt  on  stimulation  of  the  tender  area  is  a  referred  pain,  due  in  most  cases  to  organic 
disease  of  one  or  other  of  the  viscera,  in  a  few  to  some  obscure  nervous  disorder.  The 
tenderness  varies  widely  in  degree.  In  the  severest  cases,  whether  direct  or  referred,  the 
pain  may  be  such  that  the  patient  cannot  endure  even  the  light  pressure  of  the  clothes 
ordmarily  worn,  and  is  in  agony  the  moment  a  finger  is  laid  upon  the  tender  place. 

When  due  to  Local  Disease,  the  tenderness  is  usually  associated  with  rigidity  of 
the  spine  in  the  tender  section,  a  protective  reflex  designed  to  give  rest  to  the  diseased 
part.  This  is  particularly  well  marked  when  it  is  bone — the  vertebral  column— that  is 
diseased.  A  similar  but  less  complete  and  more  extensive  rigidity  will  be  noted  when  the 
local  disorder  is  in  the  muscles  or  fascia;  of  the  back.     Should  the  local  disease  or  injury 


TENDERNESS     IN    THE    SPINE  713 

be  so  extensive  as  to  involve  or  compress  the  spinni  eonl,  speeial  symptoms  (oirdle-pain, 
])aresis,  anaesthesia,  etc)  will  be  adfleil.  The  chief  morbid  states  in  which  such  tenderness 
of  the  spine  occurs  are  summarized  in  the  following  table  : — 

Diseases  of  the  skin  <irid  subcutaneous      \  Injury,  infected  wounds,  abscess-formation, 
tissue                                                             I        etc. 

Diseases  of  the  muscles,  fascia',  or  nerves  Gout,    rheumatism,    injury,    herpes,    etc. 

/  Tuberculosis  and  other  infections 

I  Caries    sicca,     spondylitis    deformans, 

.        ,  ,  '  typhoid  spine  " 

Di.seases  at  eclino  tlie  vertclirtc  -     .,      :       .  .. 

■'■'         •  •    I'^rosion  bv  aortic  aneurysm 


Trauuialie  ucurasllienia.  nitli  local  lesions  ( 
that  are  not  demonstrable  ( 


Invasion  by  nialignant  disease 
Injury 

■  Railway  spine." 


To  consider  these  lesions  in  detail  :  Obviously  the  skin  and  subcutaneous  tissues  may 
be  tender  oyer  the  spine  after  falls  or  blows  on  the  back,  infected  wounds,  in  acne  and 
fiirunculosis,  in  abscess-formation,  whether  the  infection  is  derived  from  without,  or  from 
within  as  in  ])ya>mia  ;  a  psoas  abscess  may  point  and  discharge  on  the  back  over  the 
\(Ttebral  column.  Tenderness  in  the  spine  due  to  affections  of  the  fasciee  and  muselcs  may 
be  experienced  by  any  ill-trained  person  who  over-uses  or  strains  his  spinal  muscles  :  it  is 
also  coiiiiTion  in  iioali/  patients  :  and  fretfuently  it  is  associated  in  the  rheumatic  with  attac^ks 
of  lumliago.  I)ee|)-seated  inflammations  in  this  region  are  not  rare,  and  are  seen  usually 
in  connection  with  spinal  caries  ;  less  often  the  inflammation  may  be  due  to  puivmia. 
empf/ema  perforating  spontaneously,  trichininsis  and  other  ^■e^y  rare  forms  of  mijosilis. 
when  they  chance  to  attack  the  spinal  region.  In  a  few  instances,  no  doubt,  disease  of  the 
spinal  nerves.  |)artieularly  when  their  posterior  ])riniary  divisions  are  affected,  gives  rise  to 
tenderness  in  the  spine  as  well  as  along  the  course  of  the  nerves  themselves  ;  this  may 
occur  when  pressure  on  the  nerves  or  their  roots  exists,  and  in  cases  of  herpes  zoster  or 
neuritis.  .Most  of  the  caiises  of  spinal  tenderness  enumerated  above  should  not  be  dilbcult 
of  diagnosis  if  a  careful  examination  of  the  patient  be  made,  and  his  other  signs  and 
symptoms  of  disease  be  noted. 

The  eases  in  which  the  tenflerncss  is  due  to  disease  of  the  vertebra'  are  far  more 
JMiportant  than  the  above,  and  probably  conwnoner  also,  as  well  as  far  more  serious  from 
the  point  of  view  both  of  i)rognosis  and  treatment.  Excluding  spinal  traiuna.  which 
usually  declares  itself  ob\  iously  and  is  considered  below,  the  three  disorders  to  which  the 
vertebra-  are  liable  In  this  connection  are  tuberculosis,  invasion  by  malignant  disease,  and 
erosion  by  an  aneuri/sm.  In  other  rarer  instances  they  may  lie  affected  with  similar  sym- 
ptoms and  results  by  in-linomi/eosis.  pi/a-mie  abscess,  the  sjiread  of  infection  from  adjoining 
parts  (retropharyngeal,  meiliastinal,  subdiaphragmatic,  perinephric,  or  i)elvic  absees.ses), 
hydatid  disease,  siiinidiililis  deformans,  and  vertebral  arthritis  due  to  the  gonococcus  and  other 
microbes.  When  caiiscil  hy  vertebral  tubereuhisis.  the  spinal  tenderness  is  local,  and  is 
generally  accompanied  by  mure  or  less  anguhir  deriirriiit\  of  the  spinal  column,  collapse 
of  the  diseased  and  softened  aiiteiicu-  part  ol  the  \i  ileliial  body,  causing  abnormal  ])rojec- 
tioii  of  its  dorsal  spine  at  the  same  time.  If  it  is  the  posterior  part  of  the  affected  \ertebra 
that  collapses,  the  spinous  process  will  sink  inwards  ;  it  nuist  be  remembered,  however, 
that  coni;<nit,d  defect  or  dclicieney  of  a  spinous  process  is  not  \-ery  rare,  and  may  be 
mistaken  lor  the  result  of  injury  or  disease.  Whether  ilelormily  a-conipanies  spinal  caries 
or  no.  rigidity  nl  the  diseased  part  of  the  spinal  column  is  sure  to  be  present.  It  is 
maintained  by  involuntary  contra<'tion  of  the  appropriate  muscles,  and  becomes  consiMcnous 
when  the  patient  is  encouraged  to  bend  his  back  in  an\-  direction,  cm- to  rotate  the  body  on 
the  pelvis.  In  addition,  pain  will  be  felt  in  the  back  when  the  patienfs  \erlcx.  shoulders, 
sacrmn.  or  legs  are  jarred  ;  his  gait.  too.  and  method  of  holding  himself  and  turning, 
designed  to  reliexc  the  diseased  part  (d'  the  spinal  column  from  shock  or  strain,  will  be 
eiiiracteristie.  In  elilMren  whii  :!re  iKit  w<'ll  liKiked  al't<T,  this  spinal  tenderness  and  dcfiir- 
iiiil\  ina\  lie  miiiMlieed  and  the  di.inMcisis  ol  spinal  caries  nut  established  until  a  psoas 
iiliseess  has  furiiiid  and  has  declared  ilsclf  by  pain  in  I  hi'  li'g,  or  lameness.  The  importance 
here  (if  earl\    iliagnosis  eMiiiKil    lie  (iserslaled  :    spinal   I  iilieiculosis  is  commonesi    in  children. 


714  TENDERNESS    IX    THE    SPINE 

but  may  occur  at  any  age.  It  often  happens  that  rickety  children  are  suspected  of  '  spinal 
disease  '  by  their  parents  :  they  present  marked  spinal  curvature,  due  to  flabbiness  of  the 
muscles,  and,  like  all  their  bones,  their  spines  may  be  tender  on  pressure.  But  there  is  no 
localized  spinal  tenderness  in  rickets,  there  is  no  angular  deformity,  the  spinal  curvature 
\anishes  when  the  child  is  suspended  by  the  head  or  arms,  no  pain  is  caused  by  jarring 
or  rotating  the  spinal  column,  and  there  is  no  rigidity  of  the  back  ;  the  other  ordinary 
evidences  of  rickets  will  be  present,  so  that  the  diagnosis  should  not  be  difficult.  In  adults, 
however,  and  particularly  during  the  second  half  of  life,  it  may  often  be  didicult  to  deter- 
mine whether  a  persistent  tenderness  over  some  part  of  the  spine,  associated  with  pain 
and  rigidity,  is  due  to  tnbemdosis.  aneurysm,  or  malignant  disease  affecting  the  vertebral 
column.  The  occurrence  of  angular  curvature,  due  to  softening  and  collapse  of  the  verte- 
bral body,  would  argue  in  favour  of  tuberculosis,  being  comparatively  rare  in  aneurysm  or 
malignant  disease  ;  evidence  of  tuberculous  mischief  in  the  patienfs  joints,  lungs,  or 
larynx,  a  history  of  cough  or  blood-spitting,  or  a  marked  family  history  of  tuberculosis, 
would  all  point  in  the  same  direction.  Aortic  aneurysm,  eroding  the  vertebral  column 
and  causing  pain  and  tenderness  by  i)ressing  on  the  nerves  in  its  vicinity,  would  be 
suggested  if  the  patient  were  a  middle-aged  man  giving  a  history  of  syphilis.  Examination 
imder  the  .r-rays  and  testing  for  Wassermann's  reaction  might  be  of  great  assistance  here  ; 
deep  abdominal  palpation,  under  an  anicsthetic  if  necessary,  might  reveal  the  expansile 
pulsation  of  an  aortic  aneurysm.  Secondary  deposits  of  malignant  disease,  invading  or 
encompassing  a  vertebra,  may  occasion  marked  spinal  tenderness  and  pain  in  the  back  of 
the  severest  description  ;  in  rare  cases,  the  malignant  growth  may  be  primary.  The 
\  ertebrae  are  the  bones  most  often  invaded  by  secondary  malignant  growths  ;  the  primary 
growths  most  frequently  responsible  for  secondary  deposits  in  the  bones  are  carcinoma  of 
the  thyroid,  testis,  prostate,  and  mamma,  primary  sarcoma  of  bone,  and  melanotic  sarcoma. 
Here  again  the  diagnosis  may  be  very  dilTicult,  in  the  earlier  stages  of  the  disorder  particu- 
larly, because  the  primary  growth  may  be  small  and  deep-seated,  and  may  have  given  rise 
to  no  signs  or  symptoms  leading  to  its  discovery,  so  that  the  presence  of  secondary  deposits 
is  not  suspected.  In  the  later  stages,  the  growth  often  burgeons  into  the  spinal  canal,  and 
causes  symptoms  of  paraplegia  by  compressing  the  spinal  cord.  ^Vhen  this  occurs  the 
diagnosis  is  easier,  for  the  site  of  the  compression  may  be  indicated  by  a  gir(lle-[)ain  and  a 
zone  of  hyperaesthesia  ;  while  ana*sthesia.  with  paresis  or  paraplegia,  is  found  below  it,  the 
sphincters  are  affected,  the  knee-jerks  are  increased,  and  ankle-clonus  and  Babinski's 
extensor  plantar  reflex  can  be  elicited.  But.  as  has  been  pointed  out  already,  it  may  be 
impossible  to  find  any  definite  physical  signs  in  a  patient  com])laining  of  very  severe  and 
intractable  pain  and  tenderness  in  some  part  of  his  spinal  cohmin  :  and  most  physicians  of 
experience  must  have  met  with  sad  cases  where  such  patients  ha\e  been  treated  as  malin- 
gerers, the  honesty  of  their  complaints  failing  to  win  recognition  until  a  ])athological  basis 
for  them  has  been  established  at  an  autopsy. 

I^ittle  more  need  be  said  about  most  of  the  other  local  diseases  that  may  make  the 
affected  region  of  the  spine  both  tender  and  painfid.  Caries  sicea  is  the  name  given  to  an 
obscure  rarefying  osteitis  of  chronic  course,  non-suppurative,  that  may  attack  the  vertebriB. 
The  signs  and  symptoms  of  vertebral  acliiionii/ensis  resemble  those  of  tuberculosis.  In 
chronic  pycemia  a  vertebral  abscess  may  arise,  and  in  patients  with  abscesses  in  the  spinal 
region — such  as  pelvic,  perinephric,  suhdiapliragiiiidic.  mediastinal,  or  relrnpharyiigeal — 
a  sjjread  of  infection  to  the  vertebra"  may  conceivably  occur,  giving  rise  to  tenderness  in 
the  affected  part  of  the  spine  ;  hydatid  disease  of  the  spinal  canal  or  vertebral  coliunn  may 
do  the  same  in  persons  exposed  to  echinococcus  infection.  But  in  all  these  instances  the 
tenderness  in  the  spine  will  be  but  a  minor  symptom  of  a  serious  and  more  or  less  acute 
disorder,  with  other  features  that  are  more  characteristic.  Tenderness  in  the  spine  is  often 
marked  in  spondylitis  deformans  {Fig.  274,  p.  648),  the  name  given  to  practically  any  chronic 
n(in-sup)Hirative  form  of  vertebral  arthritis.  It  is  no  doubt  an  infectious  process,  and  occurs 
after  gonorrhoea,  influenza,  enteric  fever  (the'  typhoid  spine  "),  tonsillitis,  and  other  bac- 
terial disorders.  It  is  characterized  by  stiffness  in  some  portion  of  the  vertebral  column,  with 
irregular  deposits  of  new  bone  in  the  adjoining  ligaments,  particularly  the  anterior  common 
ligament,  well  seen  by  the  use  of  .r-rays.  The  chief  sign  is  stiffness  in  the  back,  and  in  a 
few  of  the  cases  osteo-arthritis  of  some  joints  of  the  limbs  occurs  as  well  ;  in  instances 
where  the  hip  or  shoulder  are  thus  in\ohed  the  disease  has  been  named  •  spoiidylosc  rhizo- 


TENDERNESS     IN    THE    SPINE  715 

meliqiic  '  by  Marie.  Men  are  affected  four  or  five  times  as  often  as  women,  and  the  disea.se 
usually  begins  between  the  ages  of  twenty  and  fifty.  Its  diagnosis  may  be  difficult,  liecause 
the  chief  complaint  may  be  of  pain  in  tlie  hi|)s.  legs.  al)donien.  or  thorax,  or  of  "  sciatica  " 
or  '  lumbago.'  so  that  disease  of  the  \erteljral  column  may  be  neither  suspected  nor  looked 
for.  In  mcst  patients,  the  affected  region  of  the  spine  is  tender  ;  much  spasm  of  the  dor.sal 
muscles  is  found  in  the  more  acute  cases,  while  in  those  of  long-standing,  atrophy  from 
disuse  will  be  found.  The  typhoid  spine  is  a  rare  sequela  of  enteric  fever,  usually  occurring 
early  in  convalescence.  The  patient  complains  of  tenderness  and  the  most  acute  pain  in 
the  lower  part  of  the  vertebral  column,  after  an  initial  stage  of  backache.  Fever  is  jjresent 
at  first  in  half  the  cases,  and  no  doubt  the  eim.ditioii  is  commonly  due  to  vertebral  iierio.stitis 
set  up  by  the  Bacillus  typhosus.  The  symptoms  last  for  many  months  as  a  rule,  and  defor- 
mity of  the  spine  is  left  in  half  the  patients  ;  but  suppuration  of  the  affected  vertebrse  seems 
to  be  imknown.  Men  are  affected  more  often  than  women.  In  milder  cases  no  physical 
signs  of  vertebral  disease  appear,  and  .so  the  affection  has  been  described  as  hysterical,  the 
spine  as  an  irritable  spine  :  in  yet  other  instances,  the  spinal  cord  appears  to  be  involved, 
as  if  the  periostitis  affected  the  spinal  canal,  loss  of  control  over  the  sphincters  being 
observed,  with  paresis  of  the  legs,  and  changes — usually  increase — in  the  reflexes. 

Tenderness  in  the  spine  due  to  injury  may  be  the  expression  of  either  organic  or 
functional  disease  resulting  therefrom,  and  the  precise  diagnosis  may  be  extremely  difficult. 
The  trauma  is  usually  a  railway  or  other  accident  of  locomotion  ('  railway  spine  "),  a  fall, 
a  sudden  shock  or  concussion  ;  in  another  grou])  of  cases  it  is  either  a  single  sudden  mu.scular 
over-strain,  due  to  over-exertion  or  the  effort  to  avoid  an  accident,  or  the  more  chronic 
overstrain  to  which  rowing  men,  football  players,  and  the  like  are  exposed.  A  gross  injury 
may  produce  fracture  of  a  vertebra,  with  or  without  displacement  of  the  fragments  such 
as  can  be  demonstrated  by  the  use  of  .r-rays  ;  subperiosteal  or  subdural  ha?morrhage, 
haemorrhage  into  the  spinal  canal,  hsemorrhage  into  or  bruising  of  the  cord,  all  of  which  will 
give  rise  to  localizing  cord-symptoms  (girdle-pain  at  the  level  of  the  lesion,  varying  degrees 
of  paresis  and  ana'sthesia  below  it)  when  the  lesion  is  marked.  At  the  other  end  of  the 
.scale  are  found  the  sufferers  from  traumatic  neurasthenia,  who  have  been  exposed  to  identical 
injury  or  over-strain,  but  present  no  definite  signs  of  disease  in  the  spine  or  cord,  although 
quite  incai)acitate{l  for  months  or  years,  by  weakness  and  .severe  pains  in  the  injured  region. 
These  patients  often  have  increased  knee-jerks  and  even  ankle-clonus  :  but  definite 
e\  idenees  of  organic  disease  are  wanting,  tlie  sphincters  are  unaffected,  Babinski's  extensor 
jilantar  reflex  is  not  olitained.  muscular  wasting  is  not  found,  unless  from  disuse,  and  the 
various  pains  and  tindernesses  of  which  complaint  is  made  ha\e  a  neurasthenic  or  even  a 
hysterical  distribution  ami  character.  Traumatic  neurasthenia  may  follow  surgical 
operations  or  comparatively  slight  injuries  to  the  head,  back,  or  testicle,  in  addition  to 
the  severer  traumas  and  strains  already  mentioned  :  and  it  must  be  noted  that  a  delay  of 
one  or  more  weeks,  an  incubation-period,  may  intervene  between  the  receipt  of  the  injury 
and  the  development  of  the  neurasthenic  pains.  It  woidd  be  unfair  to  take  such  ii  delay 
as  CN  idence  of  a  hysterical  factor  in  the  ease,  or  of  malingering. 

It  is  clear  from  the  foregoing  paragraph  that  traumatic  neurasthenia  includes  cases  in 
which  it  is  iiol  possihlc  to  say  for  certain  whether  a  local  organic  icsioii  of  the  si)iiie  exists  or 
Mill.      Siicli  ioslanccs  I'orrn  a  natural  Iransition  to  those  in  wliicli  IIktc  is  : 

Tenderness  in  the  Spine  due  to  Functional  Disorders,  or  to  Disease  in  Other 
Parts  of  the  Body.  In  \iry  r<\v  of  llicsc  is  iIkic  any  delnniiilx-  of  the  spina!  ciilunm  : 
it  is  llc\i!i-  and  not  rigid  :  and  pain  is  rarely  priiiluciil  when  it  is  carefully  lient.  twisted, 
or  jarred,  so  long  as  direct  stimulidion  of  the  tender  part  is  avoided.  .\s  a  rule,  the  tender- 
ness is  superficial  rather  than  deep,  and  it  is  often  associated  with  other  areas  of  tenderness 
in  the  side  or  froTit  nf  llic  hody.  In  hysleriii.  complaitd  of  pain  atxl  tenderness  in  tlii'  spine 
and  back  is  not  r.in-  I  In-  '  hysterical  spine."  'I'lie  tenderness  over  the  vertebra-  is  often 
accompanied  by  tendcnicss  on  cither  side  of  theiii  :  in  extent  it  may  change  from  time  to 
lime,  in\<>l\ing  a  single  vertehra  or  e\-en  most  of  the  \crt(l)ral  column.  In  neurastlicnia  the 
spine  may  Ix-  tender  from  top  to  hottom,  and  more  or  less  rigidity  is  often  fotmd  also.  When 
tlir  tenderness  is  loeali/.ed  to  a  small  pari  of  the  \k\:-\<.  it  may  cisily  be  taken  as  cvid<'nc;- 
of  local  organic  disease:  l>iil  IIk'  prcscnrc  nf  ollici-  iinirasl  hcnic  s\riiptoms  headache, 
irritahilily.  fat  iiiuliilily  alter  hiiif  i\(il  ion  :inil  llic  absence  of  signs  of  delinile  loc:;! 
disease  or  in\ nK  cinrnl   of  llic  cdid.   siniiilil   lii'l|i   in   the  <liagnosis.     To  distinguish  elciirly 


716 


TENDERNESS    IN    THE    SPINE 


between  neurasthenia  and  hysteria  is  often  dillieult.  and  particularly  so  in  the  milder  cases 
of  traumatic  neurasthenia,  because  they  may  develoj)  hysterical  features  such  as  areas  of 
ana."sthesia.  a  craving  for  sympathy,  a  tendency  to  exaggerate  the  symptoms,  and  so  forth. 
The  harmful  effects  of  mental  worry  on  neurasthenia,  of  the  uncertainty  attaching  to  an 
imjjending  law-suit  in  which,  perhaps,  damages  for  injury  are  being  claimed,  are  well  known. 
Tenderness  in  the  spine  is  very  commonly  a  reflex  from  disease  in  one  or  other  of  the 
thoracic,  abdominal,  or  jielvic  viscera.  The  tenderness  is  characteristically  su]3erflcial 
in  these  cases,  and  acute  pain  may  result  from  light  pressure  on  the  area  involved  ;  and  if 
the  tender  tissues  can  be  pulled  aside  sulliciently,  it  will  be  found  that  pressure  on  the  spine 
itself  causes  no  pain  whate\er.  The  different  viscera  produce  this  tenderness  with  some 
regularity  in  different  and  definite  spinal  areas,  a  .scheme  of  which  is  given  in  Fi!>.  294. 

The  organs  and  diseases  most  often  giving  rise  to  this  referred  tenderness  and  pain 
in  the  spine  are  as  follows  :  The  aorta,  in  aortitis,  arteriosclerosis,  and  aneurysm  ;  the 
heart,  in  coronary  sclerosis  jjarticularly,  myocarditis,  myocardial  fibrosis,  acute  dilatation 
and  failing  compensation  ;  the  .stomach,  in  gastric  ulcer,  malignant  disease,  gastritis  ;  the 
liver,  in  cholelithiasis,  cholangitis,  new  growth,  and  the  venous  congestion  of  tricuspid 
reflux  ;  the  intestine  and  rectum,  in  acute  inHammatory  disorders,  constipation,  and  carcin- 
oma ;    the  uterus,  in  labour,  menstruation,  inflammatory  affections,  and  new  growth.     It 

would  ap])ear  that  the  lungs,  whether  in- 
flamed or  wounded,  do  not  give  rise  to  a 
referred  tenderness  ;  on  the  other  hand,  the 
whole  or  any  part  of  the  thoracic  spine  may 
become  tender  in  disorders  of  the  pleura,  such 
as  ])Ieurisy,  pleural  adhesions,  or  new  growth. 
To  illustrate  the  frequency  with  which  ])ain 
and  tenderness  of  the  spine  occur,  the  axiom 
of  many  hospital  out-])atient  departments 
may  be  quoted,  that  there  is  no  woman  in 
London  who  has  not  got  a  pain  at  the  bottom 
<if  her  back — a  libel  on  the  sex,  one  may 
hope. 

The  importance  of  distinguishing  between 
the  cases  in  which  the  physical  signs  of 
organic  disease  in  the  vertebral  column  or 
cord  are  absent,  and  those  detailed  in  Class  1 
above,  need  not  be  emphasized  further.  The 
referred  pains  and  tendernesses  disappear  or 
are  relieved  with  the  cure  or  relief  of  the 
cardiac,  gastric,  or  other  disorder  to  which 
they  are  due.  The  diagnosis  of  the  cause  of 
tenderness  over  the  fourth  dorsal  vertebra, 
for  example,  which  may  be  due  to  disease  of 
the  heart,  pleura,  or  stomach,  must  be  made  on  general  lines,  and  by  consideration  of  the 
(itlier  signs    and  symptoms    exhibited    by  the  patient.  .1.  J .  .fex-IUaI.e. 


Fi'j.  '^M. — Areas  of  referred  spiii.il  pain  and  tender: 
'li-r  Mackenzie).  A,  In  diseases  of  tlie  heart  ;  B, 
-eiisfc^  of  tlie  stomach  ;  c,  In  diseases  of  the  U\ 
In  diseases  of  the  rectum  and  uterus. 


TENESMUS  signifies  frequent  and  painful  inclination  to  go  to  stool,  associated  gener- 
ally with  straining  and  griping  but  with  very  little  evacuant  result.  A  precisely  similar 
condition  affecting  the  bladder  is  spoken  of  sometimes  as  vesical  tenesmus,  but  a  better 
known  term  for  this  is  Strangury  (p.  649). 

The  severest  examples  of  rectal  tenesmus  are  afforded  by  acute  dysenterij.  in  which, 
after  the  acute  onset  of  the  disease,  copious  loose  faecal  motions  are  passed  to  start  with, 
then  smaller  and  .smaller  quantities  at  a  time,  and  after  this,  when  there  is  jiractically 
nothing  left  to  come  away  from  the  bowel,  the  desire  to  defsecate  in-gently  and  repeatedly 
may  still  recur  perhaps  every  ten  minutes  with  jjainful  straining,  causing  the  patient  to 
groan  or  cry  out,  but  with  practically  no  evacuant  result  beyond  a  little  fluid  with  mucus 
and  blood.  The  diagnosis  in  these  ca.ses  is  generally  based  upon  the  fact  that  the  patient 
is  or  has  been  resident  in  some  ])art  of  the  tropics  where  dy.sentery  is  endemic  :  the  nature 
of  the  dysentery  itself,  whether  due  to  the  amoeba  of  dysentery,  or  to  Shiga's  dysentery 


TEXESMUS  717 

liacilliis.  or  to  otlier  less  well  known  baeilli.  is  nuide  ui)On  the  results  of  bacteriologieal 
investigations  of  the  stools. 

Similar  tenesmus  may  also  occur  in  acute  cholera  when  the  stage  of  rice-water  stools 
has  been  reachetl  :  here  again  the  diagnosis  depends  upon  the  fact  of  residence  in  a  part 
where  cholera  is  endemic,  or  in  a  district  in  which  cholera  has  recently  broken  out  in  epidemic 
form  :   it  is  confirmed  l)y  the  discovery  of  the  comma  bacilli  of  cholera  in  the  stools. 

In  this  country  there  are  various  types  of  acute  iiij'eclii'e  diarrlicea  which  may  simulate 
cholera  to  such  an  extent  that,  although  not  cholera  at  all,  they  have  been  grouped  together 
under  the  heading  of  cholera  nostras,  and  in  such  cases  tenesmus  may  be  extreme.  Tempo- 
rary acute  diarrhoea  with  much  tenesmus  may  arise  in  school-boys  and  others  from  the 
eating  of  unripe  apples  or  other  fruit  ;  after  a  brief  but  acute  illness,  and  perhaps  a 
drastic  purge,  rapid  recovery  is  the  rule.  More  serious  are  the  acute  attacks  of  vomiting 
and  diarrhtra  which  are  familiar  under  the  name  of  ptomaine  poisoning,  the  cause  being 
baeilli  allied  to  Gaertner"s  bacillus  ingested  along  with  some  article  of  diet.  Cases  of 
ptomaine  poisoning  may  be  sporadic,  but  occasionally  as  the  result  of  many  persons 
eating  the  same  cold  pork  pie  perhaps,  or  something  of  that  kind  at  a  public  function, 
acute  e])idemies  are  recorded,  some  of  the  cases  ending  fatally.  The  baeteriologv 
of  the  condition  is  complex  ;  different  micro-organisms,  including  not  only  Gaertner's 
bacillus,  but  also  Morgan's  bacillus  .\,  Morgan's  bacillus  B,  and  probably  others,  are  at  the 
root  of  different  outbreaks.  The  diarrhoea  is  at  first  painless  though  frequent,  but  severe 
tenesmus  ensues  after  the  bowel  has  become  em])ty  of  practically  everything  but  a  little 
fluid  together  with  mucus  and  exuded  blood. 

Chronic  (lijsenteri/  is  less  often  associated  with  tenesmus  than  is  the  acute  form,  but  a 
considerable  degree  of  tenesmus  may  none  the  less  be  eom|)lained  of  by  those  who  have 
suffered  from  dysentery  in  the  tropics  and.  having  returned  home  not  yet  cured,  still  sutler 
from  repeated  diarrha?a  to  the  extent  of  perhaps  twelve  or  fifteen  motions  a  day.  The 
same  applies  to  cases  of  colitis,  whether  muco-membranous  or  ulcerative,  arising  at  home. 
It  may  be  very  diflieult  in  some  such  cases  to  exclude  malignant  disease  of  the  bowel  unless 
the  history  is  too  long  for  this.  In  cases  of  doubt  nnich  may  be  learned  by  passing  the 
sigmoidoseoi)e  and  actually  seeing  the  inflamed  or  ulcerated  mucous  membrane  of  the 
lower  part  of  the  bowel. 

Intussusception  will  only  cause  tenesmus  when  the  lower  end  of  the  intussusceptuin 
has  reached  the  pelvic  colon  or  the  anus.  The  symptoms  will  be  those  of  intestinal  obstruc- 
tion, and  when  the  intussusception  is  felt  per  rectum  or  seen  protruding  per  anum,  the  only 
dilliculty  will  be  to  distinguish  it  from  a  rectal  i)olypus.  or  prolapse  of  the  rectum.  The 
condition  is  very  much  commoiur  in  iiil'ants  about  Tiine  months  old  than  in  any  other 
class  of  patient,  and  at  this  tender  age  tenesmus  will  not  as  a  rule  lie  obvious.  In  older 
patients  a  subacute  or  chronic  intussusception  is  fortunately  very  rare,  and  it  is  seldom 
diagnosed  accurately  previous  to  operation. 

Acute  summer  rliarrliwa  and  vomiting  of  infants  is  allied  to  ptomaine  poisoning  and 
is  similarly  due  to  one  or  more  of  the  enteritic  micro-organisms  ;  tenesmus  may  be  very 
severe  in  infants  as  well  as  in  adults. 

.Another  malady  allied  both  to  ptomaine  i)()isoning,  to  tropical  dysentery,  and  to 
acute  summer  diarrlnea  and  vomiting  of  infants,  is  so-called  asijlum  dysenterif.  of  which 
the  symptoms  and  results  are  very  similar  indeed  to  those  of  tropical  dysentery  ;  asylum 
dysentery  also  has  a  bacterial  cause,  and  the  micro-organism  producing  it  has  been  the 
subject  of  eonsi<lerable  in\cstigation.  The  dillieuKy  of  deciding  the  |)recise  nature  of  the 
infecting  orgaiiisin  in  all  llies<-  eases  depends  uf>on  the  siinilarit\  between  the  dilferent 
possible  baeilli  and  the  ordinar^■  bacillus  coli  which  always  abounds  in  the  e\aeualions. 

.Acute  tenesnms  may  be  a  marked  feature  in  some  cases  of  poisoning  hi/  arsenic  :  the 
diagnosis  of  this  cause  may  be  f)l>vious  either  on  account  of  the  patient  having  taken  an 
over-dose  with  intent  to  commit  suicide,  when  choleraic  diarrho-a  and  nuieli  tenesmus 
may  come  on  subscciucnt  to  the  initial  vomiting  and  collapse;  or  because,  in  less  acute 
eases,  the  patient  is  known  to  be  taking  large  doses  of  arsenic  in  his  medicine  for  instance, 
in  the  treatiTient  of  chorea  or  of  pernicious  ana'inia  ;  indeed,  the  occurrence  of  diarrlicea 
with  gri|)ing  rectal  |)ains  and  tenesmus  is  one  of  the  dilliculties  that  firesents  itself  in  con- 
tinuing the  arsenical  tn'atment  of  pernicious  ana-miu  and  other  blood  diseases  to  the  extent 
tliat  one  would  like.     On  the  other  hand,  even  when  arsenic  is  the  cause  of  diurrlucu  and 


718  TENESMUS 

tenesmus,  it  may  sometimes  be  very  diflicult  indeed  to  make  certain  of  the  fact,  althouoh 
some  suspicion  of  it  may  ha\'e  arisen  in  the  mind  of  the  physician.  Accidental 
contamination  of  the  water  or  of  some  food  may  have  occurred  ;  or.  still  more  important, 
some  member  of  the  household  may  be  administering  arsenic  surreptitiously,  cither  with 
a  view  to  getting  rid  of  the  individual  concerned,  or  occasionally  even  without  any  particular 

object, for  instance,  in  the  case  of  some  hysterical  servant  girls,  who  have  been  known  to 

administer  poisons  in  a  household  in  this  way  apparently  without  any  material  object  at 
all.  The  circumstances  of  the  case  may  make  one  suspicious  and  lead  to  a  careful  watch 
being  kept,  or  perhaps  an  analysis  of  the  water-supply  or  of  some  suspected  food  will  lead 
to  the  detection  of  the  arsenic.  In  case  of  doubt  one  might  have  to  resort  to  the  expedient 
of  taking  the  patient  entirely  away  from  the  house  in  which  she  has  been  living,  and  from 
amongst  the  individuals  with  whom  she  has  been  associated,  in  order  to  see  whether  the 
symptom  persists  when  she  is  secluded  in  a  nursing-home  or  elsewhere,  or  whether  it  dis- 
appears there  to  return  again  when  she  goes  home.  Analysis  of  the  hair  for  arsenic  in 
cases  of  this  kind  will  seldom  be  available  as  a  test  of  the  diagnosis,  because  it  is  only  in 
the  hair  that  is  growing  during  the  time  arsenic  is  being  administered  that  excess  of  arsenic 
is  stored,  and  when  sulficient  doses  to  produce  tenesmus  have  been  administered  they  will 
generally  have  been  large,  and  therefore  have  been  given  over  only  a  short  period. 

Besides  arsenic,  other  irritant  drugs  may  produce  tenesmus,  especially  perhajis 
niiithdriilcs.  calomel  in  rejieated  doses,  colociinlli,  gamhnge.  and  indeed  most  of  the  powerfid 
|)urgati\  es.  The  diagnosis  dejjends  upon  a  knowledge  of  the  diugs  that  are  being  adminis- 
tered. 

There  remain  for  discussion  a  number  of  other  conditions  v/hich  may  ])ro(hice  painful 
and  frequent  but  fruitless  straining  at  stool,  the  cause  being  either  irritation  of  the  rectum 
or  obstruction  to  it  or  within  it.     These  may  be  enumerated  as  follows  : — 

1 .  Causes  within  the  Lumen  of  the  Rectum  : 

Iin|i;u'tc'(l  r;roes  i    A    l(iicii;n  limly   tluit  has  been    |    Concretions 

I        iiiMiteil  I    Worms. 

2.  Things  in  the  Wall  of  the  Rectum  : 

Carcinoniii  I    .Adenoma  Fissure 

Rectal  prolapse  Haniorrlioids,     especially       if        Proctitis. 

Polypus  or  polypi  |        thrombosed 

a.  Things   Outside   the   Rectum: 


Enlarged  prostate 
Periprostatic  abscess 
Periproetal  abscess 
Ischio-reetal    abscess 


Vesical  calculus  Pelvic  haematocele 

Ovarian  cyst  Ectopic  gestation. 

Uterine  fibroid 
Retroverted  "-ravid  uterus 


The  diagnosis  of  all  the  above  depends  upon  careful  examination  of  the  anal  region, 
the  rectum,  and  the  vagina,  by  ins])ection,  direct  or  through  a  speculum,  jjroctoscope  or 
sigmoidoscope,  or  with  the  finger. 

Impacted  fceces  may,  from  their  symptoms,  simulate  rectal  carcinoma  \  ery  closely  : 
but  when  there  is  carcinoma  of  the  rectimi.  one"s  finger  when  inserted  seldom  comes  upon 
a  mass  of  faeces,  whereas  with  fa-cal  impaction  the  mass  is  generally  well  within  reach  of 
the  finger.  The  diagnosis  wdl  be  confirmed  by  removing  the  mass  itself  piecemeal  with  a 
s[)oon,  followed  by  enemata  or  other  local  measures,  after  which  the  patient  recovers 
com])letely. 

Jicclnl  concretions  difler  from  impacted  faeces  only  in  the  material  of  which  they  are 
composed  ;  for  instance,  instead  of  being  ordinary  fajcal  material,  they  may  consist  of 
hard  lumps  of  bismuth,  magnesium,  chalk,  or  other  drug  that  has  been  given  by  the  mouth, 
or  of  the  husks  or  products  of  some  unusual  meal,  as  an  example  of  which  one  may  mention 
the  case  of  a  boy  who  having  stolen  a  bimdle  of  cinnamon  sticks,  chewed  them  up  and 
swallowed  them,  and  a  day  or  two  afterwards  suffered  extremely  from  tenesmus  as 
the  result  of  a  mass  of  undigested  bits  of  cinnamon  stick  that  had  been  impacted  in  his 
rectum.  Hair  bulls  have  caused  similar  trouble,  though  they  are  even  rarer  in  the  rectum 
than  they  are  in  the  stomach. 

Adenomata,  or  long  finger-shaped  non-malignant  jjolypi  of  the  rectum,  occur  sometimes 


THIRST.     EXTREMK  719 

in  such  a  way  as  to  produce  a  kind  of  eiitanfjlenient.  in  which  fa'ces  l)econie  iniiiaeted  higlier 
up  than  the  linger  can  reacli.  and  the  jjatient  will  be  thought  to  be  suffering  from  carcinoma 
of  the  sigmoid  colon  or  of  the  i)el\ie  colon  :  there  will,  however,  as  a  rule  be  much  less 
wasting  than  there  would  he  with  malignant  disease,  though  both  conditions  produce  their 
symptoms  at  a  similar  age.  The  diagnosis  will  de])end  upon  examination  with  the  i)rocto- 
.scope  or  the  sigmoidoscope,  and  perhaps  ujjon  excision  of  such  polypi  as  can  be  reached, 
followed  by  microscopical  examination. 

Another  condition  which  may  simulate  rectal  carcinoma  verN-  closely  is  periproctal 
iii/lfimninlioii  followed  by  the  formation  of  an  abscess  round  the  pelvic  colon.  The  tenesmus 
which  results,  the  constant  painful  straining,  and  the  unsatisfactory  evacuations,  may  be 
associated  with  obvious  ill-health  :  ana-mia  from  loss  of  sleep  ;  and  loss  of  weight  ;  so  that 
malignant  disease  will  frequently  be  thought  the  almost  certain  diagnosis.  The  condition 
is  by  no  means  so  easy  to  detect  as  might  be  supjioscd  :  sometimes  it  is  not  until  the  patient 
has  been  anaesthetized  with  a  view  to  further  examination  with  tlie  proctoscope  and  sig- 
moidoscope that  the  nature  of  the  condition  is  indicated  by  a  sudden  gush  of  pus  escaping 
past  the  instrument  as  the  result  of  the  bursting  of  the  abscess.  The  cause  of  such  a 
condition  is  generally  some  previous  local  inflammation  in  the  rectum,  associated,  for 
instance,  with  piles,  or  a  polypus  which  has  hitherto  |)roduced  no  symptoms  at  all  ;  in 
some  cases  there  may  be  both  carcinoma  and  abscess,  the  latter  the  result  of  the  former. 

A  vesical  calculus  causing  tenesmus  will  generally  be  one  situated  in  a  pocket  of  the 
bladder  posteriorly  ;  it  is  a  very  rare  cause  of  tenesmus,  and  generally  there  is  or  lias  been 
ha-maturia  to  indicate  the  need  for  examination  of  the  bladder  either  with  the  sound  or 
the  cystoscope. 

The  remaining  conditions  in  the  above  list  need  not  be  discussed  in  detail  :  they  will 
be  diagnosed  by  rectal  or  vaginal  examination,  or  a  combination  of  the  two. 

There  remains  still  one  other  very  important  cause  of  tenesnuis.  namely,  tabes  dorsalis 
ciilli  rectal  crises.  The  symptom  is  not  so  uncommon  as  might  be  su])pose(l.  Xot  a  few 
cases  of  tabes  dorsalis  complain  that  they  are  unable  to  go  about  their  duties  as  early  in 
tlie  morning  as  they  would  like,  because  after  going  to  the  closet  in  the  ordinary  way  after 
breakfast,  they  lind  that  at  intervals  of  perhajis  half  an  hour  they  suffer  from  repeated 
urgent  and  painful  re-calls,  extending  over  jierhaps  two  or  three  hours  before  the  bowels 
.settle  down  to  comparative  comfort  for  the  rest  of  the  day.  Xot  imich  is  passed  after  the 
first  one  or  two  visits  to  the  closet,  but  the  patient  flares  not  be  far  away  whilst  the  recur- 
rent crises  continue,  for  the  call  is  mgeni  and  \ cry  painful  :  but  as  a  rule,  after  two  or  lluee 
hours  of  sullering  of  this  kind  he  linds  that  li<'  is  free  uulll  the  next  day.  'I'hc  coiiditinn 
is  (|uitc  distinct  Irom  the  incontinence  of  fa-ccs  which  may  result  at  a  later  stage  of 
Ihe  malarly  :  it  is  an  cxiniiilc  of  purely  nerxous  tenesmus,  which,  howe\er,  may  sinudale 
carcinoma  of  the  bowel  \cry  closely.  It  may  last  for  months  or  years,  and  then  cease  to 
trouble  the  patient  spontaneously,  just  as  the  lightning  pains  of  tabes  may.  'l"he  patient's 
complaint  is  generally  of  diarrluea,  but  upon  careful  inciuiry  it  is  found  that  the  diarrhd'a 
in  the  sense  of  lluid  e\aeualions  is  much  less  pronounced  than  the  tenesmus — that  is  to  say. 
the  recurrent  i)airifnl  call  to  stool  without  material  e\aeuation.  The  diagnosis  depends 
n|inn  delecting  Ihe  absence  of  knee-jerks  and   Ihe  exislenee  of    \ri;vll  Koberlson  pupils. 

Ihrlinl    I'lniili. 

TESTES,  ATROPHY   OF.     (.See  .Vruoi-uv.  Ti.si  re n  ah,  p.  (iii.) 
TETANIC   CONTRACTIONS.  HSee  CoN-ntACTioNs.  p.  i:!7.) 
THERMO-AN^STHESIA.     (See  Sknsation.  Somk  AnxoiiMAi.rriKsor,  p.  (Kit.) 

THIRST,  EXTRP:ME.  (  asrs  ,,f  .Mnmc  thirst  M,a>  lie  sul„li\  i,l<-,l  int.,  Iw,.  main 
groups;  iiaMulN,  those  with  aiirl  thusr  without  polyuiia.  Tci  llir  fdrrnrr  belong  such 
conditions  as  diabetes  mellitus.  diabetes  insipidus,  hysteria,  and  so  on,  whieli  aic  iliscussed 
under  I'oi.vihia  {\t.  y.'A).  'Id  the  other  group  belong  such  ((indilioiis  as  ai-e  fur  Ihe  most 
part  so  obvious  as  to  ncpiiri'  n<i  nioie  than  sirnpli-  enunieialiiin  nndci-  ni.iiii  headings,  as 
follows  : 

1.   l'rolong<'il  ;il)slciil  i(in   from  diirikini;  :    pur  |iiis(liil,  or  the  result  of  nect'ssily. 

•_>.   I'Vvcrs  and   f.brile  sliiles. 


720  THIRST.     EXTREME 

3.  Excessive  loss  of  fluid  :  (a)  From  the  skin  In-  iirofuse  perspirations,  natural  or 
pathological  ;  (h)  From  the  stomach,  from  repeated  vomiting  ;  (c)  F'rom  the  bowel,  from 
excessive  diarrhoea  :   ((/)  Into  serous  membranes,  as  in  acute  peritonitis. 

4.  After  severe  haemorrhage  :  (a)  External,  e.g.,  post-partimi  :  (b)  Internal,  e.g., 
fnim  duodenal  ulcer,  ruptured  tubal  gestation,  leaking  aneurysm. 

5.  Gastrectasis  due  to  pyloric  stenosis,  owing  to  the  fact  that  the  stomach  absorbs 
little  fluid  as  compared  with  the  intestines. 

(>.  Poisoning  by  such  drugs  as  dry  up  the  secretions  of  tlic  nioutli,  notably  belladonna 
and  its  allies,  or  astringents  .such  as  alum,  gallic  aci<l,  tannic  acid,  or  perehloride  of  iron. 

7.  The  exhibition  of  excess  of  various  salts,  ])articidarly  sodium  chloride,  either  as 
such,  or  incorjjorated  in  various  food-stuffs. 

It  is  clear  that  in  some  eases  more  than  one  f;;ctor  at  a  time  may  be  causing  extreme 
thirst.  Herbert  French. 

THRILLS,  PRECORDIAL. — In  order  to  arrive  at  a  diagnosis  of  the  cause  of  any 
thrill  which  is  lelt  over  the  ])raeeordia,  two  facts  must  first  be  ascertained,  namely  (1)  The 
siliialidii  of  the  tlirill  ;  and  (2)  Its  rln/thm.  Having  disco\'ered  a  thrill  over  the  mitral  area, 
that  is,  in  the  region  of  the  apex  beat,  and  foimd  that  it  is  presystolic  in  rhythm, 
it  is  oljvious  that  it  is  due  to  mitrni  stenosis.  The  \al\  ular  lesion  will  be  confirmed  by  the 
presence  of  a  presystolic  bruit,  as  it  is  rare  to  find  the  thrill  without  a  bruit  being  associated 
with  it.  On  the  other  hand,  if  the  thrill  be  systolic  in  time,  and  mitral  regurgitation  be 
present,  the  thrill  is  due  to  this  valvular  lesion,  A  systolic  thrill  at  the  cardiac  apex  may 
also  be  caused  by  pericardial  friction  fremitus,  or  pleuritic  fremitus.  A  pericardial  friction 
fremitus  can  be  distinguished  from  an  endocardial  thrill  by  being  more  rubbing  in  character, 
usually  occurring  both  during  systole  and  diastole,  while  an  endocardial  thrill  is  a  more 
jiurring  vibration,  and  it  is  confined  to  either  systole  or  diastole.  The  pericardial  friction 
is  confirmed  by  auscultation.  Pleuritic  fremitus  in  this  region  may  be  distinguished  from 
an  endocardial  thrill  and  pericardial  friction  fremitus  by  asking  the  patient  to  hold  his 
breath,  when  the  fremitus  will  disappear  imless  it  is  due  to  pleuro-pericarditis.  These 
distinguishing  features  between  endocardial  thrill,  pericardial  friction  fremitus,  and 
l)leuritic  fremitus,  ajiply  to  any  area  in  which  thrills  are  detected.  A  pericardial  friction 
fremitus  may  be  present  over  the  whole  or  any  part  of  the  pritcordia,  but  the  most  common 
situation  is  to  the  left  of  the  sternum  near  the  base  of  the  heart. 

A  systolic  thrill  in  the  second  right  intercostal  space  close  to  the  sternum  may  be  due 
to  aortic  stenosis,  thickening  of  the  aortic  valve,  atheroma,  or  dilatation  or  aneurysm  of  the 
ascending  portion  of  the  thoracic  aorta,  and  the  diagnosis  of  the  cause  of  the  thrill  can 
only  be  made  by  the  other  physical  signs  which  indicate  the  morbid  condition  present. 
Thus,  if  there  be  dullness  in  the  second  right  intercostal  space,  over  which  the  thrill  is  felt, 
there  is  dilatation  or  aneurysm  of  the  arch  of  the  aorta.  There  is  no  dullness  in  this 
situation  when  the  thrill  is  due  to  aortic  obstruction  or  to  atheroma  of  the  aorta.  Not 
only  may  dullness  on  percussion  accompany  the  thrill,  but  there  may  be  pulsation,  and 
even  a  pulsating  tumour,  in  this  region,  .showing  that  there  is  an  aneurysm  ;  an  x-x&y 
examination  (Pig.  100,  p.  209)  helps  in  confirming  the  diagnosis. 

A  diastolic  thrill  may  also  be  felt  in  the  .second  right  intercostal  space-  close  to  the 
sternum,  but  it  is  rare  ;  when  present,  it  is  due  to  aortic  regurgitation,  and  is  accompanied 
by  the  characteristic  diastolic  bruit  and  waterhamnier  pulse.  Sometimes  the  thrill,  like 
the  bruit,  is  most  marked  in  the  third  left  space  close  to  the  sternum. 

In  the  pulmonary  area,  viz.,  in  the  second  left  intercostal  space  near  the  sternum, 
systolic  thrills  are  due  to  congenital  affections  of  the  heart,  especially  pulmonary  stenosis 
and  patent  ductus  arteriosus.  An  extensive  thrill  o\'er  the  base  of  the  heart  in  young 
children  is  nearly  always  due  to  congenital  malformation.  The  apex  beat  is  generally 
near  its  normal  position.  The  cardiac  dullness  usually  extends  to  the  right  of  the  sternum 
as  the  result  of  the  enlargement  of  the  right  ventricle,  and  there  is  commonly  a  loud 
universal  systolic  bruit,  having  its  point  of  maximum  intensity  over  the  base  of  the  heart. 
The  following  signs  of  congenital  malformation  of  the  heart,  other  than  patent  ductus 
arteriosus,  are  also  to  be  expected  :  cyanosis,  either  continuously  present  or  occurring  at 
intervals,  dyspnoea,  especially  upon  exertion,  clubbing  of  the  fingers  and  toes,  and  poly- 
cytha-mia  ;  with  patent  ductus  arteriosus  (p.  150),  there  may  be  no  .symptoms  accompanying 
the  abnormal  physical  signs. 


TIIYROir)    GLAND    ENLARGEMENT  721 

A  thrill  occurs  very  occasionally  in  the  second  left  intercostal  space  close  to  the 
sternum,  in  association  with  a  functional  pulmonary  bruit.  In  such  a  case  the  functional 
origin  of  the  thrill  may  be  distinguished  by  the  general  condition  of  the  patient,  who  will 
be  suffering  from  ansemia  or  some  debilitating  condition  ;  and  the  signs  of  congenital  heart 
disease,  just  mentioned,  will  be  absent. 

Presystolic  and  systolic  thrills  sometimes,  but  very  rarely,  occur  to  the  right  of  the 
sternum  in  the  tricuspid  area,  due  to  stenosis  and  incompetence  of  this  valve. 

J.  E.  U.  Smvijer. 

THROAT,  SORE.— (See  .Sore  Tuuoat.  p.  f.13.) 

THYROID  GLAND  ENLARGEMENT — An  enlarged  thyroid  gland  gives  rise  to 
a  swelling  in  the  front  of  the  neck,  internal  to  the  sternomastoid  muscles  and  the  carotid 
vessels,  which,  if  the  swelling  is  large  enough,  are  pushed  outwards.  The  gland  is  con- 
nected intimately  witli  the  larynx  :  hence  the  most  important  sign  of  a  thyroid  tumour 
is  that  it  rises  and  falls  with  the  larynx  and  trachea  during  deglutition.  In  the  great 
majority  of  cases  the  presence  of  this  sign  alone  is  sufficient  to  make  a  correct  diagnosis. 
There  are  two  sources  of  fallacy  :  (1)  A  swelling  not  thyroid  in  origin  but  lying  in  front  of  it, 
such  as  a  sub-hyoid  bursa  or  sebaceous  cyst,  or  a  suppurative  or  syphilitic  perichondritis 
of  the  thyroid  cartilage,  may  present  the  above  sign  :  (2)  ,\  thyroid  swelling,  if  fixed,  as  it 
may  be  by  inflammation  or  malignant  growth,  may  not  ijresent  it.  In  the  vast  majority 
of  cases,  however,  a  swelling  in  the  position  of  the  thyroid  gland  which  moves  on  deglutition 
indicates  an  enlargement  of  that  gland. 

Varieties  of  Enlargement  and  their  Diffcrrnfial  Diagnosis. — During  menstruatiiin  and 
jiregnancji  the  lliyroid  becomes  enlarged,  but  seldom  sullieiently  so  to  cause  symptoms  ; 
if  the  gland  hai>p(ns  tii  he  the  seat  of  pre-existing  disease  the  increase  of  swelling  may  be 
sullicient   to  induce  respiratory  dillieidty. 

Parenchymatous  Goitre,  or  a  general  hypertrophy  of  the  whole  gland,  is  the 
eonimoiicst  form  ol  enlargement.  .\ll  parts  of  the  gland  are  affected  more  or  less  equally  ; 
the  tumour  being  bilateral,  the  normal  shape  is  preserved.  The  swelling  is  freely  movable, 
painless  and  soft.  It  is  rarely  congenital,  and  more  often  appears  about  puberty.  Its  rate 
of  growth  is  usually  very  slow,  and  it  may  attain  an  enormous  size  without  causing  any 
other  symptoms. 

Cystic  Goitre  is  a  loose  term  used  to  cover  any  form  of  enlargement  of  the  thyroid 
which  is  caused  chielly  by  the  presence  of  one  or  more  cysts.  If  the  cyst  is  large  and  lax, 
fluctuation  may  be  made  out.  The  cysts,  however,  arc  often  .small  and  tense,  and  cannot 
be  distinguished  fiom  solid  adenomata.  Cysts  .are  rarely  present  without  some  enlarge- 
mcnl   ol   I  he  irsl    ol   I  he  gland. 

Adenomatous  Goitre. — The  conmion  eausi'  of  unilateral  enlargement  is  the  presence 
of  an  adcnonui,  a  delinitc  encapsuled  tumour  which  may  contain  cysts  and  grow  to  a  large 
si/,e.  A  hicmorrhagc  into  one  of  these  cysts  may  cause  a  very  rapid  enlargement,  and  so 
give  rise  to  a  sus|)ieion  of  malignancy  ;  cases  have  also  been  reported  in  which  an  inlra- 
thyroid  hu'inorrhagc  has  been  followed  by  acute  dyspiura  and  death.  .Xdenomata  may 
be  single  or  multiple:  when  present  in  both  lobes,  the  enlargement  may  be  dinieull  to 
<listinguish  from  IIh'  parcniliymalous  foiiii. 

Fibrous  or  Ligneous  Goitre  is  a  rare  eondilion.  due  to  a  primary  chronic  inllam- 
tnation  of  tin-  whole  gland,  and  resulting  in  a  lirm  dense  enlargement. 

Malignant  Disease  is  seldom  met  with.  It  occurs  with  ccpial  freiiueney  in  both  sexes, 
and  is  rarely  seen  l)(for<'  the  age  of  forty.  In  the  early  stages,  while  still  eonlined  within 
the  capsule  of  the  gland,  il  may  be  dillieult  to  dilferentiate  from  the  other  forms  of  gi>itre. 
It  should  be  rccogni/.ed  by  its  rapid  growth,  its  hardness,  and  irregular  bossy  outline.  When 
the  neoplasm  has  penetrated  the  capsule  and  invaded  surrounding  structures,  the  diagnosis 

is  made  uilli  i e  case.     The  tumour  msiy  become  lixed,  no  longer  moving  on  deglutition  ; 

often  one  or  otlier  vocal  cord  is  paraly/ed.  a  condition  rarely  seen  with  innocent  goitre  ; 
and  invohement  and  ulceration  ol'  the  trachea  is  eonunon.  The  iNUiphalic  glands  may  be 
cidarged,  but  as  those  lirst  implicated  are  placed  deeply,  defying  deteelion.  not  much  help 
is  gained  from  this  source.  There  is  a  special  liability  for  metastatic  secondary  deposits 
to  occur  in  bones,  particularly  in  the  vertebra'  and  cranium. 

Exophthalmic    Goitre  ((;raves"s  disease,  von   Mas(do\v"s  disease)  is  far  more  common 

7,  HI 


7-22  THYROID    GLAND    ENLARGEMENT 

in  women  than  in  men  (Fig.  113,  p.  236),  and  rarely  occurs  before  puberty  or  after  middle 
life.  The  most  prominent  features  of  the  disease  are  :  (1)  Exophthalmos  ;  (2)  Tachy- 
cardia with  palpitation  ;  (3)  Enlargement  of  the  thyroid  gland,  often  pulsatile  ; 
(4)  Tremulousness  of  the  hands  and  general  nervous  excitability  ;  (5)  Breathlessness  on 
exertion.  The  vision  is  normal,  but  when  the  eyeball  is  moved  downwards  the  upper  lid 
does  not  follow  as  in  health  (von  Graefe's  sign).  The  palpebral  aperture  is  wider  than  in 
health,  owing  to  retraction  of  the  upper  and  lower  lids  (Stellwag's  or  Dalrymple's  sign). 
Pigmentation  of  the  skin  may  be  intense  (Fig.  222,  p.  527)  and  simulate  Addison's  disease, 
but  the  mucous  membrane  of  the  mouth  is  not  affected  as  in  the  latter  malady. 

A  well-marked  case  is  quite  characteristic,  but  there  are  others  extremely  hard  to 
separate  from  simple  parenchymatous  enlargement,  for  with  this,  especially  in  young  girls, 
anaemia  is  often  associated,  and  with  it  the  symptoms  of  tachycardia,  palpitation,  and 
breathlessness.  It  often  becomes  a  matter  of  opinion  whether  a  given  case  should  be  styled 
simple  parenchymatous  goitre  or  incipient  Graves's  disease. 

The  above  are  the  commonest  forms  of  enlargement.  Others  much  rarer  are  : 
Enlargement  due  to  pipgenir  infection,  either  acute  or  chronic.  In  pya'mia  it  is  not 
imeommon  to  find  the  thymid  the  seat  of  nuiltiple  abscesses.  Tubereulous  and  ginnin'iloKfi 
disease  may  also  cause  enlargement,  and  a  slight  degree  of  goitre  has  been  noted  In  tijplioid 
fever,  acute  rheumatism,  malaria,  variola,  cholera,  and  secondary  syphilis.  Hydatid  cysts 
of  the  thyroid  gland  have  been  noted  on  a  few  occasions.  It  ha\ing  been  ascertained  that 
the  swelling  in  the  neck  is  definitely  thyroid  in  origin  and  its  nature  defined,  it  remains  to 
see  whether  there  are  any  pressure  signs  on  the  surrounding  structures. 

Pressure  on  the  Trachea. — Dyspnoea  is  by  far  the  most  important  of  all  the  sym])toms 
that  may  be  produced  by  enlargement  of  the  thyroid  gland  It  may  be  the  only  thing 
complained  of  by  a  patient  not  even  aware  of  the  presence  of  a  goitre.  The  size  apparently 
is  not  so  important  as  the  sliape  and  situation,  for  one  reaching  to  the  waist  may  cause  no 
obstruction,  and  one  the  size  of  a  cherry,  if  situated  between  the  sternum  and  trachea,  may 
give  rise  to  intense  dyspnoea.  If  the  goitre  is  unilateral,  the  trachea  is  pushed  over  towards 
the  opposite  side  and  flattened  ;  if  bilateral,  as  in  the  parenchymatous  form,  it  is 
compressed  lateralh".  The  dyspnoea  may  be  constant  and  distressing,  or  only  noticeable 
on  exercise  or  on  lying  down.  Most  such  jiatients  like  to  lie  high  in  bed,  propped  up  on 
pillows.  An  idea  as  to  the  amount  of  pressure  on  the  trachea  may  sometimes  be  gained  by 
a  question  on  this  point. 

Pressure  on  Nerves. — Unless  malignant,  a  goitre  rarely  causes  much  pressure  on  nerves. 
Those  that  may  be  involved  are  :  (a)  The  recurrent  laryngeal,  resulting  in  paralysis  of  a 
vocal  cord ;  (6)  The  cervical  sympathetic,  shown  by  contraction  of  the  pupil  on  the 
affected  side  and  ptosis;  (c)  The  vagus;  (rf)  Rarely  the  nerves  of  the  brachial  and 
cervical  plexuses.  If  any  of  these  nerves  are  invoh'cd,  suspicion  must  arise  as  to  the 
malignancy  of  the  tumour. 

Pressure  on  the  Qisophagus. — Being  ])laced  behind  the  trachea,  the  oesophagus  generally 
escapes  pressure  by  a  goitre,  though  this  is  to  be  remembered  as  a  rare  cause  of  dysphagia. 

Pressure  on  Veins  is  common.  j)articularly  on  the  internal,  external,  and  anterior 
jugulars.     The  pressure  is  rarely  more  than  sullicient  to  make  them  stand  out  prominently. 

George  E.  Cask. 

TINEA,  VARIETIES  OF.— (See  Fingous  Affections  of  the  Skin,  i).  240.) 

TINNITUS  is  a  symptom  whicli  occurs  in  a  large  proportion  of  cases  of  disease  of  the 
ear,  and  occasionally  when  there  is  no  obvious  lesion  of  the  auditory  mechanism.  The 
sounds  complained  of  are  usually  subjective,  but  they  may  occasionally  have  an  objective 
origin.  Tinnitus  may  be  continuous  or  intermittent.  Its  intensity  and  character  vary 
greatly  in  different  patients  :  to  some  it  is  an  intolerable  annoyance,  and  occasionally  has 
even  been  the  cause  of  suicide.  The  character  of  the  sound  may  give  some  clue  to  the 
cause.  Thus  a  pulsatile  or  rhythmical  sound  may  be  produced  by  the  flow  of  blood 
through  the  internal  carotid  artery,  which  in  its  course  through  the  carotid  canal  is  separ- 
ated from  the  tympanimi  only  by  a  thin  plate  of  bone,  which  may  be  deficient.  A  creaking 
noise  may  be  produced  by  cerumen,  or  a  foreign  body,  in  the  external  auditory  meatus. 
A  bubbling  noise  may  be  due  to  the  presence  of  catarrhal  exudation  in  the  middle  ear. 


TINNITUS  7-28 

A  cracking  or  clicking  sound  may  be  caused  by  spasmodic  contraction  of  the  dilatator  tubae 
and  salpingopharyngeus  muscles  which  are  attached  to  the  Eustachian  tube.  When  the 
character  of  the  sound  is  described  as  humming,  hissing,  roaring,  whistling,  or  musical,  it 
is  practically  always  subjective,  and  due  to  some  irritation  of  the  auditory  nerve,  rarely 
cerebral  or  in  its  course,  but  usually  at  its  terminations  in  the  labyrinth.  In  rare  cases 
the  tinnitus  may  be  associated  with  an  intracranial  murmur  which  can  be  detected  on 
examination  of  the  head  with  the  stethoscope.  An  audible  intracranial  murmur  associated 
with  tinnitus  may  be  due  to  the  following  causes  :  (1)  Possibly  venous  murmurs  associated 
with  increased  intravenous  pressure  due  to  excessive  pulsation  of  the  brain  :  (2)  A  bruit 
de  (liable  in  the  jugular  bulb  which  may  occur  in  ana?mia.  plumbism,  syphilis,  and  scrofula  ; 
(3)  Intracranial  aneurysms.  The  sudden  exj>losive  sounds  in  the  insane  and  others  may  be 
due  to  similar  causes. 

A  distinction  must  be  made  between  tinnitus  and  hallucinations  of  hearing,  the  latter 
usually  taking  the  form  of  hearing  voices,  and  indicating  mental  trouble,  usually  of  a  serious 
nature.  Tinnitus,  however  caused,  is  usually  inlluenced  markedly  by  the  general  health 
and  environment  of  the  patient.  Thus,  sometimes  the  noises  are  less  marked  when  the 
patient  is  in  the  open  air,  when  his  attention  is  occupied  by  other  matters,  or  when 
the  sense  of  hearing  is  occupied  by  listening  to  objective  noises.  Similarly,  the  trouble 
may  be  present  only  at  night,  but  may  ajipear  in  the  day-time  if  the  patient  closes  the 
external  auditory  meatus  with  his  finger.  Generally  speaking,  tinnitus  becomes  less 
marked  and  more  bearable  when  the  general  health  of  the  patient  is  good,  and  increases 
when  the  sufferer  is  out  of  health  or  overworked,  either  mentally  or  physically.  Working 
in  close,  stuffy  rooms,  or  in  proximity  to  noisy  machinery,  over-indulgence  in  alcohol,  and 
excessive  smoking,  have  a  bad  effect  :  in  women  the  trouble  may  be  increased  during 
pregnancy,  menstrujitioii,  or  the  menopause. 

Though  tinnitus  is  very  common  in  diseases  of  the  ear.  yet  serious  lesions  of  the  middle 
ear,  internal  ear,  or  auditory  nerve,  may  be  present  without  this  symptom.  There  is  no 
constant  relation  between  tinnitus  and  deafness.  The  former  may  be  present  with  perfect 
hearing,  but  when  long  continued  the  hearing  nearly  always  becomes  impaired.  The 
sounds,  too,  may  persist  when  the  patient  has  become  totally  deaf. 

Tinnitus  may  occur  in  the  following  diseases  of  the  ear  : — • 

1.  The  presence  of  ceninicn.  niiral  puli/pi.  or  ft  foreign  bodi/  in  the  external  auditory 
meatus.  Removal  of  the  offending  body  will  in  this  ease  probably  lead  to  the  cessation 
of  the  timiilus. 

2.  In  any  iiifhiiiiiiiiildri/  rliseasr,  acute  or  eliroiiie.  .siijijiiirative  or  nou-sappiirative.  of  the 
itiiditic  ear.  In  ciitMrrhal  inllainTiiation  of  tiie  mirldle  ear,  the  noise  freipiently  has  the 
(  liaraeter  of  burst iii^!  ))uhbl(s.  and  is  due  to  movements  of  the  viscid  exudation  in  the  ear 
itself.  In  otosclerosis,  timiitus  is  a  very  prominent  and  usually  early  symptom.  It  nuiy 
occur  before  any  alteration  in  hearing  is  present. 

."!.  In  diseases  of  the  internal  ear.  timiitus  is  especiall\  lial)le  to  occur  in  a  severe  ami 
intractable  form.  Thus,  it  is  especially  likely  to  be  present  ht  Meniere's  disease,  syphilitic 
disease  of  the  Internal  ear,  and  in  those  lesions  of  the  internal  ear  which  may  arise  in  the 
course  of  ti/plioid  atid  other  speei/ie  fevers.  E,rte)isii»i  iif  siippiirntioii  to  the  lalti/riiith  from 
the  middle  car  is  also  an  important  <';iuse  :  and  il  iiii\  h<'  picscnl,  usiially  assncialed  with 
<learness,  after  a  frailiire  of  the  liiise  of  tlie  shall. 

Timiitus  has  been  recorded  as  resulting  from  a  eerehnd  liimiiar  iiudlving  the  roots  of 
the  auditory  ner\c,  but  this  is  a  very  unusual  condition. 

■■  Noises  in  the  ears  '"  may  be  complained  of  in  a  considerable  number  of  general 
diseases,  either  with  or  without  a  lesion  of  the  ear.  Thus,  they  are  fre(|ueiitly  present  in 
uiiirmia.  and  in  diseases  such  as  leiiUirmia  or  periiirious  inaemia.  in  wliich  an:eiiiia  is  a 
prominent   symptom. 

Some  enrdiae  lesion,  especially  aorti<'  regurgitation,  may  lie  fouiiil  in  the  pulsatile 
variety  of  timiitus.  (loat.  chronic  ne/ihritis.  arivniia.  and  arteriosclerosis  with  high  blood- 
l)rcssurc,  may  also  be  responsible  for  timiitus,  and  it  may  occur  during  attacks  of  niifiraine. 
Sonu-tinies  it  has  apparently  a  rillex  origin,  being  associated  with  neuralgia  or  digestive 
dislinbances,  <'speeially  in  gouty  dyspepsia.  Malaria  may  also  be  a  cause,  though  here 
the  trouble  is  likely  to  be  the  result  of  large  doses  of  (piininc.  Other  drugs  likely  to  cause 
the  Irouble  are  solici/lalcs,  inilipi/rioc.  the  excessive  use  of  tobacco,  and  alter  anifslhetics 
iiieli  as  cliinrurorrTi  or  elher. 


TREMOR 


In  persons  who  constantly  use  the  telephone  tinnitus  may  occur,  associated  with  pain 
and  some  deafness — a  condition  known  as  "  telephone  ear."  Pliili/i  Turner. 

TONGUE,  SWELLING  OF.— (See  Swelling  of  the  Tongue,  p.  G98.) 

TONGUE,    ULCERATION  OF.— (See  Ulceration  of  the  Tongle,  p.  738.) 

TREMOR  occurs  when  the  normally  continuous  contractions  of  a  muscle  at  work, 
or  tlie  normally  uniform  tone  of  a  muscle  at  rest,  are  replaced  by  a  succession  of  separately 
perceptible  muscular  twitches.  In  these  circumstances,  a  movement  which  is  normally 
uniform  becomes  tremulous  ;  a  jjosition  that  can  be  maintained  steadily  under  normal 
conditions  is  now  kept  unsteadily  or  shakily. 

The  normal  muscular  contraction  is  due  to  the  discharge  of  a  rhj'thmic  series  of 
nervous  impulses  from  the  motor  neurons  that  govern  the  muscle.  It  is  estimated  that, 
in  health,  from  fl^•e  to  fifty  such  nervous  impulses  leave  the  motor  nerve-cells  and  reach 
the  contracting  muscle-fibres  every  second,  the  actual  number  per  second  varying  in 
different  motor  neurons,  and  also  in  the  same  neuron  according  to  its  temporary  condition 
of  nutrition  or  fatigue.  It  is  when  the  number  of  nervous  impulses  received  ])er  second 
by  the  contracting  muscle-fibres  becomes  low,  that  steady  and  apparently  uniform 
muscular  contractions  are  likely  to  be  replaced  by  tremors. 

Tremors  are  of  very  various  periods,  amplitudes,  and  general  characters  in  different 
cases.  Their  physiology  and  pathology  are  not  at  present  fully  understood,  so  that  it 
is  not  yet  possible  to  classify  them  etiologically.  From  a  clinical  point  of  view  they  may 
be  classified  roughly  in  accordance  with  their  more  obvious  physical  characteristics — 
their  fineness,  periodicity,  regularity,  and  the  circumstances  that  favour  or  inhibit  their 
production  ;  but  an  unbroken  series  of  graduated  tremors  can  be  traced  in  various 
diseases,  passing  by  imperceptible  degrees  from  the  rapid  and  minute  oscillations  observed 
in  paralysis  agitans  to  the  extremely  coarse  and  irregular  movements  composing  the 
intention-tremor  of  disseminated  sclerosis.  A  similar  variety  of  regular  tremors  may  be 
observed  sometimes  in  a  normal  person,  as  the  temperature  of  his  body  falls  from  exposure 
to  cold,  or  during  the  occurrence  of  a  rigor.  Hence  a  rigid  clinical  classification  of  tremors 
is  impossible. 

Classification. 

Fine  Tremor. 


Kxposure  to  cold 
Nervousness,     emo- 
tion 
Muscular  fatigue  or 

weakness 
Convalescence 
Congenital     and 

familial  tremor 


Senile  tremor 

Paralysis   agitans 

General      paralysis      of     the 

insane 
Graves's  disease 
Occupation  neurosis 
Chronic  intoxications,  e.g.,  by 

Alcohol  Cocaine 


Tobacco 
Absinthe 
Morphia 

High  pyrexia 

Hysteria 

Neurasthenia 

Mercury 
Lead 

Itailway  spine 
Urjcmia. 

Hvstcria 

Chorea 

Unilateral  Fine  Tremor. 

Cerebral  tumour  |     Chronic   hemiplegia 

Coarse  Tremor. 

Exaggerated  degrees      i     Familial     and     hereditary  Chronic   hemiplegia, 

of  fine  tremors        I  ataxias 

Intention  Tremor. 

•    Disseminated    seler-  Hysteria  I  Some  cerebral  or  cerebellar 

osis  ;     Congenital  ecrcbrardiplegia  lesions. 


FINE    TREMOR. 

Fine  tremor  consists  of  regular  oscillations  of  small  amplitude  due  to  alternating 
contractions  in  antagonistic  muscles  or  groups  of  muscles,  rejieated  from  three  to 
nine  times  per  second.  It  is  usually  most  marked  in  the  extremities,  but  may  also — as 
in  old  age  and  in  paralysis  agitans — affect  the  head  and  neck.  It  may  occur  only  when 
.some  movement  is  attempted  ;    or  it  may  continue  also  when  the  patient  is  at  rest.     Fine 


TREMOR  725 

tremors  cease  almost  invariably  during  sleep  :  emotion  habitually  increases  them.  They 
are  not  purposive,  and  should  be  distinguished  from  the  fibrillar  contractions  (see  C'on- 
TRACTION.S.  p.  13+)  of  individual  muscle-fibres  or  muscle-bundles,  seen  in  some  muscular 
degenerations. 

Fine  tremors  occurring  in  consequence  of  cold,  nervousness,  excessive  emotion,  convales- 
cence, and  muscular  fatigue  or  iveakness.  are  matters  of  common  daily  observation.  Thej' 
tend  to  pass  off  as  the  patient's  condition  of  mind  or  body  improves,  and  should  occasion 
little  trouble  in  diagnosis. 

Congenital  and  familial  fine  tremors  occur  mostly  in  children  or  young  adults,  mainly 
in  the  hands  and  arms,  face,  or  tongue.  The  oscillations  are  often  absent  while  the  [latient 
is  at  rest,  but  make  their  appearance  whenever  movement  is  attempted,  and  are  increased 
by  nervousness  or  emotion.  They  can  often  be  suppressed  for  a  time  by  a  strong  effort 
of  the  will,  and  in  many  instances  they  disappear  as  the  patient  grows  older.  They  cause 
practically  no  inconvenience,  and  are  not  accom|)anied  by  any  other  abnormalities  in 
the  neuro-muscular  apparatus.  Their  diagnosis  should  be  made  plain  by  the  patient's 
per.sonal  and  family  histories. 

Senile  tremor  and  paralysis  agitans  may  be  considered  together.  Senile  tremor  conies 
on  with  old  age  in  the  form  of  fine  regular  or  irregular  oscillations  affecting  the  arms  and 
the  head.  IJoth  sides  of  the  body  are  involved,  the  head  early,  and  the  tremor  ceases 
during  repose  and  in  sleep.  The  muscles  of  the  affected  parts  are  neither  rigid  nor  weak. 
These  senile  tremors  must  be  carefully  distinguished  from  the  tremors  of  paralysis  agitans, 
or  Parkinson's  disease,  a  progressive  and  more  serious  disorder  :  in  this  the  tremors  are 
of  several  varieties.  A  fine  oscillatory  to-and-fro  tremor,  with  from  three  to  six  excursions 
per  sec'ond,  affects  the  extremities  and  head  in  some  cases.  In  others,  the  tremor  is  coarser, 
rhythmical,  slower,  and  to  some  extent  i)urposive  ;  in  typical  instances  it  i)ro(iuces  the 
alternating  movements  in  the  thumb  and  index  finger  described  as  "  bread-crumbling  ' 
or  '  cigarette-rolling,'  These  may  be  combined  with  more  irregular  movements  of  flexion 
and  extension  at  the  wrist,  pronation  and  supination  of  the  forearm.  The  progressive 
development  of  these  tremors  and  movements  is  often  characteristic  :  beginning  in  one 
hand,  the  fine  tremor  may  spread  to  the  other  after  some  months  or  years,  and  ultimately 
the  lower  limbs,  the  head  and  neck,  the  lijjs  and  tongue,  and  even  the  njuselcs  of  the  trunk, 
may  become  involved.  .Vs  a  rule,  the  movements  continue  when  the  patient  is  sitting, 
or  lying  at  rest  :  in  severe  cases  they  may  persist  even  during  sleep.  In  most  instances 
they  can  be  lessened  by  an  cfldrt  of  the  will,  and  diminish  also  on  passive  or  vohmtary 
movement.  If.  on  the  other  lianil.  tiny  increase  on  voluntary  movement,  a  tolerable 
imitation  of  an  inliiitiori  Ircmor  may  risult.  They  are  augmented  by  emotion  or  excite- 
ment. In  eases  of  some  duration  a  well-marked  coarse  shaking  of  the  arms  may  be  a 
noticeable  fcatiuc  ;  wliilc  eoiitraetions  alternating  in  the  llexor  and  extensor  muscles  of 
the  legs  may  cause  the  feet  to  chatter  wlien  they  are  placed  (jii  tin-  lldoi-  :  the  thighs  are 
commonly  held  in  adduction. 

I'aralysis  agitans  is  char;ictcri/,t'd  by  other  signs  that  facilitate  its  diagnosis,  and  the 
ciiief  of  these  are  : — («)  Muscular  rigidili/.  causing  a  \\\vt\,  expressionless  facial  aspect 
(sie  l''.\(  i!;s  i>.  '2:Mi).  a  monotonous  voice,  a  bent  and  rigid  carriage,  and  a  shulllinu:.  hesita- 
ting gait,  with  fcstinalion.  propiikion,  and  retropulsion.  Fcstination  implies  that  the 
patient  in  walking  from  one  point  to  another,  starts  with  slowness  and  dillicully.  but 
accelerates  as  he  goes  along,  much  as  if  he  were  rumiing  after  his  own  centre  of  gravity, 
and  at  the  end  he  may  even  fall  forwards  unless  there  is  some  object  at  hand  for  him  to 
catch  hold  of.  Propulsion,  retropulsion.  and  tlx'  rarely  observed  lateropulsion.  are  terms 
tiicaning  that  the  patient,  sent  olf  with  a  vigorous  push  to  walk  forwar.ls,  backwards,  or 
sidewjiys,  exhibits  the  same  acceleration  and  proeiixily  to  fall  down  at  the  <-n<l— for- 
wards, backwards,  or  sideways,  (h)  Muscular  weuhness  of  the  tremulous  or  rigid  parts, 
(c)  Parn-slhesia:  such  as  aching  pains  about  the  limbs  or  body.  Hushes  of  heat  or  cold.  The 
spliinctcrs  and  menial  facullies  are  not  alTcclcd.  while  the  ihep  rellcxes  are  usually  n  )rmal, 
but  may  be  increased.  Cases  of  Parkinson's  disease  occur  in  which  tremor  is  aliscnt  ; 
Ihc  presence  of  the  other  signs  mentioned  above.  h<iwcver.  shouhl  sudicc  for  its  rccognilion. 
Itilnternl  cortical  (legeneralion.  with  its  slowly  increasing  rigidity  ami  nuiseiilar  weakness, 
and  its  set  facial  expression,  may  resemble  paralysis  agitans  ;  but  it  is  accompanied  by 
progressive  mental  failure,  increase  of  the  deep  rcllcx.'s,  spliinitcr  Iroiililcs,  :iii<l  the  other 
evidences  of  cortical  degeneration 


726  TREMOR 

The  tremor  of  certain  types  of  general  paralysis  of  the  insane  is  a  fine,  irregular  oscilla- 
tion, often  with  a  twitching  character.  It  first  appears  in  the  hands  and  arms,  and  may 
spread  till  it  is  conspicuous  in  the  tongue,  lips,  and  face,  when  it  is  associated  with  the 
characteristic  changes — slowness  and  blurring — in  the  speech.  For  the  most  part  this 
tremor  occurs  on  exertion  :  it  varies  in  extent,  and  may  almost  disappear  during  periods 
of  general  improvement.  In  the  later  stages  of  the  disease  a  coarse  universal  tremor 
sets  in,  combined,  perhaps,  with  grinding  of  the  teeth.  In  these  patients  the  moral  and 
intellectual  changes,  tottering  gait,  alterations  in  the  tendon-  and  pupil-reflexes,  and 
other  phenomena  of  general  paralysis,  will  probably  not  escape  attention. 

In  Graves's  disease  a  fine,  regular,  and  rapid  tremor,  about  eight  to  the  second,  on 
exertion,  is  one  of  the  cardinal  signs.  It  affects  the  hands  most,  the  arms  much  less,  and 
least  often  the  legs  ;  it  is  increased  by  movement  or  by  excitement.  In  addition,  attacks 
of  trembling  that  affect  the  whole  body  may  occur.  It  is  only  in  aggravated  cases,  how- 
ever, that  these  tremors  are  so  severe  as  to  interfere  with  the  customary  employments  of 
the  hands.  The  tremors  of  Graves's  disease  are  likely  to  be  of  comparatively  sudden  onset, 
and  the  patient  will  generally  exhibit  many  of  the  other  prominent  signs  or  symptoms  of 
hyperthyroidism,  such  as  thyroid  enlargement,  exophthalmos  and  the  other  ocular 
phenomena,  tachycardia,  attacks  of  palpitation,  wasting,  sweating,  or  mental  changes, 
so  that  the  diagnosis  ought  not  to  be  dillicult. 

Fine  tremors  are  observed  frequently  in  many  of  the  chronic  intoxications,  particularly 
those  due  to  alcohol,  absinthe,  lead,  mercury,  nicotine,  carbon  disulphide,  morphine, 
cocaine,  and  many  other  organic  compounds  that  may  be  taken  in  excess  in  rare  eases, 
whether  intentionally  or  by  accident.  Alcoholic  tremor  is  fine,  regular,  and  rapid  ;  it  is 
well  shown  in  the  outspread  fingers  of  the  extended  hand  and  in  the  feet.  In  many  cases 
it  can  be  felt  by  the  obser\er"s  hand  more  readily  than  it  can  be  perceived  by  his  eye  ; 
or  it  may  be  rendered  more  conspicuous  by  laying  a  sheet  of  paper  on  the  backs  of  the 
outspread  pronated  fingers  and  hand.  It  is  absent  during  rest,  and  is  increased  by  move- 
ment, excitement,  or  fatigue.  It  may  also  affect  the  tongue,  lips,  and  facial  muscles, 
taking  the  form  of  a  rapid  and  rather  irregular  twitching,  increased  on  exertion.  This 
tremor  is  an  early  sign  of  alcoholism,  and  is  often  more  marked  in  the  morning  hours, 
when  it  is  due.  ])erhaps,  to  fatigue  and  want  of  alcoholic  stinnilation  :  it  can  be  controlled 
to  some  extent  by  the  will.  Associated  with  it  is  a  certain  general  nervousness  and  jumpi- 
ness  ;  in  addition,  the  patient  will  no  doubt  exhibit  some  of  the  other  signs  of  chronic 
alcoholism — venous  stigmata  or  acne  rosacea  on  the  nose  and  face,  restlessness,  insomnia, 
gastric  disturbances — particularly  the  morning  vomiting  of  mucus  on  an  empty  stomach 
— paresthesia  and  weakness  of  the  extremities,  mental  and  moral  deterioration.  If  the 
main  facts  of  the  case  can  be  made  out.  tremors  due  to  alcoholism  should  not  be  hard  to 
diagnose.  A  history  of  chronic  alcoholism  should  always  be  intjuired  after  most  carefully, 
both  from  the  patient,  wlio  may  deny  it  in  toto,  and  from  the  patient's  friends,  who  may 
hasten  to  admit  more  than  the  facts  warrant.  This  is  of  importance,  because  mere 
nervonsness  at  the  prospect  or  realization  of  an  interview  with  a  medical  man.  will  often 
bring  on  a  fine  but  temporary  tremor,  indistinguishable,  for  the  time  being,  from  the  lasting 
fine  tremor  of  the  drinker.  If  such  a  tremulous,  but  teetotal,  patient  has  indigestion  and 
acne  rosacea,  and  repudiates  any  veiled  suggestion  of  alcoholism  with  apparently  unneces- 
sary warmth,  there  is  some  danger  lest  these  evidences  be  taken  as  confirming  the  erroneous 
diagnosis  of  alcoholism. 

The  tremor  of  mercurial  poisoning,  a  very  rare  complaint  nowadays,  is  at  first  fine, 
but  later  coarse  and  even  choreiform.  It  is  met  with  amongst  workers  in  furs,  hatmakers. 
and  others  who  use  skins  that  have  been  cured  with  mercurial  compounds.  It  begins  in 
the  face,  hands,  and  arms,  and  may  spread  to  all  parts  of  the  body.  At  first  it  is  brought 
out  only  by  excitement,  or  on  attempted  movement.  Later,  it  may  persist  even  during 
sleep,  and  speech  may  be  interfered  with  from  involvement  of  the  muscles  of  the  tongue, 
pharynx,  and  larynx.  Other  prominent  symptoms  of  mercurialism  that  should  not  be 
absent  are  profuse  salivation,  stomatitis,  anaemia,  and  cerebral  symptoms  of  various  kinds. 
Mercurial  tremors  may  have  to  be  diagnosed  from  those  of  paralysis  agitans  or  disseminated 
sclerosis. 

In  lead  poisoning  a  fine  tremor  of  the  affected  limb  is  sometimes  met  with  in  cases 
marked  by  paralysis.     The  oscillations  may  also  be  seen  in  the  tongue  and  lii)s.  particularly 


TREMOR  727 

in  the  rarer  instances  of  chronic  phtnibism  that  exhibit  cerebral  symptoms  and  simulate 
general  paralysis  of  the  insane.  The  diagnosis  of  these  unusual  cases  would  be  difHcult 
unless  a  suspicion  of  lead-poisoning  were  aroused,  either  by  a  history  of  exposure  to  the 
intoxication,  or  by  the  occurrence  of  other  signs  and  symptoms  of  plumbism  (see  p,  34.) 

In  liynterin  the  clinical  picture  of  any  or  every  disorder  of  movement  or  sensation  may 
be  more  or  less  closely  reproduced  ;  and  tremors  of  every  variety  may  be  met  with  in 
hysterical  patients.  The  diagnosis  may  be  extremely  difficult  until  hysteria  is  suspected, 
when  it  may  be  confirmed  by  the  discovery  of  signs  and  symptoms  that,  singly  or  together, 
are  jjathognomonic  (p.  465).  The  diagnosis  of  hysteria  should  never  be  made  lightly  : 
but  only  after  a  careful  consideration  of  the  history,  signs,  and  symptoms,  and  when  all 
evidences  of  organic  disease  have  been  looked  for  and  found  wanting.  Unless  a  careful 
examination  be  made,  the  tremor  of  intracranial  tumour,  for  example,  or  of  disseminated 
sclerosis,  may  be  wrongly  diagnosed  as  hysterical. 

Unilateral  Fine  Tremor  is  but  rarely  seen.  It  may  be  a  hysterical  manifestation, 
functional,  and  significant  of  no  imderlying  lesion  of  the  central  nerv'ous  system. 
Unilateral  tremor  may  occur  in  tumour  of  the  frontal  region  of  the  brain  ;  if  present,  it  occurs 
in  both  arm  and  leg,  and  only  on  the  same  side  of  the  body  as  the  tumour.  The  patients 
will  often  cxhiliit  mental  changes,  such  as  inattention,  incoherence,  loss  of  memory, 
alterations  in  character  :    sometimes,  too,   irritative  ])henomena  occur. 

Unilateral  line  tremor  may  develojj  on  cither  the  same  or  the  opposite  side  of  the  body 
in  liimoiiT  of  the  mid-brain  and  siib-thalamic  regio)).  The  general  symptoms  of  cerebral 
tumour  will  be  present,  and  in  addition  certain  localizing  signs  may  make  their  appearance. 
The  chief  of  these  would  be  paralysis  of  the  third  nerve,  loss  of  sensibility  over  the  area 
supplied  by  the  fifth  nerve,  eccentric  position  of  the  pupil,  defective  reaction  of  the  pupil 
to  light,  and  weakness  of  the  upward  movements  of  the  eyeballs. 

It  may  be  added  that  fine  tremors  occasionally  occur  in  the  paretic  limbs  after  hemi- 
plegia. The  history  of  the  case  and  the  presence  of  other  signs  characteristic  of  hemiplegia 
should  make  the  diagnosis  here  a  comparatively  straightforward  matter.  Fine  tremor 
may  be  seen  in  chorea,  and  may  be  unilateral  in  such  cases. 

COARSE    TREMOR. 

Coarse  tremors  may  develop  as  temporary  exaggerations  or  later  developments  of 
the  fine  tremors  occurring  in  several  of  the  morbid  states  already  considered.  Thus, 
when  the  body  is  thoroughly  chilled  or  fatigued,  or  when  a  j)af  lent  is  in  a  rigor,  the  initial 
fine  tremor  will  often  ])ass  on  into  a  very  coarse  tremor,  as  the  amplitude  of  the  involuntary 
muscular  contractions  increases,  their  rhythm  remaining  nnich  the  same.  The  fine  tremor 
of  paralysis  agitans  or  general  paralysis  may  similarly  grow  into  a  coarse  tremor  ;  coarse 
tremors  arc  not  infrcijucntly  seen  in  hysteria.  The  diagnosis  in  all  these  cases  must  be 
made  on  the  lines  already  indicated. 

Coarse  tremor  is  met  with  sometimes  in  the  various  forms  of  familial  and  hereditary 
ataxia.  Thus  in  Friedreich's  disease  (p.  512),  in  addition  to  the  intention  tremor  considered 
below,  irregular  involuntary  motions,  described  as  coarse  tremors  in  some  cases,  as  chorei- 
form in  others,  take  place  in  the  arms  wiiile  the  patient  is  at  rest.  Irregular  nodding  or 
tremulous  moxcmcnts  of  the  head 'and  trunk,  also  Dcciir  in  a<lvanced  cases  ;  the  muscles 
of  articulation  and  of  the  face  may  exhibit  irregular  purposeless  contractions  or  (|uiveruigs 
when  conversation  is  attempted.  In  sjiino-cereltcllar  ala.ria,  irregular  ehoreiforni  move- 
ments, or  constant  tremors,  large  and  small,  may  be  seen  in  the  head,  trinik,  and  limbs 
whenever  the  attempt  is  made  to  hold  tluin  steady,  but  unsupported.  Similar  disturb- 
ances have  been  recorded  in  cerebellar  titiiria  and  in  the  iilivo-iioutii-ccrelielbtr  (ilrophti  of 
Dejerine  and  Thomas.  In  all  these  conditions  the  ataxia  is  the  prominent  symptom, 
the  coarse  tremor  being  no  more  than  an  occasional  epiphenomenon  :  the  diagnosis 
between  them  must  be  sought  in  special  manuals,  and  also  under  tlu'  heading  .VlAXV 
(p.  .-.5). 

The  coarse  Irciiior'  ul  1  he  iiHii-IciI  lirnlis  seen  in  patients  with  ehrciluc  or  spastic  hcmi- 
//Irgia  or  itiplcgia.  and  in  some  other  eercliial  disorders,  is  a  variant  ol  the  alhetoid  or 
choreirorm  nio\emenls  that  are  eharaeterisi  ic  of  those  conditions.  They  are  considered 
under  the  heading  CoMUACrioNs  I  I'araini/ochinus  multiiile.r).  p.  i:!7.  .\s  has  been 
irieiilioned    already,    it    is   pinel  ieallv    impossible    -were   it.   indeed,   desirable      to   draw   any 


r28 


TREMOR 


hard-and-fast  line  between  the  grosser  fine  tremors  and  the  finer  coarse  tremors.  In 
the  same  way,  coarse  tremors  merge  insensibly  into  the  lesser  degrees  of  athetotic  and 
choreiform  convulsions. 

INTENTION    TREMOR. 

Intention  tremor — known  also  as  aclioti  (n  lolilional  tremor — has  been  defined  as 
tremor  produced,  or  if  not  produced  at  least  exaggerated,  by  voluntary  movements. 
These  tremors  affect  the  upjier  extremities,  and  sometimes  the  head  and  trunk  also  :  the 
limb  is  (|uiet  when  not  in  actual  use,  but  as  soon  as  voluntary  movement  is  attempted, 
irregular  and  involuntary  to-and-fro  motions  begin  in  it.  and  are  superadded  to  the 
intended  movement.  These  to-and-fro  motions  become  more  marked,  and  sometimes 
more  rapid  the  more  nearly  achievement  of  the  desired  movement  is  reached.  The  greater 
the  amount  of  precision  demanded  by  the  voluntary  action,  the  greater  becomes  the 
amplitude  of  these  involuntary  excursions.  Wishing  to  drink,  the  patient  may  lift  the 
cup  from  the  table  steadily  enough  ;  but  as  the  cup  approaches  his  lip.  the  involuntary 
movements  appear  and  rapidly  increase  till  its  contents  are  jerked  wildly  in  all  directions 
as  it  reaches  his  mouth.  The  tremor  may  spread  from  the  muscles  that  are  being  put  into 
action,  and  cause  extensive  jerky  movements  of  the  head  and   trimk.     The  pathogeny 

of  intention  tremor  is  obscure.  Very  po.ssibly  it 
is  due  to  destruction  of  the  short  intersegmental 
nerve-fibres  in  the  substance  of  the  spinal  cord. 
The  (Ustruction  of  these  fibres  would  render  ini- 
])ossible  the  accurate  mutual  adjustment  of  the 
contractions  of  antagonistic  muscle-groups  that  is 
essential  for  the  smooth  performance  of  even  the 
simplest  willed  movements. 

Intention  tremor  is  one  of  the  most  char- 
acteristic features  of  disseminated  sclerosis.'  The 
arms  are  affected  most  often  and  most  markedly, 
but  careful  observation  will  often  show  that  none 
of  the  voluntary  muscles  escape.  The  head  may 
(iscillate  when  the  patient  is  holding  it  up  ;  the 
trunk  may  exhibit  jerky  movements  when  he  sits 
or  stands  ;  the  legs  when  he  stands  or  walks, 
after  the  disease  has  made  some  progress.  Dis- 
seminated sclerosis  is  a  protean  disorder.  Typical 
examples,  however,  may  be  recognized  by  the 
occurrence  of  intention  tremor  {Fig.  2!)5),  muscular  rigidity,  nystagmus,  pallor  of  the 
optic  discs,  and  staccato  or  scanning  speech.  The  deep  reflexes  are  increased  :  the  gait 
is  spastic  or  ataxic  :  Babinski"s  sign  is  present  ;  subjective  sensory  signs  are  far  commoner 
than  objective  ;  and  control  over  the  sphincters  may  sometimes  be  impaired  fairly  early 
in  the  disease.  In  many  instances,  however,  some,  or  even  many,  of  these  characteristics 
are  absent  ;  the  diagnosis  of  disseminated  sclerosis  may  then  be  far  from  easy,  especially 
in  its  early  stages.  In  hysteria,  for  examjjle,  intention  tremor  may  occur  in  just  the  same 
way  as  a  fine  or  a  coarse  tremor  may  ;  and  other  points  of  correspondence  between  hysteria 
and  disseminated  sclerosis  may  often  be  found  in  the  age  and  sex  of  the  patient,  in  the 
remittent  course  pursued  by  either  of  the  disorders,  in  the  frequent  occurrence  and  partial 
recovery  of  various  jjaralyses  and  of  amblyopia  with  contraction  of  the  visual  fields,  and 
in  exaggeration  of  the  deep  reflexes.  But  distinct  differences  between  the  two  are,  fortu- 
nately, not  wanting.  In  hysteria,  the  objective  sensory  signs  are  well  marked,  the  optic 
discs  are  not  affected,  nystagmus  is  absent,  Babinski's  sign  probably  never  occurs,  and 
control  over  the  sphincters  is  not  lost.  Attention  to  these  points  should  suffice  to  clear 
up  the  diagnosis  between  hysteria  and  disseminated  sclerosis  ;  but  in  the  earliest  stages 
of  the  latter  it  may  be  necessary  to  keep  the  patient  under  observation  for  some  little  time 
before  a  definite  opinion  can  be  pronounced.  Intention  tremor  has  also  been  described 
as  an  exceptional  feature  in  jiatients  suffering  from  neurasthenia. 

An  intention  tremor  is  not  very  rare  in  the  familial  and  hereditary  ataxias,  especially 
Friedreich's  disease  and   cerebellar  ataxy  ;    but   the   disturbance  of  movement   in  these 


06. — MoTemcnts  in  ataxy. 

show  tlie  Oirection  of  the  i 
attempted. 


1 


TRISMUS  729 

disorders  is  cliaracteristically  an  Ataxy  (p.  65).  It  also  occurs  in  some  cases  of  congenital 
or  acquired  cerebral  diplegia  of  baclvward  or  mentally  defective  children,  occasionally  appear- 
ing as  a  familial  disease,  and  characterized  by  bilateral  spastic  paralysis  affecting  the  limbs, 
or  limbs  and  body.  It  is  athetosis  that  is  characteristic  of  these  cases  ;  but  disordered 
movements  of  all  sorts  occur  in  them.  In  addition,  the  sphincters  are  commonly  affected, 
the  deep  reflexes  are  increased,  optic  atrophy  or  inequality  of  the  pupils  are  frequent  ; 
and  if  the  patient  is  able  to  get  about,  a  spastic  or  '  scissor  '  cross-legged  gait  is  to  be  seen. 
Congenital  cerebral  diplegia  in  which  the  spastic  weakness  is  most  marked  in  the  legs  is 
described  as  Little's  disease.  The  intention  tremor  occurring  in  birth  palsy  or  in  infantile 
henii])legia  has.  \infortunately  enough,  been  described  under  the  name  chorea  spastica. 

Intention  tremor  has  also  been  recorded  in  a  few  instances  of  lesion  of  the  superior 
cerebellar  peduncle,  corpora  fjuadrigemina,  or  optic  thalamus,  particularly  when  the 
tegmentum,  red  nucleus,  and  rubro-spinal  tract  are  involved-  It  may  be  noted  in  patients 
with  extra-cerebellar  tumours  growing  in  connection  with  the  eighth  nerve,  and  occupying 
the  posterior  fossa  of  the  skull  between  the  pons  and  cerebellum.  It  is  seen  in  a  certain 
proportion  of  the  cases  of  cerebellar  atrophy,  whether  the  degeneration  is  primary  paren- 
chymatous, progressive  and  due  to  interstitial  and  vascular  lesions,  or  acute  and  following 
some  acute  specific  fever.  Intention  tremor  is  also  present  in  some  patients  with  olivo- 
ponto-cerebeltar  atrophy.  The  diagnosis  of  these  rare  instances  will  naturally  depend  upon 
the  development  of  other  general  and  localizing  signs  of  intracranial  disease. 

A.  J.  Je.r-Blal;e. 

TRISMUS,  or  lockjaw,  signifies  a  maintained  closure  of  the  jaws  by  tonic  muscular 
s[)asm,  so  that  the  mouth  cannot  be  opened.  It  is  seen  best  in  tetanus.  The  term  does 
not  include  mechanical  inability  to  open  the  jaws  owing  to  such  aflections  as  mumps, 
alveolar  abscess  with  surrounding  inflammatory  oedema,  angina  ludovici,  quinsy  or  severe 
tonsillitis,  an  odontoma,  epithelioma  of  the  moutli,  myositis  ossificans,  and  so  forth  ;  but 
there  are  at  least  two  mechanical  conditions  that  may  not  at  first  sight  be  obvious,  but 
which  may  lock  the  jaws  together  and  simulate  true  trismus — impaction  of  a  ici.idom  tooth. 
and  arthritic  changes  in  the  lemporo-ma.rillarn  joint.  These  will  be  diagnosed  as  the  result 
of  a  careful  local  examination  of  the  teeth  and  of  the  joint  rcs])ectively,  and  in  the  latter 
ca.se  there  may  be  osteo-arthritic  changes  in  otlier  joints  also. 

Circumstantial  evidence  will  generally  serve  to  distinguish  trismus  due  to  hi/stcria 
or  to  facial  neuralgia  :  and  if  there  is  any  doubt  at  first,  this  will  disajipear  if  the  pjiticiil 
can  be  watched  for  a  while.  If  there  arc  convulsive  seizures  in  a  hysterical  jKiticnt  with 
trismus,  they  can  generally  be  distinguished  from  those  due  to  tetanus  or  to  strychnine 
poisoning  by  their  ijolymorphous  character,  and  by  the  fact  that  touching  the  patient, 
and  other  similar  stimulation,  does  not  bring  them  on  so  certainly  as  would  be  the  case 
with  strychnine  or  tetamis. 

The  rigidity  of  the  face  nuiscles  in  vrr[:iu\  i-.i^vs  lAliihrrnituKs  nr  imslcriiir  hiisal  nr 
ccrchrDspiiial  meningitis  never  occiws  by  ilsi-lf.  and  is  a  minor  syiuploiu  amongst  others 
thai    poiril    Id  the  correct  diagnosis.     The  same  applies  to  cpilepsi/  and  to  urcrmia. 

Malingering  may  sometimes  take  the  form  of  lockjaw,  and  it  may  be  a  little  while 
111  lore  the  fraud  can  be  detected  ;  sleep  is  sure  to  come  in  time,  and  as  the  result  of  fatigue 
the   malingerer's  nuiscles  relax  com'plctely. 

Catalepsy  may  include  trisnuis  amongst  its  vaiictiis  of  maintained  muscular  con- 
tractions :  the  giMcnil  nicntal  symptoms  will  assist  the  dia^'nosis.  and  as  a  rule  thiTc  are 
no  con\  ulsivc  seizures. 

Trichinosis  Is  very  rare  nowadays,  but  if  inl'c  cted  pork  is  eaten  raw,  or  insullicicntl,\- 
cooked,  the  larva!  of  the  parasites  find  their  way  to  many  dilTcrent  muscles,  and  they  show 
some  predilection  for  those  of  the  tongue,  mouth,  and  jaws.  The  resultant  irritation,  pain, 
and  stiffness  cause  trisnuis,  whose  nature  may  be  dillieiilt  to  determine  unless  the  history 
points  to  pork  as  the  origin.  'I'lie  patient  is  very  ill  in  the  earlier  stages,  with  liii.'li  le\<r. 
and  the  condition  is  often  fatal.  There  may  be  an  epidemic  of  the  nudady.  Tlie  lilon.l 
exhibits  eosinopliilia.  'V\\v  final  criterion  of  the  diagnosis  is  the  discovery  ot  llu'  t\|)ical 
])arasites  coiled  up  in  their  little  oval  cysts  amongst  the  all'ected  muscle  fibres.  In  a 
eerlain  proportion  ol  aeule  eases  the  einhryos  can  be  (ietccted  in  films  prepared  from  the 
eentrifugalized  (K  pcisil  Iniiu  .J  i-.c.  nt  the  patient's  blood  after  the  red  corpuscles  have  been 
lake.  I. 


7:)0  TRISMUS 

Hydrophobia  and  tetany  seldom  exhibit  trismus  as  a  prominent  symptom.  The 
former,  thouoli  it  is  almost  imknown  in  Great  Britain  now,  would  suggest  itself  if  any 
eonvulsive  illness  developed  after  a  definite  bite  by  a  dog,  wolf,  or  other  similar  animal, 
particularly  if  the  spasmodic  muscular  difficulty  was  markedly  increased  by  efforts  at 
swallowing.  The  symptoms  may  not  develop  for  weeks  or  months  after  the  bite,  so  that 
the  patient  may  fall  ill  when  he  has  come  home  after  being  bitten  abroad.  Tetany,  also 
rare,  is  at  once  distinguished  by  its  typical  carpo-pedal  contractions  [Fig.  1,  p.  3). 

Strychnine  poisoning  gives  rise  to  generalized  twitchings  and  convulsions  long  before 
trismus,  the  lateness  of  the  development  of  the  latter  serving  to  distinguish  it  from  tetanus. 
There  may  be  ev'idence  of  strychnine  having  been  taken  or  administered,  either  by  the 
mouth  or  hypodermically  ;  the  symptoms  develop  very  acutely,  and  are  apt  to  be  rapidly 
fatal. 

Tetanus  is  the  cause  par  excellence  of  trismus  :  the  diagnosis  is  often  obvious  if  the 
illness  develops  steadily  in  an  otherwise  healthy  person  or  new-born  infant,  starting  with 
stiffness  of  the  neck  muscles,  spreading  to  those  of  the  face  and  jaw,  and  thence  to  the  rest 
of  the  trunk  and  limbs,  with  a  tendency  to  extremely  painful  exacerbations  on  the  slightest 
stimulation,  even  by  a  stroke  with  a  feather  or  the  banging  of  a  door  ;  risus  sardonicus  ; 
opisthotonos;  no  complete  relaxation  of  the  stiffening  muscles  unless  chloroform  is  given  ; 
a  duration  of  days  rather  than  hours,  and  a  termination  in  death  more  often  than  in 
recovery  ;  especially  if  all  tliesc  tilings  follow  a  few  days,  or  a  week  or  more,  after  infection 
of  the  umbilical  cord  or  a  small  ])enetrating  wound  with  a  rusty  nail,  or  a  piece  of  stick 
or  other  similar  body  that  may  have  been  contaminated  with  tetanus  bacilli  from  the  soil. 
It  may  be  possible  to  demonstrate  the  drum-stick  bacilli  in  films  prepared  from  the 
deeper  jjarts  of  the  wound  (see  Plate  XXVIII,  Fig.  T,  p.  614).  The  chief  dilficulty  arises 
when  there  is  no  clear  history,  or  when  the  wound  has  been  so  small  that  it  has  healed 
or  cannot  be  found.  Even  then,  most  cases  are  so  typical  that  they  can  be  diagnosed  as 
tetanus  without  much  dilliculty.  t'nnecessary  anxiety  arises  chieHy  in  cases  of  impacted 
wisdom  teeth,  or  of  hysteria,  where  tetanus  may  be  suspected  at  first  :  the  subsequent 
course  of  the  malady  soon  serves  to  exclude  this.  Herbert  French. 

TUMOURS.— (See   SwKi.iiNc.   pp.   655   to   702.) 

TUMOURS  OF  THE  SKIN.— The  malignant  tumours  which  affect  the  skin  include 
carcinoma,  epithelioma,  Paget"s  disease,  sarcoma,  mycosis  fungoides,  and  xerodermia 
pigmentosum. 

As  a  rule,  cancer  en  cuirasse  and  nodular  (lenticular)  cancer  are  secondary  to  cancer 
of  the  breast  or  other  parts,  and  their  diagnosis  is  self-evident.  In  melanotic  carcinoma 
the  tumours  differ  greatly  in  size,  and  also  in  colour,  varying  from  a  slate  tint  to  bluish- 
black  ;  they  appear  more  frequently  on  the  genitalia  and  the  extremities  than  elsewhere. 
The  only  condition  from  which  melanotic  cancer  requires  to  be  distinguished  is  pigmented 
sarcoma,  and  for  this  histological  examination  is  necessary. 

Pagefs  disease,  occurring  chiefly  in  women  after  the  age  of  forty,  begins  as  a  reddening 
of  a  patch  of  skin,  usually  on  or  around  the  nipple,  followed  by  branny  desquamation. 
Inliltration  soon  produces  a  bright-red,  granular,  indurated  surface,  with  a  sticky,  yellowish 
(iiseharge.  which  by  forming  crusts  may  obscure  the  nature  of  the  lesions,  save  at  the 
border,  which  continues  to  be  characteristic — sharply  defined,  indurated,  and  sometimes 
distinctly  raised.  After  a  period,  which  is  usually  about  two  years,  but  may  be  nnich 
longer,  deep-seated  parts  may  become  affected,  this  extension  of  the  disease  showing  itself 
on  the  breast  by  retraction  and  induration  of  the  nipple  and  the  formation  of  a  tumour 
in  the  substance  of  the  gland.  In  the  early  stage  Paget's  disease  has  to  be  distinguished 
from  chronic  eczema,  which  it  resembles  closely.  Its  differentiating  features  are  the  bright- 
red,  granular  surface  exposed  after  removal  of  the  crusts,  the  induration  at  the  well-defined 
edge,  the  intractability,  the  age  of  the  patient,  and  (later)  the  retraction  of  the  nipple. 
The  diagnosis  may  be  made  certain  by  micro.scopic  examination  of  scrapings  in  iodized 
serum  or  liquor  potassa;,  when  the  bright,  oval,  nucleated  bodies  styled  psorosperms  will 
be  seen,  some  still  contained  within  the  host-cells,  others  surrounded  by  distinct  capsules. 

Epithelioma  begins  usually  as  a  single  growth,  superficial,  deep-seated,  or  papillary, 
but  all  the  forms  alike  are  marked  by  ])eripheral  extension,   infiltration  and  destruction 


TUMOURS    OF    THE     SKL\  731 

of  neiglibf)urin£  parts,  central  ulceration,  and  (except  in  rodent  ulcer,  for  which  see 
Ulceration  of  Face,  p.  735)  a  tendency  to  the  formation  of  secondary  growths  in 
lymphatic  glands,  in  viscera  and  elsewhere.  Epitheliomata  have  a  predilection  for  the 
natural  orifices,  for  such  moist  parts  as  the  glans  penis,  for  exposed  regions,  and  parts 
exposed  to  friction  and  trivial  injuries.  A  wart,  a  mole,  an  ulcer.  lupus  vulgaris  lesions, 
or  an  a'-ray  cicatrix,  may  be  the  starting-point.  If  the  tumour  begins  in  the  skin,  it 
appears  first  as  a  papule  ;  if  in  a  gland,  as  a  nodule.  In  the  former,  the  more  frequent 
case,  the  papule  becomes  firmer  and  extends  laterally  :  infiltration  is  evidenced  by  the 
hard,  raised,  pearly  border.  Ulceration  occurs  in  the  centre  of  the  growth  while  extension 
is  proceeding  in  the  depths  and  at  the  sides.  If  the  necrotic  process  involves  the  vascular 
tissue,  there  is  more  or  less  hiemorrhage.  If  the  lateral  extension  predominates,  the 
discoid  type  of  epithelioma,  as  in  sweep's  cancer  of  the  scrotum,  is  the  result  :  the  surface 
is  raised,  with  a  steep  border,  and  is  bright-red,  with  a  firm,  granular  surface.  If  the 
granulations  are  of  large  size,  the  growth  is  of  the  papillary  type.  The  chief  diagnostic 
features  of  epithelioma  are  :  the  origin  as.  usually,  a  single  growth,  the  site,  the  starting- 
point,  the  slight  discharge,  the  characteristic  border,  the  secondary  growths  in  glands 
and  elsewhere.  From  a  wart  or  a  mole,  epithelioma  can  be  distinguished  conclusively 
only  by  microscopical  examination  or  by  long-continued  observation,  and  should  signs 
of  ulceration  or  crustation  appear  in  such  growths,  epithelioma  should  be  suspected.  The 
so-called  tubercular  ulcerating  syphilides  are.  as  a  rule,  multiple,  and  not  rounded,  but 
rather  segmental.  (For  the  diagnosis  of  epithelioma  from  lupus  vulgaris,  sec  under 
NODVLES.    p.    A(Y2}. 

Sarcoma  of  the  skin  is  most  fre(|uently  secondary  to  growths  commencing  in  the 
lymphatic  glands  fir  the  deeper  structures.  Sarcomata  vary  considerably  in  colour,  from 
reddish  to  brown  or  bluish-lilack.  and  also  in  consistence  ;  those  of  the  spindle-eelled  type 
arc  fairly  firm,  the  small-celled  ones  soft,  with  all  intervening  grades  of  density.  They 
may  appear  in  any  part  of  the  body,  but  are  often  found  on  moles,  warts,  and  ulcers.  The 
diagnosis  usually  depends  upon  histological  examination,  and  it  must  suffice  to  say  that 
a  tumour  which  arises  in  pre\iously  healthy  skin,  or  in  a  mole  or  wart,  or  at  the  site  of  an 
inj\iry,  which  is  soft  and  reddish  from  the  vascularity  that  is  a  marked  feature  of  this  kind 
of  tumour,  or  bluish  from  i)igment,  and  which,  after  a  period  of  slow  growth,  enlarges 
rapidly,  projects  above  the  surface,  and  readily  ulcerates  and  bleeds,  is  probably  a  sarcoma. 

In  the  early  stage  of  nii/aisi.s  (angoides  the  lesions  are  dull-red  or  livid  patches,  some- 
times slightly  tinged  with  yellow,  \arying  in  size  from  the  area  of  a  llnger-nail  to  that  of 
the  palm  of  the  hand,  with  border  sometimes  well  marked,  sometimes  fading  off,  mosi 
fre(|uently  raised  or  thickened,  but  occasionally  Hat.  At  first  the  patches  are  snjooth  ami 
(lr\.  afterwards  they  become  scaly,  and  later  still  they  may  be  moist  or  covered  with 
(rusts.  Presently  the  surfaj-c  bccorTies  inliltrated.  and  tiunours  as  small  as  a  pea  or  as 
large  as  an  apple,  firm  and  lobulaled.  broader  at  the  free  than  at  the  attached  end.  and 
somewhat  resembling  tomatoes,  (troject  above  the  level  of  the  skin  ("  fungoides  ").  As 
a  rule,  progressive  thickening  occurs,  leading  on  to  fungation.  The  lymphatic  glands 
may  be  enlarged  throughout  the  body.  In  the  prcmyeotic  or  eczeniatous  stage — which 
is  sometimes  absent — the  diagnosis  may  hesitale  between  mycosis  fungoides  and  an 
eczematous  or  urticario-cczematous''  condition,  and  in  some  cases  it  may  be  impossible 
at  this  stage  to  rlistinguish  definitely  between  the  two  :  but  in  mycosis  fungoides  the 
lesions  will  make  little  response  to  t  herapi  utie  measures,  the  red  of  the  |)atclus  may  be 
slightlv  tinged  with  yellow,  and  they  are  more  persistent  than  those  of  ee/.ema.  The  only 
niaii^iianl  condition  which  mycosis  ftmgoi<les  In  the  mycotic  stage  at  all  nsernhles  is 
sareoniii.  but  there  is  seldotii  any  diHiciilty  in  distinguishing  between  the  two. 

'I'lie  initial  lesions  of  .irrailirnia  /liuiiiiiiliisaiii  (Kaposi's  disease)  are  small  spots 
resembling  freckles,  lint  rather  darker,  which  appear  ehielly  on  the  face.  neck,  arms  and 
legs,  and  generidly  begin  within  the  first  two  years  of  life.  I'sually  they  disappe:ir  in 
winter  and  return  in  summer  :  but  after  a  time  they  become  permanent,  and  often  (|uitc 
black.  .\t  first  the  condition  suggests  nothing  but  excessive  freckling,  but  presently  amid 
the  •freckles"  appear  white,  glazed,  atrophic  spots,  telangiectases,  and  superficial  ulcers 
discharging  pus  which  dries  into  yellow  crusts.  .After  .some  years,  small,  warty-looking 
growths  develop  on  the  "freckles.'  Tumours  now  form  and  ulcerate,  producing  fimgoiis 
masses,    anil    the    process    extends    liolli    wi(lel\     and    deepK  ,    and    deslro\s    e\<rv    tissue    it 


732  TUMOURS    IN    THE    SKIN 

encounters,  not  excepting  bone.  It  is  only  in  the  earliest  stage  that  there  can  be  any 
difficulty  in  recognizing  this  very  distinctive  disease.  In  that  stage  it  may  be  mistaken, 
as  is  suggested  above,  for  simple  Icntlgn,  from  which  there  may  be  nothing  but  the  more 
extensive  distribution  to  distinguish  it.  With  the  appearance  of  the  later  lesions  lentigo 
will  be  dismissed  from  consideration,  and  it  should  be  not  less  easy  to  rule  out  sclerodermia. 

The  benign  tumours  of  which  the  diagnosis  may  be,  in  very  different  degrees,  open 
to  doubt,  are  sebaceous  and  dermoid  cysts,  fibroma  molluscum,  von  Recklinghausen's 
disease,  neurofibromata,  myoma  cutis,  myxoma,  the  xanthomas,  rhinoscleroma,  molluscum 
contagiosum,  colloid  milium,  benign  adenoides  cysticum,  and  keratosis  foUicularis. 

Sebaceous  cysts,  seen  most  frequently  on  the  scalp,  the  face,  and  the  back,  rounded, 
often  somewhat  flattened  on  the  top,  and  sometimes  as  large  as  an  orange,  are  distinguished 
from  fatty  tumours  by  the  absence  of  lobulation  and  the  fact  that  the  sebaceous  contents 
can  be  squeezed  out  when  there  is  an  oj)ening  ;  in  Dercunis  disease  (p.  410)  the  deposits  of 
subcutaneous  fat  may  be  less  well  defined,  but  the  diagnosis  is  generally  obvious  from  the 
alcoholic  history.  Dermoid  cysts  may  resemble  fibromata,  but  if  they  are  incised  a 
sebaceous-looking  material  escapes.  Fibroma  molluscum.  a  pear-shaped  or  rounded  fibrous 
tumour,  usually  covered  by  smootli  skin  and  pedunculated,  varying  in  size  from  a  pin's 
head  to  an  orange,  and  nearly  always  multiple  {Fig.  291,  p.  711),  differs  from  a  sebaceous 
cyst  by  its  solid  structure,  and  from  a  fatty  tumour  by  its  usual  pedunculation  and  the 
absence  of  lobulation.  Von  liecl^liiigliauscn's  disease,  of  which  the  lesions  consist  of 
nodular  tumours,  on  and  around  which  there  is  coffee-coloured  pigmentation,  is 
differentiated  from  ordinary  fibroma  in  that  the  tumours  are  composed  of  fibrous  and 
nervous,  and  not  simply  of  fibrous,  tissue.  There  is  also  a  perceptible  thickening  of  the 
nerves  of  the  arms.  N euro-fibromata,  which  have  their  origin  in  the  tendon-sheaths  or 
the  sheaths  of  the  nerve  fibres,  and  range  in  size  from  a  pin's  head  to  very  large  dimensions, 
are  sometimes  mistaken  for  rheumatic  nodules,  but  instead  of  specially  affecting  the  region 
of  the  elbows  and  the  .scalp,  they  occur  on  the  trunk  and  extremities  generally,  nor  is  there 
(except  from  coincidence)  a  history  of  rheuniatism. 

Suijerficial  myoma  cutis  occurs  in  the  form  of  nodular  tumours  on  the  arms,  back, 
chest,  and  cheek  ;  the  deeper  kind,  originating  in  the  subcutaneous  muscular  structures, 
occurs  as  a  solitary  tumovu-,  commonly  on  the  breasts  and  genitals.  The  former  growths 
are  soft  and  elastic,  and.  like  the  latter,  are  often  painful.  The  distinctive  clinical  feature 
of  myoma  cutis  generally  is  that  it  contracts  under  the  influence  of  cold.  This,  with  tlie 
pain,  the  absence  of  any  tendency  to  ulceration,  and  the  aspect  and  slow  course  of  the 
growth  or  growths,  should  enable  the  affection  to  be  identified. 

Myxoma,  when  it  arises  in  the  skin — most  frequently  in  the  loose  skin  of  the  scrotum 
and  labia — usually  forms  rounded,  pedimculated.  translucent  tumours  which  tend  to 
enlarge  slowly.  They  have  to  be  distinguished  from  molluscum  contagiosum.  This  begins 
by  the  formation  of  small  growths  that  have  been  likened  to  tiny  mother-of-pearl  shirt- 
buttons.  They  are  usually  flattened  at  the  top,  where  as  a  rule  there  is  a  depression  in 
which  can  be  seen  a  small  aperture  leading  into  the  interior  of  the  tumour.  Through  this 
orifice  a  whitish  material,  or  sometimes  a  milky  fluid,  can  be  squeezed  out.  When  they 
are  very  small  the  tumours  resemble  the  vesicles  of  varicella,  but  a  microscopic  examination 
of  the  contents  will  obviate  the  confusion.  A  small  molluscimi  body  on  the  genitals  may 
resemble  a  hard  chancre,  but  similar  growths  will  be  found  elsewhere. 

Xanthoma  planum,  often  associated  with  jaundice  and  migraine,  and  characterized 
by  the  formation  of  yellow  or  yellowish-white  plaques  (rarely  nodules),  usually  in  the  upper 
eyelid  and  sometimes  affecting  also  the  lower  lid,  is  easy  of  recognition,  the  appearance 
of  the  yellow  patches  embedded  in  tlie  corium,  and  almost  impercejitiblc  to  the  touch, 
being  absolutely  distinctive.  Xanthoma  multiplex,  however,  is  not  identified  tpiite  so 
easily.  Here  the  lesions  are  nearly  always  nodular,  and  often  observe  a  linear  grouping, 
and  the  colour  varies,  a  blackish  or  reddish  pigment  being  mixed  sometimes  with  the 
yellow.  Usually  the  nodules  occur  in  connection  with  hepatic  disease.  The  condition 
has  been  confounded  with  urticaria  pigmentosa,  but  there  is  no  itching,  there  are  no  wheals, 
and  it  is  impossible  to  produce  factitious  lesions.  The  tumours  may  be  indistinguishable 
from  multiple  dermoids  of  the  skin  until  microscopic  examination  is  made.  Xanthoma 
diabeticorum  differs  from  other  forms  of  xanthoma,  inter  alia,  in  the  presence  of  a  raised 
red  area  around  the  yellow  spots.     This  feature  has  led,  in  the  early  stages  of  the  affection. 


ULCERATION     OF    THE    CORNEA  733 

to  confusion  with  acne,  but  if  the  lesions  are  ])unetnie(l  they  will  prove  to  be  solid.  In 
the  same  stajje  the  lesions  may  simulate  those  of  liclieii  phiiiiis,  but  the  resemblance  soon 
disappears. 

Rhinosclernmd  beoins.  usually  before  the  ase  of  forty,  in  and  around  the  nostrils  as 
nodules  in  the  cutis,  and  in  the  deeper  layers  of  the  mucous  membrane.  These  coalesce 
to  form  a  hard,  smooth,  glistening  growth  which  spreads  inwards  from  the  lip  and 
downwards  to  the  pharynx  from  the  posterior  nares.  The  growth  does  not  break  down 
spontaneously,  but  is  generally  slowly  progressive.  It  is  not  likely  to  be  mistaken  lor 
anything  but  epilheliomti.  which  is  prone  to  ulcerate,  generally  has  infiltrated  edges,  seldom 
attacks  the  upper  lip,  and  usually  begins  later  in  life.  In  rliiiiopln/nid.  pustules  are  often 
present,  the  growth  is  soft,  and  there  is  vascular  dilatation. 

In  colloid  miliiini.  small,  yellow,  cyst-like  formations  containing  a  gelatinous  substance 
appear  in  the  skin,  chiefly  on  the  upper  jjart  of  tlie  face.  They  may  become  depressed 
in  the  centre  and  be  absorbed  slowly,  or  may  inflame  and  dry  up.  The  only  condition 
from  which  colloid  milium  needs  to  be  distinguished  is  epithelioma  adenoides  cyslicum.  in 
which  the  tumours,  shining  and  translucent,  contain  one  or  more  white,  brightly  refracting, 
milium-like  bodies.  The  face  is  the  part  attacked  most  frequently,  but  the  growths  may 
ai)pear  on  almost  any  part  of  the  body.  They  are  not  yellow,  like  the  growths  in  colloid 
milium,  nor  are  they  soft. 

Kridtosia  folliruliiris  begins  as  small  brown  or  yellow  crusts,  hard  and  dry,  which, 
when  detached  from  the  underlying  tissue,  are  found  to  present  on  their  under  surface 
a  sottish  prolongation  which  dips  into  a  follicle.  At  first  discrete,  the  lesions  may  become 
confluent,  and  there  is  thickening  of  the  affected  parts  until  nodular  masses  are  formed, 
from  which  oozes  an  offensive  discharge.  The  affection  is  slowly  progressive.  .-\t  the 
outset  the  condition  may  be  mistaken  for  keratosis  pilaris,  but  it  is  not  confined  to  the 
situations  affected  by  that  disease.  The  prolongation  into  a  follicle  gives  it  some 
resemblance  to  molluscum  contagiosum,  but  it  has  a  less  limited  distribution,  nor  have 
the  growths  the  pearly  appearance  of  the  molluscum  bodies,  while  the  apcrtme  in  the 
individual   lesions   is  larger.  Mdlcdliii  Munis. 

TYMPANITES.     fScc  Mi-fkoiusm,  p.  8ss). 

ULCERATION    OF    THE    CORNEA.      The  < rse  of  all  corneal   ulcers  eonlorms  to  a 

general  tyjie.  though  the  clinical  varieties  may  vary.  The  process  begins  with  an  infiltra- 
tion in  the  substance  of  the  cornea,  either  central  or  peripheral  ;  the  result  of  this  infillra- 
tion  is  a  local  loss  of  transparency,  though  in  early  stages  the  s(U'face  of  the  eorncii  may  still 
I'ctain  its  polish.  The  inliltration  proceeds  to  suppuration,  which  is  followed  by  a  loss  of 
substance,  the  corneal  surface  being  dull  and  irregular,  and,  in  the  centre  of  the  ulcer, 
depressed  below  the  snrrounding  level.  The  base  of  the  ulcer  is  grey  or  yellowish,  and  the 
surrounding  portion  of  the  cornea  may  be  opacpie  with  more  or  less  grey  infiltration. 

The  su|)puration  is  followerl,  in  eases  which  have  a  favoiu'able  termination,  by  vascular- 
i/.;iti(in.  snperlieial  Ncssels  from  the  surroundinu  eonjunctiva  eruToaehing  on  the  cornea  and 
invading  the  suppurating  area.  The  \aseulari/,ation  is  followed  by  cieatri/ation,  the  sm- 
face  of  the  cornea  again  becoming  pojished  but  llaltened  and  opacpic.  The  opacities  result- 
ing from  corru'al  ulcers  are  loeali/ed.  well  defined  and  oi)a(|ue,  in  contrast  to  the  diffuse 
indefinite  haze  wliieh  follows  such  non-suppurative  forms  of  iullammation  as  interstitial 
keratitis.  Corneal  ulcers  may  not  heal,  but  occasionally  lead  to  perforation  of  the  cornea, 
prolapse  and  ailhesion  of  the  iris,  anterior  polar  cataract,  or  panophthalmitis.  Iritis.  Irido- 
eyelilis.  and  pus  In  the  ant<-rior  chanilxr  (hypopyon)  ma\  also  be  associated  conditions. 
The  usual  subjective  symptoms  are  pain,  photophobia,  anil  laehrymation.  The  presence 
of  corneal  ulcers  is  demonstrated  most  satisfactorily  by  the  instillation  of  a  drop  or  two  of 
lluoresein.  which  stains  necrotic  cortical  epithelium  or  exposed  corneal  sid)sl;mec,  green. 
'I'hc  l)riglitl\-stained  ulcer  shows  up  in  marked  contrast  (o  the  surrounillng  clear  (•(>ii\(a. 

Corneal  ulcers  may  occur  in  the  following  clinical  varieties  : 

Caliirrlia!.  or  simple  iiifeetivc  ulcers.  These  usually  occur  as  minute  gre\  inliltratcd 
splits  ill  I  lie  nrili-e  or  periphery  of  thecoriu'a.  They  heal  very  rapidly  as  a  rule.  They  may 
follow  injui.v  to  the  conical  epithelium  by  foreign  bodies,  or  may  be  associated  with  acute 
eonjiinctiv  ills  or  rhinitis. 


734  ULCERATION    OF    THE    CORNEA 

Phlyctenular  ulcers  are  associated  with  phlyctenular  conjunctivitis,  the  ulcer  forming 
after  the  epithelium  on  the  top  of  a  phlyctenule  has  been  rubbed  off.  They  are  usually 
inarijinal,  but  may  occasionally  make  their  way  on  to  the  cornea,  a  leash  of  conjunctival 
blood-vessels  trailing  after  them.     Similar  ulcers  may  be  associated  with  acne  rosacea. 

Ilijpopt/oit  ulcer,  or  ulcus  serpens.  This  is  a  shallow  ulcer  affecting  chiefly  the  super- 
ficial layers  of  the  cornea  in  or  about  its  centre.  The  middle  layers  of  the  cornea  are  com- 
paratively unaffected,  but  at  the  posterior  surface  the  infiltration  again  becomes  dense, 
with  much  fibrin  and  debris,  associated  with  the  formation  of  more  or  less  pus  in  the  anterior 
chamber.  The  ulcers  often  perforate  :  they  are  usually  due  to  infection  with  the  ])neumo- 
coccus  {Plate  XII.  p.  232).  The  tjus  in  the  anterior  chamber  is  always  sterile,  imless  there 
is  perforation  of  Descemet's  membrane.  These  ulcers  do  not  react  to  ordinary  methods 
of  treatment  as  a  rule,  but  require  cauterization,  either  by  pure  carbolic  acid  or  the 
galvano-cautery.     The  hyjjopyon  then  disappears  rapidly. 

Mooren's  ulcer,  or  rodent  ulcer  of  the  cornea,  is  a  chronic  serpiginous  ulcer,  usually 
affecting  the  eyes  of  elderly  people.  It  begins  at  the  margin  of  the  cornea  and  spreads 
slawly  over  the  whole  surface,  the  advancing  edge  being  much  undermined.  The  ulcer  is 
always  shallow,  and  perforation  ne\er  occurs  ;  the  ulcer  may  heal  in  ])laces,  but  this  is 
seldom  permanent,  and  the  ulceration  usually  spreads  over  the  whole  surface  of  the  cornea 
whateser  method  of  treatment  may  be  employed  to  arrest  its  progress,  though  recently 
radium  has  been  used  with  some  success.     No  specific  organism  has  yet  been  discovered. 

A  flendrilic  ulcer  is  characterized  by  its  peculiar  shape — a  long  central  stem  with  small 
linear  ramifications.  It  is  not  really  an  ulcer,  but  an  infiltration  under  the  corneal  epithe- 
lium, which  in  the  later  stages  may  become  necrotic  and  break  down.  It  is  best  treated 
by  rubbing  off  the  affected  corneal  epithelium  with  a  pointed  stick  dipped  in  absolute  alcohol. 

Corneal  uleers  may  occur  in  association  with  pannus  in  trnclioma.  their  usual  site  being 
at  the  margin  of  the  vascular  area.  Occasionally  they  penetrate  more  dee|)ly  into  the  corneal 
substance. 

Corneal  ulcers  fre(iuently  follow  goiwrrlural  and  diphtheritic  coujuuctivitis.  They 
spread  rapidly,  and  often  lead  to  perforation  of  the  cornea  and  panophthalmitis.  The 
diagnosis  depends  on  bacteriological  methods  and  the  discovery  of  the  causative  micro- 
organisms. 

Keratomalncia,  a  disease  of  childhood,  is  associated  with  night  blindness  and  xerosis 
or  dryness  of  the  conjunctiva.  Characteristic  foamy  white  patches  are  seen  on  both  sides 
of  the  cornea  (Plate  XII.  p.  232).  The  cornea  becomes  dull,  grey,  and  cloudy,  and 
ultimately  disintegrates  from  pui'ulent  infiltT-ation,  associated  with  very  slight  signs  of 
ocular  inflammation.  The  ocular  condition  is  associated  with  marasnms  and  malnutrition. 
The  ])rognosis,  both  as  to  eye  and  vision,  is  bad. 

Keratitis  e  lagophthnlmo  is  associated  with  paralysis  of  the  seventh  nerve.  Owing  to 
the  failure  of  the  orbicularis  palpebrarum  the  eye  cannot  be  closed,  and  does  not  remain 
closed  during  sleep.  The  lower  part  of  the  cornea  is  exposed,  becomes  dry,  and  the  corneal 
epithelium  dies,  with  consequent  ulceration  of  the  cornea.  The  condition  can  be  cured  by 
diminishing  the  pal])ebral  aperture  by  sewing  the  eyelids  partially  or  completely  together. 

Similar  exposure  of  the  cornea  and  consequent  ulceration  is  seen  oeeasionally  in  cases 
of  ExopHTUAi.Mos  (]3.  229),  for  in.stance  in  severe  Graves's  disease. 

Keratitis  iieuroparulytica.  In  paralysis  of  the  fifth  nerve,  or  as  a  result  of  excision  of 
the  Gasserian  ganglion,  the  cornea  becomes  dull  and  cloudy  and  necroses  in  the  centre, 
only  the  periphery  remaining  clear.  A  hypopyon  forms,  and  in  some  cases  the  whole  eye  is 
destroyed,  though  occasionally  the  keratitis  may  lead  only  to  a  permanent  opacity.  The 
condition  is  due  to  arrest  of  lachrymal  secretion  and  absence  of  corneal  sensation,  which  is 
followed  by  abolition  of  the  winking  reflex.  Foreign  bodies  lodge  on  the  cornea  and  are 
not  removed.     The  prognosis  is  bad.  and  is  little  affected  by  treatment. 

Corneal  ulcers  may  be  associated  with  herpes  froutulis.  vesicles  forming  on  the  cornea 
simultaneously  with  the  vesicles  on  the  skin,  especially  along  the  course  of  the  su])ra-orbital 
nerve.  The  ulceration  is  often  severe  and  may  lead  to  perforation  and  destruction  of  the 
eye,  and  is  in  any  case  followed  by  considerable  corneal  opacity.  The  cornea  is  usually 
insensitive,  and  the  intra-ocular  tension  may  be  raised. 

Tuberculous  idceration  is  not  conuuon  fortunately,  but  it  should  be  borne  in  mind  as  a 
possibility  in  chronic  or  resistant  eases.     The  diagnosis  depends  on  the  history,  tlie  presence 


ULCERATION    OF    THE    FACE  735 

of  tuberculous  glands  or  ottier  similar  lesions,  positive  reaction  to  tlu>  various  tuberculin 
tests,  and,  most  conclusively  of  all,  upon  the  detection  of  tubercle  bacilli  in  tlie  discharge 
from  the  ulcer  itself.  Uirbnl  L.  Enson. 

ULCERATION  OF  THE  FACE.— The  ulcers  most  often  met  with  on  the  face  are 
lupous,  scrofulous,  sypliilitic.  or  malignant.  In  lup}is  vulgaris,  the  ulceration  is  extremely 
chronic.  The  lesion  begins  as  a  papule,  develops  into  a  nodule,  and  after  a  while,  in  the 
majority  of  cases,  the  lupous  tissue  breaks  down  and  forms  a  granular  sore  covered  with 
greenish-black  crusts  ;  but  around  the  ragged  edge  will  still  be  seen  the  characteristic 
"  apple-jelly  '  nodules  in  different  stages  of  development.  The  ulceration  may  extend 
through  the  whole  thickness  of  the  skin  and  may  become  the  seat  of  warty  vegetations. 
In  the  nose,  where  the  integument  is  thin,  it  may  cause  necrosis  of  cartilage.  The  course 
the  pathological  process  runs,  from  the  paiiule  onwards,  as  here  described,  and  the  frctiuent 
presence  of  the  different  lesions  sinuiltaneously.  shed  sufficient  light  on  the  character  of 
the  ulceration.  I  need  only  say  further  that  the  ulcer  of  lupus,  however  dce])ly  it  may 
extend,  never  erodes  bone.  This  alone  is  sufficient  to  differentiate  lupus  from  tlie  ulcers 
of  syphilis  and  cancer.     It  nearly  always  begins  before  the  age  of  twentv. 

In  the  ulcers  of  scrofula,  though  they  have  no  absolutely  distinctive  characters,  it 
will  often  be  noticed  that  the  edge  is  tuidermined  and  the  surrounding  skin  blue  and  of 
low  vitality.  Their  occurrence  in  children  of  strumous  aspect,  or  in  clderlv  persons  wlio 
bear  the  stigmata  of  scrofulous  lesions  dating  from  childliood,  and  their  tendency  to  become 
chronic  owing  to  the  feeble  resistance  offered  by  the  tissues  to  morbid  processes,  leave  no 
room  for  doubt  as  to  their  true  nature. 

It  is  in  the  late  secondary  and  the  tertiary  stages  of  sjiphilis  that  cutaneous  lesions 
on  the  face,  as  elsewhere,  are  prone  to  ulceration,  instead  of  to  the  resolution  to  which 
typical  secondary  syphilides  tend.  The  whole  structure  of  the  skin,  or  nuicous  membrane, 
is  fref|uently  involved,  the  ulceration  is  deep,  and  tlie  ulcers,  while  healing  in  the  centre, 
are  prone  to  extend  at  the  margins,  and  so  assume  the  characteristic  circinate  or  serpiginous 
form.  The  appearance  of  the  ulcers,  with  the  history,  and  the  marks  of  earlier  .syphilitic 
lesions,  will  supply  all  the  guidance  the  diagnostician  needs  ;  Wassermann's  serum  test 
and  the  effects  of  mercury  and  iodide  of  potassium  or  salvarsan  may  serve  lo  clinch  the 
diagnosis. 

As  a  rule  roilcnl  ultcr  occurs  in  pers<ins  of  more  tlian  middle  age,  and  ils  laxourite 
points  of  attack  arc  the  outer  edge  of  the  orbit  and  the  side  of  the  nose.  II  begins  as  a 
small,  circumscribed  nodule,  dull  brownish-red  in  colour,  flat,  depressed  in  I  he  centre, 
and  firm  to  the  touch.  .After,  it  may  be,  years,  the  cuticle  covering  it  is  broken,  iuid  an 
ulcer  is  formed  with  depressed  gramilar  centre  and  inliltrated  border.  Very  slowly  this 
extends,  both  in  circund'crence  and  in  deptli,  inliltrating  and  destroying  the  subjacent 
tissues,  including  bone.  Usually  the  destruction  of  the  underlying  parts  is  more  nuirked 
in  the  centre,  so  that  the  ulcer  becomes  crateriform.  Its  invariable  features  -the  incon- 
siderable suffering  it  inflicts,  the  singular  slowness  of  ils  progress,  its  depressed  centre, 
and  the  linn,  raised,  rolled  edge,  its  faihu'c  to  affcel  neighbouring  glands,  and  its 
incurability  except  by  extirpation  or  by  physiotherapy  —are  so  characteristic  as  to  leave 
little  scope  for  diagnosis.  I^pitlieMcyuatous  in  structure,  it  differs  from  cpillulioma  in 
that  tlu'  jailer  growlli  has  a  vcr\-  hard  and  everted  edge,  and  a  foul  base  rougluwicd  with 
granulation,  is  oflen  attended  l)y  se\-ere  pain,  is  nuieh  more  rapid  in  ils  course,  and  infects 
the  glands  in  ils  vicinity.  It  differs  Irom  lupus  vulgaris  in  ils  moilc  of  onset,  in  the  absence 
of  the  ■  apple-jelly  "  noilulcs.  and  in  not  being  a  disease  thai  starts  in  childhood.  It  may 
be  diagnosed  from  tertiary  syphilitic  uhers  l)y  the  eliaraelers  deseril)eil  abo\c.  and  also 
by  its  usually  solitary  character  and  its  resistance   to   treatment.  Mulculm  Morris. 

ULCERATION  OF  THE  FOOT.— The  uh'cr  which  attacks  the  foot  specially,  though 
not  exclusively,  for  the  hand  may  \)v  alfcclcd  in  the  same  way,  is  that  known  as  perforating 
ulcer  (Fifi-  2!(7).  The  exciting  cause  is  pressme  upon  or  injury  to  a  foot  in  which  there 
is  interference  with  the  nerve  supply,  cither  from  peripheral  lesion,  as  in  peripheral  lu'uritis, 
or  from  damage  to  the  nerve-trunk,  as  in  leprosy,  syphilis,  or  diabetes  mcllitus.  or  lo  the 
nerve-centre,  as  in  tabes  dorsalis  and  general  paralysis.  The  commoiiesi  siliialion  of  the 
ulcer  is  al    llie   point    of  greatest    pressure   -the   under   aspect    of  the   metatarso -pliMlan^eal 


f3t3 


ULCERATION     OF    THE    FOOT 


joint  of  the  big  or  little  toe.  The  ulcer,  which  is  more  a  sinus  than  a  true  ulcer,  usually 
painless,  may  be  simple  or  multiple,  and  both  feet  may  be  affected.  It  often  begins  by 
sui^jiuration  under  a  corn.  AVhen  the  horny  covering  is  cast  off,  a  track  is  seen  which 
extends  downwards  until  the  bone  is  exposed.  The  process  is  usually  very  slow,  and  if 
the  pressure  from  walking  is  continued  the  thickened  epidermis  forms  a  kind  of  corn-shield 
around  the  opening.  The  more  essential  symptoms  of  the  disorder  of  which  ])erforating 
ulcer  is  but  an  incidental  manifestation  will  disclose  the  true  nature  of  the  lesion.  The 
only  malady  with  which  it  can  be  confused  is  a  suppurating  corn.  From  this  it  is  distin- 
guished by  the  absence  or  small  degree  of  pain,  and  by  its  irresponsiveness  to  the  simple 
surgical  treatment  to  which  a  suppurating  corn  yields  readily. 

Ulceration  of  the  foot  is  also  apt  to  arise  as  the  result  of  rubbing,  irritation,  or  other 

injury  to  parts  whose  nutrition  is  impaired,  for 
example  in  cases  of  talipes  from  nerve  disorders, 
or  when  sensation  is  impaired,  as  in  cases  of 
syringomyelia  (p.  608),  or  paraplegia  (p.  510). 

Mycetoma  is  a  fungous  disease  that  is  known 
alternatively  as  Madura  foot,  because,  endemic  in 
-Madura  and  other  parts  of  India,  it  usually  affects 
the  foot  or  the  leg,  though  sometimes  the  hand, 
and  in  rare  cases  the  shoulders  or  the  scrotum. 
The  affection  appears  in  several  forms,  according 
as  they  are  due  to  different  species  of  discomyces 
and  aspergillus.  The  lesions  may  be  black 
("  nielanoid  ")  or  pink  ("  ochroid  ').  The  disease 
l)egins  with  slight  swelling  and  redness  or  local 
induration,  and  as  it  progresses  the  foot  swells  and 
the  surface  becomes  dotted  with  small  nodules, 
each  containing  the  opening  of  a  sinus  which 
discharges  a  viscid,  syrupy,  slightly  purulent, 
sometimes  blood-streaked  Huid.  in  which  are 
suspended  rounded  greyish,  yellowish,  or  black 
granules.  As  the  foot  enlarges,  the  leg,  from 
disuse,  atrophies.  The  only  condition  from  which 
mycetoma  needs  to  be  discriminated  is  actiiio- 
nii/cosis.  This  affection  usually  begins  in  the  bone 
or  other  deep  structures  of  the  jaw,  face,  or  neck, 
may  thence  spread  to  the  surface,  and  may  involve 
the  viscera.  In  the  discharge  the  ray  fungus 
/'i;;.  ;;  J.,— r.ifoiitnu-  uii  <i  ..I  foul ;  from  a  case       mav  be  foiuid  in  the  form  of  tiny,  friable,  vellowish 

of  taf'es  tlui-salis.  ^  .1,1.  -    *  .       »  ' 

or  greyish  bodies,  though  microscopical  methods 

and  the  discovery  of  the  characteristic  ray  fungi 

(Plate  XX]' 2 1 1,  Fiii.  S.  p.  (i]4)  will  generally  be  required  before  the  nature  of  the  case  can 

be  conlirmed.  Malcolm  Morris 


ULCERATION  OF  THE  LEG  may  lie  classified  under  three  headings  :—(!)  Non- 
infective  Ulcers. — These  include  those  that  are  not  due  to  any  specific  infection,  but  which 
are  caused  by  various  factors  which  interfere  with  the  vitality  of  the  part  by  injury,  lack  of 
circulation,  or  innervation  of  the  tissue.  (2)  Infective  Ulcers  resulting  from  the  direct 
action  of  a  definite  specific  infection,  e.g.,  tuberculosis  or  syphilis.  (3)  Ulcerating 
Tumours. — These  are  malignant  tumours,  which  have  originated  in  or  invaded  the  skin. 

Non-infective  Ulcers. —  Varieties  and  Causes. 

J'uricosc  Ulcer. — The  presence  of  varicosity  in  the  veins  of  the  leg  diminishes  the  free 
return  of  blood,  and  so  leads  to  congestion  and  interference  with  nutrition,  and  thus  to 
ulceration.  In  the  majority  of  cases  the  ulcer  is  situated  on  the  inner  side  of  the  leg  about 
three  inches  above  the  ankle.  It  may  be  small,  or  may  encircle  the  limb.  For  some 
distance  round  the  ulcer  the  skin  suffers  from  the  effects  of  passive  congestion  ;  it  becomes 
indurated  and  of  a  purplish-brown  colour,  and  numerous  small  varicose  veins  may  be  seen 
in  it.     Any  slight  injury  may  cause  abrasion  of  this  weakened  skin  and  thus  another  ulcer. 


ULCERATION     OF    THE     LEG 


7H7 


Tlie  presence  of  varicose  veins  associated  with  an  ulcer  will  usually  lead  to  the  conclusion 
that  the  latter  is  dependent  on  the  former,  and  that  view  will  probably  be  correct,  but  it 
may  not  be  the  whole  truth,  for  syphilitic  and  varicose  ulcerations  may  be  present  at  the 
same  time.  Before  the  introduction  of  VVassermann's  test  for  syphilis  it  was  common 
practice  to  give  antisyphilitie  remedies  in  order  to  clear  up  the  diagnosis,  and  this  may 
still  be  done  when  the  serum  test  cannot  be  carried  out. 

Lymplmtic  Obstruction  also  leads  to  loss  of  nutrition,  and  ulceration  may  result.  The 
best  instance  is  seen  in  elephantiasis  due  to  Pilaria  satigninis  hominis.  In  this  country 
elephantiasis  is  rare.  Other  instances  that  may  be  cited  are  swellings  of  the  leg  following 
a  badly  luiited  fracture  :  the  cicatricial  contractions  of  extensive  burns  :  phlegmasia  alba 
dolens,  or  white  leg.  during  pregnancy  or  after  labour. 

Atherontd  of  the  Arteries  leads  to  a  feeble  or  imperfect  circulation  of  the  blood,  and  so 
to  loss  of  nutrition.  Ulcerative  conditions  of  the  lower  jmrt  of  the  leg  are  therefore  coniinon 
in  such  cases,  and  even  gangrene  may  result. 

Olrl  Age. — Owing  to  a  weaker  condition  of  the  tissues,  ulcers  are  much  more  fre(|uent 
in  old  people  than  in  the  young. 

Coll!. — A  similar  condition  is  brought  about  by  exposure  to  cold,  especially  in  persons 
whose  nutrition  is  imperfect,  whether  from  bad  or  insudicient  food.  The  first  effect  of 
cold  is  to  produce  a  chilblain  ;    this  if  rubbed  or  irritated  may  degenerate  into  an  ulcer. 

Trauma. — In  a  normal  individual,  any  lesion  of  the  skin  of  the  leg,  such  as  that  caused 
by  a  kick,  a  scratch,  or  a  cut,  will  heal  quickly,  and  no  ulcer  result.  Circumstances  may 
arise  which  interfere  with  the  healing  process.  Perhaps  the  most  frequent  cause  which 
leads  to  the  formation  of  an  ulcer  is  infection  with  ])yogenic  organisms,  and  the  prevention 
of  the  discharge  from  the  wound.  Occasionally  there 
is  also  accidental  contamination  of  the  wound  with 
some  spccilic  organism,  such  as  that  of  diphtheria  or 
pliaged;cna. 

.\n  important  cause  i.f  want  of  healing  of  an  iilc<T 
is  interh  rcni  f  with  its  contraction.  If  contraction  is 
impossible,  as  when  a  sore  is  situated  over  and  adherent 
to  a  bone,  healing  may  come  to  a  standstill. 

Deficient  Innervation  leads  to  loss  of  nutrition. 
Examples  are  .seen  in  infantile  palsy;  rubbing  of  tlie 
boot  or  pressure  of  an  instrument  is  prone  to  be 
followed  by  an  obstinate  ulcer.  In  cases  of  hemiplegia, 
even  when  the  patient  is  lying  on  a  water-bed,  ulcera- 
tion in  the  form  of  beil-sorcs  will  occur  much  more 
rMpidly  on  the  paralyzed  side  than  on  the  other.  I'er- 
I'linitiiig  ulcer  111'  the  fiiot  is  a  well-k?i(i\vM  si(|ucl  of  tubes 
ilursalis.  its  other  coniinon  cause  being  (liiihrlcs  iiicllilns; 
ulceration  and  (;.\N(;in-.M;  (p.  •J:!.))  arc  prone  to  occur 
because  the  resislancc  of  a  diabetic  in(Ii\idual  to  iniero- 
firganisins  is  lowered,  also  because  tlu-  arteries  arc  often 
utluroinalous.  and  possibly  bceausu  the  inri(r\  ation  of 
the    whole   body   is  interfered  with. 

attacked    by 

IS  (iiillirttr  or 

chi.'f   ulcers 


Fi'i.  2'.)!). — -Diagram  of  aTtubcreulpus  ulcer, 
iidermined  edges  witlijijcrforations  and  tags. 


*9^.- 


-Dia::ram   of  I'aiiVepitlieliomatous 
lirowtli  in  CXCG.-W  of  d&structioii. 
tilcin ;    11.    IleapeJ-up    cdgci ;     ('. 
Ulcerated  portion. 


/■■i7.  S'll.— nint'ram'Jof  a  rodent  ulcer. 
Xoriiiil  sitin  ;    II,  Smootli.  ivire-lil<c  cUgCJ 
C,  Sliallow  cavity. 
{From    Inlrotluclinn    to    Stirgrry, 
In/    I'rof.     IliMrr/nnl    .l/..rwi»l.i 


Infective  Ulcers.     The    legs    may    be 
any   lorrii    u\    acute  infective  ulcer,  such  j 
glanders,    but    such   an   event    is   rare.      Th( 
that    belong   to   this    group    are    clirdnic. 
syphilis  or  tubcrciMosis. 

,Si/jiliililic  I 'leers  are  the  rcsidt  of  gtinunata  which 
lia\c  loirticd  in  the  subcutaneous  tissues.  These  ulcerated  guiiirniita  are  almost  al\v:i\s 
circular,  and  present  a  punched-oul  appearance  (/''(V.  2!»8)  :  they  arc  generally  multiple 
anri  tend  to  run  into  ea"li  other,  so  that  the  ulcer  has  a  serpiginous  outline.  Thi'y  lenil 
to  heal  at  one  side  while  they  progress  at  allot  her.  The  scars  are  thin  and  sujiple.  and  if 
in     the    Idwir    pari    ol    llie    leg.     usualls     piyineiitc  il     rnuinl    the    edges,    wliili-    and     slightly 


drpr, 


I'd  ill 

111 

riilrc. 

ClIMIIIIMt 

:i  are  . 

itli 

•11    li 

llllul 

willi    yarioosc 

veins  oi 

■    ulee 

IS. 

and 

it 

iioba 

bli- 

tli: 

Ill     liir 

Inu    stale 

<>r  Mill 

I'll 

lull   n 

1    Hie 

tissues  causei 

1    by    the 

nbst 

nie 

lion 
IT 

nf 

738  ULCERATION    OF    THE    LEG 

venous  return  is  favourable  to  their  formation.  Diagnosis  can  in  most  cases  be  made  on 
the  distribution  and  shape  of  the  ulcer,  especially  if  they  are  on  the  outer  aspect  of  the 
lower  third  of  the  leg ;  on  the  presence  of  other  signs  of  syphilis  ;  and  on  the  effect  of  giving 
iodide  of  potassium  or  salvarsan.     In  cases  of  doubt,  a  Wassermann's  reaction  is  of  service. 

Tuberculous  Vlcer  usually  follows  the  formation  and  bursting  of  a  tuberculous  abscess, 
starting  either  in  the  subcutaneous  tissue  or  in  a  bone,  and  the  history  may  help  materially 
in  diagnosis.  The  ulcer  is  very  chronic,  and  is  characterized  by  undermining  of  the  skin 
for  a  considerable  distance  from  the  edge  {Fig.  299).  The  surface  is  pale,  and  the  granu- 
lations are  very  small,  with  here  and  there  small  areas  of  caseation.  Primary  tuberculosis 
of  the  skin,  or  lupus,  is  not  often  found  on  the  leg,  though  it  may  occur  there  as  in  any 
other  part  of  the  skin.  A  useful  guiding  rule  is  that  lupus  never  starts  later  than  the  age 
of  twenty  and  lasts  for  years,  whereas  a  gumma  starts  at  a  later  period  and  tends  to  heal 
spontaneously.  In  lupus  the  chief  characteristic  is  the  presence  of  minute,  semi-trans- 
parent nodules  at  the  margin  of  the  ulcer  and  in  the  skin  around,  resembling  apple  jelly. 
If  further  methods  of  diagnosis  are  required,  a  diagnostic  injection  of  Koch"s  old  tuberculin 
may  be  used,  or  von  Pirquet's  skin  test  applied.  .\  particular  variety  of  tuberculous  ulcer 
of  the  legs  is  described  on  p.  404  under  the  heading  of  Bazin's  disease,  or  erythema 
induratiun   scnifulosorimi. 

Ulcerating  Tumours. — Epithelioma  may  develop  in  a  simple  varicose  ulcer  that  has 
existed  for  many  years.  The  change  may  be  very  slow,  or  rapid.  The  ulcer  spreads,  the 
edges  become  heaped-up,  everted,  and  indurated  (Fig.  300).  The  femoral  lymphatic 
glands  become  enlarged,  and  if  the  disease  is  allowed  to  progress,  the  bone  is  attacked.  If 
any  doubt  arises  as  to  a  change  in  the  character  of  an  ulcer,  a  piece  from  the  edge  should 
be  removed  for  histological  examination. 

liodent  Ulcer  (Fig.  301)  usually  attacks  the  face  (p.  735).  though  it  may  be  found  on 
any  part  of  the  body. 

Sarcoma,  starting  in  the  deeper  tissues,  may  fungate  through  the  skin,  which  has  given 
way  before  the  pressure  of  the  tumour.  George  E.  Cask. 

ULCERATION   OF  THE  THROAT. -(.See  Sore  Tiihoat,  p.  613.) 

ULCERATION  OF  THE  TONGUE.— To  enable  a  good  view  to  be  obtained  of  the 
affected  ))art.  the  ])atient  sluniM  Ijc  seated  in  a  strong  light  and  the  protruded  tongue  gently 
wiped  with  a  jjiece  of  soft  linen  to  remove  moisture.  The  presence  of  an  ulcer  being 
ascertained,  its  nature  may  be  considered  under  the  following  heads  : — 

1.  fareinomatous  i    4.  Tuberculous 

-'.  Syphilitic  5.  Dyspeptic 

3.  Dental  !     (;.  Ulcer   in   connection  with   stomatitis. 

Carcinomatous  Ulcer  is  much  commoner  in  men  than  in  women,  probably  owing  to 
the  fact  that  chronic  glossitis  due  to  smoking  and  syphilis  is  more  common  in  the  male 
sex.  It  is  practically  unknown  before  the  age  of  thirty,  and  rarely  starts  before  forty- 
five.  The  ill  and  wearied  expression  of  the  patient  may  awaken  suspicion  before  the  tongue 
is  seen,  for  the  pain  and  trouble  caused  by  an  epithelioma  have  a  rapid  and  marked  effect. 
The  tongue  in  a  normal  individual  can  be  protruded  from  one  to  one  and  a  half  inches 
beyond  the  teeth  ;  if  the  protrusion  is  limited,  or  if  the  tongue  is  not  protruded  .straight, 
it  can  generally  be  inferred  (except  in  cases  of  jjaralysis)  that  there  is  some  tumour  binding 
it  down.  The  position  of  the  ulcer  is  to  be  studied,  and  its  relation  to  any  sharp  and  carious 
tooth.  Usually  an  epithelioma  is  on  the  side  of  the  tongue,  but  there  is  no  rule  :  it  ma> 
be  anywhere  on  the  upper,  lateral,  or  under  surfaces,  or  on  the  floor  of  the  mouth. 

As  regards  the  ulcer  itself,  the  typical  appearance,  when  fairly  developed,  may  be 
described  as  irregular,  deeix  foul,  sloughy,  with  raised  nodular  everted  edges,  and  a  sur- 
rounding area  of  induration.  The  lymphatic  glands  are  enlarged  and  hard,  and  they  may 
be  fixed.  The  submaxillary  set  is  generally  the  first  affected,  but  the  disease  sometime's 
misses  these  and  infects  the  carotid  and  even  the  supraclavicular  glands.  Examination, 
therefore,  should  not  be  concluded  before  the  whole  of  the  neck  had  been  palpated.  The 
diagnosis  should  have  been  made,  however,  before  the  disease  had  developed  thus  far  :  in 
its  earliest  stages  an  epithelioma  may  be  represented  by  a  superficial  ulcer  no  more  than 


PLATE     XXXII 


CANCER   OF   THE   TONGUE:   VERY   EARLY   CONDITIONS 

(From  drawings  kindly  lent  by  Sir  IIEXRT  T.  ElTLIX,  F.E.C.S.) 


> 


■^m 


.;#■ 


Fij.  B  ^'  f 


■k 


m 


/trprnttnrnt  by  /trrmiMsion 
from  ■  Tlic  Mnlicnl    li"i"'i/ 


Fig.  yl.— IJlil  Icukopliikiii  oJ  miiiiy  ycais'  duriitiuii.  Qiillo  rwoiit  dovclo|imcnt  of  cpltlicliamii,  In  the  form  of  ii  very 
slightly  rHiswl  amoolli  red  |ilii(|uc,  feeling  »bout  iia  thick  UK  n  »i.x|ioiU'e.  Ilotwocri  it  iiml  the  mldJlD  line  i.i  :i  tiny  nodule 
re»enitilinu  ii  ifimplc. ....,, 

Fig.  fl.  -.Vrcii  of  thin  leukopliikli  on  tlio  rlk-ht  border  of  the  tongiie.  witli  a  »ni«ll  opithcllomn,  which  hiul  developed 
in  the  site  of  u  bite  received  Hovcrid  monlli«  previously.  .....  .     ,,     ,.        , ,  .. 

Fig.  C— l.cuko|iliiklii  of  nmiiy  ye:irs'  dunitlon,  with  the  very  eiirlieKl  conilition  of  epithellomn  to  the  left  of  the  niiddlo 
line  in  the  form  of  a  very  amall  area  of  UMikojilakia  (a),  nliifhtly  more  riilied  and  a  little  llrnicr  than  the  rest.  The  diaKnc«i4 
depended  ili  much  on  the  sllflit  hardenirn,"  a«  on  Ihe  iip|ieariince. 


ULCERATION     OF    THE    TONGUE  789 

a  sixteenth  r)f  an  incli  in  diameter,  by  a  craek  or  a  small  lump,  without  any  enlargement 
of  the  glands.  In  all  these  conditions,  however,  the  ulcer  is  already  hard,  and  very 
resistant  to  any  form  of  treatment.  Any  ulcer  of  the  tongue  occurring  in  a  middle-at'cd 
man.  and  lasting  for  more  than  two  or  three  weeks,  should  awaken  suspicion. 

Diagnosis  from  Si/pliilitic  Ulcer. — This  may  be  a  very  real  dilliculty,  owing  to  the  fact 
that  the  two  conditions  may  exist  side  by  side,  and  that  the  syphilitic  leucoplakia  or 
leucomic  wart  may  be  the  actual  precursor  of  a  cancer.  A  positive  Wassermann's  reaction, 
therefore,  is  not  jjroof  that  an  epithelioma  is  not  present.  If  a  well-formed  gumma 
is  present,  antisypliilitic  remedies  soon  make  a  great  change  in  its  appearance,  and  a  dia- 
gnosis may  be  mad*'  in  this  way.  but  not  more  than  ten  or  fourteen  days  should  be  allowed 
to  pass  in  imcertainty.  Tliere  are  many  cases  in  which  the  cleverest  surgeon  is  in  doubt, 
and  seeing  the  rapid  course  this  disease  runs,  and  the  vital  importance  of  securing  an  early 
diagnosis,  it  is  urged  here  with  the  greatest  porssible  insistence  that  the  only  certain  method, 
and  the  one  to  be  emiiloyed  early,  is  that  of  taking  out  a  piece  of  the  ulcer,  or,  if  small, 
the  whole  ulcer,  and  submitting  it  to  histological  examination. 

Diagnosis  from  Dental  Ulcer. — The  ulcer  in  this  case  is  caused  by  a  bad  tooth,  and 
therefore  is  in  a  position  on  the  tongue  corresponding  to  the  latter.  Further,  the  ulcer  is 
soft  to  the  touch,  and  heals  rapidly  when  the  offending  tooth  is  stopped  or  extracted. 
There  is  seldom  dilliculty  in  differentiation  except  when  the  ulcer  is  of  very  long  standing. 

Syphilitic  Ulcer. — This  may  be  primary,  secondary,  or  tertiary.  Primnrt/  Si/j)liilis 
or  Chancre  is  certainly  rare  on  the  tongue  and,  owing  partly  to  its  rarity  and  partly  to  the 
fact  that  it  is  unexpected,  it  is  fre(|uently  missed.  It  is  more  common  in  men  than  iti 
women,  but  it  may  occur  even  in  children.  It  starts  as  a  small  pimple,  which  ulcerates 
and  becomes  indurated,  though  the  induration  is  not  so  marked  as  when  it  is  situate  on 
the  gians  penis.  The  appearance  of  a  secondary  rash  with  general  enlargement  of  the 
lyin])hatic  glands  would  indicate  the  diagnosis  with  certainty,  which  might  be  confirmed 
by  Wassermann's  serum  reaction,  and  the  detection  of  spirocha'tic  (Plate  XXf'III.  Fig.  .1. 
p.  014)  in  serum  from  the  sore.  Furthermore,  tlie  sore  lieals  rajiidly  under  the  influence 
of  mercury. 

Seeondarji  Si/philis  manifests  itself  by  tlie  lormition  of  mucous  jiutchcs  anil  superficial 
ulcers.  The  latler  are  almost  always  multiple,  and  situated  along  the  edges  and  tip  of 
the  tongue,  and  with  them  are  also  found  similar  sores  on  the  mucous  membrane  of  the 
cheek,  lips,  palate,  and  tonsil,  and  at  the  e.Iges  of  the  mouth.  The  ulcers  are  small,  round, 
painful,  with  sharply  cut  cducs  and  a  greyish  Ihior.  Other  secondary  symptoms  will  be 
present  to  make  the  diagnosis  clear. 

Tertiari/  Siiphilis  or  (iummatons  Ulcerations. — These  are  divided  into  superficial  and 
deep.  Siiperpcinl  gunuiiata  begin  as  small  round-celled  infiltrations  in  the  mucous  ami 
subnnicous  tissue.  The  ulcers  arc  usually  shallow,  often  irregular  and  associated  with 
chronic  glossitis,  fissures,  and  leucoplakia.  They  are  extremely  important,  for,  as  stated 
above,  such  a  condition  is  often  followed  by  an  epithelioma.  They  are  also  very  resistant 
to  antisypliilitic  remedies  other  than  salvarsan.  The  ulcers  themselves  arc  not  at  first 
indurated,  but  if  surroun<led  by  interstitial  fibrosis  may  appear  hard  ;  therefore  a  histo- 
logical examination  is  eminently  desirable  if  there  is  the  least  doubt.  .V  tieep  gumma  starts 
as  a  hard  swelling  in  the  substance  oT  the  tongue  :  later  it  softens,  breaks  down,  and  shows 
itself,  generally  in  the  middle  line,  as  ji  deep  easily  with  irrcgtdar.  soft,  undermined 
walls,  and  a  wash-leather-like  slough  at  its  base.  It  is  not  |)ainrul.  and  do<s  not  inereasi 
[progressively  in  size.  The  important  thing  is  to  distinguish  it  from  <  pithtlioma  and 
tuberculous  disease.  Utdike  epithelioma,  it  is  not  hard,  and  its  history  is  short.  I'lirllur- 
more,  it  yiehls  very  rapidly  lo  potassium  iodide  or  saKarsan. 

Dental  Ulcer  is  due  to  repeated  small  injuries  from  the  sharp  edge  of  a  decayed  tooth. 
It  is  there  lore  situated  in  such  a  position,  generally  on  the  side  of  the  tongue,  that  it  is 
opposite  the  tooth.  The  ulcer  is  single,  small,  superficial,  and  not  indurated  unless  it  is  of 
long  standing.  It  is  therefore  not  easily  mistaken  for  any  other  kind  of  ulcer,  or  il  doulil 
arises  il  is  allayed  by  the  healing  of  the  ulcer  on  stopping  or  extracting  the  tooth. 

'riicic  is  a  form  of  dental  ulcer  which  is  found  on  the  fra'inun  of  the  tongue  in  children 
sullcring  from  whooping-cough  ;  during  the  violent  expiratory  spasms  peculiar  to  the 
ilhiiss.  till-  under  surface  of  the  l<iiiguc  may  sulfer  from  rubbing  over  the  lower  incisor 
tcctli. 


740  ULCERATION    OF    THE    TONGUE 

Tuberculous  Ulcer  of  the  Tongue  is  rare,  but  it  occurs  at  that  period  of  life  during 
which  tuberculous  disease  of  the  lung  is  common,  that  is  to  say,  between  the  ages  of  fifteen 
and  thirty-five.  It  is  due  to  infection  with  tubercle  bacilli  brought  up  into  the  mouth,  and 
if  a  patient  is  found  to  be  suffering  from  tuberculous  disease  of  the  lungs  or  larynx  and  also 
from  an  ulceration  of  the  tongue,  there  is  a  strong  probability  that  the  latter  is  of  the  same 
nature  as  the  former.  The  ulcer  itself  may  be  situated  on  the  tip  or  side  of  the  tongue  ; 
it  has  an  irregular  outline,  and  the  base  is  nodular,  sloughy,  or  caseous.  It  has  often  been 
mistaken  for  epithelioma  or  gumma.  The  fact  that  it  is  not  hard,  and  that  phthisis  is 
l)resent,  should  put  one  on  one's  guard.  As  against  gumma,  a  Wassermann's  reaction 
would  be  negative  ;  moreover,  the  ulcers  are  often  small  and  multiple,  more  nearly 
resembling  dyspeptic  ulcers.  A  von  Pirquet's  test  or  a  diagnostic  injection  of  Koch's 
old  tuberculin  might  be  employed,  but  a  more  reliable  method  is  the  removal  and  micro- 
scopical examination  of  a  piece  of  tlie  ulcer,  wlien  the  histological  ap|)earanees  of  tubercle 
will  be  seen.     The  tubercle  bacillus  {Philc  XXf'III.  Fiii.  K.  p.  <il4.)  is  not  always  found. 

Dyspeptic  Ulcer,  as  the  name  implies,  is  connected  with  disorders  of  digestion.  The 
ulceration  is  often  multiple,  each  ulcer  being  round,  small,  often  covered  with  a  greyish 
slough,  and  with  a  bright  ring  of  inflanuiiation  round  it.  They  are  situated  on  the  dorsum 
and  edges  of  the  tongue  near  the  tip.  The  mouth,  too,  is  very  foul,  there  may  be  similar 
ulcers  on  the  inner  aspects  of  the  lijjs  and  cheeks,  and  the  cervical  glands  may  be  enlarged. 

Ulcers  in  connection  with  Stomatitis  (Ulcerative  Stomatitis). — Septic  infection 
of  tlie  mouth  due  to  a  variety  of  causes,  such  as  irritation  from  decayed  teeth,  alkalies, 
acids,  or  mercury,  may  be  accompanied  by  the  formation  of  small  vesicles  which,  on 
bursting,  give  rise  to  su])erflcial  ulcers.  They  are  not  limited  to  the  tongue,  but  appear  on 
the  mucous  membrane  of  the  cheeks  and  gums  as  well.  Aphthous  stomatitis  commonly 
occurs  in  conjunction  with  the  febrile  diseases  of  childhood.  It  is  characterized  by  the 
formation  of  whitish  spots  on  the  buccal  mucous  membrane,  and  by  the  shedding  of 
epithelium  small  superficial  ulcers  may  be  formed.  The  ulcers  of  the  tongue  are  here,  so 
to  speak,  accidental,  occurring  in  the  course  of  a  general  inflammation  of  the  mouth,  and 
will  hardly  be  confounded  with  any  other  form  of  ulcer  except  so-called  dyspeptic  ulcers, 
and  there  is  no  real  line  of  demarcation  between  the  latter  and  the  stomatitic  variety. 

George  E.  Gask. 

UNCONSCIOUSNESS.-! See  Coma.  p.  117.) 

UNEQUAL  PULSES.— (See  Pri.sKs.  Uneqi-.m..  i).  5,50.) 
UNEQUAL   PUPILS.— (See  I'lPii..  .\bnorm.\i.itiks  of  the.  p.  551.) 

URATE  DEPOSIT  IN  THE  URINE.— .\  precipitate  of  urates  is  often  recognizable 
at  once  by  its  |)ink  colour,  due  to  their  carrying  down  with  them  the  uroerv-thrin  pigment 
of  the  urine.  Urates  themselves  are  white,  however,  and  if,  as  is  sometimes  the  case,  there 
is  no  uroerythrin  present  for  them  to  carry  down,  they  form  a  white  precipitate  which 
may  be  mistaken  for  nuicus,  phosphates,  or  pus.  They  may  be  distinguished  at  once, 
however,  by  warming  the  urine  back  to  body  temperature  ;  they  re-dissolve  long  before 
boiling-point  is  reached.  They  are  also  soluble  in  litiuor  potassa\  unlike  phosphates. 
Microscopically  they  arc  nearly  always  amorphous,  though  in  rare  cases  they  assume  the 
form  of  small  spheres  with  irregular  projecting  spicules — the  so-called  '  thorn-apple  '  or 
'  hedgehog  '   crystals. 

Their  only  significance  from  a  clinical  ])oint  of  view  is  that  they  indicate  a  concen- 
trated urine.  It  does  not  follow  that  a  urine  is  not  concentrated  if  no  precipitate  of  urates 
occurs,  but  the  fact  that  the  urates  re-dissolve  on  warming  serves  to  show  that,  although 
there  may  be  enough  water  to  keep  them  in  solution  at  body  temperature,  the  urine  becomes 
supersaturated  with  them  as  it  cools,  and  precipitates  them  out.  The  reason  for  the  urinary 
concentration  has  to  be  learned  from  collateral  evidence.  It  may  be  that  there  has  been 
much  sweating,  and  in  hot  weather  a  precipitation  of  pink  urates  is  a  very  common  physio- 
logical condition,  which  is  apt  to  alarm  some  ])atieuts  when  they  first  notice  it.  On  the 
other  hand,  the  concentration  may  be  due  to  ijathological  conditions,  of  which  the 
commonest  are  fevers,  chronic  valvular  disease  with  heart  failure,  and  maladies  which 
lead  to  loss  of  fluid  by  vomiting,  sweating,  or  diarrhoea.  The  urates  themselves  afford 
hardly  any  clue  to  the  cause  of  the  concentration,  and  their  apjiearance  is  just  the  same 
whether  their  deposition  is  due  to  physiological  or  pathological  changes. 


URIC    ACID    DEPOSIT    IN     THE     URINE 


741 


The  most  marked  examples  of  uratic  deposits  are  to  be  seen  in  cases  of  acute  rheumatic 
fever,  lobar  pneumonia,  and  chronic  heart  disease  with  failing  compensation.  It  is  a 
general  rule,  moreover,  that  when  tlie  kidneys  are  themselves  affected  there  is  decidedly 
less  tendency  for  uratic  deposits  to  form  than  when  the  primary  disease  is  in  the  heart  or 
lungs  :  thus  when  one  may  be  in  doubt  as  to  whether  a  given  case  of  chronic  heart  failure 
is  due  to  primary  renal  disease  or  primary  heart  disease,  an  abundant  urate  deposit  affords 
some  evidence  in  favour  of  the  latter  and  against  the  former.  It  is  no  absolute  rule, 
however,  and  almost  any  concentrated  urine  may  precipitate  urates. 

Students  are  a  little  apt  to  confuse  the  significance  of  urates  with  that  of  uric  acid, 
tliou'jh  the  two  are  entirely  independent  from  a  clinical  stand|)oint.  Ilrrherl  French. 

URETHRA,  DISCHARGE  FROM.     (See  Disciiargr,  Uretuhai,.  p.  isi.) 

URETHRA,  F.CCES  PASSED  THROUGH.— (See  F.kcf.s  Passf.h  iM:ii  ruETuRAM, 
p.  2:w.) 

URIC  ACID  DEPOSIT  IN  THE  URINE.— The  most  typical  form  taken  by  a  pre- 
ci])itatf  of  uric  acid  in  a  urine  is  tlic  cayciinc-peppcr  (le|)osit,  seldom  voluminous,  of  character- 
istic light-brown,  prismatic  crystals  (Fiil.  liO'i),  arranged  either  as  separate  ■whetstones.' 
or  in  overlapping  bundles,  or  "  rosettes  '  :  occasionally,  crystallization  is  imperfect,  and 
they  appear  as  •  dumb-bells.'  Intrinsically,  they  are  colourless  ;  but  they  differ  from 
all  other  urinary  deposits  in  that  they  carry  down  with  them  the  ordinary  yellowi.sh- 
brown  urochrome  pigment  of  the  urine.  For  clinical  purposes  the  best  test  for  them  is  the 
miernscope. 


Besides  tlu>  eayeniic-peppcr  deposit,  uric  acid  (  ryslais  may  l)c  present  in  considerable 
numbers  in  the  midst  of  other  precipitates,  such  as  mucus,  or  oxalate  of  lime  ;  in  whicli 
case  they  may  not  be  disceriiibl<-  wiflKJUl  the  use  of  the  microscope  :  or.  again,  they  may 
become  aggregated  tog<'ther  into  small  pellets  or  ealcidi.  which  the  patient  may  be  conscious 
of  as  "gravel'  on  tnieluritioii. 

.\  deposit  of  uric  acid  is  generally  Inuiid  in  a  d(<iilcdl\-  aciil  urine  of  lii;.'h  specilie 
gravity  :  but  it  may  occur  in  urines  ot'  almost  any  reaction  or  specilie  gravity.  A  great 
deal  more  importance  than  it  deserv<'s  has  been  allaelietl  lo  the  supposed  relationship 
between  this  uric  acid  and  gout.  A  cai/iniic-pij/iHr  dr/tosil  hi/  no  niidiis  iniliriilcs  fiiiiil  ; 
indeed,  it  may  be  perfectly  physiological,  occurring  abundantly  sometimes  in  healthy 
young  persons,  particularly  boys.  It  rloes  not  even  follow  from  its  occurrence  that  lliere 
is  excess  of  uric  acid,  either  in  the  urine  or  in  the  tissues  :  for  the  precipitation  dcpemls 
nearly  as  much  upon  the  relative  proijortions  of  phosphates,  chlorides,  and  inorganic 
sulphates  to  uric  acid,  and  upon  the  absolute  and  relative  amounts  of  sodium,  potassium, 
and  other  bases  in  the  urine,  as  upon  the  absolute  amount  of  uric  acid.  The  greater  the 
U'lidency  of  the  bases  to  form  phosphates,  by  mass  aelion  or  otherwise  (see  Puosimiaiihia. 
p.  .-)2:i).  Ilic  l<ss  the  IcndcMcy  Inr  the  sdhihlr  .|iia(lriuralis,  and  the  greater  tlii'  liability  for 


742  URIC    ACID    DEPOSIT    IN    THE    URINE 

less  soluble  biurates,  to  be  produced,  the  relatively  insoluble  urie  acid  being  liberated  from 
the  latter  and  deposited  in  crystalline  form. 

Considerable  care  has  to  be  exercised,  therefore,  before  any  useful  clinical  deductions 
can  be  drawn  from  the  fact  that  a  urine  contains  a  deposit  of  uric  acid.  It  is  true  that  a 
persistent  tendency  to  it  is  often  associated  with  gout  ;  but  the  latter  should  be  diagnosed 
from  the  collateral  evidence  rather  than  upon  the  uric  acid  crystals  in  the  urine.  Many 
gouty  subjects  preci]>itatc  no  uric  acid  in  their  urine  at  all.  Naturally,  there  will  be  a 
greater  tendency  to  such  deposition  when  the  total  amount  of  uric  acid  present  is  greater 
than  normal.  Uric  acid  in  the  in-ine  is  derived  from  two  sources — exogenous  and  endo- 
genous. The  exogenous  are  such  foodstuffs  as  are  rich  in  nucleo-proteid,  and  in  the  so- 
called  xanthin  bases,  or  purin,  or  alloxuric  bodies,  xanthin.  guanin.  hypoxanthin,  adenin, 
heteroxanthin,  ])araxanthin,  episarkin,  epiguanin,  inethylxaiithin.  and  carnin,  which  are 
mainly  derived  from  nuclein.  Analyses  of  the  various  rooilslulTs  as  to  purin  bases  need 
not  be  given  here,  for  it  is  easy  to  remember  that,  broadly  s]jeaking,  these  .substances  are 
contained  in  largest  fjuantities  in  the  richest  food.  A  considerable  j^roportion  of  the  xanthin 
bases  are  excreted  as  uric  acid,  and  it  is  common  knowledge  that  rich  foods  tend  to  increase 
uric  acid  in  the  urine.  Endogenous  lu-ic  acid,  on  the  other  hand,  is  derived  from  the 
patient's  own  tissue  metabolism.  Birds  excrete  nearly  all  their  nitrogenous  waste  as  uric 
acid  ;  man  excretes  his  mainly  as  urea,  and  only  to  a  minor  extent  as  uric  acid.  Some- 
times, however,  too  nuich  of  his  nitrogenous  metabolism  stops  short  at  the  stage  of  uric 
acid,  instead  of  the  latter  being  nearly  all  converted  into  urea  ;  he  then  excretes  an 
abnormal  total  quantity  of  uric  acid,  with  the  result  that  it  may  be  precipitated  in  crystal- 
line form.  One  repeats,  that  this  does  not  necessarily  constitute  gout,  however  ;  it  occurs 
in  certain  healthy  subjects,  in  Icukfemia,  in  ijernicious  aniemia.  during  the  course  of  certain 
fevers,  and  in  some  cases  of  chronic  heart  disease.  Perhaps  one  of  the  best  ways  of 
avoiding  too  narrow  a  conception  in  regard  to  this  lu'ic  acid  is  to  remember  that  in  some 
respects  the  human  body  is  a  fire  ;  fires  may  burn  their  coal  well  or  badly  ;  if  well,  the 
residue  is  but  a  little  ash  ;  if  badly,  the  residue  is  not  ash,  but  clinker  :  uric  acid  is  the 
clinker  of  the  lunnan  body,  and  many  different  things  that  make  human  nitrogenous 
metabolism  incomplete  may  cause  a  deposition  of  this  clinker  in  the  urine.  Gout  is  ont- 
such  thing  ;  but  excessive  eating,  deficiency  of  exercise,  biliousness,  and  various  chronic 
imperfections  of  the  circulation,  or  digestion,  may  do  so  ;  and  the  same  may  occur  in 
apparently  healthy  subjects  who  have  never  had  any  untoward  symptoms  at  all.  Oxalate 
of  lime  (see  Ox.\luri.\,  p.  423)  is  possibly  derived  in  part  from  similar  imperfect  combustion 
of  carbohydrates  or  fats,  and  it  is  noteworthy-  how  often  crystals  of  uric  acid  and  of  oxalate 
of  lime  occur,  cither  together,  or  alternating  with  one  another.  Still  further,  error  of 
metabolism  may  jimduce  glycosuria  in  association  with  uric  acid  crystals,  so-called  gouty 
glycosuria. 

Besides  being  evidence  of  overloading,  or  of  imperfect  combustion  in  a  general  sense, 
the  occurrence  of  a  uric-acid  deposit  may  be  of  particular  clinical  importance  in  certain 
cases  <\[  frcqiiciicji  of  mictiirilion  :  of  inclhrHis  :  and  of  renal  cnkulus.  Necessity  to  mictu- 
rate fre(|uentiy.  only  small  ((uantities  of  urine  being  passed  at  a  time,  is  a  symiitom  that 
in  young  people  suggests  cystitis,  possibly  tuberculous  ;  enlargement  of  the  prostate  in 
men  over  sixty  ;  or  some  uterine  or  other  pelvic  malady  in  women.  It  is  important  to 
remember,  however,  that  undue  acidity  of  the  urine,  with  a  tendency  to  deposit  crystals 
of  uric  acid,  or  oxalate  of  lime,  may  jiroduce  the  same  symptom  in  considerable  degree. 
It  is  sometimes  spoken  of  as  irritability  of  the  bladder  ;  the  highly  acid  urine  irritates  the 
vesical  mucosa,  and  it  may  ])roduce  actual  cystitis.  The  same  irritation  may  inHame  the 
urethral  mucosa,  and  produce  a  •  gouty  '  urethritis  ;  and.  |)erhaps,  eijididymo-orchitis. 
which  may  be  mistaken  for  the  gonococcal  form,  unless  pus  films  can  be  shown  to  contain 
no  gonococci. 

If  the  patient  has  sidTered  from  renal  colic,  hainaturia,  or  vesical  pain,  suggestive  of 
calculus  in  the  kidney,  ureter,  or  bladder,  tlic  discovery  of  abundant  uric  acid  crystals  in 
the  urine  affords  confirmation  of  the  diagnosis  of  a  uric-acid  stone,  particularly  if  they  are 
obviously  aggregated  together  into  tiny  calculi  ;  there  are  generally  red  cor])Uscles,  excess 
of  leucocytes,  and  tailed  epithelial  cells  from  the  renal  pelvis,  or  pyriform  cells  from  the 
deeper  layers  of  the  bladder  mucosa,  at  the  same  time. 

The  danger  of  diagnosing  glycosuria  in  the  absence  of  sugar  when  uric  acid  is  abimdant 


URINE.     ABNORMAL    COLORATION    OF  li3 

in  a  urine  needs  special  mention.  Uric  acid  has  considerable  power  of  reducing  Fehling's 
solution.  It  seldom  gives  the  copious  brick-red  or  orange-yellow  precipitate  that  is  charac- 
teristic of  abundance  of  sugar,  but  it  may  give  just  enough  reduction  or  change  of  colour 
to  make  it  doubtful  whether  sugar  is  present  or  not.  More  than  a  few  proposers  for  life 
insurance  have  suffered  unfairly  on  this  account  ;  no  such  partial  reduction  should  be 
regarded  as  due  to  sugar  until  the  presence  of  glucose  has  been  confirmed  by  other  means, 
particularly  the  iihcnylhydrazinc  and  the  fermentation  tests.  Herbert  French. 

URINE,  ABNORMAL  COLORATION  OF. -This  may  be  due  to:  (1)  The  presence 
in  abnormally  large  quantities  of  certain  urinary  pigments,  such  as  uroerythrin  or  haemato- 
porphyrin  ;  (2)  The  presence  of  pigments  formed  in  the  organism,  but  which  are  not  nor- 
mally excreted  in  the  urine,  such  as  haemoglobin  and  the  pigments  of  the  bile  ;  (3)  The 
presence  of  i)igmentary  substances  derived  from  drugs  or  foods,  or  administered  directly 
by  the  mouth. 

Urines  oi'  unusual  tints  may  be  classified  conveniently  according  to  the  colours  which 
they  exhibit,  as  follows  :  (I)  Yellow  and  nrniige  urines  ;  (II)  Pink  and  red  urines  ;  (III) 
Broivii  and  black  urines,  inchiding  sucli  as  are  of  nurntul  litif  xvlien  ])assed.  hnl  darken  on  e.rpo- 
sure  to  air  ;    (I\')  Green  and  blac  urines. 

Yellow  and  Orange-coloured  Urines. — The  normal  yellow  tint  is  wholly  due  to 
urochrome.  for  otlur  urinary  pigments  are  ])resent  in  traces  si)  minute  tliat  their  presence 
has  no  obvious  elfect.  However  much  it  he  diluted,  normal  urine  remains  yellow  as  long 
as  any  tint  is  visible.  In  some  cases  of  diabetes  insipidus  the  urine  is  almost  colourless,  and 
the  abundant  urine  of  diabetes  mellitus  usually  exhibits  a  peculiar  pale  bright  greenish-yellow 
tint  (Plate  XXXW.  Fig.  11.  p.  748),  which  has  not  yet  been  explained. 

Urobilin,  when  present  in  large  amount,  imparts  a  rich  orange-yellow  colour  ;  and 
when  seen  in  very  thin  layers,  as  near  the  apex  of  a  conical  glass,  urines  rich  in  urobilin  have 
a  pinkish  tint,  due  to  selective  absorjrtion  in  the  middle  of  the  siiectrum.  Such  urines, 
when  examined  with  the  spectroscope,  show  a  dark  absorption  band  near  the  solar  F  line 
(Fig.  36,  p.  80). 

Urobilinnria — the  excretion  of  excess  of  urobilin  —may  result  from  widely  diriirent 
causes,  and  as  a  consequence,  its  clinical  significance  is  not  so  clear  as  might  Ite  expected. 
The  symptom  is  met  with  in  connection  with  h;cnii)Iytic  diseases,  such  as  pernieions  atnvmia. 
in  diseases  ii(  llie  liver,  such  as  cirrhosis,  and  in  eases  in  which  (M'cps.vf'w  bacleri(d  action  is  going 
on  in  the  intestine.  Tlie  bulk,  if  not  the  wliole,  of  the  urobilin  of  urine  is  derived  from  the 
intestine,  where  it  is  formed  by  the  action  of  the  bacteria  ])resent  u])on  bilirul)in.  It  is 
present  in  aljundance  in  normal  ncces,  and  in  traces  in  imrnial  urine.  Tin-  test  for  il  is 
given  on  page  32 1. 

I'roen/thrin.  -the  liiglily  unstalile  pigment  to  wliieh  tin-  colour  of  pink  urate  sediments 
is  due — when  abundantly  present  in  solution  in  the  urine  inq)arts  to  it  a  rich  orange-red 
colour,  which  may  even  be  mistaken  for  that  due  to  blood.  The  coiom-  is  clianged  to  a  pale 
greenish-yellow  by  addition  of  an  alkali.  Hepatic  derangements  of  almost  all  kinds,  includ- 
ing the  most  trifling  functional  disturbances,  may  lead  to  the  appearance  of  uroerythrin  in 
the  urine  ;  but  the  most  intensely  piid^;  urate  sediments  are  seen  in  cases  in  which  the  liver 
is  the  seat  of  pnirioMni-cil  rnorhirl  clifiiigcs.  such  as  cirrhosis,  or  the  passive  eiingcslioM  due 
to  cardiac  disease. 

Chiilariii.  Irine  which  contains  bilirubin  has  a  rich  orange  colour  with  a  greenish  lint 
at  the  edge  of  I  he  meniscus.  The  foam  formed  by  shaking  it  has  a  yellow  colour,  wliereas 
that  of  bile-free  urine,  even  when  deeply  pigmented,  is  colourless.  The  colour  of  Hie  urine 
may  be  imicli  mollified  l)y  the  presence  of  biliverdin.  in  addition  to  bilirubin,  and  may 
approach  to  black  or  dark  green. 

The  presence  of  bile  i)iginent  may  be  dcmonstrafcfl  by  (inirtin's  lest.  Tliis  is  best 
carried  old  by  allowing  the  urine  to  flow  gently  on  to  the  surface  of  some  iiilrie  aeid  in  a  lesl 
liilie  :  on  gently  shaking,  the  familiar  play  of  colours  is  seen  at  the  Junetion  of  the  liipiids. 
and  Hie  urinary  layer  often  retains  the  green  lint  of  biliverdin  for  a  eonsiderdile  time. 
Again.  1  green  ring  is  obsersc'd  when  diluted  tincture  of  iodine  is  allowed  to  How  on  to 
the  surface  of  the  urine  in  a  test  tulie  (I'tate  .V.V.VI'.  p.  T."il)). 

When  Hie  (|iiaiilily  of  bile  pigmenl  present  is  very  small.  Hie  al>o\e  tests  niiy  fiil  to 
reveal  its  presence,  and  lliiiijierfs  test  may  then  be  resorted  to.      .V  preeipitale  is  formed  by 


744  URINE,    ABNORMAL    COLORATION    OP 

the  afklition,  to  a  much  hirger  vohinie  of  urine,  of  a  sohition  of  barium  chloride  and  baryta 
water,  or  of  calcium  chloride  and  lime-water.  The  ])recipitate.  which  carries  down  any  bile 
pinnient  which  may  be  ])resent.  is  filtered  off  and  washed  into  a  test  tube  with  alcohol. 
Dilute  s)ili)huric  acid  is  then  added,  and  the  test  tube  is  heated  in  a  beaker  of  boiling  water. 
If  bile  jiigment  be  present,  the  acidulated  alcohol  acquires  a  rich  green  tint,  due  to  biliverdin. 

Choluria  is  merely  a  symptom  of  jaundice,  but  the  appearance  of  bile  pigment  in  the 
urine  may  precede  any  yellow  coloration  of  the  conjunctiva;  or  skin,  or,  as  in  eases  of  acho- 
luric family  jaundice  {Fltilc  Will.  ]>.  3H2).  the  skin  may  be  tinted  although  the  urine  is  free 
from  bile  pigment.  In  the  very  rare  cases  in  which  a  fistula  exists  between  the  biliary  and 
urinary  tracts,  choluria  of  pronounced  degree  has  been  observed,  apart  from  any  jaundice. 

Certain  drugs  impart  to  urine  a  tint  which,  although  yellow,  is  abnormal.  This  is  seen 
when  snnlonin  is  administered,  or  clirifiophaiiic  acid,  which  is  a  constituent  of  rhubarb  and 
senna.  In  either  case,  the  lu-ine  turns  ])ink  on  addition  of  an  alkali,  but  the  pink  colour  is 
far  more  brilliant  after  santonin  than  after  chrysoijhanic  acid  has  been  taken. 

Pink  and  Red  Urines. — The  conditions  which  lead  to  the  excretion  of  a  pink  or  red 
urine  may  lie  classified  as  follows:  (1)  Ihematuria,  in  cases  in  which  the  blood  pigment 
appears  in  the  urine  mainly  as  oxyha^moglobin  ;  (2)  Hsemoglobinuria — usually  in  cases 
which  do  not  belong  to  the  paroxysmal  class  ;  (3)  Haematoporphyrinuria  ;  (4)  Administra- 
tion of  rosaniline  as  a  drug  ;  (5)  Eating  of  sweetmeats  coloured  with  eosin  :  (fi)  Presence  of 
ihrysophanic  acid  in  an  alkaline  m'inc. 

11(1  iiiahirid  and  iKcnioglobiniirid. — For  the  significance  of  these  sym])toms.  and  the 
dctrction  of  blood  pigment  in  urine,  the  s])ecial  articles  dealing  with  them  may  be  referred 
to  (p.  27.")  and  p.  284). 

IldindtoiKirpliiiriiiiiria  is  a  condition  in  which  urine  is  passed  which  has  a  ])ink,  ])ort- 
wine,  or  nearly  black  colour,  and  which  contains  considerable  quantities  of  the  lia'ino- 
globin  derivative,  haematoporphyrin.  In  the  darker  specimens  the  colour  is  mainly  liuc  to 
other  little-known  pigments  which  accomi)any  the  ha?matoporphyrin.  For  the  recognition 
of  the  condition  spectroscopic  examination  is  necessary.  It  is  most  liable  to  be  mistaken 
for  ha;nioglobinuria,  but  when  the  urine  contains  no  albumin  the  distinction  is  not  dillicult  ; 
when  albumin  is  present  in  a  pink  urine,  the  diagnosis  is  more  difficult,  because  the  spectrum 
of  hajmatoporphyrin  in  the  combinatif)n  in  which  it  usually  occurs  in  such  cases  resembles 
that  of  oxyhsemoglobin  somewhat  closely,  llowexcr,  the  addition  of  hydrochloric  acid 
changes  the  spectrum  to  that  of  acid  luiinatoporphyrin  instead  of  to  that  of  acid  hsematin 
{Fig.  34,  p.  80). 

If  a  mixture  of  10  per  cent  calcium  chloride  solution  and  lime-water  be  added  to  the 
urine,  the  preci])itate  formed  carries  down  all  the  abnormal  [jigments.  and  the  filtrate  is_ 
yellow.  From  the  ])recipitate  the  hirmatoporphyrin  may  be  extracted  with  aciditied  alcohol, 
and  its  highly  characteristic  spectra  may  be  observed  and  identified.  The  trace  of  hiemato- 
porphyrin  present  in  normal  urine  escapes  detection  by  such  means,  but  the  increased 
(luantities  present  in  a  variety  of  morbid  conditions  may  be  reveailed  by  faint  bands,  even 
in  cases  which  do  not  fall  into  the  class  under  consideration,  and  in  which  the  urine  shows 
no  obvious  anomaly  of  pigmentation. 

In  the  great  majority  of  cases,  luematoporphyrinuria  results  from  ])rolonged  admin- 
istration of  sidplional  in  medicinal  doses,  and  forms  one  of  a  group  of  toxic  symptoms  of 
much  gravity,  which  often  usher  in  a  fatal  ending.  These  symptoms  may  only  develop 
after  the  drug  has  been  taken  for  months  or  even  years,  and  even  some  days  after  its  admin- 
istration has  been  stopped.  Their  development  calls  for  the  free  administration  of  sodium 
l)icarl)onate.  It  is  a  remarkable  fact  that  such  toxic  effects  of  sulphonal  are  seldom  seen 
except  in  women,  and  the  few  male  cases  on  record  have  mostly  been  of  a  mild  kind. 

-Aluch  more  rarely,  ha-niatopoqihyrinuria,  with  deep  red  urine,  is  met  with  in  cases  in 
which  it  cannot  be  ascribed  to  any  drug.  .Several  patients  have  been  sufferers  from  liydroa 
(rslivfde.  others  from  tuberculosis,  and  others  from  maladies  so  different  from  each  other 
that  no  definite  diagnostic  significance  can  yet  be  assigned  to  the  symptom.  In  such  cases 
the  hiematoporphyrinuria  does  not  apjiear  to  have  the  grave  import  which  it  has  in  sul- 
phonal cases,  nor  is  there  manifested  any  special  liability  of  the  female  sex. 

Coloration  by  constituenis  of  foods  and  drugs. — Rosaniline,  which  was  at  one  time  em- 
ployed in  the  treatment  of  albuminuria,  imparts  a  pink  colour  to  the  urine  which,  provided 
that  it  be  known  that  the  drug  is  being  taken,  offers  no  diagnostic  difficulty.     Aniline  dyes 


URINE.     ABNORMAL    COLORATION    OF  745 

have  also,  ere  now,  been  deliberately  added  to  the  urine  for  the  purpose  of  siinulatini; 
hsematuria. 

Eosin  has  been  employed  extensively  for  the  coloration  of  pink  sweetmeats  and  lozenges, 
and  the  urine  of  those  who  eat  such  sweetmeats  in  considerable  quantities  acquires  a  rich 
l)ink  colour,  and  shows  a  brilliant  {jreen  fluorescence.  The  nature  of  such  pigmentation 
can  hardly  be  mistaken  by  anyone  who  is  aware  of  the  fact  that  eosin  is  so  employeti. 

Drugs  which  contain  cfirysoplidnic  <icid  are  used  so  frequently  as  aperients  that  this 
com])ound  may  rank  as  a  common  constituent  of  urine  ;  and  if,  from  any  cause,  the  urine 
be  alkaline,  it  acquires  a  pink  or  red  colour,  which  may  easily  be  misinterpreted.  However, 
the  history  of  the  taking  "f  rhubarb  or  senna,  and  the  fact  that  the  addition  of  an  acid 
changes  the  colour  of  the  urine  to  a  bright  yellow,  renders  the  diagnosis  easy.  The  pink 
colour  which  alkalies  impart  to  the  urine  of  patients  taking  santonin  is  so  fugitive  that  it 
does  not  call  fur  cdnsideration  here. 

Brown  and  Black  Urines. — 'i"he  urine  may  be  brown  or  black  in  the  following  condi- 
tions :  (1)  .laimdiee  :  {'!)  H;ematuria  ;  (3)  H;rmoglobinuria  :  (i)  H:ematoporphyrinuria ; 
(5)  Indicanuria  ;  (fi)  Melanuria  ;  (7)  Alkaptonuria  :  (8)  Carboluria  :  and  after  the  admin- 
istration of  certain  other  drugs,  such  as  salol,  salicylates,  resorcin.  gallic  acid,  and  uva  ursi. 

In  some  of  the  above  conditions  the  urine  has  such  coloration  when  passed  ;  but  in 
others,  such  as  mclanuria  and  a!ka|)t(inuria,  the  urine  is  usually  of  normal  tint  when  freshly 
passed,  and  only  darkens  on  standing  in  contact  with  the  air. 

Brown  and  black  jaundiced  urine  is  met  with  chiefly  in  cases  of  long-standing  icterus, 
in  which  the  skin  has  acquired  a  didl  greenish  tint,  and  the  urine  contains  biliverdin  as  well 
as  biliruhin. 

In  some  of  the  early  recorded  cases  of  black  urine,  the  colour  was  certainly  due  to  blaod 
pigment,  and  the  smoky  colour  of  many  urines  which  contain  blood  pigment  in  the  fnrni  of 
metha-nioglobin  is  familiar  to  all.  In  paro.rysmrd  luvmoglobinurin  also,  the  urine  is  mil 
infrequently  almost  black.  The  ordinary  tests  for  hasmoglobin,  together  with  microscopic 
and  spectroscopi  ■  examination,  serve  to  reveal  the  nature  of  sujh  cases  (Figs.  30  el  se'j., 
p^  SO) 

That  the  urine  of  iKemaluporphi/rinuria  may  approach  to  actual  blackness,  owing  to 
the  abundant  presence  of  purple  jjigments  which  have  no  characteristic  spectra,  has  already 
been  rneiili(in(<l  in  the  account  of  that  symptom  above. 

Judiniiiiiiiu. — Ijrines  which  contain  much  indican  may  show  no  abniiriiialilN-  iif  tint  ; 
bill  occasionally,  and  especially  in  extreme  cases,  there  are  present  in  the  urine,  in  assoeia.- 
liciM  with  the  colourless  indoxyl  sulphate,  other  and  higher  oxidation  products  of  indol, 
which  im|)art  to  it  a  brown  colour,  intensified  or  developed  on  exposure  to  air.  This  variety 
of  lirown  or  black  urine  is  recognized  less  than  it  should  he.  and  it  is  probable  that  the  condi- 
licin  has  been  mistaken  not  infre(|uently  for  melamnia.  .Such  urine  is  not  blackened,  as  that 
ot  mclamiria  is,  by  the  addition  of  ferric  chloride,  nor  by  nitric  acid  in  the  cold,  but  docs 
blacken  when  heated  with  nitric  acid.  The  ordinary  tests  for  indican  reveal  its  presence  in 
large  amount.  Thus,  if  a  specimen  of  the  urine  be  hcateil  with  an  ctpial  volume  of  hydro- 
chloric acid,  and  a  ilrop  of  ii  dilute  solution  of  blea<hiMg  powder,  or  a  drop  of  nitric  acid,  il 
becoiMcs  black.  If.  alter  cooling,  the  dark-( oloured  li(|uid  be  shaken  with  chloroform,  the 
laller  takes  op  iiiiligo-bhie  (jr  -red  ifnd  ac(|uircs  a  ilccp  purple  coloiu' ;  but  the  supernatant 
li(|iiid  iiinairis  black.  If  the  chloroform  extract  be  separated  and  evaporated  to  dryness, 
the  indigo-red  may  be  dissolved  out  of  the  residue  with  alcohol,  whereas  the  iniligp-bhic, 
which  is  insoluble  in  alcohol,  may  be  taken  up  alterwards  with  chloroform. 

Indicanuria  signihes  abnormal  amount  of  protein  decomposition  in  the  alimeutar\- 
canal,  brought  about  by  intestinal  bacteria  :  but  it  is  staled  that  it  may  also  have  its  origin 
in  collections  of  putrid  pus.  such  as  putrid  empyeinata.  In  such  a  case  recently  under  the 
writer's  care.  I  hi'  aliuiidaut  indican  disappeared  from  the  urine  whi^n  a  dose  of  calomil  w.is 
gi\',-ri,  and   was  proliabls    of  intestiiuil  origin. 

Mchiiiiiiiii.  This  is  a  symptom  which  is  me!  with  in  some  cases  i>iintl(iiiiilic  sdrniniii. 
The  urine,  when  frishly  passed,  contains  a  colourless  chromogen.  melanogen.  and  usually 
has  a  n(  Ulna  I  tint.  On  exposure  to  air.  il  darkens  (piickl>.  owing  lo  oxidation  of  the  rnelano- 
g<ii  to  melanin.  Ix'comcs  brown,  and  eventually  <piite  l)lack.  When  nitric  acid  is  addeil  to 
such  a  uriiH  .  il  causes  proiTipt  blac-kcning.  <-ven  in  the  cold,  and  innuediatc  blackening  also 
lollous  the  a.ldllion  of  a  solution  of  terric  .-hNuide.      This  is  I  he  most   valuable  and  cliarac- 


746  URINE.     ABNORMAL     COLORATION    OF 

teristic  of  the  tests  for  melanuria.     Bromine  water  produces  a  yellow  or  brown  precipitate 
which  quickly  blackens. 

.\s  a  rule,  melanuric  urines,  when  treated  with  lifjuor  potassae  and  sodium  nitroprusside 
yield  a  deep  Prussian  blue  on  acidification  with  acetic  acid,  but  this  reaction  is  not  due  to 
tlie  melanogen  as  such,  is  yielded  by  some  other  urines,  and  cannot  be  taken  as  diagnostic 
of  melanuria. 

It  is  stated  frequently  that  melanuria  may  be  met  with  apart  from  melanotic  growths, 
in  cases  of  wasting  and  other  diseases.  There  is  little  doubt  that  some  of  the  cases  quoted 
in  support  of  this  contention,  and  which  were  recorded  before  the  more  distinctive  tests  for 
the  condition  were  known,  were,  in  reality.  exam)jles  of  indicanuria.  such  as  have  been 
described  above,  and  the  writer  has  never  met  with  true  melanuria  save  in  cases  of  melanotic 
sarcoma.  Even  in  such  cases  it  is  not  seen  so  long  as  the  tumour  is  confined  to  its  primary 
seat,  but  only  when  it  has  invaded  the  viscera,  and  especially  the  liver.  Indeed,  the  quantity 
of  melanogen  excreted  is  apparently  dependent  upon  the  extent  to  which  the  liver  has  been 
ijivaded,  and  the  anioimt  of  pigmentation  in  the  growths  of  which  it  is  the  seat.  Hence  it 
"happens  usually  that  the  diagnosis  of  the  case  has  already  been  established  before  the 
peculiar  pigmentation  of  the  urine  is  developed. 

Alkaptomiria  is  the  outward  sign  of  a  very  rare  anomaly  of  metabolism  which  is  almost 
always  congenital,  and  persists  through  life  without  any  serious  detriment  to  the  health 
of  its  subjects.  The  jseculiar  properties  of  the  urine  are  due  to  the  excretion  in  it  of  an 
aromatic  acid,  homogentisic  or  liydroc|uinoneacetic  acid,  a  product  of  katabolism  of  tyrosin 
and  i)henylalanin.  It  is.  in  all  probability,  a  product  of  normal  metabolism,  which  in 
normal  individuals  undergoes  complete  destruction. 

Alkapton  urine  seldom  exhibits  any  abnormality  of  tint  when  passed  ;  but  darkens 
(luickly  on  exposure  to  air,  undergoing  changes  through  brown  to  black,  which  resemble 
in  the  closest  manner  those  seen  in  melanuric  urines.  However,  the  two  conditions  are 
distinguished  readily  by  means  of  simple  tests.  When  a  dilute  solution  of  ferric  chloride 
is  added  to  alkapton  urine,  a  deep  blue  colour  appears  for  a  moment,  and  reappears  after 
each  subsequent  addition  of  the  reagent,  until  oxidation  of  the  homogentisic  acid  is  com- 
pleted. Unless  the  reagent  be  very  dilute,  oxidation  occurs  too  rapidly,  and  the  blue  colour 
is  missed. 

The  addition  of  an  alkali  causes  very  rapid  darkening,  with  absorption  of  oxygen,  and 
heat  increases  the  rate  of  blackening. 

As  homogentisic  acid  is  a  powerful  reducing  agent,  alkapton  urines  give  some  of  the 
reactions  of  glycosuria.  Fehling"s  solution  is  reduced  freely  with  the  aid  of  heat,  but  the 
blackening  effect  of  the  alkaline  reagent  gives  a  peculiar  appearance  to  the  reaction.  No 
black  precipitate  is  obtained  with  Nylander's  reagent,  but  the  alkali  therein  causes  con- 
spicuous darkening.  The  safranin  reaction  is  not  obtained,  and  alkajjton  urine  is  optically 
inactive.  An  ammoniaeal  solution  of  silver  nitrate  is  reduced  rapidly  even  in  the  cold,  a 
reaction  which  is  made  use  of  for  the  quantitative  estimation  of  homogentisic  acid.  It  is 
because  alkaptonuria  is  so  rare,  rather  than  because  its  recognition  presents  any  sijecial 
difiiculty,  that  its  properties  are  not  widely  known  and  not  infrequently  fail  of  recognition. 

Ochronosis,  i.e.,  a  blackening  of  the  cartilages,  and  deep  pigmentation  of  regions  of  the 
skin,  a  bluish-black  coloration  of  the  ears,  and  pigment  spots  on  the  conjunctiva?  (Plate 
XXXIII),  is  sometimes  the  outcome  of  alkaptonuria  ;  but  there  is  a  group  of  case^Jn  which 
similar  jiigmentation  results  from  the  application  of  carbolic  acid  to  chronic  ulcers  over 
long  periods  of  years.  There  is  also  some  reason  to  believe  that  the  lesions  of  joints  which 
sometimes  accompany  ochronosis  may  also  be  results  of  alkaptonuria. 

Cmholnrifi. — A  darkening  of  the  urine,  increased  by  ex]5osure  to  air,  is  seen  frecjtiently 
after  the  administration  of  certain  drugs  which  contain  phenol,  in  carbolic  acid  poisoning, 
and  as  the  result  of  outward  api)lication  of  carbolic  acid.  A  carbolic  acid  compress  applied 
to  the  head  of  a  child  for  the  destruction  of  pedieuli  quickly  induces  carboluria,  and  the 
taking  of  salol  is  another  common  cause.  The  urine  has  a  snwky  tint,  or  in  cases  of  carbolic 
acid  poisoning  may  be  actually  black.  In  the  slighter  cases  it  is  best  described  as  brown 
with  a  greenish  tinge,  and  the  meniscus,  when  seen  from  the  side,  appears  black. 

There  is  no  direct  chemical  test  for  carboluria,  and  the  diagnosis  is  usually  based  upon 
the  knowledge  that  phenol,  or  some  derivative  or  comjjound  thereof,  has  been  administered 
or  applied.     After  boiling  the  urine  for  some  time  with  Fehling's  solution,  a  slight  reduction 


I'LATIC     AAA/// 

OCHRONOSIS 


III.'  r.u-i-  IS  inlourcl  ,Iurk  broim  (c).  iiii.l  hciirn  ii  xlriklnK  rraciuhl.ir.iT  to 
liuvi- ..  I.luisli  u|ipc':imn™,  uml  h:in(l»  (Al,  show  ii  »lmlliir  dlwolorulloii.  Viilo  tli 
oil  o.i,-li   ,-onjuin'llva  (B). 

i;x    fiK    i»\usoi>is—ro /ace /I.  Ur, 


i'nf<p  o(  Aililison'rt  JiKonflc  ;   (lio  earn 
iiniill  MiilHli  piiii'l,  which  wu«  prcwnt 


URIXE.     ABNORMAL    COLORATION    OF  747 

is  observed  ;  but  this  is  in  no  way  comparable  with  that  seen  witli  allvapton  urine.  Indirect 
evidence  is  obtained  by  tlie  addition  of  a  solution  of  barium  chloride,  which  in  cases  of  car- 
boluria  produces  a  very  slight  precipitate  or  none  at  all.  If,  liowever,  the  urine  be  first 
boiled  with  hydrochloric  acid,  a  ])recipitate  is  obtained  such  as  is  yielded  by  normal  urines. 
This  is  due  to  the  fact  that,  in  the  ])resence  of  abundant  phenol  and  oxidation  derivatives 
tliereof,  tlie  sulphates  of  the  urine  are  for  the  most  part,  or  even  wholly,  combined  as  aro- 
matic sulphates,  which  yield  no  i)recipitate  with  barium  salts,  whereas,  when  the  aromatic 
suli)hates  are  broken  up  b\  hyilmehloric  acid,  a  precipitate  of  barium  sulphate  is  thrown 
down. 

The  diagnosis  of  the  other  varieties  of  brown  or  black  urine  which  have  their  origin  in 
the  administration  of  drugs,  is  based  upon  the  fact  that  salicylates,  or  other  drugs  capable 
of  producing  such  |)igmcnt:ition,  have  been  taken. 

Green  and  Blue  Urines.  -In  some  cases  of  jaundice,  the  bile  pigment  excreted  is  so 
largely  in  the  form  of  bilix  enlin  that  the  urine  has  a  dark  green  colour  :  but  with  this 
exception,  practically  all  green  urines  met  with  in  practice  owe  their  colour  to  the  taking 
of  methylene  blue,  either  as  a  drug  or  in  sweetmeats.  When  the  dose  is  small,  the  tint  may 
be  a  rich  green  :  but  after  larger  doses,  the  urine  is  frankly  blue.  It  is  not  always  easy  to 
account  for  the  origin  of  such  coloration  of  urine,  for  the  patient  may  be  quite  imaware 
that  he  has  taken  methylene  blue  in  any  form,  although  examination  of  his  urine  may 
leave  no  doubt  that  he  has  done  so.  Sweetmeats  are  sometimes  coloured  with  this  pig- 
ment, as  they  are  with  eosin,  an<l  it  is  sometimes  used  to  correct  the  colour  of  white  sweet- 
meats. Again,  a  ])ill  of  methylene  blue  has  before  now  found  its  way,  either  by  accident 
or  design,  into  a  supply  of  jjills  of  another  kind.  Absence  of  a  known  cause  does  not,  there- 
fore, by  any  means  exclude  tliis  kind  of  |)igmentation  :  and  experience  shows  that  unless  it 
can  be  shown,  by  careful  examination,  that  the  colour  ol'  the  urine  is  not  due  to  methylene 
blue,  it  is  needless  to  search  for  any  other  causation. 

.Mthough  the  green  urine  which  follows  the  taking  of  methylene  blue  may  appear  per- 
fectly Iim|)id.  the  blue  i)igment  is  not  held  in  solution  but  in  susjjension,  and  is,  to  a  large 
extent,  removed  even  by  a  single  filtration.  The  green  colour  of  the  filtrate  is  greatly 
reduced,  and  the  filter  jjaper  shows  a  blue  stain.  The  pigment  upon  the  filter  yields  a  blue 
solution  in  chloroform,  and  if  the  chloroform  solution,  or  the  blue  extract  obtained  by 
shaking  the  urine  with  chloroform,  be  shaken  with  liipior  potassie  in  a  test  tube  the  chloro- 
form is  decolorized,  and  the  supernatant  alkaline  lic|uid  ac(|uires  a  pink  tint.  The  original 
urine,  or  the  chloroform  extract,  shows  an  absorption  hand  in  the  red  of  the  si>e(truru 
wliieli  may  be  mistaken  for  that  of  indigo-blue. 

There  is  no  reason  to  think  that  indigo-blue  ever  produces  a  green  or  blue  coloration 
of  urine  similar  to  that  due  to  methylene  blue.  Ry  the  sjujut  uieous  breaking  down  of 
Indoxyl-glycuronic  acid,  usually  in  alkaline  urines,  indigo-blue  may  be  set  free,  and  may 
form  a  dark  blue  sediment,  or  may  impart  a  blue  colour  to  the  |)lios])hatie  film  upon  the 
surface  ;  anil  when,  in  the  earlier  years  of  the  last  century,  indigo-blue  was  employed  some- 
what frequently  as  a  drug  in  the  treatment  of  epilepsy,  a  dark  purjile  colour  of  the  urine  ol 
patients  so  treated  was  observed,  but  under  no  eirenmstanccs  are  indigo  pigments  formed 
spontaneously  In  (prmtitles  sudicient  to  bring  about  such  a  result.  .i.  !•:.  Ciirroil. 

URINE,  ACETONE  IN.     (See 'acktom  hi  k,  p.  ::.) 

URINE,  ALBUMIN   IN.     (Sc-  Ai.m  mini  iha,  p.    I.) 

URINE.  ALBUMOSE    IN.     (See  Ai.m  mosi  iii\.   p.  I.-..) 

URINE,  BACTERIA    IN.      (Sec    H.uii-.nn  m  \     p.   (i!l.) 

URINE,  BENCE-JONES  BODY  IN.     (Sec  Ai.m  mos,  ima.  p.  I.").) 

URINE.    BILE-PIGMENT    IN.     (See  liUNr.  Acnokm  \i.  (  oioiiahon oi-    p.  Tt:J.) 

URINE,    BLACK.     (Sec  IKim..  Aunohmai.  (  oiohation  of.  p.  7  t.'i.) 

URINE,    BLOOD    IN.      (See   II.kmau  ima.   p.  -.'7.-).) 

urine:,  CASTS  IN.     (Sri-  Ai.iiiMiM  jiiA    p.   t.) 


748  VEINS.     VARICOSE    ABDOMINAL 

URINE,  CHYLE  IN.— (See  Ciiyluima    p.  108.) 
URINE,  CYSTIN  IN.— (See  Cystinukia,  p.  101.) 
URINE,  DIACETIC   ACID  IN.— (See  Acetonuria,  p.  3.) 
URINE,   DIAZO   reaction  IN.— (See  Diazo  Reaction,  p.  173.) 
URINE,  EXCESS  OF. -(See  Polyuria,  p.  534.) 
URINE,   FiECES  IN. — (See  F.eces  Passed  per  Uretiiram,  p.  238.) 
URINE,  FAT  IN.— (See  Chyluria,  p.  108.) 
URINE,   GAS   IN.— (See  PxErMATLRiA,  p.   329.) 
URINE,  GLUCOSE  IN. -(See  Glycosikia.  p.  260.) 
URINE,  HEMOGLOBIN   IN.— (See  H.EMOGr.OBiNuRiA.  p.  284.) 
URINE,   INCONTINENCE   OF.— (See  Micturition.  Abnormalities  or,   p.   393.) 
URINE,  INDICAN   IN.     (Sr,-  Ini.icanuhia,  p.  314.) 
URINE,  METHEMOGLOBIN  IN.— (See  H.emoglobinuria.  p.  284.) 
URINE,  MUCUS  IN.— (Sec  Mucus  in  the  Urine,  p.  .399.) 
URINE,  OXALATE  DEPOSIT  IN.     (See  Oxai.uria.  p.  423.) 
URINE,  OXYBUTYRIC  ACID  IN.     (See  Acetonuuia.  p.  3  ) 
URINE,    PHOSPHATES   IN.— (See  Phospiiaturia.  p.  522.) 
URINE,   PUS   IN.     (See   PvriiiA,   p.  574.) 

URINE,  RETENTION   OF.— (See  Micturition.  .Abnormalities  oe.  p.  .393.) 
URINE,  SUGAR   IN.— (See  Glycosuria,  p.  260.) 
URINE,   SUPPRESSION  OF.— (See  .\nuria.  p.  39.) 

URINE,   URATE  DEPOSIT  IN.     (See  Urate  Deposit  in  the  Urine,  p.  740.) 
URINE,  URIC  ACID  DEPOSIT   IN.— (See  Uric  Acid  Deposit  in  the  Urine,  p.  741.) 

UTERUS,  BLEEDING  FROM,— (See  Menorrhagia,  p.  385 :  Mktrohrhagia.  p.  390  ; 
and  Mi;ri!o>TA\is.  p.  3i>2.) 

UTERUS,  PROLAPSE  OF.     (See  Pholapse  of  the  Uterus,  p.  5.38.) 

VAGINA,  BLEEDING    FROM.  -(See  .Menokrhagia.  p.  383  :   :Metr()ki!1l\(;ia.  p.  390  ; 
and  .Metrostaxis.  J).  :WZ.) 

VAGINA,   DISCHARGE  FROM.     (See  Discharge.  Vaginal,  p.  183.) 

VARICOSE   ABDOMINAL   VEINS.— (See  Veins,  Varicose  Abdominal.) 

VARICOSE  THORACIC  VEINS.     (See  Veins.  Varicose  Thoracic,  p.  730.) 

VEINS,  VARICOSE  ABDOMINAL.— The  point  at  which  distention  of  veins  becomes 
vaiieosity  is  arljitraiy  :  niost  ((inditinns  that  produce  undoubted  varicosity  of  the  veins 
of  the  abdominal  wall  in  some  cases,  merely  dilate  them  in  others.  When  this  dilatation 
is  considerable  {Fig,  303),  it  nearly  always  has  much  diagnostic  significance,  particularly 
if  the  direction  of  blood-flow  is  reversed.  Veins,  however,  may  seem  to  be  dilated  when 
lliey  are  but  unduly  visible  owing  to  wasting  of  the  subcutaneous  fat  ;  or  they  may.  in 
very  rare  cases,  be  simply  varicose,  like  veins  in  the  leg,  owing  to  idiosyncrasy  or  hereditary 
predisposition.     In  neither  of  these  eases,  however,  is  the  blood-current  in  them  reversed. 


PLATE     XXXIV. 


URINE      TESTS 


\j 


1,  2,  3.    'I'ln-  thrw  atiii-M  of  tho  «:nlliim   iiilroj.riKsl.li'   ti-<l    Inr  -m-i-m 4.  5.  O.    'I'lic    famo   in    ii    iirinn    cnw 

tiiiiiiiiK  no  ohvioux  nretone.  (1  and  4.  normiil  iirifio ;  2  f"Hi  5,  Itio  iippciiriinro  iiftor  lulijini;  fiiiiHtle  Hodiv  ninl 
Hodiuni  nitrojirusside ;  3  nnd  6,  the  nppearunco  ufter  adding  ncetir  arid,  3  licin«  po'iltivo,  6  noKiitivo,.(or  ncotoiic). 
7,  Uotlmra's  ti-it  tor  acetone.  8.  Jcrric  chloride  reaction  o(  diacetic  add.  0.  Inilltanuriii  lent.  10.  Jlcliihurla. 
II.  Hiiibetic  urine.     12.  The  lliiorcscoiit  reaction  o(  iirobllln. 


1X1)1  X   OF   DiAO.S'osis— 7'o  jacc  p.  718. 


YEIXS,     VARICOSE    ABDOMINAL 


749 


To  test  the  direction  of  blood-flow,  part  of  a  vein  should  be  chosen  where  there  are  no  side 
branches,  and  the  blood  should  be  expressed  from  it  by  means  of  two  fingers  pressed  down 
on  the  vein  close  together,  and  then  drawn  asunder,  whilst  pressure  over  the  vein  is 
maintained  by  each  ;  when  a  lenifth  of  the  distended  vein  has  been  emptied  in  this  way, 
one  of  the  two  fingers  is  taken  off.  and  the  time  taken  by  the  vein  in  refilling  is  noted  :  the 
procedure  is  repeated,  the  other  finger  being  taken  off  this  time  ;  it  is  then  generally  easv 
to  decide  whether  the  vein  fills  from  below  upwards  or  from  above  downwards.  Normally, 
the  blood  flows  from  above  downwards  in  the  veins  of  the  lower  two-thirds  of  the  abdominal 
wall  :  when  the  blood-flow  is  from  below  upwards  there  is  almost  certainly  obstruction  to 
the  inferior  vena  cava,  the  blood  which  is  unable  to  return  by  it  finding  a  collateral 
circulation  via  the  superior  vena   cava. 

Obstruction  to  the  inferior  vena 
cava  is  due  to  one  or  other  of  three 
main  groups  of  conditions,  namely  : — 

1.  Great  general  increase  in  the 
intra-abdominal  tension,  owiiii;  tn 
such  conditions  as  :  ascitis  :  ovarian 
cyst  ;  great  splenic  or  hepatic  en- 
largement. 

2.  Thrombosis  without  external 
obstruction. 

:i.  Obstruction  by  local  com- 
pression, especially  by  secondary 
growths  in  the  retroijcritoiieal  glariiK. 

When  the  obstruction  of  llic 
inferior  vena  cava  is  dwv.  not  Id  llic 
vein  itself  being  thromlioscd  (jr  in 
vafled  by  new  growth,  but  to  the 
general  iiitrfi-dlnlomitial  i)irssiiic  be- 
coming so  great  that  the  vein  is.  sn 
to  speak,  flattened  out,  the  varieosilv 
of  the  veins  upon  the  abdominal  wall 
is  but  a  late  symptom,  and  the 
diagnosis  will  be  marie  from  the  cause 
of  the  great  abdominal  distentidii. 
generally  .\scrri;s  (p.  i:5).  or  a  bii; 
tumour.  If  there  is  iiKirked  \:iii 
eiisily  (it  IIm-  su|ierlieial  xciiis  eailx 
in  a  case  of  ascites  the  probability 
is  that  both  are  iluc  to  malignant 
disease. 

When  the  inferior  \<iia  cava  is 
obstructed  by  '  siiii/ilc  '  llirii>nh(isis. 
the    probability    is    thai     the  clotting 

will  riol  have  started  there,  but  will  have  exleii(le<l  Ic.  it  troiii  hranelies  eillur  in  I  lie  legs 
or  ill  the  pelvis.  (IvU'nia  of  the  legs  will  be  a  promincnl  syuiplom  :  and  if  a  cleai'  liislory 
is  obtainable  it  may  geiu'rally  be  ascertaincil  that  one  leg  became  ledemalous  and  painful 
before  the  other  :  when  this  is  so  it  is  always  very  suggestive  of  thrombosis  starling  in  the 
saphenous  I. r  leinoral  \eiris.  I  he  oilier  le;;  Ix-ecming  affected  laler  ulieii  the  eliil  has  spread 
up  thniMLlli  llie  iliac  xciiis  t,\  tlie  diie  side  In  the  inferior  \-eIia.  and  I  lieiiee  diiuii  llie  iliac 
veins  of  the  other  side,  'ihe  higher  the  Ihrombus  extends  llic  higher  up  the  ba<'k  will 
the  (edema  spread  :  and  when  the  ri'iial  veins  have  been  reached,  albumimnia.  with  lube 
casts,  an<l  even  ha-maturia,  may  ensue,  .\sciles  may  also  be  present.  l)isl<'iitioM  or 
varicosity  of  the  veins  of  the  abdominal  wall  will  be  of  assistance-  in  distinguishing 
such  a  case  from  one  of  acute  or  subacute  nephritis.  besi<les  which  there  will  be  no  <edema 
of  the  eyelids  or  face. 

If  there  is  no  very   lens<-  ilislenlioii  (if  Ihe  ahdnmen  ;    it  lln-  way   Ihe  ease  bcMan  ilocs 
not  suggest  thrombosis  in  ime  Icl'.  "I-  in  the  pel\is,  cNleiidiny  upwards  ;    and  it.  ne\  erthclcss. 


r/;i.  ;i'i3.— Vii 


ISC  of  SV|>llilitl' 


50 


VEINS.     VARICOSE    ABDOMINAL 


there  is  marked  varicosity  of  the  \eins  of  the  lower  part  of  the  abdominal  wall,  with  the 
blood-flow  in  them  reversed,  so  as  to  be  from  below  upwards,  the  history  being  a  relatively 
short  one. — the  probability  is  that  the  inferior  vena  cava  is  being  obstructed  by  something 
that  is  in  immediate  contact  with  it.  There  will  very  likely  be  symmetrical  oedema  of  the 
legs,  and  possibly  albuminuria  and  ha^maturia.  It  is  surprising  how  seldom  an  aortic 
aneurysm,  or  other  non-malignant  mass,  obstructs  a  large  vein  sufficiently  to  produce  this 
collateral  varicosity  ;  hence,  the  presumption  is  that  such  varicosity  indicates  malignant 
disease.  It  is  worthy  of  note  that  carcinoma  of  the  kidney  is  prone  to  extend  into  the 
renal  veins,  and  thus  into  the  inferior  vena  cava  by  a  process  of  direct  extension  (Fig.  304) 
— sometimes  the  malignant  clot  reaches  as  far  as  the  right  auricle,  and  produces  a  pedun- 
culated polyjius  in  the  latter.  In  such  cases  there  has  generally  been  ha^maturia  or  other 
renal  symptom  before  evidence  of  inferior  vena-caval  obstruction  arose,  whereby  cases  of 
growth  in  the  kidney  invading  the  inferior  vena  cava  may  be  distinguislud  from  eases  of 
secondary  growth  in  the  retroperitoneal  glands,  which  if  they  produced  lucmaturia  at  all. 

would  do  so  by  first  obstruc- 
ting the  inferior  vena  cava, 
and  thence  involving  the  renal 
veins.  In  such  cases  there 
arc  often  other  symptoms 
l)ointing  to  primary  growth 
mrmiosnAj^  in  some  organ  whose  lym- 
mcr,'^'."m  ]]hatics  drain  into  the  retro- 
])eritoneal  glands  ;  the  testes 
and  ovaries  should  not  be 
overlooked  in  this  respect. 

It  is  often  said  that 
cirrhosis  of  the  liver  leads  to 
\  aricosity  of  the  veins  around 
f'"^'  umbilicus — the  so-called 
'""•""""  caput  nicdiisw.  It  is  a  very 
rare  condition  indeed,  the 
great  majority  of  cases  of 
cirrhosis  of  the  liver  causing 
no  distention  of  the  super- 
Jicial  abdominal  veins  until 
such  time  as  the  general 
intra-abdominal  tension  has. 
been  greatly  increased  by  the 
tenseness  of  the  ascites  which 
occurs  late.  Not  even  the 
telangiectases  that  ocriir  so 
commonly  in  men  past  middle 
,. .  ,|  age  around  the  lower  part  of 

the  chest,  in  a  line  with  the 
attachments      of      the      dia- 
pliragm.   indicate   eirrliosis  :    they  arc   quite  as  common   in  cases  of  emph\sema  without 
eirrliosis. 

In  short,  varicosity  of  the  superficial  abdominal  veins  generally  indicates  either 
thrombosis  of  the  inferior  vena  cava,  secondary  to  direct  spread  of  thrombosis  up  to  it 
from  veins  in  the  pelvis  or  in  the  leg,  or  else  stenosis  of  the  vena  cava  by  secondary 
malignant  disease.  Herbert  French. 


Fig.  301.— Renal  > 


xtcniliiis  into  til 


VEINS,  VARICOSE  THORACIC— :\Iueh  of  what  lias  been  said  above  about  varicose 
abdominal  veins  apjilies  also  to  those  of  the  thorax.  The  veins  on  the  chest  wall  may 
merely  be  unduly  visiljje  :  but  if  they  are  really  distended,  there  is  probably  obstruction 
to  one  or  other  innominate  vein  or  else  to  the  superior  vena  cava  ;  and  the  suspicion  that 
this  is  so  becomes  a  certainty  if  the  blood  current  in  the  distended  veins  can  be  shown  to  be 
from  above  downwards  instead  of  from  below  upwards.     If  the  distention  is  bilateral,  and 


PLATE     XXXV. 


URINE      TESTS 


GUNSBERG'S      TEST 


I.  The  iotlino  te-it  for  hilo  jiigmotit  iti  urine.         2.  CJtiioIhi*^  ro'terlon  for  bilo  pii^mont  Iti  iirlrio. 
3.  G llnshor(;'s  tcsl  for  Irco  1II"|  In  (jiiilrli;  Jiilcc. 


INDKX     ur     I11VI;.N1IS1S  -7V,  l„rr  p.    7511. 


VKRTIGO  751 

associated  with  frdenia  of  both  arms,  and  both  sides  of  tlie  neck,  face  and  head,  it  is  the 
vena  cava  that  is  obstructed  :  if  the  distention  is  unilateral,  with  oedema  of  tlic  corres- 
pondinir  arm,  but  little  if  any  of  the  neck  or  face,  the  obstructed  vessel  is  probably  one 
innominate  vein.  The  superficial  varicosity  may  be  only  slight  (Fig.  99.  p.  20S).  but  some- 
times it  is  extreme. 

In  arrivint;  at  a  diagnosis  of  the  cause  of  the  venous  obstruction,  indliguiml  disease 
within  the  thorax  will  be  uppermost  in  one's  mind — especially  mediastinal  sarcoma,  starting 
in  the  thymus  or  in  the  lymphatic  glands.  It  is  only  when  the  history'  and  course  arc  too 
long  for  primary  or  secondary  malignant  neoplasm  that  other  causes  of  venous  obstruction 
will  be  regarded  as  more  likely,  such  as  thrombosis  extending  to  an  innominate  vein  or  to 
the  superior  vena  cava  from  a  whitlow,  boil,  or  other  inflammatory  affection  of  the  hand, 
arm.  axilla,  head,  face,  neck,  shoulder,  or  front  of  chest  ;  or  elironic  fibrous  metliastiiiitis. 
sometimes  tuberculous  or  gummatous  (Fig.  303.  p.  749)  but  often  rheumatic  in  origin,  and 
resulting  from  repeated  attacks  of  pericarditis  and  pleurisy,  with  matting  together,  not  only 
of  the  pleura-  to  the  diaphragm  and  i)ericar(ilum,  but  also  of  all  the  structures  in  the  superior, 
posterior,  and  anterior  mediastina  to  one  another:  or.  far  less  commonly,  to  aiieiirysm  of  the 
thoracic  aorta  or  a  twtt-malignunt  mediastinal  tumour,  such  as  a  hydatid  cyst  (Fig.  137, 
p.  291),  a  dermoid  cyst,  or  a  large  congenital  fibroma,  which  may  have  been  quiescent 
within  tlic  chest  for  many  years  before  starting  to  enlarge  and  obstruct  structures  in  its 
ncigliboinhood  ;  the  latter  conditions,  except  aneurysm,  are  rarities,  and  although  an  aortic 
aneurysm  does  sometimes  obstruct  the  superior  vena  cava  sufficiently  to  cause  distention 
or  varicosity  of  the  veins  upon  the  chest  wall,  such  varicosity  is  so  much  more  marked  in 
a  case  of  intrathoracic  malignant  disease  that  one  may  say  that  when  the  diagnosi.s  lies 
between  neoplasm  and  aneurysm  the  presence  of  marked  distention  of  the  veins  of  the 
chest-wall  indicates  the  former  rather  than  the  latter,  though  the  converse  of  this  is  not 
tri'f-  Herbert  Fretieh. 

VERTIGO,  i>o|)uIarly  known  as  dizziness  or  giddiness,  depends  upon  a  disturbance  of 
the  sense  of  e(|uilibrium.  In  slight  cases  the  trouble  is  jjerceptible  to  the  sufferer  either 
as  the  apparent  movement  of  motionless  objects  (objective  vertigo),  or  his  own  body  may 
appear  to  be  moving  in  relation  to  surrounding  fixed  structures  (subjective  vertigo).  In 
more  severe  cases  it  may  lead  to  reeling  or  staggering,  and  unless  the  patient  can  gras]) 
some  fixed  support  he  may  fall. 

The  e(|uilibrium  of  the  body  is  maintained  by  the  co-ordinated  action  of  variou.s  groups 
of  nniscles.  and  the  nervous  mechanism  for  this  co-ordination  is  situated  in  the  cerebellum. 
Afferent  im|)ulses  arc  brought  to  the  cerebellar  centres  from  the  muscles,  skin,  joints,  eyes, 
and  the  semicircular  canals.  The  cerebellum  is  also  coimeeted  with  the  motor  centres 
of  the  cerebral  hemisphere,  and  thus  the  requisite  contraction  of  the  necessary  muscles 
is  ensured.  l)islurl)anc(s  of  e(|uilibrium  may  llierefore  be  the  residt  of  a  lesion  in  the 
cerebellinn  itself  or  in  one  of  the  MiTereiil  tracts.  True  xcrtigo  depends  mainly  upon 
itilcrfcrence  with  llic  iincnnt  impulses  from  the  semicircular  canals  or  froin  the  eyes,  and 
it   is  often  accompariicil  by  nystagmus  during  attacks. 

Occasionally  Ncrtigo  may  be  the  result  of  altered  cutaneous  impulses  due  to  such 
causes  as  aiiasthesia  of  the  soles  oflhe  feet.  Some  people  experience  a  slight  feeling  ol 
giddiness  on  stepping  on  to  some  soft  material  such  as  turf  or  india-rubber  pavement  after 
walking  on  a  hard  road,      limsual  cutaneous  impulses  arc  the  |)robable  explanation. 

Interference  with  the  afferent  inq)ulscs  from  the  nniscles  themselves,  such  as  occurs 
in  tabes  dorsalis,  leads  to  reeling  and  staggering  rather  than  to  true  vertigo.  The  ocular 
inq)ressions  correct  the  false  sensations  from  the  nniscles.  and  hence  loss  of  e<|uilibrium  is 
more  likely  to  occur  in  the  d.irk.  or  when  these  inqiressions  are  cut  oil  by  co\(riiig  the 
patient's   eyes. 

X'ertigo  is  sdiiut  iiriis  dixidcil  Irilii  '  ;;<n(  lal  '  M-rti^ci  and  'special'  xcrligd.  In  the 
latl<-r.  objects  appear  In  iniiM-.  or  the  patient  lends  to  fall  ill  a  dcliiiiti'  dire  ■linn.  Special 
x'crtigo  |)(iiiits  to  a  lesion  (if  a  |)arl  ieiilar  scmieirciilar  eaiial.  Tims,  il  then-  is  a  lesidii  nl' 
the  external  seinieirciilar  canal,  objects  appear  to  move  in  a  horizonlal  plane,  and  the 
patient  tinds  to  fall  towards  the  alieeted  sidi'.  When  the  superior  canal  is  tin-  scairei'  ol 
the  trouble,  objects  rotate  in  a  \crlieal  plane,  and  the  patient  falls  Inrward.  Temporary 
\(rtigo.  e\eii  of  a  very  se\cie  nature,  ma\    be  priMluee<l  readily  in  a   iicallhv    indiviclual  by 


75-2  VERTIGO 

prolonged  movements  of  rotation  or  of  swinwino-.  In  this  case  the  cause  of  the  giddiness 
is  probably  unequal  pressure  in  the  endolymph  in  the  different  semicircular  canals.  The 
dizziness  with  which  many  people  are  affected  when  near  the" edge  of  a  high  cliff  is  most 
likely  ocular  in  origin,  and  depends  upon  the  sudden  cessation  of  visual  impulses  from 
near  objects.  Some  persons  are  exceedingly  susceptible  to  alterations  in  these  impressions, 
and  travelling  by  train  or  the  movement  of  a  boat  may  be  sufficient  to  cause  considerable 
dizziness. 

Vertigo  may  also  be  of  totic  origin.  Alcohol  and  tobacco  are  familiar  examples  ;  the 
dizziness  associated  with  ptomaine  poisoning,  and  in  some  cases  of  gastric  disturbance, 
is  also  probably  of  this  nature. 

Vertigo  is  not  infrequently  of  cerebral  origin,  either  with  or  without  some  gross  lesion. 
Thus  it  occurs  in  Diisraiiic.  and  is  also  a  frequent  (iiini  of  tin  epileptic  fit.  Vertigo  may 
depend  upon  alterations  in  the  blood-pressure,  and  this  is  the  probable  ex])lanation  of  its 
occurrence  in  arteriosclerosis  and  nephritis,  where  the  blood-jjressure  is  increased.  It  may 
also  occur  in  cases  where  the  blood-pressure  is  diminished,  as  in  Addison's  disease,  some 
ancemic  .states,  and  during  eonvedescence  from  any  prolonged  illness.  This  may  be  due 
to  defective  nutrition  of  the  central  nuclei.  Attacks  of  vertigo  occurring  in  elderly  people 
with  atheromatous  arteries  or  suffering  from  chronic  nephritis  or  arteriosclerosis  must 
always  be  regarded  as  of  serious  import,  since  they  may  be  the  precursor  of  cerebral 
hiEnrorrhage  or  thrombosis.  Severe  vertigo  may  be  one  of  the  symptoms  of  a  cerebrtd 
tumour.  It  is  more  likely  to  be  present  when  the  growth  is  in  the  cerebellum,  especially 
if  the  middle  lobe  is  involved.  A  tumour  involving  the  auditory  nerve  in  its  intracranial 
course  will  also  give  rise  to  this  symptom.  A  cerebral  or  cerebellar  abscess  may  also  cause 
vertigo,  but  in  this  case  there  may  also  be  suppuration  in  tlic  middle  ear,  and  the  giddiness 
inav  be  of  labyrinthine  origin.     Optic  neuritis  should  l)e  looked  for  in  every  case  of  vertigo. 

N'ertigo  may  be  of  ocular  origin.  It  is  csitecially  likely  to  occur  wlien  there  is  some 
lesion  of  the  nerves  or  muscles  leading  to  diplopia. 

Laryngeal  vertigo  is  a  very  rare  condition  ;  spasm  of  the  glottis  is  accompanied  by 
severe  giddiness  which  causes  the  patient  to  fall  down,  and  he  may  lose  consciousness  for 
a  few  seconds.  Complete  recovery  ensues  in  a  short  time,  but  the  attacks  are  likely  to 
recur.     This  trouble  may  be  of  an  epileptic  nature. 

Vertigo  is,  however,  most  commonly  of  aural  origin,  and  is  a  frequent  symptom  of 
diseases  of  the  ear,  especially  of  the  internal  ear  or  labyrinth.  In  its  most  intense  form 
it  is  one  of  the  symptoms  of  '  Meniere's  disease.'  Its  onset  is  then  sudden,  and  so  severe 
that  the  patient  falls  to  the  ground  and  even  loses  consciousness.  Associated  with  the 
giddiness  are  severe  tinnitus,  and  unilateral  or  bilateral  deafness,  while  nausea,  vomiting, 
and  pallor  of  the  face  are  frequently  present.  The  vertigo  passes  off  after  a  few  hours  or 
days,  but  impairment  of  hearing  and  tinnitus  persist.  The  attacks  tend  to  recur.  Meniere's 
disease  is  probably  caused  by  a  sudden  increase  in  pressure  in  the  endolymph,  and,  in 
some  cases  at  any  rate,  appears  to  be  due  to  haemorrhage  into  the  semicircular  canals.  In 
some  cases  an  embolism  may  be  the  cause.  True  Meniere's  disease  is  very  rare  ;  but  the 
occurrence  of  the  syni])toms,  viz.,  vertigo,  deafness,  and  tiimitiis.  in  a  less  acute  and  sudden 
form,  is  by  no  means  uncommon.  They  may  be  present  without  any  obvious  lesion  of  the 
middle  or  external  ear,  though  sometimes  there  is  some  abnormality  in  one  of  these  portions 
of  the  auditory  apparatus.  Vertigo  may  be  traumatic  in  origin,  e.g.,  after  a  fracture  of 
the  base  of  the  skull. 

Sjipliilitic  disease  of  the  iidenial  ear  may  produce  symptoms  closely  resembling  those 
of  Meniere's  disease,  in  tliat  giddiness,  tinnitus,  and  labyrinthine  deafness  are  associated, 
the  onset  being  quite  sudden.  Vertigo  is.  however,  occasionally  absent.  The  trouble  is 
usually  unilateral,  and  may  occur  in  the  secondary  or  tertiary  stages.  The  diagnosis  will 
depend  on  the  history  of  syphilis  or  other  evidences  of  the  disease.  Similar  symptoms 
may  occur  in  congenital  syphilis,  usually  between  the  ages  of  ten  and  fifteen  years,  thougli 
occasionally  much  later.  Eustachian-tube  obstruction  is  usually  present  also,  but  treat- 
ment of  this  fails  to  improve  the  hearing,  and  other  characteristic  troubles,  especially 
interstitial  keratitis,  may  be  found.  Aural  vertigo  may  also  be  associated  with  some  lesion 
of  the  external  or  middle  ear.  Thus  in  the  former  case  there  may  be  a  foreign  body,  or  even 
a  i)lug  of  impacted  cerumen,  as  the  exciting  cause. 

Vertigo  is  not  infrequently  present  in  duonic  middle-ear  sujjpuration.     This  may  be 


VESICLES  753 

due  to  labyrinthine  inflammation  or  irritation,  but  a  definite  labyrinthine  lesion  is  not 
necessarily  present.  In  many  cases  the  giddiness  is  caused  by  pressure  on  the  stapes  or 
the  fenestra  rotunda.  Some  patients  with  a  perforation  of  the  tympanic  membrane 
become  giddy  whenever  the  ear  is  syringed.  Occasionally  the  use  of  unduly  hot  or  cold 
lotions  produces  this  trouble.  It  is  usually  the  result  of  pressure  on  the  stapes,  though 
occasionally  the  vertigo  may  have  the  special  character  associated  with  a  lesion  of  the 
external  semicircular  canal  (vide  supra).  When  this  is  the  case  there  is  probably  some 
erosion  of  the  bony  external  canal.  Similar  giddiness  may  occur  from  a  like  cause  on 
syringing  the  ear  after  a  radical  mastoid  operation. 

Vertigo  may  occur  in  otosclerosis,  though  it  is  not  common  in  this  disease,  and  is 
always  of  less  importance  than  the  Deafness  (p.  163)  and  TiNNrrus  (p.  722).  Gout  and 
gouty  dyspepsia,  with  or  without  evidence  of  arteriosclerosis,  may  also  be  the  cause  of 
attacks  of  vertigo. 

When  a  patient  com|)lains  of  vertigo,  the  ears  should  always  be  examined  carefully. 
The  hearing  should  be  tested,  and  if  the  cause  of  the  trouble  is  in  the  labyrinth,  the  <leafness 
will  have  the  characters  of  nerve  deafness  (p.  166).  The  onset  of  the  trouble  must  be 
investigated  carefully,  and  any  associated  symptoms  ascertained.  The  eyes  and  ocular 
muscles  must  be  examined,  and  if  nystagmus  is  present  the  character  of  the  movements 
should  be  observed.  A  general  examination  of  the  patient  should  also  be  made  for  some 
general  constitutional  cause  such  as  gout,  albuminuria,  or  arteriosclerosis.       Philip  Turner. 

VESICLES. — One  of  the  primary  lesions,  the  vesicle  may  be  defined  as  a  circimi- 
.scribeil  epidemuil  elevation  varying  in  size  from  a  pin's  head  to  a  small  pea,  and  containing 
serous  lluid.  which  may  become  sero-purulcnt  or  be  mixed  with  blood.  Serous  elevations 
larger  than  a  small  pea  are  classified  as  Buli..>:  (]).  96).  To  bullie,  therefore,  vesicles 
bear  the  same  relation  as  papules  bear  to  tubercles.  They  diller  from  bulhe.  however, 
not  only  in  size,  but  in  their  mode  of  formation.  They  are  always  the  result  of  an  inilam- 
matory  process,  whereas  in  the  case  of  bulhe  there  is  a  veritable  cleavage  of  the  e])i(lermis. 
Vesicles,  again,  often  contain  a  number  of  chambers,  at  any  rate  in  the  beginning,  whereas 
bulla;  are  from  the  outset  unilocular.  They  may  originate  as  vesicles,  or  may  dcveloj) 
from  papules.  Vesiculation  may  be  either  parenchymatous  or  interstitial.  In  the  one 
ca.se,  as  in  varicella,  the  plasma  accumulates  ni'lliiii  tlie  Malpighian  cells,  and  the  unicellular 
vesicles  which  are  thus  formed  run  into  each  other.  In  the  other  case,  as  in  cc/.cma.  Hie 
plasma  accunuilates  hettveen  the  Malpighian  cells. 

In  shaije,  vesicles  are  usually  rounded,  conical,  or  acuminate  ;  but  they  may  lend 
to  the  oblong  form,  as  in  scabies,  or  they  may  be  both  oblong  and  irregular,  as  in  dcrmalilis 
herpetiformis.  The  larger  ones  are  occasionally  umbilicated,  as  in  variola,  and  instead 
of  being  tense,  as  is  usual  with  vesicles,  may  be  llaccid,  as  in  herpes  and  dermatitis  herpeti- 
formis. .\t  first  the  liquid  they  contain  consists  almost  in\arial)ly  ol  pure  plasma,  and 
is  (]uite  clear,  or  with  the  faintest  tinge  of  yellow  ;  but  exceptionally  tlie  (luid  is  I'roiu  the 
beginning  mixed  with  blood.  After  a  time  the  clear  lluid  becomes  turbid.  In  some  condi- 
tions, as  in  varicella  and  miliaria,  they  remain  discrete  and  few  in  number  ;  but  usually, 
as  in  herpes,  eczema,  and  dermatitis  herpetiformis,  there  is  a  plentiful  crop  of  them, 
forming  groups  or  closely-set  clusters*  .\s  a  rule,  they  arc  of  short  duration  :  citlur  they 
rupture  and  crust  over,  as  in  eczema,  or  they  dry  up  and  a  crust  is  formed,  as  is  usual  iti 
herpes  :  or  they  enlarge  into  blebs,  as  freciucntly  occurs  in  dermatitis  herpetiformis  :  or 
they  are  transformed  into  pustules,  as  in  variola.  On  mucous  membranes  and  the  lips, 
and  in  folds  of  the  skin,  they  break  more  (piickly  tlian  in  other  situations,  and  leave 
excoriations.  Since,  as  already  stated,  vesicles  arc  the  result  of  a  more  or  less  inllamma- 
tory  process.  tlii'V  usually  give  rise  to  nmch  burning  and  itching,  though  in  someciniditioiis, 
as  in   liidrof  ystoma.   th<se  symptoms  are  absent. 

The  Miiist  (listiiiclivcly  vesicular  airccli<iris  an-  hcip.s  siMi|)l(\  and  liiipc-,  /.(isler.  In 
.«(>«/>/<•  hirjH-.s  the  lace  and  the  genital  organs  are  allVctcd  cliielly.  The  cliaiaiterislic 
lesion  is  a  chislcr  of  transparent  vesicles  varying  in  number  from  two  or  lhr(<-  lo  twenty 
or  more,  seated  on  an  (  lyt  licmatoiis  patch,  and  siuniundid  b\-  a  nainiw  red  zone.  First, 
a  slightly  red  spot  appears  on  the  skin  :  (  riusion  ((iiickly  lakes  place  under  the  epidermis, 
and  vesicles  arc  formed;  these  l)ecome  opa<|nc  sometimes  piiruliiit  shrivel  up.  and 
form   \-ellowish-brown  crusts,  which  altei-  a   ten   days  become  delarlicd,   usmmIIv  leaving  no 

1."  ■  IS 


754  VESICLES 

scar,  but  a  brownish  stain  that  slowly  fades  and  disappears.  These  four  stages  in  the 
evolution  ot  the  lesion  are  styled  the  congestive,  vesicating,  desiccating,  and  macular 
stages.  On  mucous  membranes  the  lesion  runs  a  rather  different  course.  Here  the 
vesicles  are  quickly  reduced  to  a  whitish  pulp,  which  presents  the  appearance  of  a  false 
membrane.  When  this  becomes  detached,  it  reveals  a  number  of  roundish  excoriations, 
either  scattered  about  irregularly  or  running  into  each  other  and  forming  largish  ulcers. 
The  favourite  situations  of  the  vesicles  in  herpes  genitalis  are,  in  men,  the  prepuce, 
especially  its  inner  surface,  the  meatus,  the  sulcus,  and  the  glans  ;  in  women,  the  labia 
and  the  cervix.  In  men,  the  vesicles  are  usually  discrete,  and  the  patient  complains  only 
of  the  itching  and  burning  ;  but  if  they  are  neglected,  or  irritated  by  the  application  of 
caustics,  there  may  be  severe  and  extensive  ulceration,  with  swelling  of  the  inguinal  glands. 
In  women,  the  vesicles  tend  to  become  confluent,  and  the  perineum,  the  inside  of  the 
thighs,  and  the  nions  veneris  may  be  invaded.  There  may  be  a  great  deal  of  swelling, 
excoriation,  and  discharge,  with  intense  itching  and  burning,  and,  as  in  men,  there  may 
be  enlargement  of  the  neighbouring  glands.  The  vesicles  of  genital  herpes  are  too 
characteristic  to  be  mistaken  if  they  are  seen  before  their  real  significance  is  obscured  by 
ulceration.  If,  however,  the  ulceration  is  considerable,  and  especially  if  there  is  much 
suppuration,  the  herpes  may  be  mistaken  for  chancroids.  Generally,  liowever,  soft  sores 
are  multiple,  have  a  fouler  base,  excavate  more  deeply,  and  the  healing  process  is  much 
slower.  Soft  sores,  further,  are  flattened  at  the  base,  secrete  very  little  liquid,  and  are 
auto-inoculable.  In  some  cases  there  may  be  doubt  as  between  herpes  genitalis  and  true 
chancre,  especially  as,  according  to  Fournier,  a  chancre  not  infrequently  develops  in  the 
midst  of  a  premonitory  eruption  of  herpes.  The  points  of  differentiation  are  the  absence, 
in  herpes,  of  induration,  the  less  considerable  and  more  transitory  gland-enlargement, 
the  multi])li(ity,  irregular  form,  and  small  size  ot  the  ulcers,  and  the  intense  burning  and 
itching. 

In  the  crusted  stage,  facial  herpes  may  resemble  impetigo,  but  the  rapid  course  it 
runs,  its  limited  distribution,  the  facts  that  it  is  not  auto-inoculable.  and  that  in  impetigo- 
the  li]is  are  seldom  attacked,  should  suffice  to  obviate  the  confusi(jn.  The  points  which 
distinguisli  herpes  facialis  from  vesicular  eczema  are  touched  upon  below. 

In  licrpcs  zoster  (zona,  shingles),  clusters  of  vesicles  seated  on  an  erythematous  base 
appear  in  the  region  of  skin  distribution  of  one  or  more  of  the  posterior  spinal  nerve  roots, 
preceded  or  accompanied  by  neuralgic  pain  and  tenderness  in  the  part.  The  erythematous 
patches,  more  or  less  oval,  with  the  long  axis  parallel  to  the  underlying  nerve,  come  out 
in  crops,  the  number  of  lesions  varying  from  two  or  three  to  twenty  or  thirty.  Soon  the 
surface  of  the  patches  is  studded  with  papules,  which  are  quickly  transformed  into  vesicles, 
from  ten  to  twenty  on  each  patch,  sometimes  discrete,  sometimes  running  into  each 
other  to  form  biilla;.  An  important  diagnostic  feature  of  the  eruption  is.  that  in  the  great 
majority  of  cases  it  is  unilateral,  and  appears  much  more  frequently  on  the  right  side  than 
on  the  left.  In  rare  cases,  however,  it  forms  a  complete  girdle  roimd  the  body.  The 
usual  limitation  to  one  side  of  the  body,  the  distribution  in  one  or  more  nervous  territories, 
and  the  i)re(e(ling  or  accompanying  neuralgia,  usually  suffice  to  distinguish  herpes  zoster 
from  erythema  multiforme  and  from  dermatitis  herpetiformis.  Another  important  point 
in  diagnosis  is  the  history,  for  zoster  is  not  a  recurring  disease.  These  various  characters 
serve  to  distinguish  it  also  from  herpes  simplex  and  herpes  genitalis.  The  neuralgic  pain 
may  be  mistaken  at  first  for  pleurisy,  but  the  course  the  affection  runs  soon  clears  up  the 
confusion.  I  should  add  that  in  herpes  zoster  the  forehead,  the  conjunctiva,  and  the 
eyeball  are  frequently  attacked,  and  sometimes  the  mouth,  especially  the  tongue.  In  rare 
cases  the  lesions  on  the  tongue  are  not  associated  with  an  eruption  on  the  lips  or  the  palate. 
Although  the  vesicular  stage  is  not,  as  some  authorities  consider,  a  necessary  phase 
in  the  evolution  of  eczema,  the  vesicle  is  undoubtedly  the  most  constant  of  all  the  primary 
lesions  met  with  in  that  condition.  Usually,  following  sensations  of  itching  and  burning, 
an  erythematous  blush  appears,  which  is  soon  studded  with  numerous  tiny  vesicles.  These 
grow  larger  and  often  coalesce,  but  they  soon  rupture  or  are  broken  by  scratching,  and  a 
clear  fluid  exudes,  the  •  weeping  '  continuing  as  later  vesicles  break.  In  mild  cases,  the 
inflammation  subsides  gradually,  and  as  the  discharge  ceases,  scales  or  crusts  are  formed  : 
but  much  more  frequently  fresh  crops  of  vesicles  start  up  around  the  edge  of  the  earlier 
patches,  while  new  centres  are  formed  in  other  parts,   until  nearly  the  whole  cutaneous. 


VESICLES  755 

surface  may  be  involved.  In  some  eases  papules  are  the  predominant  feature,  in  others 
erythematous  lesions  ;  in  yet  others  pustules,  and  in  e.xtensive  cases,  the  several  kinds  of 
lesions  may  be  all  present  simultaneously.  From  herpes  in  general,  eczema  is  distinguished 
by  the  characteristic  exudation,  by  the  crowds  of  tiny  vesicles,  which  coalesce  without 
forming  distinct  groups,  by  the  slower  evolution  of  the  disease,  and  by  the  fact  that  as  a 
rule  there  is  some  inflammatory  thickening.  From  herpes  zoster  it  is  differentiated  by 
the  peculiar  distribution  of  the  vesicles  in  that  affection  (see  above). 

Acute  vesicular  dermatitis  is  precisely  similar  to  acute  eczema  in  its  actual  lesions, 
but  differs  from  it  in  that  a  definite  irritant  cause  exists  and  it  does  not  recur,  as  does 
eczema,  spontaneously,  but  only  if  the  external  cause  is  re-applied.  The  effects  of  certain 
plants,  notably  primula  obconica  and  /7/((s-  toxicodetidron.  are  familiar  in  this  respect  ;  so 
also  is  the  vesicular  eruption  produced  in  some  individuals  by  sugar  (grocer's  dermatitis), 
by  the  use  of  certain  soaps  (soap  dermatitis),  by  the  sawdust  of  satin-wood,  by  the  use  of 
lime  in  making  mortar,  by  the  hairs  of  certain  caterpillars,  and  by  various  applications 
and  lotions  (ap])lication  dermatitis),  including  tincture  of  arnica  montana,  me-sotan, 
essence  of  vanilla  :  and  of  course  all  the  well-known  vesicating  drugs  such  as  cantharides, 
croton  oil,  capsicum,  mineral  acids,  caustic  alkalies,  strong  iodine  or  turpentine,  and  so  on. 
The  diagnosis  is  afforded  by  a  knowledge  of  exposure  to  any  of  these,  and  in  obscure  cases 
is  sometimes  suggested  by  the  fact  that  exposed  parts  only  are  affected,  or  that  the  patient 
is  ill  only  when  living  in  certain  places  or  doing  certain  work. 

Doubt  can  seldfuii  arise  as  between  eczema  and  dermatitis  herpetiformis.  It  is  true 
that  the  earliest  and  perhaps  the  most  characteristic  lesion  of  the  latter  disease  is  a 
vesicular  eruption,  apjiearing  on  an  erythematous  base  :  but  the  disposition  of  the  vesicles 
in  herpetiform  groups  should  prevent  confusion  between  the  two  conditions.  The  vesicles 
soon  dry  up  and  form  scabs,  but  later  they  tend  to  coalesce  into  bulla;,  which  scarcely 
ever  burst  spontaneousl\-  but,  as  their  contents  thicken,  slowly  shrink,  and  finally,  if  left 
to  themselves,  shrivel  up  to  a  thick  brown  scab.  The  "  weeping  "  of  eczema  is  Iherefore 
absent  in  dermatitis  herpetiformis,  of  which,  further,  multiformity  is  a  more  i)ronounc<il 
feature — erythematous,  vesicular,  pustular,  (japular.  and  urticarial  elements  being  mingled 
in  all  stages  of  evolution.  Eosino])hilia  is  more  pronounced  with  dermatitis  herpeti- 
loriuis  than  it  is  with  eczema  (p.  !)!)). 

The  vesicles  of  im/jetiao  eoiitaiiiosa  arc  (listiiiguisliablc  from  those  of  eczemi  l)y  the 
larger  size  anil  discrete  character  of  the  l'orni;r.  anil  by  their  tendency  to  dry  and  form 
yellf)wish  crusts  without  breaking,  or  as  soon  as  they  have  broken.  Even  when  tlic  lesions 
run  together  and  large  crusts  are  formed,  there  will  be  discrete  vesicles  and  papules  which 
will  |)oinl  to  the  true  nature  of  the  affection. 

Miliaria  ridira  may  sometimes  resend)lc  the  vesicular  stage  of  eczema,  but  here  again 
the  lesions,  though  numerous,  remain  discrete  :  they  do  not  run  together  to  form  patches, 
they  do  not  rupture,  iind  there  is  no  •  weeping."  .Miliaria  of  all  forms  is  a  very  transitory 
affection,  and  instead  of  the  intense  itching  of  eczema,  the  patient  describes  his  sensations 
as  those  rather  of  |>ricking  and  tingling.  In  the  form  of  miliaria  known  as  hidro- 
cystoma,  or  dysidrosis  of  the  face,  small  \csiclcs  like  those  of  miliaria  api)ear  on  the  face, 
but  they  arc  so  grouped  as  to  lorni  patches,  which  sliow  no  t<iidency  to  spontaneous 
iiudliition. 

Sridiies  is  another  alfertion  in  which  the  vesicles,  like  those  of  impetigo  and  of 
miliaria,  arc  discrete.  .Sometimes  the  lesions,  usually  consisting  of  papules  an<l  pustules 
as  well  as  of  vesicles,  take  on  an  cezematous  character,  but  they  arc  not  localized  as  are 
those  of  eczema,  and  instead  of  being  small,  acuminated,  or  circular,  they  lend  to  be  linear. 
In  uncleanly  persons,  the  burrows  between  the  fingers  and  elsewhere  which  mark  off 
scabies  from  all  other  affections,  can  hardly  be  overlooked.  When  they  cannot  be  foinid, 
either  because  they  have  not  yet  been  formed  or  because  they  have  been  laiil  open  by 
scratching,  the  diagnosis  of  scabies  must  rest  upon  the  irregidarily  of  the  lesions  vesicles, 
bulla-,  and  pustules  being  mingled  with  the  marks  of  the  lingcr-nails  anrl  the  n'sults  of 
secondary  inoculations  :ind  upon  the  distribution,  tlu-  parts  most  affected  being  those 
whirc  the  skin  is  least  thick,  narnily.  th<'  webs  between  the  lingers  and  toes,  the  front  of 
llic  wrist,  inside  the  umbilicus,  on  the  lower  abdomen,  the  genitalia,  the  nipples  in  womiii. 
and  the  axillary  fol<ls.      The  lace  nearly  always  escapes,  except   in  infants  in  arms. 

.\notlier  vcsi.iilar  (•on<lition   in   whi<li    llir   hands  arc  specially   alla<k<d   is  elieiriipnm- 


756  VESICLES 

pholyx.  in  which  numerous  minute  vesicles  deeply  imbedded  in  the  skin,  and  showing 
through  the  epidermis  like  boiled  sago-jirains.  are  distributed  sjnimetrically  on  the  extremi- 
ties— always  on  the  palms  and  fingers,  and  frequently  also  on  the  soles  and  toes.  The 
general  features  of  the  affection — the  limitation  of  the  vesicles  to  the  hands  and  feet  and 
their  proneness  to  unite  and  form  bulla'  which  dry  up.  the  tendency  to  recovery  followed 
by  repeated  recurrence,  and  the  constant  association  of  the  eruption  with  the  summer 
season — are  sufficiently  distinctive,  and  the  diagnosis  is  seldom  in  doubt.  In  some  slight 
cases  there  is  a  general  resemblance  to  certain  subacute  and  limited  eases  of  eczema  in 
which  the  lesions  may  present  the  sago-grain  aspect  :  but  instead  of  rupturing  and 
'  weeping,'  the  vesicles  in  cheiro]3ompholyx  tend  to  run  together  into  bullae,  which  shrink 
and  crust  over.  This  formation  of  bulla;  by  coalescence  of  vesicles  differentiates  the 
condition  also  from  pemphigus. 

In  erythema  multiforme  the  vesicle  can  seldom  be  difficult  of  interpretation,  even  in 
erythema  iris,  or  as  it  is  also  styled,  erytliema  lesiciilosum.  In  one  form  of  this  affection 
a  small  red  spot  appears,  upon  which  is  formed  a  vesicle  that  is  quickly  surroimded  by 
a  zone  of  redness.  When  the  central  vesicle  dries  up  it  leaves  a  small  scab,  and  a  ring  of 
secondary  vesicles  soon  appears  on  the  red  zone.  On  the  separation  of  the  central  scab, 
the  skin  beneath  has  a  blue,  congested  appearance.  The  whole  process  may  be  reiieated 
time  after  time  until  the  concentric  rings  of  vesicles  and  reddened  skin  suggest  eoni])aris(m 
with  a  target.  In  the  form  of  erytluina  iris,  which  sometimes  is  infelicitously  called  licrpcs 
iris,  a  large  central  bulla  is  encircled  by  vesicles  of  considerable  size.  Outside  the  first 
ring  of  vesicles  another  circle  may  develo]).  and  outside  the  second,  sometimes  a  third. 
The  symptoms  of  vesicular  erythema  multiforme  are  so  characteristic  that  the  affection 
e;-.n  hardly  be  mistaken  for  anything  else. 

Liclien  planus  is  so  characteristically  a  ])a])uhir  affection  that  the  absence  of  vesicles 
is  one  of  the  points  which  distinguish  it  from  eczema.  In  some  cases,  however — very 
rarely  in  adults,  and  rather  less  infre(|uently  in  children — vesicles  appear,  but  never  so 
as  to  confuse  the  diagnosis.  In  liciien  urticatus  a  vesicle  appears  on  the  sinnmit  of  the 
small  wheal,  and  the  condition  may  offer  some  resemblance  to  eczema  ;  but  the  individual 
lesions  do  not  tend  to  run  together  nor  to  spread  centrifugally,  as  in  eczema,  and  the  itching 
is  usually  more  intense. 

The  vesicular  form  of  secondary  syphilis  is  so  rare  that  by  some  authorities  its  existence 
is  not  recognized,  and  Stelwagon,  who  has  never  met  with  a  case,  justly  points  to  the 
possibility  of  its  being  due,  at  any  rate  occasionally,  to  drug  idiosyncrasy.  The  vesicles 
are  reported  as  occurring  in  several  forms  :  they  may  be  minute,  eczematoid,  disseminated 
and  grouped,  or  larger,  irregularly  scattered,  or  disposed  in  herpetiform  groups  ;  and 
cases  have  been  reported  which  simulate  herpes  zoster.  The  vesicles  in  syphilis  are  usually 
associated  with  papules,  and  they  have  a  papular  base,  the  disappearance  of  which  leaves 
a  long-persisting  dark  stain.  The  papular  base  and  the  slow  evolution  are  important 
diagnostic  points  ;    and  usually  other  signs  of  syphilis  will  be  present. 

In  lymphangioma  circumscriptum,  even  more  than  in  vesicular  syphilis,  the  significance 
of  the  vesicles  can  hardly  be  missed.  In  circumscribed  areas  of  the  skin  there  is  an 
eruption  of  clusters  of  small,  deep-seated,  thick-walled  vesicles,  straw-coloured,  some- 
times marked  with  red  stri;e.  and  filled  with  a  clear  alkaline  fluid  which  contains  a  few 
lymph  corpuscles.  The  affection,  which  consists  in  the  over-growth  and  dilatation  of 
lymph-vessels  and  the  formation  of  new  ones,  is  jirobably  congenital,  though  not  generally 
noticed  until  early  childhood. 

Varicella — to  come  to  the  eruptive  fevers — is  an  essentially  vesicular  affection  :  only 
occasionally  do  the  vesicles  develop  into  pustules.  They  are  usually  preceded  by  reddish 
spots  of  slight  elevation,  and  the  commonest  situations  are  the  face,  chest,  shouklers.  back, 
and  scalp,  but  they  may  also  be  found  on  the  mucous  membrane  of  the  jjalate.  mouth, 
or  lips.  As  a  rule  the  rash  comes  out  within  twenty-four  hours.  Often  there  is  but 
trifling  systemic  disturbance.  In  the  infrequent  cases  in  which  the  varicellar  eruption 
becomes  pustular,  it  may  possibly  be  confused  with  a  pustular  syphilide  ;  but  in  the 
syjihilide  the  lesions  are  pustular  from  the  outset,  or  develop  out  of  papules,  and 
although  the  lesions  of  varicella  start  as  paj)ules,  these  are  almost  in\ariably  small  and 
evanescent.  The  absence  of  itching  in  syphilis  is  another  point  of  difference.  In 
exceptional  eases  of  strophulus  the  ^•esicIc  on  the  summit  may  develop  until  it  becomes 


VISIOX.     DEFECTS    OF 


visible  macroscopically,  and  it   may  then  lie  eonfuseii  with  varicella;    but   the  cases  are 
so  rare  as  to  be  negligible. 

It  is  with  small-pox  that  chicken-pox  is  most  often  confused.  In  small-pox  the 
vesicles  are  usually  nuiltilocular  :  in  chicken-pox  they  are  usually  unilocular.  In  small- 
pox they  are  frequently  umbilicated  ;  in  chicken-pox  they  are  never  umbilicated,  and 
seldom  even  dimpled.  The  differences  between  the  two  exanthems  in  respect  of  the  rash 
and  the  lesions  generally,  as  summarized  by  Kicketts  in  "■  The  Diagnosis  of  Small-iHix." 
are  these  :  In  variola,  the  rash  is  most  abundant  on  tlie  face  and  limbs,  and  least  abundant 
on  the  abdomen  and  chest  {Fig.  305)  ;  in  varicella,  the  abdomen  and  chest  are  covered 
as  thickly  as  the  face,  if  not  more  thickly.  In  variola,  the  rash  is  much  more  abimdani 
on  the  back  than  on  the  abdomen  ;  in  varicella,  the  abdomen  and  the  back  receive  equal 
attention.  In  variola,  the  rash  is  more  abundant  on  the  shoulders  than  across  the  loins, 
and  on  the  chest  than  on  the  abdomen  :  in  varicella,  the  distribution  as  between  these 
parts  is  indifferent.  In  variola,  the  rash  favours  the  limbs  and  is  distributed  centrifugally  : 
in  varicella  it  tends  to  avoid  the  limbs,  and  when  it  invades  them  is  centripetal.  In 
variola  the  rash,  unlike  that  in  varicella,  favours  prominences  and  surfaces  exposed  to 
irritation,  and  tends  to  avoid  protected  surlacis  and  depressions.  .\s  to  the  lesions 
generally,  in  variola  they  are  deep- 
seated  and  have  an  infiltrated  base; 
are  generally  circular  in  outline  and 
homogeneous  in  character  ;  whereas 
in  varicella  they  are  superficial  and 
have  no  infiltrated  base,  are  fre- 
quently irregular  in  outline,  or  else 
oval  or  elongated,  and  are  not,  as 
a  rule,  homogeneous. 

I'firriiinl  millions  may  consist 
(1)  of  tiny  vesicles  or  small  super- 
ficial papules,  or  of  a  combination 
of  those  elements  ;  or  (2)  of  a  small 
|)apule  with  a  vesicular  or  pvistular 
head.  In  the  st'cond  case  the  erup- 
tion may  simulate  modihed  small- 
pox, but  almost  always  the  \aecinal 
lesions  arc  more  superficial  than 
those  of  the  mildest  cases  of  smimII- 
pox.  and  show  a  preference  for  tin- 
trunk. 

In  eruptions  iliu-  to  1  he  usi-  of 
hniinidrs.  iadidis.  ami  dtiici-  linifis. 
the  vc>ielc  is  ImjI  one  (jf  tile  ele- 
ments, and  llir  iialiMC  oi'  tile 
affect i( in   is    iisiiaily    indicated    with 

sufllcieiit  distinctness  liy  tlie  liisloiv  nl  flic  easi'.  Ilic  remission  that  occur' 
withheld,  and  the  recurrence  that  takes  place  when  its  administration  is  n 
that  follow  the  hilcs  or  stinfisof  "iiats.  wifKiiiilocs,  etc..  arc  tilways  easily 
the  history,  aixl  from  the  central  punctiun  to  be  seen  in  the  lesions:  nor  can  there  be 
any  doiilil  as  to  the  signili<-aiicc  of  those  dm-  to  such  a<  cidciiial  causes  as  froslhilc  and 
pressure   fioiii   ^/iliiifs.  Mahnlni  Morri'i. 


(From  a  plioloyraph  Ifj  Dr.  D.  S.  Ilarict.) 

,vheu  the  drug  Is 
unied.  Vesicles 
'cogni/.able  from 


VISION,  DEFECTS  OF.     Ihis 

(/)     .\iiniiii!     risiiiii.     ill)     .\iitlilii<iiii( 
(I  )  Ciiliiiir  lilitiihiisfi.  t\'l)  .Viiinniiiil 


iilij.il    iiia\    lie  eiiiisiiliicd  in  the  following  order  :  — 
(///)     I'lirliiil    hliiiiliii'^s.    (/I)   Comiihle  hliiiiltifsH. 
iiisiilioii.s  (if  siir.  {Ill)   Ihiil-  mill  Xi'jhI-lililiiliicsx. 


NORMAL    VISION. 

1.  Visual  Acuity.  The  act  of  vision  comprises  the  pcicepliini  nl'  I'luiii.  eolmir.  and 
liri;;litii(ss  :  :iMd.  in  vision  uilli  two  eves  the  pcici  pi  imi  of  space  and  ilislanee.  Tiles,' 
faeiillies  an-  p(iss(ss<-d  |jy  all  pails  ,,|-  IJii-  ntiiia.  Ili(.iit;li  in  varying  degrees,  anil  tlicx   are  ol 


758  VISION,     DEFECTS    OF 

varying  importance.  It  is  necessary  to  distinguish  between  peripheral  and  central  vision  ; 
or,  in  other  words,  between  merely  seeing  a  thing  and  looking  at  it.  An  object  is  seen  by 
any  jjortion  of  the  retina  that  has  visual  percej)tion  ;  but  an  object  is  only  looked  at  when 
its  image  falls  upon  a  particular  portion  of  the  retina,  the  yellow  spot,  which  is  situated  at 
the  posterior  pole  of  the  globe  on  the  outer  side  of  the  optic  disc.  The  act  of  so  directing 
the  eye  that  the  image  of  a  given  object  shall  fall  upon  the  yellow  spot,  is  termed  '  fixa- 
tion.' The  vision  obtained  by  the  fixation  of  the  eye  is  termed  '  central  vision,'  and 
owing  to  the  anatomical  structure  of  the  retina  at  the  yellow  spot,  the  vision  here  is  the 
most  acute  of  which  the  eye  is  capable,  though  its  area  is  very  limited.  In  the  normal 
eye,  central  vision  is  capable  of  distinguishing  two  points  or  parallel  lines,  which  are  separ- 
ated by  a  space  which  subtends  an  angle  of  1' — approximately  the  diameter  of  a  sixpenny- 
piece  at  200  feet — and  it  is  on  this  basis  that  ordinary  test-types  are  constructed.  Central 
vision,  however,  though  acute,  is  very  limited  in  extent,  and  it  is  estimated  that  the  field 
of  acute  vision  is  only  about  the  size  of  the  thumb-nail  held  at  arm's  length,  all  vision  out- 
side this  area  being  comparatively  blurred  and  indistinct.  This  limitation  of  the  field  of 
acute  central  vision  is  barely  appreciated  under  ordinary  circumstances,  owing  to  the 
rapidity  with  which  the  retina  receives  consecutive  visual  imjuessions,  and  the  constant 
movements  of  the  eyes.  Comjjared  with  the  visual  acuity  of  the  central  ])or(ion  of  the  field 
of  vision.  i)erii)hcral  vision  is  relatively  poor,  though  it  is  of  extreme  value  in  a  different  way. 
To  a])preciate  the  importance  of  peripheral  vision  it  is  only  necessary  to  try  to  walk  about 
looking  through  a  roll  of  music  ;  though  central  vision  is  unimpaired,  and  the  smallest 
object  can  be  .seen  distinctly,  locomotion  is  almost  impossible,  owing  to  the  inability  to  see 
where  one  is  going  or  to  ascertain  one's  position  in  relation  to  surrounding  objects,  the 
peripheral  portion  of  the  field  of  vision  being  responsible  for  the  automatic  appreciation  of 
these.  On  the  other  hand,  a  person  from  some  cause  deprived  of  central  vision  can  .see  to 
get  about  quite  well,  and  has  useful  vision  for  many  purposes,  though  he  is  unable  to  read 
or  WTite,  recognize  jseople  when  looking  directly  at  them,  or  do  any  work  in  which  fine 
vision  is  required. 

2.  Colour  Vision. — A  person  with  normal  colour  vision  can  recognize  six  or  seven 
distinct  colours  in  the  solar  spectrum,  and  is  able  to  appreciate  many  hundreds  of  varieties 
of  coloiu-  caused  l)y  mixtures  of  them,  and  the  eoloiu'  perception  of  the  normal  person  is 
most  acute  in  the  central  portion  of  the  field  ;  but  the  field  of  ^•ision  for  colours  under  equal 
illumination  has  by  no  means  the  same  boundaries  as  the  field  of  vision  for  white.  The 
fields  of  vision  for  all  colours  are  smaller  than  that  for  white,  and  the  fields  for  red,  green, 
and  blue  vary  in  extent  among  themselves.  The  field  for  blue  is  the  largest,  for  red  is  next 
in  point  of  size,  and  the  field  of  vision  for  green  is  the  smallest  of  all,  being  roughly  only 
about  half  to  a  third  the  diameter  of  the  field  for  white. 

3.  Briglitness  Perception. — The  central  and  peripheral  portions  of  the  field  of  vision 
vary  very  much  in  their  jierception  of  brightness.  In  ordinary  ihumination  the  central 
portion  of  the  field  is  the  most  efficient,  but  in  a  very  weak  illumination  the  jjcripheral  por- 
tion has  a  higher  efficiency  than  the  central  part  :  in  other  word.s.  tliere  is  in  very  dim  lights 
a  relative  central  scotoma  or  loss  of  vision.  This  fact  has  long  been  known  to  astronomers, 
who  have  found  that  in  counting  stars  of  low  magnitudes,  vision  is  nuieh  better  if  the  parti- 
cular constellation  or  group  of  stars  is  not  looked  at  directly,  the  Pleiades  being  a  well-known 
example  ;  more  of  these  stars  can  be  counted  when  the  vision  is  directed  to  a  point  a  little 
above  or  below  them  or  to  one  side,  whereas  direct  vision  is  comparatively  dim  and  confused  ; 
and  the  .same  holds  good  of  vision  for  any  object  in  a  dim  liglit.  Walking  along  a  country 
road  on  a  dark  night,  it  will  be  found  that  a  foot-])ath  or  track  can  be  seen  more  easily  if  the 
gaze  is  directed  forwards  and  not  at  the  ground  itself.  These  facts  concerning  vision  may 
be  correlatetl  with  the  actual  anatomical  structure  of  the  retina  itself.  It  is  found  that  in 
the  region  of  the  yellow  spot — the  area  of  the  retina  endowed  with  acute  vision — the  cones 
are  very  numerous,  with  few  rods  :  towards  the  periphery  of  the  retina  the  cones  become 
fewer  and  the  rods  more  numerous.  It  is  now  generally  held  that  tlie  function  of  the  cones 
is  to  work  in  light  of  considerable  brilliance,  that  they  are  capable  of  extremely  acute  vision 
for  small  objects,  and  are  also  concerned  in  the  perception  of  colour.  The  rods,  on  the 
other  hand,  have  no  perception  of  colour  ;  their  perception  of  form  is  poor  com])ared  with 
that  of  the  cones  ;  but  in  very  weak  lights  their  visual  acuity  is  greater  than  that  of  the 
cones.  In  sujiport  of  this  theory  may  be  mentioned  the  fact  that  the  retime  of  nocturnal 
animals  are  more  fully  pro\ided  with  rods  than  cones. 


VISION'.     DKFKCTS    OF  7:,9 

AMBLYOPIA. 

.\mblyopia  is  the  term  applied  to  defective  vision  in  which  there  is  httle  or  no  evidence 
of  any  ocular  condition  which  might  account  for  the  visual  defect.  It  is  not,  therefore, 
employed  where  there  is  any  obvious  intra-ocular  or  intracranial  lesion.  The  commoner 
forms  of  amblyopia  are  (])  Amblyopia  ex  anopsia  ;  (2)  Ura?mic  ;  (3)  With  nystagmus  ;  ( t) 
Due  to  alcohol,  tobacco,  lead,  quinine,  organic  forms  of  arsenic  such  as  atoxyl  ;  (5)  Migraine  ; 
(fi)  Cortical  or  (idssid  aml)lyo])ia  ;    (")  With  hysteria. 

Amblyopia  ex  Anopsia,  is  usually  associated  with  a  scpiinting  eye.  which  may  or  may 
not  have  been  put  straight  by  operation.  It  is  still  open  to  discussion  whether  the  amblyopia 
in  such  conditions  is  due  to  the  loss  of  use  by  reason  of  the  squint,  or  whether  the  squint  is 
due  to  the  \  isual  defect  :  but  the  fact  remains,  that  in  many  squinting  eyes  the  visual  acuity 
is  very  nuicli  bclnw  normal,  though  objectively  the  eye  exhibits  no  abnormal  symptoms. 

Uraemic  Amblyopia,  or  Amaurosis,  may  be  recognized  by  its  association  with  renal 
disease,  whether  com))Iicated  by  pregnancy  or  not.  It  is  characterized  by  its  comparatively 
sudden  onset,  vision  failing  either  partially  or  eomjiletely  within  a  few  hours.  The  failure 
of  vision  may  be  accompanied  by  well-marked  retinitis  in  both  eyes  ;  but  in  many  eases 
this  is  absent  and  the  discs  apjiear  (juite  nornial.  The  failure  of  vision  lasts  for  from  thirty- 
six  to  forty-eight  hours,  and  then  slowly  disappears,  the  whole  attack  lasting,  as  a  rule, 
imder  a  week.  In  the  majority  of  cases,  unless  there  is  some  definite  injury  to  the  optic 
nerve  or  retina  as  the  result  of  retinitis,  the  vision  recovers  entirely.  In  some  cases  of 
nra-mia  the  blindness  is  complete. 

Amblyopia  with  Nystagmus  is  usually  associated  with  evidence  of  visual  alleetions 
in  very  early  life.  At  birth,  lixation  is  not  developed,  and  the  higher  visual  acuity  is  only 
acquired  after  tlie  lirst  few  months  of  infant  life.  An\  allcction  of  the  eyes,  therefore,  that 
obscures  the  vision  during  the  earlier  weeks  or  months  of  life,  |)revents  the  due  development 
of  central  vision  and  leads  to  a  permanent  amblyopia,  as  a  rule  associated  with  nystagmus. 
Such  affections  are  ophthalmia  neonatorum,  whicli  leaves  more  or  less  corneal  opacity  ; 
perforation  of  the  cornea  with  anterior  polar  cataract  as  the  result  of  this  oiihlhalmia  ;  con- 
genital defects,  such  as  a  persistent  hyaloid  artery  or  macular  coloboma  ;  and  any  retinitis 
or  choroiditis  alTeeling  the  region  of  the  yellow  spot. 

The  Amblyopia  due  to  Lead,  Alcohol,  Tobacco,  Quinine,  or  Atoxyl,  is  usuallv 
described  as  a  toxic  amblyopii.  and  the  symptoms  are  somewlial  similar  in  all  the  varieties. 
In  tobacco  amblyopia  there  is  a  central  loss  of  vision  for  colours,  green  only  in  the  earlier 
stages,  subse(piently  green  and  red,  and  in  extreme  cases  even  a  central  scotoma  for  white  ; 
total  blindness  is  practically  unknown.  The  jjatient  also  states  that  he  sees  better  in  a  didl 
than  in  a  bright  liglil.  and  that  he  is  ineap.ible  of  reading  or  writing,  or  distinguishing  silver 
from  gold  coins.  The  ocular  signs  are  usually  very  sliglil.  being  limited  to  some  redness 
and  blurring  of  llic  op(ic  disc  in  early  cases,  or  pallor  of  llie  outer  side  of  the  disc  in  later 
stages.  .\l((]liolie  amblyoi)ia  resembles  in  most  ol  ils  symplonis  the  nnililyopia  due  to 
tobacco,  Ihouuh  vision  i'or  red  is  usually  lost  before  vision  for  green.  ,\ml)lyo|)ia  due  to 
lead  or  atoxyl  is  rare,  but  it  is  also  usually  eliaraeteri/ed  b>  a  (entral  scotoma  associateil 
with  some  slight  optic  neuritis  or  atrophy.  In  (piininc  amblyopia  the  nlinal  vessels  are 
extrem.'ly  constricted,  the  disc  is  pale  and  the  lield  of  \isi,,ii  is  dimiiiished  peripherallv  . 

The  Amblyopia  of  Migraine  is'  usually  liansiloiv  .  and  may  oeeur  eithei-  in  the  loiin 
of  a  central  seciloma,  hemianopia,  or  monocular  blindness.  It  is  more  rar<lv  seen  in  the 
form  of  a  (|ua(lranl  hemianopia  or  a  ring  scotoma.  In  all  eases  the  diagnosis  is  conq)ara- 
livclv  easy,  as  the  amblyopia  seldom  lasts  more  than  a  few  mitmtes,  mid  is  followed  later 
bv    the  eharMcleiistie  headache  and  siekrii'ss  of  migraine. 

Amblyopia  has  also  been  described  as  due  to  disease  of  the  Visual  tortex,  and  rare 
cases  have  been  described  of  a  Crossed  Amblyopia  m-  .leleel  of  vision  in  one  eye  due  to 
disease  of  the  visual  cortex  of  the  other.  The  loss  of  vision  is.  however,  usually  associated 
with  some  sliiihl  defect  of  visicm  in  the  opposite  eye.  .ind  hemianopia  is  much  mt)re  com- 
monly the  symptom  of  disease  of  the  visual  cortex. 

Hysterical  Amblyopia  may.  like  other  hysterical  :dh(tioiis,  lake  various  forms,  such 
as  loss  of  visual  acuity,  a  loss  of  colour  vision,  or  diminution  in  the  visual  lield.  The  eharae- 
teristic  form  of  the  visual  lield  in  hysteria  is  either  a  spiral  contraction  or  an  e\tr<-me  eon- 
eintrie  limitation.  The  symptoms,  however,  vary  very  much  at  dilferent  .xaminations,  a 
point  of  niiieh  iiiiportanee  in  diagnosis.      In  certain  eases  there  may  be  a  functional  loss  of 


760  VISION.     DEFECTS    OP 

vision  in  one  or  both  eyes,  which  can  be  recognized  as  hysterical  by  the  employment  of 
Snellen's  coloured  types  or  some  other  device  for  deceiving  the  patient. 

PARTIAL    BLINDNESS. 

This  may  be  (1)  Definite,  or  (2)  Indefinite. 

1.  Definite  :    («)  Ilemianopia  ;    (h)  Centrnl  senlonia  ;    (c)  Peripiicml  constriclion. 

(<i).  Ilemianopiu  (see  Hemianopsia,  p.  300). 

(b).  Central  Scotoma. — A  scotoma  is  a  local  defect  in  the  visual  field,  and,  from  its  posi- 
tion, may  be  either  central  or  peripheral  ;  it  may  also  be  negative  or  positive.  A  negative 
scotoma  is  one  where  the  defect  of  vision  exists,  but  where  the  patient  notices  nothing  abnor- 
mal. The  best  example  of  a  negative  scotoma  is  the  blind  spot  in  the  field  of  vision  caused 
by  the  entrance  of  the  optic  nerve.  This  area  is  blind,  but  the  individual  is  not  conscious 
of  any  visual  defect.  Scotomata  of  this  character  exist  wliere  there  is  some  injury  of  the 
visual  layers  of  the  retina  itself,  or  of  the  optic  nerve  or  tract. 

A  positive  scotoma  is  one  in  which  the  visnal  defect  is  noticed  as  a  black  or  coloured 
spot  or  cloud  which  obscures  the  vision  in  some  part  of  the  visual  field.  Such  positive 
scotomata  are  due  to  lesions  of  the  retina,  such  as  hicmorrhages  or  patches  of  pigment 
which  do  not  destroy  the  visual  layers.  Vision  still  remains  ;  but  it  is  obscured  by  some 
unusual  opacity  in  the  retina  itself  or  in  the  adjacent  portion  of  the  vitreous. 

Scotomata  frequently  exist  in  the  peripheral  portion  of  the  field  of  vision  without 
being  noticed,  as  they  are  of  little  importance  in  direct  vision,  and  arc  not  discovered  unless 
looked  for  cai'cfully.  A  central  scotoma,  on  the  other  hand,  is  noticed  at  once,  however 
minute,  because  it  affects  direct  vision  and  produces  a  considerable  defect  in  the  visual 
acuity.  A  central  scotoma  may  be  either  relative  or  absolute,  and  may  exist  for  colours 
only  or  for  objects.  Central  loss  of  vision  for  colours,  more  particularly  red  and  green,  is 
associated  with  tobacco  and  alcohol  poisoning.  The  colours  cannot  be  recognized  in  small 
objects  when  looked  at  directly,  though  a  red  or  green  object  in  the  peripheral  portion  of 
the  field  of  vision  will  be  recognized  as  such.  This  scotoma  is  associated  with  greater  or 
less  diminution  of  the  general  visual  acuity,  and  vision  in  such  cases  is  generally  better  in  a 
dull  than  in  a  bright  light. 

Absolute  central  scotomata  are  met  with  in  disseniinaled  sclerosis,  in  certain  forms  of 
hereditari/  optic  (ilropln/.  and  may  persist  after  the  acute  alleetion  of  the  optic  nerve  known 
as  retrobnibfir  neuritis,  or  in  rare  cases  after  severe  attacks  of  migraine.  In  nearly  25  per 
cent  of  all  cases  of  disseminated  sclerosis  a  central  scotoma  exists,  and  the  diagnosis  in  such 
a  ease  will  be  confirmed  by  its  association  with  the  general  symptoms  of  the  disease  and 
with  other  ocular  symptoms,  such  as  optic  atro|)hy,  paralysis  of  accommodatinn,  jjaralysis 
of  the  extrinsic  ocular  movements,  or  nystagmus.  There  is  usually  some  pallor  of  the  optic 
disc,  though  this  is  no  indication  as  to  the  amount  of  visual  defect.  The  diagnosis  of  a 
hereditarij  optic  atropli;/  depends  to  a  great  extent  upon  the  history  of  a  similar  affection 
among  family  relations  and  its  usual  jieriod  of  incidence,  namely,  early  adult  life.  It  is 
associated  with  either  neuritis  or  atrophy  of  the  optic  disc.  Retrobulbar  neuritis  usually 
occurs  in  young  adults,  commonly  attacks  one  eye  only,  and  is  sudden  in  its  onset,  vision 
failing  from  normal  to  no  perception  of  light  in  a  few  hours.  In  the  great  majority  of  eases 
vision  commences  to  return  after  the  lapse  of  a  day  or  two,  and  is  ultimately  restored  in  a 
fortnight  or  three  weeks.  If  any  defect  remains  it  is  usually  central,  and  is  due  to  some 
injury  to  those  axial  fibres  of  the  optic  nerve  which  supply  the  macular  region.  Central 
scotomata  after  migraine  are  rare,  but  may  be  ascribed  to  that  cause  when  there  is  a  definite 
history  of  sudden  loss  of  sight  associated  with  the  characteristic  hemicrania  and  vomiting. 
It  is  to  be  noted  that  central  scotomata  are  not  always  easy  to  map  out  on  a  chart,  owing  to 
the  patient's  loss  of  power  of  fixation  ;  a  careful  use  of  the  perimeter  by  an  experienced 
observer  is  necessary.  A  small  central  scoto'ma  may  cause  considerable  failure  of  vision, 
even  though  it  is  too  small  to  chart  on  the  ordinary  perimeter.  Scotomata  may  also  be 
paracentral,  in  the  immediate  neighbourhood  of  the  fixation  point,  but  not  actually  ui)on 
it,  or  may  take  an  annular  or  ring  form. 

(c).  Peripheral  Constriclion. — Peripheral  constriction  of  the  visual  field  occurs  com- 
monly in  affections  such  as  acute  or  chronic  glaucoma,  aptie  atrophy,  disseminate  choroido- 
retinitis,  retinitis  pigmentosa,  and  iHirious  functional  conditions.  The  constriction  of  the 
visual  field  in  glaucoma  is  usuallv  most  marked  on  the  nasal  side,  and  can  be  recognized 


VISION.     DEFECTS    OF  761 

from  its  association  with  the  acute  symptoms  of  glaucoma,  the  circumcorneal  injection, 
steamy  insensitive  cornea,  dilated  fixed  pupil,  hazy  vitreous,  and  general  symptoms  such 
as  trigeminal  neuralgia,  headache,  and  sickness.  In  chronic  glaucoma  it  will  also  be  associ- 
ated with  atropliy  and  cupping  of  the  optic  disc  (Plate  XX.  Fig.  I',  p.  418).  Central  vision 
may  remain  quite  good,  even  though  the  field  of  vision  is  extremely  limited.  The  field  of 
vision  is,  as  a  rule,  most  limited  in  rctiiiilis  jn'iiiiiriitosd.  where  the  failure  of  sight  will  be 
found  to  be  associated  with  night-blindness  and  cliaracteristic  ophthalmoscopic  apjiearances, 
a  small,  ill-deflned,  waxy-looking  disc,  slender  vessels,  and  difluse  superficial  jiigmentation 
of  the  periphery,  the  retina  in  patches  resembling  Haversian  bone  corpuscles.  This 
condition  often  occurs  in  two  or  more  membei-s  of  the  same  family,  and  may  exist  where  the 
])arents  have  been  first  cousins.  A  limitation  of  the  field  similar  to  that  of  retinitis  pig- 
mentosa is  often  met  with  in  cases  of  di.sseniiiKite  clinroidn-reliiiilis  {Plate  XIX.  Fig.  G.  p. 
416)  and  consequent  optic  atrophy  ;  but  may  he  distinguished  from  it  by  abundant  evidence 
in  the  eye  of  deeper  changes  in  the  retina  and  choroid.  Constriction  of  the  field  of  vision 
may  also  occur  in  certain  fiinctio)wl  .states,  but  may,  as  a  rule,  be  recognized  by  its  variable 
character  and  the  absence  of  all  evidence  of  organic  ocular  or  general  nervous  disease. 

2.  Indefinite. — .\  defective  visual  acuity  may  exist  with  no  evidence  of  any  ocular 
or  nervous  disease  (see  ,\mblyoi'ia,  p.  759).  Defective  vision  may  also  be  due  to  errors  of 
refraction,  to  opacities  of  the  cornea,  aqueous,  lens,  or  vitreous,  to  affections  of  the  choroid 
and  retina,  and  to  lesions  of  the  optic  nerve.  Opacities  of  the  cornea  can  easily  be  recog- 
nized on  illumination  of  the  eye  with  a  strong  light  concentrated  by  a  lens,  and  intra-ocular 
causes  of  defective  vision  can  be  discovered  by  ophthalmoscopic  examination.  Detailed 
differential  diagnosis  of  all  the  ocular  causes  of  diminished  vision  requires  a  special  know- 
ledge of  ophthalmology. 

COMPLETE    BLINDNESS. 

Total  loss  of  vision,  blindness,  or  amaurosis,  may  be  (I)  liiloleral.  (2)  T'ltilaleral. 

Bilateral  Blindness, — Total  blindness  in  both  eyes  may  be  congenital  or  acipiired. 
(  ongeiiital  blindness  may  be  due  either  to  absence  of  the  eyes  themselves,  eoiigeiiital  aiioj)li- 
IhahiiDS,  or  to  cniigeiiital  defects  in  the  development  of  the  eyes  themselves.  Nearly  !)()  ])er 
ccMt  of  all  cases  of  total  blindness  in  the  I'nited  Kingdom  arc  due  to  the  o/ilitlialmia  iieniia- 
toniiii.  Such  eases  can  be  rccognizetl  by  the  history  of  profuse  inflammation  or  discharge 
shortly  after  birth.  l)y  the  diffuse  opacity  on  the  surface  of  the  cornea,  associated,  in  some 
cases,  with  thinning  and  protrusion  of  the  anterior  part  of  the  eye,  and  more  or  less  nys- 
tagmus. There  is  a  jjeculiar  congenital  malady  known  as  aniaarotie  familial  iilioei/,  in  which 
several  members  of  a  family  suffer  from  conqjlete  blindness  owing  to  bilateral  ojitic  atro])hy 
associated  with  idiocy  due  to  slow  development  of  the  brain.  The  diagnosis  is  niiidc  fmni 
the  family  history  and  from  the  presence  of  optic  atrophy  dating  from  infancy. 

Total  hIiiiiliHss  may  also  be  caused  by  hilaleral  iii/lanuiintorii  affeetioiis  of  tiie  eyes, 
such  as  iritis  wjtii  lilockage  of  the  pupils  nnd  cnnscipicnl  glaucoma,  or  ultimate  shrinking 
of  the  eyes,  bilateral  primary  glaucoma,  optic  atrophy,  or  lesions  of  the  optic  chiasma.  It 
is  seldom  due  to  lesions  of  the  optic  tracts,  as  this  would  only  be  eauscd  1)\  a  bil;il(  r.il  lesion 
totally  destroying  the  optic  tract  on  botli  siflcs. 

Total  blindness  of  a  transient  nature  may  also  occur  in  renal  disease,  and  is  l<rm(il 
KKvtiiie  aiiKiiniisis.  This  condition  is  recogni/.eil  by  its  association  with  the  symptoms  of 
renal  disease,  whether  in  pregnancy  or  not.  and  by  its  sudden  onset  and  short  duration,  the 
whole  attack  as  a  rule  lasting  not  more  than  four  or  five  days.  In  the  majority  of  cases 
there  is  some  evidence  of  renal  retinitis,  though  in  others  the  eyes  arc  normal,  'i'lie  pupils 
usuall\-  re.ict   to  light,  though  occasionally  the  light   reflex  is  absent. 

Anolher  form  of  transient  blindness  occasionally  met  with,  is  apparcnll\-  due  to  spastii 
of  the  retinal  arteries.  In  these  cases  the  loss  of  vision  may  last  only  a  few  hours,  and  during 
its  continiianic  it  will  be  found  thai  tlie  ritinal  .irlcrics  arc  ol' a  very  slender  calibre.  It  is 
to  be  noted  that  no  cataract  ever  causes  total  blindness.  Provided  that  the  rest  of  the  eye 
is  normal,  a  patient  with  the  flenscst  catarMcl  c^ni  always  perceive  light,  and  also  has  the 
power  of  projection,  or  the  recognition  of  llic  din  .liiii  from  which  the  ray  of  light  is  coming. 

Unilateral  Blindness.  It  is  evident  thai  uiiilalcral  blindness  must  be  due  to  some 
lesion  in  Ihc  eye  ilsclf.  or  between  the  eye  and  the  optic  chiasma.  Lesions  of  the  opiii' 
tr:i(l  al)ii\r  llic  chiiisina  do  not  cause  monocular  blindness,  but  IIli.MI.V.NOl'SI.V  (p.  IlOd)- 
Mo ■nhir-  bliiidncss  ma\-  be  cilhir  sodchii  nr  giadnal. 


762  VISION.     DEFECTS    OP 

GradiKil  blindness  may  be  due  to  any  of  the  inflammatory  affections  of  the  eye  men- 
tioneil  above,  or  to  such  progressive  diseases  as  optic  atrophy  or  glaucoma. 
Sudden  blindness  in  one  eye  may  be  due  to  one  of  tlie  following  causes  : — 

Detachment  of  the  retina  (Plate  XX,  Fig.  T,  p.  418) 

Embolism  of  the  central  artery  (Plate  XX,  Fig.  S) 

Thrombosis  of  the  central  vein  (Plate  XX,  Fig.  O) 

Vitreous  hajmorrhage 

Acute  glaucoma  (Plate  XX.  Fig.  I') 

Injury  to  the  optic  nerve  due  to  an  accident  or  fracture  of  the  base  of  the  skull 

Compression  of  the  optic  nerve  from  ha-morrhage  or  dilatation  of  the  nasal  sinuses 

Retrobulbar  neuritis 

Migraine. 
The  diagnosis  of  the  majority  of  these  causes  is  simple,  owing  to  the  characteristic  ocular 
or  ophthalmoscopic  appearances.  The  only  cases  which  present  any  obscurity  are  those  in 
which  there  is  sudden  loss  of  vision  without  any  visible  ocular  changes.  These  cases  are 
usually  due  to  retrobulbar  neuritis,  an  acute  affection  of  the  optic  nerve  of  obscure  origin, 
characterized  by  sudden  loss  of  sight,  with  some  pain  and  tenderness  on  movement  of  the 
eye.  The  loss  of  vision  as  a  rule  lasts  for  not  more  than  twenty-four  or  thirty-six  hours, 
and  coincidcntly  with  the  return  of  vision,  more  or  less  definite  neuritis  appears  at  the  optic 
disc  (Plate  XIX.  Fig.  K,  p.  416).  In  the  majority  of  cases  vision  returns  entirely,  but  if 
there  is  a  permanent  defect  it  usually  takes  the  form  of  a  central  scotoma. 

Blindness  due  to  compression  of  the  optic  nerve  by  dilatation  of  the  accessory  nasal 
sinuses  can  only  be  recognized  after  a  thorough  examination  of  tlie  nasal  passages  ;  sinus 
disease  of  any  duration  is  always  accompanied  I)y  certain  well-defined  appearances  in  the 
nose  itself. 

Monocular  blindness  may  also  occur  in  migraine,  but  in  these  cases  it  is  of  extremely 
short  duration,  seldom  more  than  ten  minutes  or  a  quarter  of  an  hour,  and  is  followed  by 
the  characteristic  headache  and  sickness. 

COLOUR    BLINDNESS. 

Defects  in  colour  vision  may  be  cither  congenital  or  acquired.  In  congenital  colour 
blindness  there  is  inability  to  recognize  in  the  spectrum  the  six  or  seven  definitely  distinct 
colours  which  may  be  ajiparent  to  a  normal  eye.  The  commoner  cases  of  colour  blindness 
are  those  who  can  only  see  three  colours  in  varying  shades  of  black  and  white,  or  people  who 
can  only  distinguish  two  colours,  the  spectrum  being  made  up  of  yellow  and  blue,  the  one 
gradually  passing  into  the  other.  Red,  or.ange.  yellow,  and  green  are  seen  as  one  colour, 
blue  and  violet  as  the  other.     .Scarlet  and  grass-green  appear  very  similar  to  these  persons. 

Cases  of  congenital  colour  blindness  can  be  recognized  by  examination  with  coloured 
wools,  as  in  Holmgren's  test,  or  with  much  more  precision  and  certainty  in  a  dark  room  by 
means  of  a  lan+crn  with  properly  coloured  glasses. 

Ac(|uired  loss  of  colour  vision  may  also  occur  in  tobacco  blindness  or  in  optic  atroplni. 

Colour  Defects. 

lliiinlmxv  I'ision. — Objects,  especially  lights,  may  be  seen  surrounded  by  a  ring  con- 
taining the  colours  of  the  spectrum.  The  causes  of  this  are,  as  a  rule,  either  conjanctivilis — 
in  which  there  is  a  thin  film  of  mucus  on  the  surface  of  the  conjunctiva — or  glaucoma.  The 
diagnosis  in  the  two  cases  should  present  no  difficulty,  because  the  rainbow  vision  of 
glaucoma  will  be  associated  with  the  other  important  symptoms  of  this  disease,  viz.,  steami- 
ness  or  lack  of  brilliancy  in  the  cornea,  a  shallow  anterior  chamber,  dilatation  of  the  pupil, 
and  some  limitation  of  the  field  of  vision,  especially  on  the  nasal  side. 

Erijtiiropsia,  or  red  vision,  occurs  after  prolonged  exposure  to  white  or  violet  light  in 
conditions  such  as  electric  or  snow  blindness.  It  is  accompanied  by  much  inflammation 
and  redness  of  the  eyes,  conjunctival  discharge,  and  intolerance  of  light.  It  may  also  occur 
in  slight  vitreous  or  retinal  hsemorrhages,  though  in  severe  vitreous  hicmorrhages  vision  is 
abolished  entirely.  Erythropsia.  and  in  some  cases  blue  vision,  may  occur  after  cataract 
extraction,  and  appears  to  be  due  to  some  fatigue  of  the  retina. 

Xanthopsia,  or  yellow  vision,  has  been  said  to  occur  in  jaimdice  or  in  poisoning  by 
santonin,  amyl  nitrite,  cannabis  indica,  or  picric  acid,  but  it  is  hardly  ever  met  with  in 
practice. 


VOMITING  763 

ABNORMAL    SENSATIONS    OF    SIZE. 

Objects  may  appear  rapidly  to  increase  or  rliniiriisli  in  size  in  the  preliminary  stages 
of  an  attack  of  epilepsy  :  and  this  variation  in  size  of  objects  is  a  fairly  common  symptom 
in  the  slight  delirium  of  infantile  febrile  disorders.  Micwpsio.  or  abnormal  diminution 
in  the  size  of  objects,  also  occurs  to  many  normal  people  durinEr  the  act  of  reading.  The 
book  appears  suddenly  to  recede  to  a  great  distance,  and  it  and  the  type  appear  extremely 
minute,  though  absolutely  clear.  No  satisfactory  cause  has  yet  been  adduced  for  this 
jihenomenon.  It  may  be  relieved  by  a  momentary  rest,  and  is  of  no  pathological  signifi- 
cance. .\  similar  condition  may  be  produced  by  the  use  of  certain  drugs,  particularly 
cannabis  indiea  and  its  products. 

DAY-BLINDNESS    AND    NIGHT-BLINDNESS. 

Day-blindness,  or  lieincidlopiii.  is  caused  most  eonmio'ily  by  'olxtcco  poisoning,  it  being 
probable  that  this  condition  is  due  to  a  direct  poisoning  of  the  retinal  cones,  which  are 
endowed  with  the  faculty  of  effective  vision  in  lights  of  high  brilliancy.  In  snniv-blindness, 
also,  vision  imjiroves  directly  the  light  begins  to  fail,  and  defective  vision  in  bright  light  is 
a  common  symptom  of  nlliinisni.  Kxcept  in  the  case  of  albinos,  the  retina  may  show  no 
abnormal  signs. 

Xight-blindness.  or  ni/italopin.  occurs  most  frequently  in  relinitis  pigmentosa,  in  which 
on  ophthalmoscopic  examination,  the  characteristic  appearance  of  a  small  ill-defined  optic 
disc,  thin  thready  arteries  and  veins,  and  the  characteristic  spider-like  i)igment  cells  may 
be  seen  at  the  periphery  of  the  fundus.  It  also  occurs  in  cases  of  qnininc  iinihljinpin.  xerosis 
of  tlic  conjnnctivti.  rlisseniinate  clioroido-retinilis.  and  in  scnni/.  Patients  sullering  from 
high  mijopia  may  also  suffer  from  defective  vision  in  dim  lights.  Herbert  L.  Etisoii. 

VISION,   DOUBLE.-(See  DiPt.oi'i.v.  p.   174.) 

VOICE,   ABNORMALITIES  OF  THE     (See  Spkixh.  Ai!noi!mai.itii-.s  ok.  p.  r.23.) 

VOMITING. —Strictly  sjieaking,  the  term  vomiting  implies  the  return  and  exi)ulsion 
from  the  mouth  of  ])art  or  the  whole  of  the  stomach  contents.  There  are  several  conditions 
ill  which  vomiting  may  be  simulated  closely,  although  the  vomited  matter  has  never 
reached  the  stomach.  It  will  be  convenient  to  deal  with  these  before  discussing  the 
causes  and   dilierenlial   diagnosis  of  true   votniting  or  gastric  regurgitation. 

In  certain  ilisenses  of  the  ivsoplnigns.  foo<l  may  be  swallowed  and,  after  a  varying 
inter\;il  of  liim-.  Inoutilil   up  again.     'I'liese  conditions  are  : — 

.Maliiriiaiil  diseiisc  •    I'ressure    from    williout,    as    by    aneiiiysni. 

J'"ibroiis  stricture  I        new  ixrowtii.  etc. 

Spasm  '  Iiliopntliic  "  (lil:it;itii)ii 

I)i\citi<'iil;i      •  prcssiiic  ■  piiiiclics. 

If  the  nlislniclidii  be  of  Inim  slaiidiiig.  and  mar  llic  lower  end  of  llic  (e->opliauns.  the 
inter\al  between  taking  food  and  its  r<i;nriiilalioii  may  be  prolonged  considerably,  especi- 
ally in  cases  in  which  the  Iuiikii  ha'*  uiider;;(iiii'  much  dilatation.  This  may  occur  with 
fibrous  stricture,  slow-growing  <aninoiiia,  or  the  xcry  rare  eases  Uiiowii  as  "idiopathic' 
dilatation  of  the  crsopliagus. 

,\  •pressure'  pouch  produced  li\  a  lieniia-like  prol  lusioii  of  llic  miiccjus  memliriinc 
through  the  muscular  coats  of  the  upper  part  of  the  (i-sophagus.  Iiccomcs  lllled  gradually 
and,  in  juldition  to  dysphagia  caused  by  the  pressure  it  exerts  on  llic  osopliagus  below, 
may  simulate  vomiting  when  its  eonleiits  are  voided. 

The  ililierential  diagnosis  of  tlies<-  <rsopliayeal  causes  ol  voinilni;;.  or  rallier  regurgita- 
lion,  is  usiiall>-  easy.  'I'lie  returned  matter  is  piacticalJN  nnallciid.  and  is  undigested. 
II  may  be  diliiteil  freely  with  mucus,  lilood  mas  be  prestiil.  anil  i\en  portions  of  growth 
ill  cases  of  carcinoma.  In  lesophageal  |)ouclies,  food  may  bi'  iilained  for  long  periods  and 
reliirued  imehaiiiied.  The  most  important  point  to  reeo;rnize  is,  that  in  such  (csopliagi-a! 
<M)nditions  llie  returned  matter  is  alkaline  or  neutral  In  reaction.  The  diagnosis  is  eoii- 
lirmed  b\  exaniinatioii  with  a  bougie,  oi  by  the  .r-rays  after  a<luiinistration  of  bisnuitli 
emulsion  (Fig.  !«i,  p.  liKi). 


764  VOMITING 

Certain  individuals  may  acfiuire  tlie  power  of  voluntarily  regurgitating  portions  of 
the  stomach  contents  into  the  mouth,  which  may  be  ejected  or  again  swallowed.  There 
is  no  accompanying  nausea.  Tliis  condition,  known  as  '  rumination  '  or  '  Merycism  ' 
(p.  388),  must  be  distinguished  from  vomiting. 

Mention  must  also  be  made  of  conditions  in  which  the  mechanism  of  deglutition  is 
deranged,  and  in  which  swallowing  is  interfered  with  to  such  an  extent  that  the  food  or 
drink  is  returned.  This  may  occur  in  cases  of  bulbar  paralysis,  myasthenia  gravis,  etc. 
Again,  in  diphtheritic  paralysis  the  return  of  fluids  through  the  nose,  owing  to  the  paralysis 
of  the  soft  palate,  may  be  mistaken  for  vomiting.  A  similar  mistake  has  been  made  in 
cases  the  writer  has  met  with  of  bronchiectasis  in  which,  during  the  act  of  coughing,  large 
quantities  of  pus  have  gushed  up,  not  only  from  the  mouth  but  also  through  the  nose. 

The  regurgitation  of  milk  in  healthy  breast-  or  bottle-fed  infants  after  a  hearty  meal 
is  met  with  frequently,  and  is  often  wrongly  regarded  as  vomiting.  It  is  due  to  simple 
overfilling,  or  sometimes  to  too  ra])id  feeding  :  air  that  has  been  swallowed  is  belched  up, 
and  drives  out  some  of  the  milk  with  it. 

A  brief  account  of  the  mcclidiiism  af  voiuilhig  will  facilitate  a  classification  of  its  causes. 
The  parts  concerned  are  the  muscular  coats  of  the  stomach  ;  the  sphincter  at  the  cardiac 
orifice  ;  the  diaphragm,  and  the  abdominal  muscles  ;  the  vomiting  centre  situated  in  the 
medulla  ;  the  eiferent  nerve  fibres  in  tlie  vagus  supplying  the  musculature  of  the  stomach, 
the  phrenics  the  diaphragm,  and  tlic  spinal  nerves  the  abdominal  muscles. 

In  the  act  of  vomiting,  the  walls  of  the  stomach  contract,  the  diaphragm  is  pushed 
\iolently  downwards  in  full  inspiratory  position,  while  powerful  contractions  of  the  abdo- 
minal muscles  take  place.  At  the  same  time  the  cardiac  sphincter  is  relaxed,  and  the 
gastric  contents  are  expelled,  chiefly  as  the  result  of  the  pressure  thus  exerted  on  the 
stomach  by  the  diaphragm  and  the  abdominal  nniscles,  aided  to  some  extent  by  reversed 
peristalsis.  The  pyloric  sphincter  is  usually  closed,  but  it  may  become  relaxed,  in  which 
case  bile  and  intestinal  contents  may  enter  the  stomach  and  be  found  in  the  vomit.  The 
vomiting  centre  may  be  excited  to  action  by  stimuli  reaching  it  from  the  stomach  itself, 
by  afferent  fibres  in  the  vagus,  or  from  other  parts  by  many  diflerent  afferent  channels. 
The  centre  may  also  be  thrown  into  action  by  toxic  substances  acting  on  it  directly. 

In  retching,  forcible  contraction  of  the  stomach  wall,  and  of  the  diaphragm  and 
abdominal  muscles  takes  place  as  in  vomiting,  but  there  is  no  I'elaxation  of  the  sphincter. 
In  the  condition  known  as  zvaterbrasli  or  pi/rusis,  in  which  a  quantity  of  clear  fluid  is  brought 
up  into  the  mouth,  usually  on  rising  in  the  morning,  the  complete  act  of  vomiting  does  not 
occur  ;  relaxation  of  the  cardiac  sphincter  takes  place  without  attendant  muscular  con- 
traction of  the  diaphragm  and  the  abdominal  muscles. 

It  is  obvious  from  the  above  that  the  causes  of  vomiting  must  fall  into  two 
great  groups  :  (I)  Those  acting  directli/  on  the  i^omiting  centre,  such  as  certain  poisons,  e.g., 
apomorphine  ;  (II)  Those  acting  rejlcxlij  on  the  centre.  The  second  group  is  a  very  large  one, 
as  it  includes  practically  all  the  pathological  states  of  the  stomach,  many  visceral  diseases, 
and  disturbances  of  special  senses. 

I.     CENTRAL  CAUSES. 

Certain  drugs —  Acute  yellow  atrophy  of  the  li\er 

Apomorphine  Adilisoii's  disease 

Tobacco  ( iTisct  of  acute  infections,  especially  in  chikiren 

Ana-sthetics  Pn^nancy 

Uriemia  licciiiieiit,    periodic    or   cyclical    vomiting    in 
Diabetes  cliiMren. 

There  may  be  some  doubt  as  to  whether  Addison"s  disease,  pregnancy,  and  recurrent 
\oniiting  should  be  included  in  this  group,  as  their  pathology  is  not  fully  known.  The 
xomiting  of  pregnancy  may  be  partly  reflex,  but  there  is  strong  evidence  that  a  toxic 
element  exists,  and  is  probably  the  chief  exciting  cause.  The  differential  diagnosis  of  these 
conditions  presents  little  dithculty.  The  examination  of  the  urine  will  give  evidence  of 
the  existence  of  renal  disease  in  ura*mic  vomiting,  and  the  onset  of  drowsiness  and  coma 
in  a  diabetic  patient  may  be  attendcil  by  vomiting.  Persistent  vomiting  occurring  in  a 
case  of  jaundice  of  apparently  the  conunon  catarrhal  variety  should  arouse  suspicion  of  its 
proving  acute  yellow  atrophy.     The  size  ol'  the  liver  should  be  determined  carefully,  and 


VOMITING  765 

any  diminution  noted  ;  the  urine  should  be  examined  for  leucin  (Fig.  147,  p.  333)  and 
tyrosin  (Fig.  148,  p.  333).  Vomiting  associated  witli  astlienia,  characteristic  pigmentation 
of  skin  and  buccal  mucosa  (Plate  XXI.  p.  526),  and  a  persistent  low  blood-pressure,  would  be 
diagnostic  of  Addison's  disease.  The  form  of  vomiting  met  with  in  young  children,  termed 
■  periodic,"  or  "  cyclical,"  is  very  severe,  and  is  accompanied  by  great  wasting.  The  sym- 
ptoms pass  off  after  a  few  days,  but  tend  to  recur  at  intervals  of  months.  The  urine  during 
the  attacks  often  contains  acetone  and  diacetic  acid,  and  the  condition  may  be  regarded 
as  an  auto-intoxication,  probably  an  acidosis  (see  Acetonuhia,  p.  3).  The  vomiting  so 
frequently  met  with  as  one  of  the  earliest  symptoms  in  specific  fevers,  especially  in  children, 
is  chiefly  due  to  the  direct  action  of  the  specific  toxin  on  the  cerebral  centre,  though  rellex 
action  may  also  have  a  share  in  it.  The  diagnosis  does  not  usually  present  dilliculty  :  the 
acute  onset,  vomiting,  general  malaise,  headache,  pyrexia,  sore  throat,  rash,  etc.,  speedily 
give  the  clue  to  the  cause  of  the  vomiting.  In  older  patients,  scarlet  fever  is  the  commonest 
specific  fever  to  begin  with  nausea  and  vomiting. 

We  must  next  consider  the  chief  characteristics  of  the  vuniiting  due  to  reflex  causes. 

II.     REFLEX  VOMITING. 

1.  Gastric  Causes. 

Irritating  articles  of  food  (hard,   indi-  Pyloric  obstruction  : 

gestible  substances)  -Malignant  disease 

Emetics,  such  as  zinc  sulphate.  Fibrous  stricture 

mustard,  etc,  "  Hypertrophic  stenosis  "   in   infants 

Poisons  :    Corrosives,  irritants  Pressure  on  pylorus  from  without 

Gastritis  :  Venous    congestion,    as     in     morlms     cordis, 

.   ,    ,  I  (i)    Simple,  |)ortal  obstruction,  cirrhosis  of  (lie   liver 

(a)  Acute  :     ^  ^^j^  phlegmonous  fleer 

(b)  Chronic  .Malignant  disease. 
Dilatation    and    "  hour-glass  '    contrac'- 

tion 

2.  Intestinal,  Peritoneal,  and  General  Visceral  Causes. 

InlcsliTial  obstruction  I'ljtliisis-  voinitiiiy  may  l)c  of   central    origin 

.\p|)(  ndicilis  or  due  to  irritation  of  the  hroMclii  or  fauces 

Intestinal  worms  Irritation   of  the  fauces  or  bronchi  by  direct 

Kollowiri^'  administration  of  cncmata  stinuilation.  or  by  severe  eoiii.'liing  : 

Ilenocli's  purpura  Pertussis 

IVritonitis  j  Hroncliiectasis 

Hillary  <olic  Fibroid  lunj; 

Henal  colic     movable   ki<biey  ('  Dietfs      Shock — blows  on  the  cpiijastriuni,  injury  of  a 
crises  ")  testicle,  a  kick  upon  the  internal  semilunar 

Acute  pancreatitis  j        cartilage  of  the  knee,  etc. 

Certain  conditions  of  the  IVmale  yenital  |  * 

organs  : 

Pregnancy 

Hetroversion  of  the  uterus 

Ovarian  diseasi' 

F^xlra-uterine  gestation 

3.  Affections  of  the  Central  Net'vous  System. 

Special  Senses  :  — 

OITensive  smells,  tastes,  rc[)nlsi\e  sifjlits. 

Brain  : — 

Concussion  I    Cerebral  hicniorrhage                      i    Kpilepsy 

CerehriU    lunioiir  or    !    Thrombosis  of  cerebral  sjiuises        Sea-sickness 

abscess  I    .Middle-ear  disease  :    .McniiTc's    I    Fun<lii)nal   or  livslerieal 

Meningitis  disease                                                          \iimiliiiL;. 

IIydroce|)li;dy  .Migraine 
Spinal  Cord  : — 

Tabes  dorsalis,  gastric  crises. 

Certain  general  lines  may  b<'  laid  down  of  great  importance  in  the  nccuralc  diagnosis 
of  the  cause  of  vomiting.  .Vtleidion  slioidd  be  paid  lo  its  relation  to  food,  if  iiny.  and  at 
what  interval  after  a  meal  it  occurs  ;  whether  preceded  or  not  by  pain  :  whether  attended 
or  not  by  nausea.     'I'he  absence  of  nausea  is  a  point  of  great  signilicam-c  ;    this  is  usually 


766  VOMITING 

present  in  vomiting  due  to  abnormal  states  of  the  alimentary  tract  and  visceral  organs,  but 
is  often  absent  in  diseases  of  the  brain. 

The  vomited  matter  should  be  inspected  carefully,  and  its  quantity  and  general 
character  noted.  Alcohol,  and  certain  poisons  such  as  carbolic  acid  and  prussie  acid,  may 
be  recognized  by  their  smell,  or  a  fa?cal  odour  may  be  distinguished.  Blood  may  be  present, 
either  dark  or  bright  red,  or  dark  brown,  resembling  cofiee-grounds.  Slight  streaks  of 
blood  are  common  with  severe  vomiting,  and  are  usually  due  to  rupture  of  small  vessels 
in  the  oesophagus  or  pharynx.  In  whooping-cough,  blood  is  often  mixed  with  mucus  from 
the  respiratory  passages,  and  the  contents  of  the  stomach  are  ejected  during  the  paroxysms. 
The  condition  of  the  food  remains  should  be  noted  carefully  ;  the  presence  of  substances, 
such  as  currants  or  seeds,  taken  it  may  be  many  hours  or  some  davs  previously,  would 
point  to  motor  insufficiency  of  the  stomach,  either  with  or  without  'pvloric  obstruction  ; 
shreds  of  meat  returned  unaltered  some  hours  after  a  meal  indicate  deficient  protein 
digestion. 

The  reaction  should  be  ascertained  :  in  corrosive  poisoning  this  mav  be  strongly  acid 
or  alkaline  according  to  the  toxic  agent.  It  need  hardly  be  said  that  in  any  case" of  sus- 
pected ijoisoning  the  vomit  should  be  kept  for  analvsis.  Microscopical  examination  may 
show  sarcinse  (Fig.  121,  p.  241).  yeast  cells,  the  Oppler-Boas  bacillus,  or  cell  elements  from 
a  malignant  growth.  Intestinal  contents  may  be  mixed  with  the  vomit.  Bile  is  often 
present  in  severe  or  protracted  vomiting,  and  is  recognized  readily  by  its  colour  and  the 
usual  tests.  Relaxation  of  the  pyloric  orifice  in  such  cases  allovvs  of  the  return  of 
the  duodenal  contents  into  the  stomach.  Feecal  matter,  when  present,  is  recognized  by  the 
characteristic  odour  and  the  brownish  coloration  it  imparts  to  the  vomit  :  it  usually  occurs 
as  the  result  of  intestinal  obstruction.     Gastro-colie  fistula  may  give  rise  to  ffecal  vomiting. 

Gastric  Causes.— Most  corrosive  and  irritant  poisons  cause  vomiting  immediately  after 
swallowing,  accompanied  by  intense  burning  pain  in  the  epigastrium.  The  vomit  contains 
food,  blood,  mucus,  and  may  have  the  characteristic  odour  of  the  poison.  With  some 
irritant  poisons,  e.g..  arsenic,  or  phosphorus,  the  vomiting  may  come  on  later  and  resemble 
that  of  an  acute  gastritis.  The  diagnosis  will  depend  largelv  on  the  chemical  analvsis  of 
the  vomit,  and  the  associated  signs  and  symptoms. 

In  acute  gastritis  there  is  repeated  \omiting,  usuallv  verv  severe,  and  attended  bv 
nausea  and  abdominal  pain.  Vomiting  occurs  shortlv  after  taking  food,  and  causes  some 
relief  of  pain.  The  vomited  matter  consists  at  first  of  food  ingested,  later  of  mucus  and 
bile.  There  are  often  accompanying  diarrhoea  and  febrile  disturbances,  especially  in 
children.  In  the  phlegmonous  form  the  constitutional  symptoms  are  exceedingly  grave  ; 
pus  IS  rarely  found  in  the  vomit,  bile  is  often  present. 

In  chronic  gastritis  the  ^•omiting  is  associated  with  nausea  and  epigastric  pain.  There 
IS  usually  miich  flatulence.  The  vomited  matter  consists  of  partiallv  digested  food,  mucus, 
and  a  considerable  quantity  of  sour-smelling  fluid.  Hvdrochloric  acid  is  usually  reduced 
greatly  in  amount,  or  may  be  absent.  \M,en  dilatation  of  the  stomach  is  present,  the 
quantity  of  fluid  ejected  is  often  very  large  ;  portions  of  food  taken  manv  hours  previouslv 
may  be  returned.  Fermentation  takes  place  in  the  stagnant  gastric  contents,  so  that  the 
vomit,  when  collected  in  a  glass  vessel,  often  shows  an  uppermost  laver  of  brown  froth,  a 
miadle  greenish-grey  layer  of  fluid  containing  streaks  of  mucus,  and  below  this  a  semi- 
solid deposit  containing  food  remains,  sarcin^e  (Fig.  121.  p.  241).  veast  cells,  and  bacteria ; 
chemical  tests  show  the  presence  of  lactic  acid  and  a  diminution  or  absence  of  free  or  active 
liydrochloric  acid. 

•  Hour-glass  '  contraction,  due  to  transverse  constriction  of  the  stomach  bv  fibrous 
tissue,  may  be  a  cause  of  vomiting  which  resembles  in  most  respects  that  associated  with 
dilatation.  Examination  with  the  .r-rays  after  a  bisnmth  meal  will  generally  establish 
the  diagnosis  (Fig.  128,  p.  268). 

The  vomiting  due  to  pyloric  obstruction  in  adults  presents  no  characteristics  other  than 
those  associated  with  the  dilatation  .,f  the  stomach  which  usuallv  results  from  it.  The 
absence  of  free  hydrochloric  acid  in  the  vomit  would  fi^vour  the  diagnosis  of  carcinoma, 
the  presence  of  free  hydrochloric  acid  that  of  fibrous  stricture  :  the  presence  of  the  Oppler- 
«oas  bacillus  is  regarded  by  many  as  diagnostic  of  carcinoma.  Persistent  vomiting  in 
young  infants,  especially  if  breast-fed.  attended  with  wasting  and  constipation,  should 
always  arouse  suspicions  of  the  existence  of  ■  hypertrophic  stenosis  of  the  pylorus:        The 


voMrnx(;  tot 

vomitini;  in  these  cases  is  very  forcible,  the  milk  bein»-  pumped  ii|)  violently,  often  very 
shortly  after  a  feed,  and  with  little  alteration.  Visible  gastric  peristalsis  and  the  presence 
of  a  small  tumour  in  the  epigastrium  woidd  comjilete  the  diagnosis. 

Vomiting  due  to  gastric  ulcer  (non-malignant)  is  very  common.  Pain  occurs  soon  after 
taking  food,  and  is  relieved  by  vomiting,  which  usually  occurs  within  an  hour.  The  vomit 
consists  of  food,  more  or  less  digested,  according  to  the  time  which  has  elapsed  after  a  meal. 
It  almost  always  contains  at  least  the  normal  quantity  of  free  hydrochloric  acid,  and  blood 
may  be  present  in  varying  quantity. 

With  malignant  disease — carcinoma  of  the  stomach — though  the  general  character  of 
the  vomit  may  be  very  similar  to  that  in  simple  ulcer,  there  is  usually  a  great  diminution 
or  complete  absence  of  free  hydrochloric  acid,  and  lactic  acid  and  the  Oppler-Boas  bacillus 
are  often  present.  Sarcinae  may  be  present  also  when  there  is  accompanying  dilatation. 
Occasionally  portions  of  the  growth  may  be  found  in  the  vomited  matter.  In  both  simple 
and  malignant  ulcer,  blood  may  be  detected  in  the  vomit  microscopically  or  spectro- 
scopically  (see  IJlood  per  Anim,  p.  75)  when  it  is  not  recognizable  by  the  naked  eye. 
A  bismuth  and  ,r-ray  examination  is  almost  essential  (Fig.  i:i().  ]).  2(i9.  Fig.  131.  p.  'JTO. 
Fig.  132.  p,  270). 

Intestinal,  Peritoneal,  and  General  Visceral  Causes. — In  intestinal  ohslrnrliini 
vomiting  .sets  in  after  an  interval,  the  length  of  which  may  depend  on  the  situation  of  the 
blocking.  The  vomiting  is  severe  and  persistent  ;  the  contents  of  the  stomach  are  returned 
first,  and  later,  mucus,  bile,  and  intestinal  contents.  Fa»cal  vomiting  should  be  recognized 
at  once  by  its  odour  ;  obvious  pieces  of  ftccal  matter  arc  rarely  distinguishable,  but  the 
vomit  may  have  a  brownish  colour.  The  vomiting  is  more  severe  the  liigher  the  obstruc- 
tion is  in  the  intestinal  canal. 

Vomiting  is  commonly  present  in  (iii/>rn(licilis.  but  in  slight  cases  does  not  persist  after 
the  onset.  In  the  severe  forms  of  the  disease  the  vomiting  may  lie  a  prominent  symptom, 
and  resemble  that  met  with  in  intestinal  obstruction  :    it  is  sometimes  fa-cal  in  character. 

Intestinal  iLurnis  are  a  cause  of  vomiting  in  children,  probably  owing  to  the  redex 
irritation  they  set  vip.     Occasionally  a  round-worm  is  found  in  the  vomit. 

Enenidta  in  certain  individuals  cause  vomiting,  and  rare  eases  have  been  described  in 
which  the  fluid  injected  per  rectum  has  been  returned  by  the  mouth. 

Vomiting  is  a  common  symjitom  in  the  condition  known  as  Henoch's  purpura,  and  may 
be  due  to  either  gastric  or  intestinal  stimulation.  The  vomit  may  contain  blood  due  to 
ha-morrhages  from  the  nuicous  membrane  of  the  stomach.  It  is  usually  accompanied  l)y 
abdominal  |)ain.  sometimes  of  an  acute  and  agonizing  character  closely  simulating  that 
occurring  with  intestinal  obstruction,  these  symptoms  being  due  to  luemorrhage  into  the 
intestinal  wall  or  the  mesentery,  which  occasionally  sinmlalc  or  even  give  rise  to  intus- 
su.sccption.  Uecurrent  attacks  of  vfuniting  and  abdominal  pain  iissociated  with  a  purpuric 
eruption  in  a  boy  or  girl  would  i)oint  to  the  existence  of  this  not  uncommon  disease. 

In  acute  peritonitis  vomiting  is  an  early  symptom,  and  causes  great  pain  :  rarely  the 
\omit  may  have  a  fa'cal  odour.  The  history,  together  with  the  rigidity  and  irnmnbilily  of 
the  abdominal  wall,  generally  indicates  the  need  for  early  laparotomy. 

In  hiliarii  and  renal  colic  the  vomiting  accompanying  the  att;icks  of  agonizing  pain 
presents  no  special  features.  The  pSin  in  the  thorax  and  upper  part  of  the  abdomen,  and 
the  onset  of  jaundice,  distinguish  l)iliar%'  colic  from  that  due  to  n  iial  calculus,  in  which  the 
pain  is  in  the  loin  or  lower  abdomen,  shooting  down  Inwards  llic  groin  and  l(-,;iile. 
.Jaundice  is  absent  if  the  stone  is  in  the  cystic  duet. 

.Icute  jiancreatitis  may  sinndatc  intestinal  obstruction  closely  in  that  it  is  attended  by 
nausea  and  vomiting,  constipation,  and  severe  abdominal  pain.  The  vomit  is  not  fa-cal 
in  character:  there  is  usually  localized  tenderness  over  the  region  of  the  pancreas.  The 
<liagnosis  is  seldom  made,  however,  until  laparotomy  is  performed  on  account  of  the 
urgency  of  the  symi)t((nis.  when  typie.il  fat   necrosis  will  be  found  in  the  omenlinn. 

The  other  visceral  causes  of  \(imiling  call  for  no  special  notice. 

Affections  of  tlie  Central  Nervous  System.  II  has  been  pointed  out  that  in  most 
of  the  preceding  conditions  nausea  accompanies  vomiting,  and  (his  brings  us  to  a  most 
important  distinction,  namely,  that  in  intracranial  disease  a  special  ty|)e  of  vomiting  Is 
met  with,  generally  known  as  •cerebral  vomiting."  In  this.  ii;msea  is  absent,  vomiting 
occurs  suddenly  ami  often  without   warning,  and  licars  no  relation  to  the  ingestion  of  food. 


768  VOMITING 

The  whole  or  part  of  the  stomach  contents  are  returned.  Vomiting  of  this  type,  especially 
if  accompanied  by  headache  or  ocular  changes,  should  arouse  grave  suspicion  of  the  exist- 
ence of  organic  cerebral  disease, — such  as  tumour,  abscess,  meningitis,  or  sinus  thrombosis. 
'  Cerebral  vomiting  '  may  also  occur  in  hydrocephaly  due  to  increased  intracranial  pressure. 
Optic  neuritis  (Plate  XJX,  p.  416)  should  be  looked  for  in  all  cases  of  vomiting  associated 
with  headache. 

Cerebral  hcemorrhage  may  be  attended  by  vomiting,  more  often  when  the  cerebelhmi 
is  the  part  affected  than  when  other  parts  of  the  brain  are  involved. 

In  Meniere^s  disease  vomiting  may  follow  the  attack  of  vertigo.  Nausea  and  vomiting 
frequently  accompany  the  severe  headache  associated  with  attacks  of  migraine. 

Functional  or  hysterical  vo7niting  is  not  attended  by  nausea  or  pain  ;  portions  of  a  meal 
are  brought  up,  usually  fluids  ;  and  although  the  vomiting  may  be  a  frequent  occurrence, 
the  general  state  of  nutrition  often  remains  good.  Other  hysterical  manifestations  are 
generally  present  in  these  patients  (p.  465).  Cases  have  been  recorded  in  which  the  vomit 
contained  faecal  matter. 

The  gastric  crises  in  tabes  are  attacks  of  vomiting  accompanied  by  severe  epigastric 
])ain.  The  attacks  usually  last  for  several  days,  and  tend  to  recur  at  intervals  of  weeks. 
Nausea  may  be  absent.  During  the  intervals  digestion  may  be  carried  on  normally.  The 
diagnosis  depends  on  the  presence  of  the  characteristic  Argyll  Robertson  pu])il  and  the  loss 
of  the  knee-jerk. 

The  influence  of  ana-mia  U])on  vomiting,  and  the  manner  in  which  gastric  ulcer  may 
be  simulated  thereby,  have  been  discussed  in  the  article  on  An.emia  (p.  .'!(>). 

//.  Miirkij  Fkklter. 

VOMITING    OF    BLOOD.— (See   II.em.xtemesis,    p.  -265.) 

WALKING,  PECULIARITY  IN.— (See  Gait.  Abnormalities  of,  p.  U.^l  ;  and 
Li.^ii'iNo  IN  Children,  p.  362.) 

WATERBRASH.— (See  Heartburn.  ]>.  296.) 

WEIGHT,  LOSS  OF. — Loss  of  weight  sooner  or  later  accompanies  all  cases  of  cancer, 
phthisis,  starvation  from  lack  of  food  or  from  inability  to  swallow,  and  similar  conditions  ; 
but  in  most  such  cases  there  are  other  sym)3toms  jjointing  to  the  diagnosis.  The  present 
article  is  concerned  chiefly  with  those  eases  in  which,  without  other  definite  symptoms, 
the  patient  has  been  losing  weight. 

In  the  case  of  children,  the  commonest  causes  are  malnutrition  from  injudicious 
feeding,  the  eating  of  sweets  between  meals,  gastro-intestinal  infections,  and  latent 
tuberculosis  (see  Marasmus,  p.  384). 

If  the  patient  is  an  adult  and  the  loss  of  weight  has  been  considerable,  the  first 
suspicion  will  almost  certainly  be  that  there  is  either  phtkisis  putmonalis,  deep-seated  or 
latent  carcinoma  or  sarcoma,  tidjcrcnlosis  other  than  pulmonary,  or  diabetes  mellitus.  All 
the  systems,  including  the  urine,  the  rectum,  and,  if  need  be,  the  vagina,  will  need  careful 
routine  examination.  Any  sputum  that  may  be  obtainable  should  be  examined  for 
tubercle  bacilli  ;  the  physical  signs  at  the  apices  of  the  lungs  should  be  watched  with 
extreme  care,  particularly  if  there  is  any  <lifference  in  the  amount  of  subcutaneous  fat 
on  the  two  sides  in  this  region  ;  the  ,i-rays  may  be  of  value  in  detecting  mottling  (Fig.  70, 
p.  159)  at  one  or  other  apex  when  the  mischief  is  too  far  from  the  surface  to  give  abnormal 
])liysical  signs  to  percussion  or  auscultation.  Those  who  believe  that  the  opsonic  index 
to  tubercle  bacilli  is  of  diagnostic  significance,  would  estimate  it  before  and  after  inocula- 
tions with  small  or  moderate  doses  of  tuberculin  ;  the  family  liistory  might  be  of  assist- 
ance in  indicating  the  likelihood  of  a  lung  lesion,  whilst  the  personal  history  as  to  the 
drinking  of  much  unsterilized  milk  would  indicate  the  possibility  of  infection  by  so-called 
surgical  tuberculosis  in  the  lymphatic  glands,  abdomen,  a  joint,  or  the  spinal  column  ;  von 
Pirquet's  skin  reaction  (Plate  XXXVII.  p.  770),  or,  if  it  is  thought  advisable,  Calmette"s 
ophthalmic  reaction  to  tuberculin  may  be  tested.  Voaj'irquet's  is  nowadays  preferred  to 
Calmette's  reaction  on  account  of  the  occasional  ill-effects  of  the  latter  upon  the  eye.  The 
test  is  ])erformed  upon  the  skin  by  a  procedure  analogous  to  that  of  ordinary  vaccination, 
but  using  tuberculin  in  place  of  calf  lymph  ;  the  degree  of  positivity  of  the  von  Pirquet's  test 


PLATE     .\\.\J  1 

TUBERCULIN       REACTIONS 


C" 


i 


ClTiXHOUS    niCACTlOX    (I'on    Pirqiirl) 

A.  CoTitrnl;    B,  IMriftiirc  IlirouKli  lii:mnii  ol.l  Uibcrciiliii :   c,  rinicture  throir-'li  ImviTic  oM  I 

A  i-unrture  (a)  is  made  tlirou^^li  tlio  epiilortnis  with  a  small  toothed  ruiret.  reserve  a-j  :i  ' 

(B)i-iii-i'li-<'losc  by.  throui'liadrop  of  2.')  pereeat  sohitioji  of  old  tiiherculiii  (liumaii),  and  a  H 

Iroiii  II lliers.  thr6u!.'li  a  drop  of  •,'.)  per  coat  solution  of  old  tuhereiilia  (bovine).     A  pn.-i 

)irodurtiuii  of  a  hyperiwrnio  area  in  twenty-four  hours,  which  later  beeonics  a  deliiiite  iiapule. 
distinct  aureola  of  inllamniatory  reaction. 


iM;UMAL     KKAITIOX    (Wootlcock) 

A.  Area  iif  Kklii  ilciuulcd  ot  e|iidcrml»  by  niiplloalloii  o(  hlisler  plnseor  (control) ; 
B,  Similnr  nren  treated  with  old  tuoercullri— hypcni'mlu  iiii.l  U'dcniii  (ponitlve  ronctlim). 
epidermis  is  removed  from  (wo  adja.eni  skin  ureas,  by  the  appllcnllon  of  small  circles  of  blister  plaster,     'rwenly 


:  siilu 


of  old  lub. 


of  the  ,le 


Ide.l  ■ 


id  alio 


•d  lodry     Ihi 


III  hi 


WEIGHT.    LOSS    OF  769 

is  ascertained  by  using  5.  10.  15.  20  and  25  percent  strengths  of  tuberculin,  supplied  ready 
for  the  purpose  by  bacteriological  laboratories  ;  any  reaction  shews  itself  within  twenty -four 
hours  (Plate  XXXl'JJ).  A  negative  von  Pirquefs  reaction  is  of  more  value  in  excluding 
tuberculosis,  however,  than  is  a  positive  one  in  proving  that  the  patient's  svmptoms  arc 
due  to  tubercle  :  so  many  persons  have  latent  tuberculous  foci  in  glands  or  elsewhere  that 
they  may  give  a  jiositive  tuberculin  reaction  though  their  actual  symptoms  may  be  due 
to  some  entirely  different  malady  which  has  developed — a  colibacilluria  for  instance,  or 
something  else  that  is  non-tuberculous.  A  positive  von  Pirquet  reaction  shows  that  the 
l)atient  is  the  subject  of  tubercle,  but  it  does  not  prove  that  the  symptoms  one  is  investi- 
gating in  his  case  arc  due  to  the  tuberculous  infection  so  discovered.  Sometimes,  when 
there  is  doubt  as  to  whether  there  is  organic  disease  or  not,  the  nails  afford  a  clue  ;  whereas 
longitudinal  ridges  on  them  matter  little,  a  definite  transverse  ridge  at  the  same  level  across 
all  the  nails  is  evidence  of  dystrophy  due  to  illness  at  a  time  corresponding  to  that  at  which 
the  ridged  part  was  being  produced  from  the  matrix  :  roughly  speaking,  it  takes  a  nail 
between  four  and  six  months  to  grow  from  matrix  to  tip,  and  of  this  time  about  two-thinls 
ajiplies  to  the  \isjble  nail,  one-third  to  the  part  that  is  growing  but  not  yet  visible  :  if, 
therefore,  there  is  a  dclinite  transverse  ridge  on  all  the  nails  (Fig.  306)  about  half-way  along 
each,   the  jiatiiiit  was  in  bad  health  between  three  and   four  months  previously.     There 

may  have  been  a  definite  acute 
illness  such  as  pneumonia  ;  but 
<|uite  often  the  dystrophy  is 
due  to  less  definite  illness,  and 
particularly  to  the  effects  of 
developuig  phthisis. 

Notwithstanding  the  most 
careful  investigations,  however, 
doubt  as  to  the  cause  of  the 
loss  of  weight  in  not  a  few  cases 
remains  until,  in  the  course  of 
lime,  the  iiatient  cither  recovers 
I  he  lost  ground  and  gets  quite 
well,  or  else  develops  other  signs 
or  symptoms  of  growth,  tubercu- 
losis, or  other  definite  disease, 
r     »r...    ...  ■,■,,..,,  ■  ,  ,  Young    persons    may     lose 

Fi'r.  JUk   -lr.an.sverse  ncj^'irit^  of  nails  due  to  lobiu- jmeiimoma  four  luOMlhs  -it 

pnviousiy.  Weight  as  the  result  of  change  of 

surroundings,  for  instance  from 
active  out-door  school  life  to  work  in  a  city  ollicc  ;  care  and  anxiety;  the  undertaking 
of  serious  responsibilities  ;  sorrow  ;  love  ;  too  strenuous  a  life  of  pleasure  ;  irregularity 
III  meals  ;  too  long  hours  of  work;  these  are  amongst  the  evcry<la\-  causes  of  what  at  the 
time  may  appear  to  be  serious  loss  of  weight, 

.\ny  alfection  of  the  alimentary  tract  interfering  with  proper  digestion  and  ab.sorption 
of  food  may  produce  loss  of  weight,  especially  if  there  is  cause  for  sapra-mia  at  the  same 
time;  one  may  iiiention  in  this  comiection  loss  of  appetite  from  too  much  smoking, 
excessive  drinking,  monotony  of  IihhI  or  of  existence,  carious  teeth,  ill-litting  tooth  plates. 
pyorrlKca  alvcolaris,  dyspepsia.  Ilatuleriee.  the  abuse  of  ])urgalives.  and  the  constipation 
which  results  therefrom;  gastric  or  duodeuiil  ulcer;  colitis  in  its  iiiimy  forms.  Tin- 
wasting  is  seldom  severe  in  any  of  tlu'sc  :  but  when  gastric  symptoms  arc  prominent  for 
instance,  it  may  be  very  dillieult.  for  the  lime  being,  to  tell  whether  the  mischief  should  be 
labelled  merely  flyspcpsia.  or  actual  carcinoma  \-entrieuli.  Analyses  of  the  gastric  juice 
were  at  one  time  thought  to  be  valuable  in  deciding  between  simple  and  malignant 
adictions  of  the  stomach,  but  this  is  by  no  means  always  the  case  (p.  270).  If.  under 
ol)s<rvation  and  treatment,  the  patient  succeeds  in  gaining  weight,  or  even  ceases  from 
losing  more  over  a  pcriofl  of  some  weeks,  the  argument  is  against  carcinoma  ;  but  if 
doubt  remains,  and  surgical  measures  arc  to  be  adopted  before  carcinoma  has  passed  the 
stage  of  eurabilily,  it  will  often  be  wise  not  to  jjostpone  la|)arotomy  too  long  as  a  means 
of  set  1 11  on  t  he  iliagnosis.      It   is  too  late  if  one  w;iits  until  there  is  a  tumour. 

.\n\-   prialads-   which   produces  sleeplessness  or  pain.  <ir  both.   ma\-   lead   to  serious  loss 
II  « 


770  WEIGHT.     LOSS    OF 

of  weiiilit.  and  thus  to  diiriculty  in  the  diagnosis.  A  thoracic  anciiivsni.  for  instance, 
may  crndo  tlie  ^•ertebra'  and  jjroduce  severe  intrathoracic  pain,  whicli  in  turn  produces 
insomnia,  and  may  thus  cause  so  much  loss  of  weight  that  neoplasm  may  be  suspected. 

Chronic  microbial  infections  may  not  be  obvious  in  themselves,  and  yet  they  ma>- 
produce  loss  of  weight  by  interfering  with  the  general  nutrition  ;  one  sees  this  in  many 
persons  who  have  returned  from  the  tropics  after  infection  there  by  dysentery,  yellow 
fever,  malaria,  dengue,  and  so  forth.  At  home,  chronic  infections  of  joints,  of  the  skin, 
the  alimentary  tract,  the  uterus,  and  genital  organs  may  produce  loss  of  weight  in  a  similar 
way.  One  would  mention  in  particular  a  common  malady  that  has  been  recognized  only 
of  recent  years,  namely,  coli  bacilluria  (see  Bacteriuria,  p.  69),  the  diagnosis  of  which 
is  possible  only  on  bacteriological  examination  of  the  urine,  though  it  may  be  suggested 
by  the  discovery  in  the  latter  of  a  trace  of  albumin  and,  on  microscopical  examination, 
excess  of  leucocytes. 

Liver  affections  exert  a  prominent  influence  upon  general  nutrition,  and  the  loss  of 
weight  exhibited  by  some  sufferers  from  cirrhosis  is  familial',  tlmugli  in  the  early  stages 
the  patient  may  be  fat.  and  towards  the  end  loss  of  weight  may  be  masked  by  a 
false  increase  due  to  ascites.  Pernicious  ansemia  is  diagnosable  with  certainty  only  by 
blood  examination  (see  .  An^fmia,  p.  24),  though  it  may  be  suggested  by  the  primrose- 
yellow  coloin-  of  the  skin  :  but  one  marked  feature  of  the  malady  is.  that  although  the 
patient  does  not  at  first  decrease  much  in  bulk,  the  tissues,  from  conversion  into  or  replace- 
ment by  fat,  become  of  less  specific  gravity  than  normal,  so  that  he  diminishes  materially 
in  weight. 

The  effect  of  alcohol  ujion  body  weight  is  variable,  some  persons  becoming  exceed- 
ingly stout,  others  not  changing  much,  and  others  becoming  extremely  thin.  Broadly 
speaking,  it  is  spirit  drinkers  who  decrease  in  weight,  and  in  some  cases  serious  doubts 
may  arise  as  to  whether  the  loss  in  such  a  patient  is  due  to  alcoholic  habits  only,  or  whether 
there  is  not  some  new  growth  or  tuberculous  affection  as  well.  When  alcoholism  leads 
to  peripheral  neuritis  there  is  rapid  and  extreme  loss  of  weight  as  the  result  of  the  muscular 
atrophy,  and  the  same  applies  to  other  conditions  of  multiple  peripheral  neuritis  (p,  03). 

Certain  drugs  have  the  power,  especially  in  certain  individuals,  of  reducing  weight 
materially,  even  though  the  diet  remain  the  same  ;  the  best  known  of  these  is  thyroid 
extract,  whilst  a  long  way  second  comes  fiwiis  vesicnlosus.  It  will  seldom  happen  that 
either  of  these  is  being  taken  accidentally,  so  that  the  diagnosis  of  loss  of  weight  due  to 
them  is  generally  obvious. 

It  is  very  difficult  sometimes  to  be  sure  whether  the  loss  of  weight  that  may  be 
complained  of  in  a  patient  of  .sixty  or  seventy  years  of  age  is  due  merely  to  old  oge,  or 
whether  it  is  due  to  luiderlying  growth  or  senile  phthisis. 

Diabetes,  especially  diabetes  mellitus  in  young  subjects,  may  have  loss  of  weight  for 
its  earliest  and  most  prominent  symptom  ;  but  the  diagnosis  is  easy  when  the  urine  has 
lieen  examined. 

Addison's  disease  is  another  affection  in  which,  besides  the  progressive  asthenia,  loss 
of  weight,  though  not  essential,  is  sometimes  marked.  There  may  or  may  not  have  been 
syncopal  or  gastric  attacks  ;  the  diagnosis  depends  almost  entirely  upon  the  discovery  of 
abnormal  pigment  deposits  in  the  form  of  patches  or  spots,  not  only  upon  the  skin  of  the 
neck,  limbs,  and  trunk,  but  also  beneath  the  mucous  membranes,  particularly  of  the 
mouth  (Plate  XXI.  p.  526),  where  they  are  generally  best  seen  inside  the  lips,  or  within  the 
cheeks.  The  blood-pressure  is  sometimes  very  low  in  these  cases,  and  if,  on  actual  measure- 
ment, it  is  found  to  be  70  or  80  mm.  Hg,  this  fact  tends  to  confirm  the  diagnosis. 

Just  as  the  administration  of  thyroid  extract  diminishes  weight,  so  may  loss  of  we'ght 
be  a  prominent  feature  in  cases  of  Graves's  disease  :  sometimes,  indeed,  it  may  be  the  first 
symptom  to  attract  attention,  especially  in  those  cases  in  which  there  is  no  exophthalmos. 
Tachycardia,  nervousness,  fine  tremor  of  the  outstretched  fingers,  and  symmetrical  but 
not  extreme  enlargement  of  the  thyroid  gland,  would  confirm  the  diagnosis. 

Anorexia  nervosa  is  a  disease  in  which  wasting  from  disinclination  to  eat  any  kind 
of  food  except  in  the  smallest  quantities  is  the  most  prominent  symptom  ;  the  patient 
is  nearly  always  a  female,  between  the  ages  of  fifteen  and  twenty-five  :  there  may  or  ma> 
not  be  other  evidence  of  functional  nerve  disorders.  The  patient,  perfectly  robust  until 
puberty  or  shortly  afterwards,  begins  to  lose  all  appetite,  the  body  wastes,  and  tlie  weight 


PLATE     XXX J  II 

TUBtRCULIN       REACTIONS 


Dermal  Ueactiun  (,\furo) 

Pitpiik-^  resiiUint;  from  immction  of  old  tuberculin  iiiror[iuratoiI  witli  Linoliii. 

Old  tuberculin,  iiicorponited  with  an  equal  bulk  of  lanolin,  is  thoroughly  rubbed  into  tlie  skin  over  ;in^ue;i  of  1  or 
11.,  by  nic:iii8  of  a  glass  spreader.  A  positive  reaction  is  shown  by  the  appearance,  in  from  fort3'-cii,'ht  to  seventy-two 
irs,  of  hj-pcnu-Tiia  over  the  treated  are:x,  and  the  subsequent  ai)pearance  of  a  crop  of  small  papules,  which  lasts  for 


^^m^" 


iiisiillMii.iH  i>f  1  per  l-Clll 
1-frco)  iiilo  corifuiu-tiviil 
u-lc  arul  piic-ii  scniiluiuiris 


I.alcr  !<liii(«  «"li  iiijeotioii  of  coiiJuiifllTnl  vcmcis. 
OiMiTiIALMO-Tiwr  (Cnlmrllr) 
One  or  l«o  ilro|i»  o(  ii  1  per  iciil  noliilioii  of  oM  tiihcrcHllii  (glyccrlii-froc),  iiro  hmlllliMl  hi 
no  eye.     A  positive  rcailinii  is  iudlc'iiKnl  liy  the  nppcnnince,  within  twelity-toiir  lioiirn,  of  li.V| 
lini  seniiluiinris  of  tlie  ireatcij  eve,  m  coiiiiwred  willi  llie  lintrcntccl  or  control  cy 
csjicls  iniiy  he  iioloci,  Ini-lirvmiition  iirnl  cumi  niiiinpiiriilent  eMldnllori. 


eionJlllKliviil  sli-of 

[iiof  lliccnnniiii'  ikkI 

J.iiter.'liijei'lloil  of  the  eonjuiu'llvnl 


(frnm  limwiiiijii  illiinlralinr/  /■/../. 

DlACNO.Sl.S- -'/■<!  flier  ft.  770 


./.  ir.  //.  luin'n  l/uiileriun  l.rfliirc  iiii  TiihirnilMh  n/  llir  Ciiiiiiiiiclirii] 


^V  HEALS  771 

declines  even  to  so  little  as  four  or  three  and  a  half  stone.  One  sometimes  sees  girls  of 
5  ft.  10  in.  or  more  weighing  less  than  five  stone  as  the  result,  not  of  any  organic  disease. 
but  of  the  simple  functional  absence  of  appetite — anorexia  nervosa.  In  arriving  at  the 
diagnosis  it  is  iznportant  to  exclude  the  possibility  of  some  deep-seated  tuberculous  lesion, 
especially  phthisis  pulnionalis  or  tabes  mesenterica.  One  of  the  best  means  of  excluding 
these  is  the  thermometer,  for  in  anorexia  nervosa  there  should  be  little  if  any  pyrexia. 
Very  careful  examination  of  all  the  systems,  including  von  Pirquefs  and  perhaps  Calmette's 
tuberculin  reactions,  will  lead  to  negative  findings,  and  the  diagno-  is  will  be  confirmed 
by  the  rapid  increase  in  weight  when  measures  for  treatment  by  the  Weir-Mitchell  method 
are  adopted.  Herbert  French. 

WHEALS. — The  characteristic  lesion  of  urticaria  may  be  defined  as  a  flatfish, 
evanescent  elevation  of  the  skin,  the  result  of  an  CEdema  of  the  derma.  It  may  be  regarded 
also  as  a  sjjecial  variety  of  the  papule  or  the  nodule.  It  is  related  to  erythema,  and  is  the 
expression  of  angioneurotic  excitation,  internal  or  external,  which  causes  a  dilatation  of 
the  vessels  that  permits  an  exudation  of  plasma.  AVheals  disappear  rapidly  as  a  rule 
without  leaving  any  trace.  They  are  usually  pale  in  the  centre,  with  a  red  periphery  : 
but  they  may  be  uniformly  rose-red,  or  may  have  a  whitish  periphery  :  or,  as  tlie  result 
(if  haemorrhage  into  them,  they  may  be  ijurplish.  In  size  they  vary  from  a  pin-head 
ii])wards.  The  smaller  ones  may  take  the  form  of  conical  or  aeimiinate  papules,  frequently 
surmounted  l)y  a  tiny  vesicle.  As  a  ride,  they  are  flat  or  very  slightly  raised  ;  but  the 
lai-ger  ones,  when  not  the  result  of  coalescence,  are  hemispherical.  They  may  also  be 
linear,  several  inches  in  length,  and  by  running  together,  may  form  roughly  circular 
plaques.  They  usually  appear  suddenly,  and  last  only  a  few  hours,  but  may  be  succeeded 
by  others.  They  are  always  accompanied  by  itching  or  biu'iiing,  which  may  be  intense. 
The  commonest  causes  are  dietetic  ;  some  jiersons  arc  more  susceptible  than  otiiers,  but 
the  kinds  of  food  most  likely  to  cause  the  symptoms  are  fried  fish,  crab,  lobster,  mussels 
and  other  shell-ftsh  ;    strawberries  constantly  produce  an  attack  in  certain  individuals. 

It  is  not  necessary  to  give  a  detailed  description  of  the  different  forms  of  urticaria  ; 
the  only  otlier  affection  in  which  wheals  appear  is  urticaria  papulosa  (strophulus), 
I  he  differential  diagnosis  of  which  has  been  given  elsewhere.  The  sudden  onset,  the 
presence  of  the  wheals,  the  usually  fugitive  character  of  the  eruption,  the  irregular 
(listribulioii,  and  the  severe  itching,  make  up  a  clinical  picture  which  is  generally  unmistak- 
able. Ill  liiiUdiis  nrticnrin,  however,  in  whicli  the  wheal  is  crowned  or  is  re|)laccd  by  a 
hlch,  the  afleelion  may  be  confused  with  pemphigus  or  with  the  erytheniatous  stage  of 
dermatitis  herpetiformis  ;  but  its  true  nature  is  indicated  by  the  history  of  the  case,  the 
course  of  the  eruption,  and  the  almost  invariable  presence  at  some  points  of  tyi)ical 
lesions.  In  cases  in  which  the  constitutional  symptoms  are  pronounced.  I  he  rMsli  inav  be 
mistaken  at  first  for  that  of  scarlet  fever,  or  even  for  erysipelas  ;  hiil  I  lie  eoursc  ol  I  he 
lesions  will  quickly  correct  the  error. 

Wlieii  wheals  are  due  to  such  local  and  accidental  causes  as  the  bites  of  insects,  oi 
contact  with  Ihe  sliiifiiiig-iietllr,  the  diagnosis  is  furnished  by  the  history,  and  in  insect 
bites  by  the  eential  puiutuiii  :  when  due  to  drugs,  knowledge  of  what  the  patient  has 
been  taking  is  the  l)asis  ol  the  ilitfgnosis  ;  the  commoner  remedies  that  may  jirodiice 
urticarial  wheals  are  antlinrin,  siilphonal,  veronal,  aspirin,  salicylates,  iodides,  bromides, 
inoriiliia.  antimony,  quinine,  santonin,  copaiba,  and  various  normal  or  antitoxic  .sera. 

Miilcdlm  Aforris. 

WIND.     (.See  Ki.ATLi.i-.NCK.  p.  V!l(»:    ami   Mil  i.oiiism.  p.  ;!,ss.) 

WORMS.       (See   I'AHAsrrKS,  iNTIiSTINAl..   p.   .-)1!).) 

WRIST-DROP.  (See  AriiOi'iiv.  Misc.  i.ah,  p.  .-.!».) 
XANTHOPSIA.-  (See  \  isioN.  Dkikcts  or,  p.  Tli".'.) 
YELLOW    VISION.     (See  Vision,  Dkiixts  ov,  p.  7(W.) 


INDEX 


Kntries  in  large  heavy  Jcltcrsy  (V/i/.-i— ASCITES — reler  to  main  arli 
/entries  in  small  heavy  letters,  thus — Abortion,  tubal — refer  to  pa^ 

cmnUtion  indicated. 
Entries  in  small  type^  thus — Abdomen,  scabies  of — rejer  to  pages 


on   ichich  there    is   morn   than    a    mere  note  on  the 
which  the  condition   indicated  is  merely  inentionnl. 


PAGE 

4    BDOMEN,  cramps  at- 
^^-^    fecting         . .  . .  151 

-  eczema  marginatum  on  -50 

-  eiilarf^ed  (see  Abdominal 

distention) 

-  erythrasma  of  . .         . .  251 

-  Jacquefs  erythema  of. .  401 

-  lichen  scrofulosorum  on  488 

-  line.'R  albicaiites  on     . .   3fi5 

-  local  fatness  of,   in  Der- 

cnm'd   -.isease  ..   410 

Abdomen,  method  of  exam- 


ining the 

-  pediculosis  of     . . 

-  pendulous 

-  pityriasis  rosea  affecting 
rubra  pilaris  afEecting 

-  prominent,     from     con- 

^^eiiital   dislocation   of 

I'ip 

from  lordosis 


afTeo 


.    15fi 
.   -189 

Abdomen,    regional    anat- 
omy of  . .       659, 660 

-  retracted,  colic  with     ..   115 

in  peritonitis  . .   425 

tuberculous  meningitis  5GG 

-  rigid  (:;ee  Higidity  of  the 

yVbdomeii) 

-  scabies  of  . .      401,  755 

-  seborrlKEic  eczema  of  . .  401 

-  sinall-pox  affecting       . .   757 
Abdomen.  succussion 

sounds    in,       general 
account  of       . .      '*'-'.  653 

-  typhoid  nish  cm  ;;3r>,  r.ni,  t;;iG 

-  typhus  rash  on..  ..   335 

-  varicella  affecting         . .  757 
Abdominal     aorta,     undue 

pulsation  of  (see  l*ul- 

-  colic  (see  Colic) 

-  crises,  in  tabes  . .         . .  313 

-  cyst  . .  . .         44,  (i55 

-  distention  (and  see  Swell- 

ing, Abdominal) 

-  -  from  acute  dilatation 

of  stomach  . .  173 
peritonitis  . .  . .  592 

-  -  ascites              ..  43,  418 
bladder  causing  . .  45 


Abdominal  distention,  con- 
ditions causing 


115 


,vith 


from 


Abdominal  disten.,  contd.     PAGE 

by  tumour      . .  . .   418 

tympanites     ..  ..   418 

from  volvulus  . .   452 

-  fullness,  in  typhoid  fever     76 

-  injury  (see  Injury,  Ab- 

dominal)        . .         . .  173 

-  muscles,  lacerated        . .  593 
paral^'sis       of,       from 

diplitheria  . .  . .   154 

Abdominal  neuralgias  425,  426 

-  pain  (see  under  i^ain) 

-  rellex   (see   Reaex,   Ab- 

dominal) 

-  rigidity  (see  Rigidity  of 

the  Abdomen) 

-  section  (see  Laparotomy) 

-  tenderness    (see  Tender- 

ness, Abdominal) 

-  tumour     (see     Swelling, 

Abdominal,  and 

Tumour,     Abdominal) 

-  veins,  varicose  (see  Veins, 

Varicose  Abdominal) 

-  wall,  loaded  with  fat    . .      45 

Abdominal  wall,  swellings 

of 655 

reddening     of,      from 

tuberculous    perito- 
nitis  631 

liver  abscess  . .  655 

tuberculous  infiltration 


44  I 

123  ' 
cretinism  (i-ii?.  103)  233 
by  cyst  . .         . .  418 

-  -  from  cystic  kidneys  . .     12 

-  -  from   enlarged  spleen  628 

-  in  llirschsprung's  dis- 

ease..        127.  130,  389 

-  -  bill  diarrha-u  ..    173  ! 

-  -  bystorta  .  .    418 
Abdominal  distention,  from 

intestinal     obstruction 

..ll.\  tjO.  :;itl,  522 

-  -  ni:Ui-.i;iut    i^tTitunitis        49  | 

-  metearism  . .  388 

mitral  regurgitation..   211 

obesity 

ortliopn( 

-  -  from     ovarian     new 

growth         . .  . .  * 

-  -  paticroatitis    . .  . .   '■ 

-  -  poritordtis       ..      115, 
phantom  tumour  caus- 
ing   

-  -  in  jiseudo-leukajmla  .. 

-  -  from  strangulated 

hernia 


of 


48 


Abductor    ballucis,   nerve 

supply  of        . .         . .  498 

-  mitiimi      digiti,      nerve 

supply  of       . .       498  504 

-  paralysis  (sec  I'aralysis, 

Abductor) 

-  pollicis,  affected  in  ulnar 

paralysis         ..         ..  110 

ape's       hand       from 

atrophy  of..         . .   110 
-■  -  nerve  supply  of  504 

wasted  in  progressive 

muscular  atrophy. .  110 
Abortion,  acute  peritonitis 

after 592 

-  -  pain     in     the      pelvis 

from  .  .    468 

~    Ir.nri    |, Intnl. isrn  .  .       34 

Abortion,  threatened,  dia- 
gnosis of  ■ .  393 

•   -  niL'trostaxis   from      ..    392 
Abortion,  tubal  . .  690 

Omd  M-e  J-lftojiic  Gtwtn- 

Abrin,hiumogIobinui1a  from  281 
Abscess,   alveolar,   actino- 
mycosis sinnilating  ..  683 

-  -  blccdinu'  u'unis  from  . .      72 

-  -  f:i.c  ^\v..lh-n  from      ..    674 
Abscess,   alveolar,   general 

account  of  . .  683 

-  -  ;^nniipuil  and   ..  ..    683 

-  -  necrosis  of  Juw  from. .   683 

! sites  of  pointing  of  . .  683 

;  -  -  toothache  with  . .   683 

I trisnnis    ninnilati'd    by   729 

Abscess  of  antrum  of  High- 
more,  general  account 
of  ISO.  462 

app;-'ndir,d^u-,    :m.i.m.'    ..s-      ^^ 

-  albumosuria  with     .,     16 
'  -  nnmmia  from  . .     Stl 

■  -  bacillus  coli  in  652,  653,680 

bladder  opened  by  238, 

283.  575,  5H1,  582 

constipation  with     . .  665 

•  erythema  over  . .  222 

-  -  gall-bladder  simulatirrt;  678 


Abscess,  append.^  contd.       I'AfiE 

-  -  gas  in..  ..       032,  653 
infiltration    of     abdo- 
minal wall  from        . .   653 

local  rigidity  over     . .  592 

leucocytosis  with  360,  361 

pain     In     right     iliac 

fossa  from. .  . .   065 

pelvic  swelling  due  to  688 

phantom  tumour  simu- 
lating . .  . .   659 

pyosalpins  simulating  678 

pyrexia  from         582,  665 

-  -  pyuria  from   283,  575,  582 

rigors  from     . .      582,  595 

rupture  into  caecum..  557 

simulating        t3rphoid 

fever  ..         ..361 


suppurative  peritonitis 

from 

swelling   in    Douglas's 

pouch  from 

right  iliac  fossa  from 

582,  ' 

ureteral  calculus  simu- 
lated by     . .         . ,  i 

vomiting  with  . .  i 

-  axillary,  from  empyema  i 

-  -  erythema  over  . .    ; 
Abscess,    axillary,    general 

account  of  .  I 

-  -  from  inllamed  glands     i 

lipoma  simulating     . .  ( 

tuberculous    . .         . .  ( 

from  whitlow  . .  i 

-  of     back,     from     spinal 


Absci 


Ma 


-  broad  ligament  . .         . .  ) 
-t  cerebellar,   ankle   cloims 

from     . .         . .         . .  J 

ata.vy  from     . .  . .   ', 

bradypno-a  from 

from  bronchiectasis  . .  \ 

cerebellar  tumour 

simulating  . .  ..  i 

convulsions  with       . .   ] 

disseminated   sclerosis 

simulating  . .  . .  i 

intention  tremor  from  I 

knee-jerk     increased 

from  . .         . .  .' 

n^'stjigmus  from        . .  i 

from  otitis  inetlia   517,  J 

paraplegia   from        . .   '. 

-  pyrexia  with. .  , .  J 
retracted  head   from 

589,  1 

scanning  speech  from     1 

sinus  thrombosis  simu- 
lating . .  . .  J 

alow  pulse  with        . .  I 

vertigo  from  . .         . .  ' 

vomiting  from  . .  I 

-  cerebral,  aphiisfa  from. .  i 

llablnski's    sign    with  i 

brachial      monoplegia 

from . .         . .         . .  i 

bradycardia  from    84,  i 

brudypinea  from      Kl, 

from  bronchiectasis 

84, 

-  -  causes  o( 

choked  disc  from 

coma  from 

Unit  sign  of 

convulsion;*  from    I  HI, 


Abscess,  rerthral,  contd.        V.\ 
Abscess,   cerebral,   distinc- 
tion from  tumour 

-  -  from     frontid     sinus 

disease        .  .  .  .    : 

giddiness  from  . .  ; 

headache    from     147, 

300,  502,  026,  : 

hemianopsia  from     . .  ; 

hemiplegia    from    08, 

303,  : 

hyperacusis  from      . .  : 

hyperpyrexia  from  . .  ; 

hypertension  of  cere- 
brospinal fluid  with  ; 

-  -  latent : 

-  ^  leucocytosis  with      . .  ; 

from  mastoid  disease    J 

optic  neuritis  from 

84,    147,   300,  502,  ) 

from,  otitis  media    84.  : 

pupil  small  with       . .   ; 

pyrexia  from  300, 563,  i 

absent  with         84,  : 

rigors  from     . .         ..  '• 

rupture  through  ear. . 

septicemia  from       . .  ; 

simulating  trance      . .    i 

sinus  thrombosis  simu- 


Abscess,  cerebral,  subnormal 
temperature  with   5i)2,  574 


fro 


ulc 


ndo- 


carditis 
- —  unilateral     headache 

from  . .  . .  394 

paresis  from  ..   118 

uriomia  simulating  . .     85 

vertigo  from  ..         ..   752 

vomiting  from  147,  300. 

502,  597,  026,  765.   708 

-  of  chest  wall     . .       16S.   lOH 

-  cholecystic,  pus  in  stools 


froi 


from     09 


530. 


:):il.  051,  632, 

•  in  heart,  in  pyiemia  212,  . 

•  hepatic,  acute  congestion 

of  liver  sinnilating  ..  : 
■ peritonitis  from     . . 


■  age  i 
-  alb) 


id«-i 


-  -  albumosuria  with      .. 

-  -  ama>bic,   amn'biu   ab- 

sent from  lum  in    . .  f 

-  -  ania'biu  in      .  -         •  •  • 

-  -  nnnjmia  from 

-  -  anchovy  sauce  sputum 

from  . .       149,  'J 

-  -  apymxialiulervalswlth:! 

-  -  ascites  from   . .  . .   '\ 

-  -  chocolate  pus  from  . .   H 

-  -  from  chohingltis        . .  J 

-  -  colour  of  puH  in     332,  • 

-  -  common  tiite  of        . .  : 

-  -  dome-shaped   ilullnfws 

wilh..  ..      291,  : 

-  -  alter  dyHenl«ry     233, 

201,  332,  369,  t 

-  -  ompvoma  from      101,  I 

-  -  orytiiema  over  . .    1 

-  foul  sputum  from     . .  t 

-  -  taste  from  . .  . .   i 

-  from  gall-Htoin'         . .  : 


ABSCESS.    HEPATIC 


ABSCESS.   SUBDIAPHRAGMATIC 


.  /<'■/ 


i>fd. 


Abscess,    hepatic,    general 
account  of  . .  369 

L'l'iien.l    wasting   from     59 

-  -  from  gumma..  ,,   253 

gumma  simulating    . .  334 

hemoptysis  from  287,  291 

hiccough  from  . .   308 

from  hydatid  253,  369,  37B 

influenza  simulated  by  370 

from  injury    . .  . .   369 

interscapular     pain 

from  . .  461,  462 
jaundice    from      325, 

320,  330,  333.  335,  370 
laparotomy  in  diagnos- 


ing 


-  -  leucocytosis  with   360, 

361,  362,  370 

liver  dullness  increased 

upward  with  . .   367 

enlarged    with    326, 

330,  369,  658 

malaise  from  . .  597 

malaria  sinmlated   by 

362,  370 

simulating  335,  361 

Abscess,  hepatic,  multiple    332 
iM_-...M-     253 


froni 


253 


over 370 

—  pain  in  axilla  from  . .  597 

chest  from  431,  709 

epigastrium         437,  462 

hypochondrium  with 

450,  597 

hypogastrium    from  462 

shoulder  from     475,  597 

-  from  perinephric    ab- 

scess ..  ..    3G9 

-  phantom  tumour  simu- 

lating . .  . .   659 

-  pleural  effusion  from     597 

-  pleurisy  from  . .  106 

-  pneumonia  from        ..   370 

-  polymorphonuclear 

cells  increased  with  362 

-  pus  sterile  in  . .        291,  369 
"  from  pylephlebitis  332,  596 

-  pyrexia  with  . .      369,  597 

-  race  incidence  of     . .  369 

-  redness  of  abdominal 

wall  from   . .  . .   655 

-  rigors  from   291,   326, 

?,70.  7)1)5,  597 
■  -  rupture    into    intestine  370 

ibscess.    hepatic,    rupture 
through  lung  no,  i^S7, 
291,  33*,  "70,  644.   705 
into  stomach  . .   370 

-  sallow  complexion  from  332 

-  sex  incidence  of        . .   369 

-  simulating      enlarged 

gall-bladder        252,  253 
empyema    . .         . .  103 

-  skodaic  resonance  with  611 

-  subdiaphragmatic  ab- 

scess from..       451,  658 

-  sweating  from        370,  597 

-  swelling  in  right  hypo- 

chondrium from    . .  655 

-  tenderness     in     chest 

from  . .         . .  709 

-  tropical  congestion 

simulating  . .         . .  369 

-  in  Tropics        291,  332,  369 

-  tuberculous    . .         .  -    "5 

-  risible  tumour  due  to  370 

-  wasting  with..         ..  370 

-  a--rays  in  detecting  . .  370 

-  psoas     distinguished 

from  . .  . .   680 

-  pyuria  from    . .  . .   575 

-  rupture   into    bladder 

575,  581,  582 

-  swelling  in  right  ihac 

fossa  from  . .  , .   665 

-  in  typhoid  fever       . .  459 
inguinal,  fi-om   appendi- 
citis  680 

-  erythema  over  .  .    222 

ibscess,    inguinal,   general 
account  of  . .  680 

-  from  hernia    . .  . .    680 


Abscess,  inriiiinal.,  contd. 

[ from  hip  disease        . .   680 

^ sacro-iliac  disease     ..  680 

, spinal  caries  . .  . .   680 

I suppurating    glands. .   680 

I  —  ischiorectal,      felt      per 

rectum  , .  , .   58  7 

from  foreign  body    , .  584 

tenesmus  from  . .   718 

!  -  of  kidney  (see  Abscess, 
i  Renal) 

-  of    liver    (see    Abscess, 
!  hepatic) 

I  -  of  liuig,  from  embolism  260 

' hjemoptysis  from      . .   286 

leucocytosis  with      . .  360 

in  pyaemia      . .  , .   260 

in  septic  pneumonia    286 

simulating     empyema  103 

-  mammary,  from  mastitis  685 

-  mastoid,  erythema  over  222 

meningitis  from        . .  590 

from  otitis  media     . .     84 

otorrhcea  from  . .  423 

pain    and    tenderness 

over  . .         . .  202 

rapid  pulse  with        . .     84 

rupture  through  ear. .  423 

simulated  by  inflamed 

mastoid  gland       . .  203 

-  mediastinal,  pain  in  the 

chest  from      . .         . ,  435 

tenderness     of     spine 

from;  ■         . .      713,  714 

-  omental,     from     gastric 

uloer 661 

-  of  orbit,  diplopia  fi-om     177 

eyeball  fixed  by        . .   177 

proptosis  from"  . .   177 

-  ovarian,  obscure  pyrexia 

due  to  . .         . .  573 

-  parametric,  felt  per  rec- 

tum .".  ..  ..  587 
Pouparfs    ligament 

bulged  by  . .  . .  676 
swelling  in    Douglas's 

pouch  from  . .  587 

-  parotid,  rupture  through. 

ear 423 

-  pelvic,  from  appendicitis  474 
bearing-down        pain 

from  . .  . .   427 

from  diverticulitis    . .  453 

hip  disease     . .         . ,  680 

hiematuria  from    275,  283 

irritation  of  rectum  by  427 

pain  in  iliac  fossa  from 

452,  454 
mucus  in  stools  due  to  427 

-  -  pelvic  swelling  due  to  688 

pus  in  stools  from    . .  557 

pyuria  from  . .  , .   575 

rupture    into    bladder 

575,  581 
from  salpingo-odphor- 


itis 


tenderness     of     spine 

from  . .      713,  714 

-  pericolic  . .         . .  G63 

-  perigastric,  pus  in  stools 

from 557 

umbilicus        inflamed 

with  . .  fi-R 

-  perineal,    leucocj^tosis 


-  pp^ 


-  -  V' 


^ith     ..         .'.  ..  3G0 

'pliric.     r.)I-)pcess  of 

■'■  ii-'"ii         .  .  ..  369 

H  :M'1"  "  li''ilis  ..  353 

\U"\^^.>    r<,ll  ..     353 

■  'ym.y  Ir.Mii  ..    104 

1   lilk.l  out  by  352,  451 

ri  in  hypui-hondrium 

troni  .  .      450,  451 

loin  from     ..  ..451 

pus  in  stools  fi'oni     .  .   557 

riffors  from     . .  . .   595 

Abscess,  perinephric,  signs 

of         353 

from  suppuratmg  he- 
matoma     . .         . .  353 

tenderness     of     spine 

from  ..      713,  714 

-  perio3te;iL  from  injury. .   668 

ostenmyelitis  with     . .    668 

typlioid  bacilli  from..   670 

-  periprostatic,    diverticu- 

litis simulating  . .   453 


Ahsccss,  periprostatic^  contd. 

pain  in  iliac  fossa  from  452 

retention  of  urine  from  649 

strangury  from  . .   649 

tenesmus  from  . .    718 

-  periproctai,  acute  ascites 

from     . .  . .  . .     47 

anaemia  from. .  . .   719 

anajsthetic  iu  diagnos- 


ing 


from  carcinoma 

carcinoma     simulated 

by 

diverticulitis  simulat- 


from  forni-n  body     .  .   584 

Abscess,  periproctai,  general 
account  of      . .      585,  719 

-  -   in...  01  .Irrpirum        ..    719 

losa  i>i  weight  from  . .    719 

pain    iu     iliac      fossa 

from            . .          . .  452 

from  piles       . .         . .  719 

polypus           . .         . .  719 

retention  of  urine  from  649 

strangury  from         . .  649 

suppurative    perito- 
nitis from   . .         . .  47 
tenesmus  from      718,  719 

-  peri-ureteral,   from    cal- 

culus     397 

fistula  from    . .  . .   397 

-  peri-uretlu-al,     fistula 

from 397 

oedema     of     scrotum 

from  . .  , .   697 

pain  in  scrotum  from  697 

scrotal  fistula  from  . .   621 

Abscess,  popliteal  . .        . .  692 
from  periostitis  . .   693 

-  postpharyngeal,  age  inci- 

dence of         198,  616,  647 

cyanosis  from  . .  157 

dysphagia  from         . .  198 

dyspnoea  from       198,  616 

laryni    obstructed   by 

157,  418,  651 
ingitis     simulated 

590 


by 


orthopncea  from       . .  418 

sore  throat  from    613,  616 

from  spinal  caries      . .   647 

spinal  caries  simulat- 

616 


ing 


stertor  from  . .         , .  647 

stridor  from  ..         ..  651 

tenderness    of     spine 

from  ..       713,  714 

-  prostatic,  aching  in  peri- 

neum from      . .  . .   474 

acute  ascites  from    . .     47 

arthritis  from  . .   339 

from  calculus  . .   581 

-  -  frit  per  iwtum       182,  620 
Abscess,  prostatic,  general 

account  of  ..581 

hiuniaturia  from         . .    583 

increased  frequency  of 

micturition  from  . .  470 

after  instrumentation    C20 

pain     on     micturition 

with  . .         , .  182 

in  penis  from  469, 

470,  471,  473 

perineal  sinus  from  . .  620 

prostate  swollen  in    . .  182 


—  pyrexia  from  182,  470, 

—  pyuria  from    . .         . .  | 

—  rectal  examination    in 

diagnosing  470,  581,  i 

—  retention  of  urine  from 

182,   ■ 

—  -  rigors  from  182,  581,  [ 

—  rupture   into    bladder 

575.  I 

—  ■^  reccum        . .         . .  { 
urethra       . .         . .  j 

—  -  suppurative    peritoni- 

tis from 

—  tenderness  with  . .   1 

—  -  from  tuberculosis     . .  I 

—  -  uretiu-al  discharge  from  ( 

■  -  after    urethritis     182, 

470,  473,  I 

■  psoas,  aua-mia  with     .. 


581 


Abscess,  psoas,  contd. 

angular  curvature  with  6 

appendicitis  simulated 

by 

bursa  simulating 

Abscess,  psoas,  general  ac- 
count of 


46; 


36^ 

in  groin  . .  . .   68( 

hernia  simulated  by. . 

impulse   on    coughing 

in        ..       674,  67f.',  681 

lameness  from  . .   7i: 

lardaceous  disease  from  37- 

leg  movements  with . ,     6: 

limping  from  . .   36; 

pain  in  iliac  fossa  from 

453,  45 

leg  from      . .         . .   7i: 

pointing  in  back        . .    71; 

through  chest        . .   16i 

position  of  leg  with. .   36- 

Pott's  curvature  with  36- 

pus  in  stools  from     . .   55i 

pyuria  from 

reducible       674,  675,  681 

' rupture   into    bladder 

575,  581,  58i 

ureter  . .  . .  58; 

gimulating  hip  disease  36S' 

Spmal  caries  and    361, 

516,  o82,  6«[»,  712 

swelling  m  iliac  los-sa 

from  . .       582,  66^ 

inguinal  region  from  582 

ureteral  calculus  simu- 
lated by      ..  ..461 

-  pulmonary  (see  Abscess 

of  Lung) 

-  renal,  from  infarct        . .  570 

injury  .  ,         ..  ..   57i 

kidney  enlarged  from  35 

leucocytosis  with      . .  36i 

normal  urine  with    . .   57 

peritonitis  from         . .  59: 

from  pyelonephi-itis. .  57i 

pyuria  from    ..  ..57; 

from  renal  calculus  ..  27' 

-  retropharyngeal         (see 

Abscess,    Postpharyn- 
geal) 

-  atrootof  nose,  from  fron- 

tal sinus  empyema   ..  181 

-  sacral,  felt  per  rectum, 

-  sacro-iliac,    swelling    ii 

right  iliac  fossa  from      665 

-  spinal,  intercostal  neural- 

gia simulated  by  . .   707 

in  pyaemia      . .     '713,  714 

tenderness     in     spine 

from  . .         . .  714 

-  of  spleen,  acute  perito- 

nitis from  . .  . .   592 
excessive  rarity  of    . .  632 

-  subcutaneous,   gumma 

simulating  .,   403 
fi-om  inflamed  gland.,   381 

-  -  leucocytosis  with      . .   36i 

pain  in  the  back  from  42 

in  pyfemia      . .  . .   596 

-  subdiaphragmatic,  abdo- 

minal swelling  from  655 

adhesions  round        . .   367 

albumosuria  with      . .      16 

from  appendicitis 

103,  106,  451,  658 

bacillus  coli  in       651^  652 

bismuth  meal  in  dia- 
gnosing      . .         . .  532 

bronchiectasis  fi'om..  292 

bulging  epigastrium.,  658 

from  carcinoma  of  sto- 
mach ..         ..  531 

coin  sound  over        . .   451 

diaphragm  raised  by    C5S 

from  duodenal  ulcor     451. 

empvema  from     103,  104. 

658 

fibroid  lunc  from      . .   292 

foul  taste  from         . .  705 

gas-containing      451,  531, 


Abscess,  subdiaphragmatic, 

general  account  of  451.  658 
-  -  heart  displaced  bv  iiJiS,  659 


ABSCESS,   SUBDIAPHRAGMATIC 


ACID,   URIC 


Abscfss,  siihdiaphragm.y  contU. 

—  from  hepatic  abscess     451 

—  tidney  sepsis. .  . .   658 

—  leucocytosis  with  451,  658 

—  liTer  depressed  by    . .  367 
dullness     increased 

upwards  by  . .  367 
not  pushed  down  by  451 

—  from  liver  suppuration  658 

—  pain  in  chest  from     . .  658 

episrastriam  from. .  658 

hvpochondrium  from 

450,  451 

physical  signs  of       . .   658 

pleurisy  from. .       451,  658 

simulated  by         . .  658 

—  pleuritic  effusion  from  659 

—  pneumonia  from       . .   370 

pneumothorax  from       531 

simulated   by   652,   658, 

659 

—  pointing  through  chest  169 

—  pyopneumoperiear- 

dium  from  . .  . .  652 
pyrexia  with          451,  658 

—  —  resonance  over  . .  451 
rigors  from     . .      595,  658 

—  -  rub  over  . .  . .   658 

ruptured  into  lung    . .  705 

septic  look  with        . .  658 

—  shortness     of     breath 
from 658 

simulating  empyema     103 

skodaic  resonance  with  fill 

--  succussion  in..       651,  652 

tenderness     of     spine 

from     ..  ..      713.  714 

umbilicusinflamed  with  650 

i-rays  in  diagnosing      451, 

532.  652,  658,  659 

—  submammary    . .         . .  686 
pain  from       . .  . .   429 

—  subphrenic  (see  Abscess, 

Subdiaphragmatic) 

—  temporosphenoidal,  noLses 

in  tlie  head  from       . .  406 

—  of  testLs.  aching  at  exter- 

nal abdominal  ring  in  G22 

from  chronic  torsion       622 

enlarged  prostate      . .  622 

~  -  in  fevprs  .  .  . .    622 

Abscess  of  testis,   general 

account  of  621,  622 

—  -  from    jii^'niiii.-tit.aiun  622 

—  -  orchil  is  ..  ..478 

pyrexia  from  . .  .  .    622 

rigors  from     . .  . .  622 

spermatic  cord  tliick- 

ened  with  . .  . .   622 

testis  enlarged  by     ..   622 

nicer  of  scrotum  from  622 

from  urethritis  ..   622 

—  toMsilL.r  fs.T-  Quirt^y) 

Abscess.tuberculous.  of  bone  669 


-  unibilR.tl.  iii  tubcr.ulous 

peritonitis      . .         . .  483 

-  urethral,  aching  in  peri- 

neum from     . .  . .  474 

Vhcffc^P^,  albumosuria  with  16 

Ml.  f  ,-f;itic,    in    pytemia  590 

I  -  I  11  •-.  in  pya'mia       ..   596 

Kiihiry,  in  newborn     . .  557 

-  ill  throat,  prolonged  py- 

.  rexia  from      . .  . .   567 

septicnamia  from       ..  567 

Absentmindcdness  in  epi- 
lepsy    130 

Absinthe,  coma  from        . .    118 

-  Iieart  irregular  from     . .  486 

-  palpitation  from       481,  486 

-  tremor  from       . .      724,  726 
Academy  headache  . .  296 
Acantho3i.i  nigricans,   fin- 
gers affected  by        . .  240 

-  prurigo  anrl        . .  . .   489 
Acarus  scahici,  burrows  on 

wrists  and  lingers      . .   5 10 

eosinoi)hina  rare  from  219 

(:vu\  s..,.  Snibirs) 
ACCENTUATION  of  heart- 


Accessorius,  nerve  supply  498 
Accidental  albuminuria  .  ■  IS 
Accommodation,  defective, 

after  diphtheria        . .     64 

-  paralysis  of,  in  dissemin- 

ated sclerosis  . .   760 

-  pupil  constricted  in  , . .  551 
ACCOUCHEUR'S  HAND  2 
Acetabulum,    bulged    into 

pelvis 349 

Acetanilide,  bulliG  from    .  .      96 

-  cyanosis  from    . .  . .    157 

-  methJBmoglobinuria  after  157 

-  polycythaamia  from      . .  533 

-  reducing   substances    in 

urine'after     ..         ..157 
Acetate  of  cellulose,  in  aero- 
plane varnish  ..  334 

-  o£  lead,  in  Cammidge's 

reaction           . .         . .  100 
test  for  cystin       161 

-  sodium,  in  phenylhydra- 

zine  test  . .         . .  263 

-  zinc,  in  urobilin  test     . .   325 
Acetic  acid  (see  Acid,  Acetic) 
Aceto-acetic  acid  (see  Acid, 


Dii 


etic) 


Acetone,  in  aeroplane  "^ 

-  breath     . . 
Acetone,  test  for    ■ . 

-  -    ,  f'al,    A  XXIV) 

ACETONURIA 


-  diabetes  niellitus  ..   i 

-  diaceturia  and  . .  . .   '. 

-  relation  to  coma 

Acetonuria,  various  causes 


-  without  glycosuria       . .       4 

A  chalazia 198 

Aches  and  pains,  blue  brain 

and 163 

Achillis-jerk     (see    Ankle- 
jerk) 
Aching  all  over,  in  Kirk- 
land's  disease  ..  616 
from    serum    injec- 
tions   . .          . .          . .   223 

-  in    back,   in   phosphatic 

diabetes  . .         . .  523 

-  general  in  paralysis  agi- 

tans     . .  . .         . .  725 

-  in  groin,  from  spermato- 

cele       481 

syphilitic  testis  , .  479 

-  kidney,  from  carcinoma 

of  bladder       . .         . .  580 

-  loins  from  bacteriuria  . .     70 

from  movable  kidney  280 

oxaluria  . .  . .   281 

pyelonephritis 

renal  calculus 

new  growth  . .  278 

stone  in  kidney         . .  077 

tuberculous    kidney 

279,  577 
ureteric  calculus        . .  578 

-  lumbar   region,  from 

spermatocele  . .  481 

syphilitic  testis     . .  479 

vesica!  gro\}^h       . .  277 

-  lumbosacral  rc^'ion,  from 


..   278 


perineum    (see    Pain    in 


682 


the     P« 


-  shoulilcr  (see  Pain  In  the 

ShoulrlfT> 

-  in  tosticulur  abscess    . .   62- 

-  testis,  from  spermatocele  481 
Acholuric  jaundice     324,.  325, 

332,  333.  744 
trophy  333 


■irrlir 


332 


>n;irv  MTond  sound, 

li    niilral  rogUTglta-  I 

I 210 

n-rliiphcation  and  588 


I  .-rh. 


nil,  fa 


Achyliii,  diarrhu'a  from 
-  dyspepsia  from 


Acholuric  Jaundice,  fami- 
lial                  .■   332.  634 

-  -  {Plate  XV III)  ..  332 
spleen  ordarged  in  631 

-  -  from  septlcnjmia  .,  335 
Achondroplasia  fA*(i7. 117)  237 
Achondroplasia,    general 

account  of  (VV/  mi)  I87 


Achy'ia,  could. 

-  gastric  contents  with  . .   310 

-  -  HCl  deficient  in       . .  270 
Acid,     amido  -  oxybutyric, 

acetone  with  . .         . .       3 

-  acetic,  in  acetone  test  . .        3 
Acid,    acetic,    in    boiling 

test  for  albumin        4,  424 

carbonates     dissolved 

by 4 

in   clearing   up   phos- 
phates 4,  108,  183,  524,  571 

effervescence  of  urine 

with  ..  ..       4 

in  extracting  blood  . .     81 

gastric  contents         ..   320 

Hofmeister's  test      . .     16 

raelanuria  test  . .  746 

nucleoproteid   precipi- 
tated by     . .         . .       4 

in  occult  blood  test  . .  171 

stool  examinations  . .   170 

urobilin  test  . .  . .  325 

-  benzoic,  erythema  from  222 

glycuronlc  acid  from     261 

reduction      by      urini 

after 

-  boric,  erythema  from  . 

in  lavage  of  bladder 

urethral  irrigation    . 

-  butyric,  in  gastric  con 

-  carbolic,  bulla3  from     . .     97 
in  carbol-fuchsin        . .   641 

-  -  coma  from      ..  ..118 

diazo  reaction  from..  173 

erythema  from  . .   222 

ferric  chloride  reaction 

after  . .         . .  170 

glycuronic  acid  from     261 

haimaturia  from       . .  275 

haemogloOinuria  from    284 

hypothermia  from    . .  311 

ochronosis  from    528,  746 

reduction     by     urine 

after  ..  ..201 

scales  from     , .         . .  602 

tinea   circiuata  simu- 
lated by 
in  treating  pediculosis  746 


261 


320 


223 


ulcers 

ulcus  serpens 

-  UfEelmann's  test 

-  urine  after 

-  in  vomit 

■  chromic,   hajmoglobin- 

uria  from 

■  chrysophanic,  alkali  test 

for 


yellow  urine  from     . . 

-  diaeetic,  association  with 

acetone 
in  cyclical 


vomiting 

384,  765 

261,  264,  aZQ 

..170 


diabetes 

test  for 

(pl(Ue  X.XXI  V)    . .    748 

in  urino  . .  . .   170 

from  starvation     . .       4 

-  gallic,  black  urine  from    745 
thirst  from     . .  . .   720 

-  glycuronic,     Rial's    t«st 


for 
bi.<4mnth  salts  reduced 


l>.v 


Fchling'rt  solution  re- 
duced by    . .  . .  261 
osa'/ono  cry«talfl  from  2tt2 

-  phcnylhydruzine  crys- 

tals from    . .  . .   100 

phloroglucin  toHt  for. ,  261 

in  urine  alter  dnig«  . ,  201 

-  htomatin  spectrum  (Fig. 

34) 80 

-  hlppuric,  Pehlfng*8  solu- 

tion reduced  l)y        . .  201 

-  homogontisic,  alkapton- 

uria and  ..  ..  740 
estimation    by    silver 

nilrato  ..  ..  740 
reduring  power  of     . .   740 

-  hydrochloric,    in    lilaVA 

test 20! 

-  CVimmidgc's    reaction  10() 


Acidy  hydrocMoric,  could. 

carholuria  and  . .    747 

in  diazo  reaction       . .    173 

gastric,  deficient  with 

carcinoma  of  stomacli 
316,    436,    630,    653, 

766,  767 

in   gastrectasis  . .  766 

gastritis  . .         . .   760 

in  duodenal  ulcer  . .  451 

trastric  ulcer  and  . .   767 

Acid,  hydrochloric,  in  gas- 
tric juice   270.  '.■■\>'.  :'.is,  760 
Acid,  hydrochloric,  in  gas- 
tric juice,  absence  of- .     33 

(P/ale  XX  Jl  V)   . .    750 

hffimatoporphyrin  and  744 

hiemoglobimu"ia   from  284 

indican  and    . .  . .  745 

in  Perl's  test  . .  . .     24 

phloroglucin    test   for 

■pentose  . .  . .  261 
tests  for  free  . .  . .  320 

-  hydroquinone-acetic,  al- 

kaptomiria  and         . .    740 

-  indoxvlglycuronic,    blue 

urine  from     . .  . .  747 

-  lactic,  in  gastric  contents  318. 

320,  700 

with  carcinoma  of 

stomach       ..      310,  767 

-  -  test  for  . .  . .   32(1 
in  vaginal  secretion..   185 

-  methylsalicylic,    erythe- 

ma from         . .  . .  222 

Acid,  nitric,  albumin  test 

with  4.  5 
--  albumose  ring  with  10,  1(1 
brown   ring   hi    urine 

with 311 

-  -  bullffi  from     ..  90,  97 

hajmoglobinuria   from  2S4 

indican  and    ..  5,  74.' 

melanuria  and  . .    745 

nuctcoproteifi  and      5,  424 

test  for  bile  pigment. .   74 :i 

urea   decomposed    by       ■' 

-  osmic,    in    staining    fat  10? 

-  oxalic,  anuria  from      . .     4(1 

from  ve-gelables        . .  421 

coma  from      . .  . .   IIH 

Acid,     oxalic,     exogenous 

sources  of      . . 


L'luhi 


2HI 


lj_\polhornii;i  from    ..    311 

nephritis  trom  . .       S 

poisoning  by,  oxaluria 

after  ..  . .  2Q^ 
strangury  from     649,  66G 

-  oxybutyric,     association 

with  acetone  . .  . .        •' 
in  diabetes     . .  . .   26^ 

-  phosphotnngstic,     nlbu- 

mosc  test       ..  . .     li' 

-  picric,  crcatinin  and     . .   20:: 
lactase  and     . .  . .    -*'>- 

Acid,  picric,  test  for  sugar  262 

xanthopsia  from        . .    70*j 

yellow  skin  from       . .   521 

-  prussic,  in  vomit  . .   70lj 

-  pyrogallic,  hicmoglobln- 

uria  from       . .  . .  28 ! 

-  salicylic,  purpura  from     55: 

-  succinic,    leucocytosis 

from 36( 

-  sulphanilic,  in  diazo  re- 

action ..         ..  171 

-  sulphuric,  in  bile  test  . .  744 

hemoglobinuria    fron»  28* 

in  Zichl-Neolsen  stain- 
ing        641 

-  tanidc,  thirst  from        . .   72( 

-  tartaric,  In  Inllating  sto- 

mach ..         317,  318,  31! 

-  uric  . .         . .         . .  26 

-  -  ill  hinlH  . .         . .  74; 
calculuN  and    . .  . .    71: 

-  -  the  clinker  )if  the  body  71: 
crystals      H  (Fi'j.  3i)2)  71 

-  ->  diminished,    in    acute 

yellow  atrophy      . .  33; 

Folding's  solution    re- 

iluee^l  by    ..       201,  74,* 

-  In  fovom         . .         . .  74; 

-  frc(|UonL      nilcLuritlon 

luid 7-1; 

-  glycofliirln  simnlalod  by  74' 


ACID.    URIC     —    AGE. 


320 


Acid,  uric,  cvn/'l 

Acid,  uric,  gout  and  74i,  742 

-  -  eravel  duf  tu  .  .  .  .    741 

-  -  111  heart  dise;ise  . .    742 
leukcemia        . .  . .  742 

-  -  life  insurance  and     . .  743 

oxalate  crystals  with  424 

irom             . .  424,  742 

of  lime  and  . .   742 

-  -  in    pernicious   anemia  742 
Acid,  uric,  sources  of  ..  742 

urctliriti."^  nnd..  ..   742 

Arid  Ja;l  hii.iili      ..  .  .    «4l 

Acidity,  gastric,  estimation 

of        ..         . 
Acidity   of   normal    urine, 

general  account  of    ■  •  523 

-  sense  of,  from  dyspepsia     319 

-  of  stool,  from  fermenta- 

tion        170 

-  urine,  excessive,  frequent 

micturition  from        . .    742 

-  vaginal  secretion  ..    185 
Acidosis,  in  cyclical  vomit- 
ing      ..          ..      384,  705 

Acidosis,  general  account  of     3 

-  relation  of  hepatic  glyco- 

gen to  . .  . .       4 

Acids,  fatty,  bacillus  aero- 
genes  capsulatus  pro- 
ducing . .  . .    256 

-  gangrene  from  ..         ..  255 

-  haematemesis  from        . .   265 

-  mineral,  cystin  dissolved 

by       161 

dermatitis  from        . .  755 

erythema  from  . .   222 

-  strong,  sore  throat  fi'om  (113 

-  ulcerativestomatitisfrom  740 
Acne,  from  bromides        . .      US 

-  decalvans  . .  . .    710 

-  from  iodides      . .  . .     98 

-  papules  m  .  .       487,  489 

-  rosacea  (see  Bosacea) 

-  septicaemia  from  . .  637 

-  tenderness  of  scalp  from  710 

-  vulgaris,  age  incidence  of  559 
comedones   in    241,    489, 

559,  560,  563 

Acne  vulgaris,  general  ac- 
count of  . .  489 

-  -  milium  in        . .  . .   489 

-  -  parts  affected  by   489,  560 

puberty  and  . .         . .  489 

pustules  in      489,  557.  559 

rosacea    distinguished 

from  . .  . .   241 

sebaceous  glands  and  489 

small-pox   simulated     562 

sycosis  simulating     ..   559 

sypliilide  simulating      560 

xanthoma    simulixtmg  733 

Aconite,  bradypncea   frrm     84 

-  ptyalism  from    . .         . .   542 
Acoumeter,  Politzer's  (Fiff. 

73)       ..  ..  .*.   1G4 

Acromegaly,     amenorrhctja 

in  18 

Acromegaly,  bone  changes 

in  406,  ess 

-  diabetes  insipidus  and. .   537 

-  eidarged  feet  in. .  . .   637 

fingers  in        . .  ..Ill 

forehead  in    . .  . .  204 

hands  in         ..  ..   537 

and  feet  in  . .   204 

head  in  . .      352,  537 


■  -  ja 


Acromegaly,  facias  of  (Fig. 


204 


IK; 


237 


Acromegaly,    general    ac- 
count of  . .  237 

-  hemianopsia  in  . .  . .   ,302 

-  irritability  in      . .  ..   323 

-  noises  in  the  head  fi-om  406 

-  pituitary  body  and       . .   409 

-  from    pituitary    tumour 

302,  537 

-  polyuria  in         ..      536,  537 

-  pulmonary    osteothro- 

pathi"  simulating      ..  352 

-  teeth  wide  apart  in       . .   237 

-  type  car6e  . .  . .   237 

-  a:-rays  in  diagnosing     , .   537 


Acroparaesthesia,  general 
account  of      ..         ■■  • 

Actiiiuuivr.-,  huig  iilTected 
by         

-  iPiateXXv'l/l')'         '.. 

-  in  sputum 
Actinomycosis  of  ap])eudix 

-  black  graimles  m  . .    > 

-  bleeding  gum  from 
Actinomycosis    of    cxcum 

458, 
appendicitis  simulated 

by 

carcinoma     simulated 

by 

laparotomy  for 

pain  in  iliac  fossa  from 

swelling  in  iliac  fossa 

-  clir.-i  \v,(ll  uil'ected  by  . .   ■ 


Actinomycosis  of  jaw  ■■  I 
Actinomycosis   of  jaw, 

gum.  cheek 
Actinomycosis  of  liver  375,  ' 

-  microscoiie  in  diagnosing 

74,  . 

-  mycelium  in  . .  . .  i 
~  ^arts  affected  by  . . 

-  pleura  affected  by        . .  ■ 

-  potassium  iodide  for     . .  ■ 

-  ray  fungi  in       . .  . .   ■ 

-  sinuses  in  neck  from     . .  i 

-  of  spine  . .         . .      713, 

-  from  straw 

-  streptothrix  in  . .         . .  i 

-  sulpliur  coloured  granules 

-  tongue  swollen  from     . .  i 

-  j^ellow  granules  in  677,  i 
~  ulceration  of  cheek  from  ■ 
jaw  from        . .  . .   ■ 

-  vaccine  treatment 
Acute  anterior  poliomyeli- 
tis (see  Poliomyelitis) 

■     I  I     ■  I  (  Plate  xY)  : 

-  .,■-,..    |,^,.rs) 

-  i[:il.inihi.inn[i-  uf  the  eve 

(P/trl.s   XI.  XII)  230,  ; 
~  iritis  {Plate  JL'/)  . .    : 

-  rheumatism  (see  Rheum- 

atism, Acute) 

-  rheumatoid  arthritis  (see 

Arcliritis,Rheumatoid) 

-  yellow  atrophy,  in  aero- 

plane varnishers        . .    '■ 

age  incidence  of    . .  ! 

albumosuria  with. . 

bleeding  gums  in  . . 

catarrhal      jaundice 

simulated  by     . .  : 

from  chloride  "of  sul- 
phur       ..         ..  ; 

delirium  in  . .  : 

from  dinitrobenzene  ; 


epistaxis  in  . .   : 

friRht  and  .. 

Acute  yellow  atrophy,  gen- 
eral account  of      2?3,  : 


nished  in  273, 
loss  of  appetite  in. . 
malaise  in  . . 

■  meleeiia  in  . . 

phosphorus    poison- 
ing simulating. . 

■  pregnancy  and 
purpura  i 


in  rubber  workers. , 

sex  incidence  of    . , 

sordes  in     . . 

from    tctrachlore- 

thann 
tongue    dry    and 


Acufc  yclloiv  atrophjf^  could. 

from     trinitrotoluol  334 

tyrosin  in    . .      273,  765 

urea  in        ..  ..273 

vomiting  in         273,  764 

yellow   fever   simu- 
lating       ..         ..  33G 
Adamson,  on  bullous  im- 
petigo . .         . .  . .  401 

-  pemphigus    neonatorum  401 

-  seborrhoeic  dermatitis  of 

infancy  . .  . .    401 

Adder  bite,  general  account 

of        337 

Addison's  an.nemia  (see  I'er- 

nicious  Anremia) 

-  disease,  amenorrhoea  in     18 

astheuiain33,526,  765,  770 

cachexia  simulating      527 

diarrhoea  with  . .  172 

eosinophilia  in  ..  219 

fainting  in      . .  . .  526 

gastric  attacks  in  . .  770 

headache  from  . .  296 

hypothermia  in  . .  311 

-  -  loss  of  weight  in  . .  770 
low  blood-pressure  in 

33,  82,526,  752,  765,  770 

negro  blood  simulating  526 

pernicious         anaemia 

simulating       {Plate 
XXIf)         ..  ..528 

pigmentation     in     82, 

526,  765,  770 

of  the  mouth  in  33, 

528,  770 

-  -  (Plate  XXF)  . .         . .  526 
simulated  by  amyloid 

disease      . .  . .     527 

effects  of  arsenic  . .     64 

in   Graves's   disease  722 

pernicious  ansemia    526 

syphilis       . .  . .   527  i 

syncope  in      ..        33,  770 

tuberculin  reactions  f 

vertigo  from  . . 

vomiting  in 

33.  526,  7G4,  765 
Adductor     brevis,     nerve 
supply  of 

-  longus,  nerve  supply  of  498 
ossification  of  tendon  of  693 

-  magnus.  nerve  supply  of  498 

-  obliquus  hallucis, 

supply  of        . .  . .   498 
poilicis,  nerve  supply  of  504 

-  transversus         hallucis, 

nerve  supply  of        . .   498 

polUci>,  nerve  supply  of  504 

AJ.iN.  I 1 ns,  nerve 

..499 
A:.  1  n-om     ..    742 

Adenitis,  cervical,  epidemic, 

general  account  of    ..  816 
sore  tliroat  in        . .   61:^ 

-  from  scarlet  fever        ..    22* 

-  suppurative        . .  . .   37S 
Adenoides   cysticum,   skiu 

tumours  from  . .  732 

Adenoids,  anosmia  from  . .  612 

-  in  children         . .  . .  615 

-  earache  from     . .  . .  202 

-  epistaxis  from   . .      220,  221 

-  headache  from  . . 

-  from  hypertrophic  rhin- 

itis   "  179 

-  insomnia  from  . . 

-  large  tonsils  with 

-  ni-iitmare  und  . . 


-  !'■ 


l>:ii;ite  after 


202 


-  sniffing  tic  from 

-  snoring  due  to  . . 

-  sore  throat  with 

-  stertor  from 

-  taste  impairment  fro 

loss  from 

Adenoma    of    liver,    si 


Adenoma,  contd. 

-  thyroid  gland,  goitre  from  72 

hsemorrhage  into  . .   72 

malignant     disease 

simulated  by      . .    72 
Adherent  pericardium  (sec 
Pericardium,  Adherent) 
Adhesions,  appendicular..  13' 

dysmenorrhoea  from . .  451 

puia  in  iliac  fossa  from 

454,  45: 
operation  in  diagnosing  45; 

-  fi'om  caseous  mesenteric 

glands 131 

-  constipation  from         . .    12( 

-  from  gall-stones        254,  32< 

-  iritic        . .  . .        551,  73: 

-  pelvic,  dyspareunia  from  19: 
mtestinal    obstruction 

by    ..  ..       130,   151 

pain  from       . .         . .  401 

rectal  examination  for  13t 

from  salpmgo-oophori- 

tis 19; 

vaginismus  from       . .    19i 

-  perigastric,     epigastric 

pain  from       . .  . .   431 

-  peritoneal  from  appendi- 


citis 


13( 


bile-duct    obstruction 

by 32i 

from    caseous   mesen- 
teric glands  . .  13( 

encysted  ascites  from  651 

intestinal    obstruction 

from  130,  388,  45t 

jaundice  from  . .   32i 

from  tuberculous  peri- 
tonitis ..  ..   13C 

-  pleural,  apical  pyopneu- 

mothorax  from         ..   65: 

from  empyema         . .   53: 

pain  in  back  from    . .    71( 

chest  from. .  . .  43: 

partial  pneumothorax 

due  to         . .  . .   531 

-  ~  in  phthisis      . .      432,  531 
tenderness  from        . .    70t 

-  pleuro-peri cardial  . .     5^ 

-  pyloric    . .  , .  . .   17J 

-  round  subdiaptiragmatic 

abscess        ..         ..  367 

-  in  shoulder -joint  . .  506 

-  from  tuberculous  perito- 

nitis . .         . .   13C 

Adiposis  dolorosa,  ;ige  i 


den 

-  -  alcohol  ,111.1     .  . 
fat  de|.nsit>   m 

Adiposis  dolorosa,  general 
account  of 

obesity  in  '   . . 

jiain  ill  arm  from     . . 

chest  from 


431 
431 


■  of 


-  in  irrisating  bladder    . .   277 

-  as  vesical  styptic  . .  5SU 
^gophony     over    pleural 

effusion  ..         ..   299 

-  with  pleuritic  effusion  . .  1G:S 
Aerophagy 240 

-  age  and  sex  incidence  of  2  in 

-  borborygmi  with  . .     Sii 

-  flatus  from         ..  ..    216 

-  indicated      by     rapidly 

repeated   eructations     245 

-  indigestion  simulated  by  316 

-  from  sense  of  fullness  . .   24-"> 

-  ;r-rays  in  diagnosing  . .  21.'t 
Aeroplane  varnishers,  acute 

yellow  atrophy  in  . .  334 
^stivo-autumnal  malaria  31 
Africa,  Kala-azar  in        . .   633 

-  South,  bilharzia  iu      . .  282 
Mediterranean  fever  in  56(1 

-  West  Coast  of,  malaria  on  31 
After-pains  . .  . .  468 
;Vgar-agar,  for  greedy  colon  123 
Age,     accentuated      aortic 

second  sound  with    . .        1 

-  atrophy  of  testis  in      . .     »>i; 

-  baldness  iu  old  . .  . .      71 

-  blood-pressure     changes 


rtith 


AGE,   BKADYPXCEA 


ALBITMIXURIA 


f/r.    COHtd. 

Aff'-  iHcUk'nce,  contd. 

Age  incidence,  ctmtd. 

Aibiiminuria,  auitd. 

bradypiitfa  from           . .      85 

Hanofs  cirrhosis      . .   372 

Tooth's  jjeroneal  palsy    60 

-  from  cantluirides           . .     14 

constipation  from          . .   123 

heart  disease..          ..     14 

tropical  abscess        . .  369 

—  carcinoma  coU  . .         . .  354 

flementia  from  . .          ..     39 

Age  incidence  of  hemiplegia 

tuberculosis   . .         . .  355 

of  kidney       . .         . .  750 

effect  on  plantar  reflex    69 

303,  304 

tuberculous  bladder 

rectum           . .         . .       7 

-  pulmonary  second  sound   1 

Henoch's    purpura 

282,  397,  471 

-  cancerous  cachexia       ..     13 

and  functional  albumin- 

76, 343,   556 

dactylitis    . .          . .   668 

-  cerebral  haemorrhage  aud 

uria      15 

liepatoptosis   . .          . .   368 

glands         . .          . .   380 

84,  119,  303,  515 

hearing  variations  with  1(>5 

Hirsclisprung's  disease  130 

kidney         ..          . .   279 

—  in  cliolera           . .         . .     13 

hypoplasia  of  bowel  from    1'2Z 

Huntingdon's  chorea     134 

joints          . ,          ..   347 

1  -  chlorosis             . .          ..37 

ge  incidence  o:  acne  489,  559 

hypersthenic  dyspepsia  319 

meningitis  . .         . .  590 

1  -  from  chronic  ascending 

rosacea        . .      242.   489 

imjiaoted  f^ces         ..   173 

peritonitis  . .        48,  483 

1          nephritis         ..         ..       8 

-  of  acroparjBsthesia    . .  444 

Age  incidence  of  insomnia 

tongue        . .         . .  740 

-  in  chronic  nephritis    76,191, 

-  acut«  encephalitis     . .    120 

321.  322 

umbilical  hernia       ..  483 

212,  274,  298.  408 

pancreatitis           . .  131 

intermittent  clauoica- 

undue           abdominal 

peritonitis      . .         ..47 

rheumatoid  artliritis  342 

lion..          .S06,  440,  441 

aortic  pulsation    ..  543 

-  chyluria  with     . ,          . .    109 

yellow  atrophy  273,  333 

hydrartiu-osis         . .   349 

urethral  calculus       . .   283 

-  from  cirrhosis    . .         . .     1 :» 

-  adiposis  dolorosa      . .  431 

intestinal  obstruction 

urticaria         ..          .,489 

-  cold  and              . .          . .      15 

-  aerophagy      . .          . .  240 

129,  130 

vesical  calculus         ..   471 

-  from  coli  bacilluria  455,  530 

-  aneurysm      ■..      19G,  437 

intussusception 

Weil's  disease           . .   336 

-  convulsions  and. .          ..    144 

-  angioma         . .          . .  374 

78,  585,  G78,  717 

-  old,  insomnia  from      ..  322 

-  anorexia  nervosa      . .  770 

kraurosis  vulvre        . .   701 

nocturnal  mania  from  322 

—  cyclic      . .          . .          . .     15 

-  aortic  disease  14,  93, 

lateral  sclerosis         . .   140 

cedema  of  legs  fi-om 

Albuminuria    from    cystic 

209,  210 

leukoplakia  vulvie    . .    701 

414,  415 

kidneys                   12,  537 

-  apoplexy        . .          . .  147 

lichen  scrofulosorum      488 

pupils  small  iu           . .   551 

-  from  cvstitis      . .          . .    578 

-  asthenic  dyspepsia   ..  319 

-  -  lupus     179,  4U2    735,  738 

sterility  from             . .  646 

-in  diabetes         ..         ..     13 

-  bacterioria     . .          . .     69 

erythematosus       . .  710 

tremor  in        . .         . .  724 

-  diphtheria          ..         13,  14 

-  bath  pruritus           . .  540 

lymphatic  leukaemia        25 

ulcer  of  leg  from        . .  737 

-  dysentery           . .         . .     13 

-  bronchopneumonia   . .  289 

macular  choroiditis  . .  416 

varieties    of    Bright's 

-  eclampsia           . .         . .   146 

-  bulbar  paralysis       . .  589 

malignant  peritonitis       49 

disease  in   . .         . .       6 

-  after  eggs           . .          . .      15 

-  carcmoma  of  bladder 

meningococcal  menin- 

 weight,  loss  in            . .   770 

-  effect  of  exercise  on      . .     15 

472,  580 

gitis 304 

-  rise    of    blood  -  pressure 

-  from  emphysema          ..  217 

-  -  breast         . .          . .  G87 

-  ~  menstruation..          ..      17 

with 1 

-  with  empyema  ..         ..     13 

-  -  coli  . .         126,  130,  172 

mitral  stenosis         . .     96 

Ageustia 705 

-  from  enlarged  prostate  8,  13 

oesophagus..      195,  380 

myocardial  affections 

Agclulination  test,  in  dia- 

- in  epilepsy         . .         . .   144 

rectum         79,  129,  585 

11,  53,  90 

gnosing  paratyphoid  565 

-  erysipelas            . .          . .      13 

-  -  stomach      269,  316.  653 

inyopathies    . .         , .     60 

dysentery       . .          . .   172 

-  esseiiti;d              . .          . .      15 

-  -  tcstLS           . .          . .   096 

myxccdema    . .          . .  414 

for  Gaertner's  bacillus  554 

-  in  exoplithaltnic  goitre..      13 

-  -  thyroid  gland        . .   721 

nightmares     . .         . .  402 

in  Mediterranean  fever  566 

Albuminuria,  febrile,  gen- 

 tongue         . .          . .    738 

noises  in  the  head     . .  407 

paratyphoid   (and   sec 

eral  account  ..               13 

-  caseous         bronchial 

osteitis  deformans    . .  670 

Widal'sTcst)          ..   637 

—  from  libroid  lung            . .      11 

glands         . .          . .  3S5 

oxaluria           . .          ..  424 

Agraphia 626 

-  follicular  tonsillitis        ..      K". 

-  ciitarrhal  jaundice    . .  329 

oxyuris  vermicularis     520 

Ague  (see  Malaria; 

-  fuiirti.mul             ..           ..      15 

-  cerebral   embolism 

I'aget'd  discaf^e          . .    730 

Ague-cake  spleen  . .          . .  632 

Albuminuria,  functional  ..  537 

119,  133,  147 

papilloma  recti         . .     79 

Air,     bad,     shortness     of 

-  in  1  ;                .        ..  .rditis       7 

hjcmorrhagc 

parenchymatous  goitre  721 

breath  from  . .          . .     89 

-  1. -.13 

84,   119,  147,  303 

paroxysmal     hemo- 

Air-cells,   ethmoidal,   etc.. 

-   ati.l      ■   ;>,..■■  u:  :  1        ;i~SOCi- 

thrombosis..         ..   133 

globinuria  . .          . .  284 

(see  Sinus,  Ethmoidal, 

:>t.a      ..           ;.           ..      12 

-  Cheyne-Stokes  breath- 

 peliosis  rheuiuaticu  , .   556 

etf-) 

—  from  u'on<irrh(r:i              .  .      13 

ing  107 

perleche          . .          . .    366 

Air  -  hunger,      bradypncoa 

-  from  granular  kidney    1,406 

-  chorea 133 

jiernicious  anicmia    . .     24 

with 84 

Albuminuria    from    heart 

-  cliloroma        . .          . .  556 

phantom  tumour      . .  691 

-  in  diabetes         . .          . .     H4 

failure           . .  14,  53,  55 

-  chlorosis         . .         . .     36 

l)neumococcal  arthritis  340 

Airmen,  noises  in  head  in  406 

-  hiccough  with  . .          . .  308 

-  chronic     medinstinitis  435 

poliomyelitis  acuta  . .     til 

Air-swallowing   (see  Acro- 

-  with  hujh  blood- pressure 

-  -  nephritis     . .          . .     10 

chronica      ..          ..141) 

phagy) 

212,  406,  485 

-  cirrhosis         . .          . .  371 

polycystic  kidney     . .  280 

AlbinLsm,  distinction  from 

-  in  Hodgkin's  disease    . .     13 

-  cceliac  disease           ..  171 

post-hemiplegic  chorea  134 

leucoderniia   . .         . .  529 

-influenza            ..         ..     13 

-  congenital     syphilitic 

postpharyngeal       ab- 

- hemeralopia  from         . .   763 

-  intermittent      . .                15 

deafness      '. .          ..166 

scess            198,  GIG,  C47 

—  nvs(;ii5'iiuis  from            . .   407 

-  in  Kirkliind's  (lisease    ..   616 

-  cough 149 

primary  athetosis     . .   132 

Allmii.ifi  ill  ,.-.itir  iluid     18.  50 

Albuminuria  in  lardaceous 

-  cystic  epididymis     . .  697 

protrressivc    muscular 

Albumin,    boiling  test  for. 

disease     ■.  8.  :•."•.  537.  636 

kidneys       . .         . .     12 

atrophy       ..          ..      61 

precautions  In           ..  424 

-  I;ir\ir-.,i    i.tMlvi.  with  495 

-  dermatitis     herpeti- 

pseudo-bulbar  paraly- 

- in  .■.■r.l,ro-,.,n:.l  llui.l    ..    305 

^   :im/|  hlr  ,M-,ir.n..'..            ..       15 

formU          . .          . .      99 

sis    589 

-  ear  .lisrhur-e      . .           . .    421 

-  witn  liver  abscrs--^          . .   370 

-  diabetes  meltitus      ..  264 

—  pseudo-leukiemia      . .     37 

-  and     t:lobulin,     relative 

-  hi  lymphadenoma        ..      13 

-  dipletfia           . .          . .    132 

pupil  sizes     ..         . .  551 

proportions  in  urine  . .      4 

-  malaria  ..          ..  13,31.273 

-  diverticula  coli       125.  130 

pyometra       . .         . .   186 

-  in  lirtuorcotunnji          ..   421 

-  measles  . .          . .          . .     13 

-  diverticulitis  ..          ..   453 

-  -  Uaynaud's  disease    ..   441 

-  phosphates  mistaken  for  524 

-  from  meningitis            . .     13 

-  cmbrvoinu  testis       . .   696 

rectjd  polypi  . .          . ,     78 

-  in  pleuritic  Iluid            . .    102 

-  in  mcrcoriahsm             . .     13 

-  encephalitis    ..          ..132 

renal  calculus            . .      40 

-  sputum 644 

microscopic  examination 

-  endocarditis   . .          . .      93 

rhabdomyoma           . .    356 

Albumin,  tests  for..                4 

essc'iTiiil  in     , .         . .       5 

-  enlarged  prostate 

rheumatic  nodulcif  338,  4U5 

ALBUMINURIA    ..                 4 

-  from  mitral  rcgurgiutioii 

8,  281,  394.  396,  742 

pleurisy       .0          ..105 

-  from    abdominal    aneur- 

210,  211 

-  cpistaxis         ..          ..  221 

purpura      . .          . .  313 

>■■*"» " 

-  movable  kidney            . .    ttm 

-  epithelioma  of  bladder  281 

rhinoscleroma            . .    733 

-  in  acute  nephritis        42,  281 

-  with    myocardial    affec- 

- -  pi'iiis           ..          ..   619 

-  -  rickets            154.  212,  364 

rheumatism    . .         . .     13 

tions    11 

-  erythema  nodosum  . .  404 

-  -  Kiedel'H  lobe..          ..  366 

-  of  adolescence   ..         ..     15 

-  in  mvxa'dcma..        58,  41) 

-  erythnmielaluia         ..    Ill 

retrobulbar  neuritis       760 

-  albumosc  with  ..          15,  16 

-  nephritis              10.  ItlO.  ■]■:*< 

-  familial  lU'huluric  jaun- 

 rodent   ulcer           179,  735 

"  from  alcoholism            ..     13 

-  from  now  growth  of  kid- 

dice  332 

Rose  llradfor<I  kidneys    11 

-  in  angioneurotic  irdcnia     13 

ney      . .          . .          . .        7 

-  Ilbro-adenonui          of 

-  -  sarcoma  of  breast    . .  6S7 

-  ankyloslomiasis             ..      13 

-  after  nocturnal  emission     15 

breast         . .          . .   6B7 

-  -  -  testis           . .          . .  696 

-  arsenical  polsunhig       . .      13 

-  noises  in  the  head  with..    106 

-  filurlasU         . .          . .    109 

-  -  scrofula           . .          .  .    735 

-  ^  urterio^cI.Tosis   1,406,537 

-  micleoproteid   fallacy   in 

-  fragilitas   ostium       . .   242 

-  -    >.rr..ii,lM.hrii.i;i           .  .    :..-.it 

-    frnni    ,i^rit.-S          ..              ..13 

testinu'  for      . .          . .   424 

-  Friedreich's  ataxy 

-  -   -ruv.s    ri.-k.'U          , ,   .;;.. 

Albuminuria  of  athletes   . .     15 

-  Willi  UMleina  of  legs       ..    412 

60,   It3,  140.  513 

Age     incidence    of    sleep 

lri>r[i  l>  ii'ilhiriii  .  .           .  .    770 

-  orthostatic          . .          . .      15 

—  functional  albuminuria    15  ' 

requirements  ■ .        .  ■  320 

i.iiircriiiriJi          . .          , .      70 

-  orthotic 15 

hiccough     . .          . .    307 

Hpasmophilia  . ,           . .    420 

Idislering             ..          ..      M 

-  from  ovarian  cyMt            7,  13 

-  fungating  endocarditia  304 

-  -  spinal  cjirics  ..         ..713 

-  ill  blood  diMcaxcH           . .        7 

-  pale  irraniilar  kidney    . .  537 

-  gall-stone       116,  .116,  328 

Mplenumogulic  cirrhosis 

-  from        bothriocoplialus 

-  pariudtes              . .          . ,      13 

-  gastratgiu       . .          . .  -137 

332.  633 

latus n 

-  with  priroxvsnial  htumo- 

-  gastric  ulcer  . .         3i>,  268 

Kpnndvlilfs  deformans  715 

-  l.r<H.chu|.iifumoiii:i        ..      13 

Udobhiuriu       . .          . .   285 

-  gastrosliixls    . .          . .   266 

-  -  Stokes- Adams   disease  Mti 

lirichfs  di^eiise  55.    I(».'..    112 

-  from  pelvir  tutiinur     . .        7 

—  glaucoma       . .          . .  232 

fyphllitic  aortic  disease  2ln 

"  hurr.s.ir  >.-idds  ..          ..13 

in  pi'tuphluMis                          13 

-  gout .114 

pHOUdoparalysirt     ..   318 

Albuminuria  In  cachexia!      13 

--  )>ernlciuuH  anaiiniii        ..      13 

-  Graves's  disease       . .  722 

lelatiy. .         . .          . .   151 

'  cachexia  with    . .          . .      99 

-  phoftphorns  poiHoiiins  ..     13 

-  hematuria                 ..  277 

lie  douloureux          ..    117 

-  eff(H;t  of  culclmu  fuill'*  on     15 

-  phthixis 13 

ALBUMINURIA 


AMYOTROPHIC   LATERAL  SCLEROSIS 


.\ih,>n/>N»na,  rnnt.l. 

Alcohol,  coiitiutinl. 

Alcoholium,  coiUd. 

Alopecia,  could. 

Albuminuria,  physiological 

-  contractures  from         . .   140 

-  diabetes  simulated  by. .     85 

-  premature           . .          . .      71 

15,  537 

-  convulsions     from     144, 

—  dissemmated       sclerosis 

-  from  syphilis      . .          . .   403 

-  pleural  effusion  and      . .    104 

145,  146 

sii-ulatmg      ..          ..  517 

Altitude,  high,  noises  in  the 

-  from  plumljisni             . .     34 

—  cramps  from      .,           51,  66 

-  fatty  neart  tiom        210,  212 

head  from      . .          . .   406 

-  in  pneumonia      . .          13,  14 

-  deafness  from    . .          . .   166 

-  fibroid  heart  from          ..   210 

polycythaemia       from 

-  polycystic  disease         . .   So? 

-  dehydration  with          . .   391 

-  IlushiiiL,'  from     .  .          . .   241 

532,  53^ 

-  from  portal  obstruction  272 

-  delirium  from    ..      169,170 

-  f....i-,ii,,|.  1 ..          ..113 

Aluin.Tl  n-M  fn^ni  ..            ..    720 

-  postural 15 

—  Dercum's    disease    from 

-    ■        '.     .   .        riL-  in       ..   259 

Alv^                   -        (M-e   Ab- 

-  in  pregnancy      ..            9,  13 

410,  431,  732 

-     :..  ..    r..       ..fi.           85,  264 

\  '     '     '1  ID 

-  of  puberty          . .         , .     15 

-  diarrhoea  from  . .          . .   172 

-  1, .■.,!!    .  i>  ,,:_■. '^    ti-om  53, 

.      .i^.-ase     ..    376 

-  from  pyelitis      . .      57ti,  578 

-  dyspepsia  from  . .          . .   319 

:>4,   206,   210,  214 

Alii  .  .■  ■             ■■■':!     severe 

-  pyelonephritis   . .         . .  578 

-  emaciation  from            , .      66 

-  heat  stroke  simulating. .   310 

,  .           ..    120 

-  in  pyuria            . .         . .  575 

-  erythema  from  . .          . .   222 

-  hippus  in             . .          . .    552 

Amaurosts.  urxnic      759,  701 

-  with  raised   blood-pres- 

- fatty  liver  from..          ..   375 

-  insomnia  from  . .          . .    322 

Am  .   r..   !.     :  ■ !  il   i.liocv      701 

sure     1 

-  furred  tongue  from        43,  51 

-  irritability  trnni              .  .    323 

Anil>l\n[aa,  II-., Ill  al,-ulinl.  .     TT)'. 

-  in  Raynaud's  disease    . .     13 

-  gastritis  from    . .       43,  317 

Alcoholism.       Korsakow's 

Amblyopia,  general  account 

-  from  red  granular  kidney  537 

-  in  haematoporphyrin  test  744 

syndrome  from        2it,  465 

of         759 

-  renal  calculus    . .          . .        7 

-  headache  from  . .          . .  295 

-    IlHMiiury    lirlrrl^   from    .  .        2U 

AMENGRRHtEA  ..          ..      17 

-  -  infarct.            . .             7,  8 

-  heart  irregular  from     . .   486 

Alcoholism,    mental    sym- 

Amenorrhcea. causes  of  . .     18 

new  growth    . .          . .       7 

-  hiccougli  from    . .          . .    307 

ptoms  from               . .  465 

-  in  chlorosis         ..        37,  274 

ttirorabosis     . .         7,  7-49 

-  hypothermia  from         . .    311 

-  mural  iv-'ur-iiationfrom  314 

-  from    deficient    ovarian 

tumour            . .          . .      51 

-  in  indicaii  test    . .          . .    745 

-  nu-nranlial  air.-<-tionfrom    14 

activity          . .         . .  f.  10 

-  (■(■^aiiiiirii' ill  Irciitint:    ..    744 

-  infantilism  from             . .   189 

-  neVvousness     sinmlating  726 

-  with  hydrops  amnii     . .     4r 

Albuminuria  of  rowing  men     15 

-  insomnia  from  . .          . .   726 

-  pachymeningitis  from.,  516 

-  from  hyper  involution  . .  646 

Albuminuria      in      scarlet 

-  jumpiness  from. .          . .   726 

-  pancreatitis  with           . .   100 

-  internal  secretions  and. .     19 

fever 13 

-  leucopenia  from            . .   361 

-  pontine  haemorrhage  si- 

- in  myxoedema  . .         . .  3S8 

^  -.-.Lil.t  l.-v.T  U.  224,227,  617 

-  liver  lobe  dwarfed  by  . .  366 

mulating        . .         . .  310 

-  from  ovarian  cysts        . .   386 

-  s.T.,iHl;i|-v  ^yiiliilis         ..    334 

-  medulla    oblongata    de- 

- pupil  not  reacting  to  con- 

 tumour            ..       631,  689 

Albuminuria      in      severe 

generation  from        ..  197 

vergence  in     . .          . .   551 

-  phantom  tumour  and..  691 

anamia         ..         ..13 

-  mental          deterioration 

-  purpura  from     . .      553,  555 

-  from  pregnancy  19,  393.  OSS, 

-  sliirlit  when  due  to  blood     12 

from 726 

—  rubicund        complexion 

6S9 

pus 12 

-  moral  deterioration  from  726 

from 35 

-  priniary 17 

-  from  snake-bite. .         . .  413 

-  morning    sickness    from 

—  from  secret  drinking    ..  555 

Amenorrhcea.    relation    of 

-  wiih  sore  throat            ..      14 

51,  267 

-  speech  loss  from            . .   623 

ovarian  diseases  to    . .     19 

m    |-I,.ru,'  anaemia         ..     13 

-  muscular  twitching  from  726 

-  simulated  by  cerebellar 

America,    Central,    yellow 

-  myocardial  change  from  704 

lesions            . .          . .     58 

fever  in           . .         . .  33f 

M    ir  t'-sting  and          ..   201 

-  nervousness  from          . .  726 

-  stertor  from       . .         . .  647 

-  South,  hydatid  disease  in  658 

■   !■.   -^iiliilis           ..           ..13 

-  neuritis  from     . .          . .  140 

-  temperature  low  in       . .  310 

-  -  yellow  fever  in          . .  336 

-   fulN...:wU;in.|     ..            ..537 

-  uoises  in  ears  and         . .  723 

-  tricuspid  regurgitation 

Amido-oxybutyric       acid. 

Albuminuria     with      tube 

-  cedema  from      . .         . .  412 

from    . .          . .          . .   214 

association   with   ace- 

casts    and     no     pus, 

-  pain  in  the  limbs  from  66, 466 

-  vacant  facies  of . .          . .    233 

tone     3 

causes  of                   . .  6, 7 

-  palpitation  from        484,  486 

Alexia,  general  account  of  625 

Ammonia  in  acetone  test. .       3 

in  tuberculosis  . .          . .      13 

-  para-^thrsii  In.ni            ..    726 

Algidity  iu  malaria           . .      30 

-  anosmia  from     . .          . .   01:, 

-  from  tuberculous  kidney 

Alcohol,  peripheral  neuritis 

Alimentary  albumosuria..      16 

-  cystin  dissolved  by      ..101 

7,  279,  577 

from  •■•';.  *il.  66.    u::. 

Alkali,  alkaptOTi  and        . .   740 

-  in  diazo-reaction            ..    173 

-  in  typhoid  fever             ..      13 

2r.t;,    4  1:;,    icr.,    .mio. 

-  test     for     chrysophanic 

-  erythema  from  ..          ,.   222 

-  witli   un(.inua      8-3,    lir.,   315, 

555,  770 

acid 744 

-  nasal  discharge  from    . .   Hi 

417,  594 

—  polyuria  from    . .          . .   534 

santonin          . .          . .   744 

-  in  normal  urine. ,          . .   52-i 

Albuminui  ia.  uterine  causes     8 

-  priapism  from    . .         . .  538 

uroerythrin    . .          . .  743 

-  Parry's  test       ..          . .  261 

-  from  r.tiTitH' lilirrnnvoma       7 

-  pupils  dilated  and  fixed 

Alkalies,  anajmia  from     . .     99 

-  sore  throat  from            ..   613 

Albuminuria,  various  causes 

from 170 

-  appendicular     dyspepsia 

-  stridor  from       . .          . .  650 

of  slight                    ..13 

—  restlessness  from           . .   726 

relieved  by     .".          . .  316 

-  in  m-ine,  in  phosphorus 

-  in  variola            . .          . .      13 

-  retention  of  urine  and   . .   395 

-  bad  health  from            . .      99 

poisoning        . .          . .   336 

-  Tasomotor  neuroses      ..     13 

-  rosacea  from        51,  241,  726 

-  breathlessness  from      . .     99 

Ammoniacal  urine            . .  524 

-  from  vena  caval  obstruc- 

- tachycardia  from,     703,  704 

-  dermatitis  from . .          ..  755 

Ammonio-magnesic    phos- 

tion       750 

-  tremor  from      146,  233, 

-  in  diabetes         ..          ..118 

phate  524 

thrombosis         7,  13,  52 

724,  726 

-  emaciation  from           ..     99 

Ammonium  phosphate,  so- 

- in  AVcil's  disease             . .      13 

-  effect  on  urethritis       . .  184 

-  erythema  from  . .          . .  222 

lubility  of       ..          ..   523 

-  v.Hnu    ir;.,'        i:;.  -j;:-!,  336 

-  venous  stigmata  from..  726 

-  gangrene  from  . .         . .  255 

—  sulphate  in  acetone  test      3 

AHrir [1    .       ■ -rr 

-  vertigo  from      . .          . .   752 

-  haematemesis  from       . .  265 

-  sulphide,  in  reducing  oxy- 

!;<■(  r    ;     1           \  .                 1      III  ic) 

-  in  vomit             . .          . .   766 

-  pallor  from        . .          . .     99 

liaemoglobin    . .          . .   28'- 

AlhlllllM-r,    .1  - 1  |M   ,   \\  ith 

-  vomitiiii.'  from  . .          . .   726 

-  sore  throat  from           . .   613 

test  for  lead   . .         . .     65 

albumin                       . .     15 

-  wcaknrss  irnni   ..           ..726 

-  ulcerative  stonuititis  from  740 

AMNESIA 19 

-  deutero-  . .          . .         . .     16 

Alcoholic    heart,    primary. 

Alkaline    haematin.    spec- 

- (and  see  Memory) 

-  mistaken  for  albumiti  . .      10 

symptoms  of  (and  see 

trum  of  (FU/.  33)       . .     80 

Amniotic    bands,    a-doma 

-  test*;  lor  . .          . .          . .        5 

Ilfirl.    I'riinary    Alco- 

Alkalinity   of   stool,    from 

from    ..         ..          ..Ill 

Albumose.  tests  for          15,  16 

holic)   ..          ..14,  46,  418 

putrefaction   . .          . .   170 

Amoeba  coii  (Fig.  25)       . .      77 

ALBUMOSURIA    ..         ..     15 

Alcoholism  {and  see  Alco- 

- uterine  secretion            . .   185 

in  dysentery  . .          . .  173 

-  n  anit,.  liii'innatism    ..     16 

hol). 

Alkapton,    Fehlins's    solu- 

- dysenteriae,   disappear- 

Alcoliohsm,      albuminuria 

tion  reduced  by          ..    261 

ance  after  emetine    . .     77 

--  ^'■i■n<'>^-^ -'.^    . .        . ,      4 

from 13 

—   Miiiirc'--  t"'-(   and               ..    202 

-  .Iv-nrrrv  from..           ..    71G 

Albumosuria.  Bence-Jones's, 

-  acute,  r.aiiinski's  sign  in     69 

-  .ipn,'  illv    ilia. 'rive           .  .    740 

-  ln-inMi,M,/w7- ■-■■-•)       ..      77 

general  account  of     ..      16 

conL-p^tion  of  liverfrom334 

-  rr,lu,ai.L'  i.MW.T  of          ..    746 

An.u.l,.,..  ni  In^iMlir  |,ns    ..    369 

Albumosuria,  various  causes 

paiKTP-ititis  and        ..   131 

Alkapton.  tests  for           ..  746 

AmoebK,  method  of  search- 

of         16 

-  amenorrhnea  from         ..     18 

-  (lark  uria.'  tn.t,,               .  .    L'Cl 

ing  for                      . .     77 

Alcohol     (and    see    Alco- 

- aneurysm  from  . .          . .   291 

Alkaptonuria,   general   ac- 

Ampelopsis, rhus  toxicoden- 

holism). 

-  aortic  disease  from    209,  210 

count  of                     .  .   746 

dron  in  place  of        . .   I'll 

Alcohol,  absolute,  in  treat- 

- ata^ry  from         . .          ..56 

Amphoric   breathing,  over 

ing  dendritic  ulcer    . .   734 

-  brachial  neuralgia  and. .   442 

-  iiL'lai.'i.wl-;   and             .'i"'S     740 

fibroid  Umg    ..         ..   2lf 

-  acne  rosacea  from         ..    726 

-  chronic,  bottle  nose  from    51 

ALLOCHEIRIA      ..          . .'     17 

Amphoteric  reaction         . .   52."* 

-acute  gastritis  from      ..   207 

distended       umbilical 

-    in   talir^ 009 

Ampulla  of  Vater,  carcino- 

- arropar.iisthesia  and     . .   444 

veins  from      .  .          . .     51 

Alloxuric  bodies,  list  Of     ■■  742 

ma  invading           ..   330 

-  amblyopia  from             . .    759 

-  -  PpistaAisfroni               ..       51 

ALOPECIA                         .70 

gall-stone  in  .,      100.  597 

-  aneurysm  and    . .          . .   196 

Alcoholism,  chronic,  general 

-  areata,  billiard-ball  bald- 

 jaundice  from  obstruc- 

- loss  of  appetite  from     43,  51 

account  of      ..        51,  726 

ness  iu         . .          . .   249 

tion  of         . .          . .   325 

-  in  bile  test          . .          . .    744 

-  -  inL-o-nrdiMatioii      from  146 

distinguished        from 

Amputation,  in  error        . ,   092 

Alcohol,  body  weight  and . .  770 

liver  larL'e  from          . .      51 

tinea-          ..          ..249 

-  for  hysterical  sweUing  ..  4U 

~  bradypiicea  from           . .     84 

-  -  memory  illusions  in..   146 

favus       distinguished 

Amyl    alcohol   in   urobilin 

-  catarrh  of  small  intestine 

-  -  nausea  from  . .          . .     51 

from            . .          . .  247 

test 325 

from    . .          .  ,          ..   172 

paramnesia  in            . .   146 

hair  changes  in          . .      71 

-  nitrite,   angina   pectoris 

-  central  scotoma  from  . .  760 

piles  from      . .         . .     51 

note  -  of  -  exclamation 

relieved  by     . .         ..Alt 

-  cirrhosis  from     51.  2r.fi, 

sensory  perversion  in  14C 

hairs  in       ..          .,249 

xanthopsia  from        . .    763 

272.  332,  370,  555 

telangiectases    from..     51 

pseudo-pelade  and    . .  710 

Amyloid  disease  (see  Larda- 

-  colour  blindness  from  759,760 

tremor  of  tongue  from    51 

simulating        psoudo- 

ceous  Disease) 

-  coma  from  85.  118.  144,  310 

-  colic  from          ,.         ..  117 

pelade         ..          ..     71 

Amyotrophic  lateral  sclero- 

- congestion  of  liver  from    369 

-  congenital    diplegia   and  132 

ringworm    . .          . .      71 

sis,  ankle-clonus  in  62.     '  r 

AMVOTROPHIC   LATERAL  SCLEROSIS 


ANEURYSM 


Amyotrophic  lot.  sclerosis^  conld. 

electrical  reactions  iu  508 

estensor  plantar  ro-  j 

flex  ill         62,  G8,  517 

fibrillar  contractions  I 

in  .  .       135,  50S   I 

Amyotrophic  lateral  sclero- 
sis, general  account  of  508 

kri.-.--l.Tk~   iM-rr.,-;,.a  ! 

111/.  ..  i;i',   517    ' 

Pi  in  . ,    508 


lesic 


muscle    wasting    in 

Gl,  G-',  517  , 

no  pain  in  . .  . .   508  , 

paraplegia  from     ..  514  i 

penile  erection   ab- 
sent in    . .         . .  313  : 

R.D.  in        01,  135,  517  ' 

reflexes  in  . .  . .   508 

no    sensory    Xo^i    iu 

50S,  517  ■ 
Amyotrophic  lateral  sclero- 
sis, signs  of    . .         ■  ■     62 
simulated  by  syrin- 
gomyelia . .     62 
transverse     mye- 

=phincter  trouble  in     62 

AN>EM>A 20 

-  iroiii  acute  rheumatism      31 

-  alkalies 99 

-  amenorrhea  from         . .      18 

-  from  ankylostomiasis   33,  81 

-  in  aortic  res^urifitation. .   203 

Anaemia,    aplastic*    blood 

24 


cites 
bleedii 


\% 


fatty  heart  from        . .     53  [ 

ieucopenia  in,.  ..  361 

low  colour  index  in  . .     55 

myelocytes  in  . .     23 

unnamed  anaemias  and     37 

-  from    appendicular    ab- 

scess      35 

-  arsenic     . ,  . .         . .     33 

-  with  arthritis     ..         ..32 

-  from  beri-beri    . .  . .     33 

-  blood  examination  in  <lia- 

gnosiiii?  . .  . .  487 

-  from   botbriocephalus  . .     33 
..35 

90,  91, 
92,  723 

-  due  to  cachexia     21,  33,  99 

-  capillary  pulsation  in  . .     93 

-  due  to  carcinoma  21,  33, 

126,     270,    271,    316, 

317,  569,  630,  661 

-  caseous  Rlund:>  . .         . .     32 

-  chloromu  . .        32,  39 

-  chlorosis  .  .  . .      32 
Ansmia.  chlorotic.  general 

account  of  -36 


Aiueniia^  contd. 

Anaemia  from  haemophilia    33 

-  hse.uoptysis        . .  . .      32 
Anxmia  from  haemorrhage 

21,  32,  413 

-  headache  from  . .  . .   29G 

-  with  heart  disease        . .     34 

-  from  hepatic  abscess  35,  370 

-  in  Hodgkiu's  disease   37, 

55,  64,  635,  679 

-  severe,    hyperaathesiii 

from 610 

-  indigestion  and. .         . .     32 

-  in  indoor  workers         . .     32 

-  in  infantile  scurvy         . .      99 

-  infective  synovitis        . .     32 

-  insomma  from  ..      321,  323 

-  intestinal  neuralgia  and  11d 

-  intratropical      . .  . .     99 

-  with  lardaceous  disease 

35,  636 

-  lateral  sclerosis  . .         . .  140 

-  in  lead  poisoning  32,  34 

-  ieukiemia      24,  99,  283,  723 

-  lymphadenoma  . .         64,  679 

-  lymphatic  Ieukiemia  25,  556 

-  due  to  malaria   21,    29,    33, 

637 

-  mediastinal  growth   434,  435 

-  with  melffina     . .  . .     36 

-  from  mcnorrhagia        . .      32 

-  menorrhai,'ia  from         . .   3S7 

-  from  mercury    . .        33,  72G 

-  metrostaxis        . .  . .      32 

-  rayxoedema        . .  . .     38 

-  noises  in  the  head  from  295 

-  from  obesity      . .  . .     32 

-  oedema  from      ..      412,  413 

-  from  cesopbageal  stenosis    33 

-  oral  sepsis         . .         . .     32 

-  ovarian  disease..         ..     32 

-  pallor  distinct  from     . .     21 

-  palpitation  from       484,   487 

-  from  parasites  . .  26,  33,  413 

-  with     parenchymatous 

goitre  . .  . .         . .   723 

-  from  paroxysmal  hajmo- 

globinaria      ..  ..  285 

-  pediculosis         . .         . .  37S 

-  periproctitl:^       . .  . .    7l9 
Anamia    pernicious    Uc-i 

Pernici^us  Ansmia) 


21, 


.•l.hr 


■  11, 


r«,  274 
tubal  nephritis  . .     32 

-  cirrhosis  35,  333,  635 

-  from  colitis        . .         . .     34 

-  corisliputiou       ..       32,  412 

-  in  convalescence  . .     32 

-  from    dpflcient    ovarian 

activity  ..         ..  046 

-  dclinltions  of      . .  ..20 

-  delirium  from    . .         . .  169 

-  tlitteront  tyjies  of         . .     20 

-  dilated  heart  from        . .     36 

-  from  drugs         . .  . .     33 

-  duodenal  ulcer  . .        36,  271 

-  in  dysentery      . .  . .     34 

-  from  elephantiasis        . .     28 

-  empyema  . .  32,  34 

-  endometritis      . .  . .     35 

-  cpisti 


id 
in    fumili)d    iicholuric 


utidi. 


487 
332,  034 


-  fatty  heart  from 

-  funL-tioniil  bruit  with    ..    721 

-  -  tiirill  with      ..  ..721 

-  from  futigatinjc  endocar- 

ditis     7.  21,  34,  fi09,  040 

-  nastrii!  nU«r       ..        30,  209 

-  gostricT  ulcrr  simulated  in  76H 

-  irom  liaimatcmesifl       32,  30 

-  Iiaimic  aortic  bruit  with    93 


Atvxmiat  severe,  contd. 

some  causes  of         ..13 

spinal    cord    changes 

from  ..         ..610 

from  syphilis  . .  527 

tenderness  o£  bones  in  467 

Ansmia,  severe,  unnamed 

types  of  . .     37 

-  shortness  of  breath  from     87 
■barges  . .      35 


SlM,,-kslM 


;ilic  cirrho- 


633 


378 


99 

-  pleuritic  effusion  with  . .   106 

-  profound,  from  various 

parasites         . .  . .      20 

-  prolonged  pyrexia  with    509 

-  in  pseud oteukojmia    37, 

55,  G34 

-  psoas  abscess     . .         . .     35 

-  pulmonary  svstolic  bruit 

in         ..    *     ..  ..91 

-  from  purpura    . .  . .      32 
pyorrlHca       . .  . .     74 

-  pyosalpinx  . .  . .      55 

-  rectal  blood  loss  . .     32 

-  in    rheumatoid  urttiritis    35 

-  from  salic^'lates. .  . .     34 

-  in  scurvy..             38,  "2,  273 
rickets 670 

-  secondary  v.  prfmary  . .     21 

-  in  scpticoimia    . .         . .  507 

-  severe,  achc4  and  pains  in  167 

albuminuria  in  ..     13 

from  amyloid  discaiw    »27 

ankylostomiasis         . .   521 

ascites  wMi    . .  46,  55 

Habinski's  sign  in     . .     OU 

blood  changes 


from    bothriocopluilus 

latus  . .  . .  521 

cord  degenerations  in      09 

diazo-rcjiction  in       . .  173 

fatty  liver  from        . .  375 

after  hiomorrhairo     . .  406 

from  hyporlactutloi) . .     35 

-  -  in  kala-u/,ur    . .  . .      29 
Icucoponia  in. .         . .  301 

-  -  noises  in  the  head  witli  406 

-  -  pain  in  liml)S  in        . .   463 
phntopliobla  from    . .  525 

-  -  i»olkolocytof«i«  in      . .  r»72 

-  -  polyonrhonionllU  with  107 
pyrexiA  in      . .        2fi,  r>72 


-  starvation 

-  sterility  from     . , 

-  in  Still's  disease 

-  with  suppuration 

-  due  to  syphilis     31,  33,  560 

-  systolic  apical  bruit  from  90 
pulmonary  bruit  from  90 

-  in  tabes 650 

-  tachycardia  from      703,  704 

-  in  thymic  infantilism    . .  189 

-  tinnitus  from     ..         ..  723 

-  from  toxic  conditions  . .  32 

-  in  tuberculosis     32,  33,  569 

-  witli  tuberculous  joints  35 
peritonitis      . .         . .  657 

-  with    undue    abdominal 

aortic  pulsation         . .  543 

-  in  uremia          . .          ..  146 

-  from  urethral  n;evus    . .  283 

-  uterine  disr-iM-  .  .         32.  352 

Anaemia,  various  types  of 
sitiple 32 

-  vani-ja  from       ..  ..    752 

-  vomiting  duo  to  30,  412,  768 

-  from  worms       . .  . .   519 
Anassthesia     from     cauda 

erpiina  tumour         . .  62 

-  cerebellar  arterv  lesions  58 

-  cervical  rib       '..      444,  508 

-  combined  scleroses       . .  140 

-  cord  compression 

-  of  cornea,  in  glaucoma 

-  cotton-wool  in  tostitig..  005 

Anssthesia,  definition  of 

605.  606 


713 


from    haj- 
L    . .     509,  608 

cerebellar 
thrombosis 

610 


605 


-  in  diabetes 

-  dissociative, 

matomyeli 

post.     inf. 

artery 
(Fia.  304) 

svringoniyelia 

110.  257.  508,  510 
Ansesthesla,  dissociative,  in 
syringomyelia  . .  60B 

-  in  ICrl.'^  p.Uv    ..  ..507 

-  of  tiicr,  from  lifth  nerve 

lesion 700 

mid-brain  tumour     . .   727 

-  from  fracture  of  sacrum 

(Fig.  259)        . .  . .   008 

-  fracliire-disloeation       of 

sr-ine 60.S 

Anaesthesia,  general  notes 
on 

-  glove  or  stocking  typo 

50,  134.  465,  000,  009 

-  from  hmmatomyclla     ..  110 

-  Iicmi-    (see    Ilomianois- 

tbcsla) 

-  hypcralgGsia  with        . .  000 

-  from  hysteria  134,  408, 

498,  503,  716 

-  in  Klumpke's  palsy      ..   607 
Ansesthesia  In  leprosy    63, 

383.   101.  529 

-  loeal,  in  «'\amiiiiiiL.'  larynx  199 

-  in  muHt'idosplriil   paraly- 

sis         506 

-  fr«m  mycIitiH     . .         . .  008 

-  in  ncuraHthenfu. .  ..   710 

-  from  neurosis    ..         ..  518 

-  from  new  growth  tii  spine  714 

-  [laralyKls  of  sciatic  nerve  499 

-  perlpherul  nimrltb* 

50,  465,  514,  006,  007 

-  sciatica 438 

-  Mvoro  pain  with  . .  427 

-  of  Solon,  vcrtltfo  and    . .  751 

-  in  Hpastic  pnmplinria    ..  A 12 

-  from  splnnl  injury         ..  715 

-  in  tar>i-^    ..  100,  At  I.  60W 


Atwsstkesia,  contd. 

-  of    tongue,     m     bulbar 

paralysis         . .         , .  ' 
tilth  nerve  lesion      . .   ; 

-  from  transverse  myelitis 

02,  140,  ; 

-  tumour  ot  tilth  nerve  . .   : 

-  ulnar  nerve  division    . .  t 
Anajsthetic  in  diagaosLs  . . 

of  abdominal  tumour    ( 

carcinoma  coli  . .    ] 

cause  of  anal  spasm  . .   ] 

gastric  carcinoma     . .   ; 

-  -  hysteria  114,  142,  : 

hysterical  contracture  : 

pancreas  tumour       . .   ( 

phantom  tumour 

45,  390,  059,  ( 

simple  colitis 

subphrenic  abscess   . .  i 

Anaesthetics,     acetonuria 
after    . . 

-  aspiration       pneumonia 

after        , .      . .         . .  : 

-  Babinski's  sign  during. . 

-  bronchopneumonia  after  ; 

-  coma  from         . .  . .    '. 

-  for  curettage     . .         . .  ; 

-  death  from        . .  . .  ; 

-  delirium  from    . .         . .   : 

-  erythema  from  . .         . .  ; 

-  hypothermia  from        . .  : 

-  status  lymphaticus  and    : 

-  tinnitus  from     . .  . . 

-  vomiting  from  ..  ., 
Anal  canal,  congenital  nar- 
rowness of     . .         . . 

Analgesia,     in    Tlrown-Se- 
quard  paralysis         . .   • 

-  from    cerebellar    artery 

lesions 

-  cervical  rib        ..         ..   : 

-  cord  lesioiiii  and  .  .    i 

Analgesia,  definition  of    ..  I 

-  of  inusi-k'S.  in  tabe.-,      .  . 

-  pill  ill  le^tiiiLT     ..  ..I 

-  from  post.  inf.  cerebellar 

artery  thrombosis  (Fiy. 
2G4) ( 

-  in  syringomvelia  62,  03, 

97,  508,  510.  I 

-  tabes  (Fiif.  203)  440,  G07,  i 

-  ulnar,  in  tabes  . .         . .  ■ 
Anangioplast  ic    in  tan  tilistn 

(Fi>/.  91)      ■  .. 
Anaphylaxis 
Anarthria i 

Anasarca,      in      aiikylosh- 

-  chronic  mediastinitis  . . 

-  lieart  disease     ..       104. 

-  pleural  effusion  with    . . 

-  from  renal  disease      43, 

40,  54.   104, 

-  vulval  swelling  from  700, 

(and  svo  (Kd.-nia> 
Anasteoplasia,  rlaviL'les  ab- 


all  i 


Anatomy  of  axillary  lymph 

glands i 

Anatomy  of  inguinal  glands  i 


;il.  ( 


iih.l.t 


■  pilule  ]M 


from  he- 
patic abscess  ..  ..2 
vVnconeus,  nerve  supply  of  5 
Aneurvsin.  abdominal,  wi^ 

'and  sex  inciilence  of  4 

albuminuria  frnin     . . 

bruit  ovor       . .         . .  3 

carciimma  of  Klomach 

simulating   (Fiff.    2K8)  (1 
chroidt'  lu'plirltis  from 

-  -  c^tlc  siniuliited  by     .  .    1 
cplgaftrtc  tumour  from 

271.  fill,  0 

limmatome.tiH    irom 

205,  2 

hinmatoma  from       . .  (\ 

loiintlico  from  ..  3 
leaking             ..      031,  (] 

-  -  pain   In  the  (ihtlonten 

from  271,  331     4 

hack  from  271,  437,  fl 

puUatiti)  lunmur  from 

271.  4 


ANEURYSM 


ANIMAL  INOCULATION 


-  renal tn 

-  ruptur.' 


544 

,  (164 
064 


(if  4^4 


iilo- 


.   640 

-  age  inoiJeiicc-  of  1116,  437 

-  iilcohol  anil         .  .       196,  391 
■  'I   I'lii  iiectoris  from  434,  709 

I       Mvenons.exophthal- 
'    from        .  .  . .    229 

"i  iiiliit  ..  .  .    1)94 

-  Illinium  .siiiinlated  by..  476 

-  Llhiu.i  MiiiiihiU-d  by   ,.    635 

Wieurysm   of   axillary    ar- 
tery        667 

i  .:  •    :■"■ n,        434,  631 

iroill       ..  159 

;•■  i    "  mil  from  ..  76 

M  '    M    I'll  \  IIS  pressed 


■i::l,  692 
..  208 
..    1G8 


-  lieadarli.i    li.im        -Ji,! 

-  noisps  ill  ilir  liniil  uii 

,  295 
1   295 

livled  lu- 

654 

ll  l-i  ml  (Plate  XX.YI)    . 

694 

258 

•  'i  l.liiil  liiiKC-rs  from     . 

111 

■'Mini    li'i.iii  Mi|il  it:-i'  ( 

■  434 

■■  1  '1    !i . .      I  r. 

.   150 

■lite    pain 

. .    434 

■lifst  from  430 


iijl;  with     693 
.  .   268 
listinal 


1  'V         . .  . .    c 

femoral    .'.         ..      040,  t 

libroid  luti}^  from  . .  i 

neurysm  of  first  part  of 

aorta,   symptoms  and 

sicins  of  . .  2 


neurysm,  general  account 
of        

L'irillp  pain  from 
1,'routli  of  lung  simulat- 

of  heart  . .         . .       91', 
-  systolic    apical    bruit 

from 
hard  work  and    196,  291, 
of  iiepatic  artery,  ascites 
from     . ,  . .  46, 

from  embolism      . .  : 

in   funtrating  endo- 
carditis  . .        51.  : 


Aiicunjsni  oj  fit-p.  artery,  could. 

jaundice  trom      01, 

325,  331 
portal  vein  obstruc- 
tion by    . .  46,  51 

-  ha3matemesis  from    265,  267 

-  hfemoptysis  from     149, 

287,  290,  292 
first  sign  of    . .  . .  291 

-  of  iliac  artery    . .         . .  678 
expansile   tumour 

from        . .  . .   460 

felt  per  rectum      . .    587 

pain    in   iliac  fossa 

from  462,  454,  460 
thigh  from  . .   460 

-  indigestion  simulated  by 

316,  429 

-  insomnia  from  . .  . .   770 

-  intercostal    nerves    irri- 

tated by         . .  . .  432 

neuralgia  simnlated  by 

436,  707 
suggesting  . .         . .  431 

-  internal        haemorrhage 

trom 720 

-  intracranial,  bruit  with     723 

-  1  iiLni  hi. Ill   li.iii,         206,   208 

-  Ii  I :  II        Mil.  iiitiLi  from  120 

■III.  I     I      .  ."        ..    120 

I  I   I  iiiiiim     ..  120 

■  I    .  .'    Ill  tissues  120 

-  Ill     ■■•     I     I  I  imm       ..   770 

-  Ill         II. I  by  195,  434 

-  Ill  ihi._.. iiimlated  by 

432,  467 

-  mediastinal  fibrosis  simu- 

lating   159 

new  growth  simulating 

207,  435 

-  neoplasm  simulated  by     770 
f  growth  of  spine 


lating 
-  Oidema  from 
face    and    i 


714 


411,  416 
from 
1611,  413 

-  oesophageal    obstruction 

from     . .          .  .      195,  763 
Aneurysm,  orbital,  account 
of        230 

-  orthopncea  from  418, 

419,420 

-  pain  in  the  arms  from  . .  434 
back  from    195,  290, 

428,   429,  461,  716 

-  -  chest  from     290,  430,  432 
Aneurysm,  pain  in  tne  chest 

from    . .        434,   435,  /70 
neck  from       . .  .  .   434 

-  -  shoulder  from        474,  476 
.  .    483 


esti! 


pali>itation  from 


485 


692 


Aneurysm  of  popliteal  ar- 
tery  cm,  U'lm,  xxx\ 

ligature    of    femoral 

artery  for  . .    268 

obstrnction  of  veins 

by  ..  ..411 

oedema  of  leg  from    411 

-  presenting  through  back 

168,  429 
through  chest  .  .    168 

-  pulmonary,  in  phthisis..   287 

-  pulsatile  aorta  mistaken 


for        664 

ulsafile  tumour  from 
76,  92,  93,  168,  208, 
271,  331,  428,  429, 
437,    460,     516,     693, 

714,  720 
lie  iiulse  delayed  by  ..  550 
|.mu.^';l,i(ii.ii   ilu-i   to  93, 

I'.'i;,  L'ii7,  208,  209 
434 


I'k  frc 


401 


■  rujiture  into  air  passages  434 

■  -  bowel  . .  . .  . .   130 

bronchus  120,  287,  290,  292 

-  coma  from     . .  . .   118 

-  fatal  haamoptysis  from  287 

-  into  lieart       . .  . .   434 


Aneurtism,  rupture,  conld. 

into  intestme 

76 

--  lung     ..          ..      287, 

290 

mediastinum  . . 

120 

iBSophagus   120,    265 

267, 

434 

pericardium     93,  120, 

443 

peritoneum    . . 

434 

-  -  pleura 

434 

pulmonary  artery     . . 

92 

pulmonary  veins" 

434 

spinal  canal    . . 

434 

-  -  stomach  76,  120,  265, 

271 

-  -  snpeuoi  ^  ena  cava  92 

159 

oph 


105 


-  skiagram   of  ^Fiq.   100) 

209,  435 

-  spinal  caries  simulated  by  516 

simulating  . .         . .   714 

curvature  from  . .    714 

-  spine    eroded    by     434, 

483,   516,  713,  770 

-  sternum  eroded  by       . .   434 

-  stridor  from       . .  . .    G51 

-  of  subclavian  artery,  ac- 

cessory rib  ^^inmiatiiii,'  694 

clulihi  ,1  liii-iTs  tn.iu   111 

oedeni.i  ■•\  .M  III  iiMiiL    lU 

OSten-.it  t  III  o|..il  |i\ 

pain  in  nrni  from  ..    443 

-  sudden  death  from  rup- 

ture of  93,   120,  434 

-  syphilis    and    196,    291, 

331,  435,  51G,  714 

-  systolic  thrill  from        . .   720 

-  tachycardia  from      703,  704 

-  tenderness  of  spiue  from  713 
sternum  from  . .    708 

-  tracheal   obstruction   by 

418,  419,  651 

-  transverse  mj'elitis  from 

389,   516 
Aneurysm,  unequal  pulses 
from    ..        550,  551.  692 

-  unilateral     sweating     of 

face  from        . .  . .    654 

-  varicose   thoracic   veins 

from 208 

-  veins  of  n^ck  dilatp.l  from  208 

seldom  urclii,|,.,|  \.y    .  .     750 

by  {/■'/;/.  i^ii)  \:.s,'  I -v.'! 
(Fu/.it'j)  L'os,  li:;,  li.^t, 

073,   751 
opened  by  . .         . .   159 

-  vocal  cord  paralysis  from  495 


Angina  abdominalis 


flatulence  with 

from  sout 

ha:niatenu-..^is  fr< 


Sis  of 
brawny     swelling  of 

neck  from  . .  . ,   " 

cyanosis  from  . .    : 

dvsphasia  from 

--   .Ivspnu.;,.  !,n,u  ..    : 

Angina    Ludovici,    general 

account  of  . .   ( 

.rilruiii  tn.m    .. 

of  glottis  in  ..I 


Angina  Lndovici,  conld. 

rigor  in  . .  . .  G99 

stomatitis  with         . .  542 

streptococci  iu  . .   699 

stridor  from  . .  . .  651 

tongue    swollen    from 

198,  698,  699 
trismus   simulated  by  729 

-  maligna  . .  . .  . .   617 

-  pectoris,  from  adherent 


709 

-  -   ;iTiivl  riifritr  relieving     476 

-  -  Irnin  ;,ii(iir\.Mii       434,  709 

-  -    xmiIl  in-rlir  Irsion       ..    535 

tion  ..53,  207,  433,  709 

aortitis  . .      433,  709 

arteriosclerosis  434' 535, 709 

atheroma        . .         . .  535 

coronary     artery    ob- 
struction     . .         . .  431 

sclerosis       . .  . .  709 

dissectuig  aneurysm  . .  431 

distribution  of  pain  in  433 

electrocardiogram     in 

diagnosing  . .  476 

emotion  causing        . .   434 

exertion  causing    316, 

433,  434 
Angina  pectoris,  false      ..  434 

-  -  Hbroid  heart  with     .  .      53 

-  -  llatulence  with       241, 

316.  709 

Angina  pectoris,  general 
account  of  ■■  433 

heart  as  if  caugbt  in 

high  blood-pressure  and 

316,  535,  709 

indigestion    simulated 

by 310 

juvenile  . .  . .   191 

with  myocardial  affec- 
tions          . .          . .     14 
nitroglycerine     reliev- 
ing   476 

Angina  pectoris,  notes  on 
pain  of  . .  708 

pain  in  the  chest  from  430 

distribution  in    535,  708 

in  left  arm  with  316,  470 

precordia  from      . .  470 

shoulder  from    474,  470 

pale    abundant   urine 

after 433 

pericrrditis     causing 

pain  like     . .  . .    433 

polyuria  from  . .   035 

precordial    tenderness 

after  ..         ..708 

sense     of     impending 

dissolution  in         . .  433 
'jpx:  incidence  of       ..   434 

-  -    Ir.uii  s;yphilis  53,  210 
\  ill  ir[,t"i>,  sore  throat  in  013 

Aii-inl.rriiioma,  fingers  af- 

Uctud  by        ..  ..    239 

Angioma  of  kidney,  hema- 
turia from      . .      275,  278 

-  larynx     ..  ..       287,   293 

-  liver         374 

-  nose,  epistaxis  fi'om     . .  220 

-  tongue     . .  . .       698,  699 

-  vulval  swelling  from  . .  700 
Aneioiipurnpis,  rpdemafrom  415 
Angioneurotic  cedema  (^ee 

(Edema,  Angioneurotic) 


AiiL'lu-Inilii: 


hjpothei 


312 


Angular  gyrus,  alexia  from 

lesion  of         . .  . .    635 

speech  centre  in       . .   024 

Anidrosis 654 

iini.il  le,      uietbajmogiubin- 

ajnua  trom     . .         . .   101 

—  sulphhfcmoglobinaamia 

from    . .         . .  . .  1 51 

-  dyes,  bullae  from         . .     9(> 

'erythema  fi*om         ..  222 

hfematuria    simulated 

by 744 

imal  inoculation  in  dia- 
gnosing   tubercle    48, 

104,  105,  577 


ANIMALS 


A O RTI C  R EG URGITATIOX 


Animals,     experimental 
lisemoglobiuuria  in    . .   : 

-  trvpanosouies  in 
ANKLE-CLONUS.. 

-  in    amyotrophic    lateral 

sclerosis  . .        62,  . 

-  with      brachial      mono- 

plegia . .         . .  . .  - 

-  iu  Brown -S6quard  para- 

lysis    . .         . .  . .  ■ 

-  cerebellar  abscess         . .  ■ 
tumour  . .  . .   . 

-  disseminated  sclerosis 

307,  i 

-  ill  hemiplegia      39,  139,  ; 

-  in  hysteria         . .  . .    : 

-  with  increased  knee-jerk 

30, 

-  lateral  column  lasions  ind 

-  from   lateral   sclerosis . .    . 

-  method  of  elicitint,' 

-  from  new  t^rowtli  in  spine 

-  in  parapletjia 

-  physiological      . .  . . 

-  significance  of    . . 

-  in  spastic  paraplegia    . .  . 

-  • tendency  to  '    . . 

-  from  transverse  myelitis 
Ankle-jerk,  absent  in  tabes  '■ 

-  exaggerated,    in     hemi- 

plegia  ; 

in  hysteria      . . 

syringomyelia  . .   J 

-  lost,      in      intermittent 

claudication   . .  . .  ' 

in  peripheral  neuritis    • 

sciatica  , .  . .  ■ 

tabes 

Ankle-joint,     disease     of, 

rickets  simulating    . .   '■ 

-  fracture     into,     talipes 

from    . . 
haimophilic  arthritis  of 

-  hemorrhage  into  . .   : 

-  osteo-artliritis  of  . .   : 
-»  sprained,  talipes  from  . . 

-  suppurative  arthritis  of  : 

-  tuberculous  disease  of  . .  : 

limping  from  . .  ; 

l>ain  in  foot  from      . .   I 

talipes  from  . .  . . 

-  yaws  affecting   . .  . .  • 
Ankles,    large,    in    rickets 

(Fig.  S.'i)        ..  ..   ; 

-  cedcma  of  (see  QCdema) 

-  pa>  alysis  of  (see    Para- 

lysis, and    Foot-drop) 

-  position  in  tetany 

-  putliness  of,  in  nephritis 
Ankylosis,    from    arthritis 

142,  311,  I 

-  Thomsen's  disease  simu- 

lathig  . .  . .  . .  i 

AnkylnstomiasiB,  albumiii- 


-  anaimjafrom  33,  81.  113,  521 

-  anasarra   frnin  .  .    521 

-  asthfriia    liniii  ..    021 

Ankylostomiasis,    blood 

changes  with  . .         . .    26 

-  picture  in        . .  . .   521 

-  boils  from          . .         . .  •'>21 

-  in   Hrazil                          . .  521 

-  cachexia  from   . .          . .  90 

-  colour  index  high  in     . .  521 

-  in  Cornwall        . .          . .  620 

-  Egypt 521 

~  cositiophilia  from        210,521 

-  *  IImu.t>'  .,1                     ..  521 
Ankylostomiasis,     general 

account  of  ■.  521 


hl'li: 

-  .Tumaica 

-  lead  minors        . .  . . 

-  no  leucorytosis  in         . .   . 

-  nieliona  from     . .         . . 

-  in  mirioM  and  tUHncN  .. 

-  mode  of  Intection  with 

-  occult  bloort  from 

-  uidema  of  legs  from 

113,    11.",,  J 

-  parasites  id  fiucofl  In 

-  pernicious  auiumla  simu- 

lated by     . .  . . 

in  St.  Cothard  Tunnel 

-  severe  anioinia  from 

-  8liortne«n  of  iircalh  from  ■ 


Ankylostomum  duodenale    52Q 

-  -  {Fig.  27)  .  .      711 

-  -  ova  {Figs.  28,  29)    SU,  521 

in  faeces      . .  . .     SI 

thymol  for      . .  . .   521 

in  situ  {Fiff.  220)  521 

Anode         583 

Anophthaimos,   congenital  761 
Anorexia  (and  see  Appetite, 

Loss  of) 

-  from  bacteriuria  . .     70 

-  in  bullous  dermatoses  . .     99 

-  from  carcinoma  coli    . .  12G 

-  gastric  carcinoma         ..  270 

-  nervosa  . .         . .  . .     43 

amenorrhoea  in         . .     18 

carcinoma  of  stomach 

simulating  . .  . .   107 

Anorexia   nervosa,   general 
account  of  ..  770 

i,'<_-r]i-r:d  wasting  from  5S) 

-  from  polymyositis        ..  IGl 

-  after  serum   injection  . .  554 

-  in  tuberculosis  . .          . .  5G6 

-  typhoid  fever    . .          . .  G3G 
Anasteoplasia,  doititi 

-  dwarfism  from 

-  skull  in 1S7 

Anosmia,  list  of  causes  of  612 

Anterior  chamber,  shallow, 

from  dislocated  lens. .   175 
glaucoma    . .     233,  702 

-  cornual  cell   changes  iu 

syritjgomyelia    . .     62 

transverse    myelitis     G2 

cells,   in   amyotrophic 

lateral  sclerosis..  508 

lesion  of,  in  Tooth's 

palsy        ..        Gl,  513 
poliomyelitis  affect- 
ing ..  .,132 


..   187 


Anterlr  crural  neuralgia..  439 
Anterior  cruritis    ..         ..439 

-  poliomyelitis  (see  rolio- 

myeljlis) 

-  thoracic  nerve    . .  . .   501 
Anteversion     of     uterus, 

from  pendulous  belly    200 
Anthelmintics,    for    anky- 
lostomiasis    ..  ..  521 
Anthracosis            . .          . .   288 
Anthrax,  bacilli  in       060,  674 

-  bacteriological  diagnosis 

of         ..  ..      413,559 

-  gangrene  from  . .  . .  255 

-  haamoglobinuria  from  . .   284 

-  of  leg 737 

-  malignant  pustule  of     . .  559 

-  occupation  and         559,   G71 

-  redemafrom       ..      415,  671 
of  face  and  nock  from  413 

-  rigor  rare  in      . .  . .  595 

-  scab  in   , .         . .  . .  074 

-  vaccinia  simulating      ..  C74 

-  vesicles  in  . .  . .  074 
Antiformin,    in    detecting 

tubercle  bacilli    385, 

488,  612 
Antimoniurctted  J^ydrogen, 

jaundice  from  . .   325 

Antimony,  brndypmua  from  84 

-  catarrh    of   small    intes- 

tine from       . .  . .   172 

-  diarrhcca  from  ..  ..172 

-  hnimatemesis  from     2G5,  268 

-  ptyalism  from  . .  . .  512 

-  urticaria  from    . .  . .  771 
Antipyrin,  erythema  from  222 

-  purp 


i  from 
,  from 


-  urticaria  from   .. 
Antitoxic  sera  (nee  t-onimi 
Antrum  of  Itighmoro,  cur 


of,    pn^    frr. 


771 


1711 


I  Antrum  of  HIghmore.  em- 
pyema of        . .     ISO.  462 

infection,     foul     ta«t« 

lesionH.   blood-wpitting 

I  from  . .  . .   2P5 

neoplaHin  In  . .  . .  403 

jjaft-oma  of       . ,  . .  H86 


Ati'nim  Of  IIighmnri\  conld. 
suppuration  in,  meiuii- 

gitis  from  , .  . .  590 

subjective     smells 

from        ..  ..   G12 
transillumination     of 

{Fig,  84)      ..      180,  4G3 

tumours  of     . .  . .   G85 

ANURIA 39 

-  aching  in  loin  with        . .      40 
Anuria  from  calculus       39,  40 

-  from  cantharides  . .      40 

-  from  carcinoma  recti     . .        7 

uteri 39 

Anuria     from     carcinoma 

vesiCEB 


riftr- 


,Zati( 


-l  pr 


Anuria,  causes  of. 


,vitli 


39,  41 
42,  396 
'..  396 

39.  40 


42 


of    urine  di 
tinct  from      . .  . .  395 

-  twitchings  with  ..     42 

-  uneraia  with      . .  . .     40 

-  without  other  symptoms    40 
Anus,  carcinoma  of  381,620,079 

-  coli       bacilluria      after 

operations  on  . .     70 

-  condylomata  of  400,  620,  700 

-  epithelioma  of  (see  Car- 

cinoma ot  Anus) 

-  fissure   of   (see    I'lssure, 

AnaO 

-  fistnia  of  ..         78,  193 
■   glands  draining  .     679 

-  iiajmon-hage  tlirough  (see 

Blood  per  Armin) 

-  imperforate   (Figs.    249, 

252) 58G 

-  intussusception  protrud- 

ing through    . .  . .   717 

-  irritation     nmnd,     from 


-  pig""' ■■  "I    '■'  ^'I'l'- 

SoiT-  .h  .■  I  .  , .   r>2.s 

-  pityh.i-i-  n,  .-,    ,is.  t„i-  6<in 

-  pniritus  (if  . .  . ,   540 

-  retention  of  uriiic  after 

operations  on  . .    396 

-  sypiiilitio  papules  round  401 

-  ulcer  of  (see  Ulcer,  Anal) 
Anxiety,  dyspepsia  from. .  337 

-  occupation   eramj)   from  151 
Aorta,   aneurysm   of    (sec 

Aneurysm) 

-  atheroma  of  (see  Athc- 

-  dilated,  aortic  regurgita- 

tion from        . .  . .  210 

from  syphilis..  ..  210 

systolic  bruit  from    . .  208 

■'  thrill  from  . .  . .  720 

-  opened  by  foreign  body 

205,  267 

mediastinal         new 

growth  ..      265,  267 

-  pulmonary  artery  arising 

from    . ,         . ,         . .  157 

-  *!ite  of  bifurcation  of    . .  064 

-  svstohr  limit  over  ahdo- 


Aorta,  undue  pulsation  of 
abdominal  ..  543 

Hruitt  ' 

-  -  detlnilionof   ..  .,02 

-  disease,  after  aculfl  rlieu- 

matlsrn  ..  . .    209 

age  iiiddnnce  of       II.  200 

from  alcohol  . . 

antnniia  ultli  . . 

angina  ptvtorU  ulth 

-  -  rupilhirv    puNalion 

-  -  ranliiK-"    imput-..'     <li 

pliu-.-dln     .. 

Aortic  diteaie.  cauui  of 

-  -  afti-r.-horci    .. 
frnm    coriLM-nilal    mal- 

f or  III 


20U, 


209 


idnriirdiri^ 


2O0 


-4<>r/(c  (//Vertwc,  conhl. 

heart  failure  from     ..   4 

hypertesthesia  of  arm 

from  . .  . .  4 
left,  ventricle  enlarged 

from    90,     94,    206, 

2U,  2 
mitral   regurgitation 

from  2,90,  211,  212,  3 

nutmeg  liver  with     . .  3 

orthopna^a  from        . .   4 

pain  in  left  arm  fi-om     4 

shoulder  from        . .  4 

rheumatic,    age    uici- 

dence  )f     . .  . .   2 

after  scarlet  fever     . .  2 

from  sclerosis  . .  2 

sex  and 

site  of  impulse  with, ,  2 

splashing  pulse  iu     . .  2 

from  strain     . .  . .  2 

syphilitic         . .       14,  2 

age  incidence  of    . .  2 

sex  incidence  of    . .  2 

after  tonsillitis  ..   2 

-  regurgitjition,   age   inci- 

dence of 

-  -  anaemia  with  . .         . .  2 
aneurysm   with   196,   2t 

208,  2 

angina  pectoris  witli      C 

207,  210,  433,  7 

from  aortic  valve  rup- 
ture . .  . .    2 

apical   diastolic   bruit 

from 

arterifs   forcibly   pul- 
sating in     . .  . .   2 

ascites  from    . . 

-  -  hack  pressure* from  '.'. 
Aortic  regurgitation,  bruit 

of  93,2 

without  bruit  . .  4 

capillary     pulsation 

with  .,  ..2 
cardiac    impulse  dis- 

phiccd  iu     . ,  . .     I 

-  collajising  pulso  with 

217,  4! 
due  to  congenital  mal- 
formation  . .  . . 

diastolic    bruit    from 

209,  406,  7: 

thrill  with  .,  ..7 

from  dilated  aortic  ring 

93,  2 

-  -  dilatntion  of  left  ven- 

tricle witli  ..         ..  ! 

-  -  dizziness  from             . .  2i 

-  -  Durozte//s  sign  in      . .  ; 

dyspnipa  from            . .  2i 

excessive    pulsation 

from  . ,  , .  5 
exercise  bringing  out 

bruit  of      ..         ..4; 

jQintncss  from  ..  2i 

femoral  bruits  in       . .     I 

flhrold  heart  with    . ,     J 

-  -  Flint's  bruit  with      . .   2i 
due  to  fungating  endo- 
carditis      . .  . .     ! 

hiuinoplysis  from      . .  2! 

-  -  headache  from  . .  2i 
heart  failurn  from     . .     ■ 

-  -  hypertrophy     of     left 

vent  ride  from  00,  94, 21 

-  -  hisomnia  from  . ,   81 

irregular  heart  frnm. .  21 

mitral  disoaso  wilh  ..   2' 

regurgitation     from 

46,  00.  21 

noises  in  the  head  with  4i 

oedema  from  . .          . .  2( 

-  -  p'liii  til  arm  from    207.  i: 

biuk  from  . .         . .  i: 

precordja  from   207,  4: 

shouldor  from        . .  2< 

palpilitltnn  from    207,  4! 

jtri'Mytttolic  bruit  wKli  1 

-  -  p'uhnonnry     Incompe- 

leiico  Hlinulating    .,   2 

-  -  pulMilllo  arlcrlcii  with  2 

rhcumalic      . ,  46,  I 

duoto  ruptiiroof  vnlvo 

segment  . .  03,  2< 
*»clcro*!«  of  valvott    . .     J 


AORTIC   REGURGITATIOX     —    ARMS 


ortic  reguiyi/atiau.  contd. 

-  simulating  pericarditis 

-  syphilitic    4G,  53,  93,  2 

-  systolic  bruit  with  . .  i 

-  thrill  with      . .  . .  i 

-  throbbing  from  . .  i 

-  liiiiiiiiis  from  . .  ' 
iu-;iiji.i-fro  bruit  in  . . 

■   \  i.ilrnt.  arterial  pulsa- 
tion uith         ..  ..   < 

-  waterhammer  pulse  in 

207,  208,   ' 
riner,  dilatation  ot 
second     sound,     accen- 
tuated 
from  high  blood- 
pressure 
relation  of  ather- 
oma to 

loud,  in  arterio- 

sr-lercsis  . . 

chronic    nephritis 

ringing    in    chronic 

nephritis 
with  raised  blood- 
stenosis,  Jiscites  from    . . 

-  atheroma  simulating 

-  hradyoardiu  from      . .  \ 
ortic  stenosis,  bruit  of  B2,  \ 


-  ill 


from  -10,  90, 

-  palpitation  from 
~  pulse  in 

-  rheumatic 

ortic  stenosis,  signs  of  92, 

-  Fvi^hilitic 

-  tiirill  with  92,  93,  207, 


ortic    valve,    rupture   of, 
general  account  of    ■ .  ! 

ortiti^.  a. -lite,  angina  pec- 
toris from  . .  433, 
pain  in  the  back  from  . . 
-  chest  from  . .  430, 
from  rheumatism 


Aphrodisiac  drugs  . .  038 

Aphthous  patclies  in  mouth    74 
Aphthous  stomatitis        . .  740 
Aplastic  ansamia  (see  Aiibb- 
mia.  Aplastic) 
I  Apncea,  in  Biot's  breathing  107 

-  Cheyne-Stokes      breath- 

hig 107 

A  poniorphmo,    Tomiting 

from 764 

Apoplexy,  age  incidence  of  147 

-  from  arteriosclerosis     . .      11 

-  athetosis  after    . .  . .   133 

-  due  to  cerebral  hEcmor- 

rhage  . .  . .  . .   147 

-  coma  in  . .  ..      144,  147 

-  convulsions  with  144, 147,148 

-  dizziness  before. .  . .    147 

-  due  to  embolism  . .   147 
Apoplexy,  eeneral  account 


of 


147 


147 


-  (< 

Cerebral  J 

-  from  granular  kidney  . . 

-  headache  before 

-  from  high  blood-pressure    81 

-  onset  of  . .  . .  . .   147 

-  pancreatic  (see  H£emor- 
rhage  into  the  Pancreas) 


puln 
s!le 


ary,  from  mitral 


-All, I 


-ck  with  . .    167 
ulrpsv        ..    148 
56    146 

.   147 
.   147 


116 


riiiL-liiiL,'  before  . 
\MMl;nr^s  before 
>pr,ii;iiii_e  (see  Facies) 
pprinliL-itis,       abdominal 

abscess  hi  groin  from    . .   680 
acute    abdominal    pain 

-   I  .fjiMi',;;-   \um-i     131,  592 

;,.l ■I..':,    ,  .  ..130 

;.li   .!  ■     '    !■■      M_-  iiainof  316 

:ii  ,  I.!.'  it  II.  .  i,!l.ln_'n       ..    316 


ba 


.  fru 


130 


454 


musculiir  atrophy     . .  " 

-  -  syriogomyelia  . .  '. 

Lphasia,  Broca's  area  and  : 

cerebral    lesions   causing  i 

Irnni    crirhnil   svphilis.  .  : 

,l.  III. II 1      '. .        ..  I 

III  ili"i'niiii;iifii  sclerosis  ' 
Iphasia.     dysarthria     dis- 
tinguished  from    302, 


,  general  account  of  62-^ 


iiiiia  .la,  icsiniis  causing..  ) 

.  ■       !■■■     .!■     ■■  .    .  ..      ( 

Vphasia,  motor  ..  i 

-  Broca's  area  and       . .   ( 

-  mutism    distinguished 

from    . .         '.  .  . .   624 

aphasia,  sensory  . .     625,  626 
aphonia,  functional        ..  494 

-  -  cuff'il      bv      electrical 


■!■    ■.     :n  hysteria     628,  i 

:niii  iaryiiL-'eal  paralysis  ■ 
vocal  corci  paralysis  . .  i 


:oIic  simulated  by 

-  collapse  from 

-  congested  cu'cumflex 

vehi  with 

-  constipation  after  . .   126 

-  -  with     . .  . .      131,  677 

-  diarrhcea  with   . .         . .  172 

-  distention  of  caecum    . .   457 

-  duodenal  ulcer  simulated 

by        450 

-  dyspepsia  from  . .  . .   297 

-  empyema  from  . .     ]04,  106 

-  frequent  micturition  from 

394,  582,  677 

-  furred  tongue  with       . .   677 

-  gall-stones  simulatuig  . .   451 

-  gangrenous       . .  . .      436 
Appendicitis,    general    ac- 
count of  . .  454 

-  general  peritonitis  from 

388,  453 

-  hsematemesis  from       . .  274 

-  hsematm-ia  from        275,  283 

-  heartburn  from.,         ..  297 

-  hunger-pains  from    316,  451 

-  indicamiria  from       314,  451 

-  indigestion  simulated  by  316 

-  intestinal    obstruction 
130 


>  afte 


326 


Appendicitis,  kidney  tumour 
simulated  by  . .         . .  354 

-  left-sided  . .  . .   452 

-  leg  drawn  up  from        . .    677 

-  leucocvtOL-is  in  . .  . .   677 

-  n|„.r;,ii,,n    iM     i:u;.    450,    454 

-  (,\.,nii-  Mf,iMl.ii,.,|  by   ..   678 

-  I ^1  I'M.  I,,rk  from  ..    428 

-  -  rpi.MMniiin  from      ..   436 
by]tochonLlrium    from 

450,  451 

iliac  fossa  from  352,  454, 

677 

left  iliac  fossa  fi-om  . .   452 

lumbar  region  from..   354 

pelvis  from     .  .  . .    468 


Appendicitis,  contd. 

pain  hi  testis  from        ..   483 

-  pahiful  micturition  from 

582,  677 
~  pelvic  abscess  from  . .  474 
lesion  simulated  by  . .  468 

-  -  swelling  due  to         . .  688 

-  perinephric  abscess  from  353 

-  pleurisy  from     . .      106,  460 

-  pneumaturia  from         . .   530 

-  portal    vein    tlirombosis 

from    . .  . .  . .      51 

-  in  pregnancy      . .  . .   691 

-  prolonged   pyrexia  from  567 

-  pulse-rate  raised  in  454,  677 
~  pylephlebitis    after  326, 

333,  567 

-  pyrexia  in  115,  283,  454, 

460,  507,  077 
Appendicitis,  pyuria  from.  ■  582 

-  rectal  examination  in  re- 

cognizing     116.   283,  454, 
677 

-  recurrent  monthly  pains 

from    . .  . .         . .  457 

-  rigidity  with      . .      454,  677 

-  rigors  after        . .  . .  326 

-  septicaemia  from  . .  567 

-  sex  incidence  of  . .  451 

-  shock  from         . .  . .   436 

-  sunulated  by  actinomy- 

cosis . .         . .  458 

coli  bacilluria    . .      . .  455 

Diell's  crisis  . .   665 

dysmenorrhcca  . .  193 

-  -  ectopic  testis         432,  681 

ileocsecal  kink  . .   457 

inflamed  glands         . .  459 

ovary  simulating  . .   456 

injury  . .  . .   457 

movable  kidney      460,  665 

ovarian  neuralgia     . .  665 

-  -  ovaritis  . .  . .   665 
periostitis  of  ilium    . .   454 

-  -  ple-risy  . .  . .   432 

pneumonia     . .  . .  400 

pylephlebitis  . .  . .  567 

-  renal  colic      . .  . .  451 

retained  testis  . .  457 

salphigitis       . .  . .  456 

scybala  . .  . .   665 

spastic  constipation  . .   124 

spinal  lesions..  ..   461 

stercoral  ulcers         . .  459 

stitcli   . .  . .  . .   457 

-  suppurative  nephritis     594 

tuberculous  ciECum  458, 077 

glands         . .         . .  677 

twisted  ovarian  pedicle 

450,  091 
typhoid  fever  . .  459 

-  undue  abdominal  aor- 

tic pulsation  . .   643 
ureteral  calculus  281 


-  colit 


ureteritis 

-  subdiaphragmatic       ab- 

scess from  103, 106, 451, 658 

-  suppurative  pylephlebitis 

from  . .  . .  596 

-  swelling  with      . .  . .   454 

-  -  iTi  U-li  iliac  f.issa  from  452 

-  -    ihar    I,, -.-a     irom     354,  677 

Appendicitis,  symptoms  of    677 

-  tt-nii.-rn..-.-  witli  ..    454 

in  iliac  fossa  from    . .    677 

over  M'Burney's  spot 


th 


451,  454 
basis  of  iliac  veins 

from 106 

ngue  coated  in  . .  454 

imiting  in      454,  677,  765, 


Appendix,  felt  per  rectum 

-  in  hernia. . 

-  vermiformis,    actinomy- 

cosis of 
APPETITE.  ABNORMAL 
in  diabetes     . . 

-  deficient,  from  worms  . . 

-  increased,  in  diabetes 

43,  200, 


Appetite,  increased,  general 
account  of      ■ .         42,  43 

from  hyperchlorhvdria    42 

hysteria  . .     "     . .     43 

pregnancy      . .         . .   264 

tape-worms    . .         . .     43 

-  loss  of,  in  acute  yellow 

atrophy       . .      273,  333 

bad  ventilation         . .  321 

carcinoma  of  stomach 

43,  316 

catarrhal  jaundice    . .  329 

chronic  alcoholism    . .     51 

I'irrhosis  .,         43,  51 

from  defective  teeth . .     43 

dyspepsia  ...         . .     43 

erytliema     scarlatini- 

forme  ..  ..   227 

gastritis  ..        43,  317 

hip  disease    . .         . .  303 

-  -  hysteria  . .  . .     43 

with  insanity . .         . .     43 

leukaemia  '     . .  . .     25 

mitral  disease  . .     43 

nephritis        . .  . .     43 

-  -  phthisis  . .  . .   288 

renal  lesions  . .  . .     42. 

rheumatoid  arthritis       35 

from  serum  injections  223 

tetrachorethane        . .  334 

-  -  tobacco  ..         ..43 

tuberculosis    . .         . .     43 

urffimia  . .        40,  315 

-  pi-rverted,  in  children  . .     43 

insanity  . .  . .     43 

pica     . .  . ,  . .     99 

pregnancy      . .  . .     43 

-  voracious,  in  hvpopitui- 

turism 410 

from  worms  . .  . .   519 

Apple  -  ielly     nodules,     in 

lupus    179,   4-     -"' 


Apples,  colic  from 
-  unripe,  diarrha?a  from.. 
Apprehension,  sense  of,  as 
an  aura  of  epilepsy  . . 
Aqueous  humour,  particles 


738 
117 


71 


454 
. .   455 


-  turbid,  in  iritis  . .         , .  232 
Arachnoid      hfemorrha^e, 

convulsions  from        ..   146 
Aran-Duchenne     type     of 

amyotrophic      lateral 

sclerosis  . .  . .   508 

Arcus  senilis,  hiccough  with  308 
Argyll     Robertson     pupil, 

(see       I'upil,       Argyll 

Eobertson) 

Argyria 529 

Arm.  athetoses  of. .  . .    133 

-  contracture  of     61,  141,  520 

-  muscles  of,  root  umer- 


of 


509 


504 


-  myopathy  of     . . 
Arm,     nerve     supply 

muscles  of 

-  pain  in  (see  Pain  in  the 

Arm) 

-  paralysis  of  (see  Paralysis 

of  Arm) 

-  sores  on,  inflamed  axil- 

lary glands  from      . .  380 

-  spasticity  in      . .         . .  502 

-  wasting  of,  from  aneu- 

rysm   . .  . .  . .      63 

cervical  rib    . .  . .     63 


vth.. 


132 

145 


-  epilepsy  co  ilined  to 

-  intermittent  claudication  103 

-  local  fatness  of,  in  Der- 

cum's  disease  . .  410 

-  multiple  benign  sarcoid 

affecting         ..         ..405 

-  myoma  cutis  of  . .   732 

-  oedema  of  (see  CEdema 

of  Arms) 

-  position  in  tetany        2,  151 

-  short,    from    achoudro- 

'  plasia  . .         . .         . .  187 

-  swelling  from  aneurysm 

opening  vena  cava  . .    159 


// 


ARMS 


ARTHRITIS,    H.ilMOPHILIC 


dri/w,  contil. 

-  syringomj-elia  affect  ii 

-  tremor  of,  from  i 
Vrnica,  bullaa  from          . .  96  ] 
Arnica  moiitana,  dermatitis          I 

from    . .          . .          . .  755 

-  erythema  from         . .  222 

-  sore  fingers  from  . .  239 
irnold's  nerve  . .  . .  148 
ajThytliinia  of  heart,  from 

am"icutar  UDnllatiou. .  545 

-  iilierfiuUng  pulse  type  545 

-  excitement  ami        . .  545 

-  -  extrasystoles  . .          . .  545 

-  -  iii';in-t)iuck  tvpe       . .  545 

-  -  lif)Miii<:  of  hreath  and  545 
Arrhythmia  of  heart,  smus 

Type  01           -■         ..  545 

swallowimr  ainJ          .  .  54ri 

Arrhythmia  of  heart,  total  548 

(and  see  Tulse,  irrtrn- 

larj 
irscnio,  Addison's  disease 

simulated  from         ..  04 

-  albuminuria  from          .-  13 

-  amblyopia  from            ..  759 

-  anaemia  from      ..        33,  G12 

-  in  atoxyl            . .          . .  324 

-  beer          . .           GO.  526,  529 

-  bleeding  gums  from      72,  73 

-  blood  per  anum  from  . .  7S 

-  in  blood  diseases          . .  (i4 

-  catarrh  of  small  intesthtc 

from    . .          . .          . .  172 

-  chemical  analysis  in  dia- 

gnosing          . .          . .  718 

-  choleraic  diarrhoea  from  717 

-  in  chorea            ..        ilG,  717 

-  clammy  skin  from       ..  78 

-  cold  sihiulated  by         . .  178 

-  colic  from          . .          . .  6-1 

-  collapse  from    . .          . .  717 

-  contractions  from        . .  140 

-  coryza  from       . .          . .  G4 

-  criminal    administration 


of 


718 


-  diarriioea  from   64,    73, 

78,  171,  172,  533 

-  erythema  Irora  . .     222,  224 

-  fatty  heart  from         ..     53 

-  in  food 718 

-  foul  tiiste  from  . .         . .  705 

-  gastritis  simulated  after  766 

-  hajmatemesis  from       . .  265 

-  in  hair  34,  GG,  73,  529,  718 

-  headache  from  . .  . .     64 

-  herpes  zoster  from       . .     Gl 

-  hyperkeratosis  from   34, 

64,  73 

-  hysterical  administration 


ol 


-  leucopcnia  from  —   301 

-  lichen  planus  relieved  by  489 

-  in  Manchester  epidemic 

526,  529 

-  Marsh's  test  for  . .     78 

-  mucus  in  stools  from    . .     78 

-  nasal  ciiturrh  from  ..  012 
discharge  from         . .  178 

-  neuritis  from     . .  . .  140 

-  noises  in  the  head  from  406 
-oedema  from  ..  ..  415 
of  face  Irom  . .  . .  413 

-  pain  in  epigastrium  from  78 
limbs  from      . .        04,  400 

-  parnjstheaim  from         . .     01 

-  peripheral  neuritis  from 

34,  61,  04,  05,  06,  73, 
250,    443,    465,    400, 

505,  520 

-  in  pernicious  anoimia  33, 

00.  520,  717 

-  photophobia  from        ..  525 

-  pigmentation      of      tho 

mouth  from    ..        33,  526 

-  -  skin   from  33.  04,    73, 

520.  528 
Arsenic,    plomentatlon    of 
the  skin  due  to  H'tafr 


717 


78, 


Arsenic,  conuL 

-  ptyalism  from  . . 

-  pulse  irregular  from 

-  purpura  from    . . 
~  Reinscli*s  test  for 

-  in  salvarsan 

-  in  sodium  cacodylate  . . 

-  suicide  by 
~  syphLUs  and 

-  tenderness  in    abdomen 

from    . . 

-  tenesmus  from  . 

-  in  vomit. . 

-  vomiting    from 

171,'  766',  717 

-  in  water. .         . .  ..   718 

Arseniuretted     hydrogen, 

haimoglobinuria    from  284 

-  -  jaundice  from        325,  337 
-Vrterial  tension  (see  Blood- 
pressure) 

Arteries,  cerebral,  atheroma 
of  (see  Atheroma  of 
Cerebral  Arteries) 

-  forcibly     pulsatile,     in 

Graves*s  disease       . .  215 

-  sensitiveness  of  . .  434 

-  thici(ened,     in     chronic 

nephritis 

-  tortuous,      in      chroni 

nephritis 

-  visibly    pulsating,    with 

aortic  regurgitation  , . 
Arteriosclerosis,     accentu- 
ated    aortic     second 


90 


400, 


~  albuminuria  from 

iirst  sign  of    . .  . .      13 

-  angina  abdominalis  from  115 
pectoris  from  434,  535,  709 

-  apical  systolic  bruit  in . .     89 

-  apcplesy  from  ..         ..     11 

-  ascites  from       . .         . .     46 

-  and    atheroma,    associ- 

ation between  ..       1 

-  back  pressure  from    40,  212 

-  cerubral     haemorrhage 

irom    . .  12,  147,  303 
tumour  simulated   by  295 

-  Cheyne-Stokes     breath- 

ing from         . .         . .  107 

-  cyanosis  from    . .         . .  101 

-  dead  lingers  from      162,  103 

-  diabetes  with    ..         ..  255 

-  epistaxis  from  ..  ..  220 
Iirst  symptom  of      . .   221 

-  gangrene  from  . .  . .   255 
Arteriosclerosis,    general 

fijagnosls  of    .  ■  i  I 


riddii 


r  kidney, 
close  relationship  be- 
tween ..  ..  1,  11,  212 

-  hntimatemesis  from       ..  271 

-  hajmaturia  from  . .  270 

-  hiumoptysis  with         . .  287 

-  headache  trom    294,295,290 

-  heart  enlarged  in  2,  11, 

54,  200.211,212.588 

-  -  failurcfrom  14,40, 101,418 
sounds  with    . .         . .     11 

-  high  blood-pressure  with 

2,  11,  14,  40,  90,  81, 
101,  103.  211,  212, 
290.400,418,484,543,588 

-  hyperacn.-i^  in   ..  ..   309 

-  hVpothermia  in..  ..311 

-  itidomnia  from   . .      321,  323 

-  juvenile 191 

-  mcnorrhagia  from     380,  388 

-  metrorrhagia  from       ..  390 

-  mitral  regurifiUition  from 

2.   89,   90,   211,    212 

-  with  nephritis  . .         . .     42 

-  nocturnal        micturltlou 


Arferioschrosis,  to?itd. 

-  I)leuritic  effusion  with..     11 

-  with,  polycystic  kidneys 

42,  357 

-  polyuria  with  12,  90,  530,  537 

-  precordial  pain  in        . .     11 

-  ptyalorrhoea  from        . .   543 

-  radial  artery  thickened  in    90 

-  reduplication     of     Iirst 

sound  with     . .  . ,  588 
second  sound  from,    . .  588 

-  retinitis  in         . .  . .     90 

-  senile  gangrene  and     . .   258 


Artery,  contd. 

-  posterior  cerebral,  hemi- 
anopsia    from    lesion 


ngmg 


nd 


146 


274, 

274 


Arteriosclerosis,  symptoms 
ana  signs  of  ..        ..  I,  2 

-  tube  casis  Irom. .  . .   53j 

-  uterme   vessels   affected 

hv        388 

-  vertigo  Irom      407,  752,  753 

-  vessels  atlected  by       . .       1 

-  vomiiMig  irom  ..  ..   295 
Arteruivenuus  aneurysm  ot 

orbit  094 

Artery,  brachial,  atheroma 

ot         551 

forcibly  pulsatuig,  with 

aoriic   regurgitation  207 

-  carotid,  lorcibly  pulsat- 

ing, with  aortic  regur- 
gitation . .  . .   207 

-  cceliac  axis,  aneurysm  of  331 

-  comes     nervi     mediaui,  , 

collaterally  enlarged. .   050 

-  coronary,    atheroma    of      1 

heart-block  with  . .     83 

heart        thumpings 

from         ..  ..486 
fibroid  heart  from  ob- 
struction of           ..  213 

obstruction,        angina 

pectoris  from         . .  434 

pain    in    tho    chest 

from        . .         . .  434 
sclerosed,  angina  pec- 
toris from        434,  709 

extra  systoles     from  547 

pain    in    the    back 


fron 

chest  from 

-  rheumatism  of  slioul- 

der  simulated  by 

syphilitic    obstruction 

of 


213 


I  //I 


64 


vith 

loIiiL'S  in  tho  head  fn    . . 
lon-concentratiou        of 

mind  fn 

al  radial  artery 


ute. 


Arsenic    poisonln(|. 

symptoms  ot  . .  /"B 

Arsenic  poisonino,  «eneral 

account  of  ..  717,  718 
Arsenic    poisoning,     sym 

ptoms  of 

^   )<.<lv.  \  I  hii'iiiit  froiri 


-  nutmeg  liver  from 

-  nrthopna-a   from 
pain  in  the  back  from  . 

-  palpitation  from 

-  pancreatitis  with 
64,  268     -  pericarditis  with 

i3     -  peritonitis  with 


-  dorsalis  pedis,  cessation 

of  pulsation  in         . .     31 

-  femoral,   bruit  over,  in 

Hurtic  regurgitation..     93 

ligature   of,   gangrene 

from  ..         ..208 
for   popliteal   aneu- 
rysm       ..  ,.258 

-  hepatic,  aneurysm  of  325,  331 

-  hyaloid,  persistent,  nys- 

tagmus from..  ..  759 

-  iliac,  aneurysm  of,  (seo 

Aneurysm      of     Iliac 
Artery) 

-  innominate,  aneurysm  of 

{Fig,  184)       ..         ..435 

-  intercostal,  replacing!  pul- 

monary . .         . .   Ill 

-  internal  carotid,  comnm- 

nicatiiig    with   caver- 
nous Hinus      ..  ..   G94 
erosion  of  . .         . .  421 

-  middle  cerebral,  cmbol- 

tsm  of  (SCO  Kmbolism, 
Cerebral) 

endarteritis  of  301,  517 

hemianopsia     from 

le.4iori  of..         ..301 

hemiplegia        from 

IcMlon  of..         ..  303 

spcoct)  centres  aup- 

ulicd  by  . .  . .   G25 

-  opiitlialmic,  communica- 

ting   with    cavernous 
Hinua 091 

-  jmncrentlc,    opened    by 

gastric  ulcer  . .  ..  208 

-  poplitojil,   ancury.sm   of, 

(seo  AiiourysMi  of  I'o- 
plitral  Artery)  J 


of 


inferior     cerebellar, 

thi-ombosis  of       5f 
-  pulmonary,  aortic  atieuj 

ysm  opening  into 
arising  from  aorta    . 


ati: 


of 


from  mitral  stenosis  2 

embolism  of  (see  Em- 
bolism,   Pulmonary-) 
supplied  by  hi tercostalsl 

-  radial,  abnormal  . .    5 
cessation  of  pulsation 

embolism  of    . .         . .  ii 

thick    and     tortuous, 

with  chronic  nephri- 
tis     2 

high     blood-pres- 

thickened    in   arterio- 
sclerosis 

cerebral     atheroma 

with        ..         ..    J 

in  interstitial  nephri- 

,  tis  .... 

i  -  retinal,  embolism  of  (see 
Kmbolism,  Retinal) 

, spasm     of,     blindness 

from  . .         ,.    'i 

-  spinal,  thrombosis  of  (see 

Thrombosis,  Spinal) 

-  splenic,  opened  by  gas- 

tric ulcer        . .         . .   'J 

-  subclavian,  aneurysm  of 
!  (see  Aneurysm  of  Sub- 
I  clavian  Artery) 

atheroma  of  . .         . .   ^ 

stenosed    by    cervical 


rib 


stenosis  of  oesophagus 

hy : 

-  tibial,  cessation  of  pulsa- 

tion in 

-  temporal,  tortuous,  cere- 

bral atheroma  with  . .    ■ 
Aryteno-epiglottidean  folds, 
pallid  swelling  of      . . 
Arytenoid   cartilage,   peri- 
chondritis of  . .         . .   i 

-  lixed,  simulating   larvn- 

-..:.l     ,.:.r:.lyM>  ..     ■'. 

ARTHRITIS  (and  see 
JOINTS.  AFFECTIONS 
OF   THEt 

Arthritis,  acute  secondary 


-  OOntradurr^.    -iriiul:il  mi;* 

-  crepitus  from     . . 

-  deformans 

-  diphtheria  with 

-  dysentery  with  . .  . .   ; 

-  ecchondroses  from 

-  exostoses  from  . . 

-  septic,  fixation  of  joints 

after ; 

-  glanders  with    . .  . .   ; 
gonococcal    deformity 

from  . .      142, 

Arthritis.  gonococcal, 

general  account  of   . .  : 

joints  chielly   nlTectcd 

'>>■ 

overlooked  in  women 

ndsUtkcn     for     Bcut** 

rheumatism        338. 

progrosulvo  muscular 

alroidiy  ., 

tuberculous  joint  .. 

inuscio  atrophy  with 

noilulcs  with  . . 

-  pain  In  tho  limbs  In  . . 
salicylates    InelTcctual 

in  iFio.  150)      38S. 

suppuration  rare  hi  . . 

tendons     and     fascim 

atTrclid  Ml  .. 


7H4 


ARTHRITIS.  HAEMOPTYSIS     —    ASCITES.   SIMULATED 


350 


Lrthritis,  liiemoptysis  and  287 
liiemorrhagic,  in  Henoch's 

purpura 
hysterical 

infective,  anosmia  with. .     o-^ 
~  ankylosis  from  . .   GiS 

-  aitcr  diphtheria        . .  048 

-  epitrochlear  gland  en- 
larged from  . .   381 


fibrosili! 


475 


myositis  anc 

from  pyorrhoea  . .      74 

after  scarlet  fever     .  .    (548 

trthritis,  infective,  of  spine  648 

pain    in   iliac  fossa 

from         . .      452,  454 

interscapular      pain 

from        . .  . .   461 

-  after  tonsillitis  .  .   648 

-  stilt 


nllu 


alicylates 


339 


inUueir/.a  with    . . 

from  injury 

in  Malta  fever  . .      340, 

measles  with 

with  meningococcal  me- 
ningitis 

muscle  atrophy  with  61, 
340,  361,  363, 

needling  of  joint  in  dia- 
gnosing 


340 


ilated  by  . .  506 
occupation  neuroses  si- 
mulating . .  . .  476 
ochronosis  and  . .  . .  740 
osteo-  (see  Osteo-arthritis) 
pain  in  the  shoulder  from  474 
].:irnly=i';  =hnnlatcd  by. .  601 
Willi   nrliii-i- rlieumatica  556 


527 


Arthritis,    pneumococcal, 

general  account  of    . .  339 

Arthritis,  in  rheumatic 
fever,  general  account 
of  .337 

-  rheumatoid,    ;iii;t;uiui    in     35 

—  appendicitis  simuUiteil 

by 4G1 

appetite  impaired  with    3o 

Arthritis,  rheumatoid,  bac- 
teria causing  ■ .         . .     35 

absent-e       of        bony 


chanties  : 


;of 


idenc 

bacteriuria  with 

—  in  children  (see  Still's 


fron 


3i3 


Arthritis,  rheumatoid, 

general  account  of  341,342 

Urixtmi-  in       . .  . ,   343 

joints  affected  in       . .  343 

loss  of  weight  in       . .     35 

lymphatic  glands  en- 
larged in       3D,  343,  35S 

massage  in     . .         . .  343 

muscular    atrophy   in 

343»  346 
-  -  osteo-nrtliritis        con- 

343 


Arthritis,  rheumatoid,  osteo- 
arthritis distinguished 
from 346 

pain  in  the  back  from  42S 

hand  from  . .  . .   151 

limbs  in      . .  . .   4G3 

passive  movements  in  343 

pigmented  skin  in  35,  342 

pulse    rate     in     341, 

342,   34G 

from  pyorrhoea  alveo- 

laris  .,  ..   G4S 

pyrexia  with  ..        35,  341 

rarefaction     of     bone 

in  (Fifr.  156)  343, 


I  r rent 


344 


exacerba- 
tions of  . .         . .  343 
salicv  lates   ineffectual 

"in..  ..      339,  341 


Arthritis,  rheumatoid,  contd. 

spindled      fingers     in 

(Fin.   153)  342,  ; 


sweating    hands    and 

feet  in    , .         . .  342 

temperature  chart  in  341 

Thomsen's  disease  si- 
mulating    ..  .,584 

ulnar      detiectiou     in 

(Fi(/.  154)       342,  343 
ureteral  calculus  simu- 
lated by      . .  . .  461 
writer's    cramp   simu- 
lated by      . .  . .   151 

z-ravs  Ml  diagi 

scarlatinal 
Artiiriiis,    septic, 

account  of 
-  septic,  leucocyti 


osing..    343 
..    340 

general 

..  339 

;is  with  339 
mistaken  for  rheuma- 
tic fever      ..  .,339 

-  pyrexia  of      . .         . .  339 

-  sources     of    infection 

causing        . .  . .   339 

-  sweats  due  to  . ,  339 
of-  shoulder,    aneurysm 

simulating      . .         . .  476 

-  hydatid  cyst 


Asafcetida,  foul  taste  from 
Ascaris  lumbricoides       .  ■  I 

appetite  increased    by 

bile-duct    obstructed 

by    ..  ..      325,  ; 

no  blood  changes  with 

eosinophilia  rare  from  ! 

jaundice  from  . .    '. 

'  -  -  Icn^'th  of         . .  . .    ; 

-  -  ovum  of  (Fig.  217)  ..    i 
I passed  per  rectum     . .   i 

in  vomit 

without  symptoms    . . 

I  Ascending  cerebellar  tracts, 
role  in  co-ordination. . 

-  nephritic-      (see       under 

Nephritis) 

-  nephritis,      causes      of 
chn     " 


Ascites,  contd. 

-  with  enlarged  liver 
j portal  glands 

'  -  epigastric  angle  widei 
I        by      ., 
I  —  from  fatty  heart 
'  -  fibroid  heart 

-  -  lung     . . 

-  fibroid  lung  from 

-  lluid  nf  (>;ec  Mnid,  A'JC 

-  fn-tll.  rh-tniMi  from 


iiuju  u,.-..ii  .,..luie40,  02,  lU-s 
heart  impulse  displaced 


ing 


476 


mediastinal  new  growth 

simulating  . .  . .   476 

-  small-pox  with  . .         . .   340 

-  spinal,  rigidity  of  back 

from    . ,  . .  . .   461 
a--rays  in  diagncsing..   461 

-  suppurative,      albumos- 

uria with        . .         . .     16 

-  -  of  ankle  . .  . .   3G2 

limping  from  . .  . .   362 

mistaken     for     acute 

rheumatism  . .  338 

rheumatic  fever    . .  341 

from  osteomyelitis    . .    341 

pain  in  foot  from      .  ,    "62 

septic;i!nii:i  from        .  .    341 

Arthritis,  syphilitic,  general 

account  of  ■ .  348 

Arthritis,   in  syringomyelia  349 


:il]a 


tris- 


mus simulated  by 
traumatic,  mistaken  for 

acute  rheumatism  ; 
-  tubercle  and  . .  . .  , 
tuberculous,     age     inci- 


denc 


Charcot'^ 


rthi 


347 


mistiikvn  for  ..    341 

Arthritis,    tuberculous,    of 
hip.  general  account  of  363 

hysteria  simulating  ..   142 

injury  preceding        . .   348 

joints  affected  by      . .   347 

lardaceous  disease  with 

8,348 

limping  from  . .   362 

mistaken     for     acute 

rheumatism  . .  338 

muscle  wasting  with. .   348 

pallor  with     . ,  . .   348 

phthisis  rare  with      . .    348 

syphilitic   joint   simu- 

I:-ttin-  ..  ..    31S 

Arthritis,  typhoidal,  general 
account  of  ..  340 


-  -  streptococci 
Artbritism,  pruritus  from 
Arthropathy,      pulmonary 

(see  Pulmonary  Osteo- 
arthropathy) 

Artichokes,  oxalate  from. . 

Ai'ticulation,  cerebellar  .. 
defective,  in  bulbar  para- 
lysis    . . 

-  mechanism    oE  . . 

(and  see  Speech) 


ASCITES 

-  abdominal        distention 

from       ..43,418,655, 

-  from  abdominal  tubercle  171     -  due  to  hepatic  aneurysm 

-  abdominal  veins  distend- 

ed from 

-  from  abscess  of  liver     . . 

-  acute  peritonitis 

-  acute,      from      twisted 

ovarian  pedicle 

-  from    adherent   pericar- 


46,  51 


dh 


albuminuria  from 
from  aortic  disease 

aplastic  anmniia 


46  !  -  loculated 


-  .  .ii.i'.nni  I  ni  1  i^ii.i)  49,51,  329 

-  -   .iuu.k'riuMi        ..  ..51 

-  -  liver     . .   46,  52,  330,  373 

ovary 49 

peritoneum    . .         . .  657 

rectum  . .  . .     49 

-  -  stomach  49,  51,  329 


supr; 


51 


-  cardiac  impulse  displaced    44 
Ascites,  causes  of..        45,  46 

-  from  chronic  mediastini- 

tis        435 

-  -  nephritic         . .  . .   212 

-  -  yifritoniM^  U,  47,  373,  425 
Ascites,    chylous,    charac- 
ters of  fluid   in        ■  •     50 

ilivloiis  iluiil  in  chest 

witli  ..  ..106 

chyluria  with  ..  109 

from  elephantiasis    . .     50 

-  -  filariasis  . .  . .      50 


IrniiL  iiniirr     .  .           ..  .'lO 

to  thorat'ic  duct     ..  106 

leuk.xmia        . .        50,  1U6 

malignant  disease    ..  50 

nephritis          50,  106,  109 

new  growth    . .         . .  106 

obstructed  receptacu- 

lum  chyli    .,■  -     . .  50 
thoracic  duct        . .  50 

-  from  cirrhosis  35,  46,  51,  52, 
?.?.2,  371.  570,  635,  750,  770 

-  (liip  to  folon  tumours  .  .  46 
Ascites,    conditions    simu- 
lating 


vitl. 


G65 


Ascites,     distinction     from 
ovarian  cyst  . .         44,  45 

-  from  distoniu  liepaticum  328 

-  dullness  with  . .  . .  689 
due  to,  distribution  of     44 

-  due  to  duodenal  tumours    46 

-  in    Egyptian    splenome- 

galy      634 

-  from  emphysema  46,  217 
j\jscites,  encysted  . ,  . .  657 
ovarian  cyst  simulated 

by Gill 

pelvic  swelling  duo  to  6SS 


-  from  high  blood-pressure 
46,  21 3-, 

-  in  Hodgkin's  disease    46,  55^ 

-  due  to  hydatid  cyst  45,         ■ 
46,  49,  330,   Zh%'. 

-  hydramnios  simulating     6891! 

-  jaundice  with    . .  46,  50,  53: 

-  due  to  kidney  tumours. . 

-  knee-elbow    position    in 

detecting 

-  ill    lnil::pmri       I.'.   46,   51, 

-  Ii'  .   .      "  ■■  ■  from  43,  .' 

-  Ir  ■  ■   :  .1   ■  .    I  'il.  i)y         ..367 

-  litiMi    lui_^il    fiilargement 
..   330 
44,  48 

from  lung  affections     . . 

-  due    to    lymphadenoma 

45, 

-  in  malaria  . .  . .     ■ 

-  due  to  malignant  disease 

liver     . .  . .  . .     50' 

Ascites,    from     malignant 

peritonitis  . .    49 
portal  glands. .  . .     51 

-  mediastinal  growth  ..      Hi 

-  mediastinitis      . .  . .      !'• 

-  mensuration  in  . .  . .      II 

-  from  mitral  disease  . .      !'• 

regurgitation  210.  ill 

stenosis           . .  . .     53 

-  myocardial  changes  . .     46 

-  nephritis. .         . .  . .     42 

-  nutmeg  liver     . .  334,  36S 

-  with  oedema  of  legs  52,  41-'i 

-  orthopnoea  from  . .  41S 

-  with  ovarian  cyst  45,  689 
from     ovarian 

growth 
tumour 

-  palpitation  from 

-  due    to    pancreatic 

mours  . . 

-  paracentesis  for 

-  trom  [iiTihepatitis 


. .  690 
;i,  .153 
. .   485 


Ascites,  differential  diagno- 
sis of  causes   . .  46-55 


Y^r^- 


struction  51,  : 

thrombosis. . 

]ivolifer:iting    pnpillo 


46,  52 
..     45 


46, 


-  rectal    examination 

detecting        . .        49,  56 

-  respiratory     movements 

deficient  with            ..  4> 

-  ribs  pushed  out  by      . .  4; 

-  from  sarcoma        46.  52,  3"i 

-  with  severe  anaemias    , .  5; 

-  sigmoidoscope  in          . .  1! 

-  simulated  by  .abdominal 

cyst         . .         . .  I 

tumour       . .         . .  ' 

distended  bladder    . .  ^ 

hydatid  cyst  . .         . .  '  ■ 

hydronephrosis         ..  ! 


ASCITES.   SIMULATED 


ATROPHY.    MUSCULAR 


is''ites,  simulatt'iJ,  could. 

-  -  by  hydrops  ;iimiii    . .     44 

-  —  bysteria  . .  . .   390  ; 

-  -  obesity  . .  . .     44 

-  -  ovarian  cyst  . .         44.  689 

-  -  pancreatic  cyst         . .     45  ! 

-  —  phantom  tumour      . .      44  , 

-  -  tympanites     . .  . .     44 
■  skin    tense   and  sbinint^ 

from 43 

-  skodaic  resonance  from    Cll 

-  in  splenic  ansmia  46,  55,  372 

-  splenomegaiic  cirrhosis      633 

-  syphilis   . .  . .  . .     52 


2,  420 


al    L'l: 


,  031 


-  iui,-f.l  i)'>;ni,in  pedicle    689  '< 
\scites.  tympanites  distin- 
guished from  ..     44 

-  umbilicus  and    . .        43,  425 

-  uterus  in  . .  . .     45 
-'  vaginal  examination  and     49 

-  from  vena  cava  inferior 

obstruction    . .  . .     4G 

-  vena   cava   inferior   ob- 

structed by    ..      415,  749 

-  from  vena  cava  throm- 

bosis   . .  . .        52,  749 

Iscitic    fluid    (sec    Fluid, 

Ascitic) 
^pergillosis,     haemoptysis 

\3pertrillus  flavus,  in  spu- 
tum       645 

-  fumigatus,  in  sputum  ..  615  ; 

-  Madura  foot  from         . .    736  ' 

-  niger,  lung  aftectod  by. .  290 

-  in  sputum       . .  . .   645 
Vspbyxia,   from    abductor 

paralysis        . .  . .  168 

-  acute  laryngitis  . .  616 

-  angina  Ludovici  . .  G99 

-  borborygrai  from  . .  S>1 

-  coma  in  . .         . .  . .  Ill 

-  convulsions  in  ..  ..  144 

-  in  epilepsy         . .  . .  145 

-  fatal,  from    tooth-plate 

in  larynx       ..  . .   195 

-  in  heart  disease  . .   146 

-  high  blood -pressure  from 

14,  81 

-  from  Landry's  paralysis  518 

-  paralysis  of  diaphragm    518 

-  intercostal  muscles  . .  518 

-  partial,      shortness      of 

breath  from  . .  . .     89 

-  retracted  head  from     . .  089 

-  from  syphilis     . 

-  tetanus    . . 

-  whooping-cough 
Aspiration,    in    diagnosing 

bursa. .  . .  . .     676 

-  (and  .^ee  Xeedlint;) 
Aspirin,     angioneurotic 

ccdema  .simulated  after  073 

-  erythema  from  . .  . .  222 

-  noises  in  the  head  from  406 

-  cedema  from     410,  413,  415 

-  urticaria  from   ..      413,  771 


58 


138 


Vss:nn 

Knlii-aj;!i 

r  in      2!) 

■lerosis  . . 
-in    simu- 

-  bron 

^pnsrnoiiir 

535 


distiiiguishod  from  by 
eosinophilia    . .  . .    219 

-  bronchitis  with  153,  420 

-  -  simulating      . .      420,  535 

and  empliysema  from  ICO 

simulating  . .         . .  IflO 

-  curdiiLc   dyspntea  simu- 

lating   535 

-  -  from  fatty  heart      ..   213 
'  -  s])a8modic  distinguished 

from  by  eot^innphiiia  219 

-  Charcot- Ley de II  crystals 

in  ..  ..      102.  153 

-  clubbed  lingers  from    . .   Ill 

-  constipation  from        . .    128 

-  CnrJcIimaun's  spirals  In 

102.   15:1 
I) 


Asthma,  contd. 

-  cyanosis  from    . . 

-  dyspnoea  from  . . 
not  cough  the  essen- 
tial symptom  of    . .  535 

-  emphysema  from  . .    153 

-  -  simulating      . .      160,  535 

-  eosinopliilia  in   153,  219,  535 

-  eosiiiophile  cells  in  spu- 

tum in  . .       102,  219 

-  foreign  body  simulating  535 
Asthma,    general    account 

of         535 

-  goitre  simulating  ..   535 

-  hysteria  simulating      . .   535 

-  insomnia  from      -      321,  322 

-  mediastinal  new  growths 

simulating      . .  . .    535 

-  nasal  discbarge  from    . .  178 

-  orthopnoea  from       323,  418 

-  papilloma  of  larynx  simu- 

lating . .  . .  . .  535 

-  polycythsemia  from  532,  533 

-  polyuria  from    . .  . .   535 

-  renal,  spasmodic  distin- 

guished      from       by 
eosinophilia    . .         . .  219 
~  syphilis     of     bronchus 

simulating      . .  . .  535 

-  therapeutic  tests  for    . .  535 

-  thymic    . .         . .  . .  535 

-  urfemia  simulating       . .   535 

-  x-rays  in  diagnosing  . .  535 
Astigmatism,  diplopia  from  I'^S 

-  eye-strain  from  446,  524 

-  headache  front  . .      449,  712 

-  hypermetropia  with     . .  417 

-  morning  headache  from  294 

-  neuralgia  from  . .  . .  449 
Astigmatism,  optic  disc  in  417 
{Pl(i(e  XX)  ..   41S 

-  pain  ill  the  eye  from    . .   416 

-  photopliobia  from         . .   52 1 

-  tenderness  of  scalp  from  712 
Astley  Cooper,  on  hernia 

of  bladder      . .  . .  683 

Astley    Cooper,    Irritable 

breast  of  ..431 

Astringents,  thirst  from  . .  720 
Astronomers,  vision  and..  758 
jVsylum  dysentery  ..   717 

Ataxic    paraplegia,    ataxy 


Atax 


Hid 


rith 

Babinski's  sign  In      . .     6S 

lesions  of       . .         . .  517 

neurasthenia  sinudated 

by 313 

paraplegia  from        ..  511 

penile  erection  absent 

in 313 

ftTAXY 55 

Ataxy,  acute  cerebellar    . .     58 

-  from  alcoholism  56,  146 

-  astereognosis  with        . .     58 

-  from  ataxic  paraplegia. .  251 

-  athetosis  with    . .         . .     58 
Ataxy,  from  cerebellar  le- 
sions 58.  59.  251,517, 

592    010,    72S 

-  c-t_'rebL'll;ir.  intentimi  tre- 

mor in  . .  . .    72S 
from   post.   inf.   cere- 
bellar artery^throm- 
bosis  (Fig.  261)    ..  610 

tremor  in       . .  . .   727 

Ataxy,  cerebral  causes  of  ■ .     58 

-  chorea  distinguished  from  133 

-  in    combined    degenera- 

tion of  cord    ..        57,  251 

-  from  diphtheria  . .     50 

-  in  disseminated  sclerosis 

57,  307,  517 

-  due  to   loss  of  sensory 

impulses         . .         . .     56 
encophnlltis    ..  .,58 

-  nyc-closure  in  detecting    50 

-  familial,  intention  tremor 

in         72S 

-  Friedreich's  (see   l-'rlod- 

reich's  .\liix3'> 

-  hemi-      . .         . .          . .  5H 

-  after   hemiplegfa           . .  5H 

-  heroiJitary,  tremor  In  . .  724 

-  hystoricrtl           . .          . .  59 

-  in  Infantile  homiplcfflu..  58 

-  influence  of  eye-closure 


Ataxy     from     lesions     of 
brain  stem 

-  of  lip 

-  from  ocular  paralysis  . . 

-  of  palate 

-  paralysis  simulated  by . . 
Ataxy,     from     peripheral 

nerve  lesions 

-  posterior     corehellar    ar- 

tery  lesions 
Ataxy    from    spinal    cord 
lesions 

-  spiiio-cerebellar,    tremor 


-  in  tabes  dorsalis  57, 116, 

251,  466,  515 
-  of  tongue  . .  . .     59 

-  vertigo  with      . .         . .     58 

-  of  vocal  cords    . .  . .     59 

-  writing    movements    in 

{Fig,  290)       ..  ..728 

Atelectasis,         congenital, 

bronchiectasLs  from  . .   292 
Ateliosis,  general  account  of  191 
Atheroma,   abdominal   an- 
gina from       . .  . .  437 

-  angina  pectoris  with  ..  535 

-  of  aorta,  clot  upon      . .  258 

embolus  from  . .   258 

pain  in  shoulder  from  474 

-  aortic  regurgitation  from  207 
systolic  bruit  from  1, 

o3,   92,  208 

-  blood-pressure  not  higli  163 

-  of  cerebral  arteries,  dia- 

gnosis guessed  at     . .  406 

noises  in  bead  from  406 

thick  radial  arteries 

with  ..  ..406 
tortuous     temporal 

arteries  with      ..  406 

-  and   arteriosclerosis,  as- 

sociation between     1,  271 

-  of  coronarv  arteries,  heart 

block  with     . .  . .     83 

-  dead  Gngers  from        ..  163 

-  diabetes  and     ..         ..  737 

-  epigastric  pain  from    . .  437 

-  Ihitulence  from..  ..   437 

-  r.,  ,:,:!  ,,.  n.ir.rv'with  V.   271 
265,  271 


59      Athlete'^,  allniniinuria  of  . 


ML'  fro 


480 


-  inLerniitlent claudication 

and 306 

-  loud  aortic  second  sound 

with 1 

-  with  myocardial  changes     53 

-  noises  in  the  head  from  295 

-  palpitation   from  ..   484 

-  of  pulmonary  arterioles, 

hiumoptysis  from     . ,  287 

artery  . .         . .  291 

from  mitral  stenosis 

215,  289 

-  from  syphilis     . .         . .  207 

-  thrill  from  .,  ..   720 

-  tnnc^mus  from  ..  ..    137 

-  Miif'in-.l  p-il-'-  from  550,  551 
1 


ATHETOSIS 

-    i.  In  ur'-     I I     ii,    .. 

-  -  cmbolibm  ..   "l32, 
hiumorrhage  . . 

thrombosis     . . 

-  chill  causing 

-  from  cortical  lesions    .. 

-  with  dipIciTia 

-  from  encephalitis 

-  epilepsy  and 

-  of  face    . . 

-  after  fevers 

-  of  the  hand  (Fig.  57)    . . 

-  hcml-,  lu'miplegia  with 

-  fificr  h.-niipJc'L-ia 
Athetosis,  idiopathic 

-  ii>   infaulile   lii.-iiii|ilegja 

58, 

-  insanity  and      . . 

-  from     Instruments     at 

birth 

-  moriiritfcal  hnmiorrhago 

-  optic  thaliimus  IchIoii  . . 

-  parttf  alTectcd  by 


131 


209 

-  ordJi-M  h.Mi-t  ill  214,  2911 
popliteal  bursa  in     . .   692 

-  heart  changes  in  . .      15 

-  left  ventricle  enlarged  in  206 

-  stitch  in.,  ..  431,  707 
Atkinson,  Dr.  Keuell  ..  7'.' 
Atmospheric      conditions. 

shortness     of     breath 

from S9 

Atony    of     bladder  . .    395 

-  stomach,  dyspepsia  from  319 

flatulence  with         . .  241 

gastrectasis  from   174,  653 

sense  of  fullness  from  244 

-  -  succussion  with  241,  244 
Atoxyl,  amblyopia  from  . .   759 

-  erythema  from  . ,      222,  224 

-  central  scotoma  from  . .   759 

-  optic  atrophy  from      . .   759 

neuritis  from..         ..   759 

Atresia  cervicis  (see  Cervix 

Uteri) 

-  of  vagina  (see  Vagina. 

Closure  of) 
Atrophy,  acute  yellow  (see 
Acute  Yellow  Atrophy) 

-  cerebellar  , .  . .   729 

-  of  ears,  from  lupus  ery- 

thematosus   . .         . .  60." 

-  facial  hemi-  {Fig,  302)  . .  494 

-  of  band,  in  amyotrophic 

hiteral  sclerosis  . .  508 

from  cervical  rib  444, 

{Fig.  209)  508 

in  bulbar  palsy        . .  627 

progressive    muscular 

atrophy      ..         61.  109 
in  syringomyelia        . .  5ity 

-  hypothenar,    from    cer- 

vical rib  . .  . .  508 

progressive    muscular 

atrophy       ..        61,  110 
in  ulnar  paralysis     . .  110 

-  of  kidney,  from  ureteric 

calculus  . .  . .   57s 

-  limbs,  from  diphtheria. .     K\-i 

from  mercury  . .     65 

ATROPHY,  MUSCULAR..  59 
in  acute  poliomyelitis 

61,  500 

in  amyotrophic  lateral 

sclerosis  61,  62, 

135,  508,  517 

from  aneurysm         61,  0;i 

anterior  crural   nervo 


lo«i< 


rtlii 


439 
352 


-  -  uilh  ;irlhntis    01,    o:;, 

343,  346,  318,   351, 

363,   477,   58: 

from  bracheitis         ..    17' 

bracliial  neuritis       . ,  4  i: 

plexus  injury        . ,  50i 

in  cachexia    ..  .,  .■)8; 

from  callus  Involving 

from     Cauda     equina 

tumour       . ,  61,  6: 

cervical    rib    01,    63, 

110,  162,  501 

contractures  with     , ,   11' 

after  diphtheria       . .  51: 

from  disuse    . .  . .     5! 

electrical     reactions 

with  ..         ,.  58: 

with  facial  paralysis. .    19; 

flbrillar     contractions 

from  . .  ..13 

from  fracture  . .     o: 

in  Friedreich's  disease  1  li 

general  paralysis      . .     5: 

gonococcal  arthritis..  3 1' 

gumma  of  ncrvo       . .     0' 

in  hysteria     . .         . .  501 

from  inlniililo  pnrnly- 

sls  {Fig.  IV)         59,  «) 

-  -  injury  to  nervo        01,  W, 

-  Jiicksonlan  epilepsy..  13 

50 


ATROPHY.  MUSCULAR 


BACK 


ifrophf/,  muscular, 

-  -  myelitis      '   . . 

-  -  myopatby        I 


obturator  nerve  lesion  ■ 

Atrophy,  muscular,  in  one 
arm,  lesions  causing. .  i 


oi.  1.;;;.  (;i,  ;;.")i.  i  in. 

■1(;5,  512,   r.l4,   510, 

—  peroneal  atrophy 

—  -  phthisis 

—  poliomyelitis  (Fig.  9) 

59,  509,  i 
porencephalus 

—  in   primary   muscular 

dystrophy  . .  - 

—  progressive    muscular 

atrophy       . .         CI, 

—  pseudohypertrophic 
paralysis     . . 


rJieiin 


htdt- 


Atrophy  muscular,  in  scia- 
tica    . .        . .  fii,  (;:i, 

—  from  spinal  caries 

meningitis  . . 

new  growth 

splints 

—  spondylitis  deformans 
sprains 

—  in   syringomyelia    Gl, 

(>2,  110,  257, 

—  tabes  dorsalis 

—  thoracic  new  growth. . 

—  in    Tooth's    peroneal 


rills 


Atrophy,  optic,  appearances 

of        416.  il'/'ile  XX)  -■ 
from  atoxyl    . .  . .    'i 

—  black    specks    before 

eyes  from  . . 

—  blindness  from       7G1,  7 

—  from  cerebellar  tumour  !. 

—  cerebral  diplegia       . .   'i 

—  colour  blindness  from  1 

—  in  congenital  syphilis  i 

—  -  withdii-lfi^'ia  ..  ..    ] 

—  -    ini.lis^r,n|,,.Hr,|    ^,-]rn,- 

—  in  Frir.h.  . 

—  hereilii.irv .     n  ^i  i  :i 

—  in  hydrocephalus  . .  i 

—  idiocy  with    . .  . .  1 

—  from  lead       . .  . .  < 
after  neuritis  . .  . .  4 

—  -  in  pellagra      . .  .,   i 

—  from  sphenoidal  sinus 


—  visual  field  constricted 

-  peroneal,  atrophy  of  leg 

muscles  in      . .         . .  : 

—  claw  hand  from         . .   : 

-  progressive  muscular  (see 

Progressive    Muscular 
Atrophy) 
ATROPHY.   TESTICULAR 
66,  313.  408, 


nf    til 


cal  rib 


—  from  progressive  mus- 

cular atrophy       Gl, 

—  in  Tooth's  paralysis. . 

-  of  tongue  iu  bulbar  para- 

lysis   . .         197,  589,  I 
Atropine,  convulsions  from 

-  ill  diagnosing  iritis        ..  : 

'1  intna  from  . .         . .  : 

I  u|  il  ^lilated  by"  '.'.   : 

Attic,  suppuration  in  ..  ■ 
Auditive,  definition  of  an  i 
Auditory  meatus,  exostosis 


A  uditnrij  ritrrr,  a 

noises     in     i 

lesion  of 

tumour  of.  tn 

-  word  cent  I.-  (  /' 
Australia.   h\il.iii 


Austria 
AURA 


Aura,  localizing  sign  in 
Jacksonian   epilepsy-. 

-  olfactory  . .         08,  < 

-  taste      " . .  . .  . .   ' 

-  visual 

Auricle,  left,  hypertrophied 
and  dilated,  from  mi- 
tral stenosis   . .      215,  l 

-  right,  polypus  in  . .   ' 


id  tachv- 


irom   iMrdiosclerosis. . 
disappearance  of  pre- 
systolic bruit  with 
"-  -  thrill  witli 


from 
polygraph  tracings  i 

diagnosing  . . 
pulse  irregular  from. 


Automatism,  epileptic 
Autophonia 

Autojisy  (see  Post-nK 


Lyinpliatic        Clauds, 
Axillary) 
Axilla,  primary  tumours  of  i 


-  pediculosis  pubis  allect- 


I  (lands, 

I1-.   liyper- 


Azotie  diabetes 


B 


ABINSKl'S  SIGN  (and 
see  IMantar  Hellex, 
Extensor)   . . 


BACILLURIA 

—  albuminuria  with 

-  leucocytes  in  urint 


subcutaneous      em- 

pliysema  from   . . 

sul|iliidcs    produced 


530,  680  I 


■  in  cerebr'is|.iti;il  iliiid 

■  cystitis  Iruiii . ,         70 

■  empyeniii  from 
epididymo-orchitis 

from 
fretid  cystitis  from    . , 
gas  formatioji  by  530,  531     -  Pfeiffer' 

in  abscess  by  G51, 

052,  """ 
in  impetigo    . . 
membranous  vaginitis 


■  I  iiMv,      scpticajmia 

-   tii.illri  Ml  glanders         . .  97 

^ei>tioi^raia  from        . .  rtU7 

skin  lesions    . .          . .  559 

sputum            . .          . .  G-t5 

-  of  Moran-Axenfeld,  con- 

junctivitis from         . .  331 

-  Morgan's,  ptomaine  poi- 
sojiing  from   . .         . .   717 

'  diarrhcna  from  3S-1 
Oppler-Boas',  carcinoma 
of  stomach  and    31G, 


7G6, 

in  gastric  juice 

-  paratyphosus  A  and  B, 
agglutination  of 


318 


leumon  iaj,       nephritis 
due  to G9 

]iyekiiie|iliritis   due  to     G9 


-  recovered     on     blood 

culture        . .         . .  i 

-  rheumatoid  arthritis 

from 

-  subcutaneous   cmpliy- 

-  ureteritis  due  to      G"J,  ■ 


-  diphtlierias  154,  157,196, 

419,  i 

-  -  (P/afo  XXV! II)        ..   ( 

from  ear         . .         . .  ■ 

laryngitis  from  -       . .  : 

membranous  vaginitis 

from  . .  . .   - 
ineiiiimitis  from         . .   I 

-  -    \ri.-.T'--l:illlfor  157,    I 

-  -    III    |.i  I  i|>l,rt  il    neuritis  : 

-  -    -•:•■  lliroit   ;ina       Gib",   ( 

-  -  uliitU.w  ifotii  ..  : 

-  dniiiHlirk 

-  -  {r/<ifr  XX  \'// 1)      -.  I 
Bacillus  dysenteris,  char- 
acters of 

-  I'lherth's     (see    Bacillus 

Typhosus) 

-  cnteritidis,  summer  diar- 

rhoea from      . .  . .    i 

~  foetidus,         bromidrosis 
from    . .  . .  . .   ( 

-  fusiform,  sore  throat  due 

to        ( 

In  Vincent's  angiua  . ,   ( 

-  Gaertner's,  agglutination 

test  for  . .         ..  i 
in  ptomaine  poisoning 


c  diarrhcea  from  i 
glanders     (see    Bacillus 

Mallei) 
Hofmann's,   sore  throat 

due  to  . .  . .   C 

iiilluenznp.     in      cerebro- 

>],\uM  \\v.u\      ..  ..    i 


-  recovered     on     blood- 

culture 

-  sore  throat  due  to     . . 

-  in   sputum    290,    ■IG5, 

564, 
Klebs  -  LoeHler        (see 

Bacillus  diphtheria) 
]e]irosv    . . 

-  in  nasal  discliargc     . . 


by 


red  sputum  from      . .  ( 

sweat  from  . .  < 

-  proteus,  pyelitis  from  . . 

-  pyocyaneus,    coloiu-ed 

sweat  from     . .         . .  ( 

empyema  from 

in  impetigo    . .  . . 

nephritis  due  to 

pemphigus     neonator- 
um due  to  . . 

pyelonephritis  due  to 

recovered    on    blood- 
culture        . .  . .   . 

in  sputum      . .  . .   i 

ureteritis  due  to 

-  Shiga's,  dysentery  from 


172,  7ir. 
730 


~  tetani      . .        138,  41 

-  -  (Plate  XXVIII)       ..  Gl 

I from  wound  . .  . .  59! 

-  tuberculosis  (see  Tuber- 

cle Bacilli) 

-  typhosus  in  bile  passages  33i 
I  -  -  in  blood  . .         . .   5G 

I in  cerebro-spinal  fluid  '60. 

I cystitis  due  to  . .     71 

I empyema  from  . .   10 

gall-bladder    infection 

by 

meningitis  from 

-  --  in  periosteal  abscess.. 

-  -  periostitis  due  to 

-  jiyelitis  from  . . 

-  -   recovered    on    blood 

culture         ..      597, 

simnlating   B.   Oysen- 

teriaj 

thra    . . 
Back,  abscess  of  (; 
scess  of  Back) 

-  acne  affecting    . , 

-  aneurysm   point! 


-  cheu'opompholyx  on    . . 

-  curvature  of  (see  Kypho- 

sis. :  Lonlosis;Srohosi^) 


54 


G3G 


Ab- 


'GO. 


429 


multiple    beniLrn    s; 

affecting 
myoma  cutis  of. . 
.  pain  in  (see  I'ain 


niall-j)0x  affecting 
ores  on,  inflamed  axil- 
lary glands  from 
■  -  inguinal  glands  from 

tiff  I  less  of,  from  typhoid 

wflliiiLT  of,  from  aueur- 
ysni  opening  vena  cav.t 
yphilo'lein-.sof.. 


BACK 


BEKI-BERI 


oA-,  coiitd. 

/taflerhtoffictti  exam.. 

anifti 

llalduess,  cmtfd. 

tenderness  in  fset  Teniii-i 

of  red  sputum 

280 

-  erysipelas 

ness  in  DnckJ 

rigors  . . 

595 

-  favus 

urticaria  of 

isn 

ringworm 

248 

-  after  fevers 

varicella  affectiiit,'     T.'Mi. 

lii'i 

septicEDmia  555, 

507, 

-  fr(im    folliculitis    de 

c.al- 

ickache,  from  calculus. . 

400 

597, 

037 

vans    .  . 

71 

carcinoma  uteri 

46a 

-  -  soptif^nprmmiri 

597 

-  head  rolling 

711 

caries  of  spijie   . . 

409 

-  -  >ki[i   ilipiit liiTi.t 

.J5S 

-  juvenile  . . 

191 

cervical  catarrh 

4CS 

Bacteriological  exami 

ation 

-  .after  kerion 

71 

-  erosion 

468 

of  sore  throat 

614 

-  from  lupus  crytheniatosu 

Tom  endometritis     192 

s|,iii,a  niemiiyiti 

417 

71, 

'710 

3S7, 

408 

sporotrichosis 

290 

-  morphcea 

71 

m  fevers. . 

427 

spotted  fever 

554 

-  nerve  shock 

71 

Toin  t^rowth  in  spine  . . 

109 

stomatitis 

542 

-  psoriasis. . 

71 

';n-inrrl;ni'l-:        .. 

409 

syphilis 

074, 

739 

-  ringworm 

71, 

249 

■!  tnniou 

408 

tetanus 

417, 

599 

-  sclerodermia 

710 

■  .     ■■  11' 

408 

-  -  tonsillitis 

379 

—  seborrhcea 

71 

428 

tuberculous  toiii. 

tic  . . 

098 

-  senile      . . 

71 

rkache.  trom  pelvic  dis- 

 typhoid  fever 

504 

-  from  sypliilis     . . 

71 

orders             . .      'ISO, 

468 

ulcer  of  palate 

588 

-  types  of 

70 

'■  of  uterus     *    .. 

408 

ulceration  of  laryn.\-.. 

158 

P.allet-dancers,  cramps 

iu 

150 

LTOWth      .. 

409 

urethral  discharge    . . 

181 

llalloonists,  noises  in 

the 

'.iciu-iiiac   joint   disease 

40!l 

urethritis 

581 

head  in 

400 

in  smuU-pox 

272 

-  -  of  urine 

nil 

,  70 

Bandaging,  tight,  gangi 

rene 

after  typhoid  fever 

715 

-  -  A^incent's  an','in; 

014 

from    . . 

255, 

258 

from  urine  changes 

409 

whooping-cough 

045 

Bands,    amniotic.    (Tdema 

uterine  cou<,'estioii        . .   3S7 
M?k\vard     pros-iure     (and 
sec  ileart  failure) 

-  from  alcoliolism         ..    -H 

-  arteriosclerosis  ..   21- 
ickward  pressure,  causes 


of 


46 


-  ascites  from  . .    li;.  '>2,  oW 

-  from  iitlileteV  heart       214 

-  empliysema    ..  ..217 

-  over-exertion  . .   211 

-  ira>tritis  from  ..  317  i 

;ui  mrL;  liver  fi'om  . .  52 
!  Ill  t  of  legs  from. .  52 
I  .  ;  r.ititis  with  ..  100 
,  II  tt  ilc  liver  from  . .  52 
Kkward  pressure,  signs  Of  212 
IN  not  enlarged  bv  63:i 

■  ■■ ;i  ..  ..507 


icu'riiiioijicalexuminatioii, 
in  actinomycosis  71, 

008,  7:; 

-  angina  ludovici         ..    II 

-  anthrax  41^,  550,  117 

-  arthritis  . .  . .     'A 

-  of  ascitic  fluid  . .      t 

-  bacilluria        . .  . .   77 

-  of  bronchial  ca^ts     . .   <M 

-  in  cellulitis    ..  ..    U 

-  of  cci'obrospinal  Iluid     ;tO 


-  cholera           . .  . .  27 

-  colibacilluria  . .  15 

-  coiiji;iicliviti-S  . .  7:> 

-  diphtheria       Kl.    IIH,  12 

ii'kur  XXVIH)  ..  'il 

-  ilyscntery       ..  . .  71 

-  ehipyemu       ..  . .  lo 
.  of   gall-bladder  . .  25 

-  opididymo-orchitU* 
ysipela: 


icterioloQical  examination 
for  gonococclln  female  185 

-  gonorrhd'a      ..      <'''.>7,  700 

-  impetigo  .  .  .  .    558 

-  infe.-Iive    ..ud-M-.-miili^ 

tcterlolooical  examination 
in  Influenza  us.  in;. 


465. 

-  ill  liirviiL'ili'^   157,   100, 

110,  (ilO 

-  leprosy  . .        03,  ,'JS3 

-  meningitis    511,    515, 

5«(I,  500 

-  nt  naaal  dischorgcrt  178, 170 

-  hi  opisthotonos         ..  '117 

-  orrldtis  '•■' 


-  purpur 

-  pya-mii 

-  pyeliti' 


nedia  .. 
\Iilioid  .. 
i-ral  neuritis 

M'd   pyrexia 


Bacteriology  of  acute  phar- 
yngitis  613 

Bacteriology  of  laryngitis  613 
Bacteriology  of  sore  throats  613 
BACTERIURIA     ..  ..69 


lo 

cjdeiu 


70 


-  anorexia  froia    . .          . .  70 

-  ill  cluldren         . .          . .  f.O 
Bacterluria,   clinical   sym- 
ptoms of                 . .  70 

-  from  dental  abscess     . .  (JO 

-  frequent  micturition  from  70 

-  gas tro- intestinal     sym- 

ptoms from    . .          . .  70 

-  liicmaturia  from           . .  70 

-  ill-health  in  children  from  7o 

-  intermittent       . .          . .  'J'.i 
BacteriuHa,     m  Icro-organ  - 

isms  causing  . .         69.  70 


pain     ni     hypog 
from    . . 

-  loins  from 

-  perineum  fron 
in  pregnancy 


from 


-  with  renal  calculus 

-  \v\,:i\  cpitlieiium  in  u 


>aldir 


Mimatoid  arthritis   GO 
rom         ..  ..70 

r  from 


)  of 


l!0 


>celo  . 


701 


Ilaker's  cyst  ..         ..  fiOU 

balanitis,  chancre  simulated 


frrn 


301 


Balanitis,  general  account  of  617 

'  -  gonorrlKi'n  sinuilated  hy  lil? 

-  gouty      . .  . .  . .  '>18 

-  patn'in  penirt  from       ..    173 

-  priapb^m  from  . .  . .  53S 

-  pyuria  from       . .  . .   575 

-  soft  sore  simulated  by. .  ftl7 

-  ulceration  of  peids  from  t;l7 
BALDNESS  -TO 

-  from  alopecia  areata    . .      71 

-  I'ongonttal  . .  70,   7  I 

-  from  eczema     . .  . .     71 


-  sla|ihy!ococci  in 

-  from     suppurative     ne- 

phritis . .  . .  301 

-  ten<Jcrncs9  over  kidneys 

from    . .  . .         . .     70 

-  ^  (iver    tin.-tcrs  from    ..     70 


Bacterluria,  urine  changes  In  70 
-  vomiting  from  ..  ..      70 

(andsccColi-tmcilluria)   | 
Hag  of  worms  foci,  of  varl- 


Bang's  method  of  estimat- 
ing sugar  . .  263 

Banti's    disease,    clubbed 

lingers  iu       . .         . .  Ill 

cirrhosis  and..        37,  G35 

peripheral  neuritis  in      64 

splenic  anosmia  and 

37,  01,  372,  G33 
—  splenomegalic  cirrhosis 

and G33 

Barium    chloride,    in    bile 

test  -.744 
carboluria  and  . .  747 


|:;irl.'\,  ..riiiM.ii.\r.-s  iruui  lilO 

Barlow's  disease  (und  see 

>.Ni\vi        ;iS.  72,  00,  55G 

-  -  Miu'lii    >"CMls  in          ..  G5-I 

-  -  lairpuni  in      . .           ..  553 
liurrel-shaped     chest,     in 

cntpbyscma  . .  . .  167 
Bartholin's  gland,  normal 

secretion  from  . .  185 
abscess           . .         . .  471 

-  -  cyst  of           . .          . .  701 

inflamed  in  gonorrhcca  700 

ItarthoUnitis,     aching     in 

perineum  from          . .  171 

-  dyspareunia  from         ..  103 

-  from  gonorrhu-a           ..  IHI 

-  levator  ani  spasm  from  103 

-  vaginismus  from          . .  103 

Barurla 537 

Baryta  water,  in  bile  test  741 
ItasLsplicnoid,  llbrosarcoma 

of         170 

-  fracture  of,  heiuianopsia 

from 302 

-  recurrent  (Ibroma  of    ..  170 
^iirrniiia    of,    blood-spi 

till..' due  lo      .. 
iliiMiphilc    cells    iu    Uodg- 

kiti's  disease 

37,  Gl,  377,  G35 

Icukiemia        . .          . .  34 

IvmphatJc   teiikiumia  2II 

-  ^  (j'Inhs   II.   IV)  22     2G 

-  corpuscles,  characters  of  23 

-  -  (I'h.t.-  //.  /■<-/.  0) 
Basophilia,  punctate       ..  23 

{I'iithx   II,   III)  22,  21 

-  -  iuplmnhi^m  ..          ..  23 
Hath.     criM.     mr-nnrrhagia 


2H5 


3SG 


Hat  lis,    hot,    iuiionntia    re- 
lieved hv 
-  -  in  lowering  high  blood- 


Ihtzin's  disease^  contd. 

aggravated    by     aiiti- 

sypliilitic  treatment 

-  -  erythema  in  . . 

-  -  legs  aitected  by 

tulicrcnlosis  and 

ulceration  in  . .      404, 

Beading  of  ribs  in  rickets 

155,  107, 

Beaked  pelvis  in  rickets  . . 

Bean  in  oesophagus  (i^iV/. 

95) 

-  inhaled,  gangrene  of  lung 

from 

Beans,  oxalate  from 
Beard,  eczema  seborrhoei- 


falling  out  of,  from  braui 
pediculosis  pubis  affect- 


Bedclothes,   insomnia  and 
320,  321,  : 

-  intolerance  of,  in  infan- 

tile scurvy 
Bedding,  excessive  . .  : 

Bedford,  on  safranin  test  : 
Betlriddenness,   in   general 

paralysis  .  .         50.  '. 

-  tabes  dorsalis     . . 
Bedsore,  acute,  general  ac- 
count of         . .      257.  ! 

-  death  from 

-  IroiuicehaL'         .  .  ..    : 

Bedsore  of  finger  . .         . .  ) 

-  gangrene  from  . ,  . .   ; 

-  in  hemiplegia     . .         , , 

-  from  liot-water  bottle. .  : 

-  pviemia  from      . .  , .   : 

-  sitt'^  iifFectedby 


-  polyuria  Irom     . .  . .    . 

-  reguigitation     of     food 

tlu-ougn  noise  after  . . 
Beer-drinker's  heart 
[Jcer-flriT.k-iM-.  ..-.lomr.  from 


-  heart  slowed  by  . .  1 

-  pui)ils  ililated  from       . .  J 
and  lixed  from       . .  ] 

-  purpura  from    . .  . .  f 

-  scales  from         . .  . .  ( 

-  skin  dry  and  (lushed  from  1 

-  tachycardia  from       703,  't 

-  thirst  from         . .         . .  't 

-  tongue  drv  from            .  .  'i 
Itellit.'.  dinitrohei.zcne  in  ; 

Bell's  palsy,  general  ac- 
count of  ■ .  4 

-  -  and       see      Paralysis, 

Facial) 

Bell  sound,  with  jincumo- 
thora\  ..  ..I 

Hi'lt,  liver  furrowing  from   :i 

Bence-Iones    albumosuria 

tents  for 

Bence- Jones  albumosuria 
general  account  of    .  . 

Benzene  and  chloroform, 
specific  gravity  mea- 
surement with  . .   5 

lien/idin,  in  ucculL  blood- 
iest       I 

Ilet./fpic  iicid  (see  Aeld, 
llenxoic) 

llen/ot  in  aeroplane  varnish  .*! 

luridieri,  animnla  from   .. 

-  ra.-h.-\ia  from     .. 

-  di-eortieated  rlc-iiml  (13,2: 

1 

Berl-berl.  diagnosis  of 

-  nius.-le  Uii-^iini;  m 

-  M-dema  in  03,    III.    1 
piTipheraJ  iiruriti-^  from 


BERIBERI 


BLOOD  PER   ANUM 


-  on  ships  .  . 

Bial's  test 

Bicarbonate  of  soda,  lieart- 
burii  relieveiJ  by       . .  : 

in  inflating  stODiJich 

317, 
interscapular  pain  re- 
lieved by    . .         . . 
Biceps,  atrophy  of 

-  of  lei:,  nerve  supply  of. . 

-  myoclonus  of    . . 

-  nerve  supply  of 

-  paralysis    of,    in    Erb's 
palsy 


507 


Bile 


170 


-  root  innervation  of 
Biceps-jerk,    increased    in 

brachial  monoplegia..   502 
Bicuspids,  upper,  pain  in 

temporal  region  from  712 
Bilberries,  black  stools  after 

75,  385 
Bile,   inspissated,  jaundice 

from    . .  325,  328 

-  pigment,  tests  for         . .    743 

(Plate  XXXV)      ..    750 

in  urine  (see  Jaundf 

and      Urine, 
Pigment  in) 

-  salts,  slow  pulse  from 

-  in  stools,  test  for 

-  m-ine,  foam  test  Xor     . .   743 

-  m  vomit  . .         •  •  766 
Bile-duct,    carcinoma    of, 

(see  Carcinoma  uf  Bile- 
duct) 

-  catarrh,  jaundice  from. .   325 
Bile-duct,    cicatrization    of 

325,  329 

-  conu'cnital  obliter;itioii  of  325 

-  kinking  of,  from  hepato- 

ptosis  . .  .  -  •  •   368 

-  obstructed     by     ascaris 

lumbricoides  . .         . .  328 
'  carcinoma       . .       326,  330 

simulated  by.  .  •  -    374 

-  -  from  catarrh  . .  . .   326 
Bile-duct  obstruction,  causes 

of 325 

clay-coloured  motions 

from  .  ■  . .   326 

by  colon  tumours     . .   330 

cirrhosis  simul.iii.l  1>\    "7-2 

-  by  distomii  Ih|..ii  nuin  :;-js 


-  -  bvdi.na.'mnii  nniMKirs  : 

_    _    ^ull-^lnur^  ..  ..  ; 

Bile-duct         obstruction, 
general  account  of 

327,  3'JS,  32H,  330,  i 

by  hydatid  cyst       . .  i 

jauiulice  from 

325,  326,  369,  i 

large  liver  from 

326,  369,  ; 

by  liver  tumours      . .  I 

movable  kidney        . .  I 

omental  tumour        . .  ; 

pancreas  tumours     . .  \ 

ovarian  tumours        . .  i 

pancreatitis    .  .  .  .  ! 


..  h 

^  -  stuoi-  iMiii.i  vmUl     ..  ; 
Bile-ducts,  congenital  obli- 
teration of 

-  rupture  of  hydatid  into  ! 
BiUiarzia,   cystoscopic   ap- 
pearance {Plate  XVI)  '. 

-  haimatobia,        affecting 

bladder  . .  . . 
rectum 

-  -  Itlood  per  anunrfrom 

Bilharzla  hsematobia.  blood 
changes  witli 


-  in  Egypt 

-  eosinophilia  from 

-  geographical  distrlbn- 


Bilharzia   haimatobia,  conld. 

hiematuria  from 

33,  275,  282,  581 

mucus  in  stools  from     79 

-  -  ova  iFig.  26)  . .     79 


pyuria  from   575,  580, 

tuberculous     bladder 

simulated  by     282,  4 

-  pain  in  penis  from  . .  4 
Biliary    colic    (see    Colic, 

Biliary) 
Biliousness,     carcinoma 

simulating      . .  . .  4 

-  from  deficient  exercise..  I 

-  gall-stone  simulating    . .   4 

-  from  injudicious  diet  . .   I 

-  interscapular  pain  from 

461,  4 

-  pain  in  shoulder  from  . .  4 

-  photophobia  from        . .  I 

-  ptyalism  from    . .         . .  I 

-  specks  before  eyes  from 

-  uric  acid  and     . .  . ,    "i 

-  vertical  headache  from  i 
Bilirubin  in  stools  . .  1 

-  urine        ..         ..      743,  'i 

-  urobilin  from  . .  . .  'i 
Biliverdin  in  urine  743.  745, '. 
Bimanual        examination, 

carcinoma  coli  felt  on  l 
In    cases    of    bearing- 
down  pain  . .  , .  < 

detecting  fibromyoma  ; 

tubal  gestation     . .  < 

in    diagnosing    pelvic 

tumours      . .         . .  I 

pulsatile  liver        . .  i 

differentiating     pelvic 

tumours      ..  ..   ( 

hypertrophy  of  cervix  J 

inversion  of  uterus  . .   J 

-  -  for  kidney       . .  . .   t 

in  prolapse     . .  . .   I 

Blot's  breathing    . .  . .    ] 

allied  to  Cheyne -Stokes' 

in  tuberculous    menm- 

gitis 
Bu-d   foods,  sporotrichosis 

from    . .         . .         . .  i 

Birds,    feeders    of,    asper- 

gillus  of  lung  in        . .  ( 

-  oval  red  corpuscles  in . .  '. 

-  trypanosomes  in 

-  uric  acid  in  . .  . ,  'i 
Birth,     injury     at :      Du- 

chenne's  palsy  from. .  t 

-  milk  from  breasts  at  . .  ( 

-  palsies     . .  . .  . .    ] 

tremor  with   . .  . .    'i 

~  (and  see  Childbirtli :  and 

Labour) 
Bismuth,     black    motions 
from    . .  . .         . .  3 

-  enema,     in     diagnosing 

carcinoma  coli  (Fig.  54)  ] 

-  rectal  conci*etion  from..  1 

-  salts,  reduced  by  glucose  ' 

glycuronic  acid     . .  S 

lactose        . .         . .  5 

pentose       . .         . .  S 

-  subnitrate,  in  Bottger's 

test      . .         . .         . .  5 

Ny lander's  test         ..  S 

-  sulphide,     black     stools 

from    . . 

-  and  T-rays  (see  a'-Kays 

and  Hismuth) 
Bite,     dog,     hydrophobia 
from     ..         138,  197,   J 

-  snake  (see  Snake  Bitej 

-  tongue  swollen  from  . .  t 
Bites,  bug,  relapsmg  fever 

spread  by  . .     28,  i 

-  glands  enlarged  fi"om  .,  ( 

-  gnat,    swelling    of    face 

from      . .  . .  . .   ( 

vesicles  from  . .  7 

-  hydrophobia  from         . .   'i 

-  insect,  itching  from  . .  ' 
purpura  from  . .  £ 

-  itchiiuT  from       . .         . .  I 

-  leech,  purpura  fi'om     . .  I 

-  mosquito,  malaria  from 

-  swelling  of  face  from  . .   ( 

-  variou>^.  fever  from       . .   J 


581 


Hiics,  contd. 

-  vesicles  from     . .  . .  ', 

-  wheals  from       . .  . .   'i 

-  wolf.     h\.in,|  1  .,)-,i;l      flMlii      - 

Biting oi  I.  ■'■'  \'--y  I 

Biuret  t-    ;  ... 

Black-dui    [M,  ■■-■■. MM, I        ..   ; 
BLACK  SPECKS  BEFORE 
THE  EYES     .. 

from  |i[ethora  . .   ; 

from  scotomata     . .    'i 

Blacksmiths"  heart  15,  20G,  ■; 

-  cramp      . .         . .         . .  1 

Blackwater  fever,  coma  in  ] 

haemoglobinuria  in  . .  ; 

quinine  and   . .  . .    '. 

malaria  and  . .         . .   : 

purpura  in     . .  . .   I 

Bladder,  abscesses  opening 

into    238,    283,    575,    J 

-  affections  of,  pain  in  the 

back  from      . .  . .  < 

legs  from    . .         . .  4 

renal  lesion  simulating  I 

-  appendicitis  opening  the  i 

-  appendix  adherent  to  . .   i 

-  atony  of,  after  recurrent 

over-distention  . .   [ 

-  bilharzia  affecting 
Bladder,  bilharzia  of  (Plate 

XVI) J 

-  blood-clot   in,  difliculty 

in  micturition  with  . .  ; 

-  carcinoma  of  (see   Car- 

cinoma of  I  ladder) 

-  -  invading  238,  283,  394, 

575,  582,   ( 

-  caseous    gland    opening 

into : 


■  -  distended,    unirhal    cy^t 
'  simulated  by         . .  i 

catheter  in  diagnosing 

'  45,  665,  I 

dystocia  from  . .   ; 

I fi'om  enlarged  prostate 

45,  277,  ) 
I fibroid  of  uterus  simu- 
lated by     . .         . .  I 
I hypogastric    swelling 

I incontinence  from 

! ovarian  cyst  simulated 

by    . .  . .      665,  ( 

pelvic  swelling  due  to     i 

pregnancy     simulated 


bv 


665 


Bladder,  dislfnriefl,  sions  of    45 

-  -  siinul.ir ■-      ..      44 

tapped  ni  mistake  lor 

-  diverticulitis  opening  the  238 

-  dysenteric  bowel  opening  582 

-  emptying    of    over-dis- 

tended, anuria  from. .     40 

-  epithelioma  of  (see  Car- 

cinoma of  Mladder 
Bladder,  extroversion  of  539,  540 

-  -     -iiiail:it  iriL'  jirolapse  , .    539 

-  lull.  pri,ipi.-.[n  from       ..   538 

-  L'lou  1 1 1 ,  ei J lart,'ed  prostate 

smmlated  by..  ..   396 
urethra  obstructed  by  396 

-  in  hernia  . ,  . .   683 

-  idiopathic   dilatation   of 

iFig.  277)       ..  ..665 

-  inflamed    (see    Cystitis) 

-  injury  to  (see  Injury  to 

Bladder) 

-  iriilabilitv,  oxaUu-ia  and  424 

Bladder,  irritable  . .      398,  742 


■  Lavage-) 


normal  position  of       . .   i 
palpable  dilated            . .  . 
papilloma  of  (see  Papill- 
oma of  Bladder) 
paralysis  of 
pouch  of 


Madder,  contd. 

-  pressure  on,  bearing-down 

pain  from       . .         . .  42 

-  prolapse  of        ...  . .   64 

-  pyosalpinx  ruptured  into  5? 

-  ruptuied,  from  fracture 

of  pelvis      . .  . .    27 

Bladder,  stammering       . .  3S 

-  stone    in    (see    Calculus, 

Vesical) 

-  succussion  in     . .  . .   6B 

-  tuberculous  bowel  open- 

ing into  . .  . .   56 

(see    Tuberculosis    of 

Bladder) 

-  ulceration  of  (see  Xlcera- 

tion  of  Bladder) 

-  villous    tumour   of   (see 

Villous     Tumour      of 
Bladder) 
Blanching,  from  duodenal 
ulcer    . .         . .         . .  12 

-  leaking  aneurysm     120,  6; 

-  ruptured  aneurysm       . .  ii 
tubal  gestation         . .   IS 

-  severe  hsemorrhage       ..   IS 

-  in  typhoid  fever       120,  5; 

-  (and    see  Pallor) 
Bleacluiig  powder,  indican 


and 


7^ 


l;lrl,   l^rr    Mill.c) 

BLEEDING  GUMS 

Blepliaritis,    chronic    r 
ginal,  ectropion  &■ 
epiphora  in 

-  -  (Plate  Xlf)    . . 
Blind  spot  . . 
Blindness,  from  a 

idiocy 7( 

-  from  anophthalmos      . .   7( 

-  rafnrart 7( 

Blindness,  complete,  general 
account  of  . .  7( 

j  -  r,.iiL'..Miit;il,   i.liocy  with     51 

-  from      detachment      of 

I  retina  . .  . .  . .   7t 

\  -  electric,  erythropsia  in. .  7( 

i photophobia  in         . .  7( 

I  -  from  embolism  of  retinal 

artery  . .         . .     7( 

-  focal,       perimeter       in 

mapping         . .         . .  3C 

-  from  fracture  of  skull  . .  7( 
I  -  glaucoma  233,  761,  7( 
.  -  hysteria  . .         . .         . .  61 

-  iritis        7( 

-  migraine  . .  . .   76 

-  monocular,  in  migraine     7' 

-  nystagmus  from  . .   4( 
■  -  from  ophthalmia  neona- 
torum             . .          . .   7C 

-  optic  atrophy    ..      761,  76 

chiasma  lesions         . .  7( 

nerve  compression    . .  7( 

Blindness,  partial,  general 

account  of     .  -      760,  7f 

-  rajiid,   from   retrobulbar 

neuritis  . .        760,  7( 

-  from  retinitis  pigmentosa  li 

-  snow,  erythropsia  in  . .  7(; 
photophobia  in  . .   7C 

-  from    spasm    of    retuial 

arteries  . .  . .   76 

Blindness,   sudden,   list  of 
causes  of  . .  7C 

-  from  thrombosis  of  retirial 


7C 


-  unilateral     (see 

anopsia) 

-  from     vitreous    hajmor- 

rhage 7tl 

-  (and  see  Vision,  Defects 

of) 
Blinking  tic  ..         ..13 

Blistering,  albuminm-ia  from   1 

-  with  cantharides  . .     I 
..     1 


BLOOD   PER   ANl'.M 


BONE   EROSION 


Blood  per  amon,  conld. 

carcinoma  77,  78,  129, 

172,   330,  354,  453, 

585,  G30,  C66 

in  chronic  nephritis  . .     7(5 

cirrhosis  . .  . .   G35 

from  colitis    . .  77,  78 

duodenal  nicer  33,  75 

: —  dysentery       . .  . .     70 
embolism  of  pancreas     7(J 

-  -  fistula  . .  . .     78 

gastric  ulcer  . .  . .     78 

in  Henoch  s     purpura    7G 

from  intussusception 

78,  130 

with    invagination    of 

rectum        ..  ..129 

in  leukaemia  . .         . .     76 

occult . .         . .  . .     81 

from  pancreatic  haemor- 
rhage . .  . .     70 

papilloma  recti  . .     79 

piles    . .         . .  . .     78 

prolapsus  aiii  .  '.      79 

ptomaine  poisoning  . .   717 

in     purpura     haemor- 

rhagica        ..  ..76 

from  rectal  polypus. .     78 

thread-worms  . .     79 

-  -  tuberculous  bowel  76, 

657,  666 

—  typhoid  fever  . .     76 

—  ulcerative  colitis   172,  459 

venereal  ulcer  of  rectum  79 

vicarious  menstruation 


nd  . 


79 


-  casts  in  urine    . .  . .  6 

Blood  changes  in  aplastic 

anaemia                    . .  24 

-  -  with  bilharzia  haima- 

tobia   . .         . .          . .  20 

bothriocephalus    latus  26 

-  -  in  chlorosis  . .  . .  30 
Blood  changes  in  ctilorosis  274 

.  v;.nn,M^  fn.Mi  ..    157 

-  -  uiih  til:<ri;i>i-.  .  .  .      26 

Blood  changes  In  filarlasls  28 
Blood  changesalterhamor- 

rhage  .  .  . .     33 

Blood  changes  in  Hodgkln's 

disease  . .  j7.  tM.  invj 

-  -    \Mth  I.V^I..ri,iiii~r:,-,-..        20 

-  -    in    lyiii|.li...|.M,nrri;i      .  .       64 

Blood  changes  in  lymphatic 
leukaemia  ..25 

-    iu.il  .n..  ..       274,  637 

Blood    changes    in    mixed 

leukaemia  ..26 

Blood  changes,  parasitic  .  ■     26 
Blood  changes  in  pernicious 
ansmia  -  -2,  24 


37 
633 


-  in  typhoid  fever        . .  036 
CTiarcot-Loyderi  crystals 


count, 


103 
kylostomlu- 
Si9        . .  . .         26,  521 

-  cases  of   lymph-gland 

enlargement  . .  376 

-  diagnosing   carcinoma 

of  stomach  271,317 

-  -  leukmmia    , .       273,  632 
pernicious     aniomia 

274,  634,  770 
t  -.-  splcnomegiilic  poly- 

cythnmla  ..  G33 
typhoid  (ever        . .  630 

-  -  essential  in  sptenomc- 

galv  <'.ises  ..  ..   634 

-  -  malaria  . .       273,  fi08 

-  -  morbus  ciiTuleus       ..    533 

-  -  peripheral  neuritis  , .     64 

-  culture,     in     diagnosing 

cause  ol  obscure  py- 
rexia   ..  ..        63.  072 
malignant  endocar- 
ditis 34,  209,  566 

-  -  -  meningitis.,  ..  500 

. pyemia       . .         . .  050 

r septicajmia. .      560, 

^  567,  097,  037 

I.  -  _  typhoid  fever     50i,  030 


Blood  culture,  contd. 

Malta  fever    . .          . .  507 

pneumonia     . .         . .  5U7 

-  -  pyemia           . .          . .  597 

septicopjEemia           . .  597 

typhoid  fever             . .  597 

Blood  culture,  various  or- 
ganisms recovered  on  597 

-  cysts,  in  sarcoma          . .  673 

-  diseases,       albumosuria 

with 10 

anaemia  in      . .         . .  100 

hajmatemesis  in     266,  273 

haemoptysis  from      . .   2S7 

infarct  of  kidney  in. .       7 

lymph-gland    enlarge- 
ment in       . .  . .   100 

-  p!«>uriric  pffTision  in..    106 
Blood  diseases  with  positive 

blood  pictures  ..     21 

[.!uli.iLu'<>  I  pyrexia  from  503 

purpura  m     . .      553,  556 

rigors  iu         . .         . .  590 

spinal    cord    changes 

from  . .         . .  610 

splenic  enlargement  in  100 

tenderness  in  . .  706 

thrombotic  infarcts  in 

8,  040 

-  embryos  in, in  trichinosis  729 

-  examination,  in  diagnos- 

ing anamia    . .         . .  487 

chlorosis     ..         ..   274 

purpura    lieemor- 

rhagia     ..         ..273 

-  extravasation,       haimo- 

globimu-ia  after        . .   284 

-  fallopian  tubes  distended 

with  (see  Htematocelt;) 

-  filaria  embryos  in  --'8,109.220 

-  films,      in       diagnosing 

eosinophilia    ..         ..218 

relapsing  fever       . .    330 

lising  and  staining  of    21 

iu      lymphatic       leu- 
kaemia (P/o/e  V)   . .      28 

malaria  diagnosed  from  335 

parasites  in  225, 530, 

508,  637 

method     of     making 

(Fiii.   2)       ..  ..21 

-  -  in   pwiic-ious  anaimiu 

{I'htlf  III)  ..      24 

-  -  in     splenomedullarv 

leukiemia  {Plate  /  V)     26 

spirocheeta  obermeieri 

in     ..         336,  590.  637 

-  guaiacum  test  for         10,  75 

-  inspissation  of,  cyanosis 

from 101 

-  loss,  aniemia  due  to      . .     21 

-  coma  from     . .         . .  1  lb 

-  microscope  in  detecting     75 

-  and  niticus  in  stools  (see 

.Stools,     Blood     and 
Mucus  i'l) 

-  from  nipple        . .         . .   181 

-  noso  (sec  Epistaxis) 

-  occult,    ill    stools,  from 

ankylostomiasis        . .     81 

from         carcinoma 

coli  .^     125,  126 

_  • of  pancreas       . .   101 

duodenal  ulcer    101,  120 

gastric      carcinoma 

120,  317 
ulcer        . .       101,  126 

Blood,  occult,  test  for     81,  171 

-  -  III  vniiiK,  ironi  u'listric 

(';ir<-iTi(>inii   .  .       030,  707 
ulcer        . .         . .  767 

-  parasites  . .  . .     27 
it)  malaria  (sec  .Miititriii) 

-  pigment,    carried    down 

by  phosphates  . .       9 

-  per  roctnm    (so-?    Itlooil 

per  Anum) 

-  spocini!gravil  V  of,  In  col- 

lapKe  ..  ■  ..  ..  581 
■-  -  -  diahetfrt  iiit^ipirliiH..  537 
infusion  and  . .    534 

Blood,  specillc  gravity  of. 
meaiurement  of       . .  634 

normal        . .      53 1,  537 

-  Hpecirf)Kcop«  In  dctcethig     70 


Blood,  confd. 

-  swallowed,  lia-matemesis 

from    ..  ..  ..   265 

~  trypanosomes  in  28,  226 

-  typhoid  baciUi  in  . .   564 
..85 


.1,  -i:  .1  .  :jhi.,lhPli  of  fal- 
lacious ..  ..81 

high,  accentuated  aortic 
second  sound  with  1, 

81,  298 

-  albuminuria  with  212,  406, 

485 

-  albuminuric     retinitis 

with  ..  ..212 

-  angina    abdominalis 

with  ..       115,  437 

pectoris  with  316,  535,  i 

709 


fro 


81 


KW,  [•-■■,  ■:  1.  -I-. 
271,    -J.,,  vm,,  -ilb, 

484,  543,  588 
ascites  from  . .        46,  212 

-  in  asphyxia    ..        14,  81 

with  atheroma  . .   271 

back  pressure  from  40,  212 

-  cerebral     hajmorrhage 

with  84,  119,  147,  303, 
515 

Cheyne-Stokes  breath- 
ing from     . .  . .   108 

from  chronic  nephritis 

J.  2,  10,  U,  14,  42, 
40,  47,  55,  70,  81, 
106,  101,  211,  212, 
271,    290,    406,  408, 

418,    184,  588 

Blood-pressure,  high,  condi- 
tions causing. .         81,  82 

--        rV.M,.>-i^  tn.ni  ..    161 

-  -  ellucLut  n-.-,tou  ..      81 
-' -  epLstaxis  from        220,  221 

full  feeling  in  head  from  296 

in  gastric  crises         . .  437 

hiomatemesis  from  . .  271 

hajmoptysis  from      . .  212 

-  -  lieadacho  from      293,  296 
heart  impulse  dis- 

pt:u-PiI  with  ..   298 

Btood-pressure,  high,  heart 
failure  Irom  14.  n;.  hi.  108, 
16 1,  418 

-  -  iroiii  ill-art  Juilure      55,  81 

-  -  hiccough  with  . .   308 
high-frequency       cur- 
rents ill  lowering  . .  323 

hot  baths  in  lowering  323 

hydrothorax  frofti    . .  212 

hyperacusLs  with       . .  309 

infarction  of  lungs  from  212 

insomnia  from       321,  323 

-  -  internal  secretions  and  388 

-  -  largo  heart  with   211, 

212,  486,  088 

liver  enlarged  from  ..  212 

massage  in  lowering..   323 

-  -  in  melancholia  ..     81 

inenorrhagia  from  386,  387 

metrorrhagia  from    . .  390 

mitral   rcgurglUitiun 

from  . .         ..212 

in  mitraUtenoHis  14,55,81 

with  myocardial  alTec- 

tions  ..  ..     14 

-  -  noises  in  the  head  with  406 

-  -  nutnii'g  liver  from    . .  368 

mdoniu  of  legs  from  ..  212 

orthopnoja  from 


prolonged  flret  ffouud 


vilh 


-  --  ptvalorrhirMi  from     ..   513 

-  -  radial  artery  thick  with  212 

in    Raynnmrs  diseiutu    81 

reduplication    o(   llrat 

sound  with  . .  588 
Hecuiin  hoiiikI      208,  088 


,vith 


212 


retinitis  with. 

in  splenomegalic  poly- 
cythemia   . .      271,  033 

sphygmomanometer  in 

diagnosis  of  . .  485 

tinnitus  from  . .   723 

tube  casts  with      212,  485 

in  uriBmia       85,   146,  315 

vertigo  from  . .         . .  752 

-  instrument    needed    for 

measuring      . .         . .     81 

-  low,   with   acute   abdo- 

minal pain      . .  . .   437 

in  Addison's  disease  33, 

82,     290,    526,    752, 

765,   770 

-  -  anemia  . .         . .  290 

asthenic  states  . .     82 

from  cigarette  smoking    82 

Blood -pressure,  low.  condi- 
tions causing  - .         ..81 


BLOODY     EFFUSION 
CHEST 

Blotting  paper,  stained  by 


jaundiced  ur 

ne         ..  321 

ving  nopp,  pai 

1  on,  from 

frf-i.ttl  -irMf-' 

Mipyema  18n 

Blue  brain,  general  account 
ol        163 

-  eyes,  psoriasis  and        . .  <'>";i 

-  line     on     the    gums     in 

plumbism  31.  65.  119, 

121,  131,425,505 

-  pill,  polyuria  from        ..  535 

-  sclerotics     with     brittle 

bones 242 

Bluencss  (see  Cyanosis) 
Blushing,  absence  of,  from 

sympathetic  paralysis  217 

-  from  emotion    . .  . .  24 1 

-  flushing    distinguished 

from 241 

Boat  giddiness  . .  . .  752 
Boeck,  on  multiple  benign 

sarcoid  ..         ..  405 

Boiler  makers,  deafness  iu  ir.t; 

noises  in  the  head  in. .  400 

Boiling  test  for  albumin  ..  4 
Bolting  test    for  albumin, 

precautions  In 


424 


Hull 


(71 


iky  lost 

-  arthritis  from    . . 

-  ear  affected  by  . . 

-  from  cow-pox    . . 

-  erythema  from  . . 

-  face  swollen  from 

-  lingers  alTcclcd  hv 

-  from  glycosuria 

-  meningitis  front 

-  on  scrotum 

-  stiff  neck  from  . . 

-  thrombosis  o!  innr 

vefn  from 
Bone,  ulwc-sof    . . 
Bono,  acute  iniflc.lonB  of . . 

-  ntroptiy.  in  tulfes 

-  bonding  of,  in  osteitis  do- 

formans 

-  carcinoma  of  (see  Cnrci- 

noma  of    Itonc) 


nf  (s, 


i.-.) 


481     Bone,  chronic  iniec'lont  of  668 

6011,  670.  071.  (i;:- 

-  conduction.  tcHts  for  161,  lo:> 

-  congenitAl  syphilis  nf  . .   001) 

-  enlarged  by  "growth  (^iV. 


■  oroslon,     by     nnOuryMni 
431.     183,     51fl,    Ofll, 

603.  71»,  77U 


BOXE   EROHIOX    —    BRIGHTS    DISEASE 


Jkmc  civs'on.  cvntd. 

in  Kaposi's  disease  . .   7 

by  rodent  ulcer  . .    7 

-  fibroma  of  . .  , .   (.1 

-  gumma,  of  . ,  . .    "> 

-  hydatid  of  . .         . .  G 

-  impacted   in   cesopliagas  1 

-  inhaled,  gangrene  of  lung 

from    . .  . .  , .   2i 


1  kidn 


-   necrosis  of  (see  Necrosis) 
~  new  growtli  of,  muscle 

atropliy  with 
-rarefaction,    in    hip    dis- 

rheumatoid     arthritis 

{Fig.   15(;)  343,  : 


Bone,  syijluhlirafferiionsof  669     ~ 


~  thickened,  in  osteitis  de- 
Bone.  tuberculous  abscess  of  669 


lioibuifiifiui 

-  peristals: 

-  stethris</( 


Bothriocephalus  latus 

-    -  .■in.iniiiiitin..  Inini 

Bothriocephalus    latus, 
blood  changes  with 

, cachexia  from 

eosinophilia  from 

liead  oi{Fi<f.  UI5) 

ojdema    of    legs   fro 


Bottoer's  test,  for  sugar 

Bottle  nose,  in  chronic  i 

coholism 
Bougie,  in  curing  cardi 


Brain,  coiud. 

-  carcinoma  of      . .         . .  : 

-  concussion  of  (see  Con- 

cussion) 

-  congenital   anomalies   of 

-  contusion,  hyperpyrexia 

from,    . .         . .         . .  ; 

-  cyst  of : 

-  embolism  of  (see  Embol- 

ism, Cerebral) 

-  fag,  specks  before  eyes 

from 

-  fatigue    . .  , .  , ,   t 


i  obstruction 

■  —  stenosis 

■  stricture 

-  uretliral  calcnln:^ 

■  —  stricture 
ireteral  . . 

in  diagnosing  stone  in 
ureter 
:-tipped,  in  diagnosing 


455 


210 


mollities  ossium        . .  2-i 
from  rickets  . .         . .  2J 

-  brittle,  in  syringomyelia  21 
~  brittleness  of  (see  Fragi- 

litas  Ossium) 

-  chlororaa  atYecting       . .  2C 

-  curved,  m  rickets     145,  (i.^ 

-  enlarged,    in  pulmonai-y 

osteo-ai-thropathy     . .  35 

-  haemorrhage     over,     in 

scurvy  ..         ..3 

-  malignant  disease  of,  al- 

bumose  from  . .  . .     1 

-  nasal,  necrosis  of,  from 

syphilis 

-  overgrowth  of,  in  leon- 

tiasis  ossea      . .  . .   G70 

-  of  skull,  rarefaction  of. .    152 

-  swelling   on,  from  yaws  403 

-  tender  (see  Tenderness  in 

Bones) 

in  rickets       . .         . .  iir> 

scurvy  rickets  . .     38 

-  tliickening  of,  in  acrome- 

galy    ..  ..  ..   40(1 

in  leontiasis  ossea     . .  406 

noises  in  the  head  from  40(5 

in  osteitis  deformans      lui; 

-  -  from  syphilis..  []    4t,t; 

Bones,    tumours   affecting 

670,  671,  672 

of,  in  chloroma  ;;(( 

Boots,  bulUe  from . .         ..     nt; 

-  ill-fitting,  limping  from      3(12 
metatarsal     neuralgia 

and  ..         ..  439 

pain  in  foot  from      . .   362  , 

paronychia  from      . .  400  ' 

ihht,  talipes  from  II3 

I  :"i  ■"■*'■     add      (sec     Acid. 

I  tori.-) 
BORBORYGMI      ..  ..82 

absent,   in   peritonitis 

82,  388 

-  with  aerophagy  , ,     82 

-  from  asphyxia  . ,         . .     82 
distinguishing     colic 


03,  551 


!teric  calculus 
liovine  cough  witli   laryn- 
geal paralysis         49  I,  495 

-  heart        . .  . .  . .    207 

Bow  legs,  fi-oni  achondro- 
plasia   187 

from  rickets  . .         . .   186 

Bowlers,  subacromial  bur- 
I  sitis  in  . .         . .     471} 

Boxing,     enlarged     heart 

from  . .         . .   211 

Bracheitis,  acute  ..      475,  477 
r.rachial  artery  (sec  Art-rv, 

I'.nirliKil)' 

Brachial  neuralgia         I  M.  442 
Brachial    neuritis,     general 
account  of 

-  plexus,        atfectcd 

aneurysm 

cervical  rib 

new  growth 

weight  carrying       ..   I(i3 

compressed  by  thyroid 

gland     enlargement  722 

diagram  of     . .         . .  507 

lesions,  Raynaud's  dis- 
ease simulated  by . .   1G3 

palsy (12 

Brachialis    anticus, 
supply  of 

root  innervation  of  . .  . 

Brachj'cephaly      , .  . .  ; 

Bradshaw,         myelopathic 

:dl.UUiOMn'i:i    of 

BRADYCARDIA    .. 

-  :-i'f''i'-tMit.  ill  mitral  sten- 

osi.^ 

-  from  cerebral  lesions    S3, 

-  digitalis  causing  84,  ', 
~  from  drugs 

-  fatty  heart         . .  . .   :i 

-  fibroid  heart      . .         . .  ^ 

-  in  heart  block  . . 


I  of     294,301,302,2 

■  haimoirhage       in      (see 

Haemorrhage.  Cerebral) 

injury,  atrophy  of  testis 

from    . .  , .  00, 

-  falling     out    of    beard 

after 

-  pubic  hair  disappearing 

after 
not  tinged  by  jaundice . .   3 


Brain-Stem  lesions,  effects  of  6 1 0 

-  thrombosis  of  (see  Tlirom- 

bosis,  Cerebral) 

-  tumour  of  (see  Cerebral 


sign  of   pregnancy  393 


iili-  . 


absetice  of  deep  tender-    " 

ness  in,  in  tabes    . .  515 

-  carcinoma  of  (see  Carci- 

noma of  Breast) 

-  cyst    of    (see    Cyst    of 

]ire:ist) 
BREAST,  DISCHARGE 

FROM  ..    181 

Breast     fibroadenoma    of, 

general  account  of    . .  686 

■    h^•\Mi<{  u\  ..  ..    181 


Bre<ith^  foulness  of.    ronfif. 

from  oztena    . . 

paraldehyde  . . 

-  -  phthisis  ■        . ,  . ; 

putrefaction    of    food 

particles 

in  lungs      . . 

mouth 

pyorrhoea       . .  7 1 , 

rhinitis 

I smoking 

I sore  throats   . . 

: stomatitis       . .  71, 

I tartar  . . 

toxaemia 

various  acute  illnesses 

I Vincent's  angina      87,  ( 

I  -   holdino:     of,     arrythmia 

I  nf  heart  and 

I  BREATH,  SHORTNESS  OF 

'  (:ind     see     Dysitno-a : 

Drtliopncea:  an,! 

Shortness  of  Brcatli  1 

-  sounds     (see     Vesicular 
I  Murmur) 

,  -  sweet      smelUng,      from 
I  acetone  . .         . .  : 

Broatliing,  Biot's  84,  ] 

Jlrcathing,    bronchial    (see 
Bronchial     Breathing) 
^  -  cavernous  (see  Cavernoi I- 
Breathing,  and  Bron- 
chial Breathing) 

-  Cheyne  -  Stokes         (sec- 

Clieyne-Stokes  Respira- 
tion) 

-  periodic     (sec     Oheyne- 

Stokes  Respiration) 
BREATHING,  SLOW  RATE 


OF 


685 


nerve 


from  peritonitis 
with  flatulence  . . 
from  heart  failure 


593 


■     I"      lMVM,.|r,uN 84 

|.la -i,,|M-„..,|       ..  ..     S2 

-'"iiiii!!  -  tl).\  hitocausing    84 
-  Ill  si>ik<.---Aii;iins  disease 

83,  14G 

-  strophanthus  causing  . .     84 

-  from  tubercuious  menin- 

gitis      S4 

BRADYPNtEA  . !     84  I 

Bradypnoea,  list  of  causes         i 
of  84.  85 

Brain,  ahscess  of  (see   Ab- 
scess, Cerebral) 

-  aneurysm  of  (see  Aneur- 

ysm, Cerebral) 
Brain,  blue  general  account 


I  Breast,  innocent  tumours  of 
I  Breast,  irritable,  of  Astley 
j         Cooper 
;  -  irritated  by  stays 

-  lineae  albicantes  on 

-  lymphatics  of    . . 
Breast,  malignant  tumours 

of  the 

-  n,-tl,odolP.vaniii,iii-tlie 

ISl, 

-  myoma  cutis  of. . 

-  neuralgia    of       . .      430. 

-  pain  in  (see  Pain  in  the 

Breast) 

-  redness  of,  in  mastodynia 

-  sarcoma  of  ..     181.  1 

-  secretion  from,  during 

pregnancy 

-  sinus  of,  from  rM,.rivh-.  .   1 

-  soreson,iMil.iiiir,i;i\ill;ir\- 

glands  In -HI    .  .  . ."   ; 

-  swelling  of  (<rv  SuelUng, 

Mammary'; 

-  tender      ..  431,  G        ) 

-  tuberculous  (see  Tu 

oulosis  of  Breast 
BREATH,    FOULNESS   OF 


catarrhal  jaundice 
constipa      n   . . 
dental  caries  . . 
dyspepsia 
empyema 
oral  sepsis 
foetid  bronchitis 
foreign  body  . , 
L.'anijrene  of   lung 


of 


163 


-  tubular    (see    Bronchi;iI 

Breathing) 
liroathlessness    (see    Dys- 
pnoea ;       Orthopnoea  ; 

and       Shortness      of 

Breath) 
Bridge  of  nose  (see  Nose, 

Bridge  of) 
Bright's     disease,     acute 

redema  of  larynx  in 

lungs  in  . . 

peritonitis  with     4i; 

albuminuria  in  55, 105, 

anasarca    with  4i; 

Bright's    disease,     ascites 

from   46,  47,  54,  55, 

-  -  bulla;  in 

chj'lous  ascites  fi-om . . 

chyluria  from 

cyanosis  from 

deafness  from 

fungating  endocarditis 

simulating  . . 
hiEmatemesis  in 

-  -  haemorrhage  in 

into  middle  ear  in . . 

heart  failure  from  4U, 

55,  105, 

liigh  blood-pressure  in 

hypertrophy  of  heart  in 

55, 

infantilism  from 

laryngeal    obstruction 

from 

mitral      regurgitation 

from        . .  . .  : 

a?dema  in      . .      105, 

of  larynx  from  159,  1 

orthopnoea  in 

pericarditis  in         55.  : 

peritonitis  in. .  46,  55, 

pleural  effusion  in    . .  : 

jjolyorrhomenitis  in  . .  : 

purpura  in      ..      553,  ;! 

renal    epithelial    cells 

with -i 

simulated  by  aneurysm  ; 

gumma  in  chest    . .    1 

mediastinal     new 

growth    . .         . .  4 

raediastinitis  . .   -1 

Meige's  disease      . .    1 

vena  ■  cava  obstruc- 
tion        . .         . .   4 

-  -  stridor  in 

—  tube  casts  in         105, 


1150 . 

'1 


BRIGHTS   DISEASE 


BRllT,   .SYSTOLIC 


/l/hhi's   'lis-asr.    n.Hf.L 

Brnnehiectasix,  contt!. 

Bronchitis,  rontd.     . . 

Bruit,  aortic  systolic,  due 

Bright's    disease,    various 

-  leucocytosis  in  . . 

300 

-  orthopnuia  from  323, 418 

420 

to  aortic  atheroma  . . 

causes  of 

9 

Bronchiectasis,  list  of  causes 

-  Jiain  in  chest  from     432, 

435 

Bruit,  cardio- respiratory  89, 

Bright's    disease,     various 

ot         

292 

-  -  limbs  with     . .      403, 

405 

90, 

forms  of 

6.  9 

-  osteo-arthroputliy  from 

352 

-  palpitation  from 

484 

CMhi     ~.T     Xephriti- 

-  iiain  in  chest  from 

435 

-  phthisis  simulating 

644 

thorax..          ..       lOS, 

;in.i  (.|-..mil;ir   Kulnry^ 

-  p!irlii~i^  simuUitim; 

80 

-  plastic     . .          . .  " 

287 

-  de  diable  ;i7,  90,  91,  92, 

Briphtness         perception. 

Bronchiectasis,       pliysical 

casts  in 

044 

299, 

general  account  of    .  ■ 

758 

signs  of         . .     -'ii'J, 

643 

-  in  pyffimia 

596 

-  diastolic,     from     acute 

liritlii-  liuin->  |--i-f  1  iML/ilii:!- 

-  )iiilvcytlnx;mi:i  witli 

533 

-  rhoiicbi  with     . . 

217 

endocarditis  . .        93, 

Ussiutnj 

-  pus  through  nose  from . . 

764 

and  rales  with 

167 

froin  aneurysm 

—  nails 

-it  to 

-  rigors  from        . .      51)5, 

598 

-  in  rickets 

145 

with  aortic  reguro-ita- 

Broad  ligament  abscess  . . 

157^ 

-  secondary  infection  in . . 

35 

-  right  ventricle  enlarged 

tion  ..  93,  209,  lOU, 

infiltrated     by    carei- 

-  simulated  by  empyema 

80 

from    . . 

215 

from  aortic  valve  rup- 

noma 

41 

new  growth  . . 

104 

-  shortness  of  breath  from 

ture 

■Brocft's  area,  aphasia  front 

-  sputum  witli      . .        11, 

141) 

85 

,  88 

pulmonary     . .         93, 

lesions  at  . .      303, 

G2(J 

-  stench  from 

290 

Bronchitis,  sputum  in 

644 

incompetence 

hemiplegia    from     le- 

- vomiting  from  . . 

705 

-  subcutaneous     emphy- 

 (and  see   Hruit,   Mid- 

sions near  . . 

30.1 

simulated  by . . 

704 

sema  from 

203 

diastolic;  and  Bruit, 

--speech  contre  in        .. 

Gl'l 

lironchiolectasis,  foul  taste 

-  from  subphrenic  abscess  370 

Presystolic). 

Brocq,  pseudo-pelade  of  . . 

71 

from    . . 

705 

~  sucking  in  of  intercostal 

-  Flint's  presj-stolic       95. 

teruk-riiess      o£      sr;ilp 

-  simulated  by  empyema 

Sll 

spaces  from   . . 

420 

—  tiETlic 

from 

710 

Kroncliiolitis,  Clirschniaim's 

-  tightness  in  chest  from . . 

432 

-  intracranial 

Bromides,  bulku  from      '.M^ 

,  1)8 

spirals  in 

133 

-  violent  coughing   bouts 

-  mid -diastolic,  from  acute 

-  colds  simulated  hv 

17S 

Uroneiiitis,   acut«,  tender- 

from  

289 

endocarditis  . .  3,  96. 

-  coma  from 

118 

ness  of  cliest  ill 

708 

-  whooping-cough      simu- 

 in  mitral  stenosis       2 

-  detected  in  m-inc 

1)8 

-  ascites  from 

40 

lated  by 

045 

reduplicated     heart 

-  in  diagnosis  of  epilepsy 

535 

-  from  asthma     . . 

153 

Hi-oncho-cpsophageal  tistiila 

239 

sound  simulated  bv 

222 

-  asthma     distinguished 

HronchorrhcDa,    bronchitis 

-  orbital     . .         . .      230, 

-  foul  taste  from. . 

705 

from  by  eosinophilia. . 

219 

and 

291 

-  over  enlarged  spleen    . . 

-  uasal  discharge  from    . . 

178 

simulated  by         420, 

535 

—  haemoptysis  from 

287 

thyroid       gland,      in 

-  not  the  cause  of  epileptic 

-  back  pressure  from     . . 

40 

Bronchophony,  with  bron- 

Graves's disease    . . 

dementia 

20 

-  bronchopneumonia  simu 

chiectasis        . .      292, 

643 

-  postsystolic,  from  aortic 

-  oedema  from 

410 

lating 

310 

-  over  fibroid  lung 

216 

regurgitation 

-  photophobia  from 

525 

-  capillary,  d.vspnoea  from 

590 

-  in  phthisis 

288 

-  presystolic,  with  adher- 

- ptyalism  from  . . 

542 

orthopnnea  from 

418 

-  pneiunonia         . .      100, 

042 

ent  poricardiiuii 

-  pustules  from    . .        £»S, 

5(;3 

retracted  head  from. . 

590 

Ijronchopneumonia        (see 

with  aortic  regurgita- 

 acfie  simulated  bv    . . 

559 

-  Charcot-J.eyden  crystals 

Pneumonia,  lironcho- 

tion             . .         95, 

-  -  no  .oinedones  with  .. 

55  LI 

in 

102 

Uronchoscope,  caseous  gland 

cerebral  embolism  and 

Bromides,    skin    eruptions 

-  chronic,  clubbed  lingei-s 

seen  with 

158 

fvom  dilatation  of  left 

from 

98 

from    . . 

Ul 

-  in   diagnosing   bronchus 

ventricle     . . 

-  sriMll-pox    simulated    by 

5ti3 

cough  from 

ISO 

stenosis 

292 

disappearance  of 

-  taste  loss  ironi  . . 

705 

polycythajmia  from 

lironchus,   aneurysm  rup- 

Bruit, presystolic,  Flint's 

-  transmitted     to     inf;itit 

532, 

533 

tured     through     120, 

95, 

from  mother  . . 

98 

winter  cough  from  . . 

14 

287,  290, 

292 

from  ndtral  stenosis 

-  urticaria  from  . . 

771 

-  Cheyne-Stokes  breathing 

-  compression  of,  no  pain 

2,  53.  '.13.  21(i.  2S9. 

-  vesicles  due  to  .  . 

757 

from    . . 

108 

with 

4.14 

-  -  witlu.iit  niitt.il  -rch.i-i-; 

Bromldrosis 

654 

-  coiigli  from 

149 

-  empyeni!'  ruptured  into 

332 

from  rn.  k   ;  ■■!     ■•    ■■  -\- 

I'.rnijiihe     water     te>t.     lor 

-  cyanosis  from     . .       161 

420 

-  epjtlinlioma  of   .  .      287, 

292 

-  systoli.-.  n ,r.-.r  .1,.- 

nR'l;inuri:i 

746 

-  dyspncea  from  . . 

322 

-  foreign     body     in     (see 

cardilH  ■_■     >:-,  :•'.  -'■'*.'. 

llronchial   breathing,   with 

-  with  emphysema 

I'ori-iuML  liu'h-in  r.roM- 

-  -  over  :diiliiiiiiii:ii   aorta 

bronchiectasis        UDS, 

U43 

14,  4(i,  153,  107. 

217 

.-hii^i 

-  -  witli      adhereiil      jK-ri- 

over  empyema 

M3 

-  and    cmpliysenia,    from 

Bronchus,  irruption  of  case- 

.■anbiirn      ..         89, 

over  fibroid  lung    108, 

asthma 

100 

ous  gland   into    ''M. 

-  -  over  aneurysm         92, 

U06, 

2»!1 

cyanosis  from 

100 

420. 

Oil 

aneurysm  of  iieart   . . 

in  phthisis     . . 

288 

lieart  failure  from    . . 

160 

-  stenosis  of,  asthma  simu- 

 with  aortic  regurgita- 

 over  itlciiritic  elTnsioa 

—  non-consoiiating  nile?> 

lated  by     . . 

535 

tion  

ItiS, 

29!l 

in 

lOU 

by  aneurysm  208,  259 

291 

stenosis      . .        92. 

in  pneumonia        160, 

GI2 

orthopncca  from 

160 

aspiration   pneumonia 

arteriosclerosis             1 

from   pulmonary  cm- 

rhonchi  in 

160 

from 

259 

-  -  atheroma       ..1,  S.'J, 

bolus 

200 

simulating  iLsthma    . . 

100 

broncliiccUsis      from 

cerebral      h(cmorrhagc 

stenosis  of  bronclnis. . 

20() 

-  epistaxis  from  . . 

220 

291, 

292 

and 

-  glands,   (see   Lymphatic 

-  libroid  lung  from 

292 

bronchoscope   in   dia- 

 in  clironic  nephritis  1, 

Glands,    Itronchial) 

-  foetid,     dangerous     dia- 

gnosing 

292 

11 

BronchicctJisis,     albumin- 

gnosis   

643 

enlarged  glands    370, 

congenital  heartSO, 91, 

uria  from 

11 

elastic   fibres  in   spu- 

381, 

704 

111,  157,  217.  533, 

—  albumosuria  with 

1(1 

tum  due  to.. 

260 

litirttid  lung  from 

292 

diastolic,  with  patent 

—  anumua  with      . . 

■■K 

—  foul  breath  from 

86 

iiri|>.iirr.l  M.ih-  from   .  . 

208 

ductus  arteriosus  »1, 

-  from  aneurysm. . 

292 

sputum  from     260, 

043 

Bronchus,  stenosis  of,  list 

dilated  aorta  . . 

-  arthritis  from     . . 

:\y.\ 

tiwtc  from  . . 

705 

of  causes  of  .  ■ 

292 

emphysema 

-  from  bronchus  obstruc- 

 gangrene  of  lung  simu- 

 Ironi  ni'W  growth  102, 

functional  37,  01,  89, 

tion 

2111 

lated  by     . . 

260 

1(14,   U.9,  2,'i9.   290, 

308 

DO,  91.  92.  299, 

-  bubbling  rales  with     . . 

lf.8 

-  -  indicanuria  frcHn 

315 

physical  signs  of      . . 

290 

(ungating  cmloi-ju'ditift 

-  cerebral     abscess    from 

-  -  leiicoe.vlosw  in 

SOU 

from  syphilis,. 

269 

in  Graves's  disease  . . 

81,  :»0L', 

.»lt2 

-  gangrene  of  lung  in 

259 

vehicular  murmur  dcll- 

-  -  in  inlluenza   . . 

-  Charcot- I<ey den  crystals 
in         

102 

-  general          tuberculosis 
simulating 

310 

cieiit  from  . . 
Wassormaiin  lest  with 

208 
292 

in    Kirkland's  disease 

over  manubrium  from 

-  clubbed  lingers  with  11, 

-  InumoptysLs    from    149, 

-  ulcemtion  of 

287 

laru'o  lironeldaU'land 

8G,  111 

on 

280,  287,  289 

291 

ltron'/x.<l  diabetes    24,  372, 

528 

Bruit,  systolic,  from  mitral 

-  cyanosis  from    . . 

iiii 

-  heart  failure  from 

Ilroom  tops,  polyuria  from 

535 

reourgllatton  . .       "<'•. 

-  elastic  librcs  in  sputum 

11,  40,  108,   101. 

418 

Ilrown-paper  skill,  in  pril- 

Ill   milr  il   -t.'iM'-i-i     H-., 

due  to. .         . .      -(ti't 

ous 

-  ill  inHuenza 

405 

rik'o  ferox 

49(1 

-    -    Ii.iiii                nn.MiU.hiil 

-  with  libroid  lutig 

-  insomnia  from  ..     .VJl, 

322 

Brown-Sequard     paralysis. 

.■iiaiicrs  II.  .'.;;,  ,Sll. 

n,  111.  11(8.  I'll-.. 

2112 

•  intercostal  muscle  over- 

general  account  of  496 

497 

-  --  (mm      overstiiuii       .if 

-  fti'tid     brnni'liitis    simu- 

Htriiincd in 

132 

lated  by         ■ .          .  • 

an 

-  lar,viigitis  with  .. 

157 

kTiiWlli 

5S 

Bruit,    systolic    ot   patent 

-  foul  brcatli  from 

an 

-  from  liver  nbscciw 

370 

-  -  111  syrlngomyeliii 

5K 

septum  ventrlculorum 

sputum  from  2C0,  r>08 

OCI 

-  ill  Molta  fever  . . 

400 

Itruis*',  tciideniuw  frnm 

in,  157,  215. 

tJiste  from 

70S 

-  mitral  i«toiiosis  mistakei 

707, 

710 

prliosi-*    rlieiMMiitica.  . 

—  gangrene  of  lung  in 

2.19 

for 

15 

llnilsliiK  In  i^pll<'p."y 

551 

-    -  with     prrieardili'^     K9, 
91, 

sinudated  by 

-  iion-albumiiinus  sputllii 

-  gangrone  from  . . 

255 

yon,  "jno, 

(113 

in        

041 

-  J.Hin.liw.  anil      ..       321, 

555 

-        I'l'-Nrisy 

-  liojmoptsyis  from      -'87, 

21)1 

-  noii-eonsonntiiig     rAlcs 

-  limping  from 

3(12 

Bruit,  systolic,  pulmonary 

:i7.  91. 

Brull.   systolic,   with   pul- 

- hojirt  failure  from      11 

—  indicanuria   from 

1(U 
316 

with 

-  niiinmiilnr  sputum  In  . . 

on 

-  pain  long  iifler  . . 

-  from  trivial  caiirt(.>i,  from 

I7il 

—  lardaeeous  discaso  fron 

-  niitmog  liver  front 

308 

hlOOll     dlMNIKCS 

55  1 

monary    stenosis    ;•!, 

8,  376 

l!35 

-  ill  ulil  pnopln     . . 

85 

-  -  111  heallh 

SS4 

in.  157.  217. 

BRUIT,   SVSTOLIC    —    CALCULUS.   KENAL 


Bruit,  st/slolic.  cojitd. 

'  BuUce^  coiihl. 

Buttoning  coat,  ataxy  ex- 

' Cmciim,  diitcnded,  could. 

simulating  aortic  sten- 

- turpentine          . .          . .      96 

hibited  on      . .          . .      56 

from  carcinoma  eoH. .  35 

osis  208 

-  in  urticaria        . .         . .  771 

Butyl   chloral  hydrate. 

of  rectum  . .         . .  45 

—  spleiiomegalic       polr- 

1  -  from  varnish     . .         . .     96 

'bradypnoea  from       ..      84 

sigmoid       . .         . .  45 

cythsemia           . .  633 

-  veronal   . .          . .         . .     96 

Cheyne-Stokes 

obstruction    . .         . .  4r 

from  tricuspid  regurgi- 

' -  vesicants             . .          96,  97 

breathing  from..    108 

pain  in  iliac  fossa  from 

tation          ..         92,  211 

-  volatile  oils        . .          . .     9G 

erythema  from      . .   222 

454,  45 

-  to  uii.i  tro           .  .          .  .      'X', 

Bullet    wound    of    chest, 

purpura  from         . .   553 

simulating    carcinoma 

BRUITS.  CARDIAC         ..     89 

hiemopueumothorax 

Butyric    acid    (see    Acid, 

ca?ci            . .         . .  45 

Bruits,  congenital  systolic  90,  91 

from             . .          . .   652 

Butyric) 

i with  spastic  constipa- 

Bruits, diastolic  92.  93,  94. 

cord,   allocheu-ia  from     17 

Buzzhig  noises  in  head  405,  406 

tion             ..         ..12 

95,  96 

li;i/ni('iTliage  into  cord  515 

from  volvulus            ..   45 

Bruits,  pulmonary  systolic    91 

--  -  )icirii|i|.L'ia   from    303,  306 

.r-rays  m  diagnosing. .   45 

Bruits,    rub    distinguished 

r.nliiiii:nn'ous    emphy- 

/^ABLE (submarine)  re- 
V-^     pairing,    mercury    in 

-  on  left  side         ..         ..45 

from 433 

sema  from                . .    203 

-  lymphosarcoma    of       . .  6C 

-    ai.iiini      rli;.!!-.-      in.     Ill 

transverse  myelitisfrom 

saljva  a'tid        ..           ..    542 

Caecum,  succussion  In  652,  65 

flln,LMlin-    ^'fMlnriinlitiS        3-1 

389,  516 

CACHEXIA                        ..     99 

-  tubereul.UH  I.?)  1. , /'///.  19') 

Bruits,     systolic     apical. 

Bullous  dermatoses,  anor- 

-  :M.--tn„Mna  fruu.               ..         4 

i:.s,  l.-,9.67 

general  account  of    . .     89 

exia  in         . .          . .      99 

-  Addi^onV    disease   simu- 

- whipworms  ni  (F/',/.  .'IS)  52 

Bruits,  systolic,  aortic            92 

death  from    . .          . .     99 

lated  by          . .          . .   527 

Caffeine  in  cocoa  . .         . .  5i 

Bruits,  tricuspid  systolic  ..     92 

eosinophilia  from   99,  219 

-  Africana             . .         . .     99 

-  coffee 53 

l;ul>n            ,  ,          ;;s|.  CIS,  CTli 

haiinatoporphyrinuria 

-  albuminui'ia  from         . .     13 

-  tea 5i 

i;iirr;il   nm.ns;..  |.i-infiita- 

from            ..         ..99 

-  alkalina 99 

1  -  polyuria  from    . .          . .   53 

tion  of  (see  I'li,'meiita- 

mucous    membranes 

-  anffimia  due  to. .          21,  33 

Caisson    disease,    cerebral 

tion  in  the  Mouth) 

affected  by            . .     99 

-  from  ankylostomum  duo- 

softening  from          . .   10 

Bug  bite,  itching  from    . .  5 10 

pyrexia  in       . .          . .      99 

denale            . .          . .     99 

Cheyne-Stokes  breath- 

Bugs, relapsing'fever  spread    - 

Bundle   of   His,   in   heart 

-  aquosa 99 

ing  from     . .         . .   1( 

bv          ..          ..28    33G 

block 83 

-  from  bilharzia  htemato- 

, deafness  in     . .          . .   1( 

Bulbar  paralysis  (see  Tar- 

Burette,  in  estimating  sugar  263 

bia 99 

epistaxis  in     . .          . .   22 

alysis,    Bulbar) 

Burning,  from  drug  rashes  384 

-  bothriocephalus  latus  . .     99 

hemiplegia  from     303,  30 

Bulimia -13 

-  in  eczema            .  .       558,  754 

-  heri-beri             . .          . .     33 

nature  of        . .          . .   30 

BULL>E 96 

-    of  pt-lll^.   tlnln    l,rl|H-      ..     754 

-  bleeding  gums  in           . .      72 

noises  in  the  head  in. .  4C 

-  from  acetanilide            .  .      9() 

-  with    niali'M  ,1,1     |.ii-(iile  559 

-  from   carcinoma   33.  78, 

; shortness  of  breath  in    8 

-  ^ici.ls        Ji7 

-  in  inmii  li    h  iH),  1  (ii  'i\  ce's 

99,  173,  270,  527,  666,  687 

Cajaput  oil,  heartburn  re- 

- aniline  dyes       ..          . .      -ifi 

di^.M-                       -.366 

-  causes  of             . .          . .        4 

lieved  by        . .         . .  29 

-  anthrax  . .          . .          . .   559 

-  urticaria              .  .          .  .    771 

-    rill. .(nth  a                  ..               ..99 

Calcanodynia                  -.43 

-  arnica 9(; 

-  from  vesicles     . .          . .   753 

-  11- ,iivl,M^i--    ..          ..173 

1  -  brachial  neuralgia  alter- 

- in  Bright's  disease        96,  97 

Burns,  albuminuria  from        13 

-   It,  roi.,Ti,i(;,i  syphilis    ..   400 

nating  with    . .         . .  43 

-  from  bromides  . .          J6,  98 

-  bulla)  from         . .          . .     96 

-    r.Mi-r,|,;Mion   in    ..             ..    123 

Calcareous   concretions   in 

-  in  bullous  impetigo      . .   401 

-  contracture    after    (Fig. 

-  diazo-reaction  in            ..   173 

sputum  (Fig.  273)    . .   64 

-  from  burns        . .          . .     9G 

60)  142,  143,  648 

-  m    Egyptian   splenome- 

Calcification of  muscles   ..  14 

-  cantharides         . .          96,  97 

-  ectropion  from  . .         . .  220 

galy     .634 

-  valves,  after  endocarditis  21 

-  capsicum            . ,          . .      97 

-  gangrene  from  . .         . .  255 

-  from  endometritis         . .      99 

Calcium    cnrbonate,   urine 

-  carbolic  acid      . .          , .     97 

-  hsEmoglobinuria  from  . .   284 

-  esophthalmia     . .          . .      99 

cloud  from     . . 

-  carbon  dioxide  snow    . .  -  96 

-  hyperpyrexia  after        . .    309 

-  fibroids 99 

-  chloride,  in  bile  test     . .  74 

-  ia  cheiropompholyx 

-  from  radium      . .          . .   223 

-  gastric  ITCl  deficient  in    270 

effect  on  albuminuria     1 

96,  GOO,  756 

-  stiff  neck  after  . .          . .   648 

-  h»mic  bruit  in  . .          . .      92 

in     hrematoporphyrm 

-  from  chrysarobin         . .     96 

-  talipes  from        . .          . .   114 

-  from  leucorrhoea           . .     99 

test 74 

-  cold         96 

-  tenderness  from            . .   707 

-  malaria         33,  99,  173,  274 

-  deficiency,  metrorrhagia 

-  croton  oil            ..          96,  97 

-  ulceration  aftei-. .         ..  737 

-  malignant,  hypothermia 

from 39 

-  in     dermatitis     herpeti- 

- from  ar-rays        . .          . .   223 

in         . .         (Fig.  143)  312 

-  hypochlorite,  in  indican 

formis  96,  98,  710,  753,  755 

Burrows  in  scabies        562,  755 

-  from   malignant   perito- 

"test  31 

-  from  drues         . .         . .     96 

Bursa,  gastrocnemius,  en- 

nitis     49 

-  lactate,   effect   on   albu- 

- eosinophile  cells  in        . .     99 

larged             . .          . .   693 

-  mediastinal  new  growth 

minuria           . .          . .      1 

-  in  epidermolysis  bullosa 

-  under  gluteus  maximus. 

434,  435 

-  menorrhagia  and          . .   38 

96,  98 

tuberculous    . .          . .  363 

-  mercurialis         . .          . .     99 

-  menstrual    irregularities 

-  erysipelas           . .  96,  98,  674 

-  iliopsoas,    aspiratiou    in 

-  muscle  atrophy  from  . .   583 

and 39 

-  erythema            , .         . .     98 

diagnosing      ..          ..676 

-  in  negroes           . .          . .      99 

-  oxalate  (see   Oxalate  of 

bullosum         . .          96,  98 

femoral  swelling  from  676 

-  oedema  of  legs  from  413,  415 

Calcium ;  and  Oxaluria) 

iris       ..             96,  98,  756 

hip-joint  disease  simu- 

- from  oesophageal  stenosis    33 

-  phosphate,  deposit  of  . .  52 

multiforme     . .         . .  489 

lated  by     ..         ..676 

-  pain  in  the  limbs  in      , .  467 

in  intestinal  sand     . .   59 

-  from  fracture    . .          96,  97 

psoas     abscess    simu- 

palustris           . .         . .     ./■■■ 

solubility  of  . .          . .   52 

-  friction    . .          . .          96,  g? 

lated  by     . .         . .  676 

-  parasitica            ..          ..99 

stellar  crystals  of     . .  52 

-  ill  frostbite         . .          96,  97 

-*-  reducible        . .         . .  680 

-  penile  erections  absent  in  313 

urine  cloud  from 

-  gangrene              . .          96,  97 

-  over  exostosis    . .          . .  670 

-  peripheral  neuritis  in  ..  467 

-  salts,   parathyroids   and  15 

-  glanders  . .          . .        96,  559 

-  porter's     (Fig.  65)  155,   156 

-  from  phthisis     ..         ..173 

tetany  and      . .          . .   15 

-  heart  failure       . .          . .     97 

-  psoas  impulse  on  cough- 

—  pigmentation  with        . .     99 

Calculi,  cystin       . .          . .  16 

-  herpes  gestationis         . .     96 

in-  in           . .          . .   680 

in  mouth  from           . .   527 

Calculus,  biliary  (see  Gall- 

 zoster 754 

-  -  from  osrHO-arthritis  ..   681 

of  skin  fi-ora  . .          . .   528 

stones) 

-  impetigo              . .          . .   5G2 

Bursa,    semimembranosus. 

-  renalis 99 

-  pancreatic,  colic  from.,   llf 

contagiosa      . .           96,  98 

enlarged                    . .  692  > 

-  saturnina            . .          . .      99 

epigastric  paui  from 

-  from  iodides      . .           96,  98 

-  subhyoid              . .          . .   721  i 

-  scorbutica          . .         . .     99 

116,  43- 

-  tendo  achillis,    inflamed  362  ; 

-  sordes  in            . .         . .     72 

jaundice  from           . .  66 

-  leprosy 601 

-  urate  of  sodium  in        . .   344  1 

-  splenica 99 

pain  in  the  back  from  lit 

-  liquor  epispasticus        . .     97 

Btu-sitis.  gonorrhceal,  pain          i 

—  from  starvation            . .     33 

-  penile      (see      Calouhis, 

Bulls,  list  of  causes  of    . .    ge 

inf.H,rh-om    ..          ..439 

~  syphUis    S,  33,  99,  173, 

Urethral) 

pn-,.,|r|l:;r              ..             . .    476    1 

527,  559,  560,  604 

-  prostatic,  abscess  from    581 

-  from  mylabris  . .          .  .      97 

Bursitis,  subacromial,  gen- 

 lardaceous  disease  fi-om     8 

aching    in    perineum 

eral  account  of         ..  476 

-  thrombosis  in    ..          ..411 

from           ..         ..474 

-  occupations        . .          . .      96 

l'.Mi>liri-'  Ih.\>.  scoliosis  in  154 

-  thrombotic  infarcts  in. .       8 

-  —  carcinoma     simulated 

-  redema 90 

raii.-li.'i^.  vv.M-i.  in            ..    240 

-  from  trichina  spiralis  . .     99 

by 47C 

-  in  pemphigus  90,  98,  558,  601 

-    \\r,\-^  <ii-.....^..  and         ..   336 

-  tuberculosis        . .         33,  99 

catheter  in  diagnosing 

neonatorum       96,  97,  401 

I'aiti.irk.  in.Nnre  over     ..   257 

of  bowel          . .          . .   666 

470,  472 

-  from  plants        . .          . .      96 

-  eczema  marginatum    on  250 

-  uterina 99 

difficulty  in  micturition 

-  primula  obconica           . .      96 

-  glands  draining             ..   679 

-  various  causes  of          . .  415 

with            ..         ..  39C 

-  produced  by  malingerci-s    97 

-  linete  albicantes  on       . .  365 

Cacodylate  of  sodium,  ery- 

 epididymo-orchitis 

-  ill  Raynaud's  disease    96,  97 

-  pemphigus    neonatorum          , 

thema  from    .  .      222,  224 

from            ..          ,.478 

-  from  resin          . .         . .     96 

affecting          . .          . .   401  , 

Cacogeustia                      ■ .  705 

pain  in  penis  from    . .   47r 

-  rhus  toxicodendron      96,  97 

-  prurigo  affecting            . .   489  ' 

CsBCum,    actinomycosis   of 

rectal  examination  in 

-  satinwood           . .          . .      96 

-  scabies  affecting            . .   563  ^ 

458.   C77 

diaL'nosing  . .      470,  47r 

-  in  scabies           . .      cOO,  765 

-  sore    on.    inflamed     in- 

- appendicular          abscess 

-  -  ulceration  behind     . .   471^ 

-  from  scalds        . .          . .      96 

guinal  glands  from   . .   381 

opening  into  . .          . .   557 

-  renal,  abscess  from       . .   271 

-  in  scurvy            . .          96,  97 

-  wasting  of,  with  hip  di-          | 

-  carcinoma  of  (see  Carci- 

 age  incidence  of        . .      4( 

-   from  S'dints        . .          . .      96 

sease 363  1 

noma  of  Caicum) 

albuminuria  from     , . 

-  in  syphilis            . .          96,  97 

Button  in   bronchus,   lifls-          | 

-  dilated  succussion  in  652,  654 

anuria  from   . .          39,  4C 

-  syringomyelia    . .          96.  97 

moptysis  from           . .    287 

-   distended       appendicitis 

-  -  backache     from      40, 

-  from  tor  products        . .     96 

-  hirynx     . .          . .          ,  .    157 

simulated   by..          ..    -157 

278,   U',^,  577 

CALCULUS,  RENAL 


CARCLNOMA 


faicu/tis,  renal,  contd. 
~  baoteriuria  with       . .     09 

-  Cheyne-Stokes  breath- 

ing  from      . .  . .    108 

-  chronic  nephritis  from       7 

-  colic  from  278, 473,  577, 

742,   767 

-  convulsions  from      . .   144 

-  crepitation  felt         ..  337  , 

-  crystals  in  urine  with  276 

-  cystitis  from  . .   394 

-  Dietl's  crises  simulat- 

in^r 117  I 

-  destruction  of  kidney 

by '.      40 

-  effect  of  exercise  on . .  394 

-  empyema  from         . .   106 

-  epithelial  cells  i 


froir 


117 


-  frt-qnenr      micturition 

.lueto  117,278,393,   394 

ilculus,     renal,     general 
account  of  40.  278 

-  hietnaturia     from    4i), 

117,   275,  276,   27H, 

35G,  577,  742 

-  hydronephrosis     from 

40,  117,  279, 

{Fiq.  166)    35G,  536 

-  kidney  enlarged  by  41,  451 
tender  from  . .  451 

-  latent  uncmia  with  . .     40 

-  microscopic       oxalate 

concretions  from  . .  424 

-  iieuralcia  simulating     426 

-  oxaluria  simulating  . .  281 

-  pain  in  back  from    . .  451 
groin  from  . .  278 

-  hypochondrium    from 

450,  451 

labium  majus  from  117 

loin  from    ..      117,  278 

over 41 

referred   to  contra- 
lateral side  in    . .  452 

in  testis  from    117, 

278,  483 

-  -  thiKh  from  117,  278 

-  perinephritis  from    . .  106 

-  pleurisy  from  . .  106 

-  prickiiij:j  pain  in  kidney 

from  . .  . .  277 

-  pyelitis  from         576,  577 

-  pyelonephritis  from..'  577 

-  pyonephrosis  from 

279,   357,   576,   577 

-  pyriform  cells  in  urine 

from  . .  . .  742 

-  pyuria  from 


■  vi|.Ik  I i  from  ..     69 

Li  r.-l    Itr,     ..\      ..  ..     279 

Luljt;ti,iiluu.       kidney 
sinmlaUnt,'   117,279,577 

-  urecmia  from  . .  108 

-  uric  acid  and  . .   742 

-  urine  changes  with  . .     40 

-  z-ravs    in    di-itrtiosini,' 

117,  357.   451,  536 

Biculus,  salivary,  notes  on  694 

-  ptyalisin  from  . .  512 

-  totitfiH;  swollen  from..   698 
nrctend  . .  . .  . .     40 

-  abscess  from..         ..  397 

-  anuria  from  . .  . .     S9 

-  appendicitis  simulated 

by    . .         . .     281,  578 
simulating  . .  . .  582 

-  atrophy  of  kidney  from  578 

-  backache  from      469,  678 

-  calcareous  inland  simu- 

latinu'  ..  ..   455 

-  colic  from      ..  ..  742 

-  cystoscope  In  diaqnos- 

inif   ..    41.455,472,578 

-  fplt  per  rectum  41,  57S,  587 


II.  57 

:i;t 


Calculus,  ureteral^  conkl. 

micturition     frequent 

with  ,.      472,578 

operation  in  diagnosing    41 

ovarian  pain  simulated 

by 578 

pain  over       ..         . .     41 

over    external    ab- 
dominal ring  with  472 

in  iliac  fossa  from 

452,  454 

kidney  with  . .  472 

after  micturition  due 

to 397 

in  penis  from 

471,  472,  578 

testes   from  . .  483 

phlebolith    simulating  455 

pyoiiepurosis  from  ..  578 

pyuria  Uom    472,  575,  578 

rectal  examination  in 

diagnosing  . ,         . .  472 

simulated    by    spinal 

lesions        '. .  . .  461 

site  of  impaction  of  . .   454 

strangury  from         . .      40 

tuberculous     bladder 

simulated  by      472,  578 
ureteral  bougie  in  dia- 
gnosing       . .        41,  455 

m-eteritis  simulating . .  455 

uric  acid  and. .  . .   742 

uronephrosis  from    . .   578 

vesical  calculus  simu- 
lated by      ..      472, 578 
villous  papilloma  simu- 
lated by     . .         . .  472 

wax-tipped  bougie  in 

diagnosing  . .         , .  472 

i-rays    in    diagnosing 

281,(i^iy.l92)455,472,578 

-  urethral 184  ' 

aching     in    perineum 

from  . .         . .  474 

age  incidence  of       . .  283 

behind  stricture       . .  620  , 

blood     from     urethra  i 

due  to        . .         . .  396  ' 

bougie  in  diagnosing      395  j 

discharge  due  to      . .  181 

endoscope  in  detecting  | 

283,  469 

epididymitis  from     . .   697 

epididymo  -  orchitis 


Calculus,  vesical,  amftl 

pain  in  bladder  from     742 

glans  penis  from  . .   397 

penis  from  282,  469, 

470,  580,  471,  579 

passed  in  urine     395,  471 

priapism  from  . .    538 

pyuria  from   276,  282, 

471,  575,  580  ; 

renal   colic   preceding  282 

sex  incidence  of        . .  282 

skiagram  of    . .         . .  282 

sound    in    diagnosing 

282,  471,  580,  719 

tenesmus  from      718,  719 

travelling  and  . .  471 

tuberculous   bladder 

simulating  . .         ..  579 
ureteric  calculus  simu- 
lating ,.     472,  578  ' 


r-rays 


diagnosing 


Calf,  atrophy  of    . .  . .   362 

-  cellulitis  of,  talipes  from  114 

-  cramps  in  . .  . .    150 

-  fibrosis  of,  talipes  from     114 

-  hcemorrhagic    knotJ>    in, 

in  scurvy        . .  . .  556 

-  Jacquet's  erythema  of. .  401 

-  seborrhceic  eczema  affect- 

ing        401 

Callus  compressing   nerve 

61,  63.  65,  432,  504 

-  after  fracture     . .  . .   667 

-  hemianopsia  from         . .  302 

-  intercostal     nerves     in- 

volved by       ..         ..  432 

-  on  jaw 683 

-  miisculnspiral    paralysis 

from 65 

-  sarcoma  siinuhited  by..   672 

-  ot  .-I'Ki''.  .i!lM,'lifiri:i  from      17 

-  iFi     t.  I  i.i.M,  I   (. wl  muscle  142 


Clin 


Ad- 


f  ( 

felt  in  penis   . . 

per  rectum 

haimaturia  from    27.'J 

impacted 

micturition       difHcult 


478 


34 

-  -  pliitc  ot        . .  . .   770 

tuberculosis    ..         ..  573 

tuberculous  peritonitis  631 

Calomel,  iriterscapular  pain 

relieved  bv     . .  ..   462 

-  polyuria  from    . .  . .   535 

-  tenesinus  from  . .  . .    718 
CAMMIDGE'S  PANCREA- 
TIC REACTION        ..   100 

pan- 


fro 


51. 


i;30 


fith.. 


frequent  with 

• stopped  by.. 

■  -  pain  from 
■ in  penis  from 

■  -  priapism  from 

■  -  retention  of  urine  from 
282,  396 


reatitis      117, 

254,  328,  ««1 

Camphor,  cosinopliJlia  from  219 

282,  ^95  '  -  glycuronic  acid  from    . .    261 

..   394  i  -  priapism  fmni    ..  ..   538 

..    469  !  -  r.  .lu<  i\    ninir  after  261 


283,  469 


cidp 


;  of 


283 


alculus.  ureteral,  neneral 
account  of    454  (/"/. 

102)  455,  472,  578 

-  hiumaturia  from,  275. 

281,   455.    1 12.   578,   712 

-  impacted         . .  ■  -      I" 


strangury  from  . .   649 

ulceration  behind      . .   478 

-  vesical,  aching  iu  peri- 

neum from     . ,  '      . .  474 

-  -  age  incidence  of        . .  471 

behind  large  prostate  580 

couviilaions  from       ..    144 

crystals  in  urine  with  580 

cystitis  from  282,  471, 

579,  580 
cystoscope  in  diagnos- 
ing   282,    395,   397, 

471,  580.  719 
Calculus,    vesical,     cysto- 
scopic  appearance    of 
il'/fi/r  All)  ..         -  .  284 

.-    ^    i-nrv^'lf'l  ■  -    -''SO 

Calculus,    vesical,    qeneral 
account  ot    262.  471.  580 

_  -   hicmiilun  I    fn.m    j;:.. 
276,    2S2,  471,  5H0. 

719,  712 
jolting  and     ..  ..   471 

mjcturitlnii       arrested 
by      282,  391,  470,  471 

fretturiit  from    282, 

471,  579 


C;iriii  ii'i    i'mIi.  I.  ..iiTiormal 

siz."  scTis;itl(iiiH  due  to  763 

priupiHU)  from  . .  538 

xanthopsia  from       . .  762 

Cancer  (see  Carcinoma,  Silt- 

coma,  etc.) 
Cnncrum  oris,  bleeding  gimi 

from 72 

death  from     . .  . .     74 

-  -  (^'1*;.  21)         ..  ..74 

gangrene  from  . .  255 

imtiscouH  odour  from 

titomatltlH  with 

—  tcotli     dropping     out 

from  . .         . .     74 

Canter  rhvthm,  from  dila- 
tion of  heart  . .  . .   587 

Mivocardial  changes  . .   SO 

.  -  in'iH'rlcarditlH        213.  587 


042 


nlH 


587 


redupllniled     heart 

Hnund  »lmnliitod  l)y  58 
Cunthuridvf.     albuminuria 
from    . . 

-  urniria  from 

-  bliHtcrlng  Willi  . . 

-  bulliD  from 
-•  dLTmatltlH  from 

-  ervtheina  from  . 

-  Iiiiinuiluria  from 

-  iK'phrltiH  from    . 

-  priapism  from    . 


14 

..  40 
..  14 
m,  97 
..    755 

.'.'   275 

9 

..   538 


Cunf/mridcs,  ctmUl. 

-  ptyalism  from    . .  . .    i 

-  strangury  from..      649,  < 

-  tenesinus  from  . .         . . 
Capillarv  bronchitis     418. 

-  pulsation  93,  207,  : 
Capsicum,  bullte  from 

-  dermatitis  from  . .  ' 

-  erythema  from  . .         . .  : 
Capsules,  keratin-coated,  in 

diagnosing  pyloric  ob- 
struction        . .         . .  I 
Caput  medusie      . .        43, 
Carbohydrate,    excess    of, 
rickets  from  . . 

-  intestinal     fermentation 

and 
Carbol-fuchsin  stain        . .  i 
Carbol-metbylene  blue    . .  ^ 
Carbolic    acid    (see    Acid, 

Carbolic) 
Cavboluriii,     black     urine 

from 

-  Fe!iIiiiL,''s     solution     n- 

ducpd  in 
Carboluria,  general  account 
of        

-  ochronosis  and  . . 
Carbon  bisulphide,  hiumo- 

globinuria  from 

indiarubber  solvent  .. 

peripheral     neuritis 

from  . .         til. 

Carbon  dioxide,  in  fermen- 

tJition  test      . .  . . 

-  -  headache  from 
snow,  hullie  from 

-  disulphide,  tremor  from 

-  monoxide,       cherry-red 

colour  of  blood  from . . 

-  -  coma  from      ..      118, 

hfemoglobinuria  from 

headache  from 

poisoning  by  . . 

Carbonate  of  calcium,  urine 


fi-d 

C;m'i''-.   ■''       ."    ■■Kr,l     by 

Carln. ..  \  1,,1-tri,.   iiii.iii.rlicrrv 
rr.i  hlun.l  fn.m 

-  spectrum  of  (FiV/.  32)  . . 
('arbuncle,  aching  m  peri- 
neum from     . . 

-  cellulitis     distinguished 

from    . . 

-  erythema  from  . . 

-  face  swollen  from 

-  from  glycosuria 

-  furuncle     distinguished 

from    . . 

-  malii-'naiit    pustule    dis- 


-  tin.M    -30,-;       HMuh.ting  1 
Carcinoma.  iiiKMrnia  duo  to 

-  albumosuria  with 

-  cachexia  trum   ..      413,-1 

-  developing  in  scar       . .  l 

-  eosiiiopliilia  from         . .  '. 

-  fatty  heart   from  . .   i 

-  general  wjinting  from  . . 

-  hyp..'rnephroma  and     ..   ? 

-  leucocytosis  in  . .  . .   : 

-  toHs  of  woiglit  from     . .    1 

-  microscope  in  diagnosing 

379,  I 

-  o'dcma  of  legs  from  413,  I 

-  pIgmontAtlon     of     skin 

from r 

-  prolonged  pyrexia  from  f 

-  toriguo  swollen  from    . .  (I 

-  ulceratloit    of    pcrliiaum 

from «l 

-  vulval  iwidllnir  from    . .    1 

-  of  ampulla  of  Vatcr       . .  *. 

-  antrum   . .         . .  . .   1 

-  nnu9,      Ingufnat     glnnds 

HocoMdury  to,.      381,  f 

-  -  Hprrad  to  perineum  . .  i\ 

-  biliMluct,    bile    pigment 

In  urine  from. .         . .   1 

can'inomn    of   duodc* 

num  Htmulntlng    . .  C 

-  -  clay  •  coloured    stoolfl 

froai  . .         . .  .1 


CARCINOMA   OF   BILE-DUCT 


CARCINOMA  OF  LIVER 


Carchnnmi.  hile-duct^  could. 

-  -  fawal  fat  with  . .  101 

jaundice  from  325,  32G,  002 

~  bladder,  acliing  in  kidney 


fro 


580 


-  perinemn  from      ..    174 

age  incidence  of 

281,  472,  080 
Carcinoma  of  bladder,  anuria 

from    ..  39,  41 

~  -  l.owel  (>|iciied  by      ..   238 

cystitis  witli  . .         . .  394 

cystoscope  in  diagnos- 
ing   41,    281,    471, 

472,  S80 

cystoscopic  appearance 

of  iPlute  XV r)      ..   284 

fteces    per    uretlirani 

from  . .         . .  238 


Carcinoma      of      bladder, 
general  account  of  472,  580 

-  -  liaMiiaturi:!.    from,    41, 

27.J,  27(;,  2S1,  471, 

472,  .-.79,  080 

-  -  li.vdroiiepin-osis  from       41 

kidney  enlarged  by  . .   281 

micturition     frequent 

witli..  ..       471.472 

-  -  jiain  with        . .  .  .   394 
at  female  urethral 

orifice  from       . .  397 
in  kidney  from  281,  472 

-  -       perineum  from       .  .   397 
neiii^  from  281,  397, 

lf,9,  471,  472,  580 
vuli^i  from..  ..   397 


41 


-  -  pclv 


r4,'ed 
579, 


}\veIoncpliritis  frofii  . .   570 

pyonephrosis  from    . .   577 

-  -  jiym-ia   from  41,  281, 

471,  570,  580 

rectal  examination  in 

detecting'    41,    277, 
281,  471,  472,   579, 

5811,  587 

rectum  opened  by    . .  238 

i-etention  of  urine  from  281 

situation  of   . .         . .  281 

strangury  from        . .  049 

tabes  simulating      . .  050 

tubercle       simiilating 

282.  579 

ureter   obstructed   by 

281",   472 

vaginal     e.\araination 

in  diagnosing       41,  471 
Carcinoma  of  bone         . .  672 

-  -  (/••/.;.  112)         ..  ..   152 


fill 


bre 


181 


simulating  . .         . .  086 

-  duct  type       ..      181.  087 

-  early     diagnosis     by 

microscope  . .  430 

-  en  cuirasse     . .         . .   730 
..  430 


1  of  shoulder 

1  by 

illarv 

708 

380, 

OSli 

.ones 

204, 

711 

Carciiioma  of  hreaast,  contd, 

secoiictary  in  spine  154. 

:;fl  316,  618,  7U 

sui>ra clavicular  gland  380 

subclavian     vein     ob- 
structed by  . .   259 


vellii 


of 


159,  411 

tubercle  simulating 

181,  68 G 
without  aniomia       . .     33 

-  bronchus,  bronchiectasis 

haemoptysis  from     . .  287 

-  caecum,    actinomycosis 

simulating      . .  . .   458 

bladder  invaded  by  . .  582 

bladder  opened  by  238,  575 

-  -  fajces  siniuUitinj;       ..   459 
Carcinoma    of    caecum, 

general  account  of   ■-  459 

~    -    iniTKHlr.i       ]:<■  T-      Willi    (ifio 


iiig 


459,  67 


iliac  fossa  from 

454,  459 

pyuria  from  . .     '    . .   575 

?^inudated  in  cases  of 

obstruction  . .   459 

-■-  swelling  in  iliac  fossa 

from  459,  665,  677 

tuberculosis  simulating  125 

tuberculous        caecum 

simulating  . .  . .   458 

-  Cauda  equina     . .  . .      C2 
Carcinoma      of      cervical 

glands 

-  cheek,     jire-auricular 

glands  affected  from 

spread  to  nose 

submaxillary     glands 

affected  from 

-  clitoris,  inguinal  gland; 

secondary  to  . , 

-  colloid,  of  peritoneum. , 


380 


676 


-  -  AaJi-i>h-^ih--.i-.~nm"i- 

lated  by      ..  -.5 

adherent  to  liver      . .  3 

;ige  incidence  of    12G, 

130,  1 

aibuminm-ia  from     . .  3 

albumosuria  witli     . . 

anaamia  from  . .  ] 

anesthetic  in  diagnos- 
ing   1 

anorexia  from  . .   1 

ascites  from       19,  51,  ; 

asthenia  from  . .   I 

barium  enema   in    di- 
agnosing    . .  . .    ] 
bile-duct  obstructed  by  3 

-  -  bimanual  detection  of  3 


blailiiri-        iH\,h|rd       l)V 

2S:i,  575,  i 

blood  per  rectum  from 

77,  172,  ; 

cachexia  from  . .  i 

colic  from        77,  115,  ] 

colitis  simulating      . .  ' 

-  -  constipation  from  77, 

126,  130,  ; 

-  -    .li;.n-hii-:i  with       126,  ] 


of 


fistula  into  renal  pelvis 

from 

flatus    per    m-ethram 

with 
-  gastric  ulcer  simulated 
Carcinoma  of  colon,  general 
account  of     ■  ■        77, 

hasmaturia   from 

hvpertrophv  of  bowel 

■  from        ■    .  . 


Carcinoma  of  colon,  contd. 

increasing     constipa- 
tion from    . .  . .    126 

indicanvuria  from      . .    315 

inguinal  glands  second- 
ary to         . .         . .  679 

intes'tinal  sand  with..  599 

obstruction   from 

130,    388,  593 

-  -  jaunrlice  from         329,  330 

Carcinoma  of  colon,  kidney 
simulated  by  .  ■         ■  ■  354 


~  -  lii 

_  -  loss 
-   -   loss  . 


>ni  126 
..    126 


■  -  movable  kidnev  simu- 

lated bv      . ;  . .   603 

-  mucus  in  stools  from  398 
and  blood  in  stools 

from        . .         . .   354 

-  occult  blood  in  fjBces 

from  . .      125,  120 

■  -  pain  in  hypochondrium 

from    "         . .      450,  451 
the  loin  from        . .    354 

-  pericolitis  simulating     663 

-  perinephric    abscess 


fron 


353 


■  -  peritonitis  from      4:*.  593 

-  —  pigment  ii>  mouth  from  527 

-  -  jmeumoperitoneum 

from  . .  . .   652 

-  -  portal  glands  enlarged 
from  . .       329,  330 


py 


vith. 


lation  for 
130,  172,  330 

secondary  glands  with 

329,   330^  380.    381,  679 

in  liver         77,  252,  527 

sigmoidoscope  in  dia- 
gnosing        77.  126,  172 
simulated  by  diverti- 
cula coli  , .         . .   130 

spastic  constipation   |25 

simulating     enlarged 

liver  ..       330,  367 
gall-bladder        . .   253 

-  -  supraclavicular    gland 

enlarged  with  "      . .   380 

swelling  in  hypochon- 

drium  from  . .   629 

-  -  tabes  simulating   -183,  719 

tumour  with  12G,  130,  G59 

tympanites  from      . .   330 

vesicocolic  fistula  from  125  , 

visible  peristalsis  with 

77,  125,  120  j 

vomiting  from  .  .   330 

wasting  from. .  . .      77 

-  -  .I'-rays  and  bismuth  in 

diagnosing  77  (Fiff. 

53),  125,  354  I 

(and  see  Carcinoma  of  j 

Sigmoid ;     Carcinoma  I 

of  CfEcum  ;    and    Car- 
cinoma     of      Splenic  j 
l-'lexure)  I 
730  I 


in     portal     lissure 

simulating  . .   f 

of  pylorus  simulating  C 

dilatation  of  stomach 

;  from  . .  . .  1 

emaciation  from       . .  2 

j epigastric  tumour  from  f 

j fatty  stools  from      . .    i^ 

I  Carcinoma    of    duodenum, 
general  account  of   ■ .  G 

-  -  hteni;n.'iiM'n.    in.in    ..    i 

-  ~  jaui.illff.   troni         S.'.iK   i 

rarity  of  . .      272,  2 

secondary  in  left  supra- 
clavicular gland    . .  i 


simulating       enlarged 

gall-bladder        252, 

tumour  from  . .      272, 


Carcinoma,  contd. 

■  of  Fallopian  tube         . .   56 

■  fauces,  sore  throat  from  61 

■  —  submaxillary     glands 

affected  from        . .  37 

-  finger  affected  by  . .  24 

■  foot         38 

■  forehead. .  . .         . .   17 

■  gall-bladder,  cholangitis 

from    ..  ..      320,  33 

-  gall-stones  preceding     25 

■  ~  interscapular  pain  from 

401,  46 

-  -  jaundice  from  . .  32 

■  -  pain  in  hypochondriuni 

from    '         . .  .  .    15 


secondary  in  left  supra- 
clavicular gland  352, 

liver. .         . .  .  - 

simulating       enlarged 

gall-bladder  . .  : 

-  heart,  heart-block  from 
Carcinoma  of  jaw  72,  179. 


-  kidney,    aching   in   loin 

from    . .  . .         . . 

albuminuria  from     . . 

Cheyno-Stokes  breatli- 

colic  from      . .         . . 

-  -  iFiff.  304)      . . 
hiematuria  from 

kidney  enlarged  in  27S. 

liver  "displaced  by    . . 

cedema  of  legs  fi-om . , 

polypus  of  heart  from 

rarity  of        . .  . . 

secondary  in  left  supra- 
clavicular gland    . .   : 

simulating      enlarged 

gall-bladder  . .   : 

Carcinoma  of  kidney,  veins 
invaded  by     ■ . 

-  labium    majus  . . 

-  larynx,    cervical    glantls 

affected  by  . .  l 
distinction  fi"om  sypli- 

ilis    . .         . .         . .   '. 

dysphagia  from        . .  : 

haemoptysis  from      . .  : 

microscope  in  dingnos- 

Carcinoma  of  larynx,  notes 
on  ..     616,  I 

sore  tlu'oat  due  to     . .  I 

stridor  from  . .         . .  I 

submaxillary  glands 

affected  from  . .  '. 
unilateral    chs 


199, 


leg 


bile-duct    obstruction 

simulating  . .         . .  ; 

and  cirrhosis  associated  i 

cirrhosis  simulating      3 

371.  ; 

coma  from      . .  . .   ; 

diabetes   sunulating..    ; 

-  -  drvsliriv.'lIed^kiiLuirh; 
--  eo'si.iopl'iti.i   uitli       ..    ■ 

-  -  extn-nir  w.i-r.N-  iM.in  / 

-  -  gall-tiMM..    Mninliitir.g   : 

Carcinoma  of  hver.  general 
account  of      - .     331,  ! 


CARCINOMA. OF  LIVER  CARCINOMA    OF  STOMACH 


•  -  leucocytosis  with      . .  .ITi 

■  —  liver  enlarged  from  46,  50, 

52,  252,  326,  330,  373 

■  -  pain    ill    epigastrium 

from  . .  . .   437 

hypochondriiim  with  450 

■ liver  from  . .  . .   373 

right  arm  from      . .   373 

shoulder  from   . .  373 

■  -  peritonitis  over  . .   373 
larcinoma  of  liver,  primary 

52,  374 

-  pTrexia,     from     {Fitj. 

'145)   326,  373,  570,  574 

-  rapid  increase  in  size  of  373 

-  secondary  to  colon  232,  630 

■ duodenum  . .  252 

■ gall-bladder.  . .  252 

■ pancreas     . .         . .  252 

■  -■  ~  rectum        . .     252,  585 

-  -  stomach     107,  252,  630 

-  sense  of  dragging  from  373 

■  -  -  fullness  from  ..   373 

-  sfcodaic  resonance  with  611 

-  sudden   enlargement 

from   hsomorrhage 
into  ..  ..37! 

-  syphilitic  liver  sinmlat- 

ing 372 

■  ~  unibilication  with  371,  373 
lung  . .  . .      287,  200 

■  mammal  (see  Carcinoma 

of  lireast). 

■  melanotic,  of  skin         . .  730 

■  microscope  in  diagnosing  731 

■  of  nipple  ..  .'.   429 

•  nose,  discharge  from    . .  179 

■  -  submaxillary  glands 

aiTected  from         . .  379 

■  oesophagus,  age  incidence 

of     ..         .,      195.  380 

■  -  aneurysm     simulating  195 

■  -  annular  stricture  from  266 

■  -  aspiration   pneumonia 

from  . .  . .  259 

■  -  bismuth  and  x-rayR  in 

diagnosing  (Fuj.  97)  197 

■  -  bougie  in  diagnosing     195 

•  -  bronchus  ulcerated  by  287 

•  —  carcinoma  of  stomach 

simulating  . .  . .   195 

•  -  cervical  glands  affectod 

by    ..         198,  380,  495 

■  -  dysphagia  from   195,  266, 

435,  461 

■  -  fistula     to     bronchus 

from  . ,  . .  259 

■  -  haomatcmcsis    from 

265,  266 

•  -  hajmoptysis  from      . .  287 

•  -  interscapular  pain  from  461 

■  -  latent 380 

■  -  mediastinal        glands 

aJIectcd   by  . .  495 

•  -  pain  in  chest  from     . .   435 

•  -  pneumotliorax  from..  531 

•  ""  pyopneumopericar- 

diinn  from  . .         . .  652 
.  -  serondr.ry    in    glaiuU 

196,   380.  495 


196 


rigiit    supraclavicu- 
lar eland  . .  380 

-  simulated  by  mediasti- 

nal growth..  ..  267 

-  -  skiagram  showing     . .  196 
stridor  from   . .  . .  651 

-  -  trachea  invaded  by..  051 

-  vocal    cord    paralysiji 

from  ..  ..  495 

vomiting  due  to        . .  703 

a--ravs    in    dljignosing 

195,  (Fig.  97)  197,  461 

-  ovary,  anuria  from       ..     41 
' —  ascites  from  . .         . .     49 
inguinal  glands  secon- 
dary to        . .  . .    G79 

*•  ~  malignant    pcritonitU 

from  . .     49 

1-  -  retention  of  urine  from  649 

-  -  secondary  in  left  supra- 

clavicular  gland    . .  38U 
^  -  simulating  cauda 

equina  tumour      . .     63 

-  -  strangury  from  . .  6  111 
*■  -  ureters  obstructed  by     II 


Carctiioma.  conld. 

-  palate,    cerrical    glands 

affected  by     . .      379,  380 

foul  taste  from  . .  705 

microscope  in  diagnos- 
ing . .         . .         . .  588 

sore  throat  from       ..  613 

-  pancreas,  anaemia  from    661 

ascites  from   . .         . .     49 

bile  pigment,  in  urine 

from  ..  ..101 

Cammidge's   reaction 

with       51,  52,  100,  630 

carcinoma    of    duode- 
num simulating    ..  661 

diagnosis    from    pan- 
creatitis     . .  . .   239 

dilatation  of  stomach 

from  . .         . .   174 

fat  in  fseces  with  51, 

101,  239,  330 

gall-bladder    enlarged 

with  51,  254,  326.  330, 
451,  630 

glycosuria  with       51.  330 

iodine    co-elBcient    of 

urine  in      ..         ..100 

jaundice  with  51,  239,  254, 

320,  330,  451,  630,  661, 
662 

liver  tumour  simulated 

by 330 

malignant    peritonitis 

from  . .         . .      19 

-  -  occult  blood  with     . .  101 
pain  in  hypoehondrium 

from  . .  . .  451 

pancreatitis  with      . .  100 

portal  glands  enlarged 

from  ..  ..   329 

pulsation  over  . .     51 

transmitted  by      ..  330 

secondary  in  left  supra- 
clavicular gland    . .  380 

liver  . .         . .  252 

stercobilin  absent  with  101 

stomach  growth  simu- 
lated by      ..  ..   330 
swellmg  in  hypoehon- 
drium from  . .   629 

undigested  muscle  li- 

bres  in  faeces  with . .  1 01 
wasting  from  . .  661 

-  parotiil  eland     . .  . .   695 
Carcinoma  of  penis,  general 


account  of 

ti[" 


-  pai 
uU'i 


Carcinoma  of  perineum    . .  620 

aching    in     perineum 

from  . .         . .  474 

inguinal  glands  involv- 
ed from      ..      381.  621 

-  peritoneum  47.  49,  657 

-  pharynx,  cervical  glands 

affected  by    . .      379,  380 
sore  throat  from       . .  613 

-  prostate,  aching  in  jieri- 

neum  from     . .  . .   474 

age  incidence  di         . .    394 

rulculus  simulating  . .   470 

Carcinoma  of  prostate,  char- 
acters of  ■ .  470 

~  -   lK.-i.i;.turi;.  iVoin  ..    -.'Hi 

-  -  iio<'tnni;il     nii.-tniitioi) 

with  ..  ..    394 

not  uncommon  . .  277 

pain  in  penis  from        4 

470, 

rectal  examination  in 

diagnosing  . .     470,  i 

retention  of  urine  from  i 

secondary    In    crani:il 

hones  . .         .  ■ 

spine 

strangury  from         . .  > 

symptoms  liko  those  of 

ndenomntouH       en- 
largement . .         . . 

-  pylorus  .see    Carcinoma 

of  Stomach) 

-  rectum,  age  incldcuco  of 

79,  129, 

-  albuminuria  from     . . 


Carcinoma  of  rectum,  cinttl. 

ascites  from  . . 

backache  from  . .  ■ 

bearing-down  pain    in 

bladder    invaded     bv 

238,  283,  394,    575. 
582,  I 
blood  per  anum  from 

and     nuiciis     stools 

from        . .      45",  < 

cachexia  from 

carcinoma  ca^ci  simu- 
lated by      . .         . . 

constipation  from  78, 

453,  i 

diarrhcea  from         78,  ; 

difficulty  in  defaecation 

from 

distention  of  caicum 

distinction  from  vener- 
eal ulcer     . . 

dyschezia  from 

emaciation  from 

fajcal  lu-inc  from 

faeces     per     urethram 

with 

flatus     per     urethram 

with  . .  . .   . 

fretiuent      micturition 

Carcinoma      of      rectum, 
general  account  of  . .  I 

-  -  i,'l;i!ids  iTif<vt..'(l   fn.ni      . 

liEcmaturia  from  7.275, 

impacted  fseces  simu- 
lating . .  . .  ' 

incontinence   of  fceces 

with  . .         . .  ; 

intestinal    obstruction 

from  . .         . . 

jaundice  from 

latent  

leucocytes     in     urine 

from    . . 

loss  of  strength  from 

weight  from 

malignant    peritonitis 

from 

microscope  in  dia- 
gnosing 

mucus  in  stools  from 

wdema  of  legs  from . . 

pain  in  back  from    . . 

on  defajcation  witli 

in  iliiu;  fossa    from 

452,  453, 

penis  from         471, 

over  sacrum  from. . 

down  thighs  from 

periproctal      abscess 

from 

-  -  piles  from 

polypus  simulating  .. 

portal  glands  enlarged 

from 

proctoscojio  in  dia- 
gnosing 

pyuria  from  . . 

rectal  examiinttion  in 

78,  129,  130, 

renal  tube  casts  with 

ribbon-like  fnjccs  from 

sacral  plexus  Invadeil 

by 

-  -  secondary  in  left  supra- 

clavicular gland    . . 

-  -  in  liver       . .      252, 

sense  of  fnllnr'si  from 

-  -  signidiil' 


s.  12 


71     Carcinoma  of  rectum,  signs 


of 


^limulatlng    acute    ne- 
phritis 

-  -  '  Cauda  equina  (uinour 

-  '  speculum  In  <U'twtinff 

-  ■-  strangury  from         . .  ) 
strlclure  from  . .  - 

—  tidlpcit  from  . . 

IcnoHnuifl  from 

thrombosln  front 

ulcrrntlon  of  . .         . . 

unHatisflcd  dofiocatlott 

with 

—  wntiMnfl:  from . . 

—  without  nymploms  . . 


Curciuowa,  fonid. 

-  of  rib,  tenderness  from 

-  scalp 

Carcinoma     of      scrotum, 
general  account  of   . .  i 

-  sigmoid  colon,   bisninili 

and    x-rays     in     dia- 

bladder  invaded  by  . 

opened  by      238,  . 

blood  in  stools  from  i 

and   mucus  from 

cachexia  from        . .  > 

carcinoma  cajci  simu- 
lated by. .         . .  ■ 

colloid  change  in  . .  i 

constipation  from . . 

distention  of  ciecum 

diverticulitis    simu- 
lating     ..         ..I 
explosive    diarrha-a 


impacted  f:T;i'os  simu- 
lating      . .  . .   ■ 

obstruction        from 

459,  666,  ) 

operation  in  dia- 
gnosing ..         ..I 

pain    ill    iliac   fossa 

from         452-454,  • 

lialpable  tumour  witii- 

pyuria  from  . .  i 

sigmoidoscope  in  dia- 
gnosing  . .      453,  I 

spastic  constipation 

simulating  . .  ' 

swelling  in  left  iliac 

fossa  from  . .  i 


tent-s 
tnb<*r 


^  fn.i 


Carcinoma  of  skin,  general 
account  of 

-  lupus  sinnUiit.-d  l.y   .. 


lating  ..  ..7 

-  -  syphilis    distinguished 

from  . .         . .    I 

from  voricose  uh-er  . .  7 

from  .r-rays   , .  . .  'J 

-  of  spinal  cord,  malinger- 

ing simulated  by       . .    I 

pain    in    the    clitst 

from        . .         . .    I 

-  of    spine,     intersc^apular 

pain  from       . .         . .    I 

-  kyphosis  from  . ,    1 
malingering  simulated 

by  " I 

secondarv     to    breast 

151,  f 
; thyroid  gland         ..   ( 

!  Carcinoma  Of  Splenic  flexure, 
I  oeneral  account  of     .  G 

-  stermiin.tetidi-rncssfrom  i 

-  stomach,  abdominal  tu- 

mour with      . .      270,  'ii 

-  -  acctonuria  from 

age  fncidencc  of    269,  3 

albumosuria  with     . . 

-  -  anmmiu  in   33,   270,   2 

316,  II 

-  -  an:vs(lietic     in     dia- 

gnosing       . .  . .   *J 

-  anrurvsni  simulated  by 

{Fih  288)   . .  . .   I 

-  -  anoroxu  from  . .  '. 

-  -  -  nervosa     simulated 

by  ..  ..I 

-  -  nscltcM  from  . .        51,  : 
~  -  hilo-ductolwtnir(edl»y  : 

-  -  blood  changcK  with  . .  : 

cfXAmimitlfMi  In     ..  '. 

In   gastric   rontenis 

with        ..        ..  :i 
i>nche,\la  frqm  . .   *. 

-  -  carcinoma      of      duo- 

denum Hlmulathig. .  > 

fVMophagUH     Hlmii- 

liitlng       ..          ..  1 
•  pnncreas  HJinulallng  ? 


CARCIXO.MA   OF  STOMACH 


CATARACT 


0/  utoiiHii-li,  amliL 
-  —  coffee-ground      vomit 

from  . .  , .   ; 

colour  index  in  . .   : 

cyst  simulating         . .   C 

deposits     in     round 

ligament  from       . .  ( 

at  umbilicus  from. .  f 

diffuse,     difficulty    of 


\C' 


diaj? 


107 


indiarubber     bottle 

stomach  from    . .    107 
multiple  serous  effu- 
sions from  . .  107 

secondary  in  liver. .   107 

senseof  fullness  from  244 

skiagram  of  . .   270 

without    symptoms  243 

dilated  stomach  from 

174,   271,  316,  653, 

678,  7G7 
disinclination  for  meat 

due  to         . .        43,  316 
distinguished         from 

ulcer  by  x  rays     . .  174 

dyspepsia  from  . .  316  ; 

simulated  by     270,  769 

-  -  dysphagia  from        . .  195  i 

epigastric  paiti  from. . 

tumour  with 

fragments  of  growth 

vomit  .  .  . .    7GG 

Carcinoma     of     stomach, 
gastric  HCI  in  3:i,  3l<;. 

270,     436,     (130,     653, 

760,    767 

—  gastritis  simulated  by  270 


317 


0/  stomach,  co7i(i!. 

-  sex  incidence  of        . .  316 

-  simulating  cirrhosis. .   272 

enlarged  liver        . .  367 

gall-bladder    352,  253 

fungating     endo- 
carditis  . .  . .     21 

pernicious  ansemia       31 

-  sites  of  . .  . .   316 

-  skiagram  of    . .  . .    269 

spleen  simulated  by. .  630 

spontaneous     fracture 

first  evidence  of   . .    243 
subdiaphragmatic   ab- 
scess from  . .  . .   531 
-  -  sw.'llin-  j„   hvpoL-hon- 

dnuru  £ronl  .  .    62lt 

Carcinoma     of     stomach, 
symptoms  of  . .         . .  270 

tumour  due  to        318,  660 

ulcer  simulating    174,  269 

from  ulcer       . .      316,  653 

umbilical  tumour  from  483 

-  -  vomiting     270,      316, 

436,  630,  678,  765,  767 

wasting  from         . .  678 

.r-rays    in    diagnosing  I 

174,  271,  630,  678   ' 

without  symptoms  . ,   243  I 

in  young  subjects   . .  653 

-  suprarenal,  ascites  with     51  ! 
simulating       enlarged 

L'all-hlnddfr  :ij2,  253 
Carcinoma  of  testis  4tfU  euti 
secondary    in    cranial 


gnosmg 
::arcinoma     of     stomach, 
general  account  of  269. 


:;k.  630 


-  heartburn  from         . .   297 

-  hiccough  from  . .  308 

-  hysterical    vomiting 

simulated  by         . .  467 

-  in  iliac  fossa  . .  . .   678 

-  interscapular  pain  from 

461,  462 

-  jaundice  fi-om        329,  330 

-  lactic  acid  with        . .   767 

-  laparotomy     in     dia- 

gnosing    174,    271, 

317,  653,  769 

-  leaking  ..         ..531 

-  leucocytosis  from     . .  630 

-  loss  of  appetite  from 

43,  316 

strength  from        . .   270 

weight  from  270,  316,769 

-  malignant    peritonitis 

from  . .  . .     49 

-  nausea  from  . .  270,  316 
~  occult  blood  with  630,  767 
in  fieces  from  126,  317 

-  Oppler-Roas  Jjacilli  in 

31G.  ::is,  ;:-io.  ir.a,  767 

-  pain  ifi  rlir  i,;i<-[;  i,-.,in  710 

-  -  ei)iL-;(-iMNfii    hMHi 

:;ii;,  436 

after  tood  irom     . .   G30 

in    the    left    hypo- 

chondrium  from     450 
shoulder  from        . .   474 

-  pernicious     anaimia 

simulating  . .      274,  317 

-  phantom  tumour  simu- 

simulating  . .  . .   659 

-  pneumothorax  from..  531 

-  portal  glands  affected 

from  ..      329,  330 

-  ptyalism  from  . .  543 

-  pyloric  end,  skiagram  270 

-  pyloric        obstruction 

from  270,  297,  318,  653 

-  pyrexia  from..  ..  270 
arclnoma  of  stomach,  rectal 


-  glands  with 

-  in  left  supraclavicu- 

lar gland 

-  in   iieritoneuin 


714 


Carcinoma  of  thyroid  gland, 
general  account  of  . .  721 

secondary    in  bones 

204,648,072,711, 

714,  721 
-  tongue,      blood-spitting 
from    . . 

bronchopneumonii 

from  . .         . .  289 

cervical  glands  affected 

by 380 

dysphagia  from         . .    198 

earache  from. .  . .   202 

foul  breath  from       . .     87 

Carcinoma  of  tongue,  general 
account  of  (J'/nir 
A'-VA7/) 

lateral  position 

from  leukoplakia 

submaxillary     glands 


285 


738 

379 

739 


I  Carcinoma  0/  uterus,  contil. 

hajmaturia  from    275,  283 

hiccough  from  . .   308 

hydronephrosis  from       41 

metrorrhagia  from  390,  391 

metrostaxis  from       . .    392 

microscopical  diagnosis 

186,  390,  391 

pain  in  back  from     . .    710 

in  legs  from  . .   469 

in  pflvjs  from         .  .    469 

pelvi.'  ^ui'iiiML'  .lur  rn  688 

polypii-   -iiiiul  ,nii_-    ,  .    391 

-  -  pyeluii.  |.hi,u~  iruia  ..    576 

pyometiLi  Irum       iSG,   392 

pyonephrosis  from    ..   577 

pyuria  from   ..  ..   575 

rectum  opened  by    . .   238 

simulating  Cauda  equina 

tumour        . .  . .      C3 

sterility   from         645,  646 

strangury  from  . .   649 

tubercle  simulating  . .  391 

ureters  obstructed  tjy    41 

urine     leaking     into 

vagina  with        283,  582 

uterus  enlarged  from  391 

vaginal     examination 

and  . .         . .         . .     41 

-  uvula,  sore  throat  from  613 

-  vagina,  aching    in    peri- 

neum from     . .  , .   474 

bladder  invaded  by..   283 

difficulty    iw    micturi- 
tion with    . .  . .    395 

haematuria  from    275,  283 

inguinal  glands  second- 
ary to  . .  . .    381 

urine  leaking  through 

283,  582 

-  of  vertebrae    (see    Carci- 

noma of  Spine) 

-  vesical    (see    Carcinoma 

of  Bladder) 

-  of  vulva. .  . .  . .    702 

chancre  simulating  . .   70U 

difficulty    in    micturi- 
tion with    . .  . .  395 

from  leukoplakia      . .  701 

spread  to  perineum..  620 

Cardiac  crises,  in  tabes    . .  487 

-  dulness    absent    in  em- 

physema    . .  . .  217 

-  hypertrophy  (see  Heart, 
Enlarged) 

>•'■  (see  Heart  Im- 


Caries],  dental,  contd. 

ulcerative     stomatitis 

from  . .  . .   7  4i 
(and     see     Pyorrhoea 

Alveolaris) 

-  of    ear  bones   (and    see 

OtorriiCEa)   ..         422,  42; 

-  pubic     bones,     gumma 

simulated  by. .         . .  G91 

sarcoma     simulated  691 

scrotal  swelling  fiom  69; 

-  rib,   pain   in   the   chest 

from 431 

-  sicca        71^ 

tenderness     of     spine 

from  . .  . .   7Ii 

Caries  of  spine  (see  Spinal 
Caries)  . .         . .    15^ 

Carminatives,     heartburn 

relieved  by    . .  . .  297 

Carnin,  uric  acid  from     . .   742 

Carotid  artery,  forcibly  pul- 
sating   207 

Carotid    pulses,    unequal, 

from  aneurysm  . .    208 

Carpal   joints,    pulmonary 

arthropathy  of         . .  352 

Carpenter's  itch    . . 

Carpenters,  serratus  magnus 


540 


506 
Carpopedal     contractions, 

in  rickets       . .       152,  420 

tetany  . .       152,   730 

Carpopedal  spasm . .  3 

-  -  in  infants       ..  ..152 

Carpus,  tuberculous  disease 


of 


Carriers,  typhoid  . . 
Cartilage,  on  exostosis    . . 
-  internal  semilunar,  kick 

on,  shock  from 
-  vomiting  from  . . 

emi.ti.iar.    dis- 


668 
t54 


shelf  and 


587 


nni:iry  -l;nids  with 
n7,    ;;17,    329,   330, 

380,  381    I 
1  left  snpruclaviou-  | 

lar  gland  107,317,380 


^lifetted  from         ..    379 

-  -   in!,.  1,  I,.  -DMuiutiDg  ..   740 

i     il  ited   by  729 
Carcin  una  of  tonsil         ..   615 

-  ■         'l!.|n  LMll   ny        glands 

;ilYe<.-ted  from         ..   379 

-  trachea,  stridor  from  . .  650 

-  urethra,   discharge  from  184 

histology  in  diagnosing  184 

inguinal     glands     en- 
larged from  . .    184 

]iain  from       ..  . .    697 

painful    micturition 

from  ..  . .    1S4 

stricture  from        1S4,  G97 

Carcinoma  of  uterus,  anuria 
from    . .  39,    41 

bladder     invaded     by 

238,   283,   394,  575, 

582,  649 

bleeding  on  examina- 
tion - .  . .  201 

body,   pregnancy   im- 
possible with         . .  392 

broad      litrament      in- 

[ilr,:„,.,i  M-  ..     41 

-  ■  '  "ii[i  I-,.  Ill  ,|iai_;nosing  390 
~        'K    '■Im  .m  I    Innn  ..    129 

200 


pulsp) 

-  sound  (sec  Heart  Sounds) 
Card io -respiratory  bruit  .      90 
Cardiospasm  . .     198.  435 

Cardiosclerosis,      auricular 

fibrillation  from        . .   548 

-  heart-block  from  . .   546 

-  paroxysmal  tachycardia  j 

from     ..  ..      548,  549  \  CarunculEemyrtiformes,  in- 

Caries  of  bone,  spontaneous  j  flamed  in  gonorrhcea    700 

fracture  from    242,  243     Casein    indigestion,   stools 

""  ^■■'- '"  "        ,.  668  with 171 

, .  243  I  Caseous  glands  (see  Lymph- 


placement  of 

loo^t 362 

-  ulcerated  by  lupus       . .  402 

-  urate  of  sodium  in        . .   344 
Cartilages,     blackened     in 

ochronosis       . .      528,  746 
Caruncle,  uretlu-al,   bleed- 
ing from         . .  . .    702 

dyspareunia  from      . .   193 

inflamed,  retention  of 

urine  from  . .  649 

levator       ani      spasm 

from  ..  ..193 

pain  from       . .         . .  702 

prolapse  of  urethra  si- 
mulating    , .         . .  701 

strangury  from  . .   049 

vaginismus  from       . .   193 

vulval   swelling    from  700 


x-rays  in  diagnosing. .   343 

(and  see  Tuberculosis 

of  JRone) 
-  dental,     antral     abscess 

from     ..  ..      ISO,  462 

bleeding  gums  from        73 

blood-spitting  due  to     285 


atic  Glands) 


..   430 
;  itch  250 


die  fro 


,  and 


-  erosion  simulating 

-  with  fibroid    . .         . .  391 

-  foul    discharge    from 

185,  180,  391 

-  fre':]uent      micturition 

from  , .  . ,    .",9.1 


-  -  ei)itlielio 

epulis  from     . .         . .  GS  I 

face  swollen  from     .,  67  t 

foul  breath  from      . .     s; 

taste  fi'om  . .  . .    711,1 

gastritis  from  , .   317 

hidden  . .  . .     73 

inflamed   neck  glands 

from  . .  . .  370 
loss  of  weight  from  . .   769 

-  -  neuralgia  from  296, 447, 448 

pain  in  jaw  from     ..   462 

ptyalism  from  . .   542 

retraction  of  gums  from  589 

stiff  neck  from  . .  647 

tongue  swollen  from. .   698 

trigeminal      neuralgia 

from  , .         . .  447 

ulcer    of    tongue  from 

198.  739 


Casts,  bronchial  ..644 

Casts,  decidual  . .   193 

Casts,  intestmal  {Fi>/.  172) 

398,  399,  519 

-  prostatic  ..  ..399 

-  rpnni     (see     Tube-Casts) 
Casts  of  uterus      . .      192,  193 
Casts,  vaginal        ..         ..186 
1  jt;il''|p,-\ .   absence   of   fa- 
tigue in  . .  . .   596 

-  bradypncea  in    ..  84,  85 

-  dementia  and    . .         . .  598 

-  dilated  pupil  from         . .   552 

-  maintained   attitudes  in  598 

-  melancholia  and  . .   598 

-  retracted  head  from    . ,  589 

-  risus  sardonicus  in       . .  598 

-  trismus  from     . .         . .  729 
Cataract,    anterior    polar, 

from  ophthalmia  neo- 
natorum        . .         . .  759 
ulcer  of  cornea      . ,  733 

-  black  spots  before  eyes 

from    . .  . .       ' . .     7*-' 


CATARACT 


CERVICAL  (iLAND 


\tarac(,  amhl. 
blindness  never  complete 
from    . .         . .  . .   7G1 

congenital,   nystagmus 

from 407 

in  diabetes         . .         . .  "201 
diplopia  from     ..  ..   175 

extraction,    erythropsia 

after 7B2 

multiple  images  from  . .  175 
ophthalmoscope  in  dia- 
gnosing . .  . .  175 
itarrh  of  bile-ducts,  clay- 
coloured  stools  from  326 
~  jaundice  from  . .  326 
oervical,  backache  from  468 

-  sterility  from  . .   646 
of   duodenum,    pain    in 

shoulder  from  . .  474 

nasal,  anosmia  from     . .   612 

-  from  arsenic  . .  . .  612 

-  common  cold  . .   612 

-  epistaxis  from  . .  220 

-  hay  fever       . .         ..  612 

-  iodide  . .         .'.  612 

-  in  me;isles       .,  ..612 
^  MM.riM-  i\\w  to  ..    C13 

tarrh  of  small  intestine, 
causes  of  ■ -    172 

Jx.mdiee,  Catarrhal) 
iterpillar  hairs,  dermatitis 
from    . .  ..  ..   755 

-  pruritus  from  . .  540 
ttbeter,    coud6,    for    en- 

larf^ed  prostate         . .  396 
in     diagnosing    bladder 
distetition        45,  665,  688 

-  calculus     in     jirostate 

470,   473 
itheter.     in     diagnosing 
cause  of  pyuria         ■ .  575 

-  urethral  stricture      . .  394 
in  obtaining  urine  cul- 
tures   . .  . .       218,  455 

ureteral,    in    diagnosing 
stone  in  ureter  ..  455 

hra,  discharge  di 


Caustic  soda,  contd. 

Nylander's  test  . .   262 

in  producing  hsematin  284 

Cauterization     for      ulcus 

serpens  . .  . .  734 

,  Cavernitis  . .  . .  . .   473 

Cavernous  breathing',  over 
I  fibroid  lung   ..      168,  21G 

-  sinus  (see  Sums,  Caver- 
1  nous) 

'  Cavitation,  in  phthisis     . .   643 

Cayenne  pepper  deposit  in 

urine 741 


to 


181 


ithet*rization,  anuria  aft«r 

42,  396 
death  after  . .  . .  396 
epididymo-orchitis  from  478 
ri;.'or  after  . .      594,  595 

ii   .  r. -r  from  bite  of    ..   598 
1   !  tiirax  from       ..  559 

'  ji'iliocancUataand  519 
111!  I  <  iiinii,  gumma  of      62 

-  -  i.(-ri|ihenil      neuritis 
simulated  by. .         . .  515 

-  lesions,  acute  bedsore 

from  ..  ..258 

gangrene  from       . .   255 

relaxed    sphincter 


,\-ith 


of 


314 

62 


auda  equina,  tumour  of, 
general  account  of    .  ■ 
—  -  muscle  wa-sting  from 
61. 

pain    in    the    back 

from        . .        62,  5 

leg  from  . . 

paralyzed  leg  from 

one  leg  first  from  5 

paraplegia  from  514,  5 

pelvic  tumour  simu- 
lating 

peripheral     neuriti.-* 

simulated  by     . .  5 
U.D.  from  ..         61, 

-  -  rectal  examination  in 
sacro-iliac  joint  di- 

ucnse  simulating 

sciatica  simulated  by 

62,  A 

-  —  vaginal  examination 

biLstic  potash  (see  Pota«h, 
Caustic) 
soda,  in  acetone  test    . . 

-  in  biuret  test . . 

-  estimating  acidity    . .  2 

-  examining  for  elastic' 

fibres  ,.        8i;,  ( 


,'ith 


592 


paraplegia  from         ..  514 

retracted    bead    from 

589,  592 

scanning  speech  from  517 

sphincter  troubles  from  517 

tendon  reflexes  exag- 
gerated with  . .   592 

vertigo  from  . .  . .   752 

vomiting  with  ..  617 

Cerebellum,  abscess  of  (nco 
Abscess,  Cerebellar) 

-  centre  for  equtlibrium. .  751 

-  nm-ephaliti-s     of.     ninw 

frnni '-^ 


'Cellists'  cramp     . .  . .   151 

Cellulitis,  froTii  abraded  toe  410 

-  bacteriological  diagnosis  413 

-  of  calf,  talipes  from     . .   114  i 

-  carbuncle  simulating    . .   559  . 

-  from  dissection  .wounds    240  j 

-  erythema  from  . .  . .    222  | 

-  gout  simulated  by        . .  410  , 

-  leucocytosis  with  . .  410  , 

-  of  neck,  from  actinomy- 

cosis   . .  . .  . .   683 

stridor  from  . .         . .  651 

-  cedema  from     410,  413,  415 

-  orbital,        distinguished 

from  cavernous  sinus 
thrombosis     . .  . .  230 

exophthalmos    from..   229  ' 

tubercle  simulating  . .   230 

j  Cellulitis,  pelvic,  notes  on..  691 

-  pelvic  swelling  due  to   ..   688 
I  —  pyrexia  with      . .  . .  410 

-  red  streaks  in     . .  . .  410 

-  from  septic  finger  . .   410 

-  sinus  thrombosis  from. .  229 
Cellulose,    acetate    of,    in 

'  aeroplane  varnish      . .  334 

Central  canal  of  spinal  cord    62 
Centre,    cheiro-kiniesthetic 

iFig.  266)       . .  . .     624 

-  glosso-kiniBsthetic     (Pvj- 

266) 624 

-  for  vomiting       . .  . .   764 
Centres  in  brain,  for  speech 

(^Fig.  266)       . .  . .   624 

I  —  micturition         . .  . .   397 

-  reOex.  in  cord  iFig.  211)  51S  [ 
Cerebellar  artery,  posterior, 

effects  of  lesions  of   . .     58 

-  atrophy,    after    specific 

fevers      . .  . .      . .   729 

tremor  from  . .  . .   729 

-  hajmorrbace        . .      53S,  768   ' 

-  peduncle  lesion,  tremor  i 

from    . .         . .  .  -  729 

-  tracts,  role  in  co-ordina- 

tion    . .  . .  . .     55  I 

-  tumour,      anile  -  clonus 

from 517  j 

ataxy  from     58,  517,  593  i 

Babinski's  sign  with. .     68 

bradvpnoea  from      ..     84  | 

cerebellar   abscess   si- 
mulating    . .  ..  517  ' 

(iisHcniitiated   sclerosis 

sin.Nlatin-  ..  -.517 

-  falliriL'tnon.-sidcfrom  592 

-  -  lieadiiclio  with  . .   517 

hesitant  voice  from..  517 

hypothermia  with    . .  311 

intention  tremoi*from  517 

knee-jerk    increased 

from  . .  . .  517 

lateral  sclerosis  from        68 

nystagmus    with   407, 

407,  -^'l''.   592 

obesity  from  ..     408,  4ln 

optic  atrophy  from  . .  592 


Ccrehdlnm.  lesions  of,  omtd 

gait  with        . .  . .     58 

nystagmus  from        . .      59 

-  —  speech  changes  from        59 
vertigo  from  . .  . .     5S 

-  reeling  from  disease  of. .   251 

-  rule  in  co-ordination    . .     55 
Cerebral       abscess       (see 

Abscess,  Cerebral) 

-  aneurysm  (see  Aneurysm, 

C.-n.-hral) 

-  ;lrt.■lir^,  ;,tll.Toln:l  of  1,  406 

Cerebral    disease,    general 

signs  of  organic         .  ■  295 
Cerebral  dwarfism  . .    188 

-  ftniM,li-Mt[^r,   I  iiiholisni, 

\  .■vl.i-.ili 

-  ii.riiinrrilML-r       (  ^r,-       \l:V.- 

niorrliage,    L'erebral) 

-  tumour,  hypertension  of 

cerebrospinal  fluid  with  304 

-  peduncles,    ataxy     from 

lesions  of       . .         . .     58 

-  softening,  albuminuria 


vitli 


495 


from  arterial  degenera- 
tion ..  ..10 
caisson  disease  . .    10 
Cheyne-Stokes  breatli- 


Cerebrai  tuinour,  cnntd. 

hyst«ria  simulated  by  727 

insomnia  from      321,  322 

Jacksonian     epilepsy 

from  ..      137,  14  7 

knee-jerk  lost  with  . .  359 

latent  . .  . .  . .   3U"' 

lead    poisoning  simu- 
lating        ..         ..  ll;t 

lumbar    puncture    in 

diagnosing  . ,         . .   525 
I lymphocytes  in  cere- 
brospinal fluid  in  . .  305 
myxoedema     simulat- 

noises  i\\  the  head  from  4nr, 

obesity  with  . .  . .  41u 

optic     neuritis     from 

147,  264,  315,  429, 
502,  525,  537,  626,  711 

pain  in  the  face  from    447 

foot  from    . .         . .     6S 

paralyses  from       147,  315 

paresis  from  ..  . .   711 

—   -  unilateral  from      . .    118 

photophobia  from    , .  52r» 

pupil  small  with      . .  552 

without  signs  of  pre 


C02 


ing  from      . . 

lOS 

simulating     cerebral 

-  -  deep  reflexes  increased 

bajmorrhage           . .  300 

from 

72D 

trance         . .         . .   120 

diplegia  from 

515 

softening  round        . .  30ii 

-  ~  frcmi  einbuIiMU       lOS, 

515 

taste  loss  from        . .  705 

-  ■-  fi  .1  ii'r  I'ii  I 

S15 

tenderness     of     scalp 

_       1   p  1 1      ■,  ^  i  - 

108 

from            ..      710,  711 

-            1     .  i.    ;;:     ,         ::  ti 

■195 

tremor  from  . .     724,  727 

-  -     1,     In  '  |,',  1 1   ..  •  ,   irnm     .  . 

309 

tic   douloureux   simu- 

_ _    [1 .111,  ill' li.i^'e     . . 

515 

lated  by     . .         . .  447 

1  ,M  r  ■■  il  |i  .i,il,vsisfrom495 

tinnitus  from            . .  723 

inn  r.ii  i.iiliii.'  from. . 

725 

uraemia  simulating   . .     85 

-  -    |i,ir  ill  -1-  iL'ii.inssimu- 

—  vertigo  from  . .         . .  752 

lutcd   hy      .  . 

725 

vomiting    from,    147, 

paraplegia  from 

514 

204,  302,  300,  315, 

pseiido-bulbar  paraly- 

429, 502,  525,  537, 

sis  from 

589 

020,  711,  705,  7GS 

rigidity  from . . 

725 

visual  aura  with      . .     I'.K 

round  an  abscess 

300 

-  vein  (see  Vein.  Cerebral) 

a  tumour    . . 

300 

Cerebral  vomiting  84,  295. 

sphincter  trouble  from 

725 

315.  767 

from  syphilis..       lOS 

515 

Cerebritis  (see  Encephalitis) 

thrombosis     . , 

515 

Cerebrospinal     fever    (see 

weakness  from 

725 

Meningitis,      Cerebro- 

-  syphilis    (see      Syphilis 

s al) 

Cerebral ) 

-  fliiiil,    Mlliuniiri     ,■!      Irii.v 

-  thrombosis  (sec  'rlnoni- 

..nl\     ill               ..            ..     I-", 

hosis,  Cerebral) 

Cerebrospinal  fluid,  bacteri- 

- tumour,  ajihasia  from.. 

(12G 

ological  examination  of  303 

arteriosclerosis    simu- 

 cultures,  in  diagnosing 

lating 

295 

septicaimia..         ..  .'lU: 

atrophy    of    masset<jr 

in   diagnosing  menin- 

from 

•147 

gitis 590 

aura  with 

08 

Cerebrospinal    fluid,    from 

Babinski's  sign  with . . 

08 

ear      ..                119.421 

brachial      monoplegia 

-  -  IVldiiig's  solution  re- 

from 

002 

diiicd  liy    ..          ..    17> 

-  -  l.iM.lv.nili,,    irom    8't 

711 

Cerebrospinal  fluid,  general 

_        III  nh  1 1    li'iini 

84 

characters  of. .      304,  305 

- M    -iMlr.lircuth- 

-  -    ill     L'rnrr.il      [iiiriilvsis 

lir-    liMiii 

108 

i-jii,  -jKi.  oOi; 

-  -  choked  .lis,-  from      .. 

3or. 

-  -  Ivnipliocvtcs  in 

coma  from     . .       117 

Ml 

110,  120,  511 

first  sign  of 

118 

in  general  paralysis 

-  -  convulsions    with     liS 

243,  30r. 

Ml.    1  16.    I 

Cerebral    tumour,    distinc- 
tion from  abscess 

dreamy  Htatc  from    .  . 

dyspepsia  simulated  by  '. 

ebb  and  (low  of  knee- 
jerk  with    ..  ..  : 

giddiness  from       302,  ', 

glycosuria  from        . .  : 

-  -  biiiinorrhiii.'"-  into    303,  ; 
--  -  beadache    from.    147, 
264,   295,  3<I2»  306. 
315,  429,  502,  525, 
537,  626,  • 

unilateral,  from    ..  : 

Iiemiiuiopsia  from     . .   '. 

Iicinlplcgia  from 

6X,  303,  : 

"  liippurt  from  . .         ..  • 

"  liypur«ou»l8  from      . .  ; 

-  hyperpyrexia  from  . . 

h'yimlhermiii  with     . .   • 


-  -  merungococci  in        ,.   591' 
from  nose,  duo  to  frac- 
tured Iiase  119,  17S 

polvmorphonuclear 

cells  in        ..  ..511 

-  -  rale  of  Ilow  of         . .  304 

-  -  ndu.ing  powi-r  of    . .  304 
not  tint'ctl  by  jaundice  321 

-  -  trvpllnos^m.•^  in       ..     2s 

-  -  tuborcle  hiuitii  in     ..  SUit 

-  -  urea  in.  ii>  unnmia  . .     85 

-  -  Wassennann    reactfo?) 

in      ,.         116.  I2t>,  305 

.\untliu-proteic  reaction 

in     ..  .'.  ..   304 

-  -  fund  SCO  Lumbar  I'micturc) 
iVTfbnim  (Hco  Mmin) 
(Teruniuh  (hoo  Wax) 
r?enimlnouH  glands  In  ear     121 
Cervical  ginnd  (two  Lyni- 

phatlcf; lands,  Cervical) 


CERVICAL   PLEXUS    —    CHILDREN 


Cervical  plexus,  compressed 
by  thyroid  gland  en- 
largement      . .  . .    722 

Cervical  plexus,  diagram  of  507 


fro 


Chancre,  coiUd. 

-  inguinal  glanc 

with    . . 

-  n„    lip       .  . 

-  liiiiTi.'ury  and 

-  inr.lluscum    cc 

Miriill:i.t.in- 


atrophy     of     hand 

muscles  from  iFixf. 
209)..  ..  .".   oOS 

muscles  from        . .   ir;:? 

-  -  braehialneuralgiasinin- 

lated  by     /.         ..Ill' 
plexus  affected  by 

-  -  buttress     type     {Fi<i. 

1S7) Il;l 

claw  hand  from     lnn, 

111  I,   111 

-  -  ilead  fingers  from      .  .    1H2 

fibrous  band  from    . .   4-11 

Cervical    rib,    general    ac- 
count of         . .      443,  508 

ligamentous  band 

representing  . .  508 

muscle   wasting    from 

61,  03,  1G2,   508 

pain  in  tlie  arm  from 

11(1,  443,  5U8,  551 

neck  from llll 

scapular  region  from  444 

paresthesia  from      . .  551 

paresis  from  . .  . .  551 

K.D.  from      ..  . .     Gl 

radial  pulse  diminished 

by    ..         ..      110,  144 
Raynaud's     disease 

simulated  by     _    . .   444 
skiagram  of  (i^iV/.f.  186, 

187)..  .."         ..   44.-; 
subclavian  artery  sten- 

osed  by      . .  . .   551 

-  unequal  pulses  from 


550, 
vasomotor     disturb- 


CHARCOT-LEYOEN 
CRYSTALS     ..       I 

Charwomen,      acropara 
thesia  in 

Cliart,     temperature     ( 


—  Sympat.lirl  ir,  <;niii)nc^-ri| 

by  thyroid-ghmd  en- 
largement 

irritation  o£    . . 

unilateral    sweating 

fi'om        . .  . ,   I 

—  paralysis  (see  Pai-alysis 

of  Cervical  Sympa- 
thetic) 

—  ptosis  from  lesion  of. .   ' 

—  pupil  contracted  fi*om 

lesion  of     . .  . . 


)-brachial 


plexn 


Cheek,  actinomycosis  of  74. 
Cheek,    bleeding    nievi    of 


iiema  bullosum  affec 
rene  of  {Fig.  24) " 


-  -  long  i:uiiiL-!il,  Uyijmen- 

orrhoea  from          . ."  Iii2 

—  gonococci  in  . .          . .  ISO 

herpes  of        . .          . .  754 

Cervix  uteri,  hypertrophy  of  539 

—  imperforate,    amenor- 

rhoea  fromV  .          . .  IS 

-  -  riijiil.    rlv?taria    from  t'Oo 


Cheltenham  disease,  general 
account  of  . .   i 


-  diagnosing   strychi 
poisoning         . .      4 


Chancre,   soft   sore   distin- 
guished from. .      618, 

-  inM-|>liilis 
Chancre  of  tongue.. 


Chancre  In  women,  general 

account  of      . .      ('n', 

Chancroids,  general  account 


dissociative     aiiEesthesia 


Charcot's  disease  of  joints  349  I 


-  substances  causinj 

lysis    .. 
nephritis  from 


\loliativ 
^i-s'tlietk 


tluougli  jiose  alter  . .   oSa 
liancre,    balanitis    simu- 
lating . .         . .  . .   G17 

digital,  epitroclilear  gland 

enlarged  from  '. .   381 

epitbelioma  simulating 

cili,  7UI) 
extragenital  (Pig.  23)  73 

240,  870,  381,  015,   7.S9 

o£  evelid 379 

(inr^er  nffoctr.,1  by  .  .   240 

innfrf  firn-'-nlac'count-of  618 

I  ir-ed    . .   377 

"g        ..    (il9 


ubatiuii  puriod  of 


"I     :iiVr 


Cheiropompholyx,     general 
account  of      97.  755,  756 

-  liamls  and  feet  atlected 

by        000 

-  itching  in  . .        07,  540 

-  palms  affected  by       . .     07 

-  scarlatina  simulated  by      07 

-  soles  affected  by         '. .     07 


-  iKiircl->li:ip<>ii,  in  empli}'- 

>rlii:i     ..  ..       107,   36G 

CHEST,    BLOODY    EFFU- 
SION IN  ..    102  I 

-  bulged,  by  large  heart. ,   IGO 

liver  . .         . .  169 

lierioardia]  effusion  . .   169 


ents  of. 


iiiIhi  il,      from     emphy- 

iri.. metric  tracings  of.'.' 
ilrliiiriit    movement    of, 
m  phthisis       .  . 

oncsideof.  h.pncn- 

mothorax  .  .     ■ 

CHEST,  DEFORMITY  OF     166 
-  '1 1:.-,   ^  M.rtness  of 


outline 
.tod,  in 
16G,  21 


167 


11  !  Chest,  local  bulges  of 


Chest,  succussion  in,  general 
account  of  651,  652 

-  swelhng  of,  from  aneur- 

ysm opening  vena  ca\a  180 

-  tenderness  of  (see  Teii- 

dcTi.fss  in  the  Chest) 

-  li    ill.  -  ■-  1:,         n-i,  434,  435 


Biot's  type  of  84, 

from  fatty  lieart 

-  -  {Fig.  43) 
Cheyne-Stokes     breathing, 
list  of  causes  of      107, 


CHEYNE-STOKES       RES- 
PIRATION 

I  .   ■  |>"\,     oosincphilia 


-  of  ear L'li:; 

-  lingers  affected  by    230,  -1h 

-  itching  in  . .  . .   ."■  h  > 

-  limping  from     ..         ..  :;i;- 

-  lupus  erythematosus  si- 

mulating       ..         ..  iiiiL' 

-  menorrhagia  and  . .  387 

-  I>ain  in  foot  from  .  .    302 
Childbirth,  acute  peritonitis 

after .502 

yellow  atrophy  after     333 


1  of  lung  after..  290 


ient, 


206 


from      liltroid    lung 

168,  292 

witit  pleuritic  elfu- 

.     sion         ..  ..  16S 

by  pneumothorax. .   168 

myoma  cutis  of  . .  . .   732 

normal  outlme  of  (Fig. 


7) 
r-distended, 


167 


-  obturator  nerve  ir 

-  pyjemia  after     . . 

-  pyosalpinx  after 


adherent  pericardii 


-  afirxy   in.  . 

-  athetosis  in 

-  Babinski's  sign  in 

-  blood-pressure  in 

-  bradypncea  in    . . 

-  bronchopneumonia 


CHEST,  PUS  IN      .. 
Chest,  in  rickets 
CHEST.    SEROUS    EFFU- 
SION IN 

emphysema    . . 


iT-liar  dit 


160, 


■dal  spasms  i 


inchial  gland 
ni  ..  ..      149,  : 

causes  of  cough  in       . . 
cerebral  embolism  in  . . 


CHILDREN    —    CHORDEE 


rf/T/i.  cnnul. 
TPhnil  thrombosis  i 
mi-.j.-  moriopIej,'i;i  i 


m        27:i,  37U,  : 
lltii-ia  in 
il  -systolic  bruits 
00, 

.1,^  of  .. 

1.  lit  to  ri-ors  in  . 


Iiuhiric   jftuu- 
■;irUititi  in   . . 


Etiuent  micturition  in 
njtro-iiit«stinal  symp- 
toms in,  from  bncteri- 

tnerat  (cdema  in 
tuberculosis  in 
'inding  of  teeth  in     . . 
'owing  pains  in 
anot's  cirrhosis  in     . . 
»nrt  disease  in,  fatal  . . 
f.iiltirt.  in 


Children,  coiUd. 

-  pj-elonephritis  in 

-  pyrexia  in,  from  gastritis  " 

-  rarity  of  phthisis  in     . .  'i 

-  rectal  polypi  in. . 

-  rheumatic  epigastric  pain 

-  rheumatoid  arthritis  iu 

35,  {Fig.  169)  ; 

-  rickets  in 

-  Riedel's  lobe  in. .  . .  ', 

-  scrofula  in          . .          . .  " 
Children,  scurvy  in         '-,  ' 

-  sexiudly  mature  ..  1 

-  spastic  parapl^ia  in     . .  " 

-  spinal  caries  in. .  . .  ' 

-  spleen  enlarged  in     272.  ( 
palpable    normally   in  ( 

-  splenomegalic  cirrhosis  of  i 
Children,  Still's  disease  in 

35,: 
1  -  syithilitic  arthritis  in  . .  i 

liver  in  . .         . .  I 

i  -  systolic  bruit  over  manu- 
':  brium  in 

I  -  tabetic  pains  in. .         . .  -. 
,  -  tachycartlia      in,      from 
<.Mseou=  bronchial 

-  tet~Hiy  i^'i  *.'.  X  ] 
Children,   thermometry  in, 

notes  on  •  •  £ 

-  tuberculous,  anorexia  in 

-  tuberculous  cervical 

I  glands  in        . .  . .  • 

dactylitis  in  . .         . .  ( 

ear  disease  in  . .         . .  4 


purpura  in    . , 

luriKin 

I     !    I  Mills's  disease  it 

.   :,,  1    .vis   Of 

in.  frombacteri 
dren.  insomnia  off 


i.-4-jrrk  iibsont  in 
rge  iorclicml  in 
splfodwith.irrhosisin 
rvML'f.il  obstruction  in 
,,■.,.     (.      in  blood  in.. 

.:"!  in  .. 
,1   .     I  I  mis  vesicles  in 

,,        I,        ..     asi, 

I'lrlions  iu     . . 


.1   li.-;irt    failun 


Iren.  mental  detlciency 
in.  sinns  of    •  •         •  ■  ( 


vInruH  pulpablo 


Iren.  paraplegia  in,  list 
of  causes  of  •  •         -  •  * 

■  I    I,     .-..rv^n  in  ..   ) 

!  il  rtluMun  bulu'- 

n, -I   in     ..  ..    I 

■rii.lMiiil  neuritis  in  ..  I 
TlL.hr  m         ..  ..   ; 

■rvi-rt'd  uppctitc  in  . . 
wthi-niii'lcKic  chorea  in  1 
»*tphiirvnu'eal  abscess  in  I 
■ccordial  bulKlnK  in  81», 

Kill.  ; 
olapHUM  aiii  in 
•olonu'C'l  pyrexia  in  ..   '• 
leutlo-h-ukiumia  in     . . 
ihnonary  second  sound 
in 

Stenosis  in 

irpuric  Icukioniia  hi  . .  i 
relltis  in 


—  deficient  in  ] 
■  -  diminished  : 

-  in  phosphoi 


330 


;  Chlorine,  coryza  froi 

-  sore  throat  from  . .   (J13 

-  stridor  from       .  .  .  .   050 
Chloroform    and    benzine, 

specific   gravity    mea- 


I  -  glycuroiiic  acid  from    .  . 
I  -  iisemoglobinuria  from  . . 

-  bpadache  from  . . 

-  in  indican  t.-st  ..      311. 

-  methylene  bkic  jiihI      .. 
Chloroform  poisoning,  de- 
layed  ■  ■ 


tcta 


-  reduction  by  ur 

-  in  tetanus 

-  tinnitus  from 
'  Chloroma    . . 

-  age  incidence  of 


730 


tritis 


297  I  -  -  peritonitis   mi..            1< 

a^  Children,   unexplained   py- 

•''50  rexia  in 

109  -  urticuriu  in 

130  -Vomiting  in  fevers  of  7Ci. 

325  -  -  from  worms  in 

-  Werdnig-Iloffraann  par- 

70  alysisi 


39.  556 

..   556 
32,  39 

blood  changes  negative  in  550 
bone  swellings  in  39,  205,  550 
■  green  tumours  in         39,  550 
lachrymal  glands  enlarg- 
ed in    . .         . .  . .  556 

Ivmph   glands   enlarged 
'in         . .  . .       205.  556 

lymphocytes  iu  cerebro- 
spinal fluid  in  . .  305 
purpura  in          . .  . .   553 

iclatod  tn  leukojmia     . .     39 


;  of 


(.'hill,  acute  nepiiritis  from  i 

-  atlietosis  after  ..          . .  1 

-  myalgia  from    . .         . .  ■! 

-  )>ain  in  the  limbs  in  163,  -1 

-  tremor  from       . .         . .  'i 
CHILLS S 

-  (and  see  Rigors) 

Chimney-sweep's  cancer..  ( 

Cliin.  acne  affecting  . .    ■! 

-  blow  on,  ear  injured  by   J 
:  -  dropping    of,    in    inyas- 

I  thenia  ..         ..  i 

!  "  heavy,  in  acromegaly   . .   i 

-  irritation,  hiccough  from  5 

-  receding,  in  microceplialy  1 
I  -  sycosis  affecting  . .  E 

-  sypliiloderm  of  . .         . .    1 
rhina.  distoraa  pulmoimie 

ill         £ 

lung  lluke  in      . .         . .  (i 
riiloiisma,  iu  phtliciriasls    >' 
pigmentation  in  .  ■  ^ 

■  linca     versicolor    simu- 
lating . .         . .  . .   - 

-  uterinum  . .       Jfl*,  ^ 

-  from  vesicants  . .  . .  5 
Cldoral.  bradypmjea  from 

1  -  Cbfvne-Stokcs      breath- 
ing from  ..  ..  1 

-  coma  from  . .  . .  1 

-  crytliema  from  ..  ..  i 

-  hypothermia  from         ..  S 
~  purpura  from     . .         . .  D 

-  reduction  by  urine  nftor  1 
I  Chloraluniide,'      crytliemii 

1  from    . .  . .         ..   - 

Chlomtc    of    jiotiiKli    (ttec 
I  l'ota.>^^ium  Chlonite) 

Chloride  of  barium,  in  bilc- 

tf^t ] 

rarbohu'ia  and  . .   'i 

Chloride    of    caU'iuni    (see 
Calcium    Cidoridc) 

-  sodium,  thirrtt  from      . .   'i 

-  sulphur,     aciit*!     yellow 

atrophy  from  . .   'I 

-  -  jaundice  from  325,  331,  a 
Cliloridef.  in  hydatid  lluld  : 

-  pliofphaturia  and  . .   i' 


Mivaiy 


gland: 


larged 
lymphatic 


-  simulating 

leukiuuiia       . .         . .  2U0 

-  spleen  enlarged  in         . .  205 

-  spontaneous        fracture 

from    . .  . .  . .   2 12 

Chlorosis,  age  incidence  of     36 

-  amenorrht 


ly,  37 


-  blood  changes  in 

-  bruit  de  dial»Ie  in 

-  cachexia     chlorotic 

synonym  for  . . 

-  colour  index  In  , . 

-  constipation  in  . . 

-  cured  by  marriage 

-  dyspna'a  in 

-  epistaxis  iu 

-  Hushing  i 


■  ulc 


Chlorosis,  general  account 
of  .36.  274 

-  liwmatemcsis  in         2(10,  27-1 

-  liujmic  bruits  in. .  37,  99.  299 

-  heart  impulse  displaced 

from 299 

-  iron  in 30 

-  noises  in  the  head  witti  -lOO 

-  nourishment  good  in    . .  274 

-  occupation  and . .  . .     30 

-  iL'dema  in   37,  271,  -113,  415 

-  palpitation  in     ..      271,   181 

-  prognosis  in       . .  . .     30 

-  pulmonary  systolic  bruit 

in  ..  ..        91,  299 

-  rest  in  bed  In     . .  . .     30 

-  sclcrotics  liluish  in        ..  271 

-  sex  incidence  of . .  . .     30 

-  skin  greenish  in..  ..  271 

-  therapeutics  iu  diagii 


Cliolteiii'a.  rnnttf. 

-  delirium  from    . .  . .   321 

-  lieadache  from  . .  . .   290 

-  from  jaundice    . .  . .  32 1 

-  stupor  from       . .  . .   32 1 
Cholangitis,     abscesses  of 

liver  from      . .  . .  332 

-  albumosuria  with  ..     10 

-  from  carcinoma  320,  333,  662 

-  empvenia  from  . .  .  .  100 
_  _  of"'_'nn-i>iN.Mf'r  ,     :i:v.\ 

-  grill-'. M.,..  -.-,1     ■:■■(;    333,  :,.|7 


-  pain  iu  the  back  fi"um  . .    710 

-  pleurisy  from    . .         . .  100 

-  rigors    from     320,    333, 

309,  597 

-  sei)ticaemia  from  ..  037 

-  tender  liver  with      333,  309 

-  in  typhoid  fever  . .  333 

-  urobilin  with     . .         . .   101 
Cholecystitis,  duodenal  ul- 
cer simulated  by       . .  450 

-  exploration  in  dijignosing  450 

-  indigestion  simulated  by  310 

-  pain  in  hj'pochoudrium 

from    . .         . .         . .  450 

shoulder  from  . .  475 

-  phantom  tumour  simu- 

lating   059 

-  pleurisy  simulating      . .  432 

-  pyrexia  from     . .  . .  450 

-  rigors  from        . .     450,  595 

-  suppurative    from    gall- 

stones . .  . .   597 

rigors  from     . .         . .  597 

Cholelithiasis     (see     Gall- 
stones)' 
Cholera,  albuminuria  in  . .     13 

-  anuria  in  . .         . .     42 

-  blood  inspissated  in      . .   101 

-  Cheyne-Stokes     breath- 


ing i 


108 
117 


-  coma 

'  -  comma  bacilli  in 

-  cramps  after 

-  cyanosis  in 

-  gangrene  from   . . 

-  general  wiisting  from 

-  iinjmatcmcsis  in        i 

-  hyperpyrexia  iu 

-  indicanuria  from 

-  leucocytosis  in  . . 

-  maligna,  cyanosis  from     l-l 

-  menorrhagia  from        . .  3S 

-  neplu*itis  from   .. 
Cholera  nostras  ..71 

-  pain  in  tlie  limbs  in      . .  40 

-  polycythtemia  in  . .  5:! 

-  purpura  in  . .  . .   55 

-  pus  in  stools  from         . .  55 
-water  stools 


. .   255 


309 


. .    301) 


rigo 


r3,  717 
..   595 


lag 


30 


-  vicarious     menstruation 

and      ..         ..  ..  274 

-  (and  fee  Annimia) 
Chocolate   and    inilk    pus, 

from   licpatic   almcciut  253 

-  oxalate  from      . .         . .  421 
Choked  dim;  (nee  Xeurltis, 

Optic) 
Cliolttsniia.  ill  clirliOMis     . .  332 

-  coma  from         ..      117,  321 

-  convulsionti  from  . .  32 1 

-  dr-atlifrom         ..  ..321 


diarrhoea  in 

-  simulated  by  trichinosis  464 

-  tenesmus  in       . .         . .  717 

-  tliyrold  gland  enlarged  in  722 

-  uridrosis  iu        , .         . .  055 

-  vibrio  in  motions  in     . .  273 
OiiolGstcrin   crystals   (/'iV/. 

1^4) 251 

-  iu  hydrocolo  . .          . .  095 

uuicocclo        . .         . .  251 

tliolestcrol  in  asciti<!  tliiitl  GU 
Choline,    in    cerebrospinal 

lluid .105 

-  periodidc            . .          . .  305 

-  platinocltlorido    crystals  305 
Clioluria 743 

-  from  fistula  between  bile- 

duct  and  urinary  tract  741 
(and  SCO  Jaundice) 

droma,  of  breast      . .  080 


hand 


071 


07H 


-  ilium,  pain  in  ilii 

from    . . 

-  pain  in    . . 

-  of  pelvic  bourn  . . 

-  ulceration  over  . . 
Chorda  tympiuil.  pi 

of    (see     I'arulyHiH"  ol 
Chonla  'J'vnipani) 
CHORDEE      *  ..108 

-  from  fracture  of  penis..    inK 

-  gonorrlicea  ..      lOK,  Iil7 


aly.iK 


CHORDEE 


CLUBBED   FINGERS 


Cftwdec,  coH/d. 

-  from  injury 

-  penile  pain  Irom 
Chorea,  a^e  incidence  of  . 


-  ataxy  distinguished  from  1 

-  Babinski's  sign  in 

-  chronic   . .  . .  . .    I 

-  degenerative      . .  . .   1 

-  duration  of        - .  . .   1 

-  effect  of  will  on  move- 

ments of         . .  . .   1 

-  electrica  . .       134,  1 
localized     convulsions 

from  . .  . .    1 

-  endocarditis  in   90,  209    2 

-  family  history  and        . .   1 

-  fright  and  . .  . .    1 
Chorea,  general  account  of  I 

-  grasp  unmaintained  in. .   5 

-  grimacing  in       . .  . .    1 

-  habit  spasm  simulating  1 

-  hereditary  . .  . .    1 

-  in  history  of  heart  disease 
Chorea,  Huntingdon's     ..   I 

-  hyperpyrexia  in  ..   3 

-  hysteria  simulating      . .   1 

-  insaniens  . .  . .   3 

-  insanity  from     . .  . .   1 

-  irritability  in      . .  . .   1 

-  knee-jerk  iu       . .      359,  5 

-  major      . .         . .  . .  1 

-  monoplegia  from  . .  5 

-  nightmare  and  . .  . .  4 

-  position      of      extended 

hand  in  . .         . .  3 

-  post-hemiplegic  . .  1 

-  pre-hemiplegic  . .         . .  1 

-  pregnancy  and  . .  . .  1 

-  respiration  jerky  in      . .  1 

-  rheumatic  fever  and  105, 

133,  337,  464,  6 

-  sex  incidence  of  . .  1 

-  spasmodic  twitchings  in  1 


Clii/luria,  could. 

-  with  chylous  ascites 

-  coagulation  of  urine  iu. . 

-  diet  and  . . 

-  from  elephantiasis 

-  filariasis 

-  injury 

-  large  heart  with 

-  microscope  in  diagnosing 

-  nephritis  and     . .  . . 

-  oedema  with       . .  . . 

-  osmic  acid  in  diagnosing 

-  phosphaturia  simulating 

-  from  receptaculum  chyli 

rupture 
~  rect;il  '■-y;tniirntion  in   ,. 

-  safraii:  ,  ■  .  •    ■     i-i- 

-  SuU.'Jh     1  1  ;    ,  .    ■;,  .-  ..u-iNi^ 

-  froni   ii..ji.i.;,^:    au._L    ub- 

struction 

-  tube  casts  with. . 

-  vaginal  examination  in 

!  Cider.  rp';'nr"it:)rinn  of  food 


uria  from         . .  ..   i 

Chromidrosis  . .     529,  t 

Chronic       nephritis      (see 

Nephritis,  Chronic) 
Chrysarobin,  hullie  from. . 

-  diazo -reaction  from      . .  : 

-  erythema  from  . .         . .   : 
Cbrysophanic  acid  (see  Acid, 

Chrysophaiiie) 
Chvostek'ssign  in  tetany  3, : 
Chyliform  ascites  . . 
fjhylons  ascites  (see  ^Vscitcs, 

Chylous) 
Chylous  effusion  in  chest. .   I 
CHYLURIA  ..   I 

-  albuminuria    uilh 


till 


I  -  low  blood-pressure  from 
Ciliary  muscle  paralysis  (see 
'  .  Paralysis  of  Ciliary 
I  Muscle) 

'  -  vessels,  injected  iu  glau- 


'  CiiTj/o:iis  of  licci\  contd. 

gastric  HCl  delicient  in  270 

ulcer  simulated  by  272 

simulating  . .    2fi9 

-  -  gastritis  witli  43.   317,  371 

Cirrhosis  of  the  liver,  general 
account   of   332,    370, 

ot\,  372 

-  -  general  oigns  oi  ..   ^a. 

wasting  from  .  .      59 

h^ematemesis  from  35, 

51,    265,    266,    267, 
272,   273,   332,  371, 

633,  636 

haemorrhages  with   . .  G36 

Cirrhosis  of  liver,  Hanot's 

3i2,  372  I 

hypertrophic  biliary      372  ' 

infantilism  with         . .   189  j 

insomnia  from  . .   323  \ 

jaundice  from  35,  46,  51,  ' 

325,  326,  332,  371,  635  \ 

leucocytosis  with      . .  374  j 

leukEBniiit  simulated  by  273 

liver  edge  with  . .      51 

enlarged  with    47   51, 

266,  272,  326,  332,  370  , 

hard  in        . .  . .   272  I 

and  beaded 


gala 


272 


-  speech  i 

-  tongue  jerked  back  in. .  i 

-  tremor  in  . .      724,  ' 
distinguished  from  . .  ' 

-  unilateral  . .         . .  : 

-  valvular    heart    disease 

from  53.  89,  209,  485.  ' 
Choreiform  contractions  .. 

-  movements,  in  infantile 

liemiplegia 
Chorion-epithelioma,  foetid 

discharge  from  ..   391 

-  after  hydatidiform  mole  391 

-  metrorrhagia  from    390,  391  , 

-  microscopical  diagnosis     391   I 

-  pelvic  swelling  due  to  . .  688  , 

-  after  pregnancy  . .   391  ! 
Chorionic  villi,  in  casts  of 

uterus  . .         . .  193 

Choroid,  coloboma  of      ..  415 

-  ~  d'laU'  XIX)    ..  ..416 

Choroid  tubercles  307,  417, 

515,   59U,    640 

-  -  {Plate  XX)     ..  . .   418 
Choroiditis,  defective  vision 

from 416 

-  macular  . .         . .  . .  416 

-  nystagmus  from  . .   759 
Choroiditis,  syphilitic       .-  416 

-  -  {Plate  XrX)    ..  . .   416 
Choroido-retinitis      nycta-  ; 

lopia  from      . .  . .    763  , 

-  visual  field  constricted  in 


iritis  . .         , . 

Cinnamon  oil,  leucocytosis 
from    . .  . .         . . 

~  rectal  concretion  from . . 
Circumcision,  death  from    ; 
~  priapism  from  , .         . .  . 

-  status  lymphaticus  and  ; 

-  tuberculous  penis  from    i 
Circumflex  nerve  (see  Nerve, 

Circumflex) 
I  Cirrhosis  of  the  liver,  ab- 
I  dominal        distention 

with    . .  . .         . .  : 

acholuric  jaundice  in 

332,   I 

acne  rosacea  with     , . 

age  and  sex  incidence 


of 


albuminuria  from 

.  albumosuria  from 

from  alcoholism 


loss  of  appetite  with  43,  51 

weight  from  . .    770 

-  -  malaria  and  . .      335,  372 

sinmlating  . .  . .   273 

malignant    peritonitis 

simulating  . .  . .     49 

I melEena  from..       51,  371 

I menorrhagia  from  386,  387 

I meteorism  in  . .  389 

' morning  sickne^  with    51 

,  with  . .         . .   -  51 


with  ..         ..371 

cedema  of  ankles  in  . .  371 

pain  in  the  limbs  in. .   463 

pancreatitis  with      . .  100 

peripheral  neuritis  with   64 

phthisis  with  . .   266 

pigmentation     with 

35,  51 

piles  with       . .         . .     51 

polyiu-ia  in     . .  . .   535 

portal  obstruction  with  272 


332.   370,    555 


ascites  from     35,    46, 

47,     51,      52,     332, 
371,   570,  635,  750.  1 

Banti's    disease     and 

37,  64,  ( 

bile-duct    obstruction 

simulating  . .  . .  ; 

blood  per  rectum  with  t 

bottle-nose  with 

in  bronzed  diabetes  373, J 

cachexia  from  . .  ] 

caput  medusie  in    43,  1 

and  carcinoma  associ- 
ated . .  . .  5 

carcinoma   simulating 

370,  371,  J 
of    stomach    simu- 
lated by    '"         . .   ; 
catarrh  of  small  intes- 
tine from    . .  . .   ] 

in  children      . .  . .   i 

cholaemia  from  . .  ; 

clubbed  fingers  iu  111.  i 

coma  from     . .      332,'  2 

from  congenital  syphi- 
lis      2 

-  -  congestion  of  stomach 
from  . .         , .  7 

cramps  with  . . 

delirium  with  323,  332, 3 

diarrhoea  from  . .   ] 

diazo- reaction  in       . .  ] 

drowsiness  in  . .   3 

in  Egypt         . .  . .   3 

enteritis  with  . .  3 

epLstasis  with  51.  220, 

266,  C 

flatus  from     . .  , .   '2 

furred  tongne  with  . . 


rexK 


35. 


--  sail... u.i.. 

ShritiK,itM<.-  uL   U^^■l    111..     . 

simulated      by     peri- 
hepatitis 

slow  course  of 

Cirrhosis  of  liver,  spleen  en- 
larged in   51   266.  27l', 
273.     332,     374,      '131, 
ti3l.'.   I 


stai,' 


splen 


: starting   as 

I  anaemia 

I stunted  growth  from 

without  symptoms  . .   I 

syphilis    of    liver    dis- 
tinguished from     . .   ; 

in  teetotallers 

telangiectases  with  . . 

round  waist  from..   ' 

temperature  chart  in 

tremor  of  tongue  with 

tuberculous  peritonitis 

simulating   48,  570,  ) 
umbilical    veins    with 

51,  ; 

urobilinuria  in        371,  ' 

uroerythrin  and         . .   ' 

varicose  oesophageal 


Cirrhosis  of  lung   . . 

-  of  pa 


286.  288 
100.  101 
{Plai£ 


Citrates,  polyuria  from    . .  ."> 

Clamminess,  in  angina  pec- 
toris   . .         . .         . .  4 

from  arsenic  . . 

Clark,  Andrew,  arthritic 
haemoptysis  of  . ,  2 

Claudication,  intermittent 
306,  440,  4 

Clavicle,  myeloid  sarcoma 
of        .' 6 

-  nodes  on,  syphilitic  . .  6 
from  yaws      . .  . .   4 

-  rudimentary  . .  . .  1 
Clavus  hystericus  141.  296,  4 
CLAW-FOOT  {Fig.  44)    . .  | 

-  from  injury        . .  . .   1 
I  -  internal  popliteal  nerve 
'           lesiofis             . .       109,  4 

j poliomyelitis  . .  1 

!  -  sacral  nerve  root  lesions  1 

CLAW-HAND  . .   |i 

\  —  from  cervical  rib  109, 110,  4 
j  -  lower  neuron  lesions     . .   1 

-  mode  of  production  of  . .  1 

-  from    pachymeningitis 
;  109.  1 

-  perotieal  atrophy  . .   1 

-  poliomyelitis      . .      109,  1 
I  -  progressive  muscular  atro- 

I  phy     . .  . .         61.  1 

-  syringomyelia  109  {Fig. 

\  45)  110,  2 

-  from  transverse  myelitis     > 

-  from  ulnar  paralysis  109,  1 
Cleft  palate  . .  . .   5: 

I dysphagia  from         . .    1 

regurgitation    of   food 

I  through  nose  from      1 

I  Clergymen,  cluronic  pharyn- 
gitis in  . .      613, 
Cleidocranial      dystostosis    a 
Clicking  in  ear,  due  to  dila     1 
tator  tubas     . .         .      j 
Climacteric  (see  Menopai      J 
Climbing    up    oneself,       ^g 
pseudohyper  t  r  o  p      .  'r,g 
paralysis         ..  .0^ 
Clitoris,  elongated,  in  »« 
do-hermaphrodi           -.^-j 

-  epithelioma  of,  i  ; 

glands  seconda 

-  leukoplakia  of    . 

-  precocious   devel 

of,  from  hyperi 

Clit'^ris,  priapism  of 
Clonus 

-  ;(iiklf  (see  Ankle-cic 

-  in  t-i.ilepsy 


ellar 


Cloudy  swelling  in  fevers 

I palpitation  from  48^ 

'  CLUB-FOOT      (and       set 
Talipes) 

CLUBBED  FINGERS 


tdhen 


dii 


asthma 

Banti's  disease 

bronchiectasis  14,  111, 

bronchitis 

cirrhosis 

congenital    heart  dis- 
ease 91  (i^ij?.  46)  111 . 
157,   215,   217.   533, 
disappearance  of  club- 
bing from  . .         . . 

from  emphysema 

with  fibroid  lunc   14.  I 

168,  216. 1 
in  fungating  endocar- 
ditis (T^'i.?.  270)      ..  I 

Hanot's  cirrhosis       . .   '■ 

from  mediastinal  neo- 
plasm 

mediastinitis  . .         . .  ' 

mitral  disease  . .  ' 

with     patent     inter- 
ventricular  septum  : 

from  pericarditis      . .  : 

phthisis  . .         .  -  - 

pleuritic  effusion       . .  '. 

polycYthiemia  with  . .   i 

with  pnlmonary  osteo- 
arthropathy . .  ; 


CLUBBED   FINGERS    —    COLITIS,    MUCOMEMBRAXOUS 


tubbed  fitigcrs,  amid. 

-  spleiiic  anemia         ..  Ill 

-  splenomegalic  cirrhosis 

332,  633 
lubbing  of  toes,  with  cou- 
genital    heart   disease  157 

Dachmen,    Dupuytren's 

contracture  in  . .    ll'J 

oagulability  of  blood,  defi- 
cient, meoorrhiigia 
from    . .  . .      386,  387 

oagulation,  spontaneous, 
of  ascitic  fluid  . .     48 

-  in  pleuritic  effusion  . .  102 

-  of  urine  . .  . .  108 
3al  miners,  anthracosis  in  288 


of 


621 


-  photopbobi: 

-  warts  in  . .  . .  240 
jai-sely  granular   eosino- 

phile    cells    (and    see 

l!)osinophilia  and   Ko- 

sinophile  Cells) 

jcaine,  asthma  relieved  by  555 

in  examining  larynx     . .   199 

-  urethra  ,".  . .  1S3 
habit,  Slagnan's  sign  in    611 

-  sense  of  creeping  worms 

in 611 

line  sand   under 

skin  ill    ..  ..611 

palpitation  from  484,  486 
prick  marks  in  dia^'nosin■^  486 
suppository,  in  di;iL.'nos- 

ing  cause  of  anal  spasm  128 

tn-rnor  from        ..       724,   726 

;    nil.  recital examin- 

11  diagnosing  . .  587 
M  isoreover  ,.  257 
I  ifion  of,  per  rec- 

■     >ea,     auditory     nerve 
;t     ading  in        . .  . .   163 

1-1       te  uterus,  dysmen- 
II         a-u  with  . .  . .    192 

,  sterility  from  64 


Teiii 


534 

424 


434 

irom     ..  .,   267 

I vi,'uhir  from      . .   486 

p   from  . .      320,  322 

'   irom      ..  ..   424 

.1]    I  i-ionfrom        481,  -186 

\-"l  .  iii.i  from    ..  ..   534 

>]]>■•■  LTciind  vomit.     268,  269 

imn-lid  crystals  . .  . .   524 

Jin  impacted  in  uwopha- 

«,'us 195 

sound,     with     imeumo- 
thorax  . .       168,  530 

-  over  subrliaplirugmutic 

abscess        . .  . .   451 

jitiis,    excessive,    meiior- 
ih  ,11  from    ..  ..   386 

(         .'     uf  pcni-sfrom  ..    108 

Miiia  of  jienis  from  473 

u,i.-Mi|.iu.s,     ineuorrhn- 

L'ia  irom  . .         . .  388 

painful  (see  I>yspareunia) 
alcott    I'ox,    vacciniforni 

erythema  of  infants..  401 
Did,  amenorrha-a  from  . .  18 
brachial  ncurals^'iii  in- 
creased by  . .  . .  112 
bulhn  from  . .  . .  96 
cHtchiim,  in  rickctrt  ..  145 
chilblain  from  . .  . .  737 
common,  anoitmia  in    ..  CIS 

-  urKcriic  eltects  simulat- 

ing   178 

-  hromism  simulating..   178 

-  fauces  inllamcd  in    . .  615 

-  iodl»m  simulating     . .  178 

-  measles       simulatint;, 


178, 


Cold,  common  contd. 

(cdema  from  . .      413,  415 

palate  inilamed  in    . ,   615 

taste  loss  from  . .   705 

uvula  inflamed  in      . .    615 

-  dead  fingers  from         , .  162 

-  effect  on  functional  albu- 


catarrh 


..  612 


15 

-  erythema  from  ..      222,  224 

-  erythromelalgia  relieved 

by        441 

-  excessive,  coma  fi-ora  118, 119 

-  febrile 178 

-  feverish,  rigor  in  . .  594 

-  fibrillar  contractions  from  134 

-  librositis  from    . .  . .   475 

-  hsemoglobiuuria  from  . .  284 

-  intermittent  claudication 

increased  by  . .         . ,  441 

-  micrococcus    catarrhalis 

causing           . .  , .  178 

-  myalgia  from     . .  . .  467 

-  myositis  from    . .  . .   475 

-  nasal  discharge  in  ..   178 

-  nephritis  from    . .  10,  42 

-  pain  in  shoulder  from  . .  474 

-  Kaynaud's    disease  in- 

creased by     . .         . .  441 

-  retention  of  urine  from . .  395 

-  sense  lost,  in  Brown-S6- 

quard- paralysis      497 
from  cerebellar  ar- 
tery lesions        . .     58 

in  syringomyelia  62, 

63,  97 

-  sensation  as  of,  in  syrin- 

gomyelia       . .         . .  609 

-  sheets,  cough  from       . .   149 

-  stiff  neck  from  . .         ..617 
-•tic  douloureux  and       ..   447 

-  tremor  from      ..      721,  725 

-  whooping-cough      simu- 

lated by         . .         . .  645 
Coldness,  feeling  of,  with 

fatty  heart     . .         . .  212 
Coti    bacilluria    (and    see 
Hactcriuria) 

albuminuria  in      455»  530 

apparently    healthy 

urine  with  . .         . .  573 

appendicitis  simulated 

by 455 

causing  obscure  fever 

in  itifnnts   . .  . .   569 

chills  from      . .  . .   56!) 

culture  of  catheter  spe- 
cimen in  diagnosing  455 
cystitis  simulated  by     569 

-  -  diagnosis  of    ..  ..318 
frequent  micturition 

from  ..         ..  394 
Inemuturia  from        . .  275 

-  -  leucocytes  in  urine  in  455 
operation  in  cases  of. .  455 

-  -  pain  Ml  iliac  fossa  from  452, 

454,  455 

pKoumaturia  from    . .  530 

in  pregnancy..        12,    152 

pyelitis  simulated  by     569 

pyrexia  in  455.  (f^ig. 

193)  456,  569 

-  relapse  in       . .    #     . .  456 

right-sided  as  a  rule  . .  452 

strangury  from         . .  649 

sweating  from  . .   569 

ureteritis  from  , .  455 

COLIC         114 

-  abdomen  retracted  with  115 

-  abdominal  fullness  with  115 
teiidernoss  absent  with  115 

-  iicule  onset  of    . .  ..    593 

-  uiKiirv-iri  -iniuhiling    ..    115 

-  ,.|.|--r,.||.-i(i-  simulating       115 

Colic,  appendicular  ..   116 

J,MnI:.i.-.l     l,y     spinal 

h-siOMH  ..  ..      161 

-  from  arsenic      . .  . ,     '- 1 

-  biliary,  acute  abdumirud 

pain  from       . .  . .    193 

-  -  collapse  with  ..  ..116 
conMtipation  with     ..    131 

-  -  froni  i;all-Hton(>^    116, 

130,    252,    272.  326.  327 

Colic,   biliary,  general  ac- 
count of  .116 

-  -  i;4un<liri-  ui(i.        Il<^   i::l 


Colic,  hiliary,  contd. 
movable  kidney  simu- 
lating . .      450,  451 

night  attacks  of        . .  451 

pain  in  back  from     . .  450 

in  epigastrium  from  436 

hypochoudrium  from 

116,  450 

shoulder  from    116,  450 

from  pa?icreatitis  328,  329 

pelvic  lesion  simulated 

by 468 

recurrent        . .         . .  328 

rolling  about  with    . .  592 

shivering  with  . .   116 

simulated    by    renal 

colic        . .         . .  450 

-  -  simulating  dvsmenor- 

rha*a  ". .  . .   193 

-  -  sweating  with  . .  IIG 
Colic,  biliary,  symptoms  of  327 
tenderness     in     right 

shoulder  from        . .  709 

urates  i^tcr    . .         . ,  451 

vomiting    from     116, 

765,  767 


I  Colic,  conid. 
~-  pyrexia  with 

-  relief  by  pressure 

-  -  passage  of  Ilatus 
Colic,  renal 

acute  abdominal  jiaiu 

from  . ,  . .   : 

appendicitis  simulated 

by 

biliary  colic  simulated 

by    . .  . .      450,  * 

from    blood-clot   276» 

394,  . 

calculus  278,  279,  394, 

473,  577,  742,  : 

caseous  material       . .  ■; 

constipation  with     . .  ] 

Colic,  renal,  due  to  clots 
from  new  growth      . .  £ 

frequent      micturition 


\-iih. 


borborygmi  with 
carcinoma    of  bowel 

mutating 
from  carcinoma  coU 
colitis 126 

■  colitis  simulating  . .  115 
collapse  with      . .      114,  593 

■  constipation  with 


593 


126 


150 


Nlato.i  \ 

Colic,  diagnosis  from  things 
simulating  .115 

-  farie.  iM U4 

-  \vith;:;ill-liIa.KlerchI:irL'e- 

meiit 353 

Colic,  general  account  of    593 

-  in  ilfn<)<*h's  purpura    . .      76 

-  infants 321 

-  intestinal,  abdomen  rigid 

with    . . 

from  alcoholic  excess 

borborygmi  with 

in  children 

ectopic  testis  simulat- 


425 


ing 


vith 


681 


eructations  \ 

from  food       . .  . .   425 

general  abdominal  pain 

from  ..       193,  425 

Colic,  intestinal,  general  ac- 
count of  . .  425 


llr 


425 


-  -  from  iinhi.'.-ril)lL-  food   U 

legs  drawn  up  in 

nausea  with  . . 

from  obstructiori 

pain  relieved  by  pres- 
sure in 
parox^'smul  character 


of 
pelvic  lesion  simulated 


425 


Colic,  (ntestlnat,  neritonltis 
distinguished  from 

-  -  p„|..-raf  ...   ..  ..     125 

-  ~  i-yrexiawilh  ..  ..   425 

rolling  about  with    . .  592 

simulathtg  dysmenor- 

rhoca  ..  ..193 
visible  peristalsis  with    425 

-  intestinal  neuralgia  simu- 

lating   115 

-  obstruction  simuluthig  115 

-  from  intu-ssusceptiun    ..  127 
.tussusception  simulat- 


mg 


115 


-  jaundice  after    ..         ..  326 

-  |ii|)arotomv  and  . -.   503 

-  from  lead '8 1.  115,   117. 

126,  151.  425,  593 


Colic,  pancreatic 


null. 


Colic,  perllonllit  simulated 
by  ..     II''.  : 

-    pul.HC  with 

from  purtfatives 
pyloric  otwtruci ion  •(imu- 
luting  . . 


131,  ■ 

from  hypernephroma     ; 

lead  colic  simulated  by  ■ 

from  movable  kidney 

394,  ■ 

pain  in  groin  with     . .  ' 

loin  with    . .         . .  1 

penis  from  . .         , .  ■ 

testis  with..         ..  ' 

pelvic  lesion  simulated  ■ 

-  -  preceding  stone  in 

bladder       ..         ..  : 

pyrexiiv  in      . .         . ,  - 

from  renal  growth     . .  ; 

rolling  about  with    . .  i 

sinmlatbig  dysmenor- 

rhoea  ..         ..  ; 
torsion  of  ovarian  pe- 
dicle simulating    . .  : 
from  tuberculous  kid- 
ney . .         117,  279,  . 
vomiting  in  451,  765,  ' 

-  rigidity  of  abdomen  with  i 
~  spasmodic  i>ain  from    . .  • 

-  spinal  caries  simulating 

-  from  stenosis  of  bowel. .  '. 

-  sweating  with    . .         . .  , 

-  from  taht's  .  .  .  .    i 


ness  with 

-  acut«,  blood  and  mucus 

from : 

-  -  indicanucia  from       . .  ; 

■  -  pain  and  straiiung  with 

•  -  pus  in  stools  from    . .  ; 

-  anujmia  with 

-  blood  a. id  mucus  stools 

from ) 

■  rutjirrhiil  . ,  , .  '. 

■  chronic,    diverticula    of 

colon  from      . .  . .  ■ 

■  -  pus  in  stools  from  . .  ^ 

-  colic  from  . .  . .  ' 

—  simulated  by. .         . .  ; 
'  colon  thickened  from  . .  i 

constipHlion  from         . .  1 
dlarrhfua  from  . .         . .  ] 
lo88  of  weight  from      . .  ; 
'  malignant  disease  simu- 
lating    ; 

■  mombranoiui,  Indicanurin 

from : 

-  intestinal  .>uind  with.,  l 


caVu 


uid 


-  «u.st  from  {Fi»j.  172).. 

-  const  ipiit  Ion  with  (Fit/. 

52) 

-  mucous  Ktotils  from  . . 
pus  in  stot}lH  from  . . 
slircdM  in  stools  from 
1  of  i*oloii  ill  {fiff. 


52) 

spnMtic 

with 


dtipnlfun 


simulated  by  • 
4>nesnuiii  from 

51 


COLITIS.    MUCOUS 


CONGENITAL   HEART   DISEASE 


nl  pn 


;s,  abilo 

-  casts  from         . .   115,  1 

-  constipation  with     . .  1 

-  mucus  shreds  from  . .  1 

-  pus  in  stools  from    . .  5 

-  srybala  with  . .  1 

-  tapewonn  simulated  by  1 
pain  in  right  iliac  fossa 

from    . .  . .  . .  1 

sigmoidoscope     in     dia- 
gnosing . .         . .  7 

simple,     anesthetic     in 
diagnosing 

-  blood  and  mucus  stool 

from 

-  collapse  from 

-  diarrha-a  from 


Colitis,    simple    acute,    in 
infants 

n  ihiciiiess     over     colon 


264 


ulceration  of  rectum  due 


tenesmus  fi*o 

a  variety  of  dysentery 

vomiting  from 

wasting  from. . 

Widal's  cest  negative 


.  717 


Collapse,  from  abdominal 
injury 

-  acute  pancreatitis     436,  < 

-  in  angina  pectoris 

-  anuria  from        . .  40, 

-  from  arsenic      . .        78, 

-  from  biliary  colic 

-  bradypnoea  in    . .  S4. 

-  with  colic  . .      114, 

-  from  corrosives . . 

-  diarrhcea  . .      171, 

-  embolism  of  pancreas  . . 

-  extra-uterine  gestatioii 

-  gall-stones 

-  gangrenous  appendix  . . 

-  haemorrhage 

into  pancreas  76, 

-  hypothermia  in. . 

-  with  intestinal  obstruc- 

tion 
from  intussusception  . . 


CoUapse.  contd. 

-  loss  of  fluid 

-  in  malaria 

-  from  movable  kidney 

-  myocarditis 

-  pancreatitis 

-  perforated  duodenal  ulcer  436 
gastric  ulcer  . .      436,  658 

-  peritonitis  . .  . .   311 

-  phosphorus  poisoning  . .  336 

-  ruptured  aneurysm       . .  434 

-  simple  colitis     . .  . .     78 

-  specific  gravity  of  blood  534 

-  from  tubal  abortion     . .  690 

-  vomiting  . .  . .  311 
Collar,  shrugging  tic  from  136 
CoUargol,    in   pyelography 

354.  iFig.   166)  356 
Collier  on   albuminuria  of 

iiliU-tes  .  ..     15 

t  m|||,  I  ^    u:ee  Coal-miners) 

49,  676 
..  73S 
..  415 


..   415 

5  from  759 
..   415 


fro 


718 


blood  per  anum  from 

77,  172 

and  mucus  from    . .  459 

diarrhoea  fi-om  76.  77, 

172,  459,  663 
due  to  bacilli..         ..     76 

-  dysenteric    symptoms 

in 172 

emaciation  from       . .  663 

-  -  frequent      deftecation 

from  ..  ..76 

-  -  general  abdominal  pain 

from  . .  . .    459 

wasting  from         . .     59 

liEemorrhage  from  bowel 

from  ..  ..663 
indicanuria  from       . .   314 

-  -  mucus  from   . .        77,  172 

pain  from       . .  . .     77 

in  iliac  fossa  from 

452,  454,  459 

pus  in  stools  from    . .  557 

pyrexia  with  78,  663 

shreds  from    . .         . .  172 

sigmoid  colon  palpable 

from  ..  ..676 
sigmoidoscope  in  dia- 
gnosing          76.  78,  172 

sunulating  typhoid  . .      76 

stools  with     . .  . .   172 

tenderness  along  colou 


rMi,i:i.  ;irruiiiMl.iicd  fscces  In  657 

-  ascuinIiuL',  palpable  nor- 

mal       663 

visible  peristalsis  in..  663 

whip-worms    in  {Fig. 

218)  520 

-  atony  of  . .  {Fig.  50)  123 

-  bacillus  (see  Bacillus  Coli) 

-  bullous  dermatoses  affect- 


-  carcinoma  of  (see  Car- 

cinoma of  Colon) 

-  congenital   dilatation   of 

(see    Hi  i-schsp rung's 
Disease) 

-  dermatitis  herpetiformis 

affecting  . .  , .      74 

-  dilatation  of  (see  Dilata- 

tion of  Colon) 

-  diverticulum  of,  inflamed  666 

-  dropped  . .       iFig.  183)  426 

-  erythema  buUosum  afEect- 
74 


-  gas  in,  simulating  gas 

stomach  .,  ..245 

-  greedy     . .         . .         . .  123 

-  idiopathic  dilatation   of 

(see    Hirschsprung's 
Disease) 

-  inflamed  (see  Colitis) 

-  normal    . .         {Fig.   182)  426 

-  pemphigus  affecting     . .     74 

-  sacculation  of    . .  . .   453 

-  scybala  felt  in  . .         . .  657 

-  spasm  of  {Fig.  52)       . .  124 

-  succussion  in     . .      652,  054 

-  tenderness  along,  in  ulcer- 

ative colitis      . .         . .  78 

-  thickened,  in  colitis     . .  663 

-  time    relations    of    food 

in         . .  {Fig.  49)  123 

-  transverse,    hyperplastic 

tubercle  of     . .         . ,  661 

situation  of    . .         . .  660 

visible  in  rickets       . .  660 

thin   persons  . .   660 

-  tumour  of,  asrites  from     46 

portal  obstruction  from    46 

spleen  simulated  by. .   664 

Colour     blindness,     fi-om 

alcohol  . .      759,  760 

congenital       . .  . .   762 

Colour    blindness,    general 

account  of      . .      762,  763 

in  hysteria     . .  . .    759 

nystagmus  from        . .   407 

from  optic  fitrophy  . .    762 

-  -   irom  tob;irro  7:.:*."  7ilO,  762 

-  MMlrx,    in    rlilnn.^i-       SI!.    274 


3w,  in  aplastic  a 
ill  gastric  carciru 
with    parasitic 


Colour  vision,  normal 
COMA         

-  from  alcoholism  . .   ; 
simulating  diabetes   . . 

-  in  acute  yellow  atrophy  , 

-  aortic  valve  rupture   . .   ; 

-  ill   apoplexy         .  .       144, 


-  carcinoma  of  liver        ..  373 

-  cerebral  embolism 

119,  304,  640 

htemorrhage  119,  264,  303 

syphilis            . .          . .  144 

-  cholaemia            . .         . .  324 

-  chronic  alcoholism       . .  144 

-  cirrhosis  . .          . .      332,  371 

-  from  congL'iiitifl   lH-;.rt,..  U-1 

Coma,   convulsions  associ- 
ated with                  I  i::.  144 

-  in  diabeu^^   SI.   Si;,   iT.l.  70-1 

-  from  drugs         ,  .          . .  144 

-  in  epilepsy  68,  136,  144,  145 


Combustion,  slow,  carbon 
m()noxide  poisoning 
from    . . 

Comedones 

-  absent  m  drug  rashes  . . 

-  in  acne    ..241,  559,560, 

-  in   lupus  erythematosus 
<  •'WW-  iii-ivi  median  arter>' 

i  niiully   enlarged     . . 
I  Miiiiit  p  iKicilli,  in  cholera 
I  (Piiiplfxion,  earthy,  in  con- 
genital S3T)hilis  ■ 

-  florid,  in  Mongolism 

-  mottled,  in  Mongolism. . 

-  rul)irund,  from  alcohol 


of 


711 


Babinski's 

coma  from     ..  "       . .  IK 

from  head  injury     . .  Hi 

headache  from  . .  29'i 

hyperacusis   after     . .  30( 

jaundice  from         325,  33i 
tenderness     of     scalp 

from  ■     710,  711 


riL'   du 


-  with  fatty  heart 

-  from  fevers 

-  in  general  paralysis  120, 

144, 

-  from  head  injury         . .  : 

-  head  injury  arising  from 

-  with  heart  disease 

-  from  heat-stroke       119,  . 

-  hysteria  . .         . .      120, 

-  idiocy      . .         . .         . .  , 

-  incontinence     of     faeces 

during  . .         . .  ; 

-  from     increased     intra- 

cranial pressure        . .  ■ 

-  intracranial  new  growth 

-  in  Jacksonian  epilepsy. .  : 

-  Kirkland's  disease         . .   i 


Condyloma,  general  account  70( 

-  in  congenital  syphilis  385,  401 

-  cure  by  mercury  . .  70( 
salvarsan        . .         . .  70( 


39£ 


Congenital  abnormalities 

urinary  opening        ..  39 
-  absence  of  canaliculi  . .   22i 

of    levator    paliiebme 

superioris    . .         . .  54: 
olfactory  nerves        . .  61; 


-    Irujii   laivc  llivinus 

144 

Congenital  alkaptonuria  .. 

746 

■    I.M  ^  ii-r.il    -|MMri 

753 

-  Ti]:ili.s  Of  Hi.-  Iirnn.  . 

141 

Coma,  list  of  causes  of  117 

118 

30 
144 

--  ,n„,|,l,ll,ali„.i-     .. 

701 

■-  li'. !!'''.,''':  ,,n,v     ;; 

-  atelectasis,  bronchiectasi 

>     '"' 

1'    \i.  1  .  ( .      Ji-iMse 

752 

from    . . 

'  -l^: 

n  .    ,,       ,1,               114,   147, 

566 

-  baldness              . .         70.  T. 

Coma,    method   of   investi- 

- cataract,  nystagmus  from  407 

gating  a  case  of 

118 

-  cerebral     diplegia     (see 

-  in  myxoedema  . . 

119 

Diplegia) 

-  at  onset  of  fevers 

594 

-  cervical  rib 

443 

-  from  opium  poisoning. . 

310 

-  cleft  palate 

5S8 

-  in  pellagra         . .       "  . , 

225 

-  closure  of  cervix 

64.'- 

-  petit  mal             . .       '   , . 

145 

livmen 

645 

-  in  phosphonis  poisoning 

33G 

-  cochleate  uterus 

645 

-  from   poisoning.. 

119 

Congenital  coloboma 

415 

-  jmiitiiic  liiL'riinriiiage  .  . 

310 

-  cnldtir  ltliiidne;'S 

7C2 

-    Ill    \'\i-.: ■■, 

144 

Congenital  crescents 

415 

Coma,  relation  of  acidosis  to 

3 

-  ii-\  |.[niii<jnorrliii':i 

17 

-   ttdru  ri.'kn- 

144 

Congenita!  cyanosis 

156 

-  in   SLiturnine   encephalo- 

- cystic  hygroma .  . 

6lw 

pathy  ..          ..      119, 

144 

-  defect  of  spine  . . 

713 

-  from  severe  hiemorrhage 

120 

-  deficiency  in  urethra  . . 

394 

-  snake  bite 

337 

-  diaphr^matic  hernia  . . 

652 

-  stertor  in           . .      117, 

647 

-  dilatation  of  colon     126, 

657 

-  m  Stokes-Adams  disease 

-  dislocation  of  hip    156, 

83, 

144 

251, 

",6S 

-  from  syphilis     . . 

144 

-  enophthalmos    . .      217, 

218 

-  in  m-a3mia  11,  40,  42.  83, 

-  fibroma  of  mediastinum 

551 

144,  146, 

417 

-  harelip 

588 

-  after  urinary  operations 

42 

-  heart  disease,  aortic  . . 

209 

Combined  scleroses   of  the 

blood-count  in 

533 

cord,  :it;i\y   uitli       '.7, 

251 

bruits  with        156, 

1.57 

C.\t<'ll-<i|-    )i|:i|it,ir    IC- 

without  bruits    157, 

633 

llcM'-     Irniii 

444 

-  -  -  chibbed  fingers  and 

liylu-ra.MlK-i:,    fr.Mii 

610 

toeswith  111.  167 

increased        tendon 

215, 

533 

jerks  in  . . 

444 

coma  from . . 

144 

lesions  of    . . 

517 

convulsions   from.. 

144 

parEesthesia  in 

444 

cyanosis  with  111, 

144, 

paraplegia  from  414 

514 

150,  167,  215, 

533 

sypliilis  and 

517 

dyspncea  with 

215 

CONGENITAL   HEART   DISEASE 


CONVALESCENCE 


Cougtiiitul  /ifarl  di.scasf.  con 
Congenital  heart  disease. 
»  heart  large  from  tti, 
Congenital  heart  disease, 
notes  on 


tricuiorum       111, 

phthisis  and 

polycythsemia    with 

215, 
pulmonary   stenosis 

prognosis  in 

rarer  types  of 

Congenital    heart    disease, 

symptoms  of  ■ .         ..  : 
~ysto!ir  apical  bruit 

Ilirills  with'       157, 

Congenital  hernia..         . .  i 

-  hypertrophy    of    cervix 


-  hypoplasia  of  bowel    . . 

-  it'lithyosis  . .  . . 

-  lymphangioma     circum- 

scriptum 

-  macrocheilia      . .         . .  > 

-  macroglossia      . .  . .   i 

-  malformation,  hemiplegia 

from    . .  . .  . .  : 

meningocele  from     . .  . 

of  pelvic  organs,  dys- 

Tnenorrha-a    from 


ulcer  with      . .         . .  734 

-  photophobia  from     231,  524 

-  ptosis  from         . .  . .   541 

-  rainbow  vision  from    . .  7G2 
-staphylococci   causing..  231 

-  ulcer  of  cornea  with  231,  733 

-  xerosis     of,      nyctalopia 

from 7G3 

Connective     tissue,    undi- 
gested,  in    fteces  101, 

170,  172 
I  Consciousness,  double,  hys- 
'  terical  . .         . .     20 

'  -  loss   of  (=ce  Coma) 
"   ,  .  ■  r-  ■':■■  .i.,i-  ^tate  of, 

li   tumour     G8 
CONSTIPATION     .  .  ..121 

-  ., I.. ...;,.!■    ■!      ■..  llmgfrom 

Constipation,  acute,  causes 
of  129.   130.   131 

,  Constipation,  acute,  distinc- 
tion from  intestinal 
obstruction  . .   129 

from  embolLsm  of  jian- 


Constipation,  could. 

-  in  Henoch's  purpura  . .     70 

-  Hirschsprung's  disease 

130,  390 

-  with  hypertrophic  sten- 

osis of  pylorus  . .    766 

-  in  hypochondriasis       . .   124 

-  from  hypoplasia  of  bowel 

muscle  . .         . .  123 

~  from  hysteria    . .  . .  128 

-  from  ileocajcal  kink      . .  457 

-  increasing,      from      car- 

cinoma" . .  . .   UO 

I  -  indicanuria  from  . .  314 

'  -  in  infants  . .  . .   128 

:  -  from  inflamed  piles     . .  128 
I  -  inhibitory,  a:-rays  in  dia- 
gnosing . .         . ,  124 

-  from  insanity  . .  . .  124 
I  -  insomnia  from  . .  . .  321 
I  -  intestinal,    aperients    in 


Constipation^  confil. 

-  scyb;ilai.;.lp:.ble  in 


12f 
12J 


-  from  too  high  w.c.      . .  12S 

-  too  little  food    . .         . .  12:i 

-  toxiemia  from   . .  . .  40)i 

-  with  tropical  liver       . .  30ii 

-  from    tuberculous    peri- 

tonitis ..         ..  G57 

-  with  twisted  ovarian  cyst  131 

-  types  of 121 

-  in  typhoid  fever        564,  b'J'> 

-  with    undue    abdominal 


reli( 


1^1 


fjEces  in  rectum  in    . . 

from  htemorrhage  into 

pancreas 

rectal  examination  in 

from  acute  congestion  of 


129 


Constipation,    intestinal.. 

general  account  of  122-127 

palpable  scybala  in   . .    121 

-  from  intestinal  fermenta- 

tion       241 

Obstruction    241,316,388, 

522,  592,  593 

-  intussusception  127,  678 

-  invagination    of  rectum  129 

-  kink  of  colon     . .  . .    126 


aortic  pulsation 

-  vertical  headache  from 

-  with  visceroptosis 

-  with        vomiting,        ir 

Henoch's  purpura    . . 


yplin 

Contort  ion  isls,   ham&trings 
elongat(-d  in  . .  . .    . 

-  lordosis  in          . .          . . 
CONTRACTIONS,     ATHE- 
TOTIC, etc 

-  carpo-poilal,  in  tetany  . . 
Contractions,  choreiform.. 

-  contra.'turc-s  distinct 


Congenital    malformations. 

liver 

334 

-  large  abdominal  tumour  127 

-  crim]|.~  .li-Iiir_'ui-l„  .1    . .    i:;i 

of  rectum  (Fi<js.  24'j- 

pancreatitis            131, 

661 

-  with  lead  colic  . .         . .  131 

Contractions,  hbrillar      . .    134 

■j-'>-) 

586 

peritonitis 

131 

-  from  lead  poisoning  (Fig. 

Contractions,  spasmodic  . .    136 

s|)ina  bilida  from     . . 

61U 

yellow  atrophy 

333 

.31)       . .          .  .         34,  124 

Contractions,     spasmodic. 

of  uterus,  detection  of 

102 

-  adhesions 

126 

-  after    leaking    duodenal 

causes  of                 .144 

-  meningomyelocele 

B94 

-  agar-agar  for     . . 

123 

ulcer 126 

Contractions,  tetanic       ..   137 

-  nn.TVfi^m  " 

388 

-  anaemia  from     . . 

32 

—  gastric  ulcer  . .         . .  126 

Coritr.Tlurc,     \  oikmaiiirs. 

-    n:iiro\\  rji--;  .if  :ui:il  canal 

129 

-  in  aneemic  girls  . .      123, 

412 

-  lessening  etfect  of  pur- 

111. .'.Hi; 

Congenital   obliteration   of 

-  from  anal  ulcer. . 

128 

gatives  in       ..          ..   122 

nerve  paralysis  simu- 

bile-ducts 

329 

-  with  anorexia  nervosa. . 

43 

-  in  Malta  fever   . .          . .  406 

lated  by     . .          . .   ■'■'Ih; 

-  r.iwfrii.i  joii  m|  .luodemim 

13(1 

-  from  aperients  . . 

124 

-  meningitis          . .          . .  128 

CONTRACTURES..         ..   138 

-  -  ilium 

130 

-  appendicitis     124,    12G, 

-  menorrhagia  from     38G,  387 

Contractures,  active        . .   139 

-  -  lachrymal  ducts 

220 

131,  6G5, 

677 

-  with  mesenteric  embolus  131 

-  archnli-  :.ri.l       ..           ..    M2 

-  a-dema    . . 

■110 

-  with  ascites 

127 

thrombosis      . .          . .   131 

-  -  siniiil:il.-.l  l.v.  .           .  .    :i.".l 

-  optic  nerve  blindness  . . 

Sll 

-  from  asthma 

128 

-  muconiembranous        co- 

-  in   Iir;ii-lii;tl  nuino|ilcL'iji      .'>0"_' 

-  perforation  of  palate  . . 

388 

-  belladonna  relieving    . . 

124 

itis  (Fi!>.  52)             ...124 

-  after  a  burn  (Fig.  On) 

-  persis:ence  of  pupillary 

-  with  biliary  colic 

131 

-  mucous  colitis  . .         . .  116 

142,  ii:i 

membrane 

3.51 

-  in  cachectic  states 

123 

-  mucus  in  stools  from  . .  398 

-  contractions  distinct  from  l.'ll 

-  ptosis 

542 

-  from  carcinoma    77,  78, 

-  in  myelitis         . .          . .  128 

-  cramps  simulating       ..   l:{'.t 

-  pulmotiarv  n'L,'uri.'itation 

'j:i 

126,  330,  585, 

630 

-  from  nervous  depression  124 

-  in  dijilegia         . .          . .    l;i'.i 

-  -  ^It-n.HJs   (M-.-   I'uln^on- 

-  in  catarrhal  jaundice  . . 

320 

-  in  neurasthenia. .          ..   124 

Contractures,  from  disuse    141 

arv   Stfiio;-is> 

-  charcoal  test  for 

121 

-  noises  in  tlic  head  from  400 

-  after  enterica    .  .          ..Ill 

Congenital  pyloric  stenosis  384 

-  in  chlorosis        . .        37, 

123 

-  with  obesity       . .         . .  127 

-  facial  MdfA.M.  108---'llli). 

^    .-,,:, ^!,r      ,.:.>-;., .Iw.:,,      kv- 

in  chronic  peritonitis  . . 

47 

-  from  (esophageal  obstruc- 

4U2,   IIM 

1 :,.. 

colic  with           ..      115, 

122 

tion      ....          ..123 

-  in   Fri.dni.li's  discnsc.    1  lo 

Congenital      syphilis     <  •' 

from  colitis 

124 

-  in  old  age          ..         ..   123 

-  Iroiii  l.ii'M.iilomyclia     ..    1  In 

Syphilis.  Congenital) 

colonic  succussion  from 

651 

-  opium  relieving. .         . .   124 

Contractures,  hysterical  l.'il,  141 

;onoenital  systolic  bruits  9C 

,  91 

from  congenital  oblitera- 

~ overcome    by   linger   in 

-  from  later  il  sclerosis  ..    11(1 

Congenital  talipes,  general 

tion  of  bile-ducts     . . 

329 

rectum           . .         . .  128 

Contractures,  list  of  causes 

account  of     . . 

112 

-  cumulative 

121 

~  from  pain  in  abdomen.,  124 

of          . .          . .       138,  1  311 

ir'itii.r                   .  .       71'  1. 

723 

-  ilatinp  from  infancy     .. 

123 

-  pancreatitis      204,  694,  707 

-  from  lower  neuron  lesions  3M 

Coiifo-r.il  ic-t  for  free  IICI 

320 

Constipation,  from  deficient 

-  pericolic  abscess           . .  003 

-  nnissnge  in  preventing    'III 

Conjnn.-tivu,      briglit,     in 

Intestinal  motor  activity  123 

-  with  peritonitis         120,  602 

-  movement  in  preventing  1  1 1 

< jr.'ives's  discfise 

230 

-  petroleum  for    . .         ..  123 

-  from  muscle  hijury     ..    1 1:{ 

-  deposits  in,  in  Oauclicr's 

.if  iMllc.i-;L 

124 

-  photophobia  from         . .  525 

-  nerve  injury      ..          ..Ill 

(iiseiLsc 

R3I 

-  dclinition  of 

121 

-  pigmentation  from       . .  52S 

-  neuritis Mo 

-  herpe*  of 

701 

-  from  discayo  of  duodenum  124 

-  after  j>n'gtiiincy            ..    127 

-  occu[ta(ion  and..         ..    112 

-  inj«-tc.l.  in  glnncoma  . . 

233 

-  -  gall-bladder    . .« 

124 

-  pseudo-diarrliica  with..    121 

-  of    palmar    fascia          ..    112 

-  ofliroiiosis      of      (Plate 

genital  organs 

124 

-  from  jnirgativcs            ..   709 

-  from  poliomvelitis    1  In,  .'iii'.i 

-V.Y.Y///)       . . 

7-f(! 

stomach 

124 

-  from  pyloric  obstruction  123 

■  from  iiriilonC'cd  rest     .  .    Ill 

-  in  iiernirjous  itniiimia  . , 

32» 

-  disregard     of     call     to 

-  with  renal  colic.         ..   131 

-  scars       1 1:; 

-  pii;meuted,  in  ochronosiH  74r» 

defipcate 

128 

-  in  rickets            ..      123,  146 

Contractures,  spastic       . .  139 

-  lero-iis  of 

734 

-  rlislenlion  of  colon  from 

«,'ifl 

-  from  shock        . .         . .  124 

-  from  tendon  ifijiu'y      ..    1  i;; 

-  yellow,  from  iiicric  acid 

S29 

-  diverticula  from        125, 

453 

-  soa])  In  overcoming       . .    128 

Contusion    of    lung,    gnn- 

Conjinn-tivltis,  ncnte  (.Plate 

-  from  dlvcrliculitls 

453 

-  from  siilanclniic   inhlbl- 

grono  of  lung  from  . .  200 

A/) 

3»0 

-  emphysema 

128 

lioT 124 

-  spintd     cord,     prlitplsm 

-  ani^nlni* 

231 

-  with  enterospasm 

438 

-  spasm  of  sphincter  ani. .   128 

from S38 

-  Iilirikiri^'  tic  from 

131! 

-  enuresis  from     . . 

218 

-  spastic,  ahdnmiiiut  pain 

(  onval.-scen.o.  anicmla  In     32 

-  dipl.tln-rilic       231,  5S8, 

731 

-  familial 

123 

from                              . .    2l.'» 

~  iirrhvlhinia  in    .  .          ..   :>V, 

-.diplo-hncillns  of 

231 

-  from  fatty  bowel 

123 

-  -  .li'^leiidnl  la^.iini  with   121 

.-..nch  .luring     ..          ..    119 

~  i-pjphurji  in 

220 

-:  In  fevers 

123 

Conillpatlon,  spastic,  general 

-  .•ijinips  in           . .          .  .    I.*>2 

-  f.'.lHi-  ;iJ  of  LTit  in  i-vi! 

231 

-  Itatulencc  causing 

123 

account  ol                . .   124 

-  Iiv|..iii.  I..I     ilinim,-       .  .   311!! 

I..III.  (iNir  U'lulr  XI}  -.MiJ 

231 

-  Ilatus  from 

240 

-  niucomembranous  colitis 

I.i|..ll,..i .           .  .    311 

Conjunctivitis,  general  ac- 

- foul  breath  from 

87 

will 125 

k.,..'  i.il.    .x  .i:-.i..lc.|  III  3.-,» 

count  o) 

231 

-  fragmentary 

121 

-  pain    in   left  iliac  fossa 

-  n'.l.'iiM   i.l    li  1'^  ill       11  1,  4ir> 

•.i,„.,rli.r:.l          ..        ■.'.11, 

731 

-  from  gastritis    . . 

267 

from            . .         . .  452 

-  polyuria  In         . .      636,  Mr, 

Conjunctivitis,    iritis,    and 

-  from  greedy  colon 

123 

-  sense  of  fulliMsw  from..  245 

-  priapism  In       . .         . ,  538 

glaucoma  compared  . . 

232 

-  habitual  (Fiij.   17) 

122 

-  simulating  appcndlclllH. .  124 

-  sliorttuwA  of  breath  in  . .     .'<.s 

231 

-  from    luBmorrliago    Into 

bowel  tumour            ..   124 

-  slow  piilwi  in     . .         . .  6 18 

'  1  inous 

231 

pancreas 

2M 

cnrclnonni  coli           . .  453 

-  tachycardia  in  .  ,          ..   701 

1  n^d       Iiiclirynml 

-  from  hardness  of  fji'ccs 

128 

l-rnv»  in  dlngnoslng 

-  trntnnr  In           . .      72 1,  726 

ini^<liikcn  for    . . 

220 

-  hendnclie  from  . . 

290 

124,  346 

-  vertigo  from      ..         ..  732 

S04 

CONVULSIONS      .. 

-  in  acute  yellow  atrophy 

-  albuminuria  from 

-  from  alcohol      14-1,  1-15, 

-  aphasia  after     . . 

-  iti  apoplexy     "144,  147, 

-  from   arachnoid   haeraor- 

-  aspln-Ai;/'  '.'.  '.'. 

Convulsions,  associated  with 
coma  ■ . 

-  from  atropine    . .  . . 

-  bloody  saliva  in. . 

-  from  brain  lesions 

-  cerebellar  abscess 

-  cerebral  abscess        14("i, 
aueurysm 


CONVULSIONS 


CRAMPS 


syphilis  . .      1 1 4 .  I  H  • 

tumom-  . .       lit;,  1 1 7 

-  cerebritis . ,        . .  . .    1 J  D 

-  choltemia  . .  . .   :>_  1 

-  congenital  heart  ..    Ml 

-  cyanosis  in         . .  . .    14it 

-  in  dissemuiated  sclerosis 

144,  148 

-  from  drugs  .  -      144,  145 

-  ear  disease         . .  . .   144 

-  in  eclampsia      . .  . .    14(1 
from  emotion     . .  . .   144 

-  encephalitis       li'O,  502,  511 

-  enlarged  thymus       144,  145 

-  in  epilepsy  " 

(IS,   137.   144,   146,  148 
Convulsions,  epileptic 


epilq.i 


rhnnliM;. 


-  -  frn 
Convulsions,     epileptiform, 

conditions  causing  Mi; 

in  Lreneral  paralysis  l:iU,;ior. 

rigors  simulated  by  . .   594 

in  saturnine  encephalo- 

patliy  . .  . .   119 
Stokes-Adams  disease     S3 

-  -  ursemia  . .         . .  594 

-  with  fatty  heart  . .   212 

-  from  fevers       . .         . .   144 

-  fright .144 

-  fimgating  endocarditis. .     34 

-  general  paralysis  144, 146,  243 

-  heart  block       . .         . .  4Sri 
disease  .  .      141.  1  1') 

-  hydrocephalus    . .       1 1  o .  U  t , 

-  hydrophobia 


-  liyperpyr 
Convulsion 


after 


147.  :'.i(i 


417 


cnuiiai  pressure        . .    O'.'U 

-  idiocy       .  .  . .      144,  146 
Convulsions,  infantile      ..   144 

-  injury  during'     . .  . .   143 

-  from     intracranial     new 

growth  . .  . .   144 

-  irritating  food  . .  . .   144 

-  Ja^-ksonian  epilepsy  137,  147 

-  jaw  L'lenching  in  .  .    143 
Convulsions,  localized,  causes 


of 


,  144 


202 


Convulnio/is.  could . 

-  from  santonin    . .  . . 

-  in   saturnine   encephalo- 

pathy . .       119,  : 

-  scarlet  fever  . .  . .  . 
;  -  after  severe  haemorrhage  : 
'  —  from  sinus  thrombosis 

!  120,  i 

-  status  lymijhaticus      . .   '. 

-  stertor  in. .        . .         . . 

-  in  Stokes- Adams  disease 

144,  146,  ■ 

-  from     strychnine     138, 

144.  729,  ■ 

-  subdural  haemorrhage  . .  : 

-  MMlulis " 


Convulsions,        unilateral, 
general  account  of    . .   I 

-  fnun  nr;i'iiii:L  4ii.  s;.,  i;;7. 

Ml.  Ml.;.  4 

-  after  urinary  operations 

-  from  vesical  calculus^  . .   ] 

-  whooping-cough         144,  ] 

-  worms ] 

Co-ordination,   mechanism 
of       

Copaiba,     erythema    from 

-  resin,  polyuria  fi-om    . .  i 

-  purpura  from    . .         . .  I 

-  rash,  small-pox  simulated 


-  SUlpllllh-    Ml    l.mirl     IrM   .   .  \\\ 

Fehhng'stes't..  ^       ..  261 

-  -  Pavy's  test  . .  . .  261 
Coraco-brachialis,       nerve 

supply  of       . .         . .  504 

-  root  innervation  of  . .  509 
Cor  bovinum  . .  . .  207 
Cord,  spermatic  (see  Sper- 


Corpusclcs,   basophile  (see 
BasophUe  Cells) 

-  eosinopliile  (see  Eosino- 

phile  Cells) 

-  hyaline  (see  Lymphocytes, 

Large) 

-  red  (see  Red  Corpuscles) 
~  white  (see  Leucocytes) 
Corrosive    sublimate    t&st 

for  bile  . .         . .  ] 

urobilin       . .  . .  ] 

Corrosives,  abdominal  pain 

from    . .  . .  . .  i 

-  acute  gastritis  from     . .  '. 

-  albuminuria  from         . .   S 

-  collapse  from     . .  . .   ' 

-  dysphaLriii  from  . .  i 

-  hieraateniesis  fi-oni       . .   - 


if  re 


-  rapid  teeble  pulse  from  ; 
!  -  sore  throat  from  . .  I 

-  taste  loss  from  . .  . .  ' 
!  -  tongue  swollen  from  . .  ( 
,  -  vomiting  from  267,  7C5,  7 
'  Corsets,     liver     furrowing 

from    . .  . .  . .   ; 

Corti,   organ   of,   deafness 

from  changes  in  . ..  1 
Coryza,  acute,  in  influenza  ■ 
pahi  in  the  limbs  in 


Cough,  conUl. 

-  hernia  of  lung  fi 

-  from  hysteria    . 

-  after  influenza  , 

-  in  influenza 

-  from     laryngeal 

biiity  .. 

-  laryngitis 


long 


vuia 


..    14 
149,  15 


measles 

-  mitral  regurgitation     ..  21 

-  new  growth       . .       149,  43 

-  pain  in  the  chest  from. .  43 

-  from  paralysis  of  vocal 

cord     . .         , .  . .   14 

-  paroxysmal ;   in  whoop- 

ing-cough      . .         . .  42 

-  pharyngeal  causes  of    . .  14 

-  in  phthisis 

88,  149,  150, 159,  2SS,  47 

-  pleurisy  . .         . .         . .   15 

-  pneumonia         . .     149,  33 

-  relation      of      laryngeal 


to 


14 


-  shortness  of  breath  and  15 

-  from  stomach  disorder. .  11 

-  tobacco  smoke. .         . .  14 

-  treatment  of     . .         . .  14 

-  useful  and  useless       . .  14 

-  vagus  nerve  in  relation  to  14 

-  violent ;         hsemoptysis 

from    . .         . .      286,  28 
in  whooping-cough    . .  28 

-  vomiting  and    150,  420,  76 

-  wakiiii:;  patient  at  night  15 

:.ftrruiMH,pin-cOUgh    ..  U 


npli.1 


144 

irjii 
Mr. 


Convulsions  in  malingerers 
137,   141,     147, 

-  from  me;isles 

-  menhigeal     litemorrliage  146 

-  meningitis  120,  138,  144, 

145,146,147,307,  511,  i 

-  morphia  . .         . .         . .  : 

-  mouth  foaming  in       . .  : 

-  from  nasal  disease 

-  nephritis. . 

-  at  onset  of  fevers 

-  optic  neuritis  and 

-  from  otitis  media 

-  oxygen  in  checking     ..  146 

-  from  phimosis    . .  . .    144 

-  phosphorus  poisoning  . .   336 

-  plumbism  34,  119,  146,   147 

-  pneumonia         . .  . .    144 

-  poliomyelitis      . .      110,  509 
~  porenceplialus    . .         . .  146 

-  in  pregnancy      137,  144,  146 

-  pyrexia  hi  . .      144,  574  ' 

-  from  renal  c^^ilculus      . .   144 

-  rickets     . .         144,  145,  420  \ 

-  rigors  and  . .         . .   143 


i,U  Cord) 


-  opacity      of,      defective 

vision  from     . . 

-  -  from  iritis       . . 

from  keratitis  72, 

ophthalmia     .  . 


Cornea,  rodent  ulcer  of  ..   734 


■   I  Mr 


tion  of  tliG  Cornea) 
Corneal    rellex    in    facial 

paralysis  . .  . .  A 

Cornet  player's  cramp  . .  1 
Cornwall,  ankylostomum  in  a 
Corona  veneris      . .  . .   4 

Coronary  artery  (see  Artery, 

Coronary) 
Corpora  quadrigemina,  le- 
sion of,  tremor  from. .    7 
tumour    of,    pupil   re- 
acting to  light  but 
not  to  accommoda- 
tion in        ..  ..5 
Corpus     luteum,     hajmor- 
rhage  from   (see   Hai- 
morrhage  from  Corpus 
Luteum) 

cyst,     hcemorrhagic, 

pain  in  pelvis  fi'om  ^ 
-  striatum,  lesions  of,  py- 
rexia from      . .  . .    S 


1  ,in/,i     ,•    leiio    (SCT'    lliii 

4S2,     4S3,    674,    675 

1  .ILT) 

050 

OS 

h.Mi,  ifHlides      .. 

73 

hydrocele  of  cord 

68 

-  Ill  ii:Hit  gases     . . 

178 

lipoma  of  cord 

OS 

-  ill  measles         178,  3Si, 

440 

psoas  abscess  074,  075 

OS 

-  rickets     . . 

145 

bursa 

OS 

—  taste  impairment  from . . 

706 

saphenavarix074,675 

,68 

Costermongers,     clironic 

varicocele 

48 

pharyngitis  in       (il3. 

016 

-  cedema  from      . .      413 

41 

Cotton,  actinom^-cosis  from 

-  pain   on,  from  liver  ab- 

'•1, 

645 

scess    . . 

37 

-  sporotricliosis  from 

290 

in  epigastrium  from.. 

43 

Cotton-woDi  in  ear,  deafness 

-  regurgitation     of     food 

from    . . 

165 

through  nose  from  . . 

58 

-  forgotten  in  ear 

422 

-  subcutaneous  emphysem 

b 

-  in  testing  ancestliesia  . . 

005 

fi-om    . . 

20 

( 'imiir  I'litlieter,  for  enlarged 

-  violent,  frieuum   lingua. 

[inistate 

396 

abraded  by    . . 

28 

COUGH        

148 

Cousins,  marriage  of,  retin- 

- ;iL'<-  iiu-idenceof. . 

149 

itis  resulting  from    . . 

76 

-  alterntion  of  voice  and. . 

150 

Cow-pox  in  man   . . 

24 

-  from  aneurysm  . .      149 

150 

Crab,  pruritus  from 

04 

-  aural  causes  of  . . 

148 

-  ptomaine  poisoning  from 

21; 

-  on  going  to  bed . . 

150 

-  urticaria  from 

77 

-  bovine,    witii    laryngeal 

Cracked-pot    sound,    over 

paralysis         . ,     494, 

495 

fibroid  lung    . . 

21 

-  brassy,  from  aneurysm 

158 

Cracking  noise  in  ear 

72 

laryngeal  jiaralysis  . . 

494 

-  in  head  . . 

40 

-  t.r 'Ih  iI  .Mliirrh 

150 

Crackling,  egg-shelj 

15 

^    .  ■  .     .                   149,  150 

289 

fi'om  aneurysm 

69 

.-   1 ,  •  ,  ,|,   ,  iinitmia 

149 

arthritis 

15 

-    .   1  ...11^  1,1 hial  glands 

149 

craniotabes     . . 

15 

-  imI'I  liL'ilrooni 

149 

hydrocephalus 

15 

■    -In'C'ts  , . 

149 

in  osteosarcoma     15U 

69 

-  ilunifg  convalescence    .. 

149 

with  pulsation 

15 

-  from  debility      . . 

148 

from  sarcoma 

67 

-  diphtheria 

149 

subcutaneous  emphy- 

- dust 

148 

sema 

15 

-  dyspepsia 

148 

tenosynovitis 

15 

~  emphysema 

289 

-  riiles  (see  Kales,  Crack- 

- f.\;iniiM:ili(in  for  tubercle 

ling) 

iKhilli    \\  illl 

149 

Cramp,     abdominal,     in 

-    nil    i\i-rliiill 

150 

Henoch's  purpura     . . 

55 

Couoh  with  expectoration 

in  plumbism  . . 

48 

U9. 

ISO 

(and  see  Colic) 

-  without  expectoration 

-  delinition  of 

13 

lis. 

149 

-  typist's 

44 

-  from  fibroid  lung 

216 

-  writer's 

44 

-  food 

148 

CRAMPS 

15 

-  foreign  body  in  larynx 

149 

-  in  ballet-dancers 

15 

-  frontal    pain    on,    from 

-  after  cholera 

15 

fi'ontal    sinus    empy- 

— in  chronic  alcoholism  0] 

,  6 

ema     . .         . .         ' . 

ISO 

-  cirrhosis  . . 

5 

-  from  gangrene  of  lung  . . 

259 

-  convalescence    . . 

15 

-  on  getting  up     . . 

150 

-  from  debility     . . 

15 

-  hfEmoptysis  and       28(i, 

288 

-  distinguished  from  con- 

- from  heart  disease     1 19, 

150 

tractions 

13 

-  -  failure 

lis 

-  in  fevers 

15 

CRAMPS    —    CYST  OF  KIDNEY 

60 

- .   rotlftl. 

Cristas,  fjnstric,  coiittt.                         Cii/slal.t.  phviiijl ,  couhl. 

(>/;l<).i/.v.  rniilJ. 

-    ■  iiii.', 15U 

vomiting  due  to       . .    7G5 pentosazone,    melting 

-  high  blood-iiressure      ..   10 

r.niioundei-s      ..          . .  15U 

without  absent  knee-                         point  of      . .         .  ~ 

262 

-  hydropneumothorax     . .  65 

-     '  '    Il^i:s.  from  peri|ihorul 

jerk 437     -rosette 

741 

-  inspissation  of  the  blood  10 

.  iiritis           ..         00,  -105 

-  intestinal,  in  tabes  115,             -  on  skin,  in  uridrosis     . 

655 

-  iodism 15 

iL-lit 150 

110.410.487,0119     -thorn-apple 

740 

—  irruption  of  caseous  gland 

over-escrtioii       . .   IJO 

colic  simulated  by    . .  115     -  triple    phosphate    (fiV 

into  trachea  . .         . .  42 

\\\Va           ..       ISy,  150 

-  laryngeal,  in  tabes                                                                  221) 

524 

-  laryngeal  obstruction  .'.   15 

'  '  -sional        .  .          .  .   151 

139,  418,  420,  487     -  tyrosiii    . .       (Fig.  148) 

3?3 

-  laryngismus    stridulus 

'   i.-iaiion  to  colic.  .          .  .    150 

-  in  pneumonia    . .      100,  574     -  urate 

740 

157,  42 

-  in  rowing  men  . .          . .  150 

-  -  (Fig.  272)       . .          . .   042     -  -  of  sodium       . . 

344 

-  laryngitis            ..      157,  10 

■-  BiDiulating    contractures  139 

-  pyrexial,  in  meningococ- 

- uric  acid  . .      (Fig.  302) 

741 

-  ligneous  thyroiditis      . .   15 

-  in  stokers          . .          . .   150 

cal  meningitis  310,  500,  590 

in    Rright's  disease 

9 

-  loss  of  fluid        . .         . .   15 

-  swimmers           . .          . .   160 

Crises,  rectal,  from  tabes  173, 

-  in  urine,  from  vesical  cal- 

-  lung  lesions       . .         . .  15 

-  syringomyelia    . .          . .  60i) 

.115,  5111.  O.W,  719            cuius 

580 

-  mediastinal  fibrosis    159,  -13 

-  in  tetany             . .       139,  131 

-  renal,  in  tabes    .  .          .  .   515      -  whetstone 

741 

-  methtemoglobin«mia 

-  in  typhoid  fever          . .   15? 

-  sweating,  in  tabes        . .    054 

Cubebs,  erythema  from  . . 

ooo 

137,  10 

>]  bones,  new  ^M-owtli 

-  in     tabes,    spontaneous 

Cud  chewing  (see  Merycism 

) 

-  in  myxoedeiua   . .         . .  23 

.   secondary  to  tliv- 

cessation  of  . .         . .  719 

Cuneus,    lesion    of,    hemi- 

- with  nutmeg  liver        . .  33 

>l      ..          ..          ;.    Til 

-  in  tvphus  fever  333  (Fig. 

anopsia  from 

301 

-  from  a-dema  of  larynx. .   15 

iiiionvs  of    ..          ..711 

209)  039 

Cup,    physiological    (Plate 

—  in  pancreatitis  . .          . .   15 

:  i'>es,    from    con- 

-   iir.-jliril 515 

XIX) 

416 

^  -  paroxysmal  tachycardia    54 

ital  syphilis          ..    205 

Crises,  various,  in  tabes    ..515 

Curettage,  ansesthcsia  need 

1  -  parts  affected  by          ..    l.'i 

Crises,  vesical,  in  tabes  iil9.  650 

«I for  I V 

390 

-  from  patent  septum  veii- 

iction  of  skull  bones 

(;,-„ss-l.~.-._T.|      -:iit.      friini 

-  in  diagnosing  carcinoma 

triculorum     111,  150.  21 

Hum loL' 

c-crelTal  diplegia       ..    729 

uteri    . . 

390 

-  phthisis 15 

-  Irom  rickets      . .          . .   20.5 

in  Little's  disease     . .  139 

.senile  vaginitis 

392 

-  pneumonia         . .          . .   10 

Creatinine,  coloration  with 

Crosseil  amblyopia          . .  759 

-  dysmenorrhcea  cured  by 

192 

-  pneumothorax  . .      432,  53 

iiitroprusside             ..       .1 

Crotin.       haimoglobinuria 

-  endometritis  cured  by. . 

192 

-  polycythtemia  with      . .  53 

'  '!iiu''s     sointion     re- 

from 28 1 

—  sterility  curable  by 

646 

-  from  postpharyngeal  ab- 

i rd  by        ..          ..   201 

Croton  oil,  bulla;  from     90,  97 

Currants,     in     diagnosing 

scess    15 

ic  from     . .          . .  -12-1 

dermatitis  from        . .    755 

stagnation  in  stomach 

317 

-  pulmonary  embolism  159,  28* 

acid  test  and     . .   262 

erythema  from         . .  222 

-  testing  gastric  iiiotilitv 

320 

—  stenosis   91,  156  (Fin. 

'  r.-iiM-ter,  nerve  supply  of  499 

Crura  cerebri,  ataxy  from 

CURSCHMANN'S  SPIRALS  153 

67),  137,  21 

tYeosote,  foul  taste  from . .   705 

lesions  of       . .          . .     58 

CURVATURE.         SPINAL 

-  Raynaud's  disease     162, 

Crciritations,  mediastinal      435 

'Iruritis.  anterior   ..     439,477 

(  -i-t     ,-|.mi-,    <  ■ur\  ,i[iii-i 

441,  09' 

-  in  pneumonia    . .      100,  042 

Crus  peni?,  gtunma  of      . .  098 

•  il  ) 

-  Riedel's  disease            . .   Vtf 

-  renal,  from  calculus     . .  357 

Crusliing,  gangrene  from..  255 

Cut.  pneumothorax-  from 

532 

-  in  rigor 59 

CREPITUS 152 

Crusts  (and  see  Scabs) 

-  tenderness  from 

707 

-  splenomegalic  polycyth- 

-  from  fracture     . .       152,  707 

-  in  cheiropompholvx     . .  COO 

Cuts,    excessive    bleeding 

lemia       157,  161,  534,  03. 

-  osteosarcoma     . .          . .    152 

-  in  eczema,  558,  000,  002, 

from,  from  htemophilia 

273 

-  in  Stokes-Adams  disease     8. 

-  silken 152 

753,   754 

-  septicaimia  from 

597 

-  from    sulphhaimoglobin- 

-  from  .subcutaneous  em- 

-  in  lavns  . .         . .     247,  000 

Cut-throat,  stenosis  after. . 

660 

aemia    . .         . .      157,  16 

Irtiysema        ..         ..153 

-  in  herpes            . .      000,  753 

-  stridor  after 

650 

-  sulphoiial           . .         . .  15 

-  from  synovitis   . .          . .    152 

-  honey-like,   in   impetigo 

-  ulceration  of  larynx  after 

-  tabes 15! 

Crescent,   coTiL'enital  optic 

contagiosa      . .         . .     98 

287, 

292 

-  tracheal  obstruction    . .   15 

(/'/«/.,-  .V/.V)  . .          . .   41B 

-  in  impetigo       558,  502,  755 

Cyanosis,    from    abductor 

-  trional 15" 

-  form  of  malaria  parasite     31 

-  in  keratosis  follicularis. .  733 

paralysis 

lliS 

-  in  typhus          ..         ..   101 

-  mahiiTd  (/•/„/,.  .Y.V  17//)  614 

-  leprosy 001 

-  acctanilide 

157 

-  from  ulceration  of  larynx  U^> 

Crescent,  itiyoiiic  ..         ..416 

-  lupus       . .          . .      001,  735 

-  acute,    from    aneurysm 

—  vena  cava  superior  ob- 

in sputum  420 

-  in  mycosis  fuiigoides    . .  731 

opening    into    [lulmo- 

struction          . .      157.  20." 

;    /.   S8)          .  .    189 

-  in  nose,    from   atrophic 

nnry  artery    . . 

92 

-  veronal    . .         . .         . .   15" 

1...  ■     ■■■:■'     ,,,«..              ..       l.S 

rhhiitis           ..         ..179 

superior  vena  cava  92 

-  in  yellow  fever  . .          . .    10 

-  ,-„:.i-.-  c-;ir~  in    ..          ..   234 

-  in  I'agefs  disease        ..  730 

pneumothorax- 

159 

Cyclic  albuminuria                 15 

Cretinism,  facies  of        . .  234 

-  pemplligus         . .         . .  601 

tabes  . . 

159 

-    v.iniiliir.-.:!.  1  l.iiiiiria  Willi 

-  frou-bclly    in  (Fiy.  103, 

-  pityriasis  rubra  pilaris 

-  from  aneurysm..      159, 

208 

Cyclical  vomiting  of  chil- 

p. 233).  234 

488,  604 

-  angina  ludovici  . . 

15S 

dren  . .                 384.  765 

-  hair  scaiitv  in   . .          ..    234 

-  prurigo    . .          . .          . .  489 

-  arteriosclerosis  . . 

161 

Cycling,  menorrhat'la  from  :w\ 

'-  hypothermia  in..          .  .   311 

-  from  pustules    . .          . .  558 

-  asthma    . . 

ino 

Cyclitis,  photophobia  from  52 

-  idiocv  simulating          ..511 

-  in  gcrofulodcrmia         . .  559 

-  blooil-clianges    . . 

157 

Cyrtomctric     tracings     of 

-    l:,r--.-'li.-;.d  in      ..           ..    234 

-  seborrhoea          . .          . .   002 

-  Hriglit's  disease 

159 

chests            ..         ..    Hi" 

,^    \.    -1   in           ..    234 

-  sycosis     .  .          . .       559,  600 

-  broncliiectMis   . . 

161 

Cyst,  abdominal,  simulat- 

■   ■    '  )  ivicles  in  23-1 

—  on  svphilides     .  .          .  .   500 

-  bronchitis           . .      161, 

420 

ing  ascites      ..          ..     44 

ni              ..    51U 

Crusts,'ln  syphilis..        ..  601 

and  emphysema 

160 

-  abdominal  swelling  from  05.'' 

-  .1  ,-i.. Mh  in       ..   234 

-  from  vesicles     . .          . .   753 

-  bronchopneumonia    160, 

420 

-  blood-,  in  sarcoma        .  .   07: 

-    iilinf.rnial    temperature  234 

Crutch,  niusciilospirnl  par- 

- cholera 

101 

-   linker's OH'. 

-■  thyroid  gland  defect  and  19U 

alysis  from     . .        05,  504 

-  -  mnligiia 

157 

-  llartlioliniuii      . .         . .   701 

treatment  in  diagnos- 

Crying  in   children,   from 

-  chninic  niediaslinitis    .. 

435 

-  of  brain,  lieadaclic  from  291 

ing  ..       ..       ..  :,n 

colic    . .         . .          . .  425 

Cyanosis,  congenital 

156 

-  of     breast,     carcinoma 

Ml     distinguishing 

-  ii-denia  from      ..      413.  41G 

-  in   congenital   heart   di- 

simulated by  . .         . .  08i 

from  mongolism     238 

CrMiscMpv  111  rcrelirospinal 

sease        Ul,  111,   144, 

llbro-iulenonia  and    . .   0S7 

•   iirotrudcd  in     ..  234 

■    llu..r    ..           .»          ..   304 

160,    157,     210,    217, 

from  nin.Htltis          181.  mi 

..lien  in      ..          ..  «98 

CryptomenorrliiBa           . .     17 

533, 

720 

pain  in                       . .    121 

skin  in  . .         . .  234 

Crvptorchisni    (see    Testis. 

-  in  convulsions   . . 

143 

-  calcitled  retroperitoneal. 

1  lie  neck  ..          ..  429 

Kcloplc) 

-  from  diphtheria 

157 

dilatation  of  slolnach 

IS.        subacromial 

Crystals,  nmuionio-magnc- 

-  drinr* 

157 

from            . .         ..171 

itig  in      ..         ..  470 

'    sic         521 

-  in  dysentery 

161 

-  corpus   luteiim,   liiDinor- 

'  irtilage,  perlchon- 

-  .■:,l,iMni..Mil,,tc(/-'../.lMl  !!.■:; 

-   (rriiii  i'in|iliysenia 

161 

rliagic,  pain  in  pelvis 

1  ~  of,  sore  tliroBt 

-    in    unnf              9    ■_■  1  s    -J.IS 

■  litiToi'cnilUS 

101 

from    . .         . .          . .    l^;^ 

to            ..          ..   013 

CRYSTALS.     CHARCOT-              CYANOSIS,  EXTREME  .. 

156 

-  <|prmohl,  bacillus  coll  in  53i 

"I'.gy,  opilepR.v  and    20 

LEYOEN                102.   l-'i:!     -  "1  f-nc 

156 

-  -  on  ear              . .          .  .   20:: 

1  ri-i    ,  ciirdiac,  in  tabes  ..   487 

-  .holisterin        (Fig.  124)  251     -  -  In  splcnoineifiillc  poly- 

Ilbronui  simulating  . .    73*. 

Crises.  DIeti's              115,  280 

-  choline  pcrindidc          . .   3115 

eytlia'lnla  . . 

531 

o(  mediastinum         ..   751 

-  -  appendicitis  siintllntcd 

-  -  platino-chlorldo        . .  305 

-  from  llhrold  lun« 

101 

orlill 231 

i,v «05 

-  collin-lid              .  .          .  .    524 

-  foreign  body  In  larynx . . 

157 

—  ovarian,  ectopic  g"st«- 

III!  movable  kidney 

-  cvstin       .  .          (Fig.  72)  161 

-  goitre 

158 

tiun  rlmiihitlng     . .   ' 

005,  765 

-dumb-bell                   423,741 

-  granular  kidney 

161 

-  -  fkin     

lilting  from          . .   765 

-  envelope. .                     . .  '123 

-  growth  of  lung  . . 

150 

-  -  Kuppiiratlon  in 

blood-prcs.suro 

-  faltv.  In  alciols  101.  170,   172 

-  hiimiorrliiwo  Into  Intra- 

vulval  Hwelling  from.  . 

•1  in         ..          ..  437 

-  hedgehng           . .         . .   740 

tliornclc  Knrconiu 

150 

Cyst  Of  the  epidlilymis     .481 

1'  simulated  by    . .  11a 

-  knlle-rester        ..          ..  521 

inr<llaiitinum 

151) 

-   in  tlliriii'l  "f  uri-ril-        .  .    n'.n 

i-ral  abdominal  )>nii) 

-  leueln       ..       (Fig.  147)  333 

—  tliyinus 

1511 

-   Iivl.iti.l  ( Ih'l.ilidl 

-  iihcnyl  olucosazoncffiV.          1 thyroid 

158 

-  Inini  hy.l.ili.l.if  .Miirgiurni  IHI 

Crises,  nastrlc.  In  tabes  1 15, 

127)  262     -  of  liiiniN,  from  corvl.al 

-  Imphintntlnn,           vulval 

116.     173.     315.     425, 

melting  point  «(    . .  262             ril 

III 

Hwellini/  from             . .    7iK 

437',     l«l,     4K7,    515, 

-  -  Inctosnione,  mellhig           I  Cyanosis,  from  heart  failure 

-  i.t  kldniy                         . .   357 

(109,  708 

point  ot      ..          ..262 

157,  ISI, 

694 

-    -   kidney    I'liliirgi-d    fnim  35'- 

CYST.   MUCOUS 


DEFINITIONS 


contd. 

vulval  swelling 

from 700 

of       omphalomesenteric 

duct    ; 483 

from  organ  of  Giraldes. .  481 
■  of  omentum       . .  . .   661 

-  pelvic  swelling  due  to  688 
ovarian,        albuminuria 

from    ..         ..  7,  13 

-  amenorrhcea  from     . .  386 

-  ascites  with  45,  49,  689,  691 
simulated  by         . .  689 

-  bacillus  coli  iu  . .  530 

-  bladder  distention  si- 

mulating    ..       665,  683 

-  chronic  nephritis  from       7 

-  cystic  kidney  simulat- 


dipping  in  detecting. .   689 

'  -  distinction  from  ascites 

44,  45 

-  -  dullness  over  45. '689 

dystocia  from  . .   201 

ectopic  gestation  simu- 
lating ..  ..690 

—  endometritis  rare  with  387 
fibroid  simulating  386, 

688,  690 

lluid  from       . .  . .     45 

652 

691 
..   678 


gas  in  . . 

liydatid  cyst  simulate 


mg 


iliac  fossa  . 

jaundice  from  ..  331 

kidney  simulated  by 

353,  354 

lipoma  simulating    ..  691 

malignant     peritonitis 

from  . .  . .     49 

-  -  mensuration  with      . .     45 
micturition     freq^ueut 

with  ". .  . .   394 

palpitation  from      -. .  485 

pedicle  twisted,  acute 

abdominal  pain  from  193 

-  -  -  -  appendiciti 


hitod  bi 


45(; 


-  -    -  constipation  with  131 
lluid   in  abdomen 

-  -  -  laparotomy  for  . .   45G 
pain  in  hy])ochon- 

drium  from     . .   451 

iliac  fossa  from 

452,  454,  456 

pelvis  from     . .  468 

simulating     dys- 

menorrhcea      193 

strangulated 

hernia         ,.  456 

-  pelvic  swelling  due  to  688 

-  pregnancy   simulating  688 

-  proliferating     papillo- 

matous        . .  . .     49 

nal  colic   simulated 


by 


Cyst,  pancreatic,  coiud. 

from  pancreatitis      . .  1 

position  of 

Cyst,  pancreatic,  signs  of  ■ .  I 

simulating  ascites     . . 

swelling  in  hypochoii- 

drium  from  . .   ( 

Cyst,  retroperitoneal,  notes 


bv    . 
isible 


stenosis    fro 


tube  casts  due  to  . .       7 

retention  of  urine  from  649 

ruptured  . .  . .   193 

simulated  by  hysteria  390 

sound  in  diagnosing..   386 

strangury  from  . .    649 

suppuration  in  . .   530 

tenesmus  from  . .    718 

-  -  thrill  with       . .  . .     46 
tuberculous  peritonitis 

siraulatnig  . .  . .     48 

twisted  pedicle  of      . .   689 

umbihcus  and  . .     44 

urachal  cyst  simulate 

ing    .  .  .  .      666,  691 

-  -  urethral  stenosis  by..       7 
uterus  drawn  up  by. .     45 

-  -  vaiiinal  examination  in 

diagnosing    45,  394,  353 
obstruction 


on 

-  -  ryio 


-  sebaceous,  on  ear      203, 
of  face 

fatty  tumour  distin- 
guished from 

of  neck,  movement  on 

swallowing 

parts  atfected  by 

on  scrotum     . .       523, 

of  skin 

at  umbilicus  . . 

vulval    swelling    from 

-  suprahyoid,  tongue  swol- 

len from 
Cyst  of  the  testis    . . 
hydrocele  simulating 

-  thoracic,  cervical  sympa- 

thetic affected  by     . . 

unilateral  sweating  of 

face  from    . . 

-  in  thyroid  gland 

-  transiucency  test  for    . . 

-  urachal,  distended  blad- 

der simulatint: 

-  -  hypo--. -fri,-      ■■v.''-Ming 


-  -  pelvK-  bu..-lhii-  >hii.'  to  ( 
tuberculous  periLoiutis 

simulated  by  . .   ( 

-  from     vas    aberrans    of 

Haller  . .  . .  -. 

Cyst,  vulval 

Cystalgia : 

Cystic  degeneration,  of  li- 

hi-ni,!:.  .  .  .  .    ; 

Cystic  disease  of  breast    ■  ■  I 

-  -     rpi,h,lvilll~         ..  ..     ( 

Cystic   disease   of   kidneys, 

Vsee  K.idllfy:^.  (Jystiu) 

-  hygroma  of  axilla         . .   I 
Oystin,  calculi  of  . .         . .   ] 

-  crystals  (Fiff,  72)  . .   : 

-  formiiln  of  .  .  .  .    : 

-  iiniTosi-(t|ir    in    detecting 

Cysttn.  tests  for     . . 
CYSTINURIA 

Oyslicerct ■ 

Cystitis,  aching  in  perine- 
um from         . .         ..  -. 
Cystitis,  acute,  symptoms  of 
282,  * 

-  albuminuria  from         . .  I 

-  ammoniacal  urine  from    i 

-  arthritis  from    . .         . .   : 

-  due  to  B.  coli  . .        70, 
typhosus     . . 

-  -  calculus  282,  394,  471, 


Cystitis,  pain,  contd. 

perineum  from         . .  l 

vulva  from     . .  . .  2 

-  painful  micturition  from  I 
~  from  prostate  obstruction  t 

-  prostatitis  simulating  . .  ' 

-  pyelonephritis  from      . .  i 

-  pyonephrosis  from        . .  •- 

-  from  pyosalpinx  . .  I 
~  pyrexia  from  282,  470,  t 
~  pyuria  from      183,  194, 

282,  470,  575,  I 

-  from  retention  . ,      578,  ( 

-  retroverted  gravid  uterus  I 


Danciog,   deterioration   in 
quality  of,  in  general 


-  due  to  staphylococcus  . . 

-  strangury  from. .  . .   I 

-  due  to  streptococcus    . . 

-  with  stricture    . .      578,  ! 

-  suprapubic     pain     from 

282,  470,  578,  I 

-  in  tahes  . .      578,  i 

-  tabes  simulating  . .   ( 

-  tenesmus  from  . .  . .    ' 

-  triple  phosphate  crystals  I 

-  due  to  tubercle  bacillus 

-  tuberculous  (see  Tuber- 

culosis of  Bladder) 

-  ulceration  of  bladder  in 


(-■y-s 


t'le. 


ung 


pen 


from 

-  dystocia  from    . .  . .  : 

-  simulating  prolapse  . .   i 

-  sound  in  diagnosing  . .   I 

-  vulval  swelling  from  . .  ' 
Cystopurin  for  gall-stones  ( 

-  for  pyuria           . .  . .   ( 

Cystopurin,  strangury  from  I 
Cystoscope.       appearances 

seen  with  li'hi/' s  AT. 

X  VI)  ..         . .      282,  J 

cystitis  . .         . .  ■ 

pyelitis  . .         . .  i 

-  ill  diagnosing  appendix 

adherent  to  bladder. .   \ 

bilharzia         . .      283,  ■ 

calculus  in  bladder  . .  • 

cause  of  bearing-down 

I'^iiii ■ 

Cystoscope,    in    diagnosing 

cause    of    haematuria 
277,  : 
Cystoscope.    In    diagnosing 

cause  of  pyuria 

-  -  !i--.luln  into  bladder    .'.    . 

pyelitis  

renal  growth. . 

simple  ulcer  of  bladder 

tuberculous      bladder 

471,  . 

kidney     282,      355, 

576,  577,  . 


yst  t  s  ge  e  a   d    oun    o 


DACHSHUND     type     of 
dwa  87 

D  c  y  ube  cu  ous  668 


-  htematuria  after  . .   1 
Darier,  on  prurigo        489,  ■ 
Davies,  Dr.  D.  S.,  illustra- 
tions by         561,  562, 

Day-blindness 

-  (and  see  Vision,  Defects 

of) 
DEAD  FINGERS  ..       162, 
DEAFNESS 


genital  svphiti; 
235, 

I  by  tuning-fork 


-  Mctiurr'.  ,|iM-;ise       160,  ' 

Deafness,    methods  of  in- 
vestigating 

-  otitis  media  165,  30S,  422,  ■ 

-  otosclerosis         . .      166. 

-  from  syphilis  of  internal 


-  tests  for  . .         . .         . .   ] 

-  tinnitus  and  . .  . .  'i 
Deafness,  various  causes  of 

165.    I 

-  from  wax  in  ear  164,  < 
Deal  jiorters'  bursa  iFi<j. 

65) ] 

Death  from  functional  dis- 
ease      ( 

-  impending  delirium  from  1 

-  from  inadequate  causes, 

lymphatism  and       . .  • 

-  malaria  . . 

-  serum  injections  . .  i 

-  simulated  by  trance    . . 

-  sudden,  from  aneurysm 

93,  120,  287,  '. 

fibroid  heart  . .         . .  ! 

pulmonary    embolism 

159,  : 

rupture  of  heart      . .  ; 

in  thjTnic  infantilism     ] 

from    tooth-plate     in 

larynx        . .         . .   1 
Debility,  cough  from      . .   1 

-  cramps  from      . .  . .   ] 

-  general,  flushing  with  . .  '. 

-  in  Malta  fever  . .         . .  ■^ 

-  muscular,  in  rickets    . .   1 

-  pain  in  the  back  from. .  •: 

-  from  polymyositis       . .  '■. 

-  spinal  caries  simulated  by - 
Decerebrate  rigidity  . .  J 
Defaecation,   difficulty   on, 

from  carcinoma'  recti 

-  erroneous  posture  for  . .  ' 

-  frequent  desire  for,  from 

rectal  polypus 

-  involuntary,  in  epilepsy  : 

-  muscles  of,  nerve  supplj" 


of 


of   relief    on, 
from  cai'cinoma  recti 

normal    time,    relation- 
ships of  . .  . .   '. 

peremptory    deshe    for, 
as  an  aura  of  epilepsy 
ecipitate,  fi-om  spastic 
paraplegia      . .         . .  : 
from  spinal  lesions    . .  : 
le  of  levator  ani  in  127. 

u  (Satisfied,  with  invagin- 
ation of  rectum 
)     nition  of  amblyopia  . . 


lalgesia. . 

rgyll-Robertson  pupil 
1  auditive 
ppus    . . 
ucocytosis 
Licopenia 

enorrhagia 

erycism 
neteorism 

etrorrhagia 

etrostaxis 

idules  . . 

•stagmus 

thopnoea 

aluria  . . 

Ipitation 
papule 


DEFINITlOXvS 


DIARRHCEA 


so: 


G60 


Drfhtitioii,  mill'/. 

-  of  panipIi^'iiL      . .     _    . .  510 

-  phosphaturia      , .  . .   522 

-  priapism  . .  . .   537 

-  pruritus  . .  . .         . .  540 

-  ptyalisra 542 

-  purpura  . .  . .  . .   552 

-  shoulder  . .         . .  . .   475 

-  stertor     . .  . .  . .   G47 

-  strangury 

-  stridor    . . 

-  taciie  c6r6brale 

-  tachycardia 

-  tenesmus 

-  thermo-anfesthesia 

DEFORMITY     OF    THE 
CHEST 

D^eiieration,  reaction  of 
(see  Reaction  of  De- 
generation) 

Dejerine,  myopathy  of    . . 

-  olivo-ponto       cerebellar 

atrophy  of 
Delicacy,  from  deep  caseous 

glands 

DELIRIUM 


:  yello 


,itli  cirrht 


atrophy 

273,  333 

.  .       It59,  170 

.  .    324 

Delirium,  classified  causes  of  169 

-  cordis,  from  digitalis  . .    iU4 

-  with  hysterical  pyrexia    310 

-  JD  Kirkland's  disease  . .  616 

-  objects  varying  in  size  in  763 

-  from  otitis  media        , .  202 

-  in  phosphorus  poisoning  336 

-  prognosis  with  . .  . .  169 

-  pupil  changes  in  ..    170 

-  in  scarlet  fever. .      169,  273 

-  with  typhoid  fever     76,  169 

-  in  unemia  . .        40,  169 

-  tremens,  from  alcohol  ..  170 

with  cirrhosis  ..   37 i 

hyperpyrexia  from  . 

spasmodic  twitching  in 

Deltoid,  nerve  supply  of  . . 

-  paralysis    of,    in    JOrb's 

jtalsy    . . 

-  pseudohypertrophy  of 


309 


607 


,  of 


509 


-  wasting  of,  in  phthisis 
Dclusinns  concerning  Christ  405 

God 405 

voices  . .          . ,         . .  405 

-  genital,  prognosis  with  613 

-  -  subjective  smells  and  813 

-  loss  of  appetite  and     . .  43 

-  in  myxa-doma  ..       38,  119 
Dementia,  catalepsy  and. .  598 

-  from  cerebral  syphilis  . .  146 

-  epileptic 323 

-  irritahilily  in      .  .          ..  323 
Dementia,  memory  defects 


m 


Dementia,  mutism  In 

-    Ml  invxii-ilrriia    .. 


19 

624 

3S 

-  penile     erection     absent 

from 313 

-  pnccox,     cerebrospinal 

fluid  sugar  reduced  in  304 

-  from  saturnine  encephalo- 

pathy   119 

DenienLs."  slobbering  in    ..  543 
Dendritic  ulcer  ■  ■  734 

DenKue.  urytheiriu  in 

222,   22.-.,  166 

-  fevf^r  in n;r. 

Dengue,  general  account  of  466 

-  hmmatcmcsLs   in            . .  265 

-  hcadnclic  in       . .          . .  460 

-  inllucnza  similar  to      . .  46G 

-  loHs  of  weight  after      . .  770 

-  mctcorism  in 


-  pnu)  : 

—  -  loins 


joints 


limbs  ; 
clcs  i 


-  pulse  rapid  in    . .         . .  460 

-  pUH  in  stools  from       ..  567 

-  roscolar  eruption  in      . .  466 

-  sore  throat  in    . .         - .  466 

-  yellow  fever  simulniiog  336 
DcntJil  caries  (see  Caries, 

Dontiil) 


ulcei 


Dentition,      delayed,      i 

anosteoplasia 
Depression,  from  arsenic. 

-  constipation  from 

-  with  fatty  heart 

-  from  gastritis     . . 

-  in  influenza 

-  myxoedema 

-  pyorrhcea 

-  with  toxic  diarrhoea     . 

-  with  tropical  liver 
Dercum's  disease,  age  inci- 


Dextrose.  tests  for  . .  261 

-  in  urine  (see  Glycosuria) 
Dhobie's  itch  . .  250 

bathing  drawers  area 

affected  by  ..401 

Diabetes,    azotic,  polyuria 

in         . .  . .       536,  537 

total  nitrogen  in  urine 

increased  in  . .  537  , 

-  bronzed,  cirrhosis  in  372,  528 

pigmentation  of  skin  in  528 

Prussian-blue  reaction 

in 24 


den 


of 


431 


alcohol  and 

fat  deposits  in       431,  732 

Dercum's  disease,  general 
account  of     ..         ..  410 

-  -  obesity  in       . .  . .    4U8 

pain  in  the  chest  from  431 

sex  incidence  of        ..  431 

Dermatitis,  acute  vesicular  755 

-  application         . .  . .    755 
itching  in       . .  . .    540 

-  from  caterpillars  . .  540 

-  exfoliative,  general  health 

impaired  by  . .  489 
pitrria=iL=;  rubra  pilaris 

.listiiitTuislied  from     489 
Dermatitis,  eczema  distin- 
guished from  .. 

-  gestatioiiis,  itching  in  . .  540 

-  herpetiformis,   age  inci- 

dence of         . .         . .     99 

-  -  blebs  in         . .         . .  753 
bleeding  gums  with  . .     72 

-  -  buUsB  in  ..  96,  98,710 

-  -  colon  affected  by      . .      74 
Dermatitis    herpetifbrm  Is, 

eczema     distinguished 

from 755 

~  —  eosinophilia  in  ..   219 

-  -  erythema  in  ..        98,  710 

-  -  tinc'Prs  affr<nrfl  hy     .  .    239 

Dermatitis      herpetiformis, 
general  account  of    . .     98 


-  insipidus,  acromegaly  and  537 

from  cerebral  lesions    537 

colourless  urine  in  . .  743 

from  fractured  base..  537 

-  -  frit,'ht 537 

Diabetes  insipidus,  general 

account  of  . .  537 


and 


537 


755 


UulRT,.. 


98 


itching  in        98,  540, 

raucous    surfaces    af- 
fected by   , . 

pityriasis  rubra  after 

in  pregnancy . . 

pyrexia  in 

relation  to  diet 

sex  incidence  of       . .     99 

tenderness     of     scalp 

from  ..  ..710 

08 
771 


lt\ 


polyuria    ni  533,  534, 

535,  536,  537,  719 
simulated  by  drinking 

habits         . .         . .  537 
specific     gravity     of 

blood  in  diagnosing  537 

thirst  in  ..  .'.   719 

urine  changes  in      ..  537 

-  mellitus,  abdominal  pain 

in         ..         ..        85,  389 

acetone  in      261,  261,  536 

acidosis  in      . .  . .       3 

age  incidence  of       ..    261 

Diabetes  mellitus,  air  hunger 

of  . .  84,  85.  86 

-  -  albuminuria  in         . .     13 

alcoholism  simulating    85 

alimentary  glycosuria 

and 536" 

alkalies  in      . .  ..118 

amenorrhcea  in  . .     18 

appetite    increased  in 

43.  264 

arteriosclerosis  with . .  255 

atheroma  and 

balanitis  in    . . 

boils  in 

brachial  neuralgia 

bradypnoea  in 

carbuncles  in.. 

carcinoma    of    li 

simulated  by 

cataract 

coma  in 


. .  618 
. .  260 
id  442 


260 


261 


urtic 


simulating 
vagina  affected  by 

-  -  vesicles  in      . .     710,  753 

-  occupation  . .  . .   755 

-  from  primula  obconica. .  510 

-  pruriginosa   polymorplia 

recurrens    graviditatis    96 

-  from  rhus  toxicodendron  540 

-  from  satinwood  sawdust  540 

-  septic,  simulating  small- 

pox (Fig.  23<^)  . .   562 

.-  from  soaps         . .  . .   540 

-  sugar 540 

Dermatitis,  various  causes  of  755 

-  vesicular,   from   occupa- 

tions     97 


84.  86.  117, 

261,  764 

first  sign  of  ..   US 

constipation  in  . .      . .  125 

delirium  In    . .         . .  169 

—  diacotic  acid  in 

261,  264,  536 
dimness  of  vision  in . .  260 

-  -  drowsiness  in  85,  764 

eczema  in      . .  . .  260 

of  penis  in  . .         . .  401 

perineum  from     . .  474 


ulva  in 


still 


front 


261 


;  irritants  < 


ing 


-  from 
Dermatograpliia  . . 
Dermatomyosltii  .• 
Derniftloses.  bullous 
phiha  in 


Dei 


Uc 


..   466 

463,  460 

..   466 


id» 


Cyst, 
I  from  cliciro* 


Dcsr|unmuti( 

pompholyx     . . 

-  after  erythema  scnrlAtini- 

forme  . . 

-  in  I'ngot's  disciiso 

-  pityriasis  rubra 

-  after  scarlet  fever 

-  (and  sec  Scales) 
Detached  retina  (see  Itutinu, 

Detached) 
Dcntcro-albumose  in  urine 


hard  dry  fojci 

headache  from 

hunger  in 

liypotliormla  in 

intertrigo  in  . . 

-  -  irrltAbillty  in 
kncc-jorlu  lost  tn 

n3,  261,  359 

-  -  lassilu.Io  ii 260 

lo^of  weight  from  768,  77t» 

meleorism  in..         ..  389 

micturition  frc(|uentin 

260,  303 

neurit  iH    of    extvnml 

popliteal  nerve  In..  490 

-  -  ohrvHv  nn-i    ..  ..    26H 

Diabetes   mellitus.   oinilly 
preceding  •  ■  408 


id  In 


26  1 


-  -  \mui  III  hnihri  in       63.    166 
from  piimn'ailc  Icflloriii  101 

—  penllo  orp<*tloit  alisoitt 


Diabetes  nuUihts,  coiKd. 

perforating    ulcer    of 

foot  in        . .      735,  73 

peripheral  neuritis  from 

59,  61,  63,  140,  255, 

260,  443,  466,  49! 

pneumaturia  in        . .  53( 

pneumonia  iu  . .  26- 

polyuria  iu 

260,  533,  534,  536,   71: 

prognosis  in  . .         ..26* 

pruritus  from  . .  54( 

reaction    of  degenera- 
tion in        . .  . .      5! 

retinitis  in     .,         ..26! 

senile  gangrene  and  . .  25! 

shedding  of  nails  in. .  40i 

shortness     of     breath 

from  ..  87,  8i 

specific    gravity     of 

urine  in      . .         . .  53i 

stupor  in        . .         . .     81 

—  sugar  in  cerebrospinal 

fluid  in       . .         . .  30 
tenderness  of  scalp  in     71; 

-  -  thirst  in         260,  264,  71i 

tongue  in       . .         . .  26 

torula)  in  urine  in    . .   26 

tuberculosis  of  lungs  in  26 

Diabetes  mellitus,  urine  in  26 

..,,!,, Ill-  III      .  .  ..    74: 


of 

vomiting     in. . 

wasting  in 

-  -  weakness  in   . .         43, 

xanthoma  in. . 

Diabetes,  Phosphatlc    522,  i 

aching  in  back  in     . . 

emaciation  in 

polyuria  in     523,  536, 

thirst  in         . .         . .  i 

Diacetic    acid    (see    Acid, 

Diacetic) 
DIACETURIA 

Diamond  mines,  silicosis  in  : 
Diaphany,    in    diagnosing 

gastrectasis    . .         . . 
Diaphragm       contraction, 

phantom  tumour  and  i 

-  immobilized,   by   empy- 


pleural  effusion        . .  < 

with  pleurisy . .         . . 

with  pneumothorax.. 

subphrenic  abscess  . .  i 

-  lesions  of,  tenderness  due 


-  nerve  supply  of  . .  ' 

-  paralysis  of  (see  Paralysis 

of  Diaphragm) 

-  pushed  up,  by  meleorism  i 

-  r^lo  in  vomiting 

-  root  innervation  of      . . 

-  tenderness   along   inser- 

tion of,  from  neuralgia 

-  x-rays     in     determining 

position  of      . .       432,  i 
Diaphragmatic    neuralgia 

-  pleurisy     (see     Pleurisy. 

Oiaplinigmatic) 
DIARRHEA 


.  I'.'l 

Diarrhoa.   acute   inlectlve 

.    2Uli 

-     jri     \.|ili...ii'.  .li-.'ii-^.'      .  . 

.    WU 

Dlarrhoa  In  adults 

.   311 

-  iiiiK'iuni'urotii-  ii'iiL'tim  ,, 

.    300 

-  appciiilicititt 

.   .133 

-  nnonic  01,  73,  78,  171, 

-  brndypiKTa  from 

-  from  ciirctiioinii  coll  130, 

173,  313,  ( 

-  -  rccll    ..  78,  173,  t 

-  in  c'lillilr<-ii 

Olirrhaa,  chronic  . .  I 

-  from  (liv  nrliiir  itlTcK'linii 

-  .olllls      ..    77,  7(1,  ll.'i,  1 

-  i-o)lii|i<40  (mm     .  .  . .    : 

-  mill    .-ohMll.:!!!..!! 

-  .l.'|in'«.-hMi   friini  ,.    1 
-'  from  fliHlomii  Ixjpntk'uni  ! 

-  illvcrtk'UlltiK      . . 

-  ilj«(!til«ry    70,  171,  710.  : 
'  (lyHpoptlc 


DIARRHCEA 


DIPLEGIA 


Dmrrhica,  cnutd. 

-  epidemic. .         . .         . .  . 

-  '-  knee-jerks  dimiuislied 

-  in  exophthalmic  goitre. .  ; 

-  explosive  172,  313,  i 

-  fatty,    from    pancreas 

lesions  . .         . .  * 

-  fatty  stools  from         . .  ; 

-  from  faecal  impaction  . .  '. 

-  fontaneile  sunken  from 

-  from  food 

-  gastric  juice  analj^ses  in  '. 

-  from  gastritis    . .     267,  ' 

-  sjastrogenic         . .  . .  ' 

-  in  Henoch's  purpura    . .  ; 

-  hill  . .  . .      172,  : 

-  hypothermia  after  severe  ; 

-  indicanuria  from  . .  ; 

-  from  indiscretions  in  diet 

-  in  infantile  diarrhcEa    . .  : 

-  infantile,     fatty     stools 


I)tf 


Vtlftl. 


-  dyspepsia  from  unsnitable319 

-  effect  on  chyluria         . .  109 

-  errors  in,  acute  gastritis 

from 267 

vomiting  from          . .  384 

-  gall-stone  pain  and      ..  437 

-  glaucoma  and  . .         . .  232 

-  glycosuria  and  . .         . .  2G1 

-  indiscreet,      biliousness 

from     . .           . .           . .  ii2fi 

nightmare  from        . .  402 

-  influence  on  gastritis  ..  317 

-  insomnia  from  improper  321 

-  intestinal  colic  and      . .  425 
constipation  and       . .  122 

-  night    terrors   from    im- 

proper            . .          . .  321 

Diet,  oxaluria  and       281,  424 

-  pellagra  and       . .          . .  226 

-  pruritus  and      . .          . .  540 

-  relationship  of  gout  to. .  344 
Diet,  rickets  and 


witu 

in  influenza 

4C5 

-  ^   >i   ^  -     .     1           72,  273, 

556 

_ 

from  intestinal  fermen- 

-   ■     .■          ■.    ■■■      :nid          .. 

670 

tation  

241 

-  1      .           1 .ruttbloodl71 

- 

with  intestinal  obstruc- 

-   UiL  i. :;.','.  L~    -iii'L    .  . 

729 

tion     

241 

-  urticaria  and     . .      673, 

771 

_ 

in  lardaceoils  disease 

-  vomiting  and    . . 

705 

8,  35,  172,  375 

636 

Dietary,  ergotism  and  224, 

259 

_ 

marasmus  from 

384 

Dietl's  crises         ..     115, 

280 

_ 

in  Meige's  disease 

226 

appendicitis  simulated 

605 

_ 

morning  . .          . .      172, 

173 

from  movable  kidnev 

- 

nervous  . . 

173 

665, 

765 

- 

paradoxical 

172 

simulating  calculus  . . 

117 

_ 

in  pellagra 

225 

vomiting  from 

765 

-. 

pernicious  anajmia 

172 

Differential  leucocyte  count 

- 

ptomaine  poisoning 

in   diagnosing  eosino- 

171,  224, 

717 

philin 

218 

~ 

pulse  feeble  and  irregular 

|..uk;T-mia 

632 

with 

171 

Differential  leucocyte  count, 

- 

from  pyjemia     . . 

596 

normal 

23 

- 

with  pyonephrosis 

357 

in    pernicious    anse- 

_ 

pyrexia  with     . . 

171 

24 

- 

rectal  examination  in  . . 

170 

(and    see    Lympho- 

~ 

in  rickets 

145 

cytes  ;  Myelocytes ;  Poly- 

_ 

severe,  from  arsenic     . . 

533 

morphonuclear  t>\\-i  etc 

) 

- 

-  in  cholera 

533 

Digitalis,  bradycardia  fron 

_ 

—  fluid  loss  fi'om 

533 

84, 

704 

_ 

-  in  Infants       . . 

533 

-  delirium  cordis  fi-om    . . 

704 

_ 

-  polycythcemia  from    . 

533 

-  effect  with  adherent  peri- 

- 

-  in  ptomaine  poisoning 

533 

cardium 

214 

- 

sigmoidoscope  in 

170 

mitral  regurgitation 

214 

- 

'skin  inelastic  from 

171 

-  headache  relieved  by  . . 

296 

— 

from  sprue         . .      172 

239 

-  heart  affection  benefited 

485 

- 

_  summer,     hypothermia 

-  in  mitral  stenosis 

53 

573 

-  palpitation  fi'om       484, 

486 

— 

-  in  infants 

717 

-  polyuria  from    . . 

535 

~ 

"-  or  infective    . . 

171 

-  tachycardia  from      703, 

704 

- 

from  suppurative   pyle- 

Dilatation of  bladder  (see 

phlebitis 

590 

Bladder,  Distended) 

in  tabes  

719 

-  cCECum     (see     Otecum, 

- 

'test  meals  in     . .      170 

172 

Distention    nh 

_ 

tetany  from 

3 

-  colon.    If -r  if  ai..ii 

1150 

— 

thirst  from 

720 

-  -  idiop;. II.'   .-h- 

- 

in  tropics 

172 

Spru:;^'       1  ',-1    1    >   ! 

- 

from  tuberculous  bowe 

from  ui.;uiiaiu!i  (.57, 

663 

458 

657 

succussioii  ill.. 

654 

- 

in  typhoid  fever  7G,  171 

.T-rays  in  diagno=?ing. . 

054 

-  ulcerative  colitis  70, 172,  • 
■-  unripe  fruit       . .      171,  ' 

-  urate  deposit  due  to    . .   ' 

-  .and    vomiting,    general 

wasting  from 

infantile,  acetonuria  in 

tetany  from  . .         . .  : 

-  zymotic,     micro-organ- 

isms oausuig  . .         . .  ; 
Diastolic  bruit  (see  Bruit, 
diastolic) 

-  collapse   of  veins,  with 

adherent   pericardium 
90,  : 

-  shock,      with      adherent 

pericardium    . .        90,  '. 
OIAZQ-REACTION 
Diet,  before  stool  analyses  ! 

-  beri-beri  and       63,  226.  - 

-  colic  from  indiscretions  in  '. 

-  deficient,       constipation 

from    . .  . .  . .   ] 

-  dermatitis  herpetiformis 

and 

-  diarrhnea  from  . .  . .    ] 
and  vomiting  from  . . 


j  -  duodenum,    from    carci- 

!  noma  of  duodenum..  062 

-  heart  (see  Heart,  Dilata- 

tion  of) 

-  sigmoid    colon,    suceus- 


052 


DILATATION  OF 

STOMACH  ..I 

-  -  ;iiM!i,iii.-ii    distended 

iruni  ..  ..    1 

acetonuria  from 

after    abdominal    in- 
jury . .  ..    1 
Dilatation  of  stomach,  acute 
173.  I 

in  acute  fevers         . .   ] 

from  adhesions         . .   1 

with      asthenic     dys- 
pepsia        . .         . .  3 

from  atony    174,  244, 

317,  (1 


174 


from  calcified  cyst 

-  -  carcinoma      174,  271, 

316,  678,  76 

-  ■ of  duodenum     174, 

661,  60; 

gall-bladdi 

pancreas 


HUatalion  of  stomach,  conhl. 

chronic 

copious  vomit  froni  . . 

diaphany  in  diagnos- 


mg 


dilatation     of     colon 

simulating  . .         . .  ( 

dipping  in  diagnosing  ] 

from  duodenal  ulcer. .  ] 

eructations  from       . .  ] 

by  excess  of  food  or 

drink  . .  . .  ] 

from  fermentation    . .  *, 

from  gall-stones        . .   1 

-  -  by  gas  . .  .  .    1 
Dilatation  of  stomach,  gas- 
tric contents  with     . .  i 

iui.-..-       ;ni:dvM.'>       in 

aiu^'iiotiiig  ..    ] 

-  -  from  gastric  paralysis  ] 

ulcer  . .       "  . .    ] 

Dilatation  of  the  stomach. 

general  account  of  . .  ^ 

in  heart  failure         . .    ] 

hiccough  from       173,  \ 

hour-giass    stomach 

simulating  . .  . .   ■; 

from  hydatid  cyst    . .  '. 

lavage  in  diagnosing. .   ; 

idiopathic     (.Fig.  276)  ( 

indicanuria  from      . .  i 

indigestion  from       . .  ; 

inflation  in  diagnosing 

174,  ; 

in  mitrnl  stenosis      . ,    : 

after  operntions^         .  .    '. 

paradoAJ'Vil     .  .  . .    ; 

Dilatation  of  the  stomach, 
physical  signs  of  521,  \ 

in  pneumonia  . .    ] 

ptyalism  from  . .  ! 

from  pyloric  obstruc- 
tion "317,  653,  600, 
720,  ', 

renal  tumour  . .  J 

sarcinre  with  . .     115,  ( 

signs  of  . .  . .  ; 

from  spasm  of  pylorus  ( 

splasliing     with     115, 

K4,  522,  652,  ( 

not  proof  of  . .  l 

tetany  from   . .  3,  : 

thirst  from     . .         , .   ; 

torulae  with    . .         . .  ] 

visible  peristalsis  with 

174,  653,  t 

vomiting  with       115, 

173,  522,  653,  : 

3"-rays    in    diagnosing 

115,  317,  653, ( 
Dilatator  tubre,  clicking  in 

ear  due  to     . .  . .  \ 

Dinitrobenzene,  acute  yel- 
low atrophy  from     . .  ; 

-  in  bellite 


fro 


325,  334, 


-  in  rohurite 
Diphtheria,     accommoda- 
tion affected  by 

-  acute  nephritis  from    . . 

-  albumiimria  in  . ,  13, 

-  arthritis  with     . .  . .   . 

-  ataxy  from 

-  bacillus  of  (see  Bacillus, 

Dinlitheria^) 
Diohtheria  { r''".^  X.WII)  i 
Diphtheria,    bacteriological 

recognition  of        il9.  i 


-  1ji 


Cheyne-Stokes  breathi 


174 


-  conjunctivitis  from 

-  couffh  from 

-  cultures  in  diagnosing.. 
I  Diphtheria,  cutaneous     .. 

-  diagnosis  from  other  sore 

throats 

-  diazo-reaction  in 

-  difficult  swallowing  after 

-  digital : 

-  dilatation  of  heart  in  . .    ; 

-  dysphagia  after  04, 

-  dyspnoea  from  . . 
of  . 


Iiil>hl}urat.   a.nhl. 

Diphtheria,  follicular  ton- 
sillitis and     ■■         .  ■  ( 

-  foot-drop  from  , .  ] 

-  foreign  body  simulating  ] 

-  gangrene  from  . .  . .  '. 

-  gastritis  from     . .  . .  ; 

-  heart-block  from  . .  I 

-  infective  arthritis  after  ( 

-  influenza  simulated  by. .  t 

-  Kirkland's  disease  simu- 

lating  

-  Klebs-Loeffler  bacilli  in 

154,  196,  .: 

-  knee-jerks  lost  in         . .  J 
Diphtheria,  laryngeal       . .  i 

-  -  nlistruction  from    l."i7, 

lis,  ; 

-  leucocytosis  in  . .  . .  .' 

-  limping  after     . .         . .  : 

-  measles  with     . .         . .  ] 

-  membrane  on  pharynx  - 

uvula  . .         . .         . .  - 

~  meningitis  in     . .          . .  .- 
simulated  by  . .          . .  ■ 

-  menorrhagia  from         . .  ; 
Diphtheria,  mild  cases  of, 

paralysis  after  ■ .  ! 

-  mistaken     for    laryngis- 

mus stridulus 

-  nasal : 

bacterial  diagnosis  . .  : 

-  -  voice  after      64,  154,  5 

589,  ( 

-  neuritis  after     . .      140,  : 

-  ophthalmoplegia  interna 

from i 

-  orthopncea  from        418,  • 

-  otorrhoea  from  . .         . .  ' 

-  paralysis   of    abdominal 

muscles  from . .         . .  : 

of  ciliary  muscle  after 

64,  197,  i 

the    diaphragm    from 

palate  after     04,  154, 

196,  512,  588,  027,  : 
pharynx  after           . .  { 

-  peripheral  neuritis  after 

50,    61,    64,    65,    113, 
153,154,  197,465,512,: 

-  prognosis  of  purpux-ic  . .  i 

-  ptyalism  after  . .  . .  ; 

-  pupil    not    reacting    to 

convergence  in  . .  f 
reflexes  after  . . 

-  purpura  in  . .      553,  t 

-  regurgitation     of     food 

through  nose  after  64, 

154,  196,  512,  588,  1 

-  retracted  head  from    . .  I 


-  scoliosis  from 

-  simulated     by 

bronchial  gland         . .   '. 

-  sore  throat  in    . .        64,  i 

-  spleen  enlarged  in     632,  i 

-  stomatitis  from  . .  i 

-  stridor  from      . .         . .  ' 

-  submaxillary  glands  in- 

flamed from  . .         ..  '• 

-  tachycardia  after  65, 703, 

-  throat  swabbings  in    . .  > 

-  and    tonsiflitis,    relative 

pyrexias  of    . .         . .  ! 

-  tosfemia  in        . .  . .   ' 

-  typhoid  fever  simulated 


by 


174     -  epistaxis  fro 


I  -  ulcer  of  cornea  from    . .  ' 

-  ulceration  of  larynx  from 
I  287,  : 

I  -  vagal  neuritis  after 

! paralysis  after 

I  Diphtheria.    Vincent's   an- 
gina simulating        .  -  I 


Diphtheria,  wrist-drop  from 

iFig.  22) 
Diphtheritic  antitoxin,  pur- 
pura from      . .         . .  I 
.  Diplegia,     from     bilateral 
cerebral  softening    . .  I 
-  cerebral,  athetosis  from 
132,  7 

embolism        . .         . .  1 

dysarthria  in  . .  fi 

facial  paralysis  in     . .  4 


DIPLEGIA 


DRUG   RASH 


plf^ia,  cerchrai,  couui. 

IHsc/iargr.  nrelhral,  cnntd. 

Jiiaseminalcti  sclerosis,  contd. 

Dog-bite,  hydrophobia  from 

-  intention     tremor    in 

dwe  to  syphilis 

181 

impaired    articulation 

138,  197, 

730 

724, 

729 

with  testicular  abscess 

622 

in 148 

Dogs,  effect  of  toluyleue- 

-  mental    backwardness 

due  to  tubercle 

181 

intention  tremor  in  148, 

diaminc  on    . . 

337 

with             . .       132, 

729 

without    micro-orfjan- 

307,  496,  317,  724,  728 

-  jaundice  in 

337 

-  optic  atrophy  with  132 

729 

isiiis 

ISl 

-  -  knee-ierk  increased  in 

-  tasiiia  ecliiiioioocus  in  . . 

65S 

-  ^ri—.r  LMU  uiih    i:iV. 

'-r,;| 

DISCHARGE.  VAGINAL.. 

185 
186 

307,  517 
-  -  mercury        poisoning 

simulating  . .         . .  72G 

Donif->li:.ii.'l          .liilliicss, 

inim    l,,'|,  .II,-  .il,~._-r'ss 
Dorsi.ii-    ],,,,li-    ..1  i,Ty,   .■i-^- 

3  ill 

legta.  conaenttal  cereoral 

-             l(  iiiii  fii'i Iritis.  . 

l,s,-, 

-  -  monoplegia  in           . .  502 

sntii.ii    I't    ],iiU..ti..ll    ill 

31 

general  account  of    ■ . 

132 

iibroid 

186 

-  -  neuralgia  in  . .         . .  609 

Double  consciousness,  llys- 

.intc:iit  llir-     ill  .  . 

139 

hydatidiform  mole 

186 

neurasthenia  simulated 

tericai . . 

20 

n.,„    |„„-,„r,.|,l..|llS        .. 

139 

polypi 

186 

by 313 

-  vision  (see  Diplopia) 

(Kiftli.-  inlaiitili-         132, 

139 

cervical  erosions 

183 

neurosis  simulated  by 

Douches,  astringent,  steril- 

remor from 

727 

—  endocervicitis 

185 

517,  318 

ity  from 

640 

jlobacilli     of     Morax- 

-  ~  endometritis  . .      185, 

391 

numbness  in  . ,         . .  009 

-  meiiurrlKiLTia  from 

3S0 

Axeufeid,     eonjuncti- 

foul,  from  carcinoma 

nystagmus     iu,     148, 

Douglas's  pouch,  malignant 

vitbi  from 

231 

185,  180, 

391 

408,  496,  503,  317, 

deposits  in 

587 

Dlococcus  intrnccUtilaris 

ctiorion  eiptbelioma 

391 

728,  760 

hydatid  in 

49 

(see  Meningococci) 

fibroid 

185 

ocular  paralysis  in  . .  760 

swelling  in  (see  Pelvic 

-  meningitidis  (see  Men- 

 pessaries     . .      185, 

186 

optic  atrophy   in   148, 

Tumour ;    Swelling, 

ingococci) 

pyometra    . .     186, 

392 

496,  502,  517,  760 

Pelvic ;   and    Swell- 

ineumoni^e   {Plate 

Discharge,  vagina:,  gonor- 

neuritis  rare  iu     . .  517 

ing     in     Douglas's 

XXVI 11) 

014 

rhiBal 

185 

optimism  in  . .         . .  148 

Pouch) 

PLOPIA 

174 

in  puerperal  fever     . . 

596 

pallor  of  optic  disc  in 

Dragging,    in    cliest,  from 

roMi  ;.l.sfesj  of  orbit,  . . 

177 

pyosaipinx  with 

678 

728,  700 

clironic  mediiustinitis 

433 

lopia.  binocular,  general 

salpinpo-oophoritis  ant 

690 

parajstliesia  iu          . .  517 

-  loin,  from  Iiydrocele    . . 

481 

account  of      175,  176, 

177 

ulceration  of  perineum 

620 

paralj-sis  of  accommo- 

- sensation,   from   liepato- 

l<i--''i    1  /■■;'/,    >■_'  1 

171) 

white 

1.S3 

dation  in    . .          . .   700 

ptosis 

SOS 

175 

-  -  yellow 

185 

one  leg  in  . .         . .  496 

in         hypochondrium 

n  tlissfiniriateii  sclerosis 

496 

Discomyces,   madura   foot 

paraplegia  from     502,  514 

from    varcinoma  of 

roni    lijtmorrbage    into 

from 

736 

penile  erection  absent  313 

liver 

373 

orbit    

177 

Dislocation    of    hip,    con- 

precipitate  defaecation 

Drauglit,  myalgia  from  . . 

467 

onio.iyrnous  (Fi,l.  81) 

176 

Kcnital 
abdomen  prominent 

130 

ill 314 

-  stiir  neck  "from  .. 
IirawiiiL'    up   of   legs  (see 

429 

li(Hl 

173 

from 

251 

uitii        ■        ..           ..     I'i7 

L.'L'-.  Drawing  up  of) 

lopia,  monocular,  general 

lordosis  in  . . 

251 

Disseminateij  sclerosis,  sen- 

1 iicaiiiy  state,  from  cefebra 

account  of 

175 

waddling  gait  from 

351 

sory  changes  In        . .  609 

tiiiiK.iir 

OS 

n.iM  r.rl.il-.l  LTo«th       .. 

177 

-  of  jaw,  ptyalism  from . . 

513 

Disseminated  sclerosis,  signs 

Dribbling     of     saliva,     iu 

JQpia  from  paralysis  of 

-  lens          

175 

of        148 

babies 

542 

eye  muscles  (I'l'j-  S3) 

\n 

ophthalmoscope  in  dia- 

 spasticity  in  .  .      307,  5112 

-  -  bulbar  paralysis     542, 

5811 

liy,i..l„-ir;.l      .. 

17.5 

gnosing 

175 

-  ^  .spi-irh  in        3117.  517, 

facial    paralysis 

493 

roni  strabismus       177, 

649 

pupil  irregular  from. . 

551 

037,  738 

(and  see  Ptyalism) 

ertif^o  from 

752 

shallow  anterior  cham- 

- -  tpliiHit.i-     iniill.le     ill 

-  of     urine     (see      Urine, 

inU  see  StrabismiLs) 

ber  from     . . 

175 

US.   llii;.  .-.113,  517,   738 

Dribbling) 

>ping      . .         . .        44. 

371 

-  -  tremor  of  iris  from  . . 

175 

Disseminated  sclerosis,  sym- 

Drinking, diabetes  insipidus 

t,  marasmus  from 

385 

-  of  spleen..        629,  830, 

611 

ptoms  of                 ■ .  307 

simulated  by . . 

537 

yplms  fever  and 

335 

Diseases,      proper     names 

-  -  tremor  in       . .         . .  724 

-  polyuria  from  534,  535, 

S3G 

■atint,' 

43 

associated     with   (see 

variations  in  symptoms  517 

-  secret 

565 

isea.sc    . . 

09 

end  of  Index) 

voice  hesitant  in      . .  517 

neuritis  (nun.. 

60 

>c,  choked  (see  Neuritis, 

Disorientation  in  alcoholLsm 

20 

vomiting  in    . .         . .  295 

Drop  1 ,,    1  ,,..1  .Irop) 

Ojuic) 

Disparateness 

175 

writers'   cramp   simtt- 

0n.|,  1,  ,       »  1  i-i  .Irop 

■chart;e  from  tlie  ear  (see 

Disparation 

175 

Intcd  by     ..          ..151 

Dr.AM-"    .  11. P    .. 

150 

Otorrbipa) 

Disposition,  change  of,  in 

Dissolution,   sense  of   im- 

Dron-i ,, 1.  yellow 

ve,  from  opiitliahnia  . . 

761 

general  par.alysis 

130 

pending,     in     angina 

alri.].liy 

273 

SCHARGE,  NASAL     .. 

178 

Dissecting-room  sore,  epi- 

pectoris          . .         . .  433 

-  from  cerebral  disease  . . 

295 

-  from     aiilnil      disease 

troclilear     gland     en- 

Distention, abdominal  (sec 

-  cirrhosis 

332 

17'.i.   I«(i.  4(12, 

n.'ig 

larged  from   . . 

381 

Abdominal  Distetition) 

-  diabetes  . .          . .       85, 

704 

-  ba.-illus  Wyr.v  in        .  . 

383 

finger  affected  by    . . 

340 

Distonia     hcpaticum     335.    338 

-  meningitis 

560 

-   h^.cl.-nal    .-.i.Milli.fiur, 

178 

Disseminated         sclerosis. 

-  pulmolial.'            2S7.  39"_',  01.-| 

-  phosphorus  poisoning  . . 

330 

charge,    nasal,    various 

abdominal        rellex 

Disuse,  contractures  from 

-  nr.emia   . .         . .        40, 

290 

causes  of  178,   179, 

180 

atisent  in    . . 

303 

139,  141 

Drug  rash       90,  563,  554, 

-  -  allo.-hoiria  in 

17 

-  muscle  wasting  from    . .     59 

003,  755,  757, 

771 

5CHARGE   FROM  THE 

-  -  ;iiiil.lvopia  in 

738 

Diuretics     . .         . .          . .  535 

from  acetanilide 

!ni 

NIPPLE 

181 

-  -  i.iikl.'-i-lonus  in       307, 

517 

Diuretiii,  polyuria  from  . .  535 

from  arsenic  . . 

22 1 

L.1(M..I  .,l.iii..f,l,     from 

-  -  aphasia  in      .  . 

148 

-  relief  of  angina  by    316,  438 

-  -  aspirin            2'.'2,  ^13, 

771 

087 

iistereogiiosis  in 

609 

Divarication  of  recti,  test 

-  -  iitoxvl..          ..      •222, 

22  1 

-  bloody 

181 

-  -  ataxy  iu  57,  231,  307, 

517 

for 521 

atropine           .  .       222, 

602 

-  milk,  at  pubertv 

086 

Babinski's  sign  in 

visible  peristalsis  from  521 

belliidonlia 

602 

-  -  soon  after  birth    . . 

686 

68,  148,  307, 

728 

Divors,iioises  in  the  head  in  400 

-  -  bromide   90,    98,    222, 

-  milky 

68.5 

black  spots  before  oyes 

f)ivcrtlcula  of  colon,  iigc 

569,  560,  563,   7.17, 

771 

730 

from                       . . 

72 

incidence  of  ..      120,  130 

blitylchloral     hydrate 

-  purulent          ..       181, 

685 

central  scotoma  in  517 

760 

carcinoma   coli   simu- 

222, 

55:; 

5CHARGE.  URETHRAL  181 

—  cerebellar  tumour  simt 

lated  by     ..         ,.125 

cftt^odylate  of  sotla  233 

22 1 

-  bactcriji  in     . . 

67 

latiiig 

517 

obstruction  from      ..   125 

chloral . .         . .      323, 

553 

-  bacterial  dla^'iiosis    .. 

181 

coma  from     ..       117, 

144 

—  (lericolltis  from        ..   125 

eliloraliimide 

222 

184 

contracted  visual  fields 

-  -  sigmoiiloscope  in  dia- 

 chlorate  of  jiotasli     . , 

55:; 

-  from  .liancT.' 

184 

in     ..          ..      517, 

738 

gnosing       ..          ..    125 

-  -  copaiba  222,  384,  553, 

Charge,  urethral,  entto- 

-  -  convulsions  in        144, 

148 

-  ^  simulating    ciircinoma  130 

503, 

771 

scope  In  Investigating 

.     ,1,1,.     t '.-IL'II      h.i.lt    .    . 

183 

1.S4 

diploiiia  in 

-  -  d.vsarthria  in  . . 

4'iO 

vesicocollc  llsltila  from   125 

Divcrllciilltis,  absi-es.s  from 

-  -  Cllbebs 

euejilyplus,  son!  lingers 

-•"-' 

-     11.     L-l.'i'T                     .    .           IM', 

183 

erythromelalgiu  with 

441 

238.  453 

from 

C.19 

charge,     urethral,     in 

extensor  plantar  reflex 

DIvartlculltii,  acute,  general 

-  -  iodide  98,     559,  5(iii, 

gonorrhoea     182.  3S|, 

.  fi- 

409 
181 

in     . .         . .      502, 
-  -  faciei  of 

517 
334 

account  of     . .     453.  oiii: 
-  i'.ir.'ii...iii.i   -.iniiiliil.'.l   U\ 

503, 
-  -  -  nodules  due  to      . . 

98 

-    ,lu.-    lu    l..l|..- 

|U| 

-    -    (.llit'iibillly    ill 

MS 

1311,  I5:i,  ii;i; 

-  tiimniir  »ith      ..          ..    130 

piirpurii  from 

puslules  from      98, 

r5S 

l:.ii-.d    Ir.Mii 

:;sl 

DIsseminateil    sclerosis. 

liiMTti.-iiliim,        .\forkur..'. 

5110, 

no:: 

(Charge,  urethral,  method 
of  Investigating 

183 

181 

general  account  of    ■ ■ 

-    -  f.nll.rpi.ii.ni  .. 

728 

3011 
0119 

iiilc-tiniil    obstruction 

from 130 

-  fif  u'S4iphiigiis,  vomiting 

-  -  , —  acne  siniulated  by 

-  -  -  -  no  comedones  will 

-  -  -  small-pn\      slniula- 

559 
559 

-  due  to  pi(i>illoniata  . . 

184 

headache  In    . .      294 

395 

due  to             . .          . .    7113 

leil  by     .. 

503 

183 

-  -  hemliuiiRsthesia  in    . . 

009 

Diving,  eplKlnvlH  from     ..   331 

-  -    -  sypliillile  Filnuilalltig 

5011 

-  pro'^tatii'  ali.,,c'cs:l 

G20 

hemiplegia  In        303, 

307 

-  friicl tire  tif  Hpltio  from  ..  243 

—  -  lirllcarla  from 

771 

»  rheumatism    . .          .  • 

181 

Iilppu.s  ill 

r.S2 

Diisluciw  ( 1  luKi  Vertigo) 

-  -  -  vo*ti4f«  iliip  (o      . . 

757 

-  ilue  to  soft  xorea 

184 

hyuterln  simulated  by 

727 

-  before  iipliplexy            ..    Ill 

tatloform 

232 

-  from  stricture 

183 

slmulnlliig  . . 

738 

-  from  aortic  regnrglliil loll  3or 

-  —  piirpiini  from 

653 

810 


DRUG   RASH  DYSOSTOSIS 


Drtuj  rash,  coufd. 

-  -  mercury  . .      212,  553 

-  -  neo  salvaisan  . .  234 

pityriasis  rubra  after  604 

from  quinine. .  . .  602 

rhubarb  . .  . .  222 

rhus  toxicodendron  . .  224 

salvai-san         . .  ..  3.'4 

sandalwood  oil  . .  222 

santonin  . .  . .  771 

scales  in  . .  . .  602 

serum  injections         . .  223 

sulphonal        222,  553,  771 

sypliilis  simulating  . .  384 

trional. .  . .  . ,  222 

-  -  urticarial,  causes  of..  771 

from  vanilla  . .         . .  775 

Drugs,    acute    osdema    of 

tongue  from  . .  . .  698 

-  amblyopia  from 


33 


Drugs,  anuria  from         . .     40 

-  aphrodisiac         . .  . .   538 

-  black  urine  from        745,  747 

-  bradycardia  from         ..      84 

-  bullie  from        . .  . .     96 

-  carboluria  from  . .   746 

-  CheyrH^-Stnkc^  l.rciithing  108 
Drugs  causing  wheals  ..  771 
Drugs,  coma  from         118,  144 

-  convulsions  from       144,  145 

-  cyanosis  from    ..  ..157 

-  deafness  from    .  .  . .   166 


delir 


I  fro 


169 


-  dermatitis  from  . .   755 

-  diazo-reaction  from      ..   173 

-  discoloration    of    skin..  529 

-  eruptions  due  to  . .  757 
pityriasis  rubra  after    604 

-  erythema  from  ,  .  . .    222 
Drugs,    Fehtinq's   solution 

reduced  after         157,  261 

-  foul    breath  from  .  .      86 

-  -  taste  from      . .  . .    705 

-  for  Kall-stniips    .  .  -.650 
Drugs,  glycuronic  add  in 

urine  after  ..261 

-  headache  from  . .  . .   295 

-  bEematuria  from        275,  650 

-  hfemoglobinuria  from  . .   284 

-  hypothermia  from        . .  311 

-  jaundice  due  to.  -  . .   325 

-  leucocytosis  from  . .   360 

-  ieucopenia  from  . .  361 

-  methaamoglobinsemia 

from 161 

-  methicmoglobinuria  from 

157,  533 

-  noises  in  the  head  from  406 

-  oedema  from     410,  413,  698 

-  palpitation  fi-ora       484,  48(5 

-  photophobia  from        . .  525 

-  pink  urine  from  . .   745 

-  poIycytha3mia  from      . .   533 

-  polyuria  from    . .  . .   535 

-  priapism  from    . .  . .  538 

-  ptyalism  from    . .  . .   542 

-  purpura  from     . .      553,  554 

-  rectal  concretion  from..   718 

-  scaly  eruptions  from..      6  '2 

-  sore  fin!?ers  from  . .   2.H9 
Drugs,  strangury  from  649,  650 

-  suIphhEemoglobinfemia 

from    ..  '        ..  ..161 

-  in  sweat. .  . .  . .   655 

~  tachycardia  from       703,  70^ 

-  tenesmus  from  . .  . .    718 

-  thirst  from         . .  . .    720 

-  tinnitus  from     . .  . .    723 

-  transmitted  by  suckling  145 

-  tremor  from       . .  , .    726 

-  unequal  pupils  from     , .   552 

-  urine  color;ition  from  . ,    744 
Drugs,  urticaria  from 


Diihring,  on  scrofiilodermia 

539 

Duodenal  ulcer,  contd. 

Dijschczia,  contd. 

Dijliring's  dLsease., 

99 

pain  in  the  abdomen 

-  faeces  needing  to  be  dug 

eosinophilia  in 

219 

from 

271 

out  in . . 

Dullness,  abdominal,  with 

back  from  . . 

428 

-  from  fibroids 

ascites 

44 

epigastrium  from  . . 

462 

-  fibrous       stricture       of 

-  "  all  over 

47 

pain  after  food  with. . 

75 

rectum 

from  ovarian  cyst     . . 

089 

in      hypochondrium 

-  (Fi{f.  48) 

in  tuberculous  perito- 

with 

450 

Dyschezia.  general  account 

nitis 

48 

hypogastrium    from  462 

of        

-  over  aneurysm  . . 

208 

shoulder  from 

474 

—  intestinal      constipation 

-  cardiac,     increased     to 

pancreatitis  from  100, 

101 

distinguished  from   . . 

left  in  chi-onic  nephritis 

11 

perforation   of 

47 

-  from      invagination      of 

in  mitral  regurgita- 

 collapse  from 

436 

rectum 

tion          . .        89, 

210 

laparotomy   for 

436 

-  ovarian  tumour. . 

increased  to  right,  in 

pain  in  epigastrium 

-  pressure  on  rectum 

congenital  heart  dis- 

from 

436 

—  rectal     examination     in 

ease  . . 

91 

pneumoperitoneum 

diagnosing      ..      121, 

-  over   distended   bladder 

45 

from 

652 

—  insensitive  rectum  with 

-  dome  -  shaped,       from 

shock  from 

436 

-  sigmoidoscope     in     dia- 

hepatic abscess 

291 

pleurisy  from . . 

106 

gnosing 

-  over    enlarged    thymus 

ptyalism  from 

543 

-  suppositories  in  relieving 

gland 

419 

rapid    emptying    of 

-  in  women 

-  fibroid  lung 

20G 

stomach  and 

272 

~  .T-rays  in  diagnosing     . . 

-  in    flanks,    with    acute 

sex  incidence  of        75, 

451 

Dysentery,  abscess  of  liver 

peritonitis 

592 

simulating       enlarged 

after    ..          ..      332, 

ascites            , .        44, 

689 

gall-bladder 

368 

-  acute  ascites  in . . 

in  general  peritonitis 

388 

gall-stones  . . 

36 

-  agglutination  test  in    . . 

-  hepatic,     deficient    (see 

gastric  ulcer 

36 

-  albuminuria  in  . . 

Liver  Dullness) 

subdiaphragmatic  ab- 

- albumosuria  with 

-  over  hydrops  amnii 

45 

scess  from  451,  652, 

655 

-  amoeba  causing  77,  17:.', 

-  with  ovarian  cyst 

45 

suppurative  peritonitis 

-  amemia  with     . . 

-  over  pleuritic  effusion 

from 

47 

-  arthritis  with     . . 

168, 

206 

vomiting  from        75, 

271 

—  asylum    . . 

-  in  pneumonia    . . 

642 

a-rays  in  diagnosing. . 

272 

-  atony     of     colon     after 

-  to  right  of  sternum,  from 

Duodenum,  ankylostomiasis 

(Fig.  50) 

aneurysm        . .          92 

93 

of         

521 

-  bacillary 

with  tricuspid  regur- 

- carcinoma  of  (see   Car- 

- bacteriology  in  diagnos- 

gitation . . 

92 

cinoma  of  Duodenum) 

ing 

Dumb-bell  crystals       423, 

741 

—  catarrh  of,  jaundice  from 

-  bladder  opened  by 

Duodenal   bleeding,   coma 

325, 

474 

-  blood  inspissated  in     . . 

from    . . 

118 

pain  in  shoulder  from 

474 

and  mucus  stools  in 

noises  in  head  after  . . 

406 

pancreatitis  from      . . 

100 

76,  172, 

-  le.sions,        subcutaneous 

—  congenital  obstruction  of 

130 

-  chronic 

en]]ili\  -riii.i  h-nni 

203 

-  dilatation  of 

662 

-  colon  thickened  in 

—  obstnii  1  Kill    \  i-ihli'  peri- 

-  gall-stone  ulcerating  into 

-  coma  in 

sta!-i^  11- .  . 

521 

265, 

272 

-  cyanosis  in 

—  ulcer,  alMliiiiiiiial  t.'iider- 

-  kinking  of,  with  movable 

-  diarrhoea  with   . . 

ness  from 

271 

kidney            . .         . . 

331 

-  general  abdominal  pain 

acute  ascites  from    . . 

47 

~  movable  kidney  dragging 

from 

peritonitis  from    . . 

592 

on    . . 

280 

wasting  from . . 

adhesions  from 

174 

~  obstruction    of,    no    ab- 

- hsematuria  from        275, 

albumosuria  with     . . 

16 

dominal  distention  withl30 

-  hyperpyrexia  in 

anaemia  from      33,  36 

271 

-  tumour  of,  ascites  from 

46 

-  indicanuria  from 

appendicitis  simulating 

450 

portal  obstruction  from 

46 

-  liver  abscess  after    253, 

-«  -  blanching  due  to 

120 

-  ulcer   of  (see   Duodenal 

391, 

blood  per  anum  from  33,  75 

Ulcer) 

-  loss  of  weight  after 

cholecystitis  simulating  450 

Dupuytren's     contraction. 

-  meteorism  in     . . 

cicatricial  fibrosis  of. . 

174 

finger  pads  with 

347 

-  mucus  due  to    . . 

dilatation  of  stomach 

-  -  (Fig.  59) 

142 

-  pain  in  iliac  fossa  from 

from 

174 

from  gout 

142 

454, 

distinction  from  gas- 

 occupation  and 

142 

limbs  in 

tric  

75 

-  fracture,  talipes  from  . . 

114 

-  purpura  in 

empyema  from      104, 

106 

Durham,  trichophyton  rosa 

-  pus  in  stools  from 

exploration     in     dia- 

ceum in 

247 

-  pyuria  from 

gnosing 

450 

Duroziez's  sign 

93 

-  rigor  rare  in 

gall-stones  simulating 

272 

Dust,  cough  from 

148 

-  Shiga's  bacillus  in    172, 

gastric  HCl  with 

451 

-  sore  throat  from 

615 

-  stenosis  of  bowel  after. . 

ulcer  simulating    . . 

271 

Dwarf,  dachshund  type  . . 

187 

-  suppurative     peritonitis 

Duodenal     ulcer,     general 

-   p.a,L'un,-]ik.-         .. 

1K8 

from    . . 

account  of     . . 

271 

-  scaMikr 

188 

-  tenderness    over    colon 

general  peritonitis  from  3SS 

DWARFISM 

186 

from 

haematemesis  fi'om  75, 

Dwarf  elder,  polyuria  from 

535 

-  tenesmus  in  76,  172,  716, 

265, 

271 

Dyers,  stained  nails  in    . . 

399 

-  ulceration  of  bowel  from 

heai-tburn  from 

297 

Dynamometer,  in  Dercum'b 

opening  into  bladder 

hunger  pain  with     36 

75 

disease 

410 

of  rectum  due  to 

Duodenal     ulcer,     hunger 

-  testiu-  lianU-L'ri).s 

303 

-  ulcerative       colitis       a 

pain  of           271,  437 

450 

Dysarthria,  aphasia  distin- 

variety of 

hypera.-idity  with     .  . 

''/' 

guished  from  302.  iii'6 

627 

Dysidrosis,  cheiroporapho- 

755 


-  vomitiiitr  from 

-  weicrht  rcJucing  . .'  770 

-  xanthopsia  from  . .   762 

-  yellow  urine  from  . .  744 
Drug-taker,  shifty  eyes  of  234 
Drummers'  cramp  . .  151 
Drums  beating  in  head  . .  406 
Drumstick  bacilli  . .  730 
Duchenne's  palsy  . .  . .  507 
Ductus    arteriosus,    patent 

(see     Patent     Ductus 


us) 


Tidicanuria  from 

indigestion  from       . .   317 

internal     hsemorrhage 

from  118,  120,  720 

interscapular  pain  from 

461,  462 
leakage     from,     con- 
stipation after       . .   126 

local   peritonitis  from  174 

rigidity  over  . .  592 

spot    of    tenderness 

from         . .  . .   317 

loss  of  weight  from  . .  769 

melaena  fi-om  36,  75,  271, 

451 

nocturnal  pain  from. .   450 

occult  blood  in  faeces 

with  ..      101,  126 
fcdema  of  log?  after  . .   414 


from 

paralysis 

-  bulbar  palsy 

-  cerebral  diplegia 

-  disseminated  sclerosis  . . 
Dysarthria,  general  account 


627      DYSMENORRHCEA 


of 


"  in  gon.a-al    i,araiv>i-      ..    627 

-  gummatous  niciitiiL'itis. .    627 

-  hemiplegia  and..      302,  620 

-  from     internal     capsule 

lesions  . .  . .  302 

-  myasthenia  gravis        . .  627 

-  myopathy  . .  . .   628 

-  peripheral  neuritis  and     627 
Dyschezia  from  carcinoma  129 

-  diarrhcea  with  ..  -.122 

-  from  distended  tubes  . .  129 

-  enemata  in  relieving    . .   122 


ul     pain 

-  from    appendicular    ad- 

hesions . .         . .  - 

-  blue  brain  and  . .  . . 
Dysmenorrhea,  conditions 

simulating 
DysmenorrhfBa,      list      of 


caun 


of 


Dysmenorrhoea.  membranous 
I'.':.'.  J  J 
Dysmenorrhoea.     types    of 

pain  in  -H 

Dysostosis,      clei.lo-cnuiial 

dwarfism  from  . .   11 


DYSPAREUMA 


ECZEMA 


811 


yspareunia 

yspareunia,  causes  of  193, 

icraurosis  viiIv;b  193,  194, 
Sterility  from     . . 
yspepsia  (and  see  ludiges- 

tion) 
from  achylia 
Ifspepsia.  acid 
acut*  abdominal  pain.. 


193     DYSPHAGIA 


-  pt 


W.'ohol 


ly.j, 

-  from     bilateral     facial 
I  paralysis 

-  in  bulbar  paralysLs    ISo, 

197,  589,  543, 

I  -  from  carcinoma  195, 19'J. 

36(J,  435, 

-  cervical  adenitis 

-  cicatricial  stenosis 

-  cleft  palate 


/spepsia,  asthenic         ..  : 

irotn  atony         . .  . ,    '. 

bleeding  gums  from     . . 
brain  lesions  simulating  . 
carcinoma     of    stomach 


yspepsia,  changes  in  stools 
with 

clirn-iii  .      from      gastric 

iilr.-r I 

with  cirrhosis     . .  . .   ; 

cough  from        . .  . .   ' 

from  defective  teeth    . . 
deficient  exercise  . .   '. 

diarrhcea  from  , .  . .   : 

from  emotion     . .  . .   ; 

flatulent  . .  . .   I 

~  heMrtbnrn  from  . .   I 

foul  l.rp:,l),   I'r;,rn 

irspepsia.  funLtional,  gene- 
ral account  of       318,  : 


-  dermatitis  herpetiformis 

-  after  diphtheria         196,  I 

-  erythema  buUosum    74,  : 

-  general  paralysis  . .   ; 

-  hydrophobia       . .      138,  ! 

-  hysterical  . .       I9t;,  : 
~  from    idiopathic    dilata- 
tion of  (Esophagus    . .  ] 

-  after  irritants    . .         . .  : 

-  larynx  lesions    . .       198,  '. 

-  lead  poisoning  . .  . .   '. 
Dysphagia  lusoria.. 

-  from  mercury    . . 

-  mumps    . .  .  .      19S,  ) 

Dysphagia    due    to    nerve 

causes  -  -   I 

Dysphagia  from  oesophageal 
obstruction     194.   195, 
;  Dysphagia    from    pain    on 

I  swallowing 


v-i'oglossali 


ill-. 


gastralgia  . .  . ,    . 

gastritis  simulated  by.. 
gouty  ..  ..  319, 
from  grief  . .  . .  : 

hasty  meals       . .  . .  ; 

headache  from  . .  . .  : 

heart  dise:ise  simulated 

by         .  .  133,  435,  ' 

from     hypiTurstlicsia    of 

hyiMr''l,lnri,;.Mri':i'  ". ".    ] 

irspepsia,  hypersthenic  . . 

hysteria  simulating       . .  ; 

insomnia  from   . .  . .  : 

liver  congestion  with  . .  '. 
loss  of  appetite  from  . . 

-  weight  from  . .         , .  ' 
myocardial        affections 

simulating      . .         . .  • 

luria  and. .  • 


from 

with  imrriir-  livt-r  ..    : 

irspepsia.  organic,  differ- 
ential diagnosis  of 

316,  317.  : 

from  ovfT-fatigiie 

over-work 

oxaluria  and      ..       281, 

pain  in  the  back  from.. 

—  chest  from 

-  round  lieart  from 
palpitation   from       435,  ■ 
pelvic    lc8ion    simulated 

by       

photophobia  from 
precordial  pain  from    . .  ' 
prcffnanry  simulating  . . 
from  pyloric  spaem       ..   ; 
pyorrln 


frot 


from  Hh...k 

yspepsia,     simulated     by 
fatty  heart 


nulatii 


froi 

tenilfriii'ss  in  chest  from 
from  tctrarhlorcthoiic. . 
tinnitns  from     . . 
from  tobiK'co     . .  . . 

tongue  swolIcTi  in  , .   i 

—  tootl.-tndcntctl  from. . 
ulcer  o'  tongue  from 

738, 
from  uiiHUitAble  food  . . 
vertigo  from 
from  worry        . .  . .  ■ 


Dijspncea,  confd. 

-  heart  disease     . .         . . 

-  with  hepatoptosis 

-  hydrophobia 

-  hydropneumothorax     . .   ' 

-  insomnia  from  . .         . .  ; 

-  from  laryngeal  obstruc- 

tion    . .         . .         . .  , 

-  ligneous  thyroiditis 

-  mediiistiual  new  growth  ■ 

-  mitral  regurgitation 

-  myocardial  changes     . .   I 

-  myocarditis        . .  . .  : 

-  osteitis  deformans        . .  i 

-  overstrain  of  heart       . .  ; 

-  phthisis : 

-  pneumothorax  . .         . .  ' 

-  polycythaemia  and        . .   . 

-  from  post-pharyngeal  ab- 

scess   ..         ..      198,  I 

-  pulmonary  embolism  159, ! 

-  Kiedel's  disease. . 

-  renal,  asthma  simulated 

by        ; 

;  -  retracted  head  from     . .  . 
[  -  spasmodic,  from  asthma  • 
I  -  from  thyroid  gland  en- 
I  largement       . .         . . 

I  -  from  uriemia     . .       40,  : 

-  (and  see  Breath,  Short- 

ness   of:     and    Ortho- 


-  ph;iryiii,'eal  stenosis      . .   198 

-  post-pharyngeal  abscess  198 

-  pouch  of  oesophagus  19G,  7G3 

-  ptyalism  from   . .  . .   543 

-  from  quinsy       . .  . .   198 

-  sore  throat         . .      198,  615 

-  spasm  of  oesophagus    . .  435 

-  spasmodic,     in     hydro- 

phobia ..  ..197 

-  from  stomatitis  74,  198 

-  syphilis  . .         . .      197,  199 
I  -  thyroid    gland    enlarge- 

I  ment    . .  . .  . .    722 

i  -  tongue  lesions    ..  ..198 

-  tubercle  of  larynx         . .  199 
1  OYSPNSA  -.199 

-  from  abductor  paralysis  158 
I  -  acute,    from    aneurysm 

'  opening      into      pul- 

I  monary  artery  . .     92 

superior  vena  cava    92 

I aortic  valve  rupture. .  210 

!  -  -  bronchitis       . .  . .  420 

bronchopneumonia  . .  420 

hicmorrhage  into  thy- 
roid ..  ..  721 

irrnyition    of    caseous 

gland    into    trachea    420 

laryngeal  paralysis   . .   495 

pneumothorax  . .  159 

tabes 159 

tooth-plate  in  larynx    195 

-  from  alkalies     . .         . .     09 

-  from  aneurysm..        93,  159 

-  angina  Ludovici  . .   158 
I  -  aortic  regurgitation      . .  207 

-  asthma    . .  . .  '       . .   32^ 

-  athletes*  heart  . .  . .  214 

-  with  anuria       ..  42 

-  from  bronchitis  ..  322 

-  bronchopneumonia       . .   590 

-  capillary  bronchitis      . .  590 

-  cardiac, asthmasimulatcd 

by        535 

-  in  chlorosis        . .         . .  274 

-  (rhronic  mcdiastinitia  . .  435 

-  chronic  nephritis  . .  722 

-  from  congenital  heart 

215,  217,  720 

-  diphtheria  . .         . .   157 
emphysema        . .         . .  322 

-  with  fatty  heart        212,  213 

-  fibroid  heart      ..         ..  213 

-  -  lung 210 

-  tioitre       . .  . .       158,  722 

■  GravfiK'n  dlwiwo  . .    722 

■  liiDmurrhtMfe  lido  hitra- 

thoracic  SHrc<inui      . .   15{> 
-  mcdfiiKlinum  ..         ..   I5l» 

-  -  thymus  ..159 

-  -  thyroid  . .    15H 


DYSTOCIA 

-  from  rj-tk-  kMiicvs      .. 
Dystocia,  list  of  causes  of 

in-n.     ■  ■     .     .la-    (see 


EAR,  Arnold's  nerve  of 
the 1 

-  boils  affecting    . .  . .  2 
Ear,    cerebrospinal    fluid 

from    ..  119,  4 

-  chilblains  affecting       . .  2 

-  component  parts  of  the  1 

-  condylomata  in. .         ..  4 

-  dermoid  cyst  of . .         ..  H 

-  diphtheria  of     . .         . .  'i 

-  discharge  from  (sec  Otor- 

rhea) 

-  eczema  of  . .      203,  4 
cough  from    . .         . .   1 

-  epithelioma  of  378,  4 

-  erysipelas  affecting       . .  2 

-  foreign    body     in,    (see 

Foreign  Body  in  Ear) 

-  furuncle  in        . .         ..4 

-  hfflmorrhagc    from    (sec 

Hicmorrhage  from  Kar) 
into  middle    . .         . .   1 

-  herpes  affecting  . .   'J 

with  facial  palsy       . .  -1 

Ear  lesions,  noises  In  the 

head  from  ..A 

nystagmus  from        . .   -1 

vertigo  from  . .  . .    1 

-  liquor  Coturmii  escaping 

from    . .         . .         . .  -1 

-  lobules,  absent,  in  pro- 

geria   . .  . .  . .   1 

-  lupus  affecting  . .  . .    i 

-  polypi  in  (see  Polypus  of 

Ear) 

-  pulsation     detected     by 

208,  II 

-  rodent  ulcer  affecting  . .  4 

-  sebaceous  cyst  of         . .  '2 

-  "  glands  in        . .  . .  4 

-  swelling  of,  from  furuncio  4 
Ear.  syphilis  of  Internal  . .  7 

-  telephone  . .  . .  t 

-  urate  of  sodium  in        . .  ;i 

-  wax  itt,  coui;li  from      . .  I 

deafness  from        I'M,  I 

Ear     of     corn.      Inhaled, 

giingronc  of  lung  froiri 
EARACHE 

Earache,  various  causes  of 

202, 

EarH.  atrophy  of.  from  Iiipii^ 

ervthenmto^U'* 

-  blue",  blue  bniiii  imd     . . 

-  coarso,  In  cretinism 

-  cvniioxis  of 


Ears,  coutd. 

~  hiematomata  of,  in  gen- 
eral paralysis  . .  243 

-  large,  in  mongolism     . .  23S 

-  pitcher-shaped,  in   mon- 

golism ..         ..  23S 

-  Raynaud's  disease  affect- 

ing      . .  203,  256,  G99 

-  singing    in,    in    arterio- 

sclerosis . .         . .     11 

-  thick,  in  myxcedema    ..  234 
Eason's  reaction,  ia  hemo- 
globinuria     ..         ..  28.". 

Eating  of  dirt        . .  . .     43 

-  excessive,  lu-ic  acid  and  742 

-  rapid,  sense  of  fullness 

after 243 

Eberth's  bacillus  (see  Ba- 
cillus Typhosus) 
Ecchondroses,  from  arthri- 
tis         143 

Ecchymoses           . .          . .   552 
Echinococcus  (see  Hydatid) 
Eclampsia,  general  account 
of        146 

-  convulsions  in    ..      137,  ln^ 

-  rigors  simulated  bj-     . .  594 
Ecthyma GOU 

-  impetigo  and     . .      557,  558 

-  pustules  in  . .  . .   557 
Ectopic  gestation,  felt  per 

rectum  ..  ..   .'.^: 

Ectopic  gestation,  notes  on  690 

-  -  abdominal  pain  from     ".^'^ 
acute  abdominal  pain 

from  ..      193,  :>:• 

blanching  due  to      ..  !_' 

bimanual  examination 

in  detecting  . .  ^Gi> 

-'-  blood     per     vagiuam 

with  ..  ..  593 

collapse  from  . .   393 

coma  from      . .         . .  lis 

faintness  from  . .  393 

internal  bleeding  from 

.^93,  593,  72(1 

-  -  leucocytosis  from      . .   593 

metrostaxis  from     . .  39- 

pain      in     hypochon- 

drium  from  . .  451 

the  pelvis  from  468,  68S 

pallor  from    . .         . .  593 

pelvic    swelling    with 

393,  688 

rigidity  from  . .  593 

ruptured         . .      120,  193 

simulating   dysmcnor- 

riicea  ..         ..  193 

licritonitis  . .         . .  593 

swelling  in   Douglas's 

pouch  from  . .  SS7 

tenesmus  from  ..  71S 

tubal  mole  from       . .  393 

uterine  bleeding  due  to  393 

vomiting  from  . .  765 

Ectothrix 21  s 

Ectromelus  . .  . .    1S^ 

Ectropion 220 

Eczema,  anidrosis  with    ..   651 

-  biildness  from    ..  ..      71 

-  bathing-drawers     region 

ttlTecteil  by    .,      401,  «U'> 

-  burning  in  . .  . .   55s 

-  chciropfunpholj'x    simu- 


r.im. 


Eczema,  dermatitis  distin- 
guished from 
-  ear  alTcchd  bv  148,  202, 

203,  422 
t  margiiiatuui  dlK- 


755 


422  tiuguisli.'d  from         ..   250 

752  -  cn-,Mn|.|,,l,..  r.m-m        ..    219 

203      -  i-r\  ll 11 .  .      222.  602 

:iM      -  .■i\rl.t ,11, 111, .ring       251 

118  -  fiivii-  .(t-iu.,'iii-ii.-d  from  247 

165  '  -  llni;.TSiilT<-ctr'.|  hv      y3l»,  240 

i  -  fotlii'uliti^tfrom  ..         ..  2111 

260  ,  -  folliculorum        . .          . .  602 

202  -  -  papnh^in       ..  ..    IS7 

Eczema,  general  account  of 

203  754,  755 

I  -  fn.rn  ;,'Iv.■o^nl■ill ,  .           ..    '.■<•.<. 

603  -  kTMhido^N  rubni  r..i-i  dl- 

1  .3  iliigulHtied  from        . .   <; 

231  ,  -  inipeUglimnM,   culnneou- 

156  dlplitheriu    Kimuliilliii' 


ECZEilA    —    EMPHYSEMA 


Ejaculatorj    ducts,    gono- 


-  itching  in  491,  510,  55S, 

500. 

coccal  infection  of     . .   182 

710 

751! 

Elastic    fibres    in    sputum 

-  lens  in  diagnosing 

488 

(see    Sputum,    Elastic 

-  lichen  urticatus  simulat- 

Fibres in) 

ing 

756 

Elbow,  osteo-arthritis  of..  347 

-  lips  :iir.-.-t,.fl  In-         S65 

600 

-  pneumncoccal  arthritis  of  339 

-  ln;n-L'iii,ii  urn.         1.  nliiiis; 

-    positiiHi  in  ti't,in\-           .  .         -J 

,ll.l      ..    '             :■.      .■                  .rtCd 

401 

-  tubc-ri'iil..ii-ih  .'.i-i'iil  ..    317 

iIIim! ,         h.l        ,  . 

250 

Hlbow-ji  rk-.    nil  rri-i'il,   lu 

-  _  cuiuiiii     .li.-.liu-iiiihed 

brachKil  iiiua.JljluL.-u..    .jn2 

from 

250 

-  -  hemiplegia      . .          . .   303 

epidermophyton  caus- 

Elbow-joint    disease,    arm 

•  ing  :.          ..      248 

250 

atrophy  from             . .     61 

erythrasnia  simulating 

251 

Elbows,  psoriasis  affecting 

niicrn?(-ope  iadiagnos- 

4.89,  491,  602,  603 

irii; 

250 

-  pityriasis    rubra    pilaris 

Eczema  maroinatum,  parts 

affecting          . .          . .   489 

affected  by     . . 

250 

-  rheumatic  nodules  on  . .  732 

seborrhea  distinguish- 

- seborrhceic  eczema  affect- 

ed from 

250 

ing       401 

-  miliaria  simulating 

755 

-  small-pox  affecting       . .  561 

-  mycosis  fungoides  simu- 

- xanthelasma  of  . .         . .  324 

lating  

731 

Electric      blindness,      ery- 

-  nails  aHected  by      250, 

399 

thropsia  in      . .          . .    762 

-  nipple  affected  by 

730 

-  currents,  gangrene  from  255 

-  no  discoloration  after  . . 

487 

—  light,  ej^e-strain  from   . .  446 

-  CEdema  from 

502 

-  steel   groovers,   subacro- 

- from  otitis  media 

422 

mial  bursitis  in         . .  476 

-  otorrhcea  from  . . 

422 

welders,    photophobia 

-  Paget's  disease  simulat- 

in  524 

ing      

730 

Electrical  reactions  in  my- 

-  papular 

600 

astlicaia  gravis          .'.    584 

blood-crusts  in 

487 

Electrical  reactions,  normal 

-  -  itching  in        . .      4S7. 

488 

582,  583 

Eczema,     papular,     lichen 

in  Raynaud's  disease, 

planus      distinguished 

etc.' 584 

from    . . 

487 

-  -  tetany             . .         3,  584 

scrofulosoruni  ^imu- 

Thomsen's  disease    . .  684 

latiiig      . . 

488 

(and  see  Reaction  of 

-  -  vesicles  in       . . 

488 

Degeneration) 

-  papules  in 

487 

-  treatment  of  functional 

-  pityriiisis  nil.ni  nfter    .  . 

(104 

aphonia          . .          . .  495 

pil.ili^    -niiiil.il  iiiL'.  , 

i;iil 

Electricity,    insomnia     re- 

-   prUrJL'o       ili^lllr.Mll^llid 

lieved  by        . .         . .  323 

fri.r.1 

490 

-  in  lowering  high  blood- 

Eczema,    psoriasis    distin- 

pressure         . .         . .  323 

guished  from  . . 

603 

Electrocardiogram,  in  dia- 

~ pustular               .  .      557, 

560 

gnosing    angma    pec- 

 impetigo  simulating.. 

558 

toris    476 

-  ringworm  simulating    . . 

249 

auricular  fibrillation 

-  rubrum , 

600 

94,  485,  {Fij/.  196)  48G 

-  scabies  sinuilating 

755 

heart-block    . .          . .  486 

-  scabs  in  . . 

600 

heartburn       . .         . .  297 

-  scales  in     JSS.  1101 .  C02, 

G03 

myocardial  clianges  15,485 

--  seboniinir         f.iin.  (;(12, 

603 

paroxysmal     tachy- 

cardia 548,  (/■iy.289)  703 

1 1 1 1  _■  1 1 1  ~  I  1  . 1  n  1 1 1 1  [     .  . 

401 

Stokes  -  Adams's    dis- 

- -  of  llu-l,  iir.M    ,  . 

242 

ease            ..          ..486 

Eczema,  setiorrhteic,  of  in- 

 between  stomach  and 

fants   

401 

heart  lesions         . .   709 

p.arts  affected  bv 

491 

-  of  heart-block  (Figs.  37. 

-  -  scaliiiess  in     .." 

242 

38) 83 

-  small-].., X  -iliiill:it.-,l   l.y 

562 

-  heart  cases        . .          . .  544 

-  staiTni.L-  .,1  -km  lr..rii      .. 

602 

-  showhig     extrasystoles 

-  syphili.lr-  ^ii.iiiNiiiii-  l'.ll 

560 

(Fig.  231)       ..          ..644 

-  tendeni---^-;  ..1  ■-.  i!).  from 

710 

Electrolysis  of  water-pipes, 

-  tinea     circiiuita     distin- 

plumbism  from         . .      65 

249 

Elcpllantiasis,    atrophy    of 

of  umbilicus  . . 

483 

testis  from     . .     '    . .     06 

versicolor     simulatinf^ 

250 

Elephantiasis,  blood  changes 

-  vesicles  in  487,  488,  600, 

in        28 

75o, 

754 

-  chylous  ascites  with    . .     50 

-  due  to  wax  in  ear 

422 

-  chyluria  from                 28,  50 

-  weeping  in 

600 

-  from  fllariasis   28.  109,  411, 

i';ii'erYcscence.  urinai-\' 

1,  5 

701,  737 

EFFUSION      IN      CHEST, 

-  geographical  distribution    28 

BLOODY 

102 

-  impotence  from            . .   312 

EFFUSION      IN      CHEST, 

-  from  lymphatic  obstruc- 

SEROUS 

104 

tion'                            .     411 

(aii.l       see       I'lcuril 

Elephantiasis,  pseudo-     ..411 

Ktfusion  ;       and 

-  scroti 095 

n,.|i|-iti,-  KlliiHi,.n 

-  syiiliilis  simulating       . .   701 

-  peril':. ri  I'll    1  -1'.'    I'l'i  ii'itr- 
di'il          ,    . 

Embolism,  cerebral,   acute 

rheumatism  and        ..   119 

Kggs.  nil'',"  ,    ','    .    ,    1  ,'  .  . 

15 

age  incidence  of     119,  147 

EGGSHELL    CRACKLING 

ISO 

aphasia  from..          ..   026 

from  atipurysin 

693 

apoplexy  from         . .   147 

osteosarcoma. .      152, 

693 

-  -  athetosis  after       132,  133 

-  nail          

400 

in  children     ..         ..133 

Egypt,  ankylostomiasis  in 

521 

brachial     monoplegia 

"  bilharzia  in        . .       79, 

282 

from            . .          . .    501 

-  cirrhosis  in 

370 

Babinski's  sign  with . .     68  j 

-  relapsing  fever  in 

596 

cerebral  softening  fi-om          i 

-  splenomegaly  in 

634 

108.  515  ! 

EHRLICH.    OIAZO  REAC- 

 Cheyne-Stokcs  breath- 

TION OF 

173 

ing  from     . .         . .  108 

EmlfoMsni,  cerebral,  contd. 

-  -  coma  from  118,  ll'J, 

304,  640 

diplegia  from  . .  133 

from  endocarditis     . .  147 

epilepsy  after  . .  133 

fungating  endocarditis 

and  31",  ll'J,  303,  304,  640 

Embolism,    cerebral,    hae- 
morrhage after        . .  640 

-  -  lieadaclie  from       291,  295 

lieart  bruits  and       . .    119 

from  heart  disease  133,  515 

hemianopsia  from  301,  302 

hemiplegia    from,    08, 

133,  258,  303,  304,  640 
from  intracardiac 

tlirombosis. .         ..  147 

mental  defect  after  . .   133 

from  mitral  stenosis 

303,  304 

spastic  paraplegia  after  132 

speech  defect  after  . .  133 

from  thrombi  . .  133 

tremor  from  . .  . .    133 

unilateral  paresis  from  118 

-  of  cord,  in  infective  endo- 

carditis . .         . .  517 

-  in  fungating  endocarditis      8 

-  gangrene  fi'om  . .  . .   255 

-  from  heart  disease       . .    258 

-  infarction  from..  ..       8 
of  kidney  from         .  .        7 

-  from  intracardiac  throm- 


bus 


ha-ii 


-  -  frui 
intestinal    obstruction 

simulated  by        ..  389 
laparotomy  in  diagnos- 
ing    389 

raelseiia  from. .         . .   131 

meteorism  from        . .  389 

peritonitis  from        . .   389 

simulated  by         . .   594 

-  peripheral,  in  fungating 

endocarditis  . .         . .  640 
~  pulmonary,     bronchial 

breathing  from         . .   290 

after  childbirth         , .   290 

from  clot  iji  heart    . .  289 

cyanosis  from        159,  289 

dyspnoea  from      159,  289 

gangrene  of  lung  from 

259,  644 

hsemoptysis  from  159, 

289,  290 

infarct  from  , .         . .    160 

from    infective    endo- 
carditis       . .      159,  290 
lateral    sinus    throm- 
bosis . ,       159,  644 

mitral  stenosis         . .  289 

after  operation         . .   290 

orthopnoea  from      . .  289 

from  otitis  media     . .  159 

pain  in  chest  from 

159,  289,  290,  430 

pleuritic  rub  from    . .  290 

rales  from      . ,         . .  290 

sudden     death     from 

159,  290 

from  venous  thrombus 

159,  290 

in  pyajmia      . .  . .   59G 

(and  see  Infarct  of  Lung) 

-  of  radial  artery,  in  fungat- 

ing endocarditis        . .   551 

-  renal,  in  fungating  endo- 

carditis ..         7,  640 
haimatnria  from        . .    283 

-  -  iiifarctiun    from  ..    283 

-  -   iKiiit   ill   Initi   in  ..    283 

Embolism,  retinal,  appear- 
ances after  ..  416 

-  -  {Plate  XX)     ..  . .   418 
black  spots  before  eyes 

from  . .  . .      72 

blindness  from  . .    7G2 

in  fungating  endocar- 
ditis . .  . .      34 

-  of  spleen,    in  fungating 

endocarditis       34,  632,  Old 

Embolism  of  spleen,  general 
account  of  . .  640 


Emhoiism  of  spleen,  conitl. 

pain  iu  chest  from  .  .   6 

spleen  enlarged  from    6; 

-  sudden  pain  from       . .  2. 

-  unetjual  pulses  from  . .  b, 
Embryoma  of  kidney     . .   3: 

aching  in  loin  from  . .   2 

colic  from       . .  . .   2 

liEcmaturia  from     27"»,  2 

renal  enlargement  from  2 

Embryoma  of  testis  480,  6! 
Emetics,  vomiting  from  . .  7( 
Emetine,  disappearance  of 

amcebaj  after. .  . .     ' 

Emissary    vein   (see    Vein. 

Emissary) 
Emission,  nocturnal,  albu- 
minuria after  . .     1 

oxaluria  and  . .         . .  4: 

Emotion,     acute     yellow 
atropby  after  '. .   3| 

-  angina  pectoris  from    . .   4i 

-  blushing  from    . .  . .   2< 

-  convulsions  from         . .   1^ 

-  diarrhoea  from  . .         . .   I' 

-  dyspepsia  from . .         . .  3; 

-  jaundice  from    ..      Z2o,  31 

-  menorrhagia  from        . .   3i 

-  palpitation  from        481.  4i 

-  ptyalorrhosa  from        . .   5^ 

-  tremor  from       ..      724,  7; 

-  uncontrolled,  facial  par- 

alysis and       . .  . .    4i 

-  uncontrolled,  in  pseudo- 

bulbar jials.y  . .  . .  O; 

Emphysema,    albuminuria 
from    . .  . .  . .   2] 

-  ascites  from       . .        4G,  2] 

-  from  asthma      . .  . .  1' 

-  asthma,     distinguished 

from  by  eosinopliilia    2] 

simulated  by. .         . .  oS 

~  back  pressure  from     46.  21 

-  barrel-shaped  chest 


167 


Emphysema      and     bron- 
chitis   If 

-  bronciiitis  with     14,  40. 

153.  167,  2] 

-  bulging  above  and  below 

clavicles  in     . .         . .  1( 

-  cardiac  dullness   dimin- 

ished in  . .       167,  2( 

-  chest  changes  with      . .     ] 
expansion  slight  in   . .  1( 

-  Cheyne-Stokes  breathing 

from    . .  . .  . .   1( 

-  clubbed  fingers  from    . .  11 

-  comiiensatory,    with    fi- 

broid lung      . .  . .    2] 

-  constipation  from         . .   IS 

-  cyanosis  from    . .  . .    K 

-  deficient  vesicular  mur- 

nnu-  in  . .         . .  1( 

-  dyspnoea  from  . .  . .  3S 

-  epistavis  from   . .  . .   2S 

-  expiration  jTrolonecd  in     1(1 

Emphysema  and  fatty  heart, 

difficulty  of  distinguish 
ing 

-  QatulL-iice  with..  ..    2-] 

-  liEeuioptysis  from         . .   28 

-  heart  failure  from  14.  46. 

108.  161.  41 

impulse  impalpable  in  16 

obscured  by  . .      217.  28 

sounds  hard  to  hear  in  16 

-  liy per- resonance  from  , .     8 

-  inelastic  skin  with       ..    16 

-  insomnia  from  ..      321.  32 

-  intercostal  spacer  wide  in  IC 

-  liver  dullness  diminished 


48 


107 


21 


■  menorrhagia  from     386.  38 

■  neck  short  in     . .  . .   16 
cedcma  of  legs  from    . .  21 

■  iu  old  people     , .         . .     8 

■  orthopnoea  from        323,  41 
outline  of  che^t  in  iFuj. 


SO) 


16 


■-distended  chest  in  16 
pain  in  chest  from  .  -  43 
-  limbs  in  . .  . .   46 

palpitntion  fron\       484.    18 


EMPHYSEMA 


ENDOCARDITIS 


K13 


,,,l„js,m„.  ,:„„.l. 

iphysema,  physical  signs 

of        217 

>neuinotliorax  fj-om  . .  531 
joljt'.vthEemia  from  532,  533 
resonance  increased  in. .  167 
ibs  everted  from  . .  3GG 
■igbc  ventricle  enlargett 

fiom  ..  215,  217,  2!IU 
rupture  of  bleb  in  .  .  531 
jhortness  of  breath  from 

85,  89 


IPHYSEMA.  SURGICAL  203 


750 


I.  ■  I  .-  of  chest  in  ..  708 
(IL.-.II1M  —  in  chest  from  432 
tru-u-in.l      regurgitation 

vesicular  murmur  dimin- 
isiied  in  . .         . .   167 

violent  coughing  bouts 
ironi 289 

winter  bronchitis  with. .  lliO 

-  couL-l.  from  . .  . .  li 
iil.rn-ih.iluiius,  1'.  tetanus  138 
IPYEMA  .103 
npyema.   abnormal  sites 

oi                    so,  103.  643 
abseiii'f  01  hrcatli  sounds 
with 1113 

-  voice  sounds  with  .  .  U»3 
adhesions  round  . .  532 


albi 

a^Junlc,^nri:l  witli  ..  10 
anannia  with  .  .  32,  3-1 
npyema   of    antrum    of 

Highmore              180,  462 

-  -  suliicotive    smells 

from        ..          ..  012 
from  apiiendicitis    103, 

104,  100 

ascending  nephritis      . .  lOG 

a.\illar.v  alxscess  from  . .  G6C 

bacillus    iroli    communis 

causing  ..  ..104 

-  pj'ocyancus  causing. .  104 
bronchial  breathing  over  103 
broncliiocta-sLs  after  . .  292 
from  bronchopneumonia 

103,  1(111 

bursting  Ihrnut-h  lung..  2S7 

npyema,  causes  of       ..  103 

chest  bidged  on  one  si<le 

by        108 

-  shrunken  from     153, 

184,  108 

from  cholangitis  . .  100 
cluhbing  of  fingers  from 

80,  111 

crackling  nlles  over     ..  103 

,1m, |, 1,1, .-111  .Icprcssed  by  OSS 
npyema.    difficulties    In 

locating                   . .  843 
froT,,  ,l,i<„liMnil  ulcer  101,  lUO 


roi. 

lung  all  IT 

. .  292 

till 
late 

bronchitis 
1   bv 

..  043 

III  b 

rcalli  from 

..     8G 

spu 

lull  from. . 

200,  043 

npyema  of  frontal  sinus    180 

-  .(:u..i>r.->imi-^.  l-ronhiO 
cuU-t>Iit<liIer,  iilhiimosuriti 

with  ..         ..     HI 

-  from  .nrciiiomii         . .   320 

-  rliolani.'itiR  from         ..   333 

-  from  clioliiiik'iti*'        . .  326 
■-  from  Kall-l'Ii«'l<lt*i-  •"''•<■- 


Empyema  of  gall-bladdrr^  coutd. 

gall-bladder     enlarged 

by  ..  ..  25S 

from  gall-stones         . .   320 

leucocytosis  from  254,  360 

operation  for  . .  25-1 

from  typhoid  fever 

254,  333 

-  gangrene  of  lung  simu- 

lated by         2G0,  290,  G43 

-  from  gastric  ulcer   103, 

104,  lOG 

-  gumma  of  liver. .  . .   106 

-  haemoptysis  from      287,  291 

-  from  hepatic  abscess  104, 

106,  370 

-  hydatid  cyst  of  liver  . .  106 

-  indicanuria  from       315,  745 

-  from  infarction  of  lung    106 

-  injury      . .  . .  . .   104 

-  lardaceous  disease  froro 

S,  635 
•-  latent 103 

-  leucocytosis  with     35, 

360,  361 

-  lobar  pneumonia  . .  103 

-  after  measles     . .         . .  597 

-  needling  in  diagnosing  35, 

103,  160 

-  nephritis  from  . .         . .       9 

-  from  new  growth  of  liver  106 

-  after  operations  . .  106 

-  osteo-arthropathy  from     352 

-  from  otitis  media        . .  106 

-  pain  in  the  chest  from 

430,  431,  432 

-  paths  of  infection  in    . .   104 

-  from  pelvic  peritonitis. .   lOfi 

-  perinephric  abscess      . .  104 

-  perinephritis      . .  . .  106 

-  periodic  pus  expectora- 

tion from       . .         . .  291 

-  from  jieritonitis  . .   lOfi 

-  phthisis 101 

Empyema,  without  physical 

signs    . .  86,  643 

-  after  pleurisy     . .  . .   597 

-  pneumococcal     103.  104,  105 

-  after  pneumonia    35,  104, 

{Fig.  71)  160,  291, 

574,  597,  043 
pneumothorax  from     . .  531 

-  pointing  ..         168,  169,  222 

-  polymorphonuclear  celts 

and      ..         ..        35,  3C1 

-  prolonged  pyrexia  from 

563,  507 

-  from  pylephlebitis       ..  106 

-  pyosalpinx         . .  - .   100 

-  pyrexia  of         . .  . .  574 

-  rarity  of  peritonitis  from  100 

-  from  renal  calculus      ..    100 

-  retraction  of  chest  after  169 


rigo 


Empyema,    ruptured    into 
lung  86.  168,  291,  531. 

532.  643,  705 

-  after  scarlet  fever        . .    597 

-  scoliosis  from    . .         . .  153 

-  septicemia  from        567,  637 

-  simulated  by  abscess  in 

the  liver         . .    #     . .  103 
..   103 
ab- 
..   103 

-  simulating  bronchicclasitt    86 

-  sinus  from  ..  ..635 

-  staphylococci  causing  . .    104 

-  stench  from       . .  . .   2D0 

-  sireptwocci  causing     . .    104 

-  from     subiliaplirogmatic 

abiici^t    103,  104.  370,  C58 

-  sudden  abundant  expec- 

toration of      . .  . .      ***'» 

-  (enderrioss  of  spiiio  from  713 

-  from  tuberculous  ki'Jney  106 
^  typhoitl  bacilli  causing..  104 
Kiit-eiWiiiliti.",  age  incidence 

of  120,  132 

-  ataxy  from       . .         . .     58 

-  athetosis  after   . .         . .   132 
'  -  brocliint  monoplegia  from  502 

-  coma  from         ..      117,  591 
I  -  convulsions     with     120. 

140,  502,  511 

-  headache  with  120,  502,  525 


Encephalitis^  eontii. 

-  hemiplegia  from       303,  3 

-  lumbar  puncture  in  dia- 

gnosing . .         ..  t 

~  meningitis  simulated  by  5 

-  optic  neuritis  from  120,  5 

-  paraplegia  from        132,  5 

-  photophobia  from        . .  5 
--  post-mortem      diagnosis  1 

-  prognosis  in       . .         . .  1 

-  pupil  small  with  . .   5 

-  pyrexia  from     . .       502,  .5 

-  retracted  head  from     . .  5 

-  relation  to  poliomyelitis  1 

-  simulating       meningitis 

120,  5 
sinus  thrombosis   120,  5 

-  vomiting  with  120,  502, 

511,  5 
Enccphalocele,   exophthal- 
mos from       . .  . .  2 
Encephalopathy,  saturnine 
Knchondroma     of     meta- 
carpal {Fig.  282)      . .   6 

-  sarcoma    simulated    bv 

(Fig.  282)      . .         . .  6 

simulating      . .  . .   C 

Endarteritis,  cerebral,  hemi- 
plegia from    . .      303,  3 

-  -  from  syphilis..         ..  I 
thrombosis  from       . .  3 

-  cerebral  softening  from  * 

-  gangrene  from  . .     255,  2 

-  hemiplegia  from  . .  I 

-  S3-philitic  . .         . .  I 

headache  from  . .  ' 

spinal,  allocheiria  from 

Endocarditis,    absence    of 

pyrexia  with. . 

-  acute,  from  acute  rheu- 

matism, 90,   96,  105, 
209,  211,  283,  404,  ( 

Endocarditis,  acute,  brulti 
from 2 

cardiac    impulse    dis- 

pluted  from  . .  1 

in  children      . .  . .   t 

aortic  disease  after  . .   : 

regurgitation  from 

systolic  bruit  from 

Endocarditis,     acute,     of 
aortic  valve   . .        ■  •  S 

apic.'il    diastolic    bruit 

from 

systolic  bruit  from  2, 

89,  no,  ; 
calcincation  of  valves 

after  . .         . .   2 

-  -  in  children     . . 


Endocarditis,  fungating^  contd. 

, apical  systolic  bruit  in    SO 

I .iscites  in        . .  7,  51 

I axillary  aneurysm  from  067 

I blood  cultures  in    34, 

209,  5i;o 

I bruits  in         . .  . .  560 

without  bruit  8,   566,  Ol'i 

a  case  of        . .         . .       7 

' cerebral  abscess  from  5U- 

hseinorrhage  from..  640 

f'hevne-Stokes  breath- 

iil-  ill  ..  ..    lOS 

Endocarditis,       fungating, 

chief  signs  of..  34 

-  -  coma  in  . .      117,  04" 

convulsions  from      . .     34 

disappearance  of  pulse 

embolism  in  ..  8,  51 

of  spleen  in  . .     31 

of  brain  in  34,  119, 

303,  301 


-  _  fn.n.    .ryMp.-hL.         .. 
Endocarditis,  acute,  general 

account  of  ••  'i 

mid  -  difustolic       bruit 

from  . .  2,  96,  « 

-  -  miir:il     regurgitation 


prerurdiid  puiu  from 

from  pueriHTiil  fever 

-  -  reduplicution    of    first 

sound  from  . .   : 

from  scarlet  fever 

90    200,  : 

—  solero^ltui  valves  after  ; 
from  scpticiBmia 

m  tonsilliti! 


oge 


idence  of 


-  aortic  dlwose  from 

-  cerebral  cniboliHin  from 

-  fungatirit'.  ucule  abdom- 

Endocardltis.     fungating, 
acute  aneurysms  In  . . 

....phritis  frmn        .. 


idht 


aUcrniilivu  numes  for  I 

-  -  aniumia  from  7,  21,  31,  i 

ancuryHMi  from 

of     hepatic     artery 

from         . .        51,1 

aortic        roguruitnUnn 

from  . .       93.  : 


-  lu 


59, 


pancreas  m  . .      ('• 

radial  artery  in  ..  551 

: retina  in     . .  . .     34 

I spleen  in     . .  34,  03_' 

I fingers      clubbed  in 

I               (Fig.  270)  . .   040 


fro 


34 


Endocarditis.       fungating. 
general  notes  on        . .  640 


hojmoptvsis  from      . .  2SS 

-  -  haiiuorrhages  with    . .     34 
haimorrhaii ' 


hyperpyrexia 

3011 

iulluenza  sunulating 

oOi 

intestinal    obstruction 

simulated  in        7G, 

38il 

-  -   i.aundice  with 

334 

no  liiK-ocvtosiswith.. 

31 

-  -  li\cr  enlarged  in  (fiV 

270) 

040 

meningitis  from 

50 ; 

simulated  by 

507 

micrococcus  rlieumati- 

cus  in 

209 

mitral      vegurgitation 

from 

211 

-  -  of    monllis'    duration 

567 

Endocarditis,       funoating. 

multiple  emboli  in    ■ . 

640 

'  a'dema  of  ankles  from 

■  -  face  from    . . 
obscure  pyrexia  from    ." 
optic  neuritis  with  .. 
from  osleonnclilis  ..  S 
piiiii  in  llic  back  from 
pariilysis  fruni  34,303, 
304,  0 

'  peripheral  neuritis  from 
pcritunitlc  rub  in 

'  peritonitis  front        . .  .'I 
pclechiin  in    . .  . .  5 

pl.iirisy  in       . . 
piiuumo.'uccnl         2011,  5 
from  iihciimoiiia       ..  2 
prolonged  pyrexia  frotii  Ti 
|,nlinoii!irv,     iliciimpe* 

leiice  Iniui  . .  . .   ; 

of  pulmonary  valve. .  2 
purpura  with  34,  M3, 

ifil).  230),  t 
pyrexia  front      7,  34, 

S»4,  ,•, 
wilhoiitpyrovla        ..  a 
renal  lube  ciihIk  In   . , 
ri-l  iniil  hii'inorrlingus  in 
rigors   in         34,   SII5,   I 

•  i,eriiui  treattiieitt 

-  tiliortniiis     of     broall) 
frutit  . .         . . 


ENDOCARDITIS 


EPISTAXIS 


..21 

pernicious  anaemia      21 

simulating  nephritis  7,  283 

hfemic  bruits         , .       7 

-  -  spleen  cnlar^red  in  3-J, 

'"/./.  270)  640 


209 

209 
2S3 


Kiilar-ed) 


206 


teniperaiurf-  rlwut  in     506 

tonsillitis  ui   . ,  . .      34 

tube  casts  in. .  . .   283 

typhoid  simulated  by  567 

simulating  . .  . .   565 

typhus  simulated  by 

563,  567 
Taccine  treatment    . .     34 

-  pulmonary  regurgitation 

from    . .  . .        93,  217 

-  pyrexia  from     . .         . .  574 

-  without  pyrexia  . .   574 
Bndocervicitis,  character  of 

discharge  from  . .  185 

Endometritis,  acute  perito- 
nitis from       . .  , .   592 

-  ansemia  from     . .  . ,     35 

-  backache  from  192,  387,  468, 

716 

-  blood-stained  watery  dis- 

charge from  . .         . .  391 

-  cacliexia  with    . .  . .     99 

-  characters   of   discharge 

from 185 

-  cored  by  curetting       . .  192 

-  dysmenorrhcea  from    . .  192 

-  leucorrhcea  from       192,  387 

-  menorrhagia  from     185, 

192,  386,  387 

-  metrorrhagia  from    390,  391 

-  microscope  in  diagnosing 

387.  391 

-  pigmentation  of  face  with    99 
cyst. .   387 

..   387 


(for      other     Enlarge- 
ments,      see       under 
^'arious  Organs) 
ENOPHTHALMdS  ..  217 

-  from  paralysis  of  cervical 

sympathetic  217,  541,  552 
Entassement  .  -  499 

Enteric  fever  (see  Typhoid 

Fever) 
Enteritis,    acute,    indican- 

uria  from        . .         . .  314 

-  blood  and  mucus  motions 

from    . . 

-  with  cirrhosis 
Enterolith,  felt  per  rectum  584 
Enteroptosis,     abdominal 

swelling  from  . .   655 

-  with  movable  kidney  . .   331 

-  undue  abdominal  aortic 

pulsation         . .  . ,   543 

-viscera  displaced  in    ..  659 
Enterospasm 


El-iil.rmnhi.s..'^  I.ullosa.  fn„hl. 

Epidermolysis  bullosa,  general 
account  of  • ■     98 

nails  affected  by         . .  399 

related  to  urticaria  . .  98 

Epidermophyton  inguinale 

248,  250 
Epididymis,  cysts  of  the  481,  i:;i7 
Epididymis,  encysted  hydro- 
cele of 695 


orcliitis  ..  ,.   478 

-  gonococcal   infection  of  182 

-  new  growth  of  . .  , .  697 

-  nodule  in  47S.  479.  622 

Epididymis,  swollen,  general 


nt  of 


>dli!r 


697 


399 


426 

4:js 

43S 


■  with  retroflexion 

■  retroversion 

■  salpingo-oophoritis 
senile,     foul 

from 

-  metrostaxis  from 

-  pvometra  from 
^terilitv  from     .  . 


:ith  ; 


uiuti. 


387 


646 


Endometritis,  symptoms  of  387 

-  in  virgins  . .  . .   387 
Endoscope,    calculus   seen 

through  . .         . .  184 

-  in  diagnosing  stricture 


218 


Enterospasm,    general  ac 
count  of  . .   124 

-  mucomembranous  colitis 

with 438 

-  relation  to  food. .  . .   438 
Entropion,     pain     in    eye 

from  . .  , .   445 

-  from  trachoma  . .  . ,   331 
ENURESIS 

-  nocturnal,  from  oxalur 
Envelope  crystals. .  ..   423 
Eosin,       Charcot  -  Leyden 

crystals  stained  by  . .  102 

-  mucus  stained  by  . .    399 

-  pink  urine  from  . .  745 

-  in  sweets  . .      745,  747 
Eosinophile  cells,  in  asthma 

102,  153 
coarsely  granular,  char- 
acters of     . .  . .      22 

iPlale  11,  Fig.  L)    22 

normal  numbers  of    . .   218 

in  pleuritic  effusion  . .  102 

relative  numbers  of  23,  218 


Endoscope,    in    diaonosing 
urethritis  -      183 

-  herpes    dI    aietlir;i   sKen 

through  . .  . .   184 

-  papillomatauretlurseseen 

through  . .         . .  184 

-  polypus  seen  with        . .  183 
~  soft  sores  of  urethra  seen 

through  , .         . .   184 

Endothelioma  of  antrum 

180,  685 

-  hypernephroma  and     . ..  356  : 

-  of  jaw,  spread  to  nose. .   179 

-  nose,  discharge  from  179, 180  i 

-  T'^lnte.  microscope  in  dia-  i 

'--nosirtg  ..  ..588 

695 


I  sputum 

■lucvtes 
{I -late  IV) 


102,  219 


218 


EOSINOPHILIA     . 

-  :n]k\instomiasis 

-  Ill  asthma  153,  219^  535 

-  in  bullous  dermatoses  99,219 

-  with  cancer  of  liver       . .  375 

-  cysticerci  causing         . .   405 

-  in     dermatitis    herpeti- 

formis . .      219,  755 

-  with  elephantiasis 


Epididymis,   various  affec- 
tions of  the  477.  478.  479. 
480,  481 

-  iitn.pliy  ..f  ti-^ti?  h-vm.  .      (JO 

Epididymitis,  causes  of    . .     66 
Epididymitis,    gonorrhceal. 


Epididymitis,  septic  ..   697 

Epididymitis,  tuberculous      697 

Epididymo-orchitis.  general 
account  of     477,  478,  479 

-  gouty 742 

-  hydrocele  from  .  .  .  .    481 
Epididymo-orchitis,  list  of 

causes  of  . .  478 

-  from  mumps      . .        06,  096 

-  after  typhoid     ..  ..   696 
Epigastric  angle,  wide,  from 

emphysema   . . 
'widened  by  ascites  . . 

-  sensation,  as  an  aura  of 

epilepsy 
Epigastrium,  fullness  in  . . 


Epikpsij.  confil. 

-  headache  in      143.  14:.. 

-  heart  thumpings  from , . 

-  hebetude  after  . . 

-  hysteria   simulating 

-  indigo  blue  In  treating, . 


Epilepsy,  Jacksonian 

-  -  aura  m  ..         67, 

consciousness  in        . .   : 

head  injury  and       . .  : 

localized     convulsions 

from  . .  , .    : 

scar  on  head  and     . .    : 

'  spread  '  of  attack  in  ! 

from  svphilis. .  . .   ' 

-  -  unilateral   convulsions 

in ] 

Epilepsy,  Jacksonian,  local- 
izing signs 

-  jactitations  in  . .         . .   ] 

-  laryngeal    spasm    repre- 

senting . .  . .    ', 

-  lassitude'  after  . .  . .   ] 

-  loss  ot  consciousness  in 

of  reflexes  during  fit. .    ] 

Epilepsy,  major,  account  of 

typical  . .   I 

-  mania  after        . .  . .   1 

-  medico-legal  aspects  of 
Epilepsy,  memory  changes 


tn 


21 


. .   436 

-  muiry  lo.  ^liock  from  ..    765 
Epigastrium,    organs  con- 
tained in  . .  660 

-  pain  in  (see  Pain  in  the 

Epigastrium) 

-  pulsatile  tumour  in      . .   437 

-  pulsation  in,  from  large 

heart 206 

-  stomach  seen  in  . .  G60 

-  succussion  in     . .         . .  660 

-  tenderness  in(see  Tender- 

ness in  Epigastrium) 

-  tumour  in  (see  Swelling 

in   Epigastrium) 

-  visible  peristalsis  in 

-  sense   of   weight   in,    ir 

gastritis 
Epiglottis,  tuberculous  ul- 


660 


. .   55: 


293 
742 


219 
219 


testis, 


Endothelioma 
notes  on 
-  vulval  swelling  from  . .   700 

Endothrix 248 

Enema,  barium,  in  dia- 
gnosing spastic  con- 
stipation . .  . .  -^sr. 
Enema,  barium,  technique 


Eosinophilia.  list  of  causes 

of  218.  219 

-  parasites  26,  33,  109 
219,    405,    464,     519 


>of. 
Epiguaniu,  uric  acid  fi"i 
Epilepsia  media    . .         . .  145 
Epilepsy,  absentmindedness 
in         ....         . .  136 

-  albuminuria  in  . .      144.  140 

-  aphasia  an  expression  of  626 

-  apncea  in  . .  . .     8-5 

-  asphyxia  in        . .  . .    1 45 

-  atlietosis  .associated  with  132 
145 


-  myoclonic 

-  objects  varying  in  size  in  76: 

-  palpitation" from        484,  48i 

-  parageustia  in   . .  . .   70J 

-  partial nj 

-  paver  nocturnus  and   . ,   32! 

-  from  ptumbism. .  . ,     3*: 

-  polyuria  from    . .  . .    53; 

-  priapism  from   . .  . .   53f 

-  pupils  immobile  i 
dilated  from  . . 

-  purpura  in  . .  . .    554 

-  pyrexia  in  , .  . .    144 

-  rigidity  of  face  in  . .    72J! 

-  rigor  simulated  by        . .   594 

-  simulated  by  apoplexy     (48 

eclampsia        . .         *. .    146 

in  heart  disease        . .   14fi 

lung  disease  . .         . .   146 

Epilepsy,     simulated     by 

malingerer  137.  (47 

Stokes-Adams's  disease 

140,  540.  54H 
uraemia  . .         . .   146 

-  sleepiness  after  . .         . .   143 

-  smel!  aura  in    . .         . .  ol2 

-  stertor  in  . .  . .     85 

-  stupor  after        . .  . .     85 

-  taste  aura  in     . .  . .    705 

-  tetanoid  . .         . .         . .   145 

-  tongue  bitten  in       594,  098 

-  urine  passed  during  143,  594 

-  vertigo  in  . .  . .   752 


vomiting  due  to 
—  voluntary  suppresi 
attackin 


..  220 


21,  729 
;i,   729 


-  til. 


I  of 


Of 


nth. 


125 


Epicritic  sensibility 
Epidemic  cervical  adenitl< 
general  account  of  . 

sore  throat  in 

-  diarrhrea 


nfe.-ti' 
if1]i 


dysche^i.j  ii_.ii.  ;  l,|  J..^ 
erythema  from.,       222 
fcecal  accumulations  re- 
moved by       . .  . .   , 
ileociEcal  valve  passed  by 
{Fig.2H2-)       .. 


-  of  t«tauy 

-  trichinosis 
Epidermolysis 

bullse  in 


Epilepsy,  aura  in,  varieties    67 

-  automatism  after        20,  144 

-  Babinski's  sign  in         . .     69 

-  bradypncea  in   . .         84,  85 

-  bromide  in  diagnosing. .  535 

-  bruising  in  . .  . .   554 

-  from   cerebral  embolism  133 

-  clonus  in  ..  ..137 

-  coma  in  . .         117,  144,  145 

-  convulsions  in  OS,  137,  143, 

144,  145,   146.  148 

-  deafness  from    . ,  . .   166 

-  defalcation  during  fit  . .   143 

-  dementia  from  . ."         . .     20 

-  enuresis  from     . .  . .   218 

-  family  history  aud       . .   145 

-  flushing  in     *    . .  , .   241 

-  foamirii:  at  mouth  hi    .  .    145  , 
~  hands  in. .  . .  . .   147 


Epileptiform  neuralgia 
EPIPHORA 

-  in  facial  paralysis 
Epiphyses,  large,  in  rickets  635 
Epiphysis,  separated  . .  093 
in  congenital  syphilis 

348,  670 

paralysis  of  limb  from  :i4S 

Epiphysitis,      from      con- 
genital syphilis         . .  ouli 

-  in  infants  . .  . .   609 

-  limping  from     . .      362,  363 

-  pain  in  the  leg  from       . .   670 

-  paralysis  simulated  by. .  070 
Episarkin,  uric  acid  from. .  742 
Epispadias,    urine    stream 

changes  from  . .   304 

EPISTAXIS  ..220 

-  in  acute  vellow  atrophy 

273,  333 

-  age  incidence  of  . .  221 

-  anemia  from     . .  . .     32 

-  blood-spitting  from  .  .  285 
Epistaxis,  causes  of      220.  221 


EPISTAXIS 


EXCITEMENT 


tisiaxis,  confd. 

in  chronic  alcoholism  . .  'il 

-  nephritis   11,   76,  2i'l,  2G(J 

in  cirrhosis  51,  220,  26C,  635 
common    site    of    ulcer 

causing            . .          . .  221 
concealed            . .          . .  221 
in  familial  acholuric  jaun- 
dice       332 

Enllne=s  in  head  relieved 

t-v        221 

''  -■■     ■■  Miesis  from   265,  2C6 

.M.jiliilia   ..      221,  273 

I  i.  ;.'■  n  -  purpura         . .  76 

auJ^;vni'o  disease         ..  274 

iuteriiul  carotid  erosion  421 

in  leukaemia       . .        25,  221 

relap^in?  fever  ..         ..  336 

^r?r]f'   fpver      220,  221,  273 

"'  f:nL'  haimatemesis  221 


iof 


diagnosing 
igalic    poly- 


221 


in    splei 

cythiemia 
tinnitus  relieved  by  . .  221 
in  typhoid  fever  76,  221,  636 
vicarious     menstruation 

and 221 

lithelial  casts     . .  . .       6 

Mils,  similarity  of  renal, 

teral,    and    vesical  575 


-  renal,  in  chylu 


. .  109 
9,  10 


-  in  acute  nephritis 

-  from  bacteriuria       . .     70 

-  from  calculus  . .    117 
ithelioma    (see    Carcin- 
oma) 

idenoides  oysticum      . .  733 
Jisli.iction  from  rodent 
nl.x-r 179 

ithelioma,  general  notes 

on  ..     730,  731 

ifrn,hlr-:n-  cliinds  (see 
I  I'lliiticGlandSjEpi- 
..    ■  h.ir) 

ling  gums  from     72 

LJ  IS    hbrous        ..       671,  884 

.1  ..  ..    672 

■  I";  in  diagnosuig     74 

•   from   . .  . .   542 

uihbnum.  mechanism  of 


otism,  dead  fingers  in. ,  1G2 


i  IV  disease  simu- 
I  .;-i   hv         ..  ..  259 

roni  ryo'  ..  ..259 

ctany  from      . .  . .  151 

jsion  of  bone,  by  aneur- 
ysm  431,  4*83,  516, 

693,   713,    77(1 

•  in  Kaposi's  disease  ..  732 

•  by  rodent  ulcer       ..   735 
rervicftl,  backache  from  46S 

-  charatrtcr  of  dischartre 

from  . .  . .   1  Kf) 


Eructations,  conid. 

-  with  intestinal  colic     . .  ■ 

-  rapidly    repeated,   aero- 

phagy  indicated  by  . .   : 
Erysipelas,  albuminuria  in 

-  bacteriological  diagnosis  - 

-  baldness  from    . .  ' 

-  bathing  -  drawers      area 

affected  by    . .  . .  ' 

-  bullae  in  . .  96,  98,  ) 

-  diazo-reaction  in  . .   ] 

-  dilatation  of  heart  in    . .   : 

-  of  ear : 

-  endocarditis  with 

-  erythema  in       . .  . .  1 
simplex  simulating  . .  : 

-  of  face    . .  . .  . .  ( 

-  gangrene  from  . .         . .  : 

-  hyperpyrexia  in  . .  l 

-  leucocytosis  with  ..   ; 

-  lupus         erythematosus 

simulating      . .  . .   1 

-  meningitis  from  . .  i 

-  oedema  from     . .     413,  4 

-  pvrexia   in  98,  567,  I 

-  rigor  in  . .         594,  5D5,  ( 

-  from  a  scratch  . .  . .  i 

-  simulated    in    angioneu- 

rotic cedema  . .  . .  ! 
Meige's  disease         . .  5 

-  sloughing  from  . .  . .  ( 

-  spleen  enlarged  in    632,  ( 

-  streptococci  in  . . 

-  stridor  from       . .  . .   ( 

-  temperature     chart     in 

iFig.  245)       . . 

-  tenderness  of  scalp  from  * 

-  toxaemia  in        . .  . .  * 

-  urticaria  simulating     . .   '» 

-  weak  first  sound  in      . .  i 
ERYTHEMA  .2 

-  i)cute  febrile      . .  . .  I 

-  in  acute  rheumatism  . .  I 

-  in  atigioneurotic  uedema  -"j 

-  from  arsenic      . ,  . .  2 

-  urtefaetum         . .         . .  S 

-  from  atoxyl       . .  . .   2 

-  bromides 

-  bullosum,  acute  cedema 

of  tongue  from         . .  C 

bleeding  gums  with  . . 

bullje  in  . .         96, 

colon  atfected  by 

dysphagia  from         . .   1 

-   -  eosinophilia  in         99,  i 
Erythema  bullosum,  general 
account  of 

-  -  nioutli  iilTcctcd  by    .. 

\  iL'iii:!  iilTected  by  . . 
in   ( trrl.ruspiual  menin- 
-iti^      ..  ..      225,  t 

Erythema,  classified  causes 

of         .-.  222.  2 

-  from  copaiba      . .  . .  :: 

-  i[i  dengue  . .      225,  1 

-  dermatitis  herpetiformis 

98,  710,  7 

-  eczema    . .         602,  754,  7 

-  after  cneniata     ..  . .  I: 

Erythema     exfoliatlvum. 
neneral  account  of  223,  2 


r«>r     ..I     refraction 

ir.fri.-iinn.  Krro 

jctacio  nervosa.. 

I'l  itiMiiv.     acid, 


1'  utc     dilatation 


?x[>Iu>ive,     after 

water,  ct<^.     . . 

Vom  gastritis    . , 


of 

-  in  (icrtnan  measles      ..  ; 

-  gestationis 

-  in  lierp''^  •  •  -  •  ' 

-  from  herpes  progcnitalis  ' 

-  hydatid  disease  . .  '. 

-  ab  igne ; 

-  in  impetigo        . .  . .  I 

Erythema  Induratum  scro- 
futosorum  . .  ' 

~    -    l.il.(T.'iil..n.    ;Ln.|         ..     ■ 


froi 


)dides 


J.njihnna  iri.s,  a>„hl. 

Erythema  iris,  general  ac- 
count of 

vesicles  in 

-  intertrigo,  bathing-draw- 

ers area  affected  by  . . 

-  itching  in  . .      "    . .    , 
Erythema,  Jacquet's  infan- 


tile 


Erythema  in  leprosy 

-  in  malaria 

-  measles  . . 

-  Aieige's  disease  . . 
■  -  multifornip 


..    404 
225,  3S3 


latir 


. .   4S 


small-pox  simulated      o^V- 

strophulus  sunulating  is;* 

urticaria  simulating..  4Sit 

vesicles  in       . .      227,  756 

-  from  neosalvarsan        . .  224 

-  nodosum  in  acute  rheu- 

matism 105.  228,  614 

age  and  sex  incidence  404 

Bazin's  disease  distin- 
guished from         . .  404 
bilateral  character    . .   401 


401 


Erythema  nodosum,  general 
account  of  ■■  404 

leprosy  simulating  4U3,  -104 

limping  from..  ..   362 

multiple  swellings  with  668 

osteomyelitis  sunulated 

by    . .  . .       404,  668 

pains  in  joints  in     ..  404 

pyrexia  in      . .         . .  404 

shins  affected  by      . .   668 

successive  crops  of    . .  404 

no  ulceration  with    . .  404 

-  papulatum         . .         . .  489 
from  parasites  . .  226 

-  with  peliosis  rheumatica  556 

-  in  pellagra         . .      162,  226 

-  ~  (PlaJc  X)        . .  . .   228 

-  from  polymyositis        ..  464 
ptomaine  poisoning     . .  224 


radii 


I  ratbite  fever. 


-  frci 


224 


I  Erythema      scarlatiforme. 

general  account  of  223,227 

:  -  -  scale;,  m  . .  . .   602 

I  -  in  scarlet  fever  ..  ..  614 
I  -  from  sea-cata  . .  . .  224 
j  -  in  sehorrhceic  dermatitis  401 
I  --  from  MTUni  injections  . .    223 

-  ^impl.-v 223 

erysipelas  simulating      227 

'  Erythema  simplex,  oonera! 

account  of     . .     227,  228 

j leprosy  sinuilating    . .  383 

I  -  -  scales  in         ..  ..  602 

I scarlet  fever  simulated  227 

I  -  in  small-pox      . .         . .  6G1 

-  from  sodium  cacodylftto  224 

-  from  strawberries  . .  220 

-  tape-worm         . .  . .  226 

-  toxHimia             . .  . .  220 

-  trade       . .         . .  . .  22-1 

-  trypanosomiasis  ..  226 

-  vacciniforni,  of  infants..  401 

-  ve>>iru!ar.  perli^cho  with  30fi 

-  vrsienloHUUi        . .  . .  756 

-  from  weever-flsh  . .  224   , 


Crythriemla 

Ki  \  tt.r:i>iua,ljii(hing-dniw- 
-IS  ;.rea  affected  by  .. 

Erythrasma,  general  ac- 
count of 

Erythrocythtemia 


Erythromelalgia,  age  inci- 
I  dence  of        . .         . .  ' 

-  in    apparently    healthy 

persons       '   . .         .",  ^ 

-  cold  relieving    . .         . .  ' 

-  in  disseminated  sclerosis  ' 

-  ergotism  simulating     . .  I 

-  erythema*  in       . .  . ,   ! 

-  Hushing  of  feet  in        ..  < 

-  gansrene  from  . .      255,  ! 

Erythromelalgia,  general 
account  of  ..  ' 

-  intlucnce  of  jiosture  on.  . 

Erythromelalgia.  intermit- 
tent claudication  differ- 
entiated from  . .   i 


. .   22.1 

-  -  in  ■■i.-ur.-  rhcinii;iti.^m      lUo 

Erythema  multiforme, 

general  account  of    . .  489 

-  -  le:.ioiis  ul        .  .  . .    4S;t 

parts  affected  by    489,  562  I 

pityriasis  rubra"  after    604  I 

prurigo  simplex 


Erythromelalgia.  Raynaud's 
disease  differentiated 
from    . .  . .  44-1 

-  sex  incidence  of  . .    11] 

-  in  s3T:ingomyelia  ..    141 

-  tabes  dorsalis    . .  . .    Ill 
Erythropsla            . .  . .  762 
!-(:■.   ni  vanilla.  derma- 
Essential  albuminuria      ..     15 

Essential  hsematuria,  general 
account  of  ..281 

-  leucocytosis  from  .  .  36(f 
Esthiomene,  syphilis  and     70! 

-  vulval  swelling  from  ..  699 
Estimation  of  nlkapton  by 

silver  nitrate. .  , .   746 

Estimation  of  surar  ..  263 
Estimation  of  tttal  acidity 

of  gastric  contents   . .  320 


I'lU'rr 


dis- 


touhfd    in 

-  luemoglobinuria  from..   284 

-  headache  from  . .         . .  29S 

-  leucnpenia  from  ..   361 

-  in  .ir.MiIl    ti!.,rHl   U^M        ..    171 

-  l.n'i|.lMK,l   N.fuiiK  from  _^61 

Ethri.ni^lal      ,.ir      irlis      (s'ec 

Sinus.   i-Uiiniuidal) 
Eucalyptus,    sore    fingers 

from    . .  . ,  . .   23'.i 

Eunuchs,  obesity  in        . .  409 
Eustachian  tube,  adenoids 

obstructed,      deafness 

from    ..  ..  ..   165 

in  syphilis      . .         . .  166 

Exanthematn   (see  Fevers, 

Acute) 
Exercise,  anaemia  and      . .  487 

-  deficient,  biliousness  and  526 

-  -  obesity  from  . .      408,  485 
uric  acid  and. .         . .  742 

-  effect  on  albumimiria  . .     15 
aortic  regurgitant 

brnit  ..         ..  485 

pulsc-rnto       . .         . .     88 

renal   calculus  . .   39 1 

-  hff^maturia  after  . .  280 

-  intermittent  claudication 

and      . .  . .  . .   441 

'  irregular     heart     mado 

regular  by      . .         . .     8S 

-  palpitations  and  ..   4K7 

-  jiulse-ratp  and  485.    1S6.  701 

-  pyrexia  from     ..         ..  571 
~  rheumatism  relieved  by  466 

-  urine  amount  and         ..   634 

-  violent,  opistaxi.**  from..  220 
Excitability,    in    Graves's 

disease  . .      215,  722 

-  of  nuiscles,  increased  in 

tetany  . .  . .    152 

Excllntion.     irascible,  in 

myxu-deina  . .  . .  119 
Excitement,  arrhythmia  of 

heart  and       . .  . .  545 

-  dlarrlnra  from  ..  ..'173 

-  after  epileptic  III  ..    143 

-  insnnuifu  from  . .  . .   320 
-  nightmare  from  ..   402 

-  ]iaro\ysnnil     hieiiutglo- 

lilMiiriii  from  . .  28S 

~  precordial  pain  from    . .  433 

-  pulse  rapid  from  549,  702.  7l»4 

-  pyrexia  from      . .  . .    573 


EXCORIATION   OF  LIP 


FACIES   OF    ACROMEGALY 


Excoriation  of  lip,  in  nasal 
iliphtheria 

-  nose,  in  nasal  diphtheria 
Exertion,    an^iua   pectoris 

caused  by      316,  433, 

-  ijrachial     neuralgia     in- 

creased by 

-  excessive,    hfemoglobin- 

-  pain   in   eipgastrium  in- 

creased by     . . 

-  precordial  pain  on 
Exhaustion,  with    liepato- 

ptosis  . . 

-  liypothermia  from     571, 

-  impotence  from 

-  insomnia  from  .  .      321, 
Exhaustion  during  labour, 

signs  of 

-  in  malaria 

-  myasthenia 
icalized    con- 


fro 


fron 


EXOPHTHALMOS 

—  frooi  aneurysm..       2: 

-  cavernous  sinus  thi-o 


f>97 


~  distended  nasal  sinus  229,  230 
~  encephalocele    . .         . .  229 

-  epiphora  from    . .         . .  220 

-  from  exostosis  . .  . .   221) 

-  in  Graves's  disease,  215, 

220,229,236,486,703, 

722,  726,  734 

-  from  gumma     . .  . .  229 

-  intermittent,  from  vari- 

cose veins      . .  . .   230 

~  from  meningocele         . .   229 
~  myopathy  . .  . .   235 

-  new  growtli        . .  . .   229 

-  orbital  cellulitis. .  ..   229 

-  pulsating,  from  aneurysm  230 
~  from  thrombosed  cavern- 
ous sinus        ..  ..229 

-  tubercle  in  orbit  . .    229 

-  tumour  of  orbit  . .   220 

-  ulcer  of  cornea  from    . .   734 

-  unilateral,  from  exostosis  671 
Exostoses,  from  arthritis . .   143 

-  bursa  over       . .  . .  670 

-  cartilage  cap  on  . .  670 

-  family  history  of         . ,  693 

-  of  femur  (SUfj.  2S1)  670,  692 

-  ivory,  exophthahiiosfrom671 

of  frontal  bone      204,  23U 

skull 671 

-  multiple  hereditary      . .  671 

-  orbital,       exophthalmos 

from    . .         . .         . .  229 

-  ar-rays  in  diagnosing  204,  671 
Expiration,   prolonged,  in 

emphysema    . .     167,  217 

phthisis  . .         . .   288 

Exploratory     needling     of 

chest  (see  Keedliug) 
Explosives,     liigh,     acute 

yellow  atrophy  fi-om     334 
Exposm-e,     hypothermia 

from    . .         . .      311,  571 
Extensor  brevis  digitorum, 

nerve  supply  of        . .  498 
pollicis,  nerve  supply  505 

-  carpi    radialis    brevior, 

nerve  supply  of        . .   505 
longior,  nerve  supply  505  | 

-  -  ulnaris,  nerve  supply  of  505  I 

-  communis    digitorum, 

nerve  supply  of     499,  505 
r61c  in  claw-hand  . .  109  ' 

-  hallucis,  nerve  supply  of  499 

-  indicis,  nerve  supply  of    505 

-  lougus  digitorum,  nerve 

supply  of       . .         . .  49S 

hallucis.  liTTpertrophied 

in   Pcicdreich's  dis-  ; 


Extensor,  contd. 
~  plantar  reflex  (see  Plan- 
tar Reflex) 

-  proprius   hallucLs,   nerve 

supply  of        . .  . .   49S 

External  auditory  meatus, 
lesions  of  . .  422 

-  cutan.'.iu-  n,T\..  p., ill  ill  439 

-  plaiit;ir   u.^^•■      ..  ..498 


-  rectus,  paralysis  01    176, 

177,  493 
Extract,    pancreatic       . .  191 
Extragenital  chancre  f^Fig. 
23)  73,  240,  379,  381, 

615,  739 
Extrasystoles,   arrhytlmiia 

from    . .  . .  . .   545 

-  auricular,  in  mitral  sten- 

osis       547 

-  auscultatory  phenomeua 

with 547 

-  from  :■ -^■■.    -,I.  iM^is     547 

.-  '■nrv-  ^'  ..  .  /■   ■    j:;i)  544 

-  ^Ii-npi.,  ..   547 
Extrasystoles.    general   ac- 
count of                    . .  547 

-  heart-block  simulated  by 

546,  547 
--irregular  pulse  from    ..   549  ' 

-  .Murki'jizi..'  on     ..  ..    547    I 

Extrasystoles.      need      for 

graphic  tracings  in  dia- 
gnosing . .  547 

-  irom  nervousness         . .   547 

-  polygraph  tracing  of  {Fig. 

234) 547 

-  pulse  with  . .  . .   547 

-  pulsus    bige 


phobiu) 

Eye,  physiological  cup  of..  415 

-  prickniL'.    from    wvor    of 

refraction         .  .  . .    295 

Eye,  rodent  ulcer  of       . .  734 

-  running  at  (see  Coryza) 

-  sarcoma  of         . .  . .   252 

-  shifty,  of  drug-taker    . .   234 

-  ulceration  of  (see  Ulcera- 

tion of  the  Cornea) 

-  watering,  fi-om  error  of 

refraction       . .         . .   295 
Eyeball,    fixed,    from   ab- 
scess in  orbit  . .   177 

growth  in  orbit        . .  177 

hiemorrhage  into  orbit  177 


of 


754 


Ext^a^ 


poll  it 


..140 
ssupply  of  505 


supply  of       . .  . .   ; 

-  ossis.  metacarpi  pollicis, 
escape      in      plumbic 


-  of  uniir. 

Extroversi( 

EYES.    ACUTE    INFLAM-' 
MATION   OF  -  .231 

-  -    ul   U-'"l.s  M.  .V//) 

•J3n,   232 

-  almon.l-^liapc-d.  in  Mon- 

golism ..  ..238 

EYES,     BLACK     SPECKS 
BEFORE  ..     71 

-  blue,  psoriasis  and       . .   003 

-  burning,   from   error  of 

refraction        . .  .,   295 

Eye,  choroid  coloboma  of    415 

-  rlnHML'      nf.      ;,,;,vv      rxbi- 

i'lrr,!  <.,,  .".  -„j,  57 

Eye.  congenital  crescents  in  415 

-  conjugate    deviation     of  118 

-  deformed,  by  exostosis    204 

-  difficulty    in    closing   in 

myopathy       . .  . .   235 

-  ilischarge  from  . .  . .    761 

-  displaced,    iu    hydroce- 

phalus..        ..         ..  205 

-  embolism  of  (see  Embol- 

ism, Retinal) 

-  feeling  of  grit  1 

conjunctivitis 

-  foreign     body 

Foreign  Body  ...  . 

-  herpes  of,  pain"  from  '. .'  445 

-  infarction  of  (see  Embol- 

ism, Retinal) 

-  inflamed,  from  conjuncti- 

vitis      231 

glaucoma        . .  . ,   23'! 

iritis    . .  . .  . .   ^31 

-  injury    of,    photophobia 

pupil  irregular  after. .  551 

-  melanotic    sarcoma    of, 

(see  Sarcoma) 
Eye,  myopic  crescent  in  ..  416 

-  nerve    connections    of 

(Fiff.  138)       . .  . .   300 

-  oblique,  in  Mongolism  ..   237 

-  ochronosis      of      (Plafe 

AXXirrt       ..  ..   74G 

-  opacities  in,  in  congenital 

^vpbiii'^  ..         ..   -2?,:, 

Eye,  opaque  nerve  fibres  in  416 


EYEBALL.  RETRACTION 

OF  THE         ..217 

Krc-hrows.     defective,     in 

mj'xoedema    . .       234,  409 

-  eczema  seborrhceicum  of  491 

-  overhanging       . .  . .   203 

-  sycosis  aftecting  . .   558 
f^  il.i-li'-.  ["-'liL'ulosispubis 

.■!l-'im-  ..  ..401 

I'A  I'lhU,  jh-fiire  of  hair  011     71 

-  ;in;.'cioneurotic  oedema  of 

411,  (ii'ty.  178)  412 

-  chancre  of  . .  . .   379 

-  cliromidrosis  of  . ,   654 

-  drooping,  in  myasthenia  235 

-  epithelioma  of  . .  . .   378 

-  tedema  of  (see  Oedema) 

-  pigmentation    of,    in 

Graves's  disease    215,  23G 

-  puffy,  in  myxoedema  . .   234 

-  quivering  of,  in  hysteria  137 

-  -  malint't-ririg    ..'         ..137 

-  red.frutr,  ,■,;,,  ,„,ii-  -mus 


tin 
-  chr 


-  .    229 
H  231 


-  Jrtitching      together     of, 

in   treatment  ..    734 

Eyelids,  xanthelasma  of  . .  324 

-  .xanthoma  of      . .  . .    732 
Eyestrain,  from  astigmat- 

-  close  work  . .  . .    524 

-  oi-ror  of  refraction      146,  525 
Eyestrain,  general  account 

of        446 

-  irlaucoma  from  . .         . .    232 

-  headache  from  . .       294,  296 

-  from  hypermetropia     , .   524 

-  occupations  causing     . .   524 

-  pain  in  the  eyes  from  . .   446 

-  ph0t0phiih|:i     IJ-nlii  .         :,!'  | 

Eye-ten.iMM.       .Innini^i,,.,!. 

from  !>:ir.ll\  -I-  nl  ,  i-i  \  I- 


from 


231 


I  Eye) 


actii 


736 


Face,  coiad. 

-  dysidrosis  of      . .         . .   ; 

-  endothelioma  invadin-     1 

-  enlarged,  in'  acromegalr  (3 

-  epilepsy  confined  to     .'.  i 

-  epithelioma  of  . .         . .  G 

-  erysipelas  of      . .  . .   (j 

-  erythema  multiforme  af- 

fecting . .         , .  4 

-  fibroma  of  . .         . .  e 

-  flush  area  of      . .  . .   2. 

-  flushed,  in  diabetes      . .  2 
yellow  fever  . .  . .  2 

-  flushing  of  (see  Flushing) 

-  gumma  of         . .         . .  5. 

-  habit  tic  of       . .  . .   l, 

-  haematidrosis  of  . .  6. 

-  healed  gumma  of  (Fin 

227)  ..      ..      :.  5 

-  hemiatrophy      of       61 

iFig,  202)  4; 

-  Henoch  s  purpura  affect- 

ing (^Fig.  157)  . .  3< 

-  herpes  of  . .         . .  ?{ 

-  hysterical  spasm  of      . .  4! 

-  impetigo  affecting        . .  g( 

-  leprosy  erythema  of     . .  3i 

-  lichen  scrophulosorum  of  41 
Face,  lupus  of                . .  7^ 
erythematosus    affect- 
ing  ..          ..      247,  6( 

-  meningocele     proiecting 

into      . .        {Fig.  102)  2J 

-  miliaria  of         ..  . .  7S 

-  multiple  benign  sarcoid 

affecting         . .  . ,   4C 

-  myoclonus  of    . .  . .  13 

-  myopathy  of     . .  . .  5| 

-  ochronosis      of  (Pluu 

XXXIID      ..  ..74 

-  redema  of  (see  CEdema) 

-  pain  in  (see  Pain  in  tlie 

Face) 

-  paralysis  of  (see  I'aralv- 

sis,   Facial) 
Face,     pellagra    affecting 
{Plate  IX)     ..  .22 

-  I>emphigus    neonatorum 

affecting         . .  . .   40 

-  i»igmentation  of  (and  see 

Pigmentation    of    the 
Skin) 52 

-  pityriasis  rosea  affecting  60 

-  prurigo  affecting  . .   48! 

-  puffiness  of,  in  nephriti>     4' 

-  rigidity  of,  in  epilepsy  . .    731 
meningitis      . .      '    . .    72! 


Face,  rodent  ulcer  of    735.  731 

-  rosacea  affecting        241,  I81 

-  scarring     of,     ectropion 

from    . . 

-  sclcrodermia  affecting  . . 

<rl.;ir<.'OUS   cyst    of 

-<  iinirhcea  affecting     . . 
^^  n^nrr   areas   of   {Figs, 
is^,  189,  191) 

-  small,  in  anosteoplasia. . 

-  small-pox  affecting    561. 
subcutaneous        emphy- 


22( 


448 


.  of 


■iful 


from 


iFig.   178)       . 

-  asymmetry      of, 

facial  paralysis  ,  .   493 

with  torticollis  . .   142 

-'athetosis  of      131,  132, 

133,  493 

-  atrophy  of,  from  seventh 

nerve  paralysis         . .     C3 

-  bleeding  nsevi  of  (Plate 

XVIT)  ..  ..292 

-  bloated,  from  aspirin  . .  413 

-  bones    of,    enlarged,    in 

leontiasis  os; 

-  cliromidrosis  o 


670 


■poid 


of 


(Plale  XXXP) 
~  colloid  milium  of         . .  733 

-  contracture     of      (Figs. 

198-200)  . .  . .   492 
from  Bell's  palsy  140,  494 

-  cramps  in,  in  tetany    . .   151 

-  cyanosis  (see  Cyanosis) 


-  swelling     of    (and 

CEdema)         . .         . .  673 
from    vena   cava   ob- 
struction    . .      15S.  159 

-  sycosis  affectmg  . .    .'i.JS 

Face,  syphilis  of   209,  383. 

490,  5G0,  735 

-  s^Tingomyelia    affecting 

60S,  609 

-  tics  affecting     . .         . .   1 36 

-  tinea  versicolor  on       . .  i.'50 

-  tremor    of,    iu    general 

paralysis         . .  . .    1 4t; 

-  tumours  affectiuL'        . .  ';7;; 

-  ulceration  of      . .  , .   7:;"p 
Face,  unilateral  sweating  of  654 


FACIES.      ABNORMALI- 
TIES OF 
Fades    in    achondroplasia 


FACIES    —    FEET 


'aci^s,   confd. 
bloated  from  aueurysm  : 

-  from  aspirin  . .  . .   ■ 

-  vena     cava     superior 

obstruction  . .  : 

in  catalepsy       . .  . .  ; 

chronic  alcoholic  . .  : 

in  colic  . .  . .  . .   ; 

acies,  congenital  syphilitic  I 
congested,    from    mitral 

regurgitation  .  .    : 

acies  of  cretinism     is;*, 

(Fig.  S8)  ; 
expressionless,  in  paraly- 
sis agitans     . .  . .  • 

in     familial       acholuric 
jaundice  . .  . .   ( 

(PMfe  xvirr)  .. 

acies.  in  familial  lenticu- 
lar degeneration        . .  '. 


duo- 


fceccs,  coiitd. 

-  esaminatiou  of, 

denal  ulcer     . . 

-  fat  in,  in  chronic  pan- 

creatitis . .         . .  : 
jaundice         . .         . .  : 

-  fats  in 

-  fatty        

iridescent,  from    pan- 
creatic disease       . .  : 

-  flukes  in : 

-  gall-stone  in      . .      IIG,  : 

-  hard,  dyschezia  from  . . 

-  impacted,  age  incidence 


l;ir  -clero^i--     .  .  .  .    L'3 

acies,  in  Graves's  disease 

(Fig.  113)       ..  ..    '2Z 

hippocratica,  from  peri- 
tonitis.. ..      3SS,  59 
in  leontiasis  ossea        . .   2U 
mitral  stptiosi^  . .  . .     5 
acies  in  Mongolian  idiocy 

{/•■",<.  118,119)23 
acies,  myasthenic  ■■  23 
acies.    myopathic    (Figs. 

109.  110)  23 
acies,     myxoedematous 

(Fig.  ir.)  38,  23 

in       ochronosis      {Pfate 

XX  XI 1 1)       ..  ..74 

acies  of  paralysis  agitans 

(Fig.  114)  236,  72 
peach -blossom,  in  scarlet 

fever    . .  . .  . .   22 

in  pellagra  (Plate  IX)  . .  22 
pigmented,  with  uterine 

lesions. .         . .         . .     9 

rat-like,  in  microcephaly  18 
in  risus  sardonicus  . .  59 
rubicund,  from  alcohol  3 
sallow     pigmented,     in 

cirrhosis         . .         . .     0 
senile,     in     congenital 

syphilis  . .  . .  40 

in  seventh  nerve  paralv- 

Kis         . .  . .  1 .    10 

iacles     in    splenomegalic 
polycythsemla  . .  53 

(I'lah-  XXIX)  63 
s*)u;ire,  ill  acromegaly  ..   23 
starcliy,       in       pseudo- 
bulbar palsy  . .  ..  G2 

in  strychnine  poisoning  5? 
tetanus   . .         . .  . .  58 

tecal  vomiting  (see  Vomit- 

inc,  l'*iecftl) 
tofes  (and  see  Stools) 
abdominal  swelling  from  07 
accumulation  of,  in  colon  tic 

-  movable  kidney  simu- 

lated by      .*.         ..  fiC 

-  eneinata  in  diagnosing  'iZ 
aces,  accumulated,  notes 

on       63 

-  obstruction   from      ..   (ivl 

-  pain  inhypochondriutn-l.'i 
acid,  from  fermentation  21 

-  pancreatic  disease  , .  IC 
alkaline,  with  gall-^tonn 

obstruction     ..  . .    IC 

inn.-fuctlon  ..         ..24 

1      I     of,  CammidgeV 
t       lion  and  ..         ..  1^ 

hloo.l  and  mucus  in  (se*- 
Stools,  Itlood  and 
MUCU.S  in) 

bul>bly,  from  fermenta- 
tion     . .  . .  . .   24 

ciny-colourcd     . .      321,  32 

in  colon,  swelling  in 
hypochondrium  from    Ci 

dry  nnd  hard,  from 
deficient  water  intake 

121,  12 

-  -  in  diabetes  121,  I'J 
in  hot  woatiier      . .  li 

■ obstruction  due  to    I'J 

enema  In  diagnosing  tu- 
mour due  to  . .  . .  CI 
It 


of 


simulated 

by    ..  ..      453, 

diarrhcea  from 

enemata  in  diagnosing 

felt  per  rectum 

intestinal    obstruction 

from 
pain  in  left  iliac  fossa 

from 
rectal  examination  in 

diagnosing  . . 
swelling  in  right  iliac 

fossa  from  . . 
tenesmus  from 

-  incontinence       of      (see 

Incontinence  of  Faeces) 

-  keratin  particles  in 

-  lead  in    . .         . .        73, 

-  meat  flbres  in,  in  chronic 

pancreatitis    . . 

fragments  in,  in  putre- 
faction 

Fseces.  microscopical  ex- 
amination of  ■ . 

i'l  parior-fatitis 

-  mucus  ana  Mood  in  (see 

8tuol=,       IMood      and 
Mucus  in) 

-  muscle    flbres   in,    from 

hitcstinal  putrefaction 
pancreatic  disease.. 

-  occult  blood  in.. 
with    carcinoma   of 

the  pancreas     . . 

duodenal  ulcer 

gastric  ulcer 

pancreatitis 

-  offensive,  in  jaundice  . . 

-  ova  in     . .         . .      226, 

-  of  ankylostomura  in    . . 
ascaris  in 

distoma  in     . . 

-  pnlpnhlf  in  =irmoid  colon 


FvECES      PASSED       PER  ' 
URETHRAM  ..  J 

irorn  i..r.iiioiiia  recti  i 

ry-Tiri-^  siimdating     '. 

FsBces  passed  per  urethram, 

list  of  causes  of        . .  ' 
pi.fuinalnria   with      1 

-  ribbon-like,  from  carcin- 

oma recti 

Fnces.  simulatino.  kidney  : 

enlarged  liver  . .   '. 

spleen         ..         ..  ( 

-  small    in    amoun^    yet 

normal  . .         . .  1 

-  starch     cells     in,    from 

carbohydrate  ferment- 
ation    '. 

-  stercobilin  absent  from, 

in  carcinoma  of  pnn- 

-  tryplic  activity  of        ..  '. 

-  tubercle  bacilli  in  76,  385, ' 

-  tumours  simulated  by. .  • 

-  urobilin  in  . .         . .  ' 

-  vegetable  cells  in  . .  J 
rcsifluc   in,   with   fer- 
mentation . .         . .  : 

Fainting,  after  flusltfng  . .   \ 

-  attacks,     in     Addison's 

disease            . .         . .  J 
Faintness,  in  nngina  pec- 
toris      

-  from  aortic  rcgur^ritalion  '. 

-  arsenic    . .         . .         . .  '. 

-  cxtro-ulerino     gestation  '. 

-  fatty  heart         . .  . .  : 

-  luErantemcsIs     . .         . .  '. 

-  hepntoptowis      . .         .  -  I 


33, 


Faiiiiticss,  contd. 

-  movable  kidney 

-  paroxysmal   tachycardia 

-  preceding  hajmatemesis 

-  from  snake-bite. . 
Falls,  deafness  from 

-  on  head,  fractured  spine 

from    . . 

-  shoulder,     Erb's     palsy 

from    . . 

-  subacromial  bursitis  from 
Fallopian  canal,  lesion  in 

-  tube    affections,    pelvic 

swelling  due  to 

suppuration     in     (see 

Pyosalpinx) 

-  tubes,    absent,    sterility 

from    . . 

distended,     dyschezia 

from 
False  images 

Familial  acholuric  jaundice 

(PUUe  X  VIIl)  332, 

spleen  enlarged  in. . 

-  amaurotic  idiocy 

-  ataxy,  tremor  72 1,  727, 

-  constipation 

-  jaundice 
Familial  lenticular  degenera- 
tion      : 

-  merycism  . .  . .  ; 

-  over-weight        . .         . .  * 

-  tremor    . .  . .      734,  ' 
Family  history,  in  acholuric 

jaundice         . .         . .  ) 

acute  rheumatism  133, 

337,  4G4,  » 

angioneurotic    oedema  ( 

chorea  . .         . .  : 

congenital  sypliilis   . ,  i 

epilepsy  . .         . .  ; 

exostoses        . .         . .  i 

Friedreich's       disea.sG 

140,  i 
Gaucher's  disease     . .  i 

,  -  -  gout    . . 
bfemophilir 

' Hanot's  cirrhosis      . .  ; 

heart  disease . . 

; Huntingdon's    chorea 

-  -  Meige's  disease  . .  ■ 

myopathy       . .      509,  l 

paramyoclonus 

pavor  nocturnus       . .  ; 

-  -  phthisis  . .      104, 
pseudo  -  hypertrophic 

paralysis     . .         . .  i 

Quincke's  disease     . .  ■ 

retinitis  pigmentosa.. 

splenome^ralic  cirrhosis  i 

' Tooth's  ijcroneal  atro- 
phy 113,  512,  i 
'  Famine,  relapsing  fever  and 

33t;,  ) 

-  tvphus  fever  and         ..  ; 
I  Faradic  current.  In  muscle 

testing  ..  1 

'  Fascia!,   gonococcal    infec- 
tion of  ..         ..  ; 

Fastigium i 

Fat  hoy  of  I'eckhatn        . .  • 

-  boj-s,     hvpcniephroma 

and ,   ' 

pituitary  lesions  and    • 

-  dotieiency  of  rlcVeta  and  '. 

-  rlroptets,  stains  for      . .  '. 

-  in  fcpceu  . .         . .  , . 

In  jaundice     . .         . .  ; 

from  pancrc.^*  disease 

IIG,  172,  204,  : 

. Saponified      and     un- 

gnponlCed   . .         . .  : 

-  globules  hi  ascitic  fund 

fffices  . .         . .         . .   ] 

tube  costs 

•  -  indUrcstlon,   stools  with  ' 

-  nccroHis,   in   acute  pan- 

creatitis 1.11,  3K9,  < 
pancreatitis    . .      501,  ' 

-  ftubculAncous,   doflclent, 

in  tabes  . .         . .  : 

Fat-padfl  nbovo  clavlclcH  In 
cmtlnlKm        ..         ..  : 

-  In  myxii'dema  . .         . .  ; 
Fatigability,      undue,      In 

neurnstiienla  . .  . ,    > 

Fatigue,  dyspepHia  from.,  i 


Fatigue,  could. 

-  fibrillar  contractions  fi-om  ] 

-  haemoglobin  uria  from  . .  *. 

-  insomnia  from   . .         . .  i 

-  localized        convulsions 

from    . .         . .         . .  ] 

-  specks  before  eyes  in  . . 

-  tremor  from     724,  725,  'i 

-  twitching  from  . .  . .   ] 
Fatness,  myocardial  change 

associated  with 

-  in  pituitary  infantilism     1 

-  (and  see  Obesity) 
Fatty  casts 

-  change,  heart  large  from 

-  crystals,  in  stools         . .  ] 
from   pancreas  dis- 

-  degeneration     of     heart 
I  (.see  Heart,  Fatty) 

liver     in     phosphorus 

poisoning    . .         73,  J 
I  -  infiltration,  ascites  from 

of  bowel,  consiipatiou 

from  . .  . .    ] 

Fatty  liver,  general  account 


of 
325     FATTY  STOOLS 


.  239 

duudenuni  .  .          . .  'JZ'J 

[ ^  pancreas     ..       51,  23D 

I chronic  pancreatitis. .  239 

' jaundice         . .         . .  239 

-  superposition  of  heart  53 

-  tumour  (see  Lipoma) 

-  Fauces,  dermatitis   her-  ~ 

pntifortnis  affecting  . .  74 

-  cpiihclinmn   of  37 
,  -  ervtlu^nia  hullosnni  of. 


613 


G13 


Fauces,   inflamed,   general 

account  of  ..615 
sore  throat  from       . .  61 :! 

-  mucous  patches  on,   in 

syphilis  ..         ..618 

-  pemphigus  affecting     . .     74 

-  red  in  scarlet  fever      . .  227 

-  tuberculous  . .  . .  G13 
Favus,  achorion  Schonleinii 

causing  . .         . .   216 

-  alopecia    areata    distin-      "* 

guished  from. .         . .  247 

-  baldnei?s  from    .,         ,.     71 

-  crusts  in  . .         . .  60U 

-  diagnosis    obscured    hy 

treatment       ..         ..247 

-  eczema  distinguished  from247 
Favus,  general  account  of 

(Fig.  123)  246,  247 

-  hair  changes  from         . .   "JIT 

-  honey-comb  api)carani  c 

in         246 

-  lupus  erythematosus  sinui- 

lating  . .         . .         . .  247 

-  microscope  in  diagnosing  247 

-  mousy  smelt  of  . .         . .  246 

-  mucous  membrane  affected 

by        246 

-  mycelium  in       ..         .,  247 

-  nails  affected  by  247,  250,39!! 

-  preference  for  scalp      ..  246 

-  ringworm    distinguished 

from 241* 

-  seborrha>a  distingulslicd 

from 217 

-  simulating  psoriasis     ..  24  7 

-  sporen  In  ..         . .  247 

-  sulphur  4]iscs  of  . .  246 

-  tenderness  of  scalp  from  71u 
Fear,  amennnluiMi  from..  IS 
Febricnia.  i^ntcrlc  and     ..  461 

-  ga^l^n-into>^tirlal     upsel*. 

and 461 

Febrlcula.  general  account 
of        573 

-  mcuslcH  and        . .  . .    461 

-  pain  in  the  limbD  In  463,  161 

-  pneumorda  and  ..    16  1 

-  pulmonar}'    tulicrcTulosiw 

and 461 

-  rhi-umatiKm  and  ..  46  1 

-  scarlet  fever  and  . .  461 

-  Koro  throat  and. .  . .  461 
Fcot,  ncropaniwllintla  of. .  411 

-  nthelmlKof        ..         ..  ini 

-  hhin,  with  tiilipcM  ..  112 

-  hroati,  In  myxa'dema  . .  Ilu 

02 


818 


FEET    —    FINGER 


Feet^  conld. 

-  bromidi-osis  of  . .         . .  G54 

-  cheiropompholyx  of  600,  756 

-  cold,  insomnia" from     . .  322 

-  cyanosis  of         . .  . .   15G 

-  enlarged,  in  acromegaly 

204,  537,  685 

-  erythema   of,   from   ex- 

posure to  cold  . .   224 

multiforme  affecting     489 

nodosum  of    . .  . .   404 

-  flat  . .  186,  362,  438 

-  Hushing  of,  in  erytliro- 

melalgia         . .         . .  441 

-  gangrene  of,  in  syringo- 

myelia . ."         . .   257 

-  hsematidrosis  of  . .   655 

-  position  iu  tetany         . .       2 

-  pulmonary  osteo-arthro- 

pathy  of  {Fig.  1G5)  . .  351 

-  scabies  affecting  . .  563 

-  sore  on,  inflamed  inguinal 

glands  from  , .         . .  381 

-  sweating  in  acute  rheu- 

matoid arthritis        . .   342 

-  trench      . .  .  ,  . .   224 
Fehljng's  solution,  in  esti- 
mating sugar..         ..  263 

reduction  hy  alJcapton 

261,  746 

by  carbohiria         . .   746 

cerebrospinal  fluid 

178,  304 

creatinin      . .  . .   261 

after  drugs  157,  261 

by  glycuronic  acid    2G1 

homogentisic  acid..  746 

lactose        . .  . .  261 

pentose        . .  . .    261 

uric  acid  261,  743 

xauthiii        ,  .  . .   261 

Fehling'stest  ..261 

Femoral  artery  (see  Artery, 
Femoral) 

-  glands    (see   Lymphatic 

Glands,  Femoral) 

-  hernia  (see  Hernia,  Fe- 

moral) 

-  tlirombosis  (see  Tlurom- 

bosis) 
Femiu-,  epiphysitis  of,  limp- 
ing from         ..         ..363 

-  exostosis   of   {Fig.   281, 

p.  670)  692 

-  fractured   (see   Fracture 

'>f  Femur) 
'I    '  I"id  sarcoma  of     . .   672 
'.  I. -is  of 
1 -i.niiiyelitis  of,  limping 
irom    . . 

-  periostitis     of,     Imiping 


692 


363 


from 
popliteal  abscess  from  692 

-  sarcoma  of         . .      363,  692 

-  separated  epiphysis  of. .  093 

-  swelling   on,    in   scurvy 

rickets  . .  . .   670 

-  typhoi.I  u-n  II,-  Ml         ..    340 
Fen  disiM.  .    ,  fn  ,:,,,.   ,n..   G32 


Fenwick,  Jliir; 


753 


Fergusson's  speculum,  in 
examining  for  gono- 
cocci 185 

Fermentation,    acid    stool 

from 170 

-  in  estimation  of  sugar. .  263 
~  flatulence  from..         ..  241 

-  gastric,  stomach  dilated 

from    . .  . .  . .   241 

-  intestinal,     borborygmi 

«ith     ..  ..    '      ..      82 

-  '  cnrboln-.lr,-,!.-   :,rM]    ..      82 

Fermentation.  intestinal, 
characters  of  stools  with  246 

-  -  constipation   witli      ..    241 
diarrhfca  with  241 

-  -  distineiiislied     from 

putrefaction  . .  246 

flatus  from     . .  . .  216 

stools  in  . .  . .  241 

tetany  from  . .  . .        3 

wind  with      . .  . .  241 

-  tost  for  gluco^^(■.  .  . .  7I:j 
Fermentation  test,  for  sugar  262 


Ferments  in  pancreatic  cyst  451 
Ferret-facies      in      micro- 
cephaly ..  ..'188 
Ferrets,  fever  fi-om  bite  of  598 
Ferric    chloride,    alkapton 

and 746 

in  Bial's  test  . .  . .  261 

indican  and   . .  . .    745 

melanuria  and  . .   745 

reaction,  after  cai-bolic 

acid  . .  . .   170 
after  s;iltcvhit.-s     ..    170 


afte 


170 


Festination.     in     paralysis 
agitans  . .  725 

Fever(:ih.:    .,;■;,       ..  ,,M 

-  blacku'.i<Kl',;rhM>L'lMl,in- 

uria  in  . .  . .    284 

-  continued  (see  Pyrexia, 

Prolonged) 

-  relapsing  (see  Relapsing 

Fever) 

-  typhoid     (see     Typhoid 

Fever) 
Fevers,  acute  dilatation  of 

stomach  in     . ,  . ,   173 

nephritis  iu    . .  1(1,  42 

Fevei-s,     acute,     aphthous 
'    stomatitis   in..  ..    740 

-  -  backache  in    . .  . ,   427 

baldness  from  ,.      71 

cerebellar  atrophy  after  729 

Cheyne-Stokes  breath- 


ing I 


108 


coma  in          . .  117,  144 
at  onset  of. .  . .  594 

-  convulsions  from  . .  144 
at  onset,  of . .  . .  594 

-  cramps  in       . .  , .  152 

-  deafness  from  . .  166 

-  delirium  in     . .  . .  169 


173 


—  dilatation  of  heart 

211,  214 

eosinophilia  after      . .   218 

epididymo-orchitis 

from  . .  . ,   478 

epistaxis  in    . .         . .  221 

gastric   HCl    deficient 

in 270 

hiematemesis  in    265,  272 

hjcmaturia  in  , ,  275 

haemoptysis  in  . .  287 

hffimori'hagic   erosions 

ill     ..         ..         ..   269 

hydrocele  from         . .  481 

hyperacusis  after      . .  309 

hyperpyrexia  in        . .  309 

hypothermia  after    . .   311 

infective  parotitis  in. .  694 

-  -  insomnia  from  . .   321 


Fevers,  arute,  jai 


mitral       rcLjurL'itation 

from  .7  ..   211 

necrosis  of  jaw  from. .   683 

nephritis  after  . .  281 

pain  in  the  eyes  iu    . .  446 

in  the  limbs  in      . .  463 

parenchymatous    ciw- 

diac  changes  in     . .  214 

photophobia  in         , .  525 

polyuria  and  . .  . .   536 

prolonged  pyrexia  from  563 

-  -  purpura  ill       ..       553,  554 
l-yrlonrpliritis  in       ..   576 
702 
594 

Fevers,   acute,   splenic  en- 
largement in  . .      632.  638 

taste  loss  from  . .   705 

tetany  from  . .  . .    15I 

tmnitiis  from . .  . .    723 

lu-ic  acid  in    . .  . .    742 

vomithig  iu    . .         . .  765 

at  onset  of . .  . .    764 


of 


nlbtiininuria  in 


134 


■     hiL-ath  in..     87 
..  72,  73 

-  -iM-ii.j  i.'.jrji.ilegia  after    132 

-  speciQc,   vaginal    atresia 

from    . .         , .  . .     18 
vaginitis  from  . .      18 

-  thirst  in  . .  . .         •. .    719 

-  m-ate  deposit  due  to    . .    740 
Fibrillar  contractions 
in  amyotropliic  lateral 

sclerosis       . .      135,  508 

bulbar  paralysis        . .  130 

myopathies    . .         . .  504 

from  poliomyelitis   . .  140 

iu  progressive  muscular 

atrophy       . .  . .    135 

Fibrillation,  auricular  (see 
Auricular  Fibrilliition) 

-  of  ton!7uc.inbull.:irp;>Uv  627 

Fibro-adenoma    of    breast, 
general  account  of   . .   686 


id    km- 
Fibroid) 


(,.u. 


li.n.id) 
Liin-, 


-  of  uterus  (see  Fibromy- 

oma  of  Uterus) 
Fibrolipoma  of  abdominal 

wall 656 

Fibroma  of  bone  . .  , .  671 

-  breast 686 

-  dermoid  cyst  simulating  732 

-  of  face 673 

-  femoral 675 

-  of  jaw      ..  ..      683,  684 

-  larynx,  asthma  simulated 

by        ...         ..         ..535 

stridor  from  . .         . .  650 

-  of  mediastinum. .  , .   751 

-  mdlluscum  .  .    732 

-  of  nose,  (-pi-i  i\i-     lima  L'L'n 

-  ovary,  ascuu-s  uith      ..    USM 
twisted  pedicle  of     , ,  6S9 

-  of  vulva..  ..       700,  702 

-  of  uterus,  anuria  from. .     41 
bearing-down        pain 

from  . .  . .   427 
bladder  distention  simu- 
lating 


itli 


vpUi 


690 


-  -  chru 

cysti 

diihcultyinmicturitioi 

with 

dyschezii  from 

dysmenorrhtca  from 

dystocia  from 

ectopicgestationsimu- 

lating 

expulsion  of  , . 

extrusion   of  . .  ,.   391 

foul  dischari,'e  from  . .    185 

frequent    micturition 

from  . .  . .   394 

haemorrhage  from     . .  539 

in  iliac  fossa  . .  . .  678 

inversion  simulated  by  539 

kidney  simulated  by    354 

malignancy  simulated 

by 690 

menorrhagia  from 

386,  391,  688,  G89 

metrorrhagia  from  390, 391 

necrobiosis  in  . .   G90 


-  nthctosLs  ;ifter 

-  bleeding  gums  i; 


by    ..         ::s.;.  kss. 

■  pain  ill  prh  1-  tioni   .  . 

■  pelvii.-    ^\\.■|Im-    ihir    In 

■  pigment:. lion     ul     iacc 

with 

■  pregnancy   simulating 
projecting  from  vagina  . 
renal  tube  casts  due  to 
retention  of  urine  from  1 
of  round  ligament     . .  1 


Fihromyoma  of  vterusy  co/iftl, 
sarcoma  from         391,  69 

-  _  simulating   tumour  ot 

Cauda  equina         . .     6 

sloughing        . .  . .    39 

softened  in  pregnancv 

201;  69i 

sound  in  diagnosing. .   38 

stenosis  of  urethra  hy 

sterility  from  . .  64 

strangulation  of        . .  39 

strangury  from  . .   64 

tenesmus  from  . ,  71 

uterus  enlarged  by  . .  39 

ureters  obstructed  by    4 

vaginal  examination  in 

diagnosing  . .      353,  39 

-  of  vagina  ..      539,  70 

-  vulval  swelling  from    . .   70i 
Fibromyxoma    of    parotid 

gland 69; 

Fibro neuromata  of  brachial 
pie. 


Fibr. 


of 


pharynx 
snoring  due  to  . .   61; 

-  of  scrotum  . .  . .   69i 
Fibrositis,  from  cold  and 

damp  . .         . .  475 

-  gonorrhoeal,  pain  in  foot 

from 43J 

-  infective  periarthritis  and  47-' 

-  from  injury        . .  . .   47i; 

-  interscapular  pain  from  46] 

-  occupation  neurosis  simu- 

lating   470 

-  pachymeningitis    sirau- 

latins"  . .  . .  . .   477 

-  pri).,  i.,  Hip-l!OM!,!prfrom  47-1 

Fibrositis  of  shoulder  region  475 

'■''■■  ■■■-i,lin,p-  __^_^ 

-  osteomyelitis  of,  lunping 

from 362 

-  periostitis     of,     limping 


Fin,  .;.i.,,„:,i;..-,.  ,n  ..  28 
FiU.uirni.    Ill    uiiiiu,    fi-oni 

gleet 183 

Filaria  bancrofti  nocturna    28 

-  diiirna     . .         . .  . .     28 

-  embryos,  in  blood    109,  226 

-  -  (I'/atc  XXVIIl)        ..    t;i4 

-  perstans  . .  .  .  28 
Filariasis,  age  incidence  of  l09 
Filariasis,  blood  changes  in 

26,  28 

-  chylous  ascites  from    . .     r»ti 

-  chyluria,  from    ..        5ii  Insi 

-  elephantiasis  from      28, 

109,  411,  695,  701,  737 

-  eosinophiUa  in  ..      109,  219 

-  erythema  from  . .  223,  226 
Filariasis,  general  account  of  28 

-  jiarasites  in  blood  in    .  .      27 

-  tpdema  from      ..  ..    liu 

-  sex  incidence  of  ..   Iim 

-  in  tropics  . .  . .  luu 
File-maker's  cramp  . .  151 
Fillet,  sensory  path  through  55 
Film,   blood-   (see   Blood- 


Finger,  bedsore  of..         ..  ; 

-  broad,  in  a^iondroplasia  '. 
myxcedema    . .         . .  i 

—  bullaa    of,     in    .'lyringo- 


u(cu]tation  and 
chciropompholyx  of 
clubbed    (see     Chibbci 

Fingers) 
cow-pox  of 
cyanotic,    in    linvnaud' 


FINGERS    —    FORDYCES   DISEASE 


819 


INGERS,  DEAD..         ..    162 

-  frum      arteriosclerosis 

1G2,  103 

-  atheroma       . .         . .  1G3 

-  blue  brain      . .     1G2,  1(!3 

-  carbonate  of  soda    . ,  1G3 

-  cervical  rib    . .  . .  102 

-  cold 162 

-  ergotism         . .  . .  1(>2 

-  menorrhai»ia  and      . .  387 

-  from  occupation        . .   162 

-  in  peiiagra      . .  . .    162 

-  washerwomen  . .   163 

-  from  weight-carrying  163 
enchondroma     of     (Fig, 

283)  671 
enlarged,  in  acromegaly  111 

-  pulmonary     osteo-ar- 

thropathy  ..  ..Ill 

erytliemakeratodesof  . .  405 
erythematous  lesions  of  239 
tnoers.  gangrene  of   240, 

(Plate  XIII)  256 

-  in  Haynaud'^  disease     162 

gonococcal  arthritis  of. .  310 
Heberden's  nodes  on 

(Fig.  155)  343 
necrosis  of,  in  Raynaud's 

disciise  {Fig.  126)  257 

nodoscd  juvenile  . .  191 

imnihnpss    of,    in    acro- 


;of 


iu 


239 


pilarii 
alfccUng  ..  ..   -189 

-  podgy,  in  my-vcedema  . .     38 

■  position  in  "tetany        . .       2 

■  pulmonarv  osteo-arthro- 

pathy  ofl  11  (Fig.  IGi)  351 

■  pustular  affections  of  . .  239 

•  Raynaud's  disease  atfcct- 

ing  162,  256,  257,  G99 

■  rheumatic  fever  afTecting  337 
'  septic,  celhilitis  from    . .   110 

■  -  epitrocldear  gland  en- 

larged from  ..   380 

■  vcahics  of  . .      5G3,  755 
'INGERS.  SORE..         ..  239 

-  -  inllanied  axillary  glands 

from  ..  ..380 

-  spindled,  in  acute  rheu- 

matoid arthritis  (Fig. 

153)  3i2 

■  sciuamous  aflections  of    240 

•  syphilis  affecting         . .  239 

■  swolleti,  from  tuberculous 

dactylitis        . .         . .  G68 

•  thickened,  in  myxirdema  109 

•  three   middle   ecpial,   in 

achondroplasia  ..187 

•  tremor    of,   in   Graves's 

disease  ..      703,  770 

■  tuberculous  (sec  Dacty- 

litis. Tuborculous) 

■  ulceration  of      . .       161,  2 10 

•  vesicular  alTections  of..  339 

-  xanthelasma  of  . .  324 
"iremcn.  left  ventricle  en- 
larged in        . .  . .  206 

,'i?.h,  poisonous     . .  . .  224 

-  trypanosomes  in  . .     28 

-  urticaria  after    . .      673,  771 
i'L-ihbone.  aorta  opened  by  267 

-  in  gum,  ptyalisni  from  512 
.  inhaled,      gangrene      of 

lung  from       . .         . .  259 

-  ■.aor.hif/us  perforated  by  267 

,-riim  ..  ..   584 

.  ,  -1.   swollen  from    ..  698 

I     11.  erythema  in  ..   224 

I       III'  .     ;inal,    iichiiig    in 

porhipum    from  . .    171 

-  —  dyspareunia  from     . .   193 

-  -  levator  ani  spasm  from  193 

•  -  pain      on     drfnfcation 

from  . .  . .   585 
in  penis  from      171,  473 

-  -  rectal  examination  in 

diagnosing  . .         . .  194 

-  -  S|)cculum  in  diagnos- 

ing   194 

-  tenesnnis  from  ..  71H 

-  of  tongue,  syphilitic      ..   739 


I'istula,  anal 

vagismus  from  . .  ] 

-  between    bile-duct    and 

urinary  tract. .         ..   'i 

-  broncho-cesophageal     . .  *, 

-  gastrocolic,  ftecal  vomit- 

-  genital,  sterility  from  . .   ( 
Fistula,  rectovaginal        . .  i 

-  rectovesical        . .  . .  J 
after  childbirth         . .   '. 

-  renocolic,    from     c:irci- 

pneumaturia  from    . .   i 

-  scrotal     . .  . .      479,  ( 
from   rectal   suppura- 
tion. .          . .         . .  ( 

stricture  . .  . .   ( 

syphilitic  testis        . .  ( 

tubercle  bacilli  from. .  -i 

from  tuberculous  testis  f 

urethral  extravasation  i 

-  umbilical  fa?cal 

from  pneumococcid 

peritonitis  . .  . .   (. 

tuberculous  peritonitis 

43,  48,  631,  f 

-  urethral,  aching  in  peri- 

Fistula.    urethral,    general 
account  of  - ■   E 


Flaitts.  conhl. 

-  cirrhosis  . .         . .  . .  : 

-  constipation       . .         . .  : 
I  -  fermentation      . .         . .  : 

-  fullness  relieved  by  pas- 

sjxge  of  . .         . .   ! 

,  -  from  heart  failure        . .   : 
I  -  jiassiiLTi:  of,  colic  relieved 


"\V 


from  putrefaction 


Flea-bites,  itching  in       .  .   540 

-  purpura  from    . .  . .   553 
Flexor    brevis    digitorum, 

nerve  supply  of        . .  498 

, hallucis,  nerve  supply  498 

minimi    digiti,    nerve 

supply  of  . .       498,  504 
pollicis,  nerve  supply  504 

-  carpi     radialis,     nerve 

supply  of        . .  . .   504 

ulnaris,  nerve  supply  504 

root  innervation  of    509 

in  ulnar  paralysis. .  110 

-  longus  digitorum,  nerve 

supplv  of  ..         ..  498 

-  -    li;illnri^.   iL.TVi-    supply  498 

-  -  |.m||i,-i-.  M.Txr  supply  504 


Flushing,  cniiKl. 

-  general  debility  . .   211 

-  giddiness  after  . .  . .   241 

-  in  Graves's  disease      . .  236 

-  with   hysterical  pyrexia  31o 

-  from  indigestion  ..  241 

-  in  lactation        . .  . .   241 

-  local,  from  visceral  dis- 

ease      428 

..   241 


bUppI 


of 


501 


Fistula,     urinary,     general 

Fk-xores  <lii;il(inini,  ruin  in 

account  of               . .  397 

cluw-lmnil       ..          ..    lll'J 

—  vesical,     cystodcope     in 

Fhes  and  disease            28,  21) 

iliajjiiosing      . .          . .   i>30 

Flint's  murmur    . .     '95,  2  i 

-  ve*;i('noolic           .  .          . .   125 

Flowers,  in  ankylostomiasis  521 

Fits,  dBfinltion  of  6in.l  see 

I'l'ilte.  liver            .  .       3115.  328 

(■,.ll^H^M.n-J   .. 
l'-iv:iu.iii  m  \].]nM.  . 

Fixing  fluid  for  histological 
specimens       . .     390. 

Flagellum,  trypanosonie 
bearing 

Flail  joint  . .         . .      346. 

Flashes  of  light,  Irom 
plethora 

Flat-foot,  limping  from    . . 

-  metatarsal  neuralgia  and 

-  pain  from 

-  in  rickets  (Fiy.  S5)       . . 
FLATULENCE      . . 

-  acute    abtlominal     pain 

from    . . 

-  in  angina  pectoris   241. 

310,  433, 
abilominalis   . . 

-  asthenic  dyspepsia 

-  atheroma 

-  bismuth   and  x-rays 


Fluid,  ascitic,  characters  of    48 
Fluid,      ascitic,      chylous, 
characters  of. .  50 


!Ot  . 


1 ,1.  I  I  i:i:j,  435, 

' '       '  4i;l, 

Flatulence,     intestinal, 
general  account  of  241. 

-  lo^s  oi  rt.-iKhl  In.m      .. 

-  merycisni  antl    . . 

-  |miii  iti  chest  from 
epiuastriuni  from 

round  heart  from  433, 

in  left  hypochondrium 

from  . .  . . 
shoulder  from 

-  pnlpitiilinii  Irimi 
.-  pelvi,-     l.~ion    sin, 

-  Willi    juilvcvslie   k 

-  Willi  pylori.'  iibsti 


435. 


rhi 


tendorness  in  chest  from 

-  from  tctraclilorethaiio.. 
FlatiiB,  absent  with  Intes- 
tinal obstruction 

-  in  acute  pancreatitis    .. 

-  from  aeropliagy 


439 

~  ccrctir"-iiirril    (sec  Cere- 

438 

brospinal   I'luidl 

18G 

-  livdatirl.  hooklel-   in   411, 

240 

ISl, 

37(1 

-  hydrocele 

481 

193 

-  loss  of,  in  cholera 

ini 

cyanosis  from        157, 

liil 

709 

from  diarrlu£u 

720 

31U 

dysenter.v 

101 

319 

excessive,  hriidvpnoea 

437 

after 

84 

extreme  thirst  from . . 

720 

241 

infusion  for    . . 

534 

82 

inspissntion      of     the 

123 

blood  from 

101 

241 

from  peritonitis 

720 

354 

—  polycythmmia       from 

241 

532, 

533 

—  from  severe  diarrha'a 

633 

240 

vomiting     . . 

532 

207 

sweating 

720 

241 

-  -  in  typhus       . . 

—  from  vomiting 

1(!I 
720 

709 

in  yellow  fever 

IIU 

321 

-  ovarian 

Fluid,  pleurlllc,  charicten 

45 

462 

of                  ..      102, 

104 

~  spermaloceie      ..          .. 

481 

246 

I'luorescin     in    .lelecting 

ulceration  of  cornea, , 

733 

388 

Fliinrcscciico     In     urobilin 

7011 

trat 

336 

437 

(I'lale  XXXin     .. 

748 

435 

Flush,  malar,  mitral  stenosis 

mid  . .            63,  485, 

7114 

450 

ill    myxtcdcnia    38, 

471 

(Fii).   101)  231, 

409 

485 

FLUSHING 

241 

4n8 

241 

42 

--  from  alcohnl 

241 

211 

-  blushing     disllnguished 

from 

241 

193 

-  in  brachiiil  neuralgia    , . 

442 

709 

-  chlorosis. . 

241 

331 

-  at  clhimcleric    . . 

241 

-  in  erylhromelnlgln 

441 

129 

-  of  face  in  inalnrltt 

30 

131 

fnlntlng  lifter     . . 

241 

2  Hi 

~  from  feeble  clrriiliillun. . 

211 

-  menstruation     . . 

-  nausea  after       . .          . .  241 

-  numbness  after..         ..  211 

-  palpitation  after          ..  241 

-  in  paralysis  agitans      . .  725 

-  paresis  after      . .         . .  241 

-  in  pregnancy     . .         . .  241 

-  rosacea 211 

-  sense  of  suffocation  nfter  241 

-  in  tic  douloureux         . .  447 

-  tinnitus  after     ..         ..241 

-  tremor  after      ..         ..241 

-  vomiting  after  ..  ..  241 
Flute-players'  cramp  . .  151 
Fluttering,  in  precordia  . .  703 
Foam  test  for  bile..  ..  74.'i 
Foaming  at  mouth  in  con- 


epilepsy 

malingerer 

Foetal    heart,    with    prcg 

somids   proving  preg 

nancy 

witii"  hydrops  amnii     4 

-  movements,  with  hydrops 
amnii  . .         . .         . .     4 

presnancy      . .         . .  68 

Ftctid  bronchitis  (see  Bron- 


19 


I'uT.i. 

ni      1,1,  , III     (sec 

I'.T 

Hh,  1  ,„i|,i,-«  of  the) 

r.ptii-. 

tni 

11 10 

1'"ol;,   li: 

sal  discharge  from  178 

l-'Dlic   <■! 

■ciilaire      ..         ..  405 

F..lli.-,il 

.1        .iiiiinnctivitis 

I  /■/,;'.     A71    230.  231 

-  1 

,   ,  ,    l,ii.-illitLs) 

V il::,-  ■;,,    ,1     •;<         ..      71 

-  .v/,  ,1,  ,!,,n.  ,.    249 
Font  allelic,          depressed, 

from  diarrhoia      171,  384 

-  late  closure  of,  in  rickets 

145,  035 
Food,  arsenical  contau  ' 


of 


718 


foul  taste  from  . . 
irritating,  vomiting  due 

to        705 

in  larynx  . .         . .    167 

regurgitation       through 

nose(see  lleglirgitation 

of   Food) 
between  teeth,  foul  tnste 


fro 


705 


Foods,     urine     coloration 

from    ..         ..         ..711 

Foot,  Charcot's  joint  in  ..  34  9 

-  diiw        ..         ..       109,  41i;i 

-  epithelioma  of    ..  ..381 

-  llat  (sec   Fhit-fooll 

-  lorci/n  bo.ly  in  .  .  .  .    30:; 

Foot,   gangrene  of  (/'Ai/> 

-V/l) 258 


73i; 


in  till 


-  piiin  ill  (»i 

l'o.>ll 

-  pallor  of.  from  Intermit- 

tent clauillciition      ,.  441 

-  perforating  ulcer  of  257, 

515,    735,   (^'1./.  297)     730 

-  smiill-pov  iilTectIng      ..  501 

-  ulceliitiiinoKseo  Ulcera- 

tion of  Foot) 
I'oot-dr.ip  ..  ..        50,   113 

I'oolballers,  cramps  ill     ..    lAII 

-  eiiliirged  heart   . .  . .   21 1 

-  iio.li's  on  shins  of         . .  007 

-  leiidiriii-ssnfsplneln  ..  715 
l''oraiiien  ciiH'iini,  enilHsiiry 

vein  througl 220 

.  iival.  piiteni  ..  ..167 
Forceps  lit  delivery,  iinrn- 

plivla  from    , ,     510,  611 


ll;i 


FOREARMS 


FUNGIFORM   PAPILLAE 


Forcai-ms,  erythema  multi- 

Foul nir.  lir;i(l;iche  fi'om  ..    295 

Fracture  of  spine,  conui. 

Friedreich's  ataxy,  contil. 

forme  affecting          ..   -ISit 

FOUL  BREATH    .-          ..     86 

paraplegia  from     2i3,  538 

~  -  pneumonia  in           . .  513 

nodosum  of    . .          ..   -iUl 

KournicT,  on  chancre  from 

priapism   from           . .   538 

-  -  posterior    column 

-  looal  fatness  of,  in  Der- 

herpes 754 

spontaneous,         from 

changes  in..         ..     57 

ciim's  disease           . .  410 

Fourth     disease,     general 

.    caries          ..         ..243 

pseudonystagmus  in , .  ■107 

-  paralysis  of,  Volkmann's 

account  of     . .      228,  229 

transverse        myelitis 

pupils  normal  in      ..  512 

(Fill.  58)        . .         . .   141 

Fowls,   blood    of,   used   by 

from            ..          ..516 

rigidity  in      ..          ..13; 

-  septic,  epitroclilearglaud 

malingerers    . .          . .  286 

urine  dribbling  after     39S 

scoliosis     fi-om      140, 

enlarged  from           ..  380 

Fox,  Colcott,  on  vaccinif  orm 

FRACTURE,   SPONTANE- 

1.54, 512 

Forehead,  aciie  affecting.  -  489 

erythema  of  infants. .  401 

OUS    242 

no  sensory  disturbance 

-  bulging,     in     achondro- 

- Tilbury,  impetigo  cotita- 

from  carcinoma     242,  672 

in 513 

plasia  . .         . .         . .   187 

giosa  of          . .         . .  401 

-  -  caries  . .          . .      242,  243 

sex  incidence  of        . .   140 

-  -  rickets 187 

Fracture,     badly     united, 

-  -  chloroma        ..          ..242 

simulating       infantile 

-  carcinoma  of     ..         ..179 

elephantiasis  from    . .   411 

fragilitas  ossium       . .   242 

paralysis     . .          . .      60 

-  cheiropompliolyx  on    . .     97 

ulceration  over      . .   737 

general  paralysis   242,  243 

-  -  speech  in  113, 140,  513.  G27 

-  chromidrosis  of..         ..  654 

-  of  base  of  skull,  blind- 

 hydatid           ,.          ..   673 

nosphincter  trouble  in  512 

-  cireoid      -aneurysm       of 

ness  from       . .          . .   762 

new  growth   . .          . .   243 

-  -  talipes  in  60,  113,  1-Ii>.  51L 

(Plate  XXXi)           . .  694 

cerebrospinal     fluid 

sarcoma          . .          . .   242 

-  -  tremor  in  140, 51--',  7i^7,  728 

-  congenital          syphilitic 

from  ear  due  to . .  119 

in  scurvy-rickets       . .   670 

Fright,  acute  yellow  atrophy 

eruption  on    . .          . .   400 

nose  due  to  119, 178 

syringomyelia            . .   257 

after 333 

-  downy,  in  Mongolism  . .   2.38 

deafness  from        . .   166 

-  of  vertebrse       . .          . .  715 

-  chorea  after       . .         . .   133 

-  herpes  of           . .          . .   754 

diabetes      hisipidus 

-  i-rays  in  diagnosing     . .  152 

-  convulsions  from           . .    14'^ 

FOREHEAD,    ENLARGE- 

from       . .          . .   537 

Fracture- dislocation,  spinal. 

-  diabetes  insipidus  from    537 

MENT  OF  THE    203,  204 

epistnxis  from       . .   220 

nllocheiria  from         ..      17 

-  menorrhagia  from         . .   38G 

-  haamatoma  of    . .          . .    205 

haemorrhage       from 

Fracture-dislocation         of 

-  palpitation  from       484,  486 

-  pigmentation  of            - .   527 

ear  due  to       1 19.  421 

spine,  atiEesthesta  from  608 

-  paroxysmal   tachycardia 

-  prominent,  in  congenital 

nose  due  to        . .  119 

knee-jerks  lost  after. .    358 

fi-om 70S 

syphilis  (/"if?.  lOG)  234,  235 

timiitus  from          . .   523 

Frrenum    linguje,  abraded, 

-  pupil  dilated  by             ..   551 

vertigo  aftpr         . .  752 

by  violent  coughing. .  289 

Froelich's  syndrome         ..    190 

-  syphilis  of           . .          . .   490 

-  basisphenoid,  hemianop- 

 ulcer  of,  in  whooping- 

FruL'-hellv,      in      cretinism 

-  wriidilpd.  in   arnnnPLralv  237 

sia  from          . .          . .   302 

cough          . .         .".  739 

(Fi,j.    IO:j)  23:5,  234 

-  -  in  l.nlM.^  n-in.  \\:<\    ..   23G 

-  buUffi  from         . .           96,  97 

-  penis,     perforated,     by 

Frontal  bone,  exostosis  of 

Foreign  in-.h  m  mi-  |.  i-iu'e, 

-  callus  after        . .          . .   667 

soft  sore         . .          . .  618 

230,  671 

aslhri.  1    -iMiul  ,f,-.|   \.y     535 

-  compound,  talipes  from  114 

Fragilitas      ossium,     blue 

tumours  of    . .         . .  SO'? 

fuul   l.n.aLi,    In.m  '.  .      87 

-  crepitus  from     . .          . .    152 

scleroties  witli            . .   242 

-  lobe      lesion,     agraphia 

aorta  perfoiatod  l«y  . .   267 

-  Dupuytreii's,     talipes 

-  -  .iu^u-iiM.i   with           ..    187 

from    . .          . .          .  .   62r 

in   bronchus,  bronchi- 

fi-ora  114 

Fragilitas  ossium,   general 

speech  centre  in        .  .   6l;4 

ectasis  from           . .   292 

-  of  femur,  oedema  of  legs 

account  of                ..242 

Frontal  lobe  tumour,  signs 

gangrene     of     lung 

after 414 

-  ~  ns{enni;il;ieiri,  and      ..    187 

of        727 

from        259,  2G0,  652 

sciatic  nerve  paralysis 

Fragility  of  red  cells,  en- 

- ridges,  enlarged,  in  acro- 

 haamoptys's  from  . .  287 

from           ..          ..499 

larged  spleen  and      . .  G34 

megaly            . .          . .   237 

pyopneumothorax 

-  of  fibula 362 

in  familial  acholuric 

-  sinus  disease  (see  Sinus, 

from        . .          . .   G52 

-  greenstick,    callus    first 

jaundice  . .         . .  332 

Frontal) 

simulating  diphtherial57 

evidence  of    . .         . .  667 

mode  of  testing    . .  634 

-  veins,  engorged,  in  caver- 

 stridor  from           . .   650 

of  femur,  limping  from  363 

Frambcesia              . .          . .   403 

nous  sinus  thrombosis  229 

cyanosis  from            . .    157 

-  -  of  fibula          . .          . .    362 

France,  ringworm  of        . .   247 

Frost-bite,  bullso  from     96,  97 

-  -  in  ear,  deafness  from    165 

limping  from..       362,  363 

Freckles,  in  acute  rheuma- 

- fingers  affected  by    239,  240 

earache  from          . .   202 

-  -  from   Tnollities  ossium  242 

toid  arthritis..         ..  342 

-  gangrene  from  . .          . .   2r>i 

otorrhoea  from      . .  422 

from  rickets  . .          . .   242 

-  Kaposi's  disease           . .  731 

-  hiemoglobinuria  from  . .  284 

speculum  in  detect- 

~ of  humerus,  paralysis  of 

-  von        Recklinghausen's 

-  Raynaud's  disease  simu- 

ing         ..         ..  423 

musculospiral     nerve 

disease           . .         . .   710 

lating  162 

tinnitus  from     722,  723 

from 504 

-  xeroderma  pigmentosum 

-  vesicles  from     . .         . .   751 

vertigo  from         . .  752 

-  jaw          683 

simulating      . .         . .   383 

Fruit,  colic  from  ..          ..   117 

in    eye,    blinking    tic 

ptyalism  from          . .  542 

Freezing-point    depression 

-  diarrhcea  from   ..      171,  717 

from            ..          ..   13G 

-  muscle  atrophy  with    . .     61 

of  ascitic  fluid          . .     50 

-  nightmare  from. .          ..  402 

pain  from  . .          . .   445 

-  from  muscular  effort    . .  242 

Fresh    air,    deficiency    of, 

Fruit-stone    in    bronchus. 

photophobia  from. .   524 

-  affecting   nerve,   muscle 

rickets  from   . .          . .    145 

haemoptysis  from     . .  387 

ulcer  of  cornea  from  733 

wastiner  from            . .     61 

Friction,  auricular          . .  548 

Fuchsin  stain         . .          . .  641 

fatal  li;i?ni;nenK.-sis  (rem  2t;7 

MA),  from  ..           ..61 

-  bulijB  from           .  .           96,  97 

Fucus  vesiculosus,  weight 

in   inn; ,    li[ ■    iMifii    :;.;:■ 

Fracture.  i)ain  long  after.-  476 

Friction-sounds,  in  pericar- 

reduction by  . .         . .  77C 

],:i ,1. 

ditis     433 

Fullness    in    chest,    from 

in  LMIIU         j.l  ■■     i|       III    ■! ".1 

i-i  ii      1     iinm           ..   499 

-  perisplenitis       . .          . .  450 

mediastinal  new  growth  43^ 

ha3ni;iii-iin-i-    ti- .  .   1';  1 

-  -  iui..iNt..     ,.f     bladder 

-  pleurisy  . .          . .          . .  450 

-  episnstrium,    from    gas- 

 in  knee,  limping  from  .^il.' 

from            . .         . .  278 

-  pleuropericarditis         ..  433 

tritis  ..        ..     '  ..  ;n7 

-  -  larynx..          .,      149,  157 

urethra  injured  by  . .  470 

-  (and  see  Rub) 

-  ETiistnc,   from   atony      ..    l' U 

death     from     {Fig, 

-  penis 108 

Fried  fish,  colic  from      ..  117 

Fullness,    gastric,    general 

on           . .          . .   195 

-  Pott's,  talipes  from      . .   114 

Friedliinder's  bacillus,  (see 

account  of               . .  243 

foul  lnv:(fh  Inini     ..      87 

-  of  rib,  crepitus  with     . .   707 

Bacillus  Pnenmonise) 

from  hypertonus       . .  244 

l;.rVir_M.;,l         nl,    inlr- 

emjiyema  from          . .   104 

Friedreich's  ataxy,  age  inci- 

 leather-bottle  stomach  -J It 

11. .11    liv    .  .         MS.    lilt 

litemoptysis  from      . .   286 

dence  of   60, 113,  140,  513 

rapid  eating  . .         . .  2i:i 

nirniriL'in— niiMli.l.'d 

rarity     of     pneumo- 

 no  ankle-clomis  in     . .   512 

-  in  head,  from  high  blood- 

by              .  .           - .    590 

thorax  from          ..  532 

-  -  ataxy  in  57,  113,  140,  251 

pressure          . .         . .  296 

orthopncea  from  418,  419 

surgical      emphysema 

Babinski's  sign  in     . .      68 

plethora         ..         ..  221 

simulated  by  abduc- 

from            . .       203,  532 

choreiform  movements 

-  intestinal,    from    excess 

tuv   paralvsis      ..    158 

tenderness  from        . .   707 

in 513 

of  gas 24.") 

-  -  in  rin^,..  ,l,..li.M.|.  irnm  179 

a:-rays  ni  (iiK-nu-inL'. .    707 

contractures  in      138,  140 

FULLNESS,  SENSE  OF  ..  432 

I'Pi  1  1    1-    : .  .    i.'2n 

Fracture  of  sacrum,  anaes- 

- ^  familial  nature           .  .    14(1 

-  -  from  acute  congestion 

fi.ul   ! 1      .  .       S7 

thesia  Irom  (/'"/.  I'v.i)  608 

-  -  family  history  in      . .    512 

of  liver       . .         . .   .".:',  1 

OeS(l|i|i:i'Ji'  i|         -  li-Ni.-lS 

-  skull,  lM-;H|ypn.,.:L  fnnii        84 

Friedreich's  ataxy,  general 

aerophagy  due  to     . .   245 

from            .  .          .  .    194 

cerebrospinal         fluid 

account  of            140,  512 

from     asthenic     dys- 

 in  oesophagus,  bougie 

from  ear  after       . .  421 

hallux  erectus  in  113, 

pepsia          ..          ..319 

in  diagnosing        . .  267 

coma  from     . .         . .  118 

512,  513 

in    hypochondrium. 

haiuiatcmesis  from     265 

hyperpyrexia  from  . .  309 

hypertrophy  of  exten- 

from   carcinoma    of 

unilateral  paresis  from  118 

sor   longus  hallucis 

liver             ..          ..   373 

Ml  r-i  (■  ii-        1  '.h;,  2G7 

-  spine,  acute  bedsore  from  258 

in 140 

rectum,   from   carcin- 

  ]ii-i  1. \,\        . .   267 

allocheiria  from        . .     17 

inco-ordinatjon  in    . .  251 

oma             ..          ..129 

jp\-.ipiirinini[.i  1  li'iir- 

from  diving    . .          . .   242 

intention  tremor  in  . .   728 

piles             . .          . .     78 

'i.Uum  from          ..    652 

-  -  fall  on  head    . .          . .   648 

knee-jerk  absent  in 

-  -    -  nvr-.l  iM-.lviM!^          ..    7S 

a-rays  in  diagnosing  2G7 

girdle  pains  from   431,  4S6 

113,  512,  513 

Functional  albuminuria  15.  537 

Foreign  body  in  rectum    .  ■  584 

fi-om  hunting. .         . .  310 

-  -  kyphosis  in    . .         ..140 

-    lit-i'  l-r     i|.'  11  ll    llOlll                   t;''ii 

abscess  due  to      . .  584 

hyperpyrexia  from 

main  bote  in  ..         ..140 

-  nerve   Irouhie  (see  Hys- 

 tenesmus  from      . .   718 

309,  310 

muscular  atrophy  in . .   140 

teria  ;  and  Xe  rosis) 

in  urethra      . .      181,  184 

from  muscular  effort    242 

myopathy    simulating     60 

I'ungatmg  endocarditis  Csee 

Formalin  fixing  fluid  391,  701 

myelitis  from            . .   310 

nystagmus  in  113,140,513 

Endocarditis,  Fun  gat- 

;Formication           , .          . .   540 

pain  in  neck  from     . .   648 

optic  atrophy  in       . .   513 

ing) 

Formosa,  distoma  pulmon- 

 paralysis    of    bladder 

paraplegia  fi-om      510.  512 

Fungiform    papiilse,    pro- 

ale  in  292 

from            . .          . .  398 

-  -  phthisis  in     . .         . .  513 

^   minent,  in  scarlet  fever  -.7 

FUNGOUS  AFFECTIONS 


GASES 


UNGOUS     AFFECTIONS 

OF  THE  SKIN  ..  ! 

'urfuriildpliytle     in     Cum- 
in idije's  reaction        . .  '. 
"urnacemen,  left  ventricle 

enlarged  in     . .  . .  : 

photophobia  in  . .  > 

tirs,  workers  in,  mercury 

poi=^oning  in   . .  , .  ' 

tiruncle,    carbuncle    dis- 

tiiitpiished  from        . .  ; 

in  ear,  earache  from    . .  : 

erythema  from  . .  . .  : 

sinus  thrombosis  from. .  : 

uruncuiosis    of    external 

auditory  meatus        . .  ' 

im-.uk-ir,  ..  ..  I 

vulval  swelling  from    . .  i 

usiform  bacilli     . .       013,  < 
—  of     Vincent's      angina 

(Plate  X£V III)  < 


AIT,     ABNORMALITIES 


'.'a II -bladder  enlargement,  contd. 

duodenal  ulcer  simu- 

lathig  . .         . .  368 

from  empyema         . .  253 

gall-stones       . .      253,  327 

gastric  ulcer  simulating  368 

hydatid        simulating 


Gall-bladder    enlargement, 
kidney    simulated    by 
laparotomy     in      dia- 
gnosing       . .      253, 
movable  kidney  simu- 
lated by      . .      253, 

from  mucocele      253, 

new  growth  . . 

from  pancreatitis 


IM'IV 


rllii 


116,  253,  254 
■  688 

353 

368 


Oall-stoncs,  could. 

-  interscapular  pain  from 

461,  462 

-  intestinal  obstruction  by  272 

-  jaundice  from  101,  116, 

252,272,325,326,337, 

328,  374,  451 

-  liver  enlarged  from  272,  374 
tender  witli    . .  . .  272 

-  Ioc;il  peritonitis  from  ..  174 

-  nu-Ut;ri;i  fcom     . .  . .   272 

-  niiir(il.i:il  causation  of . .   254 

-  Miur()r..lr_.  after  ..  254 

-  olKiiur  pyrexia  due  to    573 
-pain    at   angle   of    right 

scapula  from..         ..  116 

in  the  back  fcom  327, 

428,  716 

epigastrium  from  327, 

437,  462 

after  food  from         . .  437 

over  gall-bladder  with  272 

in        hypochondrium 

from  ..      3" 

hypogastrium  from 

left      hypochondrii 

from 

shoulder  from    116, 

327,  47; 


450 


450 


i.tii'.ic  Cst-e  Ata\yl 

latiiig           . .      663,  078 

-  pancreatitis  and        100, 

437 

:i  ih".rninatod  sclerosis 

738 

rlL-iil  ■■.•.■luisunulatini;  659 

-  -  simulating 

328 

Jit,  cerebellar      .. 

58 

Gall-bladder    enlargement, 

-  pyloric  obstruction  from 

174 

1'  L'L'ed,  from  cerc- 

things  simulating      ..  252 

-  pyrexia  from  252,    254, 

-i.'l  .iiplegia  .. 

729 

-  -  in  lyiiliOiil  levLT    L\-,3, 

327, 

437 

-  ill  Little's  disease    . . 

139 

2.54,  335 

-  renal  colic  simulating  . . 

451 

festinatiiig,  from  paralysis 

-  infection,  empyema  from 

-  rheumatism  of  shoulder 

agitans 

252 

104,  IOC 

simulated  by . . 

708 

halting  (see  Limping)  . . 

261 

pleurisy  from            . .  lOG 

-  Riedel's  lobe  and 

300 

in  hemiplegia    . . 

139 

-  inflamed,    local   rigidity 

-  rigors    from    254,    320, 

hesitant,     in     paralysis 

over 592 

327,  374,  595, 

697 

agitans 

603 

-  mucocele  of       . .         . .  254 

-  saponified  Eats  with    . . 

101 

-  in  peripheral  neuritis 

57 

-  opened  by  hydatid,  cyst  328 

-  seldom  felt 

130 

high-steppage    . . 

57 

-  rupture    of,    peritonitis 

-  sex  incidence  of  116,310, 

limping  (sec  Limping).. 

251 

from 254 

328,  437, 

451 

-  in  sacro-iliac  disease 

csu 

in  typhoid  fever        . .  254 

-  shivering  from  . . 

437 

-  from  trench-foot 

224 

-  suppurating  (see  Empy- 

- simulated  by  cicatrizatior 

in  paralysis  agitans  252, 

725 

ema  of  Gall-bladder) 

of  bile-duct    . . 

329 

with  paralysis  of  sciatic 

tabes 252 

-  sizes  of 

327 

nerve  . . 

499 

-  tender      . . ,        2.54,  437,  597 

-  spasms  due  to  . . 

31G 

reeling  (see  Ata.xj') 

251 

Gall-stones,  abscess  of  liver 

-  stercobilin  and  . . 

101 

«;issor.     from     cerebral 

from .ICO 

-  suppurating  gall-bladder 

diplegia 

729 

-  adhesions  caused  by    . .  320 

from    . . 

320 

-  with  diplegia. . 

132 

-  age  incidence  of  IIG,  310,  328 

-  tenderness  over        254, 

450 

-  in  Little's  disease     . . 

139 

-  alkaline  ficces  with       . .  101 

gall-bladder  from     . . 

437 

shuflling,    from    lateral 

-  bile-duct  obstruction  by 

in  right  shoulder  from 

709 

sclerosis 

252 

325,  320 

-  after  typhoid  fever 

254 

-  in  paralysis  agitans  . . 

498 

-  biliousness  simulated  by  4G2 

~  urobilin  with     . . 

101 

spastic,  in  disseminated 

-  carcinoma  following     . .   252 

-  vomiting  from  . . 

.127 

sclerosis 

728 

simulated  by. .         . .  374 

-  wind  due  to 

310 

-  (and    see    Paraplegia, 

-  catch      in     breath     on 

-  without  symptoms 

327 

Spnsti.) 

palpating       . .      437,  450 

-  z-rays      in      diagnosing 

In  spinal  caries  . . 

154 

-  cholangitis    from    254.    326, 

110,  (Fig.  140) 

327 

staggering,    from    cere- 

333, 597 

Gallic  acid  (see  Acid,  Gallic 

bellar  tumour 

517 

-  chronic  pancreatitis  with  204 

Gallop  rhythm  (see  Canter 

-  in  dlKseminatcd  scler- 

-  cicatrization  of  bile-duct 

Khythin) 

'wi>< 

617 

from 329 

Galvl  (see  Salvarsan) 

HI  1  ill.  -  (lorsalis          07, 

262 

-clay-coloured  stools  from  320 

Gallon's  whistle  (/'isr.  75) 

106 

11 ii's  disease 

684 

7  colic  from  110,  130,  262, 

'                      273,  320,  327,  32S 

Galvanic  current.  In  muscle 

Nil'  1  KiL'.      in      general 

testing 

582 

p.ii.ilvsis 

720,, 

-  collapse  from    . .         . .  3'.'7 

Galvanometer,    in    muscle 

-  unsteady,  in  peripheral 

-  diagnosis  from  pancrea- 

testing  

683 

neuritis 

5G 

titis     239 

GambOL'c,  tenesmus  from 

718 

waddling,  with  congenita 

-  dilatation  of  heart  Simu- 

Games, cramps  during     . . 

150 

.|i^lo.-ation  ot  hip  15fi, 

251 

lating  430 

Gaol  fever  (see  Typhus) 

n.  |.  .  ii.lo-hypertrophic 

stomach  from            ..   174 

GANGRENE 

255 

1 vsis          ..      251, 

613 

-  duodenal     ulcer     simu- 

Albumosuria with.. 

10 

1:.  !.■               ..       420. 

C8G 

lating  3fi 

-  from  aneurys'n . .   ' 

259 

1   M  i.Mrr,  .■nr.'inoma  o( 

simulated  by         . .  272 

-  atheroma 

737 

1  .,  ,   (    ,r.  .t...r,,,ofGall- 

-  duodenum  ulcerated  into 

-  ot  bladder,  from  cystitis  078 

M  i.l-lfi  1 

bv        . .         . .      2G6.  272 

-  bulla)  in  . .           lit;,  97, 

256 

.  Hi.  , .  r,  ,  1  .  .    1  riipyema 

-  dyspepsia  from..      297,310 

-  of  check  (Fiij.  il) 

74 

.il     f  .   ill    I.I   -1   I'TJ 

-  in  fat  women     ..         ..130 

-  In  diabetes 

737 

ALL-BLADDER     EN- 

- in  fnKCS..         110,  272.  .127 

—  linger  alTccted  by    . . 

240 

LARGEMENT 

252 

-  gall-bladder    contracted 

-  from  embolism  . . 

258 

ab-ir    .      iiiml..ling    .. 

253 

from 25 1 

-  nndnrteritis 

258 

-  .ip|,,i.,h\..l,M:ussBlmu- 

enlarged   from        2.'i3.  327 

^  epiileinic,  from  ergot  . . 

259 

latod  by      . . 

1178 

not  c-nhir.-iil  witll  320,  451 

-  from  erythromelalgia  .. 

260 

-  carcinoma   simulating 

Gall-stone,     gastric     ulcer 

-  U-i Ml   ligature 

268 

2.1.1, 

368 

distinguished  from    ..  437 

ot  Iliiu'cTS,  in  Ilaynaud's 

-  from    carcinoma    of 

,ii.iul;.t.-.l   bv          .  .    272 

'li.''M<l' 

102 

duodenum  . . 

662 

Gall-stones,  general  account 

Gangrene    of    the    fingers 

-  with     carcinoma    of 

o(        327 

and  fool  (I'lalr,  Xlll. 

pancreas   61,   253, 

251, 

-  liinmateinesis  from    205,  272 

Xl  1)  . .        . .     256, 

258 

320,  330,   161, 

030 

-  heartburn  from             . .  297 

-  from  flingating  enilontr- 

-  from  cholecystitis    . . 

697 

-  hcxamethyleiictetramlne, 

dltls 

34 

-  cicatrization  of  cystic 

etc.,  for          . .         . .  060 

'  of  gums 

74 

duct 

329 

-  tndlcanuria  umisual  with  461 

-  from  glycosuria 

300 

I  (iniuircnc.  coiiHl. 

I  -  f rom hot-wutcr  bottle..  257 

'  -  ice-bag 2.JS 

-  injury     . .         . .         . .  25t; 

-  intermittent  claudication 

440,  441 

-  of  jaw 74 

-  in   leprosy  ..  ..257 
Gangrene,  line  of  demarca- 
tion in -'of.. (y'/«/,'Avr)  258 

Gangrene,  list  of  causes  of    255 
GANG  RENE  OF  THE  LUNG  259 

from  bronchiectasis  . .   25li 

from  bronchitis        . .  259 

in  diabetes     . .      259,  644 

elastic  fibres  in  sputum 

from  260,  290,  644 

from   embolism      259,  644 

foetor  from    , .         . .  644 

from  foreign  body  259,  260 

-  -  foul  >putuiii  Irt.Mi      ..    643 
,,,.,..  ir,..ii  .  .  ..705 

Gangrene  of  lung,  general 
account  of     259,  643,  644 

h:emoptysis  from      . .  287 

after  immersion    260,  644 

indiearmria    from  315 

from  infarct    . .  . .   652 

inhabitiou  of  food    . .  259 

injury 260 

latent  . .         . .         . .  260 

from      lateral      sinus 

thrombosis..         ..  259 

leucocytosis  with      . .  360 

from  liver  abscess    . .  370 

-  new  growth    . .         . .  652 
in  old  people  . .         . .  259 

-  -  from  phthisis  . .  259 

physical  signs  of       . .   259 

from  pneumonia,  259, 

644,  652 
pneumotlK 


531, 


sym- 


370 
259 


m  pyajmia      . .  . .   26U 

pyopneumothorax  from  652 

simulated  by  bronchi- 
ectasis      200,  2110,  fit:; 

empyema  260,  290,  6i;; 

fa-tid  bronchitis    ..   2i;u 

phtliisis       ..       260,  290 

-sputum  in      ..  ..    1 19 

Gangrene  of  lung,  sputum 

In        259 

stench  of         . .       86,  290 

from    subphrenic   ab- 
scess 
Gangrene    of   lung, 

ptoms  of 

-  -  nnsuspeclcti    . .  . .  ■-'.>;• 
from  wounds..  ..   'J5'.' 

-  from  pemphigus  ..  6nl 

-  peripheral  neuritis       ..  256 

-  in  llaynaudV disease  256, ■Ml 
Gangrene,  senile   ..        ..258 

-  of     skin,     leucocytosis 

slight  with     ..         ..  SCO 

-  from  snake-bite  . .  387 

-  sprcadintr  .  •         -  ■  36*" 

-  subcutaneous  oniphysema 

from 203 

-  in  svriniromyolia  . ,   257 

-  ot  testin 482 

-  from  thrombosis  ..  258 

-  tiu'ht  ImndairiiiK  ■•   258 

-  of  toes,  in  diabi-Urs      . .   240 

from  etnbolistn  . .      34 

tabes  . 

fJnrdener'ri  il 

Oarllc,  foul  hrcuth  from 

tosto  from 

Gas  in   abdomlniil    cavity 

652.  653,  n56 

-  carbon  monoxide  poison- 

ing from        . .         . .  119 

-  per  urethrani  (deo  Pnou- 

mnturiii) 

-  in    pleural    cavity    (wo 

rrienniolhorax) 

-  workent,    eurclnotnii    of 


filU 
80 
706 


kToln 


6^1 


.  inhalation  of,  hiomo- 
Klnbfmirla  from         . .   28  I 

-  Irrlmnt,  coryza  from    ..  17H 

-  larynKltiB  from         ..  157 

-  poiHonou)<,  liendncho  from  295 


822 


GASSERIAN    GANGLION 


GENERAL   PARALYSIS 


Gasserian  ganglion,  exci- 
sion of,  necrosis  of 
cornea  from  . .         . .  734 

herpes  of       . .         . .  447 

G^astralgia,  dyspepsia  from  319 

-  epigastric         tenderness 

from 437 

-  pain  in  epigastrium  from 

319,  43fi 
after  food  from         . .   43  7 

-  in  young  women  ..   437 
I  iastrectrisis    (see     Dilata- 
tion of  Stomach) 

I  iastric  c.ircinoma  (see 
Carcinoma,  of  Stomach) 

-  COiltfMil--,  ■■if^rriir  in        .  .       78 

-  -    binoil     111.     Ilnlii     ,:irci- 

lloni.i   nf  ■^InUM.-h    ..     317 

Gastric  contents,  in  carci- 
noma of  stomach      . .  270 

Gastric  contents,  in  dilata- 
tion of  stomacli        .  ■  766 

Gastric  contents,  estima- 
tion of  total  acidity  of  320 


HOI 
Hv 


Acid, 


occult  blood  in        G30,  7G7 

Oppler-Boas  biicilli  in  320 

Gastric    contents,    organic 
acids  in  . .  320 

-  -  poison  in    78.  Sij,  108,  417 

-  -  sarcinff)  in       llo,  241,  320 

strychnine  in  ..417 

unduly      acid,      with 

gastric  ulcer  . .   437 

-  -  yeasts  in  241,  318,  320,  766 


Gastric  flatulence,  general 
account  of  ..  : 

-  fullness     (see     Fullness, 

Gastric) 

-  juice,  absent,  in  gastritis  ; 
Gastric  juice,   absence   of 

HCI  from 

-  "  acidity  diniinislicd,  iu 

analyses,  in  diagnosing 

gastrectasis  . .   '. 

diarrlicca     . .  . .   ; 

chan.Lrcs,    with    cai-ci- 


Gastric  juice,  characters  in 
chronic  gastritis      43, 

-  -  unduly     su-id,     with 

duodenal  ulcer 

gastrin  ulcer 

(and  see  under  Gastric 

Contents) 
Gastric  peristalsis,  visible. . 
~  sarcoma  (see  Sarcoma  of 
Stomjich) 

-  ulcer,  abdominal  tender- 

ness with 

abscess    of    omentum 

from  . .         . .  I 

acetonuria  from 

acute  ascites  from   . . 

peritonitis  from    . . 

adhesions  from 

age  incidence  of      3G, 

albumosuria  with     . . 

ana3mia  with..        3G, 

blood  per  anum  from 

in  vomit  from 

-  -  carcinoma  from     316,  ■ 

in  chlorosis    . .         . . 

chronic  dyspepsia  from 

cicatricial  fibrosis  of 

coffee-ground      vomit 

Gastric    ulcer,    diagnosis 
from  anaemic  vomiting 


~  -  dist 

denal 
-  -  distingu 


fron 


from       104,  lOli 


Gastric  ulcer,  contd. 

epigastric     liyperaas- 

thesia  from  . .   : 

pain  with     . .         30, ! 

excess  of  acid  with  . .   ■ 

-  -  females  affected  by  . . 
Gastric     ulcer,     gall-stone 

distinguished  from    . .  < 

Gastric  ulcer,   general  ac- 
count of  36,  : 

peritonitis  from     .. 

htematemesisfrom,  36, 

75,    2G5,    266,    268, 
269,  317,  ' 
lisemorrhagic   erosions 

and  . .         . .         . .  : 

-  -  HGl  in 

heart-burn  from       . .   : 

liyperacidity  with     . . 

indicanuria  from     . . 

inflammatory  matting 

round        \.  . .    '. 

leaking  . .  . .   . 

constipation  after..   : 

local  peritonitis  from 

-  ' rigidity  over  . .   ; 

spot   of    tenderness 

from        . .       317, 
loss  of  weight  from   . . 

-  -  mela^na  from    7."*.  268, ! 


ub    Mouil 


h'l.  rj 


-    CEd.-ni:i    i^r    \---^   :iltrr.. 

■  pain  HI  tlic  buck  ivom 

269,  428,  437, 

■  -  chest  from. . 

■  pain  due  to    . . 

■  -  in    the    epigastrium 

from        208,  436, 

-  after  food  from  75, 

269,  317, 

-  left  hypochondrium 

from 

-  hypogastrium   from 

-  shoulder  from 
jiancreatic  artery 

opened  by  . . 
pancreatitis  from    100, 
perforation  of  47, 

-  acute     abdominal 

l)ain  from 
panci'eatitis  simu- 
lating . . 

-  collapse  from 

-  pain  in  ejjigastrium 

from 

-  laparotomj'  for     . . 

-  pneumoperitoneum 

■  -  shock  from 


pie 


^y  fro 


ptyalism  from 
pyloric  stenosis    from 
174,  269,  297,  317. 


■  -  cirrliosis      . .       269, 

-  -  duodenal  ulcer     36, 

-  -  dysmenorrhcea 

■  -  gastric  ulcer 

■  -  gastrostaxis  36,  76, 

266,  268,  : 

-  heart  disease      436, 

■  ~  lealiing  pelvic  lesion 

-  -  tabes  . .         . .  , 

-  undue       abdominal 


-  -  splc 


I'.V 


.--  -  subcutaneous    einphy 

sema  from..         ..   203 

subdiaphragmatic  ab- 
scess from  103,  451, 

531,  652,  658 

sudden  pallor  from  .  .    268 


Gastric  ulcer,  contd. 

suppurative  peritonitis 

from 
tenderness     in     cliest 

from  . .  . . 

tetany  from  . . 

tumour  witli  . . 


.r-rays     m    diagnosmg 

Gastritis',  acute,  abdominal 
pain  from      . .  . .  ' 

from  alcohol  . .         . .  ; 

arsenic  poisoning  simu- 
lating . .  . .   ' 

from  corrosives        . .  : 

diarrhoea  with 

diphtheria  bacilli  caus- 


ing 


267 


from  errors  of  diet  . .  267 

-  -  i7astroscope  in           . .  267 
Gastritis,     acute,     general 

account  of                . .  267 

-  -  h;.-iti.ii.- -i>  from  265,  267 

-  -  from  irrU;uits            ..  267 

-  -  nausea  from  . .          . .  766 
phosphorus   poisouhig 

simulating  . .          . .  760 

pneumococci  causing  267 

from  pyorrha'a  alveo- 

laris 267 

pyrexia  with  . .          '. .  766 

from  septic  teeth     . .  267 

stomatitis       . .          . .  267 

streptococci  caushig. .  267 

-  from  alcohol        43,  267,  317 

-  appetite  diminished  in.,.  43 

-  carcinoma    of    stomach 

simulating      . .         . .  270 

-  chronic,  from  alcohol  . .  317 

in  cirrhosis     . .          . .  317 

epigastric  pain  from. .  766 

fullness  in  epigastrium 

from            ..         ..  317 
Gastritis,    chronic,    gastric 

juice  changes  with    ■■  317 
Gastritis,    chronic,   general 


account  of 

uatc 


Iru 


HC!  diminished  in    . . 

loss  of  weight  from  . .  : 

nausea  from  ..      317;  ' 

from  oral  sepsis       . .   ; 

ptyalism  from  . .  i 

in  renal  disease        . .  : 

secondary     to     back 

pressure      . .  . .   , 

from  tea         . ,  . .   , 

weight  in  epigastrium 

from  . ,         . .  : 


iHi 


43, 


Gastritis,  general  account  of  317 

-  heart   dise;i.su'   sunulated  435 

-  with  mitral  disease 


vith 


320 


-  with  nephritis    . .         . .  43 

-  pain  in  the  back  from  . .  716 

-  -  limbs  in          . .          . .  403 

round  heart  from     . .  435 

in  shoulder  from       . .  474 

-  palpitation   from           . .  435 

-  rheumatism  of  shoulder 

simulated  by..  ..  708 

~  from  tobacco     . .        43,  317 

-  toxic,  hfematemesis  from  265 

-  uremic 315 

-  vomiting  from  317,  765,  766 
Gastrocnemii,  pseudohyper- 

ti-ophy  of       . .  . .   513 

i  Gastrocnemius,  bursa  under  692 
~   ^^orvf'  Mipplv  nf  498,  499 

■,,Hi,iiiM  ■  linni'  ..    766 

t,  i^ii.>.h.ipl,,Mi\       .  .  ..660 

Gastro-enterltis,       general 
oedema  from  . .        . .  413 

-  influenza  complicated  by  563 

-  in  trichinosis     . .  . .   464 
G  astro-enter  ostomy  in  error, 

in  tabes  . .  . .   484 

-  for  pyloric  stenosis      . .  174 


G  astro-intestinal     disorder 
febricula  representing 

headache  from  . .  ; 

insomnia  from  . .  ; 

from  round-worms    . .  i 

in  rickets       . .         . .   : 

rigor  fi'om      . .         . .  i 

tetany  from  . . 

-  secretions,  not  tinged  b^' 

jaundice         . .         . .  ; 
Gastroptosis,  asthenic  dys- 
pepsia with    . .        ' . .  ; 

-  with  gastric  atonj'       . .  : 

-  movable  kidney  with  . .  : 

-  a:-rays      in      diagnosing 

(Fig.  141)  ; 
Gastroscope,  in  diagnosing 

acute  gastritis  . .   : 
carcinoma  of  stomacli 

Gastrostaxis 

-  age  and  sex  incidence  of  : 

-  in  chlorosis        . .         . .   : 

-  gastric ulcersimulatedbv 

76',  ; 
simulating  . .      268,  : 

-  hsematemesis  from    205,  : 

-  from   hsemorrhagic   ero- 

Gaucher's  disease,  conjunc- 
tivas in  . .         . .  t 
familial  acholuric  jaun- 
dice and     . .         . .  * 

family  history  and    . .  t 

special  cells  in         . .  ( 

spleen  enlarged  in    . .  < 

splenic  ancemia  and  . .  i 

von   Jaksch's   disease 

and ( 

Gauze    packing,    pain    in 
pelvis  after    . .         . .  - 

Gelle's  test 

Gemelli,   nerve   supply   of  • 
General    paralysis    of    the 


Argyll       Kobertsori 

pupil  in   . .  , .   , 
bedriddenness   from 

bleeding  gums  in  . . 

cerebral     softening 

from        . .  . .  '. 
cerebrospinal     fluid 


coma  in    117,  120, 

144, 

congestive  attacks  in 

convulsions   in    li'ii. 

141,  116, 

deep  reflexes  in     . . 

defective   wxiting, 

etc.,  in    . . 

dementia  from 

dysartln-ia  in 

dysphagia  in 

epileptiform  seizure 


i(l<-a<     in 
120.  146.  243 


-  grinding  of  teeth 

-  haematomata  in    . . 

-  headache  from 

-  hearing  of  voices  in 

-  hemiplegia  in    303, 

305, 
■  insomnia  from 
irritability  in 
judgement  defective 


brospiiial  Ihiid  in 
305,  ; 

uiemoiy  defective  in 

mental    and    moral 

changes  in 
mental  work  and. .  : 


GENERAL  PARALYSIS 


GOXOCOCCI 


ewral  paralysis  of  insanf,  con. 

paraplegia  in     514,  518 

penile  erection  ab- 
sent in    . .         . .  313 

perforating  ulcer  of 

foot  in    . .  , .   735 

plumbism  simulating 


119, 


14G 

170,  552 
simulating    cerebral 

hiemorrhage   120,  305 

sordes  in    . .         . .     73 

spasmodic     twitch- 

ings  in    . .  . .  13G 

speecli    blurred     in 

14G,  720 
spontaneous  fracture 

in  ..      242,243 

stammering  from..  628 

" syphilis  and       243,  495 

tottering  gait  in  . .  72G 

tremor  m  140,  724, 

726,  727 

-  -  Wassermann  reaction 

in..  ..      120,  243 

wasting  in  . .         . .     59 

weakness  of  muscles  140 

worry  and  . .         . .  243 

writers*  cramp  simu- 
lated by..         ..  151 
eniculate  branch  of  ob- 
turator nerve  . .  303 
enital  organs,  coli  bacil- 
luria  after  operations  on  70 

-  condylomata  round  . .   400 

-  clepliantiiwis  of         ..28 

-  external,  elands  .Irain- 

ing 079 

Bnital  organs,  herpes  of 

753,  754 

-  Jacfiuet's  erythema  of  401 

-  myoma  cutis  of        . .  732 

-  CDdema    of,    in    acute 

nephritis     . .         . .       9 

-  precocious,         hyper- 

nephroma and  (Fi(i. 
175,    p.    408),    409.    030 

-  scabies  of       . .         . .  755 

-  syphilides  affecting  . 

-  syphilitic  papui( 


560 


297 


tmd 

region,  lice  affecting    . . 
cnito-orural   region,  ery- 

thrasma  of     . .         . .  ! 
entian,  heartburn  relieved 

by 
taste  of 
eographical     distribution 

of  ankylostomiasis  81,  521 

-  beri-beri  . .  . .     03 

-  bilharzia  . .        79,  282 

-  chorea  major. .         ..   134 

-  (U'lit-'ue  . .  . .  400 

-  lii-iinina  pulmonale  ..  292 
(  1(11:1  marginatum..  250 
'  l<  i.liintianis  ..  ..28 
I  I'll' nilc  gangrene    ..  250 

I  I  1'  hillOSJA        . .  . .    404 

li>'i>.iUr  abHces.1         . .  291 
!.«,  I  .1  id  dLsonse  49, 291,058 

I  m  1 1 1  ■  I  iu'o  herpotlform Is  98 

k.Ui-azar         . .        29,  633 

-^  linig  lluko       ..         ..  015 

-  malaria            , .          . .  H32 

-  Malta  fever    ..          ..  100 

-  Mediterranean  fever..  300 

-  mollitles  ostium        . .  212 

-  mycetoma       . ,          , .  730 

-  oidium  tropicale       ..  015 

-  primary  alcoholic  heart    53 

-  relapsing  fever      330,  590 

-  slcejiing  sickness       . .  28 

-  yellow  fever  . .      273,  336 
Lsleit,  albumin- 


I  In.. 


13 


-  dij 


from  scarlet 


enlarged  posterior  cer- 
vical glands  ill       . .   502 
erythema  in  . .      223,  228 
fourth    dtKcnse    simu- 
lating ..  ..230 
Ivniphatlc  glands  cn- 
■  lurired  In    228,  370, 

377,  378,  502 


German  measles,  contd. 

macules  in     . .         . .  502 

measles    distinguished 

from  ..         ..377 

occipital  glands  en- 
larged in    . .      377,  378 

rash  of  . .         . .  228 

scales  in         . .         . .  602 

scarlet  fever  distin- 
guished from         . .  377 

simulated  by     . .   228 

sore  throat  in  . .  613 

Germany,  primary  alcoholic 

heart  in  . .         . .     53 

Gestation,      ectopic      (see 

Ectopic  Gestation) 

-  tubal  (see  Ectopic  Gesta- 

tion) 
Giant  cells  in  tuberculosis  403 
Giddiness  (and  see  Vertigo) 

-  in  angina  abdominalis. .   115 

-  arteriosclerosis  ..  ..      11 

-  from  cerebral  abscess  . .  306 

-  -  tumour  ..      302,  300 

-  after  flushing     . .         . .  241 

-  due  to  increased  intra- 

cranial pressure        . .  590 

-  in  nephritis        . .         . .     42 

-  pellagra  . .  . .  . .    225 

-  preceding    hffimatemesis  280 

-  from  snake-bite. .         ..  337 

-  in  unemia  . .         . .     40 

-  Weil's  disease  . .  . .  330 
Giemsa's  stain,  for  spiro- 

chfBta  pallida  . .   701 

Gigantism,  infantilism  with  188 
Gigantoblasts    {Plate     11, 

Fig.   P,  3)     22 
Ginger,  heartburn  relieved 

by        297 

Gingcrheer,     regurgitation 

through  nose..         ..  588 
Gingivitis,     blood-spitting 

due  to. .  . .  . .  285 

-  septic,  purpura  and     . .  557 

-  suppurative    (see    Pyor- 

rhcea  ^Vlvoolaris) 

-  from  syphilis  . .  . .  73 
-  tuberculous  . .  72,  74 
Giraldis,  organ  of,  cyst  from  48 1 
GIRDLE  PAIN  .260 

from  aneurysm  . .    131 

from  cord  compression 

200,  516,  713 
in  disseminated  scler- 
osis   200 

from  fractured  spine 

431,  430 
hromatomvelia 


velitis 


from 

spin 


,vth 


200 


714 


spastic  paraplegia     200 

from  spinal  injury    . .    715 

syphilitic  spinal  menin- 
gitis ..         ..  260 

-  -  in  tabes  . .  260,  430 
with  transverse  myelitis 

140,  430 

-  sensation,  in  disseminated 

sclerosis  . .  . .   009 

-  -  tabes  ..  ..*  116,  609 
Gland  puncture  fn  diagnosis  28 
Glanders,  arthritis  with  . .  340 

-  bacillus     (see     JJacillus 

Malloi> 

-  bacteriology      in      dia- 

gnosing . .  . .  550 

-  hullm  in  . .         00,  07 

-  horses  and         . .  . .     97 

-  of  leg  . .  . .    737 

-  lungs  affected  in  . .      07 

-  nasal  discharge  in  ..    170 

-  ow'upatlon  in  rliagnosinv  170 

-  pyrp\iu  in  . .  . .      07 

Glanders,  skin  lesions  of. .  559 


-  -  epithelioma  of 
Glaucoma  {Piute  XI) 

-  age  f ucidnncp  <if . . 

-  anterior  chamber  shallow 


Glaucoma,  contd. 

-  ciliary  vessels  injected  in  : 

-  from  close  work  . .  : 

-  conjunctiva  injected  in 

-  cornea  anaasthetic  in  . .  ; 
steamy  in       . .      232, 

-  cup,     distinction     from 

physiological  . .  . . 

-  from  dietetic  error 
Glaucoma,  disc  of.. 

-  disc  in  {Plate  XX)      . . 

-  halos  round  lights  from 

-  headache  from  233,  294, 

295, 

-  hyperacusis  from 

-  in  hypermetropes 

-  inflammatory     . . 

-  iris  discoloured  in 


-  i.jii 


-  pain  from  . .         . .  : 

in  the  ears  from        . .  '. 

eye  from       233,  445,  i 

face  from       . .         . .  - 

head  from      . .  . .  : 

teeth  from     . .  . .  : 

-  photophobia  from    231, 

524,  i 

-  presbyopia  increased  by  ; 

-  pupil  dilated  in         232,  ' 
and  fixed  in  . .  : 

-  rainbow  vision  from  233, 

-  sex  incidence  of  . .  ! 
~  sick-headiiche  simulated 

by       : 

Glaucoma,  signs  of 

-  tenderness  of  eyeball  in  : 
scalp  from      .  .  .  . 

-  tension    of    eyeball    in- 

creased in      232,  233, 

-  unequal  pupils  from   . .  ; 

-  visual  field  constricted  in 

760,  ' 


Gleet,  general  account  of 

182,  183 

-  gonorocrj  in       , .  . .    isi 

-  marriage   in    relation    to  IKI 
GR'nard's  disease..  ..  059 
Glioma    of    brain,     hemi- 
anopsia from  . .  301 

-  eauda  eqtiina     . .  . ,     (i2 
Gliosis,  spinal,  pain  in  arm 

from 413 

-  in  Hvringomvclia  ..   110 
Globulin      and      albumin, 

relative  proportions  in 

-  in  ascitic"  fluid   V.  IH,  50 

-  cerebrospinal  fluid        . .  305 
Globus  hystericus  197,  465,  051 

-  aphonia  and  . .         . .  495 
hi  hysteria     . .         ..Ill 

-  major,  tuhercidous       . .  097 

-  minor,     swollen,     gonu* 

coccal 097 

Glossina  palpalli,  trypano- 

somcs  from  . .  . .  28 
Glossitis,    chronic,   cnrcln- 

omaaml         ..         ..738 

-  -  leukoplakia  and         . .  008 

smoking  and . .         . .   738 

Kvphilis  and   . .  . .   73K 

-  dyMp'"Hri'*  from. .  . .   lOK 

-  lonKiic  swollen  from  I  OK.  008 
Glosso-kinnwlhetie     centrn 

f^iV?.  206)  024 
Glossu-phar\*ngeal       nerve 

pnnily«is  ..  ..  "00 
Glot  l\9,     trdcma    of    (wee 

fKdemn  of  T.iir>'nx) 
Glovf»  aniiwtheHlii,  hi   hys- 

U'tU  ..       131,  406 

fnim  peripheral  neuritis  50 

in  syrlngoniyctlii       . .  609 

-  and  stocking  aninMlhwIa 

(/■/;?.  250)  «nO 


Glucose,  quantitative  esti- 
mation of 

Gluteal  nerve,  hiferior 

superior 

-  region,  condylomata  on 
Glutei.    at:i-ophy    of.    from 


Gluteus     ni;i\-imus.     nerve 
supply  of        . .         . . 

-  medius,  nerve  supply  of 

-  minimus,  nerve    supply 

of         ■ 

Glycerin,    hemoglobinuria 

from : 

Glycogen,  relation  to  acid- 


-  albuminuria    in    testing 

for 

-  from  alcoholism  85, 


estini;itinn  by  fermenta- 
tion       

fermentation  test  for  . . 


nc.  -Jui,  :vM),  437,  ■ 
peripheral  nemitis  from  . 
phenylhydrazine  test  for 
in  pituitarv     infantilism 


Glycosuria,  proqnosis  with 
Glycosuria,  significance  of 

263.  E 

-  in  starvation 
Glycosuria,  symptoms  of  .  : 

-  temporary,  in  aUnlM.ltr^  : 
from  cerebral  hnMiior- 

rhaw  ..         ..  ; 

-  -  head  injury     '.'.  '.'.I 

-  -  p:inrnMtiti<     .  .  ..    : 

Glycosuria,  tests  for  .  ! 

-  nrir  a.'i,!  :ind      .  .  .  .    : 

-  (:ind  M-cIijahrtes) 
Glycuronic  a<'i<l  (see  Acid, 

Glyciironic) 
Gmelin's  test  for  bile 
Gnat  bite,  swelling  of  face 

from    . .         . .         . .  ( 

-  vesicles  from      . .         . .  ' 
Goat's  milk,  Mediterranean 

fever  froi  . .  4(jO,  i 
God,  dehision  <'oncernlng  ■ 
Goitre,   asthma  simulated 

by      : 

-  cyanosis  from    . .  . .   1 

-  dyspnira  from  . .  . .  1 

-  oxoplithidmic(seeOraves'H 

Disease) 

-  hemorrhage  into  . .   1 

-  parencliymatoutt,  in  anio- 

mic  girls        . .         . .  : 

breath le-wness    with..  1 

palpitation  with        . .  ' 

simulating      Graves's 

*  (liseiLse        . .         . .  I 

-  -  tnchycanllft  with       . .  ' 

-  Huppuiiilioii  in  . .         . .  1 
Goitres,  varieties  of  (and  him- 

Thvroi.l  Gland.  En- 
lart'.'d)  ..  ..    : 

Gold  ininrr-.  sllicoHi^  in    ..   I 

Golfers,  Rubncrotninl  bur- 
sitis in 

Gonococcal  arlhrtlls  (se« 
ArlhrilK  GnnococcaO 

Gonn.-mvi(/V.ir.-.YAI7//)  ) 

-  acute  itscitcH  from 

-  arratiifcr it  in  pairs  . .   I 

-  In  arthritic  thi{<l  ..  : 

-  In  asoitic  fluid 

-  bacterliiria  from 

-  Inoervlx 


824 


GONOCOCCUS 


GROOVERS 


Gonococcus,  characters  of  182 

-  incliordee  ..  ..108 

-  infective        endocarrlitis 

from     . .  . .      i317,  574 

-  fasciiB  affected  by        . .  340 

-  in  female  ui-ethra         . .   700 

-  gleet        184 

~  go'norrlicea  . .  . .   617 

-  lesions   due   to,   oiisonic 

index  in  diugnosins  . .   340 

-  inside    leucocytes      1^2, 


-  orcliitis  li'uni      . .  , .     07 

-  in  otitis  media  . .  , .   422 

-  prostatitis  due  to  . .     70 

-  recovered  on  blood  cul- 

ture      597 

-  retiiform  shape  of         . .  591 

-  rheumatoid  arthritis  from    35 

-  spread     to     ejaculatory 

ducts,  etc 182 

-  tendon  sheaths  affected 

by        340 

-  in  urethral  discharge  G7,  181 

-  urethritis  due  to       70,  182 

-  in  urine 69 

-  vaginal  discharge  . .   18.'> 

-  vulval  discharge  . .   700 
Gonorrhcea                    182,   183 

.ih--.v^--  .,f   t.-li.  ffMiii   .  .    022 

Gonorrhcea,  arthritis  and  ■  ■  340 

t;iiid      see       Arthritis, 
Gonococcal) 

-  ascending  nephritis  from    13 

-  bacteriology  "   in      dia- 


ulating     . 
from 
lands  red  i 


700 

-  I.in->i(is  irum      ..  ..439 

-  ..amiicule     myrtiformes 

inflamed  in    . .         ..700 

-  honlee  from     ..      108,  617 

.  n,,iin,,'tiviti^  from       ..   231 

n-,,  inn-    from  ..    142 

.   ■      UM      h.nn  ..  ..     182 

--riM|,N.I,  ,  iruni            ..  219 

iri.li.lvnuli^  irom        66,  697 

'■IM.liilymo-urchitis  from  478 

Gonorrhoea  in  female,  notes 

on        700 

-  iibrositis  from   . .          . .  439 

-  gangrene  from  . .          . .  255 

-  gout  simulating             . .  742 

-  hsematnria  in     . .      182,  282 

-  indamnl     livmeueal    re- 

in ir.-'  fr.ufi     ..  ..194 

■I  in  ;  il     I  Ml. Is  enlarged  381 

■   iiii-.MMH,  tr>i.  in  ..   182 

-  luiuL  leMuris  U'Om       252,   340 

-  micturition  fi'equent  in     182 

-  orchitis  from     . .         . ,     66 

-  oxynris  vermicularis  simu- 

lating . .  ..  ..   520 

-  pain  in  feet  from  . .  439 

penis  from       . .  , .   469 

urethra  from  ..  ..   (517 

-  painful  erections  in      . .  182 
micturition  in  . .  182 

-  papilloma  uretlirge  from 

184,  700 

-  I'lin^^phaturia   suggesting  524 


5m8 


Gonorrlicea,  prostatic  threads 
after 399 

-  prostatitis  from. .  ..   473 

-  pyuria  from       ..         ..  575 

-  red  meatus  from  . .  182 

-  residual  in  prostate     . .     67 

-  retention  of  urine  from  649 

-  rigors  from         . .  . .   597 

-  scalding  in         . .      182,  700 

-  soft  sores  from  . .         . .  700 

-  spondylitis      deformans 

from    . .  . .  , .    714 

-  strangury  from..  ..   649 

-  -^-"r.Nv.-Wi  in  ..  .,341 

"        IT   ..  ..396 

■  !  la   after    66,  313 
182 


Gonorrhcea^  contd. 

-  uretlu-al  discharge  due  to  469 

-  urethritis  simulating    . .   181 
Gonorrhoea,    vaginal    dis- 
charge of  .185 


uhal  . 


Gonorrbceal  rheumatism 
(see  Arthritis,  Gono- 
coccal) 

Goodhart,  Sir  James,  on 
blue  brain       . .  . . 

Gooseberries,  oxalate  fi'om  ■ 

-  oxaluria  after    . .  . .   '. 
Goose-flesh,       xerodermia 

simulating      . .  . .   ■ 

-  papules  in  . .  . .   - 
Gordon    Museum,   illustra- 


-  ;iri;;iiLii,  ^il Kiuniiiialis  from 

-  atrophy  of  testis  fi'om. . 
~  lialaiiitis  from   . .         . .  ' 


<-  from 


734 


Mgiaand..  442 


~  i>ii|iuviiv[i"s  contracture 

-  dyspepsia   from  319, 

-  eczema  of  perineum  from  ' 

-  epididymitis  from 

-  epididymo-orchitis  from 

478,  ■ 

-  epistasis  from  . . 

-  erythema  in 

-  family  history  of 
Gout,  general  account  of. 

-  giddiness  from  . . 

-  glycosuria  and  . .      264,  't 

-  gonorrhcea  simulated  by  ' 

-  great-toe  ioint  and       . .   X 

-  of  hands  (Fig.  158)       . .   i 

-  lieadache  from  . .         , ,  i 

-  jaundice  from    . .  . .  ] 

-  joints  affected  by         . .  i 

-  Micuiicz's  syndrome  ill. .  ( 

-  nails  affected  by  . .  ; 

-  nausea  from       . .         . .  ] 

-  neuralgia  in       . .         . .  ■; 

-  orchitis  from      66,  478,  1 

-  osteo-arthritis  simulating  ; 

-  o.^aluria  in         . .         . .  h 

-  pain  in  big  toe  from     . .  ■; 

limbs  from     . .         . .  - 

penis  from      . .  . .   - 

-  peripheral  neuritis  from 

61,       t  ■] 

-  from  plumbism . . 

-  priapism  from  . .         . .  I 

-  pyiemic  joint  simulating  ; 

-  p3rrexia  in  . .      344,  ^ 

-  rarity  of  suppuration  in 

joints  in         . .         . .  J 

-  rigors  from        . .         . .  f 

-  salicylate  ineffectual  in  ; 

-  senile  gangrene  and  . .  ; 

-  skiagram  of        . .  . .  ; 

-  soles  affected  by  . .  i 

-  swelling  of  bones  in  . .  ( 

-  syphilis  simulating  . .  ; 

-  tabes  simulating  . .  ■: 

-  temperatm-e     chart  in 

acute  . .         . .         . .  ; 

-  tenderness  of  spine  from  ' 

-  tendon  sheaths  affected  ; 

-  tinnitus  from     . .  . .  1 

-  urate  of  sodium  deposits 


-  urethritis  from  181,  538, 

Gout,  uric  acid  and      741,  \ 

~  vertigo  from 

-  vomiting  from  . .         . . 

-  a:-rays  in  diagnosing     . .   ; 
Gowers,  epilepsia  media  of  '. 

-  myopathy  of     . . 
Graafian    follicle,    htemor- 

rhage  into 
Gracilis  nerve  supply  of. .  ■ 
Grain,  sporotrichosis  from  : 
Grand  mal. . 


Grandidier  on  hsemophiUa 
Grandiose  ideas,  in  general 
pnralysifi 


-  -  ;,llmh nia  with  406,  537 

~  -  apical  .-,yst,olic  bruit  in     89 

apoplexy  from  . .     11 

arteriosclerosis     allied 

to  ..    1,11,212 

Granular     kidneys,     from 
ascending  nephritis  ..      8 

ascites  from  . .  46,  55 

back  pressure  from  . .     46 

cerebral     haemorrhage 

with       12,  84,  119,  303 
Oheyne-Stokes  breath- 
ing from      . .          . .   167 
--  -  cyanosis  from             .  .    161 
Granular    kidneys,     cystic 
type 12 

„  _  ..,,i-t,iM-~  irnm  ..    220 

-  -   h;e.Mal.r'.     ■-    M-nTi,     ,.    271 


heai 


I  Ob, 


Granular     kidney,      heart 
failure  from  H,  14,  46,  55, 

161,  418 
high        Iilood-pressure 

with    2,  14,  40,  81, 

90,    106,    161,   211, 

400,  418.    184,  588 
mitral   regurgitation 

from  2,  89,  90,  211 
nocturnal   micturition 

with  .,  ..12 

noises  in  the  head  with  406 

-  -  orthopnn-a  from        .  .    418 


aftr 


14 


Granular  kidneys,  pale 
contracted.  general 
account  of  II 

palpitation  from       . .   484 

pericarditis  with       ..     11 

peritonitis  with         . .     11 

pleuritic  effusion  with     11 

from  plumbism         . .     34 

polyuria  from  12,  90, 

533,  535,  536,  537 

precordial  pain  in     . .     11 

pregnancy  and  . .       9 

radial  artery  thickened 

with  . .  . .     00 

Granular  kidneys,  red 
contracted,  general 
account  of  II 

-  -  rcfluplicaliun     of    first 

sound  with..  ..  588 
second   sound  from  588 

-  -  retinitis  with..        90,  106 
ringing   aortic   second 

sound  with..  ..  106 
Granular  kidney,  signs  of.  ■  2 
simulating  mitral  sten- 


55 


Granular  kidney,  symptoms 
and  signs  of  . .         . .       t 

tube  casts  from        . .   537 

-  -  (and      see       Brierht's 

Disease:  and  Nephritis) 
Granulosis  rubra  nasi      .  ■  654 
Grape  sugar  in  urine  (see 

Glycosuria) 
Grating  in  joints  . .      346,  347 
Gravel         741 

-  in  urine  after  renal  colic  451 
Graves's  disease,  Addison's 

disease  simulated  by     722 
age  and  .sex  incidence 


of 


albuminuria  in 

amenorrhcea  in 

arteries  forcibly  pulsa- 
tile i 


215 


breathlessness  : 

bruits  in         . .          ..  215 

cachexia  in     . .          . .  99 

conjunctiva  bright  in  236 

Dalrymple's  sign  in..  722 

diarrhcea  with           . .  172 

-  -  difficult  cases  of       . .  722 

excitability  in        215,  722 

exophthalmos  in  215, 

320,  229,    236,  4SG, 

703,  722,  726,  734 


(haves' s  disease,  contd. 

eyelids  retracted  in  . . 

Graves's  disease,  fades  of 

iFig.  113)  23i 

flushuig  in     . . 

functional  bruit  i 

-  -  glycosuria  in  . . 

heart  enlarged  in  206,  21 

hyperacusis  in 

irritability  in . . 

loss  of  weight  in    215,  77' 

low  blood-pressure 

menorrliagia  in 

mental  changes  in     . .   72< 

Moebius^s  sign  in   215, 

nervousness  in       229. 

4SG.   703,   77( 

-  -  noises  in  the  hea.i  in..   40i 
Graves's  disease,  notes  on 

703,  722,  721 

redema  of  eyelids  in  . ,  23' 

palpitation     in      484, 

486,  722,  72( 

pigmentation  in     21'>, 

236,  (^Fig.  222)  527,  72: 

pupil  in  . .  . .   23( 

Graves's     disease,      short 
account  of  ..  2fE 

shortness    of     breath 

from  . .         . .     81 

skin    moist     in  . .   23i: 

spasm  of  levator  pal- 


spasmodic    twitchings 


229 


130 


stare  of  . .  . .   230 

Stellwag's  sign  in  215, 

229,  722 

sweating  in    . .         . .  720 

tachycardia    in     215, 

"    229,  486,    549,  702, 

703,  722,  726,  770 

tears  excessive  in     . .  23C 

thyroid  gland  enlarged 

in      215,    229,    486, 

703,  722,  726,  770 

~  -  pulsatile  in     215, 

694,  722 

tremor  in     215,   229, 

703,  722,  724,  720,  770 

ulcer  of  cornea  in     . .  734 

with  undue  abdominal 

aortic  pulsation     . .  543 
violent  arterial  pulsa- 
tion in         . .  . .   094 

von  Graefe's  sigu  in 

215,  229,  722 

wasting  in       . .  . .    726 

winking  deficient  in. .  23C 

without  exophthalmos  48R 

thyroid  enlargement  486 

Gravid  uterus    (see  Preg- 
nancy) 
Greedy  colon        . .         . .  123 
Green   cancer  (see    Chlor- 
oma) 

-  sickness   (see   Chlorosis) 
Greenstick     fracture    (see 

Fracture) 
Grief,  dyspepsia  from      . .  337 
Grimacing,  in  chorea       . .   133 

-  hysterical,     simulating 

tetanus  ..         ..138 

Grin, -sardonic  (see   Risus 

Sardonicus) 
GRINDING  OF  TEETH    ..  265 

in  general  paralysis  . .   72G 

from  gumboil  . .   205 

-  -  habit 265 

worms  . .  . .   205 

Grip,  pelvic  . .         . .  200 

Griping    (see    Colic ;    and 

Tenesmus) 
Groanings  in  head  . .  406 

Grocer's  dermatitis  . .   755 

-  itch  540 

Groins,  cliromidrosis  of  . .   655 

-  eczema  marginatum  on  2r^0 

-  lymph    glands    in     (see 

Lymphatic  Glands, 
Inguinal ;  and  I^ym- 
pliatic  Glands,  Femoral> 

-  swelling    in    (see   under 

Swelling) 
Grooms,  glandere  in       . .  179 
Groovers,      electric     steel., 

subncromiiil  bursitis  in  -170 


GROWING   PAIXS 


H^EMATTRIA 


Stowing  Pains  IJ,  362,363, 

464,  46C 

-  -  iu    liistory    of    heart  ' 


363 


Jrowth,      stunted, 

coeliac  disease          ..  171 

-  in  cretinism    . .         . .  33-t 

■  -  Hanot's  cirrhosis  . .  372 
•  -  spteiiomeKalic  cirrhosis  332 
Juaiacol,       diazo-reaction 

from 173 

■  foul  breath  from           . .  86 

■  -  taste  from  . .  . .  705 
Joaicum  test  for  blood  . .  75 
-  -  iodine  in  urine  and  . .  98 

■  -  in  verifyiiii?  hJEmoptysis286 
ruanin,  uric  acid  from  . .  742 
hiinea-pig  inoculation  (see 

Animal  InocuHtion) 
lUinea-pigs,  general  tuber- 


culo 


ini 


;,  epithelioma  of      ..   :iiit 

paiiilloma  of      . ,         . .     T 1 

rumboil,  alveolar  abscess 

and      ..  '..  ..683 

foul  taste  from..  ..   705 

grinding  of  teeth  from. .   265 

pain  in  the  fare  from  . .   446 

ptjalism  from  . .  . .  542 

Jumma,  abscess  from     . .  253 

-  simulated  by  . .  403 
Bajrin's    disease    distin- 
guished from..         ..  404 

of  "hone 348 

Cauda  equina    . .  . .     62 

peripheral     neuritis 

simulated  by     . .  559 
cerebral,  giddiness  from  302 

-  headache  from       291,  302 

-  hemianopsia  from  301.  303 

-  hyperac'jsis  from      . .  308 

-  vomiting  from  . .  302 
chronic         mediastinitis 

from    .,  ..  ..  751 

of  cord,  allocheiria  from  17 
cms  penis,  caries  of  puhcs 

simulating      . .  . .   69S 

fact",  healed  (/'t'7*  227)..  541 
fauces,  sore  throat  from  613 
heart-block  from  ..  546 

hemianopsia  from  . .  302 
of  liver   . .  . .     372,  527 

-  abscess  simulated  by    334 

-  ascites  from  . .  . .  330 

-  carcinoma  simulated  by334 

-  empyema  from         . .   106 

-  hiccoutili  from  . .   308 

-  jaundice  from  . .   334 

-  liver  enlarged  from 

330.  334,  568 

-  phantom  tumour  simu- 

lating ..         ,.  609 

-  pleurisy  from  . .  106 

-  pyrexia  from..      334,  568 

-  simulating       enlarged 

gall-bladder  . .  252 

-  -  new  growth  . .  253 

-  Bkodaic  resonance  with  611 

-  therapeutic  test  for 

253.  334 
mediastinal,        Bright's 
disease  simulated  by    413 

-  cpdoma  from  . .     413,  415 

-  vena  cava  obstructed  413 
of  menitiges,  brad3'pncDa 

from  . .  . .  . ,  84 
mercury  in  diagnosing..  230 
of  nerve,  muscle  wasting 

from 61 

-  orhitnt,       exophthalmos 

from    . .         . .         . .  229 

-  of  pjilatn,  foul  taste  from  705 

-  -  sore  throat  from       . .   013 

-  panilvtiis  of  oiip  ie-,'  from  496 

-  pelvic,  simul: 


oriu 


-     Ill.rl    Itlnr,     ,I(U-    to 

jMmma  of  periosteum 

-  iicriloiiiUs  .)\.r, . 

-  potas'iium  iodide  in  • 

gnoHing 

-  of  rectum 


03 


GumjTia,  conid. 

-  salvarsan  in  diagnosing    i 

-  of  spleen. .         . .         . .  ( 

-  synovial  membrane      . .   ; 
Gumma  of  testis  47'J,  622,  E 

-  of  tongue  . .      379,  7 
foul  taste  from         . .  7 

-  tongue  swollen  from    . .  C 

-  of  tongue,  tubercle  simu- 

lating . ,         . .         . .   J 

-  tonsil,  carcinoma  simu- 

lated by         . .  . .  C 

phthisis  and  . .         . .  C 

sore  throat  from       . .   (■ 

therapeutic  diagnosis  of  f 

-  ulcer  from         . .         . .  l 

-  of  urethra         . .         . .  1 

-  uvula,  sore  throat  from    ( 

-  vocal      cord      paralysis 

from    . .  . .  . .  4 

-  wash-leather  slough  in. .  't 

-  Wassermaiin  test  "in  dia- 

_'fni-in_'        2no.  253,  ; 

Gums,  actinomycosis  of  .. 
GUMS.   BLEEDING 

|-iliH,.|--^pittiiiL'   from.,  t 

in  iiif:xntite  scurvy  99,  .' 

Gums,     bleetlinot     list    of 
causes  of 

sraall-pos       . .  . .  '. 

from  stomatitis  72,  74,  '. 

yellow  fever  . .         . .  : 

-  blue  lineon,  in  plumbism 

34,  65,  119,  124,  131, 
425,  ; 

-  epithelioma  of  . .         . .  i 

-  fcetid,  in  f-curvy 

-  foreign  body  in,ptyalism 

from    . .         . .         . .  J 

-  trangrene  of 

-  Koplik's  spots  on  (Plate 

VITI)  17S,  ; 

-  recession  of,  from  i>yor- 

rhcea    . . 
GUMS.   RETRACTrON  OF  I 
-~  spongy,   in    scurvy    38, 
72,  260,  273,  I 

scurvy-rickets  . .  ( 

mercury         . .         .  -  i 

-  tender •: 

-  tuberculosis  of  . . 

-  tumour  of 
Gum-sncking,  hfemoptysis 

from    . .         . .         . .   - 

Gun-headache        . .  ■  ■    '. 

Gunsbem's      test      (Plate 

xxxr)      ..       ..  ; 

Gunshot  wounds,  haimatc- 
mesis  from     . .         ..  '. 

pneumothorax  from 

631,  C 
Gurgling,  in  hernia       074,  ( 
Guy's    Hospital    Gazette, 
illustrations    lent    by 
141,230.520,  i 

Museum   (see  Gordon 

Museum) 
Gymnastics,     menorrhagia 
from    . .         . .  ■  •  • 


HABIT  spasms..  «       -I 
localized      con- 
vulsions from         . .  1 

simulating  chorea    . .  1 

tetanus  simulating   . .   1 

-  nne(|ual  palpebral  fissures 

from    . .         - .         '  •  '■ 
ITabits,  chanffcd,  amcnor- 

rhroa  from 
H£MATEMESIS  ..  -2 

-  after   abdominal   opera- 

tions   . .  . .         . .  '• 

-  in  acute  fevers  . .         . .  '- 

gastrths  . .         . .  1 

yellow  atrophy         ..  i 

-  nntomla.  from      . .  32, 

-  from  anenrysm..      207,  i 

-  anifina  abdominulis      ..  ' 

-  antimony  ,.  . .   '. 

-  appendicitis       . .         . .  '. 

-  arsenic    . .         . .         • •   • 

-  atheroma  . .         . .  i 

-  in  blood  diseases  . .  '• 

-  from  carcinoma  of  duo- 

denum . .         . .  f 


Hcematcmesis,  contd. 

-  in  chlorosis        . .         . .  : 

-  cholera    . .         . .         . .  : 

-  chronic  nephritis         . .  : 

-  cirrhosis        35,  51,  267, 

272,  371,  I 
of  childhood  . .         . .  '■ 

-  coma  from 

-  with  duodenal  ulcer    75,  : 

-  from  epistaxis  . .         . .  ; 

-  epistaxis  simulating     . .  : 

-  from     epithelioma     of 

oesophagus     . .         . .  : 

-  famtness  from  . .      268,  : 

-  in     familial     acholuric 

jaundice         . .         . .  : 

-  from  foreign  body     267,  : 


-  gastrostaxis 

~  giddiness  preceding      . .  ! 

-  in  hemophilia   . .         . .  ; 

-  from  hemoptysis      266,  ! 
Hssmatemesls,  hssmoptysis 

distinguished  from    ..  : 

-  from    liajmorrhagic   ero- 


-  in  Henoch's  purpura  76, 

343,  \ 

-  Hodgkin*s  disease        . .  ; 

-  from  injury        . .  . .  '. 

-  instrumentation  . .  : 

-  irritants : 

~  leucocytosis  after         . .  : 

-  in  leukajmia       . .  . .  : 
Hsematemesis,  list  of  causes 

of  . .     265.  : 

-  from  malaria     . .         . .  : 

-  malingering  and  . .  : 

-  from  mediastinal  growth  ; 

-  nausea  preceding  . .  ; 

-  noises  in  the  head  after  ■ 

-  cedema  of  legs  after     . .  ' 

-  oppression  iu  epigastrium 

before  . .         . .  : 

-  from  pernicious  anicmia  : 

-  pliosphorus         . .  . .  ; 
Hsemato'nesis.  from  portal 

obstruction  . .  £ 


-    I.rnln 


Hsematemesis.  profuse,  three 
common  causes  of  ..  266 

-  in  purpura  hieniorrhaeica  273 

-  rapid  feeble  pulse  from  268 


I  rclapsii 
restlessness  froni 
in  scarlet  fever.. 


-  suiMcri  pnllnr  from 

-  syncope  from    . . 

-  from  syphilis     . . 

-  tarry  motiOTis  after 

-  from  varicoHC  ccsoplii 


..    336 

..   268 

..   273 

..   273 

..   272 

274,  372 

..   272 

osis     033 

271,  033 

268 

268 


el  In 


'  fev 


Hamatidrosls 

Hiomatin,   arid,  spectrum 

ot(Fig.  34)     ..         ..SO 

-  alkaline 281 

-  -  spectrum  of  {Fia.  33)    80 
Hiematooelo,    atrophy    of 

testis  fro?n     . .  . .     fifi 

-  from  corpus  lutcum     . .   688 

-  eclonir    fe«it;ition  ..   688 

Hnmatocele,  oeneral  account 

of        482 

-  hv.lr.K-.-h.  simur.tiii;:  ..  -ISI 

-  afe.T  injitrv  4Sl.  482 

-  operation  in  diiignoHlng 

4H1.  483 

-  pelvic,  nlbumoiiurla  with     10 
hearing-down        pulti 

from  . .  . .   427 
tencrimu*  from  ..   718 

-  yo\\\Q  swelling  duo  to..  0H8 

-  after  puncture  ..         ..  482 

-  .tinitdating  noopln<4m  of 

tcittis 481 

-  not  tranHlui'cnl. .         ..  482 


HaBmatocele.  from  tubal 
abortion  . .  690 

Hiematocotpos,  amcnorrhtea 
with IS 

Haematocolpos,  notes  on..  631 

-  pelvic  swelling  due  to  . .  688 
Haematoma  of  jaw  ..   6811 

-  pelvic,  dystocia  from  . .  20U 

-  pelvic  swelling  due  to..  OSS 

-  of  penis  . ,  . .  . .   473 

-  periiieiiliric,  sujipuration 

Hematoma  of  scalp,  char- 
acters of  . .  205 

-  from  vesical  calculus  ..   471 

-  of  vulva.,  ..  700,  701 
H«ematomata,  albumosuria 

with 16 

-  in  general  paralysis  . .  243 
H£ematometra,  amenorrhoea 

with IS 

-  pelvic  swelling  due  to  ..  688 
Qsem atomy elia,  ana^thesia 

with 140 

-  common  site  of . .         . .  509 

-  contractm-es  from     138,  140 

-  dissociative     anaesthesia 

from 509 

-  drawing  up  of  legs  with  140 

-  jjirdle  pain  with  . .   140 

-  iiy|.L'ra',stli.-ia    with       ..110 

HEematomyelia,  sensory 
changes  with..         . .  60S 

-  simuliniri-::     Klumpke's 

palsy 5U9 

-  spastic  paraplegia  from  509 

-  sphincter  trouble  with..  140 
Hsemato-nephrosis,     from 

papilloma        , .  . .   278 

Haimatoporphyrin  . .    74:'. 

-  spectroscope  in  detc'ctintr  711 
Hsmatoporphyrin,  tests  for  744 
il;Einatoporphyrinuria,  black 

urine  from     . .         ..  745 

-  in  bullous  dermatoses  ..     i)9 

Haematoporphyrinuria,  gene- 
ral account  of  . .  744 

Hiemato-rachis  ..  ..113 
Hscmatosalpinx,     amenor- 

rhcea  with      . .         . .     IS 
Hicmatozoa    in    blood,    in 
malaria  27,  29.  31,  32, 
225,     334,     536,    568, 

590,  637 

-  malarial,  crescent  forms    31 

effect  of  quinine  on  ..      31 

piKUient  granules  in..     32 

ring  forms      . .  . .     31 

-  -  (See  Plate  XX  VI 11)..  614 
HEMATURIA  ..275 

-  in  acute  nephritis       42,  2Sl 

-  ace  incidence  and       ..  277 

-  anmmia  from     . .         . .     32 

-  from  angioma  of  kidney, 278 

-  appendicitis       . .         . .  283 

-  bacteriuria         , ,  . .     70 

-  bilharzia  33,  282,  581 

-  black  urine  from  . .    745 

-  from     bladder    growths 

281,  471 

-  calculus      40,  117.  278, 

281,    282,    356.     455, 
471,    472,    677,     578, 

580.  719,  712 

-  carcinoma     of     bladder 

281,  472.  579,  580 

-  -  invading  bladder  283,  582 

-  -  of  kidney  . .  . .  750 
prnstnto  . .  . .   281 

-  rectum 


41 


-  colic  with  . .  . .    270 

Hematuria,  colour  of  urine 
with 9 


fro 


268 


12.  I-'.  280.357 

■-   cy^lili-      'J^J.    17n.   .-,7S.   581 

Hamaturla.   cystoscope   In 
dlagnosino  cause  of 

277.  :i3H 
Hamaturla.       cystoscoolc 
anoearances  In  (/'/u/r 

..  282 


dVH' 


-  oITect  of  cxfTciw  oi 

-  from  ondocardiliK 

-  onIrirge«l  prostnti' 


270 


H.^5MATURIA 


H^JIORRHAGE 


ditis*  .  .  . .        7,  8 

HaematurJa,  general  points 

concerning 


Hfemophilia,  ansmia  from 

Haemophilia,    arthritis    in, 

general  account  of  ■ . 

~  blee.liii-  -1111. ~  im  72, 


276 


1U2, 


-  li;i;iiioi::lobinui-ia      simn- 

latiiij? 284 

-  ill  Henoch's  purpura  7G, 

343,  556 

-  hydronephrosis  . .      280,  356 

-  livpernephroQia  . .   356 

-  iilfarction  . .  . .        S 

-  leukiEmi:i  . .  . .    283 
Haematuria,  list  of  causes 

of        275 

--  in  malariii  . .  . .   273 

-  from  movable  kidney  115. 460 

-  oxaluria  . .  . .  . .   281 

-  papilloma  of  bladder  . .  472 
kidney  . .  . .   278 

-  palpation  of  kidney  and  277 

-  from  pelvic  abscess     . .  283 

-  purpura  . .  . .  . .   283 

-  rectal  examination  and    277 

-  from   renal   calculus  40, 

117,  278,  356,  577 

-  after  renal  colic. .       131,  451 

-  fi-om  renal  new  growth  7, 

51,  278,  355,  750 

-  -  thrombosis      . .  7,  749 
tuberculosis    . .          . .   356 

-  renal  tumour     . .  . .   330 

-  salpingitis  . .  . .   283 

-  in  scarlet  fever.  .  ..273 

-  scurvy     . .  . .  . .   283 

-  shape' of  clots  with       ..   276 

-  simulated    after    aniline 

dyes 745 

paroxvsmal    hoemo- 

globinuria  . .         . .  285 

-  slight  albuminuria  with      12 

-  in  small-pox       . .  . .   272 

-  spk'riome;,'aIic        jmlycy- 

th:iMin-n  ..633 

-  stippin-iiivr  ,M.|,l,rilis  ..    594 

-  (hictM^iipiMf'ii.il  nunour  630 
~  from  Tui.r,vulnii~  Madder 

L'SL',  3H7,  471,  579 

kidney    279,  280,  282, 

.S55,  579 

-  ulceration  of  bladder  . .  580 
bowel 283 

-  unilateral,   from   growth       7 

-  from  ureteral  calculus 

281,  455,  472,  578 

-  urethral  calculus  . .  282 

-  lu-oerythrin   simulating     743 

-  from  urethritis  . .  . .   282 

-  urntropine  . .  . .   650 

-  vena  cavnl  obstruction     750 

-  vesical     calculus      282, 

471,  580,  719 
Hsmic  bruits  ..91 

Hiemochromatosis  . .  528 

~  argyria  simulating        . .   529 
H?emooytonicter    . .  . .      21 

HffimoLrloIiiii,  ;iVio\  (■  normal, 

-  frc-  III  iirHH-  111  iirpliritis     10 

-  redu.'.'.l,     ^p.-rrnriii     of 

{Fifj.  31)   SO 
Ha^moglobinometer,     }Ial- 

dane-Gowers'  . .      21 

HEMOGLOBINURIA      ..  284 

-  black  urine  from  . .    745 

-  colour  of  urine  in  . .   284 

-  Eason's  reaction  in       . .  285 

-  experimental     . .         . .   284 

-  hfematoporphyrimu-ia 

simulating      . .  . .   744 

-  hsematuria  simulated  by  284 
Hsemogloblnuria.     list    of 

causes  of                 . .  284 
Hasmoglobinuria,    parox- 
ysmal   284 

-  spectroscope      in      dia- 

gnosing . .  . .   285 

-  syphilis  and      . .         . .  285 

-  urine  dark  brown  in    . .  275 

-  various  drugs  causing . .   284 

-  lA'asserinann  reaction  in  285 


blood  clia 


t  patlK 


/ 1 cemo pit/sis.  conlxl 

-  in    splenomegalic    poly- 

cythaemia 

-  tickling  in  throat  preced- 

-  tubercle  bacilli  and 

-  from  violent  coughing.. 

wlinopin-congh 


ir,t 


-  epistaxis  from  ..     221,  : 

-  excessive  bleeding  from 

cuts  in            . .         . ,  '. 
after  tooth  extrac- 
tion in    . .         . .  ; 

-  family  history  in  33,  73,  \ 

-  Grandidier  on   . .         . .  : 

-  hfematemesis  in        266,  : 

-  haematuria  iu    . .         . .  : 

-  hasmoiThage   into   ankle  ; 
hip  joint  in    . .         . .  ; 

knee  from       . .         . .  ; 

-  haemoptysis  in   . .         . .  : 

-  hsemorrhagic  otitis  in  . .  - 

-  limping  from     . .      362,  ; 

-  menorrhagia  from     386,  : 

-  metrorrhagia  from    390,  ; 

-  pain  in  foot  from  . .   I 

-  purpura  in         . .  . .   i 

-  sex  incidence  of        273,  ; 

-  stomatitis  in      . .  . .   i 
Haemopneumo thorax,  from 

bullet  wound. .         . .  1 

-  needling  in  diagnosing 


with..  ..   651 

HAEMOPTYSIS  ..285 

-  ansemia  from     . .  . .      32 

-  from  aneurysm  149,  290, 

291,  292 

-  aortic  disease    . .         . .  288 

-  back  pressure    . .  . .  212 
~  bronchial  casts  after  , .  644 

-  from  bronchiectasis      . .  291 

-  bronchitis  149,  289,  291 

-  bronchopneumonia       . .  289 

-  carcinoma  of  lung        . .  290 

-  cIu*onic  nephritis  . .   212 

-  coma  from         . .         . .  118 

-  from  congestion  of  lungs  212 


-  emphysema       . .         . . 

-  empyema  . .         . , 

-  epistaxis  simulating     . . 

-  in  familial  acholuric  jaun- 

dice      : 

-  fatal         . .  . .      287,  ! 

-  -  in  phthisis      . .  . .   ! 

-  from  fibroid  lung  . .  : 

-  frequency  at  night       . .  : 

-  from     fungating     endo- 

carditis ..         ..   : 

-  gangrene  of  lung 

-  hajmatemesis  from    265,  : 
HEemoptysrs,  hsematemesis 

distinguished  from    ..  i 


■   higii    Mnu.|-prr-> 

hydatid  of  lung, 
infarction   of  lui 


106, 


-  injury  to  chest  . . 

-  laryngitis 
Hxmoptysis,  list  of  causes 

of  ..     286, 

-  from  lobar  pneumonia. . 

-  hiTig-fluke 

-  malingering  of  . . 

-  from     mediastinal     new 

growth 

-  miner's  phthisis 

-  mitral  regurgitation-    . . 
stenosis  149,  288, 

-  new  growth        149,  290, 

-  noises  in  the  head  after 

-  fiedema  of  legs  after     . . 

-  at    onset     of    pneumo- 

thorax 

-  from  phthisis  149,  159, 

-  sarcoma  of  lung 

-  simulated     by     bacillus 

prodigiosus     . .      286, 

tooth-hrusb  injury  . . 

tooth-plate  injury     . . 


Htemorrhage,  anxmia  from 

-  into  ankle  . .  . .   ; 

-  arachnoid,      convulsions 

ft*om    . .  . .         , .  \ 

-  beneath  skin  (see  Pur- 

pura) 
~  blood  cliangos  after 

-  into  carcinoma  . .  . .   ; 
in  liver           . .          . .    J 

-  cerebellar,  priapism  from  I 
vomiting  from  . .  ' 

-  cerebral,     absolute   rest 

for       . .         . .  . .  ■ 

accentuated         aortic 

second  sound  with    : 
age  incidence  of    84, 


-  -  albuminuria  with    84, 
119,  303,  c 

aphasia  from . .         . .  f 

apoplexy  from      147,  l 

arterial  changes  with 

84,  .1 

arteriosclerosis  and 

12,  147,  3 

athetosis  from  . .  ] 

3abinski's  sign  with . . 

brachial     monoplegia 

from  . .         . .  a 

bradycardia  from 

bradypnoea  from 

Clieyne- Stokes  breath- 

cerebral  softening  from  * 

tumour  simulating     T 

~  -  coma  from    118,  119, 
204,  I 

diplegia  from  . .  I 

distinction     from    ab- 
scess and  tumour. . 

after   embolism  . .    ( 

Hxmorrhaqe,     cerebral, 
general  account  of    ■ .    I 


'        -I.I  111,  303 

-  -  he;i.]  i.h.    II, MM       -J'.if,  295 

-  -  heart  sounds  with  119,  303 

-  -  hemianopsia  from  301,  302 

■  —  hemipartesthesia  from    302 

-  -  hemiparcsis  from  118,  302 

■  -  hemiplegia    from    68, 

119,  258,  303 


-  in  Hodgkin's  disease    : 

-  hyperpyrexia  with  84, 

306,  ; 

-  hypertension    of   cere- 

brospinal fluid  with  i 
■  -  hypothermia  with     ..   ; 

-  intermittent   claudica- 

tion sinnUating      . .   I 

-  Jacksonian  epilepsy..    '. 

-  from  labour    . .         . .  ', 

-  large  heart  with     119,  '. 

-  lead    poisoning    simu- 

lating 


Hemorrhage,  contd. 

-  into  the  cord  from  injiu-j-  5 

multiple,priapism  from  5 

paraplegia  from         . .   5 

seldom  spontaneous. .  5 

-  from  corpus  luteum     . .  G 
cyst,  pain  in  pelvis 

-  duodenal,  coma  from  . .  1 
noises    in    the     head 

after  . .  . .  4 

Haamorrhage     from     ear, 

causes  of  .4 
ironi     Iraotured     base 

119.  4 

-  Graafian  follicle  . .   1 

-  from  groin,  from  malii.'- 

nant  glands    . .          . .   6 
HAEMORRHAGE     FROM 
GUMS 

-  -  111  yrlli.u-  fever  ..    3 

Hfemorrhage      into      hip- 
joint        3 

-  hypothermia  after        ;     3 

-  internal,  after  abdominal 

injury 5 

fi'ora    duodenal    ulcer 

120,  7 
leaking  aneurysm  120.  7 

-  -  ruptured  tubal  gesta- 

tion    120,  393,  593. 

690,  7 
in  typhoid  fever     120,  5 

-  intestinal,  from  colitis. .   6 

-  into    intestinal    wall    in 

Henoch's  purpura  556,  7 

-  intrathoracic       sarcoma  1 

-  jaundice  and      . .         . .  3 

-  "into  joints  273.  350.  362.  3 
Hxmorrhage    into    knee- 
joint    3 

-  leucocytosis  after  . .   3 

-  from  lungs  (see  Hiemo- 

ptysis) 

-  in  lymphatic  leukaemia     5 

-  into  mediastinum  . .    1 

-  into  medulla,   laryngeal 

paralysis  from  . .  4 

-  meningeal,  atlietosis  from  1 
bradypnffia  from 

coma  from     . .         . .  1 

convulsions  from      . .   1 

from  head  injury      . .   1 

hemiplegia  from       . .   1 

from  labour   . .         . .  1 

monoplegia  from      . .   1 

spastic  paraplegia  from  1 

-  trephining  for  . .   1 

-  mesenteric,  in  Henoch's 
purpura  . .         . .  7 

-  into     middle     ear,     in 

Bright's  disease        . .  1 

■ deafness  from       . .   1 

■ in  leukfemia  . .   1 

pernicious  anaemia     1 

from   the   mouth ,   from 

internal  carotid  erosioii  4 
-  in  splenomegalic  poly- 

cythEemia   ..         . .  Cr 
~  (and  see  Bleeding  gums; 
mucous   membranes,   in 
blood  diseases  . .  5! 

in  Dseudo-leukiemia 

scui-vv-rickets        . .   6' 


-  occult 

i.edeni 
into 


optic 


^ith 


■  -  paraplegia  from    132, 

-  pyrexia  from  85,  306, 

-  —  rapid  onset     . . 

-  -  retinitis  and  . .        119, 

-  senile  changes  and    . . 

-  systolic  bruit  with    . . 

■  -  tube-casts  and 

■  -  uricmia  simulating   . . 

■  -  verti'.'o"  proi-cdiiiL'     .. 


hype 


Hxmorrhage  into  orbit  ..   I 

iito       pancreas,       acute 
I  abdoniinal  pain  from 

I blood  per  anum  fi'om     * 

collapse  from  76,  2( 

I constipation  from  76,  21 

I  -  -  in  fat  persons  . .     * 

glycosuria  from         . .   31 

intestinal    obstruction 

simulated  by       76.  2( 
' laparotomy  in  diagnos- 


pain  in  abdomen  fror 

-  jierinepliric 

-  periostea!,  from  injury. 


3( 


HEMORRHAGE    —    HEADACHE 


EnioirJia(/e,  coiittl. 
pontine,  alcoholism  siuiu- 
lating "'\'>  \ 

-  bradypnoea  from      . .   _  *>^ 

-  coma  from     ..  ..310 

-  hyperpyrexia  from 

119,809,310,311 

-  opium  poisoning  simu- 

lating . .      119,  310 

-  pin-point  pupils  from 

'  119,  .310 

-  thermometer    in    dia- 

gnosinff        .  -  ■  ■   311 

post^partum,       anoemia 

from  ; lis 

-  coma  from     ..  ••   f^^ 

-  leucocytosis  after     . .  3G0 

-  noises  in  the  head  after  400 

-  (Edema  of  legs,  after. .  -113 


IJa 


^r!ia'i':'<,  rnnfih 


secondary 

-  thirst  from 

ICMORRHAGE 

RECTUM 


720 


PER 

od     per 


renal,  blood  c.i.sts  with . .       « 
-  (and  see  Ha;maturia) 
.  retinal     ..  ..      .   .•.-  -J}^ 

.  -  in  albuminuric  retmltis  416 
.  -  with  chronic  nephritis  212 
•  -  erythropsia  from  . .  762 
■  -  from   f ungating  endo-_ 

carditis       .  ■  7,  34 

.  -  with       high       blood-  ^ 

l>ressure      . .  .  -  212 

.  -  macular       choroiditis 

from  ..         ■•  ^1" 

-  scotoma  from  •  ■  'GO 
from     thrombosis    of 

retinal  vein  . .  410 

-  into  semicircular  canal, 

M^'iu6re's  disease  from  752 

-  severe,  blanching  from  120 
coma  from     ..         •  ■  P^ 

-  -  pulse-rate  raised  by..   J 20 

-  shortness  of  breatli  from    87 

-  into  spinal  cord  hl\,  ol.i,  IJ-IS 

-  spinal,  from  injury        ..    ilo 

-  -  paralysis    of    bladder 

from  -.         ••  •"J 
urine  dribbling  from     398 

-  into  spleen,  from  injury  fill 

-  in  splenic  anaimia         ..3i2 

-  subcutaneous  (see  I'ur- 

liura) 

-  subdural,       convulsions 

from l;" 

-  subnuicous,  in  small-po.K  2(1. 

-  thirst  from         . .  ■  ■  Iz^ 

-  into  thymus      . .         -  -  ipJ 

-  thyroid  adenoma  ..   '21 

_  toiik'ue    . .       . .     698,  can 

-  tunica      vaginalis      (see 

llajmatocele) 

-  from  ulcerating  cpithcli- 


_      |,i,'   ,1:,.     '.-rlinsis       633 

_  .    I  ..633 

Haemorrhagic  erosions,  gene- 
ral  account  of  •  -  269  | 

hiematemesis  from   .  .   26o 

from  portal  obstruction  273 

Hemorrhoids  (see  Piles) 
Hajmosidcrin,  in  macules    382 
Hair,  arsenic  in  34,  66,  73, 

529,  718 

-  brittle,  in  certinism     ..  234 

-  broken  oH,  in  ringworm 

247,  248,  249 

-  discoloured  by  fay;is    . .  247 
Hair,  effects  of  ringworm 

on  ■ .     247,  248 

-  fair,  psoria.sis  and  . .   603 

-  falling  oat  of,  from  favus  247 

I in  myxcedema  . .  409 

I from' pityriasis  . .  249 

psoriasis  . .  ■  •   -"*" 

-  follicles,  pityriasis  rubra 
pilaris  and     . .         .  •    'o^ 

-  lanugo-like         . .         ■  •     ™ 

-  lustreless,  from  favus  . .  247 

-  note  of  exclamation 
shaped  .  •        71,  249 

-  mouse-coloured,  iu  Mon- 
golism . .         •  ■  --^^ 

-  in  myxcedema     38,  231,  409 

-  precocious  pubic  and 
ax-illaiT,  hypernephro- 
ma and  . .         . .  630 

-  pubic,    falling    out    of, 
after  brain  injury     . .     (>7 
hypernephroma  and. .  331 


llitmh,  Cfnilil. 

-  atrophy  of  (sec  Atrophy 

of  Hand) 

-  blue,  blue  brain  and  . .   163 

-  broad,in  myxedema  409.410 

-  bulla;  of,  in  syringomyelia    97 

-  Charcot's  joint  in         . .  349 

-  cheiropompholyx  of  000,  7.j.t 

-  chorea  affecting  , .  1.^3 

-  cold,    menorrhagia    and  387 

-  cyanosis  of        . .         .  ■  ^^^ 
T  from  cervical  rib       . .  414 

-  enchondroma    of    (Fij. 


--2) 
-  enlarged. 


legaly 


071 


-  in  epilepsy 

-  erythema  multiforme 

-  gangrene  of,  i[i  syringo- 


velii 


.   257 
340 


117 


731 


■  umbilical,  from  congenital 
ohlitoration    of    bile- 

.l,„.,s 329 

M,ja  simulated  after  120 

M-,  from  fibroid   ..  .™> 
....-rsion         ..         -•  "■*'* 
i  I  L.uncd  placenta      ..   201 
(and  see  .Menorrhagia, 
Metrorrhagia,  Metros 


-  recession  from  forehead 

in  myxcedema  .  -  -■>■* 

-  scanty,  in  cretinism     . .  234 

-  -  Mongolism      . .         .  ■  238 
myxedema    . .  . .  ;31 

-  sycosis  of  • .         :  •  ''**^ 

-  thin  at  back  of  head,  in 

rickets  ..         ■•   l''' 

-  wiry,  in  Mongolism      . .  238 
Hair-ball  in  rectum     584,  718 

-  stomach ] 

Hair-cutting,     cramps     u> 

arm  from        . .         •  •    '■'■' 
Ilair-wasli,  lead  poisoning 

from '"'•' 

Haldane-Gowers'      hajmo- 

globinometer  ■■     -1 

Hale  White,  Dr.,  illustration 

lent  by  ..  ••   -•>* 

Ilaller,    vns    abcrnms    of, 
I  cyst  from        •  •      .  •  •  i^J 

Hallucinations  of  hearing     '-3 

-  in  pellagra         . .         •  •  •■j'-^ 

-  concerning  voices         ..    i'J" 

-  in  Friedreich's  disease 

113,  .'>I2,  .'.U 
Ilalos  round  lights,  from 

Klau<-oma  . .  .  •  •  -'^ 
Halting  gait  (sec  Limpmg)  ^ 
Hammer  toe,  limping  from  .lii 
Hammerings  in  heail 
Hamstrings,  cramp  of,  ii 
treadlers 
elongated,  i"  contortion 


-  gonococcal  arthritis  of 

-  gouty  (Fig.  168) 

-  -  skiagram  of  . . 

-  h:nmatidrosis  of 

-  impetigo  affecting 

-  isclueniic  paralysis  of  . . 

-  lupus         erythematosus 

affecting 

-  in  malingerer  simulating 

epilepsy 

-  myxcedematous  (Fi*.  16) 

-  pain  in  (see  under  Tain) 

-  paralysis  of    (see  under 

Paralysis) 
Hanits.    pollanra   affecting 

( Plolr.1  I X .  .\ )       226.228 

-  pignionlod    and    red.    in 
pellagra  ..         .-   --'> 

-  pulmonary  osteo-arthro- 
pathv  of  («!?.  Ifil)  ■  •   ^31 

-  rheumatic  fever  affecting  337 

-  scabies  affecting       401,  363 

-  small-pox  affecting       . .  ""fil 

-  succulent,     in     syringo- 


IJmtl.  cntd.  , 

-  sweating  of.  in  rickets. .  1  •■ 

-  tender,  m  rickets  . .  1 1' 
Head.    H.,   on   amesthesia 

(F.V;.  257)       ..  .-   «'"■ 

-  segmental    areas    (Hgs. 

292,  293)        . .  .  ■  712 

HEADACHE  ••  M? 

-  in  acroineg.ily    -  •         ■  -  "'^•' 

-  acute  yellow  atrophy  . .  33:: 

-  from  Addison's  disease    iw. 

-  antemia  . .         . .         ■  -  ^.'ij 

-  aortic  regurgitation      . .   -0^ 

-  before  apoplc.xj-  .■  1"/ 

-  from  arsenic      . .  '  *    ,'  . 

-  arteriosclerosis  . .      29...  -.'i' 
Heailache,  from  astigmatism 

. bad  ventilation  ..   32! 

-  bradypnoea  with  . .     I*] 

-  from  cerebellar  tumour    ol' 

-  cerebral  abscess       147, 
306,  502,  026,  'OS^ 

aneurysm  ..         ••  ^jj'j"' 

embolism  . .         .  ■  -9-» 

hajmorrhagc  . .         . .  -•'•• 

--  lesions  ..         •■     8' 

syphilis  ■ .         ■  ■  "'.' 

thrombosis  . .         -  •  -"*' 

-  -  tumour  147,  204,  302, 
300,  315,  502,  5'25, 

537.  020,  76S 

-  in  chronic  nephritis     ..     11 

-  from  crvptomenorrhtBa      1  '^ 

-  in  dengue  .  .  ■  •   '•'''"' 
_  di"it:dis  in  relieving     ..  291. 

-  in'.lissciniTiated  sclerosis  293 

-  from  ear  disease  .  ■    1'" 

-  in  eclampsia      . .         . .  Wt. 

-  from   encephalitis    120, 


..iyelif. 

-  swe.-iting,  in  acute  rheu- 

matoid arthritis       . .  31 

-  tremor  of,  in    Graves's 

disease 
from  mercury  33, 

-  urate  deposits  on  (Fio 

158)     ..         .. 

-  xanthelasma  of 

-  (nnd  s,.,.  l-ingors) 


406 


IJmmI.h        iiom  ..    W. 

(1  ■,  ihtnp  1  I  from       . .   71.2 
id\.d.  Iruni  caruncle  ..    70*.i 
frimi       priila[wc       of 
urethra       ..         •■   '«-' 
Hajmorrhiiges      in      acute 

yellow  atrophy      333,  33(. 
-  Ilriglit's  disease  . .  05r> 

chronic  nephritis  . .     1 J 

cirrhosis •  "'•' 

congenital  obliteration  01 

bil.-.h... »2» 

taniiliil    ;„liolurlO   jauii- 


lla 


it's  cirrhosis 
ich's  purpura 


HAND."    ACCOUCHEUR'S 
Hand,     accoucheur's,     In 
tetany 

_  ;,|.,   r,       in       |.nn..ri-ssivc 
muscular  atrophy     . . 
-  syringomyelia  . . 

claw   (see  Claw-linnd) 

-  Dupiivtren's  contrjictlon 

of(/.'iV.39)    •■ 

-  ochmnosls      of      {PIOJc 

XXXIII)       ■■ 
-pink        ..         •■       ,•• 

-  preacher's,  InfirogressUo 

muscular  atrophy    . . 
syrlngomyell 


110 


septic,  opitrochlear  gland 

enlarged  from  •  •  •>'>" 

Volkmaim's  contracture 


Hanoi's  cirrhosis  .  •  ■  ■  332 
Hanoi's  cirrhosis,  general 

account  of  ■  ■  3*2 

Hansen.  Dr.  Armauer,  illus- 

trations  lent  by  404.  50.5 
Harelip,  cleft  palate  and. .  588 
Harrison's  sulcus  in  rickets 

145.  107.  187.  035 
Hat-makers,  mercury  poLson-_ 

inghi  ..  ..  ■•  '-fi 
Hats,  need  to  get  larger,  in 

loonliasis  osaea         . .  670 

-  rabbit  Bklns  for  33,  08 
Hay,  sporotrichosis  from  '290 
llaV  fever,  anosmia  in     ..  t»l2 

-  -:  nasal  catarrh  in  . .  «l:'2 
_  -  -  discharge  from  . .  1 '  8 
tasto    loss    from    178, 

nl2,  705 
Head,  asymmetry  of       ..   153 

-  cidarged,  ill  acromwralv 

352,  .'3 1 

-  congenital    syphllils 

crotlnlsm 

liydrocephnlii. 

jenntiasls  otwi' 

_  -  osteitis  di'lonilaiis     .  .   IWO 

-  -  rickeis  It.-..  205,  311 

-  Ilxcd.  In  M|.innl  cari<.s    . .    12!' 

-  liot-erosslinn   Khupi'd  ..    -O.i 

-  Injury    f«eo    Injury    to 


602,  52.J 
in  epilepsy  ■  -  •  •  l"];' 
after  epileptic  fit  . .  14.i 

from  erroi-s  of  refraction 

295.  440,  449.  712 
frontal  sinus  empyema..  ISiJ 

■  gastritis         •    . .        ,••  '-;;' 

-  glaucoma  233.  295,  712,  '1.1 
722  I  -  high  blood-pressure      . .  29i, 

■  hvperacusis  from         . .  •>">' 

■  from  hypermetropia  446,  il2 
345  -  in  hysteria  . .  .•  •  '  j"- 
3»4  ,  -  with  hysterical  pyrexia    31" 

-  due  to  iiicrea.sed  intra- 
111  cranial  pressure        ■■  •">'•"' 

-  in  inlhicn/.a        . .         •  ■  .[fi-' 

;!r  in 'Sieving-      '""  iJi; 

Headache,  list  Of  ^gU^sof^gg 

-  (nnn  low  blood-pi 


alari' 


..   46 


of 


.500 


505. 


(1711 


ph(is|)horus  iioLsonhlg 
i>..eudoleuka!inia 


arlhrMH  < Flo.  .W  -.  '  - 
.  BiiKcloneurol  ic  ,i-d.nm  nf  III 
.  athctoslsof  131.  (/■•<!/.  "')'•'- 


nrrvoHupplyoffFfo.'jnO)  710 
lioliu."  In  ("'•<'  N'"!'""'  '» 
the  Head) 

.inndrni...  In  rickets     . .  n3.> 
rclrnclcd    ("■>•     Helra.- 

tlonof  the  Head) 
rolling.  Ill  ticket"      II.'.  711 
sensory  nreiw  of  (Ft*;*. 

IHHIOI)  ..118 


-  Malta  fever        ■     .  „„. 

-  from  meningitis  1'20, 29.), 

315,    323,    515,    326, 
'  BOO,  -Of 

-  in  migraine        . .      310,  70V 

-  from  morbus  corilis     . .   -i" 

-  myalgia  simulating       ..   2.11 

-  with  nephritis    ..  11,  1- 

-  neuralgia     dlstiiiguislied 

from    . .         • .         •/  'i/}\ 

-  In  iieunislhenla         I '!■ 

-  occipital,   from   i-erehnil 

Headache  duo  to  orqanlc 
cerebral  disease,  general 
characters  ol  ■ •        ■  ■  fB 

-  from  pucliylin.nink-lli-  ..   ... 
_  lnpelli.gr..  ...       •■    -- 

-  pbiwpliiiriis  pnis.nnng  .  .   .l-I 

-  .It.iiiary  inUllli-m    ..   19 

-  (rompliiliibl-in  .•        •■".  '' 

-  In  pollonivlllls..         •■    '; 

-  Willi  poly.-ysll.-  kl.lnc.vs      1 

-  in  ral-hlte  levr  . .  .'1 

-  from  renilliig     ...      •  •    ' ' 

-  renal  .lliM-aiM'      ••".  *"•  :^. 

-  In  si'nrlet  fi'ver  ..  ..  '•' 

-  Irniii  sea-cat  priiks       . .   '.. 

-  serum  liiJp<.tloiis  . .  i- 

-  from  sewing      ..         •■    ' 

-  sick  (WH.  Hick  Ileil'laehe) 

-  phiilopliohl"  '»■•  ••    "■ 

-  from  sliiun  tlininiliosli 

I'JI),  6UT,  71 


828 

Ucadache,  caiifd. 

-  in  small-pox 

-  times  of  occurrence  of! ." 
Headache,  toxic  causes  of 

-  in  tuberculous  meninf^itis 

oeij,  574, 

-  typlioid  fever    76,  064, 

566,  572,  G3b' 

-  mv-cmia  . .        40 
Headache,  various  types  of 

-  Tomiting  with  . . 

-  from  weeyer  flsb  pricks 

-  in  \yeii's  disease 

-  yellow  fever      . .      273 
Hearing,    defective    (see ' 


HEADACHE 


I'V,  dilatatii 
typhus 


,'itli 


336 


-  hallucinations  of  . .  723 

-  impaired,     with     facial 

Pa'sy 493 

Irom  otitis  media  20" 

Hearing,  tests  for..         ..   164 

-  variations  with  age      .      165 
Heai-t,  abscess  in,  in  py;e- 

";'»..  ..      212,  596 

-  acu(e  dilatation  of    211    214 

-  aneurysm  of      . .        9i_  213 

ruptured  into  . .   434 

systolic    apical    bruit 

from  .-  Qo 

-  athlete's. .         . .         . ."  214 

-  beer-drinker's    . .  '     300 
Heart  blocic                     .."    gs 

-  -  from  acute  rheumatism  546  ' 
ausculatory    diagnosis 


of 


540 


-  -  bradycardia  from     .' '.     oc 

-  -  bundle  of  His  lesions 

.causing       . .         , .     S3 
from  carcinoma        . .     83 

cardiosclerosis  . ,  ,'>4g 

convulsions  from      .' .'  486 

(rpm  diphtheria        . .  540 

dropped  beats  from. .  545 

-  -  electrocardiograpli    in 

detecting    ..        83,  486 

epileptiform  attacks  in 

-      83,  546,  549 

extrasystoles    simu- 

'■^''""           ..      .J16,  .347 
Heart  blocl<,  general  account 
?•        545 

-  -  Irom  gumma..  ..   54^ 

-  -  niCuenza  .  .  . .    54Q 

intermitting  pulse  from  549 

Heart  blocl<,  pairs  of  beats 

wi"' 550 

-  -  fiom  p,„,u,nonia  ..  646 
-^  ~  polyKr:,|,li  in  detecting  83 
Heart     blocl<,      polygraph 

tracing  of  (Fuj.  232) 

545,  (Fig.  233)  546 

trora  sarcoma  , .     S3 

simulated      by     sin'o- 

auricular  changes. .  546 

slow  pulse  from 

546,  548,  549 
btokes-jldams's      dis- 
ease and      . .      486,  546 

-  -  syncopal  attacks  In 

646,  549 

-  -  from  syphilis. .  83 

-  -  type  of  arrhythmia  . .  045 

-  -  from  ulcerative  endo- 

carditis      . .  540 

-  itoviiie  . .  , ,  '  ■  .-i^jy 
leart.  brief  physiology  of"  545 


-  -  asphyxia  in    . .         . .   146 
catarrli  of  small  intes- 
tine from    . .         . .   172 

cerebral  embolism  and 

119,  133 

from  chorea  . .         . .  485 

coma  in  . ,         . .  144 

congenital   (see  under 

Oongenilal       Heart 
Disease) 

I congestion  of  stomach 

'™m  . .         . .   765 

. convulsions  in       144,  146 

cough  from     . .    149,  150 

j cyanosis  From  . .   161 

diarrhcea  from  . .   172 

dyspepsia  simulating    436 

electrocardiograph    in 

investigating  ,  .   544 

epilepsy  simulated  in  146 

epist.ax-is  from  . .  220 

flatulence  with  . .  241 

-  -  gastric  HCl    deficient 
1"  .,: 270 

gastritis  simulating  . .  435 

-  "  -  with  , .         . .     43 
haim.atemesis  from  . .   265 

, hajmoptysis  from     . .  286 

headache  from  , .  296 

[ heartburn  simulating    297 

hyperajsthesia  of  arm 

.  -from  ..         ..445 
infantili.sm  from        . .   191 

-  insomnia  from      321,  322 

loss  of  appetite  with . .     43 

menorrhngia  from  386,  387 

mesenteric     embolism 

from  . .         , ,  i.fji 

thrombosis  from  . .  1.11 

in  Moneolism  ..    |g| 

niyvt'Edema  simulating  414 
luifmei:  liver  with     , .   368 

orthopnoja  from        . .   322 

-  -  pam  in  tlie  chest  from 

430,  433 
left  arm  from  . .   445 

limbs  in      . .         . .  403 

precordia  from     . .  433 

of,     simulated     by 

flatulent  dyspepsia  433 
palpitation  from    322,  484 


HEART 

I  //ran.  comj. 
HEART,  ENLARGED      ..  206 

with     adherent    peri- 
cardium 14,  54^  213 

from  alcoholism      54 

210,'  214 
-  -  aneurysm        . .  . .    208 

aortic  stenosis         92,  20S 

arteriosclerosis      1.  2, 

11,  54,  212 

m  athletes     . .  . .  214 

in  Bright's  disease    . .     46 

bronchiectasis  from..  292  I 

cerebral     haemorrhage  I 

,  •■>nd  . .  . .      119    147 

chest  bulged  by       . .  169 

from      chronic      lung 

disease        ,.         ..     54 

in   chronic   nephritis 

1,  2,  10,  11,  42,  64, 
55,  76,  106,  109, 
,    ,  274,  29-,  408 

chyluria  with  . .   109 

epigastric       pulsation 

with .  . .         _  206 

from  fatty  change   54,  212 

fibroid  change         . .     54 

lung  from  . .         . .  292 

in  Graves's  disease  . .  215 

from  hard  work      54,  214 

hiccough  from  . .  308 

with  high  blood-pres- 
sure-■  ..      298,  485 

impulse  displaced  206,  29g 

heaving  \\  ith         . .  2O6 

left     ventricle,     with 

arteriosclerosis      . .  688 

granular    kidney  688 

high     blood-pres- 
sure    ..  ..688 

reduplicated  first 

sound  with     . .  688 
from  mitral  regurgita- 
tion-. ..        89,  210 

with  myocardial  atlcc- 

tion  . .  . .     14 

from  myocarditis      ..  212 

orthopnoea  from     418  420 

with  patent  interven- 
tricular septum     . .  215 
Heart,    enlarged,    physical 

signs  of  . .  206 
prolonged    fiist  sound 


Heart  failure,  general  ac- 
count of  52 

from  granular  kidney ' 

1.  11,  -fii,  1 

high    blood-pressure 

1,   46,   55,   81,   1 

hypothermia  with     . .  3 

jaundice  from  3 

Heart  failure,  list  of  causes 

0;        4 

liver  enlarged  from  . . 

lividitv  witii. .  .     G' 

Heart    failure    from    lung 

conditions  14,  , 
disease        . .          . .    11 

-  -  menorrhagia  from  386,  31 
from  mitral  disease  46. 

03,  ! 

myocardial    affections 

46,  ij 

-  -  nephritis  . .  .  .  '  5 
Heart  failure  from  nephritis, 

points  in  distinguishing     I 

17,  .-)i;,  o.i,  j:m,  69 

cedema  from  ..  ..41 

of  hands  and   arms 

,    from         ..  ..41 

legs  with    52,   105, 

413,  415,  69 

orthopncea  with   105, 

420,  69" 

pain  in  the  back  from  71( 

epigastrium  from  . .  43( 

pancreatitis  with      . .   10( 

pleural  effusion  from 

104,  lOi 
from  pulmonary  sten- 
osis . .         . .         . .     4*6 

pulsatile  liver  with  52,  094 

respiratory  blood  pump 

420 


nth 


I...I1 


dth 


100 

„       ■. ■■  """  ..      34 

Heart  disease,  polygraph  in 

investiqatinq  . .  . .  344 
Heart  disease,  referred  pains 

'■■om    . .  433 

Heart  disease,  shortness  of 

breath  from  . .  si  88 
Heart  disease,  splenic  en- ' 

larqement  and  632 


1  of,  heart-blodc ' 

:■         ••         ..     83 

I'-sion  of,  pain  with  434 
I  ;' liital  (see  Congeni- 
tal Heart) 
dilatation  of,  from  an- 


-  from    .nri,iiMhi  214 

-  pain     in     qu^-..auinu, 

.    ^rom  ..  ..  4.,g 

-  in  pernicious  aniEmia  587 

-  scarlet  fever  . .         . .  214 

-  from  toxiemia  .'.'  2I4 

-  in  typhoid  fever        .  !   314 


tliiumi.'i   simul.ltirig 
-  stom.ach  lesions  simu- 

■  tenderness     of     spiiie 
from  (Fig.  294)     . . 


633 


reduplicated  first  sound 

,  "i'b  ..  ..688 

from  rheumatic  myo- 
cardial changes     . .      54 

skodaic  resonance  from  611 

in  splenomegalic  poly- 

cythaimia   ..         ..633 

uraimia  . .         .     14c 

-  failure,  acute  dilatation 

of  stomach  in  .."•"" 

from     adherent    peri- 
cardium 

Heart  failure,  albuminuria 
from    ..  14,   53, 

from  aortic  disease  . . 

arteriosclerosis    1 


spleen  not  enlarged  i 

632,  6t0 

in  tetanus      . .         . .   138 

urate  deposit  due  to 

740,  7(1 

from  valvular  disease 

■      14,  46,  108,  161 

-  fatt.v,  from  alcohol      . .  210 
apical    systolic    bruit 

^ith..         ,,         ..89 

-  -  in  aplastic  anajmia    . .     53 

from  arsenic  . .         . .     03 

asthma  from  . .         . .  213 

ascites  from  . .  46    53 

back  pressure  from..  '  46 

canter  rhythm  from..  0S7 

Heart,  fatty,  causes  of    ..212 
cardiac  imi)ulse  feeble 

with..  ..       212,  213 
Cheyne-.Stokes  breath- 
ing with     ..      108,  213 

coma  from     . .         . .  212 

convulsions  from      . .  212 

-  -  depression   from        ..    212 

-  -  dilated   heart  from    .  .    '■"- 
Heart,      fatty,      dyspepsia 


Heart  disease,  valvular,  dia- 
gnosis of  (4 

h.vpotl)ermia  in     ..  31I 

from  rheumatic  fever  485 

scarlet  fever  ..  435 

s.yphiiis       . .         . .  435 

Tomiting  from  . .  765 

-  displaced,  by  fibroid  lung 

,  ■  .,  Ill,  292,  643 
hyclatid  of  liver       . .  375 

..   104 


"Htll 


I''"'"''"  "llusiou         ..   694 
-  -  pneumothorax        432, 

,  ,  530,  652.'  659 

■  -  subdiaphragmatic  ab- 

,   scess  . .      C62,  G59 

-  (and   see    Heart    Im- 
pulse, Displaced) 


40,  85,  161  I  - 

ascites  with      40   52, 

^     ^  53,  105,  694 

borboi-ygmi  from     .. .     82 

in  Bright's  disease  46, 105 

from   bronchiectasis. 

bronchitis        . .        46,  161 

and  emphvsem; 

-  -  bulUB  in       "  . .         90,  97 
cases  due  to  different 

can-PS        ultimately 
j  -I'llte  ..  .. 

Heart  failure,  causes  of     2  46 

-  -  Cheyne-Stokes  br 

iTig  from     .  . 

-  -  coiieh   from    .  ,  .  .    143 
Heart  failure,  cyanosis  from 

Heart     failure,     diagnosis 
between  chief  causes  of     14 

-  -  from  emphysema      40,  101 
--  enlarged  Uver  with    ..      63 

-  -  from  fatty  heart      . .     53 

-  -  fibroid  lung   ..        40,  161 

flatus  from     . .  . .    246 

gall-stones     simulated  436 

-  -  gastric  ulcer  simulated  430 


simulated  by  .'.  '"..  485 
d.vspnoea  from       212.  213 

emphysema  simulated 

by 4S5 

-  enlargement  due  to..  213 

fainting  attacks  from    212 

feeling  of  coldness  from  212 

after  fevers    . .         . .     53 

fibroid     heart     simu- 
lating . ,         . .     .53 
heartburn     simulatinsr  297 

heart  failure  from    40 

u       .     .  63,  108,  418 

Heart,    fatty,    general  ac- 
count of  . .  2(2 
-  heart     lailnre    from 

46,  53,  lOS,  418 

from  lead        . .  . .     53 

mitral      regurgitation 

from  89,  90,  211 

from  obesit.v  . .        90,  212 

orthopnoea  'from        .     418 

Heart,     fatty,    palpitation 
from  . .         . .      484,  485 

in  pernicious  ana'mia 

!)3,  687 
m  phosphorus  poison- 
ing  ..     .'-.s,  73,  212,  337 


HEART 


HENOCHS  PURPURA 


irt,  juUil,  coiUtl.  Hmyl  impnlsf,  cou'd. 

■  from  "pttliisis  ••  -12 site  of 200 

-  pulse  irregular  from..  212 wavy,   with   adherent 

-- slow  from  ..         ..  212  pericardium  ..  213 

-  -  weak  with  . .         . .  213     Heart,    irregular   (and  see 

-  shortness     of     breath  I'ulse,  Irreinilar)       . .  545 

from  . .  53,  SS from  absinthe  . .  4SG 

art.  fatty,  symptom?  of    14    —  alcohol  . .  iso 

-  syncopal  attacks  from  coffee -180 

212,  213 in  mitral  stenosis        2,  94 

-  tachycardia  from      . .  7U4 from  myocardial 

-  from  typhoid  fever  . .  212  chances       . .         . .     8S 

-  wasting  diseases       . .  212 rendered    regular    by 

-  weak    cardiac   sounds  exercise       . .         . .     88 

with  ..  ..   213 from  smoking'  ..   -186 

Bbroid,  from  alcohol    . .  210 tea -180 

-  aneurysm  of  heart  from  213     Heart,  nerve  segments  cor- 

-  angina  pectoris  from  responding  to. .         ..  708 

h\  213     -  percussion  in  determining 

-aortic       regurgitation  size  of 200 

with  . .         . .     53     -  polypus  of         . .         . .  750 

-  apical  systolic  bruit  in     89     -  primary  alcoholic  14,  40, 

-  ascites  from  . .         . .     46  '  53,  418 

-  back  pressure  from  . .     4G heart   failure    from  418 

-  Cheyne-?5tokes  breath-  orthopnoja  from    . .  418 

ii.t;  from      . .  . .    lOS palpitation  from  . .   484 

-  fatty  heart  simulating     53  :  -  rupture  of  . .  . .   213 
sart,  fibroid,  general  ac-         '  -  sarcoma  of,  heart-block 

count  of         ..         ■■213  from    ..         .■         •  ■   ,^2 

-  heartburn  sunulating    297     Heart,  sensory  nerves  of.^  433 

-  heart  failure  from   40,  HEART      SOUNDS,      AG- 

IOS, 41S  CENTUATEO         .  I 

-  heart  large  from       ■■     54 arr.ntvnt- >l      jfroinl. 

-  mitral    regurgitation  from     liiu'h     blootl- 

from  ■■        89,211  l««sure       .,        81.298 

-  orthopntea  from        ..418 in  arioriosclcrosis  11,  90 

-  nai[i  in  the  back  from  716 cerebral     h;umorrh:ige 

-  palpitation  from        ..484  and..  ..       119,303 

-  shortiie^sof  lireath  from  88  , first,   accentuated,  in 

eart.  flbroid.  symptoms  of     14  ]  mitral  stenosis     . .  216 

-  from  svphilis..         ..     53  I from  nervousness..       2 

-  ta<-hyeardia  from     . .  704 like    second,    from 

foetal       . .  19,  45.  689  myocardial  changes    88 

[eart  impulse,  accentuated  i prolonged,  in  chronic 

first  sound  at. .  ..2'  nephritis..         ..  408 

-  diffuse,    from    dilata-  ' from  hypertrophy  298 

tion 2"B reduplicated,     from 

pericarditis  . .  213  |  over^itrain  of  heart  211 

-  diminished,  in  emphy-  , slapping,   in    mitral 

sema  . .      107,  217  \  stenosis  2,  95.  289.  ISa 

lEART    IMPULSE,    DIS-  ! weak,  in  diphtheria  214 

PLACED  •■  297  I erysipelas  ..  21-1 

from  acute  endocar-  fatly  heart        . .  21.i 

ditis  . .         . .  211 scarlet  fever      . .  214 

with  adherent  peri-  [ typhoid  fever    . .  214 

cardium  . .         . .  213  i typhus    . .  .  •  214 

in  aortic  disease    . .  207 foetal,    proving    prcg- 

regurgitation     . .     94  nancy  19,  45,  689 

by  ascites   . .         . .     44 hard  to  hear,  in  cm- 

fibroid  lung        168.  plivsema     ..      107,21. 

200.  210.  299  I inaudible    second,    in 

. witli  1  lint'y  Ijriui  .  .      95  1  mitral  stenosis       ..     95 

. h.-;iri   .III  II  •!  TIM  III     206 lumpy  llrst,  in  ar- 

feart     Impulse,    displaced,  1  teriosclorosis      ..     11 

I'ln'mUrafreU'"-  '"     "  '  '"  "''To,' H.  at  Tot!  408 
tion  .".     °  89,  210  I  -  -  lumpy    first,   cerebral 

. stenosis   ..  ..   216  haimorrhnge  and   ..   119 

overstrain  of  heart    214 in  chronic  nephriliK  10 

. patent    intcrveiitri-  prolonged    first,    with 

cular  septum     . .  218  |  cardiac  hypertrophy 

pericarditis  . .   21.1  | in  clironic  iifphri- 

by  pleural  effusion    298  ti.^!        ..         ••     H 

pleuritic  effusion  . .  168  ' from  high  blood- 

-  -  -  pneumothorax    168.  206  ■  pressure         . .     »J 
when  right  ventricle             at  impulse         . .       1 

enlarged  . .         .  ■  215  ; pulmoimry  second,  nc- 

.  (and    see    Heart,    Ub-  ccntuated  iii.n"|i;''l    ,^,^ 

-  -  feeble,  from  fatty  heart           Heart  sounds,  redupllpaled      2 
<  212,  213   I iro.n     high      blnoil- 

-  myocarditis  . .  212  pressure . .         .  •  29» 

-  o/erstrai.i  of  heart  214 second.     In     mitral 

heaving,  from  hyper-  sl*>nosls    96,  .'in.  -os 

trophy        . .  . .  206 reduplication    of   (see 

impalpable  ill  emphy-  |                Rcdiiplicallon) 

sema           ..          ..107  _  -  weak  llrsl,  from  myo- 

increased,   in   perlcar-  carditis       1- 

ditis S13  -stopping  and  going  on 

--indiscernible,    in    em-  \         with  a  jerk     ..         ■■'>*' 

,.hysema     . .         . .  297  I  -  syphilis  of,  heart  block     ^ 

from     perlcardiol  !          from    . .         .  ■         -j 

etTusion   ..         . .  297  i  -  thrombus  in       13.1,  14  ■ 

in  mitral  stenosis     ..  216  -  thumping  of,  from  atlier 

normal  silo  of            . .   297  omtt     . . 

■  -  obscured   bv    omphy-  '.  -  -  epilepsy         -  - 

■^           sema            ..       200.217  --  on  getting  Mito  bed  . . 


Heart  tlnniipim  of,  aitittt. 

-  -  from   smoking  . .    180 

-  viigus  liraTicUcs  to  ..  14S 
HEARTBURN  .296 
Heartburn,  causes  of  296.  297 
Heartburn,    characters    of 

pain  of  ..297 

-  drugs  relieving  . .  .  .   297 

-  electrocardiograph       in 
diagnosing      ..  ..297 

-  in  health  . .         . .  296 

-  heart  disease  simulated 
by       297 

-  palpitation  with  . .  297 

-  pyrosis  with  . .  . .  436 
Heat  cramps         ..         ..151 

-  e"-ythema  from  . .  222 
~  gangrene  from  .  .  . .  255 
Heat  regulation,  notes  on. .  571 

-  sense  lost,  in  Brown- 
StVquard  paralysis     . .   497 

from     cerebellar 

artery  lesions    . .     58 

in  syringomyelia  62, 

63,  97 

-  stroke,  alcoholism  simu- 
lating   310 

-  -  coma  in  118,  119,  310 
hyperpyrexia  from 

120,  309,  310 
occupation  in  diagnos- 
ing . .         . .         . .  119 

opium  poisoning  simu- 
lating ..  ..310 

post-mortem   examin- 
ation in  diagnosing  120 

prognosis  in  . .         . .  120 

Heaviness  in  abdomen, 
from  chronic  periton- 
itis       425 

-  sense  of,  in  liver  region, 
from  hepatoptosis    . .  368 

Heberden's  nodes  346,  405 
Hebra,  prurigo  ferox  of  . .  489 
Hedgehog  crystals  . .  740 

Ileel.  bedsore  over       .  . .  257 

-  Jacquet's  erythema  of. .  401 

-  pain  in  (see  Pain  in  Heel) 

-  rubbed,  limping  from  . .  362 

-  small  conical,  in  talipes  112 
Hegar's  sInn  of  pregnancy  393 
Heller's  test  •  •     .^ 

-  -  for  allmmose..  ..  l.> 
Uelinitol,  for  gall-stones  . .  050 

-  pyuria     .  .  ....   050 

Hermltol,   strangury  from 

049.  6S0 
Hemeralopia  .  -  763 

Hemianiusthesia     in      ilLs- 

seminnted  sclerosis  . .  609 

Hemlanosthesia,  general 
account  of    .-        <<  610 

-  hemiplegia  and    302,300,810 

-  in  hysteria    59, 141,  400,  010 

-  spitial  injur}-  . .  .  .  300 
HEMIANOPSIA    300,  301,  302 

-  in  acromegaly   . .      302,  685 

-  alexia  with         . .  . .   025 

-  after  apoplexy  . .  . .  3ti2 

-  from  cerebral  embolism    302 

-  hemianie-sthesia  with  . .  610 

-  hemiparn^sthesla  with  . .  302 

-  heniipU-gia  with  .  .    302 

-  from  intermit  tent  closure  302 
Hemianopsia,  lesions  caus- 

Ing 301 

-  in   iniLT.iine         3lll.  3112,  7.V.1 

-  from  o,v,pilal  I. 


8-29 

Uemiparesis    (see    Hemi- 

plegiiil  ..  ..OS 

HEMIPLEGIA  ..  30- 

-  AolullLsierksin..         ..  so:; 

-  acute  bedsore  in  . .  25^ 
Hemiplegia,  age  incidence 

of  .  ■     303.  304 

-  agraphia  with    . .  .  .   02' 

-  ankle-clonus  in    39.  l^i'.l,  3U:; 
Hemiplegia,  aphasia  with 

3U3,  626 

-  ataxy  after        . .  . .     5^ 

-  athetosis  after  . .     133,  134 

-  bedsore  in  . .  . .   737 

-  from  caisson  disease     . .  307 

-  cerebral  abscess  68.  300 

-  -  embolLsm      133,    258, 
304,  040 

haimorrhcgc  . .      119,  258 

-  -  syphilis  . .         . .  140 

thrombosis    119,  258,  304 

tumour  . .       68,  3O0 

I  -  chorea  after      ..  ..131 

-  from     congenital  mal- 
formation      . .  . .  30  t 

-  contra. -tnres  in..  ..    13^ 

-  crosseil '■•"- 

Hemiplegia. -detection    in 

slight  cases    . .        . .  303 

-  diagnosis    of    commoner 
-    304 


__  ..      303 

-  from  difficult  labour    ..   113 

-  in  disseminated  sclerosis  307 

-  double,  dysarthria  in  . .  026 

explosive  laughter  from  234 

lesions  causing         . .  502 

-  dysarthria  with  . .  302 

-  elbow -jerks  in    . .         . .  303 

-  from  encephalitis        . .  304 

-  endarteritis        . .     304,  517 

-  extensor  plantar  reQe.x  in 

39,  68,  139,  303 

-  facial  paralj-sis  with    . .  492 

-  from  fungating  endocar- 

ditis     304 

-  gait  in 139 

-  gangrene  from  . .         .  t  2.'i5 

-  in  general  paralysis  305,  024 

-  hemianoisthcsia  with 

302,  300,  010 

-  hemianopsia  with         . .  302 

-  hemiathctosis  with       . .  301 

-  hysterical    59,  141,  307,  497 

-  uifantile  . .         . .       132,  304 
atflxv  in         . .  . .     5S 

-  -  nlheiosis  in    . .       58,  493 

talipes  with   . .         . .  112 

tremor  from  . .         . .     58 

-  from  injury  at  birth  113,  304 
'  -  internal  capsule  lesions    302 

-  knee-jerks  in       39,  303,  SoS 

-  leg-raising  test  of  hys- 

terical..        ..         ..  307 

-  from  lesions  near  Brocu's 

area    . .         . .         . .  303 

-  limping  from     . .         . .  251 
Hemiplegia,  list  Of  causes  Of  303 


rb: 


ii:; 


301 


fror 


289 

48C 

. .    186 

480 


Hemlanopila.   pupil   reac- 
tloni  and       . .      302.  552 

-  nuadrnnl.  in  migrahie..   759 

-  varieties  of        . .  .  ■   31(1 

-  from  visual  cortex  lesion  759 
lleiniataxia  ..  ..58 
llemiathetUHls,  Itcniiplegia 

with 801 

llemiutrophv   of    fneo  fli, 

(A'lV.  202,  p.  494) 
llemlchon-a  ..      133,300 

-  hemiplegia  from  . .  303 
neniicrnnla  in  migniine  . .  "nil 
Hemihidtosi!  -BM 

lli'niiopia(-.ee  llemllinopsin) 
lleniipani-l  111 -la.  from  cere- 
l.i-nl  hii'iiiorrliiigo      ..   .".03 


-  meningitLs           . .      304,  300 

-  mitral  stenosis  . .         . .  301 

-  puiii  in  the  shoulder  in 

475.  4  77 

-  from  pons' varolii  lesions  30-_* 

-  prognosis  in  .  .  . .  303 
-.  r....urrei,t,  in  nl.l  people  :;n.; 
Hemiplegia,  rigidity  and 

139,  303 

-  from  sinus  thrombosis. .  3"! 

-  from  spinal  cord  injury  300 

-  syiihilis   ..         ..      119,  301 

-  teliilon    relleies    absent 


nith 


31 1:: 


-  tremor  after      131,  724,  727 

-  twitrhlngn    jirenionilory  131 

-  wrUt-jcrku  in    . .         . .  303 
Henoch's  chorea   eleclricn 

134,  137.  Ml 

-  purpura,  abdomlmtl  pain 

in  .  .       343.  707 


Henoch's    purpura,    acute 
abdominal  symplomi  In  76 

nephritis  siniiiliiting  .1.111 

ago   inclilence  of    70. 

343.  59C 


HENOOHS   PURPURA 


HIPPOCRATIC   SUCCUSSION 


Ifiwdi  X  piirpu 
-  arthritis  in 


-  -  of  face..        (/''■'/.  U7)  345 
Henoch's  purpura,  general 

account  of     . .      343,  556 

-  -  ha-iiKitemfsis  in       7i.;,  Ml.'l 

-  -  lKiiiiKituri;i  ill    70.  olM,  oof, 
hiBiiioglobinuria  in    . .  •JS4 

-  -  haemorrhage  into  ankle  ^i\'2 

hip-joint  in           . .  30." 

k[iee  from  . .         . .  3G13 

intestinal    obstruction 

simulated  by       7G,  7G7 
intussusception    simu- 
lated by       7fJ.  OoG,  707 
joint  pains  in            . .  o.'.i; 

-  iimpin^^  in      . .      ':i>-J,  ;it;:; 

Henoch's  purpura,  notes  on  767 

pain  in  fjot  from      . .    363 

the  joints  in  . .   343 

-  -  peliosis        rlieumatica 

simulated  by        . .  550 

pyrexia  in      . .  . .   343 

recurrent  chaivieter  of  55G 

simulating    rheumatic 

fever  . .         . .  3 13 

-  -  vomiting  in   7G,  343, 

705,  707 
I  [  epatic   abscess  (see   Ab- 
scess, Hepatic) 

-  artery,  aneurysm  of   325,  331 
Hepatitis,  pain  in  epigas- 
trium from     . .  . .   437 

-  -  hypochondrium  with     450 

-  tropical,  pain  in  slioulder 

Hepatoptosis,    general   ac- 
count of  ■.  368 

-  from  tight  lacing  . .   3G6 
nierald  patch,  in  pityriasis 


Hereditary  ataxy  (se 
Friedreich's  Ataxy) 

-  optic  atrophy,  central 
scotoma  from 


(Fn 


and 


Heredity, 
oedema 

-  anosteopli 

-  blue  sclerotics  and 

-  brittle  bones  and  . .  242 

-  chorea  and        . .  . .  134 

-  cystinuria  and  . .  . .  161 

-  exostoses  and  . .  . .  671 
~  Meige's  disease  and  . .  236 

-  obesity  and       . .  . .  408 

-  palpitation  from  . .  484 

-  paramyoclonus  and  . .  13G 

-  paroxysmal       hiemoglo- 

binuria  and   . .  . .  284 

-  sick  headache  and  . .  526 

-  telangiectases  of  mucous 

membranes  and  . .  221 

-  trophoedema  and  . .  414 
Hermaphroditism,  pseudo-  646 
Hernia,  appendix  iu  . .  683 

-  bladder  in  . .  . .  683 

-  cerebri,  pnlsalion  in  ..  OiH 

Hernia.         diaphragmatic, 
general  account  of  ..  652 

-  -  thunin,'         :-ihvns<ion 

from  .  .  . .   Gul 


epigastric,    pai 
?astr' 


epi- 


43G 

Hernia,    femoral,    general 
account  of     . .     674,  680 

gland  simulating  G75, 

07S),  GSO 

liydrocele  of  sac  of  . .   075 

Hernia,  femoral,  irreducible  675 

limpin:,'  from.  .  .  .    363 

-  -  ]isoas     absces 


080 


604 


Ifcniia.  femoral,  fonfd. 

sex  incidence  of     674,  GSO 

-  -  strangulation  of        ..   675 
testis  simulating       . .   681 

-  gurgle  on  reduction  481, 

674,  682 
Hernia,  hydrocele  of  sac  of  681 

-  -  simulating       .  .  .  .    481 

-  impulse  on  congliing  in 

4S1.  G74,  680 

-  inguinal,  atropliv  of  testis 

from    .  .  '..  . .      06 


if<, 


-  -  «  ith  e<.topic  testis    . .   4S3 
Hernia,    inguinal,    general 
account  of  .  ■  680 

hydrocele  of  canal  of 

Xuck  simulating   . .   702 

limping  from. .  ..363 

oblique  and  direct    . .  081 

sex  incidence  of        . .   680 

spermatic    cord    com- 
pression  by  . .     CO 

vulval  swelli'ncr  from     700 

Hernia,         inguinoscrotal. 
general  account  of    ■ ■   682 


Herpes   of    genital    organs 

753,  754 

-  -  ge^tationis.  bulhe  in..      'M\ 

eosinophilia  in     HO,  2111 

Herpes  gestationis,  general 

account  of     . .        96,  98 

impetigo  herpetiformis 

and 98 

itching  in       . .  . .      96 

-  glandular      enlargement 

from    . .  . .  . .    754 

-  impetigo  simulated  by. .   754 

-  iris  756 

eosinophilia  in  . .   219 

Herpes  iris,  general  account 


of 


-  macules  in  . .  . .    383 

-  mucous  membranes   af- 

fected by       . .         . .  754 

-  neuralgia  after  . .         . ,  431 

-  no  scarring  after       600,  754 
~  ocular,  pain  in  eye  from  445 


710 


vulval 


cliit 


ill  linea  alba 

-  semilunaris     . . 

lipoma  simulating 


al     ob- 


fro 


Hernia,  obturator,  general 
account  of  . .  681 

obturator       neuralgia 

from  ..  ..439 
pain  in  iliac  fossa  from  454 

-  -  in  thigh  from  . .  081 
rectal  examination  in 

detecting    ..         ..081 

vaginal      examination 

in  detecting  . .  681 

-  omental,  Taricocele  simu- 

lating   697 

-  perineal,  vulval  swelling 

from 700 

-  reducibility        G80,  682.  702 

-  resonance  over,  482,  680, 


of 


682 

aftei 

13, 


702 


Hernia,  retroperitoneal    ..  452 
Hernia,  scrotal,  characters 
of  ..     481,  482 

-  of  stomach,  .r-rays  in  dia- 

gnosing . .  . .    652 

-  strangulated,     constipa- 

tion from       . .         . .  682 
, ectopic  testic  simulat- 


■  —  intestinal    obstruction 


-  suppnratinii  ol    .  . 

Hernia  testis,  general  ac- 
count of  .  .       ^'''2'1, 

sypliilitic 

tuberculous    . . 

-  translucent 

-  umbilical 
age  and 


483 


of 


..  482 

.,    65G 
icidence 

..   483 


irreducible 

obesity  and   . . 

-  -  omentum  iu  . . 

pain  in 

sebaceous  cyst  siniulat- 


mg 


-  ventral,     visible     peris- 

talsis in  . .         . .  521 

Herpes,  brown  stain  after 

GOO,  754 

-  chancre  simulated  by  . .  754 

-  chancroids  simulated  by  754 

-  crusts  in..  ..      600,  753 


of  ( 


203 


with  facial  palsy 

-  face  753 

-  facialis,  in  meningitis  . .  225 
pneumonia     . .      335,  642 

-  febrilis,  lips  affected  by  365 

-  frontalis,  ulcer  of  cornea 

froni 73i 


431 


-  p.n:,  iM  ihr  hackfrom  ..  428 

-  ni   ),..,,,.     isl.  .173.  753,  754 

-  pciiLThr  yiiimlating      ..    36G 
Herpes  progenitalis,  general 

account  of  . .  618 

ulct^ration      of      penis 

from  . .  . .   G17 

-  from  syphilis     ..  ..   184 

-  tenderness  of  scalp  from  710 

-  of  spine  from     . .  . .   713 

-  ulceration  from..         ..  754 

-  of  urethra  . .  . .   184 

-  urethral  discharge  from  184 

-  vesicles  in  . .         . .  753 

-  zoster,  from  arsenic     . .     64 
axillary     glands     en- 
larged with  . .  431 

bilateral  . .  . .   754 

of  conjunctiva  ..   754 

distribution  ot  patches 

of 431 

-  -  of  eveball       . .  . .    754 

-  -  forehead  .  .  .  .    754 

-  -  L-asSfriaii  gaiiu'lion     ..    447 

Herpes  zoster,  general  ac- 
count of         ■  ■      753,  754 

Iiypenesthesia  from..  610 

inguinal     glands     en- 
larged with 

iutercostal  nerve 

fected  by   . .         . .  431 

pain  from  ..  ..   707 

-  -  of  lips..  ..       365,  754 
lymjihocytes   in    cere- 
brospinal fluid  iu  . .  305 

of  mouth       . .         . .  754 

pain  in  arm  from    445,  477 

chest  from  430,  431 

face  from   . .         . .  447 

hvpochondrium 

*from         ..      450,  451 

iliac  fossa  from  452, 

454,  460 

shoulder  from     475,  477 

thigh  from . .  . .   460 

of  palate         . .  . .   754 

persistence 

after 

pigmentation  after 

pleurisy  simulated  by  754 

scabs  in  . .      431,  400 

scarring  after         431,  707 

severe  neiu-algic  pains 

after  ..         ..431 
supra-orbital,     photo- 
phobia from  . .    525  ! 

syphilis  simulating  . .   756  ; 

tenderness  from    700, 

707,  710 

of  spine  from        . .   713 

of  tongue       . .  . .   754  1 

unilateral  nature       . .   754 

vesicles    in  431,    460,  I 

477,  GOO  I 

without  eruption      . .  460 

Heteroxanthin,    uric    acid 

from    . .         . .         . .  742 

Hexamethvlenetetramine, 

for    -.'all-stones            ..    650 
-  -  j.ynria 650 

Hexamethvlenetetramine, 

strangury  from      649.  650 
HICCOUGH  .307 


paui 


448 


acute  dilatation  of  ston 


Hi. 


Hidrocystoma        ..       G51, 

High-frequency  current;s 
insomnia  relieved  by 

in  lowering  high  blood- 
pressure 

Higlimore,  antrum  of  (see 
Antrum  of  Highmore) 

High-step  page,  in  peri- 
pheral nem-itis 

-  in  tabes  . . 

Hill  diarrhoea        . .      172, 

Hill,  on  pyrexia  from  exer- 


Cha: 


'  of 


ski  a, 


of 


..   6i 


—  disease,  abscess  iu  g 
from    , . 

anaemia  with. . 

bursa  simulating       . .   6, 

buttock  wasting  with  3f 

in  children     . .         . .  Gf 

congenital  syphilitic. .  3( 

delicate  look  with    . .   3( 

difficult    to    diagnose 

early  . .         . .  3C 

atrophy  in     . .         . .     ( 

insomnia  from  . .  3S 

lardaceous  disease  from 

8,  3' 

leg  movements  with. .     ( 

limping  from   252,  3G3,  3( 

lordosis  from. .  . .   11 

loss  of  appetite  with. .  3( 

mensuration  in      363.  3( 

natal  fold  oblique  with  3£ 

night  starting  from  . .   3C 

obturator        neuralgia 

from  ..  ..43 

pain  in  the  hip  from    3E 

iliac  fossa  from     . .   45 

knee  from  252,  348,  36 

pelvic  abscess  from..  68 

posture  of  limb  with. .  36 

Poupart's        ligament 

bulged  by  . .         . .  67 
psoas  abscess  simulat- 
ing   3G 

pyrexia  with  . .         . .  3G 

rarefaction    of    femiu: 

with  ..  ..36 

rickets  simulating    . .  36 

sacro  -  iliac        disea.se 

simulating  . .  36 

sciatica  simulated  by    43 

spinal  caries  and      . .  51 

simulating  . .   36 

starting  pains  at  night 

from  . .         . .  32 

swelling  in  iliac  fossa 

from  . .       6G5,  07 

thigh  wasting  from  . .  15 

traumatic       . .         . .  36 

tuberculous    . .       347.  36 

with  tuberculous  peri- 
tonitis        . .  . .     4: 

wasting  of  hip  muscles 

with  . .         . .   M\ 
T-rays  in  detecting   ..   30 

-  liEBmorrhage  into  . .   36; 

-  hysteria  affectins         . .    14! 

-  injury   to,  sciatic  nerve 

paralysis  from  . .   49! 

-  dislocation    of,    limping 

from    . .  . .  . .   36: 

-  osteo-arthritis    affecting 

345.  340,  071 
psoas  bursa  from     . .  6S' 

-  raritv  of  trout  of  . .  34; 


i.i  f.- 


Hip-joint.  tuberculous, 
general  account  of  ■  ■  36; 

Hippocampus,  lesions  of, 
subjective  smells  from  Clt 

Hippocratic    facies,    from 

general  peritonitis    . .   38E 

thorn X   ■  ..  ..    16S 


HIPPURIC  ACID 


HYDROt'EPHAHS 


8ol 


ppuric     acid,     Fehliiit'.- 

HodffkiiVs  disease,  contd. 

Husks,    rectal    concretion 

solution  reduce!  by . . 

261 

swellings  in  abdominal 

from 

71S 

Hpus       

552 

wall  in 

055 

nutchinson.   teeth   of,    in 

rschsprunK's         disease. 

temperature  chart  in 

570 

congenital  svphilis  (Ftq. 

a!)domiaaI    distention 

.r-rays     in     detecting 

108) 

23.-. 

from     . .         127,  130, 

389 

glands  in    . . 

570 

Hyaline  casts 

affe  incidence  of  . . 

130 

(and  see  Lymphaden- 

-  corpuscles  (see  Lymi»ho- 

-  in  children     . . 

130 

oma) 

cvtcs.  Large) 

-  colon  dilated  in  {Fig, 

Hodgen  splint,  paralysis  of 

FTvaloid  artirv 

7511 

55)  127, 

G57 

sciatic  nerve  from    . . 

113 

Hydatid   cyst',     abdominal 

-  rnnL,.rnitnl        .  . 

007 

tjilipes  from  . . 

113 

distention  from 

45 

-  .■,-,„-.li|i,ition  witli   127. 

Hofmeister's  test  for  albu- 

;il>-i< -,-  from  . . 

253 

i:in.  (/■•„,.  171)  :;sii, 

:;90 

mose   . . 

16 

of  li\or  from 

3G9 

rschspruns's  disease,  gene 

Holland,  Dr.  C.  Thurstan, 

;irtliriti>  simulated  by 

476 

ral  account  of 

126 

skiagrams  by  105, 125, 

ascites  from     45,  49, 

658 

-  intestinal    obstruction 

12G,     152,    1.59,    195, 

-  .-  bacillus  coli  in 

530 

from             . ,      127, 

130 

106,     197,    198,    245, 

bile-duct    obstruction 

-  laparotomy      in     dia- 

209,    270,    280,    327, 

by    ..         ..      325 

328 

gnosing        . . 

390 

350,     350.    419,    420, 

—  of  bone 

073 

-  meteorlsm  in . . 

389 

455,  460,  069, 

672 

breast  

181 

-  prognosis  in  . . 

127 

Hollow  back  (see  Lordosis) 

clear  fluid  iu  . . 

65B 

-  sigmoid  volvulus  and 

054 

Holmgren's  test  for  colour 

daughter  cysts  in     . . 

058 

-  tympanites  from 

130 

blindness 

702 

dilatation  of  stomach 

-  visible  peristalsis  in . , 

127 

Homicide,  from  mania    . . 

405 

from 

174 

-  :r-rays    in    diagnosing 

-  by  strychnine    . . 

417 

in  Douglas's  pouch  . . 

49 

390. 

054 

-  voices  urging  to 

405 

felt  per  rectum 

49 

S,   bundle   of,    in    heart 

Horaogpntisic  afid 

716 

galI-bIaiidcro|ieiiedby 

328 

block 

S3 

Honevconih  appearance  of 

Hydatid  cyst,  general  ac- 

ssing noise  in  ear 

723 

fKvus   

246 

count  of 

658 

-  ill  head 

401} 

Hooklcts.  hydatid 

058 

geographical  distribu- 

ir.i" !    il      examination 

-  ill  ascitic"flui.l   18.  {Fiij. 

tion 

49 

'TiiToscopicai  K>- 

IS)  49,  ISl, 

376 

booklets  in     . . 

658 

tolomcal     preparations, 
techniaue  for..        ..  390 
■     .  from  lar.yngitis  199 
[  i>prs,  cramps  in  150 
; ,'  I  III  -^  i  iisease,  albumin- 


-  amenorrhcDa  : 


.  .     18 
55,  04 

-  ascites  in        . .         40.  55 

-  basophile  cells  in    04.  377 

-  bleeding  --'Unis  in       .  .      72 

-  —  of  mouth  ill  . .   274 

dgkin's   disease,    blood 
changes  in     . .       37,  635 

-  tirnii.-liiectasis  from  ..  292 

-  tiTMiH-iiusstenosisfrom  292 

-  rcn-l«ral  haemorrhage  in  274 

-  cervical  glands  enlarged 

in 370 

•  epistaxis  in    . .  . .  274 

-  fibroid  lung  from      . .  292 

-  ( r,.,.   lr,S)       .  .  .  .    377 
dgkin's  disease,  general 

account  of  ..  635 

,.VA\\-/m\     lvm|.h- 

L-l.!M,l,iil:.rL'.-Mi.-iit  ill  .".70 

dgkin's  disease  glands, 
characters  of         377.  380 

-  liu'iii;it.'ni.-i-   in      266.   271 

-  ha;morrlia::es  in         . .   274 

•  jaundice  from  . .  329 

•  iarge-cellcrt        hyper- 

plasia in     . .         . .  379 

•  leucocyte  changes  la      37 

•  no  leucocytosis  iu    . .  570 
'  lymphatic  glands  en- 
larged in  37,  55,  04, 
376,  (Fig.  168)  377, 

.'169,  035 

-  IvmphadenODia       nn<I 

377,  03,-1 

rviH|,l,...iM  ..if. I  .  .    377 

dgkin's  disease,  lympho- 
sarcoma and  .  . .  377 
inyclncytcs  in  '23,  01.  377 
nucleated  red  cells  in  01 
occipital  glands  en- 
larged in  . .  . .  378 
ii'ilema  of  legs  in  413,  415 
peripheral  neuritis  from 

61,  04 
pigmentation  of  skin  in  527 
pici 


al  L-lan.ls 


329 


dgkin's  disease,  pyrexia 
In         . .  25,  563,  569 

-  rigors  in         . .         . .  ..yf. 

-no  special  blood  changes 

-  spleen  enlarged  in  37, 

55,     04,    370,    380, 

5G»,  632,  G35 


Hooklets  of  tsnia  solium 

{Fiq.   212)  ..  ..519 

Hook-worms  . .  520 

Hiiotings  in  bead,  in  in- 
sanity .  .  . .   405 

Hope     and     French,     on 

Meige's  disease  . .  414 

Horse-dealers,  glanders  in  179 

Horse-hair  workers,  anthrax 
ill         074 

florsc-ri.iprs,  ossification  of 
tcii.loM  in 


torsi 


480 


Horses,  bacillus  mallei  from  045 
-  glanders  in  . .  . .  97 
Hospitals,  sore  throat  and  015 
Hot  weather,  constipation 

from    . .  . .  . .  125 

urate  deposit  due  to..  740 

Hot-cross-bun  head  . .  205 
■■  -  in  congenital  syphilis 

009,  711 
Hot-water  bottles,  gangrene 

from 237 

Mour.gliLss  pelvis  in  rickets  187 

Hour-glass   stomach,   dia- 
gnosis of  ..  318 


iiilliitinn  in  diagnosing  318 
]jaradoxical  dilatation 


•ith 


318 


-  -  skiagram  of  (,Fi(i.  128)  268 
stetlioscopo     in     dia- 
gnosing      . .  . .  318 

vomiting  from       765,  766  , 

;r-rays    in    diagnosing  I 

174,  318,  700  1 

-  uterus      . .  . .       'iOII,  201 
Housemaid's     knee    '(see  \ 

Knee,  Housemaid's). .    I7G 
Humerus,    drojiping    of, 

from  hracheitis         . .    177 

-  fracture  of.  paral.vsis  of 

-  myeloid  sarcoma  of     . .  072 

-  tuberculoiiK  periostitis  of  608 

Huntp-biK'k  (sec  Kyphosis) 
Hunger.      abnormal     («co 
Appetite,  Abnormal) 

-  borborvgmi  from         . .     82 

-  insomnia  from   ..      321,  322 
Iliim;crpaili.froi 


iaundice  from        32-i.  328 

-  -  of  kidney        . .  . .   357 

liver        . .         49.  220,  057 

adenoma  simulating  374 

ascites  with         46,  330 

distinction  from  car- 
cinoma   .  .         . .  374 

dome-shaped  dull- 
ness with  . .  375 

entp.vema  from     . .  106 

gall-bladder  simu- 
lated by..         ..  373 

heart  displaced  by    375 

jaundice  from    330.  375 

liver  dullness  in- 
creased upward 
with        ..         ..  .367 

enlarged  from   . .  330 

j.Ieurisy  from        . .  106 

rupture     into     bile 

passages  ..375 

simulating  enlarged 

gall-bladder  252,   253 

jileuritic  etTusion    375 

skodaic    resonance 

with        ..         ..611 

without  s\Tnptoms    253 

suiipuratibn  of       ..   370 

tlirill  in       ..  ..   375 

-  "  -  urticaria  from        ..   370 
of    lung,    hiumoptvsis 

from  ..      287,  291 

simtdating  phthisis    291 

skiagram  of  . .   291 

without  symptoms    291 

:r-ravs  in  diagnosing  291 

-  -  of  mediastinum     470,  751 
mesentery      ..      657,  65H 


Ilifdatid  cysix,  contd. 

-  -  of  joints         . .         . .  350 
laparotomy      in      dia- 

L.-iiosiiig"      2.'-.3,  328,  OOS 
Hydatid  disease  of  liver  ..-475 

-  -  pain  in  the  chest  from  4!r_' 

senuu  reaction  in     . .  226 

serum  test  for       253, 

291,  376,  658 

of  spine  . .         . .    155 

taenia  echinococcvis  and  658 

-  fluid,  no  albumin  in      . .  376 

chlorides  in  . .         . .  370 

hooklets  in    . .      181,  376 

-  hooklets,  iu  a.scitic  fluid    4.'> 

-  of  Jlorgagni.  cyst  from  4S1 

-  of  rib.  tenderness  from. .  707 

-  of  spine,  kyphosis  from  151 
tenderness     of     spine 

from  71 1 
excessive  rarity  of    . .  032 

-  of  sternum         . .         . .  707 

-  of  thyroid  gland           . .  722 
H,vdatidiform  mole,  blood- 
stained discharge  from  186 

chorion      epitlieliomn 

after  ..  ..391 

Tfydrajmia,  definition  of  . .     20 
Hydramnios.  iiscites  simu- 
lated by  . .  . .  6.19 

-  detection' of        .  .  .  .   200 

-  dystocia  from    . .  . .   2(iO 
Hydrarthrosis,  intermittent, 

account  of  . .  349 

Hydroa       . .         . .         . .     y.i 

-  EQStivnIe,  hajmatoporpby- 

rinuria  Irom  . .  .".741 

-  from  bromides  . .  . .     OS 

-  eosinophilia  in  . .  . .  219 

-  erythema  front  . .  . .  222 


-  gcstationis 

-  from  iodides 
Hydrocele,  aching  in  testis 

from 

-  in  acute  fevers  . .  . . 

-  atri.iil.v  .if  i.-ii-  from.. 

-  of  .■.hmI  ,,i   \n,  k,  luTiiia 


Hydrocele,  causes  of 


-  Ik 


-  cvsl   ..I    Ir-ii-  -iiiiiiI.Iihl;  1M 

-  dra^-vHiL-  111  I. .ill  In. Ill    ..  ISl 

Hydrocele,  encysted,  of  cord  695 
Hydrocele,     encysted,     of 

epididymis                . .  695 

-  Willi     .■|.i.li.hiii,,...ivliilis  ISl 


:.l.-|.ll.|HI 


ISl 


3li; 


I'liol... 


Ihiiili.i  •.    Il  .in  .111.1.1    after 

Huntlnndon's  Chorea 
Hupperl's  test  for  bile  pig- 
ment  . .  743. 
Huskiness,  from  Iiirvngitis 
-  walerbriisli 


—  movable  kidney  simu- 

testis to                     ISl 

695 

lated  by     .. 

663 

Hydrocele  of  sac  of  hernia  675 

iu  omentum  . .       057, 

658 

-  scrotal  li.Tl.ia  .~inillla(iliL 

ISl 

ovarian  cyst  sinuilated 

-  siniulalc.l    l.y    lici>pla..|i 

bv    ..         .. 

091 

ISO 

ISl 

-  paii'i  ill  -lioiiMcr  from 

4  71! 

-  straw-coloured  fluid  froii 

181 

pi'lvi.'  >ni'llilii-  due  to 

688 

-  from  syphilis     . . 

4711 

Hydatid  cysts  of  peritoneum 

-  transhicencv  of  . .      6M2 

6».'. 

15.  49.  22li.  657. 

6.5H 

-  -  test  for  " 

4SI 

senim  reaction  for  .. 

49 

Hydrocophnluri,      uiiosmii 

simulating  ascites     . . 

43 

from 

Ol'.' 

—  in  spleen 

037 

-  Choync-Stokos  breathing 

Ins 

-  -  sterile 

40 

-  congenital 

r.11 

—  suppuration  In      233, 

-  convulsions  wiili        1 15 

1111 

309, 

330 

-  dwarflsm  from  . . 

iss 

—  without  symi>toniH  . . 

6D8 

-  dystocia  from    . . 

201 . 

swelling  in  lilac  foR»a 

-  .-gg-shell  cn.cklliig  Willi 

I5m 

from 

078 

-  enlrirgcil  lieiid  from 

511 

-  -  thrill  In 

038 

-  ey(.s  displiiccl  in 

205 

r.rays    in    diagnosing 

-  foreheiid  large  from 

•jnl 

'.'91, 

170 

~  lieiid  eiilargeil  In 

2U5 

-  <ll..icaiie,  iilidomliud  swell- 

- Iieailache  from  . . 

2UI 

ing  from 

0.-i5 

-  after  melilnglllK         2U3, 

fill 

bloofi  cinniges  with  . . 

20 

-  o|illc  atrophy  with 

iK< 

^  '  coslnophlllii  In  19,  22«, 

-  paraplegia  from 

All) 

2.-13.   291.   371.  37B, 

«3K 

-  rarefacl  inn  of  skull  lionn 

-  .    irylheiini  from      223, 

S'-'fl 

from 

133 

832 


HYDROCEPHALUS  HYSTERIA 


Jlijdroa'pkalus,  contd. 

-  "recognition  in  utero     . .   201  | 

-  rickets  simulating         . .   204 

-  Tomiting  due  to  . .  765 
Hydrocliloric  acid  (see  Acid, 

Hydrochloric) 
Hydrocyanic  acid  in  vomit  7G0 
Hydroe;en     peroxide,     in 

occult  blood  test        . .    171 
Hydro  neplirosis,  abdominal 

distention  from  . .      45 

-  from  bladder  growth   . .    281 

-  Ironi  calculus      40,  117, 

279,  (/"/?.  166)  356,  536 

-  carcinoma  uteri. .  . .  41 
_  _  TPsica?  .  .  . .  41 
Hydronephrosis,       general 

account  of  . -  356 

-  fn"owth  simulating         . .    280 

-  haimaturia     from      275, 

280,  35G 

-  kidney     enlarged    from 

280,  352,  355.  530 

-  from    movable     kidney 

115,  451,  536,  6f)5 

-  obstructed  ureter         ..     41 

-  palpation   in  diagnosing  253 

-  from  papilloma. .  . .   278 

-  pelvic  swelling  due  to  . .  688 

-  polycystic    disease    dis- 

tinguished from        .  .  280 

-  polyuria  from  535,  536,  665 

-  from  prostate  disease  . .  280 

-  pyelography   in    detects 

ing       . .        {Fig.  166)  356 

-  simulating  ascites  . .  45 
enlarged    gall-bladder 

252,  253 

-  from  stricture    . .         . .  280 

-  ureteric  calculus  . .  578 

-  urine  variations  with  . .   280 

-  varying  size  of  45,  356 

-  x-rays  in . .  . .  . .   536 

Hydrophobia,  from  bites. .   730 

-  convulsions  from,      144,  730 

-  delirium  in         ..         ..170 

-  difficult  swallowing  from  543 

-  from  dog-bite    . .      138,  197 

-  dysphagia  in      . .      138,  197 

-  leucocvtosis  in   . .  . .   360 

-  localixed         convulsions 

from     . .  . .  . .  144 

Hydrophobia,  notes  on  . .  730 

-  priapism  from   . .  . .  538 

-  ptyalism  from  . .  . .  543 

-  respiratory  spasm  in  . .  138 

-  retracted  head  in  . .  589 

-  rigor  rare  in        . 


Hyperacidity,  with  duode- 
naf  ulcer 

-  gastric  ulcer 

-  vi  urine,  frequent  mictu- 

ritiori  from     . . 
HYPERACUSIS     ■• 

-  with  facial  paralysis     . . 

-  from  Fallopian  canal  le- 

sion 


138 


-  teni|. ..-.■:.-      ■•■    i:_-li  in  170 

-  triMlJI-      M..':.  ..730 

Hydni|,,MiMMMi„.|-i,  mlium, 

rhurnini,'  sounds  with  652 

-  succussion  in  chest  from  651 
Hydropneumothorax,     ex- 
ploring needle  in  dia- 

Hydropneumothorax,  gene- 
ral account  of        651.  652 
Hydrops  amnii  44,  45 

Hydroquinone-acetic    acid, 

alkaptomiria  and       . .   746 

Hydrosalpinx,  pelvic  swell- 
ing due  to      . .         . .  688 

Hydrothorax,    from    back 

pressure  . .         . .  212 

-  chronic  nephritis  . .  212 

-  high  blood-pressure      . .  212 

-  mitral  regurtritation     ..   211 

-  orthopnoea  from  ..   418 

-  (atul    see  Chest,   Serous 

Effusion       in  :       and 

Pleural  Effusion) 
Hydroxylamine    sulphate, 

in  estimating  sugar  . .  263 
Hygroma,  cystic,  of  axilla  667 
Hymen,    closed,    sterility 

from     . .  . .      645,  646 

-  inflamed,       dyspareunia 

from  . .  "  . .  193,  194 
vaginismus  from       . .   193 

-  imperforate,amenorrhcea 

with IS 

-  unruptured,  dyspareunia 

from 193 

Hyoscyamus,  delirium  from  109 


-  otitis  media  . .  . .  166 
Hypertesthesia  acustica  (see 

Hyperacusis)      . .  . .   166 

Hypergesthesia     in     blood 

diseases  . .  . .   610 

~  bracliiai  neuralgia  . .  442 
~  Brown-S6quard paralysis  497 
Hyperesthesia  of  chest  ■ .  708 

-  from  combined  scleroses 

of  cord  . .  . .   610 

-  epigastric,    from    gastric 

ulcer 269 

Hy perse sthesia.  general  ac- 
count of  610 

-  from  h^matomyelia     . .  140 

-  herpes  zoster     . .         . .  610 

-  in  hyoid  area,  from  ear 

disease  . .  . .  449 

-  from  hysteria    . .      468,  610 

-  in  neurasthenia  . .   610 

-  from  neuritis      . .  . .   140 

-  new  growth  in  spine     . .   714 

-  in     peripheral     neuritis 

440,  465 

-  in  pernicious  anemia   ..  610 

-  with  pyelitis      . .  . .   451 

-  referred  pain      . .  . .   42S 

-  from  spinal  caries         . .   610 

-  of  stomach         . .  . .   319 

-  in  tabes  . .  . .      609,  610 

-  with  transverse  myelitis  140 

-  from    tumom"    of   spinal 

meninges         ..  ..   610 

HyperEBSthesia  vesicae  . .  398 
Hyperalgesia,      antes  thesia 

with 606 

-  in  aneina  pectoris  . .  70S 
Hyperalgesia  of  chest      . .  708 

-  in  nerve  regeneration  . .  607 

-  peripheral  neuritis  606,  607 
Hyperchlorhvdria,  appetite 

increased  in    . .         . .     42 

-  dyspepsia  from  . .  . .   318 

-  pain  in  epigastrium  from  436 

relieved  by  food  in   . .  437 

Hyperidrosis  . .  654 

-  in  brachial  neuralgia    . .   442 

-  egsshell  nail  and  '  . .  400 
Hyperin volution  of  uterus, 

amenorrlicea  from     . .   640 

sterility  from         645,  646 

Hyperkeratosis,   from    ar- 
senic     . .  34,  04,  73 
Hyperlactation,       anaemia 

from    . .  . .  . .      35 

Hypermetropia, 
■     tism  with 

-  crescent  with 

-  eyestrain  from 

-  glaucoma  and 

-  headache  from 

Hypermf 


Dtjcdiscin  417 


418 

-  pain  I'll''    ■.\:-  tium    .  .    446 

-  photophobia  from         . .   524 

-  progressive,     from     tu- 

mour of  optic  nerve  . .  230 

-  pupil  small  with  . .   551 

-  strabismus  from  . .   649 

-  tenderness  of  scalp  from  712 
Hvpermnesia  . .  . .  19 
Hvpernenhi-oma,  colic  from  356 
Hypernephroma,    general 

account  of  . .  356 

-  hiEinaturia  from  ..   356 

-  of  kidney,  aching  in  loin 


froir 


278 


colic  from 

haematuria  from    275,  278 

renal  enlargement  fi'om  278 

slow  growth  of  . .   278 

-  kidney  enlarged  by       . .   355 


Hf/pernephroma,  contd. 
-"obesity  from      ..      40S.  409 

-  precocious  genitalia  witli 

(Fi(7.  175)       ..      408,  409 

pubic  hair   with  331, 

iFiff.  174)  408,  409,  630 

-  spleen  simulated"  by      ..   662 
Hyperpiesis     (see     Blood- 

Pres.sure,  High) 
Hyperplasia,     large-celled. 

in  Hodskin's  " 
HYPERPYREXIA 


fro 


309 


astigma- 

..  417  ; 

..  415  ! 
..      446,  524  , 


-  witli     cerebral     liremor- 

rhage   ..  ..        84,  306 

-  definition  of       ..  . .   309   | 

-  delirium  with     . .  . .   169  ' 

-  from  head  iniurv  .  .   574 

-  ill   lic:a-^lrnk,-      ..  ..     120 

Hyperpyrexia,  hysteria  and  310 
Hyperpyrexia,  list  of  causes  309 

-  in  midaria  ..  ..      30  I 

-  nvUingeringof    ..  .  .    310  i 

Hyperpyrexia,  notes  on    ..  574 

-  from     pontine     haemor-  I 

rhage   . .  . .      119,  311 

-  in  rheumatic  fever    169,  574 

-  septic  states      . .         . .  574  ; 

-  typhoid  fever    . .         . .  574  i 

-  uraemia    . .  . .  . .   574  [ 

Hyper-resonance  of  chest,  | 

from  emphysema     89,  217  < 

-  over    sound    lung   when  I 

other  fibroid  . .  . .    168 

-  with  pneumothorax  432,  530 
Hyper-resonance  in  thorax  611 
Hypertoims,  sense  of  full-  [ 

ness  from       , .  . .   244 

Hypertrophic  pulmonary 
osteo-arthropathy  (see 
Pulmonary    Osteo-ar-  | 

tliropathy) 
Hypertrophic    stenosis    of  i 

pylorus  . .  766  ! 

Hypnotics,  delirium  from     169   ■ 
Hypochlorhydria,   dyspep- 
sia from         . .         . .  318  I 
Hypochlorite    of   calcium,  ' 

in  indican  test  . .   314 

Hypochondriasis,  blue  brain 

and 163 

-  constipation  from         . .    124 

-  hyperacusis  in  . .  . .   309 

-  insomnia  from  . .         . .  322 

-  oesophagismus  in  . .   435 

-  oxaluria  and      ..  ..   424 

-  pruritus  from    . .  . .   540 

-  witli    undue    abdominal  | 


HYPOTHERMIA  .. 

-  in  alcoholism     . .  .  .   ; 

-  Anglo-Indians    . .  . .   ; 

-  with  anuria 

-  cerebral  abscess  503,  [ 

-  in  children        : .  . .  { 

-  after  convulsions  . .   i 

-  in  cretinism      . .  . .   '. 

-  definition  of       . .  . .   J 

-  from  exhaustion  571.  { 

-  exposure            . .  . .  i 

-  heart  failure      . .  . .   I 

-  intense  pain       . .  . .   I 
Hypothermia,  list  of  causes 


of 


-  mitral  stenosis  (Fir/.  142)  ; 

tuberculosis   . .         . .  ', 

"  in  myxcederaa  . .         . .  : 

-  neurasthenia      . .         . .  ■ 

-  from  opium  poisoning 

119.  : 

-  snake-bite  . .         . .  : 

-  summer  diarrhoea        . .  J 

-  in  uraemia 
Hypothyroidism    . . 

-  at  menopause    . .  . .  • 

-  obesity  from      . .  . .  ■ 
Hypothyroidism,  therapeu- 
tic test  of      . .        ..  i 

Hypotonia  of   muscles,   in 

tabes   dorsalis  . .   ! 

Hypoxanthin,     m-ic     acid 

Hysteria,    abdominal    dis- 
tention from. .  . .    • 

-  absence  of  fatigue  in    . .  - 

-  administration  of  poisons 

from    . .         . .         . .  ' 

-  amblyopia  in     ..      728,  ' 

-  amputation  in   . .  . .  • 

-  anesthesia  in   134,  468, 

498,  503,  ' 

-  auEestbetic  in  disignosing 

114, 142, 351, ; 

-  ankle-clonus  in..         ..  ' 

-  no  ankle-clonus  in       . .  '. 

-  ankle-jerk  exaggerated  in  ■ 

-  anorexia  due  to. . 


pnis; 


543 


Hypochondrium,  left,  organs 
contained  in  . .        ■  ■  660 

-  priin  in  C^oe  Pain  in  the 

HvpoclinndriunV) 

Hypochondriuii,  rinht,  or- 
aans  contained  In      . .  660 

-  swelirr'    :■,   ,  -.  .     -■■..IInil,' 
Hvpor),x;  ..319 

Hypoaastriu-n,  organs  con- 
tained in  ■ .  660 

-  pain    in    (see    Pain    iu 

Hvpogastrium) 

-  swelling   in   (see    Swell- 

ing in  Hvpogastrium) 
Hypoglossal    nerve,    para- 

Ivsis  of  63,  135,  543 

Hvpomnesia  . .  . .     19 

-  in  alcoholism      . .  . .      20 

-  epilensy  . .  . .  . .      20 

Hypooituarlsm  ..410 

-  obesity  from  . ,  . .  408 
Hypopyon  ulcer  . .  . .  734 
from  fifth  nerve  paraly- 


-  with  iritis  . .         . .  : 

fr-om     lachrymal     sac 

suppuration  . .   ! 

ulcer    of   cornea    231, 

(Plate  XIF)  232,  ' 

Hypospadias,  urine  stream 
changes  from  . .   ! 

Hypothenar  muscles,  atro- 
phy ,\of  (see  under 
Atrophy) 

root  innervation  of  . . 


-  anuria  from  . .  40,  ■ 
Hysteria,  aphonia   in   197, 

465,  495,  628.  6 

-  arthritis  simulated  in  . .  3 

-  ascites  simulated  by    . .  3' 

-  asthma  simulated  by  . .  5 

-  ataxy  from        . .         . .     i 

-  Babinski*s  sign  absent  in  1 

-  blindness  in       . .         . .  6 

-  borborvErmi  in   . . 

-  in  abov 

Hysteria,    brachial    mono- 

plenia  in,  general  ac- 
count   5i 

-  bradvpncea  in    . .  84,  1 

-  bullJB  in . . 

-  carcinoma    of    stomach 

simulating      . .         , .  4 

-  cerebral    tumour    simu- 

lating   7 

-  Charcot's    spasmogenic 

-  chorea  and  . .  . .  1 
I  —  clavns  in  ..  141,  4 
I  -  constipation  due  to  43,  1 
'  -  contracted  visual  fields  in 

[  728,  7 

-  contractures  in  134, 139,  V 
! disappearance     imder 

I  anesthetics  . .  1 

persistence  during  sleep  1 

!  -  coma  in  . .         . .     118.  1 

-  convulsions  in  137.  144. 

■  310,  7 
I  Hysteria,  convulsive  fits  In  I 

-  cough  from       . .  . .  1 

I  -  craving  for  sympathy  in  7 
I  -  deafness  in         . .  . .   V 

I  -  deeo  reflexes  inci-eased  in  li 
[  -  delirium  in         . .  . .  3! 

I  -  disseminated       sclerosis 

simulated  by. .         . .  71 
! simulating  . .         . .  7: 

-  double  consciousness  and   l 


HYSTERIA     —    INDIGESTION 


Tysteria,  could. 
dyspepsia  simulate  J  by  315 
dysphagia  in  ..  I9tj,  197 
emaciation  due  to  . .  43 
epilepsy  simulated  by  . .  137 
exaggeration     of     s^-m- 

ptoms  in         . .  . .   710 

fliisliiii-s  in        ..  ..   310 

foul  l;istefroni  ..  ..705 

ysterja,  general  signs  of 

4(;5,  466 
globus  hystericus  in  141, 

197, 465, 495,  651 
headache  from  296,  310,  71'J 
hemianaesthcsia  from  59, 

141,  466.  610 
hemidrogis  in  . .  . .  654 
hemiplegia     from       59,  I 

307,  497,  303  ' 
ysteria,  hiccough  in      ■.  307 
ysterra  and  high  tempera- 
tures     310 

Ini-  diMM-..-  <itiiul.ited  by  141 
hyper;icusis  in  . .  . .  309  , 

hypersesthcsia  in       408,  610  i 
^—  of  breast  in    . .  . .   611 

-  <.v;iry  in  ..  ..    611   ' 


ll>/sferia.  contd... 

-  sex  incidence  of . .         . .  465 

-  simulating   new  growth  143 
pregnancy      . .       142,  390 

-  Snellen's  type  in  detecting760 

-  spasm  of  face  from      . .   494 

-  spasmodic  twitchings  in  136 

-  spiral  contraction  of  field 

of  vision  in  . .         . .  759 

-  stocking  and  glove  anjes- 

thesia  in         . .  . .  465 

-  strangury  in      . .  . .   G49 

-  stridor  from      . .         . .  651 

-  strychnine    poisoning 

simulated  by  417,  598,  729 

-  subjective  smells  in      . .  612 

-  suggestion  treatment  in 

308,  487,  526 

-  tachypnoea  in    . . 

-  talipes  from    .  . . 

-  tenderness  in 
in  chest  in 

-  -  nf  soaip  frnm 

Hysteria,      tenderness 
spine  from 

Ill  inii-cl-siii  .  . 

-  tet:uiic  <|JUiliis  Ml 

-  tetaiuis  simulated  by 


85 
114,  141 


1.1         on  tremor  in    724,  728 
lii- '-  jLTks  m    307,  308, 

468,  497 
knee-joint  disease  simu- 
lated by  . .  . .  141 
Inpurnrnmy  in  mistake  in  390 
1.  •  r  M~i,.L'"testin  ..  307 
I  ■  ■  I  '■  'I'dema  in  ..  411 
i       i:  ■  1        convulsions 

huni 144 


417,729,  730 


loss  of  hearing  in        . .  610 

-  smell  in         . .         . .  610 

-  taste  in  . .  610,  705 
malingering  distinguL^hed 

from 350 

memory  defects  in  . .  20 
meteorism  in  . .  . .  390 
little  muscle  atrophy  in  351 
muscle  wasting  in  . .  503 
myoclonus  in  . .  ..  136 
neurasthenia  simulating  716 
neurosis       distinguished 

from 487 

noises  in  tlic  head  in  . .  40ti 
oesophagismus  in  . .  435 

opisthotonu.s  in..  138,  417 
orthopnoea  from  . .  418 

ovarian  cyst  simulated  by  390 

-  disease  simulated  by    468 

-  pain  from  . .  . .  468 
pain  in  the  breast  from  430 

-  a  joint  in       ..  ..  350 

-  the  limbs  from      463,  465 


■■■k-^  , 


141 


/^turta.  paralysis  In     141,  13 1 

.._ii  ,(,-  -itriiihiling     ..   003 
ysteria,  paralysis  of  one 
leo  from  . .  497 


I  inl.in  in  525,  526 

I  I  i.llex  in         69,  308 

M,    in      ..      307,  497 
[I     I    I  I'lious      convul- 

1 417 

|..,      ,   ,  ,    from    ..      G35,  719 
inuM    I     trom    ..  ..   540 

).!..        iiotn        ..  ..    141 

I  I  iiMi-a  from      642,  543 

|n,,|.  ,,  ,  irom     ..  ..   554 

.(ui^.jiu-  eyelids  in      ..    137 
reUuxe^  in  . .  . .   503 

rcgurcitatton     of     food 
thrnnirh  im*<o  from   . .   589 


n^u^  >.tni.ir,i.ii.-i  in        ..   598 
scoliosis  from     . .  . .  153 

screaming  in      ..  ..137 


ICEBAG,  bedsore  from. . 
-  gangrene  from 
Iceland,  hydatid  disease  in 
Ichthyosis,  anidrosis  with 

-  fingers  aOfected  by       . .  ; 

-  hystrix ■ 

-  keratosis  pilaris  one  form 

of        ■ 

-  onychogrj-phosis  with..  ' 

-  tinea    imbricata     simu- 

lating . .         . .         ..  '. 

Icterus  gravis  of  children 
325,  326,  ; 

-  (and  see  Jaundice) 
Ideas     of     grandeur,     in 

,  general  paralysis    120,  ! 

I  Idiocy,  amaurotic  family. . 

1  -  coma  in : 

1  -  congfnital  blindness  with  ! 

-  convulsions  with       114,  1 

-  cretinism  simutatiiig  ..  i 
;  -  kyphosis  in  . .  . .  ] 
I  -  niicroceplialv  and        . .   ] 

Idiocy.  Mongolian..     237,  S 

-  -  facics  of    {I'ig.t.     118, 

119)         ..       ..  ; 

thyroid    treatment    in 

distinguishing  from 
cretinism    ..         . .  '. 

-  paraplegia  from  . .  ( 

-  speech  defect  in  . .  * 

-  tongue  swollen  in     237,  t 

Idloglossia < 

Idiopathic     dilatation     of 

colon     (see     Hirsch- 
wpruiig's  Disease) 

cesophagufl,    vomiting 

I  due  to        ..         ..    I 

i  Idiotft,  clobbering  in        . .  C 
I  Ilcocujcjil  kink       297,  451,   I 
I  -  volve,    souiuls    of    food 
I  passing 

I tuberciilositt  at         , .  -1 

'  Ileum,  congenital  obstruc- 
tion of  . .         . .   ] 


simulating 

-  tetany  in  . .  . .  loii 

-  thirst  in 719 

-  torticollis  from..  ..   141 

-  trance  due  to     . .  . .  120 
!  -  tremor  in            134,  724,  727 

-  trismus  in  . .      138,  417 

I simulated  by. .         . .  729 

1  -  typhoid  spine  simulating  715 
I  -  with    undue    abdominal 

i  aortic  pulf^ation        . .  543 

-  urgent  desire  to  mictu- 

i  rate  in  ..         ..  398 

'  -  variability  of  symptoms 

in         759 

-  vomiting  from  315,  467, 

765,  768 

-  wrist-drop  in     . .         . .  350 
I  -  (and  see  Neurosis) 

I  Hystero-epilepsy  ..         ..  137 

-  retracted  head  in        ..  589 


Iliac  absceiis  (see  Abscess, 
Iliac) 

-  artery,  aneurysm  of  452, 

454,  460,  587,  678 

-  crest,  bedsore  over      . .  257 

-  fossa,    swelling    in    (see 

Lymphatic  Glands, 
Iliac  ;  Swelling  in  Iliac 
Fossa) 

-  vein  thrombosis  8,  106,  411 
Iliacus,  nerve  supply  of  . .  498 
Iliocostal  space,  elongated 

by  cystic  kidney  . .  354 
Iliopsoas,  nerve  supply  of  499 
Ilium,  chondroma  of,  pain 

in  iliac  fossa  from  454,  460 

-  osteoma  of,  pain  in  iliac 

fossa  from      . .       454,  459 

-  osteomyelitis  of  . .  303 

-  periostitis    of,    append!-  ■ 

citis  simulated  by    . .  454  I 

pain  in  iUac  fossa  from  j 

452,  454 

-  sarcoma  of,  paui 

fossa  from 

-  tumour  of,  pain  i 

fossa  from 
Illusions,  from  alcohol 
Illustrations,  list  of  . .  xiv 

Imbeciles,  slobbering  in  . .  543 
Imbecility,  amenorrhoea  in     18 

-  dwarfism  from  . .         . .  188 

-  microcephalv  and        . .  188 

-  in  mongolism     . .  . .   190 
Immersion,  aspiration  pneu- 
monia after    . .  . .   260 

-  gangrene  of  lung  from 

260,  644 
Impacted    wisdom     tooth, 

simulating  tetaims    . . 
Impetigo,      bacillus      coli 

causing 
pyocyaneus  causing.. 

-  bullfe  in       96,  98,  401, 

-  bullosa    . .         . .      401, 

-  circinata  . .         . .  5.')8 

-  corit:ii,'io^a  .  .  401,  558 
Impetigo  contagiosa,  bullffi 

in  90,  98 

-  -  li.ni.v-liko.Tu>ts:u  ..     :i8 


t  iliac 
454,  400 
iliac 

459 


138 


US, 


833 

Incoherence,  from  frontal 

lobe  tumour  ..         . .  727 

Xncompatimlit-y,     sterilitr 

f.uiu    .,         ..         :.  lUi; 

INCONTINENCE  OF  FAE- 
CES      313 

due  to  increased  intra- 
cranial pressure    . .  590 

from  lateral  sclerosis    517 

in  tabes         . .         . .  719 

-  urine,  cystitis  from     ..  578 
from    destruction    of 

micturition  centres    398 

distended  bladder     . .     45 

enuresis  distinct  from  218 

due  to  increased  intra- 
cranial pressure    . ,   590 

from  myelitis..         ..  578 

retention   sirhulating     395 

from  retroverted  gravid 

uterus         . .         . .  689 

sphincter  paralysis  ..  218 

in  tabes         . .         . .  578 

Inco-ordination  (and  see 
Ataxy) 

-  from  peripheral  neuritis  465 

-  in  tabes 609 

India,    ankylostomum    in 


81, 


-  kala-azar  ii 

-  mycetoma  in     . .         . .  736 

-  retai)sing  fever  in      336,  596 
Indian    ink    method    for 

spirochaata  pallida   . .  701 
India-rubber  bottle  stomach 
(see      Carcinoma      of 
Stomach,  Diffuse) 

-  carbon  bisulphide  in  dis- 

solving . .         . .     05 

-  workers  in,  paralysis  in    65 
Indican,  indigo  from       -,  314 

-  Moore's  test  and 


of 


314 


nitric 


cuUmeous        diphtheria 
simulating      . .         . .  558 

-  ecthyma  and     . .      557,  558 

-  erythema  in      . .         . .  558 

-  of  face  and  hands        . .    560 

-  no  fever  in        . .         . .   562 

-  fingers  affected  by       . .  239 
Impetigo,  general  account  of  558 

I  -  gyrata     . .         . .  . .  5.'»8 

-  herpes  simulating        .  .   751 

I  -  herpetiformis,  in  Austria     98 
pregnancy      . .  . .     98  ! 

-  leucocytosis  slight  with    360 

-  lips  seldom  attacked  by     734 

-  occipital  glands  enlarged 

from 378 

-  papules  in  755 

-  part«  affected  by         . .  662 

-  i)emphigus-like   typo   in 

infants  . .         ..     97  , 

-  perlck;he  with    . .         , .  306  ' 

-  piisttUar    eczema    simu- 

lating . .         . .         . .  658 

-  pustules  in         557,  558,  500 

-  riiitrworm  simulating  ..  249 
Impetigo,  scabs  of         ..  600  I 

~  from  scrat<;liing. .  . .  71i)  I 

-  small-fiox  simulated  by  562 

-  staphylococci  cjiusing  . ,  558  ' 

-  streptococci  causing     . ,  558  [ 

-  syphilirles  simulating  . .  560  I 

-  vpsicM  In         558,  562.  755  I 
Inii.liint'iiiori    cyst,   vulval  ' 

sw.Iliiiir  from  ..  700 

IMPOTENCE  ..  312  I 

-  d.-Ilrnti.-n   of  .  ,    312 

Impotence,  functional  tem- 
porary  313 

Impotence,  list  of  causes  ot 

312.  313 

-  senile,  priapiwm'pn-ccdiug  538 

-  sterility  distinct  from  . .  312 
Impulse  on  roughing  (nen 

roughing,  ImpuiHe  on) 
Inattention,   front    frontal  i 

lobe  tumour  . .         . .  737 


262 
314 
Indican,  tests  for  ..     314.  745 

-  -  t/V.//,   AAA'/ I'}         ..    7  IS 
INDICANURIA 

-  ai'i.cii'luitis  and 

-  black  urine  from 

;u-i(l  due  to    ..  5,  314 

Indlcanuria,  causes  Of  314.315 

-  from  duodenal  ulcer  ..  101 

-  empyema           . .  . .  7 15 

-  gastric  ulcer      . .  . .  lul 

-  in  healthy  persons  ..  315 

-  intestinal   catarrh  . .  101 
putrefaction   ..      101,  745 

-  mclatuiria  simulated  bv 

745.  746 
Indlcanuria,  notes  on      ..  745 


all  r 


1 5 1 


INDIGESTION     (uul     .sic 

Dyspepsia)     . .         . .  315 

-  air-swallowing  simulating  3 1  u 

-  aneurysm  simulating  316, 4*J'.t 

-  angina  pectoris  simulat- 


ing 


3lfi 


-  casein,  stools  with 

-  of  children,  uppendlcitlji 

and 31<i 

-  cholecystitis  simulating    316 

-  chronic,  aniemia  from  . .     32 

-  diarrtura  from  . .         . .   172 

-  from    dilatation    of    the 

Htomuch         . .         . .  317 
duodenal  ulcer  ..   317 

-  fat,  atooN  with  ..         ..171 

-  flushing  from     ..  ..241 

-  in  infantjf  ..         ..  .121 

-  inRomnia  from  ..         ..321 

-  iutcrsca])ular  pain  from 

Ifll.   102 

-  intestinal        obstruction 

siiniilating      ..  ..   316 

-  niigruino  sitmilatiiig     . .   310 
.-  oxaliirlu  and  phosphaturin 

alternating  in         423,  421 

-  pain  in  nhoulilor  from  . .  471 

-  from   jiuncreatlc   ki^loHs 

101.  661 

-  phtlli^i4  sinnilKtirig       ..   315 

-  plfurl-y  simulating      ..   .110 

-  from  pylori-'  obHtrut'llon  123 

-  Hpinal  caries  Himuliiting  3|it 

-  HUgar.  rttuolM  with        ,.    171 

-  urwrnia  xlmulating       ..  315 


884 


INDIGO 


INJURY 


314 


Iiidigo,  from  iiidican 
Indigo-blue 

-  epilepsy  treated  by 

-  methylene     blue     s: 

latiiig  . . 
Indigo-red 
Indol 

-  indicaiiuria  and 
Indoxyl-glycurouic 

blue  urine  from 
Indoxyl  sulphate 
Inertia,   uterine,    d; 

from    . . 
Infantile    hemiplegi 

Hemiplegia,  Infantile) 

-  paralysis  (see  Paralysis, 

Infantile) 

-  uterus  (see  Uterus,  In- 

fantile) 
Infantilism  with  achondro- 
plasia . .  iFiff.  86)  18 

-  anangioplastJ 

-  ateliosis  and 

-  from  cretinii? 


acid, 


(S( 


745 


314 


40 


Id     dw 


iFiff.  91)  190 
(Fi(t.  92)  190 
(Fitj.  88)  189 


distil 


lysis  ot  . .  . .   : 

Infarction    of    brain    (see 
Embolism,  Cerebral) 

-  intestine  (see  Mesenteric 

Embolism;  Embolism, 
Kenal ;  and  Kidney, 
Infarct  of) 

-  lung,  after  appendicitis 

from  embolism       160,  ; 

empyema  from        . .  ; 

gangrene  of  lung  from  ( 

haemoptysis  from  106, 


188 


^  lished 
Infantilism,  general  account 
of  I8B-9I 

-  gigantism  with  . .         . .   188 

-  Herter  on  . .  . .   189 

-  improved  by  pancreatic 

extract  ..  ..191 

-  pituitary  (^Fiff.    89)  189, 

190,  410 
~  with  splenomegaly       . .  189 

-  tliymic 189 

-  thyroid 190 

Infants,  acetonuria  in     . .       4 

-  acute  arthritis  of         . .    341 
infants,  acute  colitis  in    . .    78 


.    blad>irr    ML    .   .,1  ..     I 

blood  l'"-i-  uiuiiii  in 
bullous  impetigo  in      . .   ■ 
carpopedal  spasms  in  . . 
caseous  bronchial  glands 


Cheyne-Stokes  breatJiing 
117,  : 


-  coli  bacilluria 

-  colic  in    .  . 
Infants,  convulsions  of 


Infants,  cyclical  vomiting  of 
Infants,  diarrhcea  in 

-  diarrhuia  and  vomiting  in 

-  drawing  up  of  legs  in  . . 

-  diibbling  of  saliva  in    . . 

-  epilepsy  in 

-  epiphysitis  in    . . 

-  general  oedema  in 
~  hiemoglobinm-ia  in 

-  bemiathetosis  in 

-  hemiplegia  in     ..      303, 

-  Hirschsprung's     disease 


Infants,  insomnia  in 

-  intesthial  obstruction  i 

-  intussusception    in     7! 

13 

-  Jacquet's  erythema  in. 
Infants,  jaundice  In 

~  knee-jerks  diminished  i 

-  liver  proportions  in 


pemphigus  hi    . . 
plantar  reflex   extensor 

in         ..  ..         G9,  . 

postpharnygeal  abscess  in ' 
priapism  in  . .  . .  . 
pupils  small  in  . .  . . 

■  pyloric  spasm  in  . .   < 

■  rarity  of  phthisis  in     . .  : 

■  regurgitation  of  food  in 

■  rheumatic      fever      un- 

known in       . .         . .  . 
•  rigid  abdomen  in 
-  scabies  of  face  in 
screaming  in 

■  scurvy-rickets  in 


Influenza,  often  diagnosed 

wlien  not  present    oi, 

110,  465, 

-  diphtheria  simulating  . . 

-  duration  of        . .  . .   ' 

-  epidemics  of      . .         . .  i 
~  epididymitis  from 

-  epididymo-orchitis  from 

-  epistaxis  from  . . 

-  febricula  representing  . .   ■ 

-  gastro-etiteiitis  in         ..   . 


stro-i 
pto 


Influenza,  general  account 
of  465.  564,  638.  I 

-  haemorrhagic  otitis  in  . .  ■ 

-  headache  in       . .  . .   ■ 

-  heart-block  from  . .   ■ 


-  ieucoo; 

-  malign 


impaired  note 

from    infective    endo- 
carditis 
lateral     sinus    throm- 

-  T-  leukEemia 

mitral  stenosis 

after  operations 

from  otitis  media     . . 

phthisis  simulated  by 

pleurisy  from 

pyopneumothorax 


287,  289,  290      -  meningitis  in      . .  . .   , 

-  menorrhagia  from        . .   . 

-  neuritis  from     . . 

-  orchitis  from     . .        66,  ■ 

-  otitis  media  in  . .         . . 

-  pain  at  back  of  eyes  in 
446,  I 


fro 
rub  ( 


deQ- 


(and     see     Embolism, 

Pulmonary) 

-  retina     (see     Jimboiism, 

Retinal) 

-  spleen  (and  see  Spleen, 

Embolism  of) 
Infarct  of  spleen,  general 

account  of     . .        . .  i 
hiccough  from  . .   i 

-  -  rub  ofer  34.  629.  i 

-  -  thrombotic,    in    biood 


J-;ndo 
ng) 


Inferior    cerebellar    arterj% 
tlirombosis  of  58,  ( 

-  dental  nerve     . .  . ,     ■ 

-  gluteal  nerve      . .  . .  ' 
--laryngeal  nerve. .  . .   '. 

-  oblique  muscle,  paraly- 

sis of       . .      {Fig.  83)  : 

-  rectus,  paralysis  of  iFin. 

83) 

-  vena    cava    (see    Yena 

Cava  Inferior) 
Inflation  of  stomach,  tech- 
nique . .        . .     244,  : 

m  diagnosis  174,  244, 

317,  318,  330,   630, 
653,  I 
Influenza,abdominalpainin' 

-  albumimu-ia  in  . . 

-  anosmia  after    . .  . .   * 

-  arthritis  with    . .         . . 

-  atrophy  of  testis  from. . 

-  bac'ilU"(see   Bacillus  lu- 

fluenzce) 
Influenza,     bacteriological 
diagnosis  of     178,  440, 
465,  I 

-  brachial  neuralgia  and 

-  bronchitis  in      . .  . .   ■ 

-  bronchopneumonia  from 


-  cardiac  bruits  in 

-  chill  in 

-  conditions    wTongly    la- 

belled 

-  coryza  in 

-  coryzal    . . 

-  cough  after        . .      148, 

-  deafness  from    . , 

-  delirium  with    . . 

-  dengue  simulating 

-  depression  in     . . 


-  -  limbs  in  . .       463,  4 
lumbar  region  in        . .   5 

-  pancreatitis  in  . .         . .  1 
peripheral  neuritis  from 

61.  64,  465,  4 
Pfeiffer's  bacillus  in  465,5 
photophobia  in..  ..5 
pneiunonia  in    ..      465,  5 

-  prolonged  pyrexia  from    5 
prostration  in    . .       465,  fi 

-  rigors  in. .         . .      594,  5 
retrobulbar  neuritis  from  4 

-  simulated     by    paraty- 

phoid . .  . .         . .  5 

softening  of  cord  from. .   5 
spleen  enlarged  in       . .  6 

-  spondylitis       deformans 

from    . .         . .         . .   7 

-  sticky  rales  at  bases  from  2 
sudden  onset  of. .  ..6 

sweating  in        . .  . .   6 

tachycardia  from      703,  7 
talipes  after      . .  . .  1 

temperature     chart     of 

prolonged  {Fig.  240)  5 
things  simulating  . .  5 
thrombosis    of    cerebral 

veins  after     . .         . .  1 

■  tubercle  and     . .         . .  5 

■  typhoid  fever  simulated 

by       C 

■ simulatmg  . .      564,  5 

■  Tagal  neuritis  after      . .   7 
Infraspinatus,  nerve  supply 

of        S 

paralysis  of        . .  . .  E 

pseudohypertrophy  of..  E 

R.D.  in S 

wasting  of.  in  phthisis. . 
lufundibiilnin.  ?^o1!iTtc-  tit, 

dis<'>  '  -.2 

Infusion.,,.!,  n,.,  ,     112,4 

-  hi  replacing'  iu^i  llui.1  ..    I 

-  specific  gravity  of  biood 

and      . .         . .         - .  S 
Inguinal  abscess   (see  Ab- 
scess Inguinal) 

-  canal,  testis  in, .         66,   \ 

-  glands    (see   Lymphatic 

Glands,   Inguinal) 

-  hernia  (see  Hernia,  In- 

guinal) 

-  lymph  glands  (sec  Lym- 

phatic    Glands,     lu- 
•jninan 

Inguinal  region,  left,  organs 
contained  in  . .         . .  ( 

Inguinal  region,  right,  or- 
gans contained  in     ■  ■   E 


Injnry^  abdominal,  could. 

chyluria  from  . .    1 

collapse  from. .  . .    I 

internal  bleeding  .after  I 

laceration    of    muscle 

with  . .  . .    Ti 

laparotomy  after      . .   I 

Injury,  abdominal,  notes  on  £ 

peritonitis  after         . ,    ' 

— simulated  after     . .   I 

pulse  small   and  fre- 
quent after  . .    '.. 

rigidity  after . .  . .  ^ 

shock  from    . .  . .   'i 

skin  cold  and  clammy 

after  . .         . .  S 

Tomiting  from  . .   J 

receptaculum        cbyli 

ruptured  by  . .   1 

-  abscess  of  liver  from    . .   'i 

-  allocheiria  from 

-  anuria  from        .,  40, 

-  appendicitis     simulated 

after 4 

-  arthritis  from    . .         . .  '1 

-  axillary  aneurysm  from  t 

-  to  back,  fracture  of  spine 

from ? 

■  -  hyperpyrexia  from  . .   3 

■  -  myelitis  from  . .  '^ 
~  neurasthenia  after    . .  'i 

■  -  strangury  from         . .   (i 

■  at     birth,     hemiplegia 

from    . .         . .      303,  2 

■  to    bladder,    liEematuria 

from    . .         . .         . .  i 

strangury  from         . .  (; 

bleedhig  gums  from 
blood  spitting  from      . .  'J 

-  bony  swelling  due  to    . .  C 

-  of  brachial  plexus,  effects 

of        E 

-  breast  pam  from  . .  4 

-  bridge  of  nose  fallen  in 

from 1 

to  cervical  spine,  hemi- 
plegia from    . .         . .  3 

■  of  chest,  hsemopneumo- 

thorax  from  . .  . .   C 

-  hjemoptysis  from  286,  2 

-  hydropneumothorax 

from  . .         . .  C 

■  -  pneumothorax   from 

531,  I 

■  chylous  ascites  from    . . 

-  chyluria  from     . . 
claw-foot  from  . .  . .    ] 
contractures  from      13S,  1 
during  convulsions       . .    1 

-  deafness  from  . .  . .  1 
diaphragmatic       hernia 

from    . .         . .         . .  6 

to  ear,  noises  in  the  head 
from    . .         . .         . .  4 

■  ectropion  from. .         . .   ii 

-  empyema  from  . .  . .  3 
epididymitis  from 

■  epididymo-orchitis  from  4 

■  epistaxis  from  . .  . .  2 
of  eye,  photophobia  from  5 

■  -  pupil  irregular  after  . .  5 
fibrositis  from  . .  . .  4 
of  foot,  limping  from    . .  .1 

■  gangrene  from  ..  255,  2 
girdle  pains  from  . .  4 
hfematemesis  from       . .  2 

■  haematocele  after      481,  4 

-  hfematoma  from  . .   7 

■  -  of  penis  from. .  . .   4 

-  -  scalp  from     . .  ..  "2 

-  hajmorrhage    into    cord 
from    . .         . .         . .  ■ 

from  ear  due  to      . .  4 

to  head,  bradypnoea  from 
coma  in  . .      1 18,  • 

-  —  causing     and      not 
caused  by  . .  1 

-  concussion  from       . .   1 

-  depressed  fracture  from  1 

-  fractured  base  from..   1 
■  glycosm"ia  from        . .    - 

headache  from  . .  - 

-  hyperacusis  from     . .  3 

-  hyperpyrexia  from  . .   I 

-  Jacksoniau     epilepsy 

from  . .  . .    1 

-  memory  defects  from 


INJURY 


INTESTINAL    OBSTRUCTION 


835 


ijury.  conld. 
to      liead,       moningpal 

ha!niorrli;(«e  from. .  ] 
memory  df-fects  from  . . 

—  neurastlieuia  after    . .  ' 
hip-joiiit,    :^('iatio   Jicrve 

paralysis  from  . .  ■; 

liydrocele  from  . .  . .  - 

hyperpyrexia  after       . .  ' 

hypothermia  after       . .  ; 

insomnia  from  . .  . .  i 

jacksonian  epilepsy  from  ] 

of  jaw.  effects  of         . .  f 

to  kidney,  abscess  from  i 

—  lia^mataria  from     275,  5 

—  renal  enlargement 

from  . .  . .  S 

knee,  shock  from         . .  7 

—  vomiting  from          . .  i 
lung,  gangrene  from    . .  S 

—  suhcutaneous  emphy- 

si-nia  from  . .  . .  S 

:..  : I'll,  ptyalism  a(t4?r  I 


neoplasm  of  testis  after    4 
to     nerve,     contracture 
from     ..  ..       138,  1 

-  R.D.  from      ..  (il, 

-  musfnlar  atrophy  from 

f.l, 
tiury.  neurasthenia  from  7 
t  ,    ■  ijirnis  after  ..   4 

I  I  inn  cramp  from  3 
i  ;         11  from     . .  . .  4 

(J  hrliihiioplegia  interna 

from 5 

orchitis  from  66,  478,  A 
ossiQcation     of     tendon 

from    . .  . .         . .  I) 

pachymeningitis  from  . .  5 
pairf 'in  the  back  trom  . .  -i 

-  iliac  fossa  from    4.'i2, 

451,  I 

-  shoulder  from  . .  A 
paralysis  of  sciatic  nerve 

from  ..  ..  113,  A 
to  pflvi-.  liniitiric  from  3 
I  .  I  i.ir  I-  CM  -^1  i.:il;itefrom  5 

i  -i    ,,,,■■       ')...tri  ..    i 

\.-  v.-.-  :•■  '\  :ii.    '■--  from  6 

prrio-titi<  from  ..  7 

pnpuniococca!     arthritis 

aft*;r 3 

purpura  from    . .         . .  5 

rectovesical  flstula  from  2 

sarcoma  from  . .  . .  4 
of  sciatic  nerve,  talipes 

from    . .  . .  . .  1 

septicjemia  from  . .  fi 

Ppinal  thrombosis  from  5 
to    spine,    difficulty    in 

micturition  after      . .  3 

iJury  to  spine,  effects  of . .  7 

-  h('mtaTi!ii'<tlii.*-iia  from  'A 

-  hemiplegia  from       . .  3 

-  incontinence  of  fasces 

from  . .  . .   3 

-  paraplegia  from     113,  li 

-  priapism  from  . .  Jj 

-  sciatic  nerve  puraljrsls 

from  . .  . .  1 

-  talipes  from   . .         . .  1 

-  testis  atrophy  after  .. 

-  transverse     myelitis 

from  . .      38it,  -I 

spleen,    enlargement    of 
spleen  from   . .      032,  ( 

-  pain  in  left  hyporhon- 

drium  from  . .  0 

-  nipturf  of  spleen  from  t 

-  r\vi<tcil  hilum  from  . .  f 
vftff  uork  from          r,47,  « 

ut.  n.iiiial  bursitis  from  4 

1.  imI-  ,n.-s  from        707,  1 

.It      [■iiir-   from  ..   'i 

I.   ii>  ..trophy  after  no. 


-  nenrasthenia  after 

-  shock  from     . . 

-  vomiting  from 

to  thigh,  limping  from..  ; 
thoracic    duct,    chylous 
efTuf ion  due  to 


Injury,  conld. 

-  tibia,     arrested     growth 

from    . .  . .  .  .   114 

overgroTiVth  from      . .    114 

-  tongue  swollen  from     . .   098 

-  torsio  testis  from        . .  G96 
Injury,  transverse  myelitis 

and 165 

-  tuberculous  arthritis  after  348 

-  tympanic  membrane  rup- 

tured by        . .         . .   421 

-  ulceration     of     bladder 

from 580 

larynx  from  15S,  199, 

387,   292 

-  -  leg  from         . .         . .  737 

perineum  from      G19,  620 

rectum  due  to  . .   085 

-  to    uretlu-a,    aching    in 

perineum  from  , .   474 

discharge  due  to      . .  181  | 

extravasation  of  urine 

from  . .      278,  470  | 

haimaturia  from     275,  278  | 

inability  to  micturate  , 

after  . .  . .   278 
pain  in  penis  from  469.  470 

-  vaginal  closure  from     17,  18 

discharge  from  . .   185 

Innervation  of  arm  muscles 

504.  509 
Innervation  of  leg  muscles 

498.   499 
Innominate  arterv.  oni-ur- 

ysm  of  . .      (Fig,  184)   135  , 
Innominate  bone,  sarcoma 
of,  sciatica  simulated 
by        438 

-  vein,      obstructed      by 

mediastinal  glands   . .   381 
growth         ..  ..  419  I 

-  -  thrombosed    . .         . .  751 
Inoculation,  guinea-pig  (see 

Animal  Inoculation)  ^       I 
Insanity,  from  alcohol 


orrh< 


18  I 
Hd  with  132  j 


I  -  enuresis  and  . .  . .  218 
!  -  epilepsy  and      . .  . .    145 

I  -  explosive  sounds  in  head 

!  in        723 

I  -  foreign  body  in  nose  in  179 
I  -  hearing  of  voices  in  405,  723 
I  -  Huntingdon's  chorea  and  134 

-  insomnia  from  . .  321,  322 
!  -  from  insomnia  . .  . .  322 
,  -  loss  of  appetite  in        . .     43 

-  in  mvxoedema  . .         . .     38 
Insanity,  noises  In  head  in  405 

-  panigoiistia  in   ..         .-  7U5 

-  from  podagra     . .  . .   225 

-  perverted  appetite  in   ..      43 

-  subjective  smells  in    612,  013 
Insect    bites,    swelling    of 

facp  from       . .         • .  074 
wheals  from  . .         . .  771 

-  in  ear.  earache  from    . .  202 
Insects  crawling,  sensatii 


of 
INSOMNIA.. 

-  from  alcoholism 

-  anojmia  . . 


clern-i^ 

..VptMll 


ik; 


540 


323 

322 

Insomnia,  chief  causes  at 

various  aoes  ■       321,  322 
Insomnia  of  children  321 

-  inr).ruiu.-iM-pliriti.       ..       II 
•-  from  cirrhosis     . .  . .   323 

;  Insomnia,  list  of  causes  of 

320,  321 

-  mnlink;cring  of   ..  ..   32.1 

-  ptumhisni  . .  . .     34 

-  spe<'ks  before  eyi«  from     71 


talx 


07,  313  ,  Insomnia,  treatment  Of  322.  323 


-  elTcet  on  iirolbritLs        ..    184 

-  epidldvinitirt  from        ..  «97 

-  opididynio-orchltb  from  478 

-  Inumatcmctls  from       ..  271 


I/isfrnmcnfalion,  cnntil. 

-  prostatic  abscess  from 

581,  f 

-  urethritis  from  . .  . .   ] 
Insular  sclerosis  (see  Dis- 
seminated Sclerosis) 

Intellect,  dull,  in  myx- 
tcdenin      3S,  231,  409,  ." 

Intention  tremor,  general 
account  of     ■  ■      517,  ; 

(and  see  Tremor) 

Intercostal  artery,  replac- 
ing pulmonary  . .  ] 

-  muscle,     overstrain     of 

431,  4 
paralj-sis  of    . .  . .  •: 

-  nerves       (see       Nerve, 

Intercostal) 

-  neuralgia  (see  Nei 

Intercostal) 

-  spaces,  filled  out, 

carditis  . .         . .  : 
narrow,   from    fibroid 

lung 

obliterated,    by    liver 

abscess       . .         . .  : 
sucking    in    of,    from 

bronchitis  ..         ..  ■ 
bronchopn 


algi» 


1  peri- 


laryngeal     obstruc- 
tion . .      419, 

in  laryngitis 

wide,  in  emphysema. . 

Intermittent  albuminuria. . 

Intermittent     claudication 

440. 


Intestinal  adhesions  (see 

Adhesions) 
Intestinal  colic  (see  Colic) 

crises  in  tabes  lIO,  487,  609 
—  fermentation    (see     Fer- 

Intestlnal  flatulence,  general 

account  of  . .  241 

Intestinal  fullness- ■         ■■  245 
Intestinal  neuralgia  ..   115 

Intestinal  obstruction,  ab- 
dominal distention 
from        1!-.  130,  3l(i,  522 


Intestinal  obstruction,  acute, 
general  account  of  129. 

ISO.  13 

visible       peristalsis 

with        . .         . .   12 
acute  pancreatitis  simu- 
lating 131,  389,  66 

from  adhesions       130,  45 

age  incidence  of     129,  13 

from  appendicitis      ..   13 

ballooned  rectum  in. .  13 

from  bands    . .         . .   13 

borborygmi  with    131,  38 

from  carcinoma    120, 

130,  388,  459,   630, 

066,  070,  07 


atheroma  and 

—  cerebral     hasmorrhage 

simulated   by 
Intermittent     claudication, 
general  account  of 


Intermittent    hydrarthrosis, 
account  of 

Intern;. 1     .mi-uI."     h-sions, 
dysiirtliria  with 

(and     sec     Iltcmor- 

rhage,  Cerebral ; 
Embolism,  Cere- 
bnU,  etc.) 

hemiaiitcsthesia  with 

302, 

hemianopsia  from 

301, 
liemi|)legia  from   . . 

-  carotifl  artery  (sec  Artery, 

IntcrintI  Carotid) 

-  plantar  nerve     . . 

-  popliteal       ncryo      (see 

Xervc.  Internal  Popli- 
teal) 

-  rectus,  paralysis  of  (Fi{f. 


-  secretions,     disturbed, 

monorrhagia  from    . .   '. 

effect  on  inctiHtruation 

Intcrossci    of    foot,    norvo 

supply  of      . ,         . .  ■ 

-  hand,  nerve  supply  of  . .  i 
root  iiniervation  of  . .   J 

-  pantlyis  of.  talipes  from 

-  rftle  in  .luw-lumd         . .    : 

-  wanted,  from  cervical  rib  I 
in  progrci-tive  muscu- 
lar   atrophy 

Interphalangeal  JniritH  (hoo 
.lolnts,  Interplmliin- 
gcal) 

Inten-capuliir  pain  (Wo 
Pain.  IiitiT-u-iipuIftr) 

-  region,    p^-z-cma      (tebor- 

rluriciun  of   . .         . .  ■ 
Intenttlltiil  knrutlliM  (Piatr 

-r//) •• 

Intertrigo,  iicliinn  in  peri- 
neum from     . .  . .  ' 

-  from  glycosuria. .         ..  ; 

-  of     iimhillcUM,     in     fat 

porsoHH  ..  ..   i 

Intervenlrlcular  Keiilum. 
pprfonitiil  (>HH»  riit4>nt 
S<>pium  Vrntricnlnr- 
uin) 


lated  by     . . 

from   caseous   ; 

teric  glands 


colic 


vith 


-  simulated  by        . .   1 
-  collapse  with         131,  3 

colonic  succussion  from  (i 

from  congenital  mal- 
formation of  duo- 
denum       . .         . .  1 

of  ilium  . .         . .  1 

■  constipation  with  241, 

316,  388.  522,  592,  fi 
diarrhcea  with  . .  2 

'  dilatation  of  colon 
from  . .         , .   C 

disteruioii    of    cfficum 

from  . .         . .  4 

from  diverticula  . .  1 
dry  hard  faices  . .  I 
after  dysentery         . .    1 

■  cnematJi  in  diagnosing  ] 
•  frocal  vomit  with  115, 

129,  388,  ; 

■  no  fasces  in  rectum  in  1 

■  no  flatus  with  . .   1 

■  foul  breath  in 

■  from  fungating  endo- 

carditis      . .         . .  .1 

■  by  gall-stones  . .   1 
'  general  abdominal  pain 

in 1 

Ilenoch'a         purpura 

simulating  . .  . .  1 
from  hernia  120,  388,  t! 
.  hiccougli  from  . .  Z 

in  Hirschsprung's  dls- 


'  Indicnnnria  from      . .  3 

-  Indigestion    Hiniulated  3 

■  in  Infantft       . .  . .    I 
from     intussusception 

130.  .188,  W.'i,  1178,  7 
'  leucocytosls  in  . .  3 

■  from    malformed   rec- 

tum  1 

'  Mockers  divcrtlcuhim  1 
'  minute  hernia  . .  6 

'  operation  In  dlHgnoitlng 
raiwe  of      . .  . .   2 

pnln  with       . .  . .    1 

~  in  pplguMtriiun  from   I 

-  Iiyi>0(*hnndrhim  from  I 

■  -  llliic  ftwwa  from     . .  4 

-  ritfhl  iliac  ftwwi  from  4 
piiurreatltis     Mlmuhit- 

hig   ..        261.  504,   7 
by  polvic  ndlie<tlonH  . .    1 

-  from  perlrollIlM         . ,   1 

■  piTllnrionl  liiind         . .   .1 

■  pcrlloidllH  from    .188,  a 


836 


INTESTINAL   OBSTRUCTION 


ITCHING 


Intestinal  obstruction,  peri- 
tonitis distinguished 
from 

simulated   by         . .   ■ 

ptu'gatives   in  . . 

no  pyrexia  with        . .   '. 

rectal  examination  in 

129,  130,  ■ 

sacculation    of    colon 

from  . .         . .  ( 

shock  with     . .         . .  '. 

sigmoidoscope  in  dia- 
gnosing cause  of 
241,  316,  i 

simulated   by   embol- 

isin  of  pancreas    . . 

heemorrhage       into 

pancreas. .        76,  '. 

Henocli's      purpura 

—  mesenteric  embolism  ; 

thrombosis         . .  ; 

sordes  in 

swelling  in  iliac  fossa 

from  . .         . .  4 

from    tuberculosis    of 

bowel  . .         . .  ( 

-  -  tuberculous  peritonitis 


ule 


Intestinal  obstruction,  vis- 
ible    peristalsis     with 

130,  241,  3m,  ass,  522, 

661,  € 

from  volvulus  130,  388,4 

vomiting    with,    115, 

131,  315,  4.36,  522, 
C75,  765,  1 

wind  with      . .         . .  £ 

a:-rays  and  bismuth  in 

diagnosing  cause  of 
241,  316,  4 

-  putrefaction  (see  Putre- 

faction) 
Intestinal  sand  . .  £ 

-  stasis,  pig^mentation  from  5 

-  toxfemia,  infantilism  from] 

noises  in  the  head  from  4 

cedema  from  . .         .,4 

Intestine,    aneurysm   rup- 
tured into      . .         76,  ] 

-  carcinoma  of  (see  Carci- 

noma of  Colon) 

-  casts  of    115,    116,  (Fi(i. 

172)  398,  399,  E 

-  contracted,  felt  by  hand  1 

-  embolism  of  (see  Embol- 

ism,  Mesenteric) 

-  hypertrophy     of,     fi-om 

carcinoma  of  bowel  . . 

-  hypoplasia  of  muscle  of    1 

-  idiopathic   dilatation   of 

(see     Hirschsprung's 


-  lardaceous  (see  Lardace- 

ous  Disease) 

-  large  (see  Colon) 

-  liver    abscess    ruptured 

into 370 

-  mucous  cast  of  (J^(V.  173) 

398,  399 

-  paralysis  of        . .       389,  425 

-  stenosis  of         . .         . .  125 

-  tuberculosis       oC       (see 

Tuberculosis  of  Bowel) 

-  visible  coils  of   . .         . .     44 

(and    see     Peristalsis, 
Visible) 
Intestines,  deficient  motor 
activity  of     ..        ..123 

-  gas    in,    liver    dullness 

diminished  by  . .  3G6 

-  lymphoid  structures  in, 

enlarged  in  lymphat- 


-  matted,     from     chronic 

peritonitis       . .  . .     47 
tuberculous  peritonitis    48 

-  putrefactive  changes  hi, 

indicanuria  from       . .   101 
Intracranial  lesions,  acoto- 

nuria  from     . ,         , .       4 

-  pressure,  increased, 

bradycardia  from    84,  548 

bradypncea  from   . .     84 

ebb     and     flow     of 

knee-jerk  with  . .   359 


lutvacmnial  pressure,  conUl. 

increased,      headache 

from        ..  ..84 

hypothermia   with     311 

knee-jerk  lost  with    359 

optic  neuritis  with       84 

Intracranial    pressure,    in- 
creased, symptoms  due 

to        590 

vertigo  from  . .     84 

vomiting  from      . .     84 

Intrathoracic  tumour,  bulg- 
ing due  to      . .         . .  168 

chest  bulged   on   one 

side  by       . .  . .   168 

Intrathoracic  new  growth    104 

arm  wasting  from. .      63 

brachial  plexus  af- 
fected by  . .     63 

cough  from  . .  150 

paininshoulderfrom474 

ar-rays  in  diagnosing 

63,  150 
(and  see  under  Med- 
iastinum) I 
Introduction    to    Surgery, 
iUustri-itions  from  142, 


..   612 


■J"  [. : 

IntuhMti.. 

lao  I 
Intussn-'-''!'! ;" 
tumour  Ir 
127,    130. 


737 


115 


678  I 


78  I 


659,    663, 

665,  678 

-  a^e  incidence  of  ..717 

-  blood  per  anum  from  . .     78 
and    mucus   from    78, 

127,  130,  585,  663,  678 

-  in  children         . .     585,  678 

-  chronic   . .         . .         . .  678 

-  colic  from  . .         . .  127 
simulated  by  . .   115 

-  collapse  from     . .  . .     78 

-  constipation  from 

-  drawing  up  of  legs  from 
Intussusception,       general 

account  of 

-  Henoch's  purpura  simu- 

lating ..  .  .        76,  556 

-  from  Henoch's  purpura    767 

-  hypogastric  swelling  from  665 

-  indicaniu"ia  from         ..315 

-  in  infants  ..       78,  130 

-  intestinal       obstruction 

from  130, 388, 585, 678,  717 

-  kidney  simulated  by    . .  678 

-  mucus  in  stools  from  . .   398 

-  operation  in  diagnosing  717 

-  polypus  simulating      . .  717 

-  prolapse  simulating     . .   717 

-  protruding  per  anum  . .    717 

-  pulse-rate  increased  in. .     78 

-  rectal    examination    for 

78,116,127,  130,585.  717 

-  screaming  from. .  . .      78 

-  simulated  by  simple  colitis  78 

-  sii:i=nuHlic  pain  from    ..   663 

-  !■■'..  ■mil-    fi-Miu  663,   717 
663,  (] 


Iodide,  contd. 

~  nasal  catarrh  from 

discharge  from  . .  178 

-  nodules  due  to  . .  . .      98 

-  noises  in  the  head  from  ..406 

-  cedema  from     4lO,  413,  415 
of  face  from..  ..   413 

-  -  larynx  from   159,  418,  650 

-  orthopnoea  from  ..  418 

-  peculiarities     of     sweat 

after  . .         . .  655 

-  photophobia  from         . .   525 

-  ptyalism  from  . .  . .   542 

-  purpura  from   . .  . .   553 

-  pustules    from    98,  560,  563 

acne  simulated  by  . .  559 

from,    no    comedones 

with  . .  . .  559 

-  rash,     small-pox    simu- 

lated by  . .  . .    563 

Iodide,  skin  eruptions  from    98 

-  stridor  from       . .  . .   650 

-  sjpliilitic      bone      pains 

relieved  by  . .  669 
pyrexia  checked  by..  568 

-  taste  loss  from  . .         . .  705 

-  transmitted     to     infant  , 

from  mother  . .         . .     98  i 

-  in  urine 73 

-  urticaria  from  . .         . .  771 

-  vesicles  due  to  . .  . .   757  i 
Iodine,  bullae  from  . .     97 

-  in  Cammidge's  reaction    100  . 

-  co-efficient  of  urine     . .  100  I 

-  dermatitis  from . .  ..   755  , 

-  scales  from        . .         . .  602  i 

-  starch  grain  stained  by  170  I 

-  test  for  bile  pigment  . .  743  | 
Iodized  serum,  in  examin-  | 

ing  for  psorosperms  . .  730  i 
Iodoform  capsules  in  test- 
ing for  pancreatic  dis- 


191 


-  erythema  from  . . 

-  purpura  from     . . 

-  test  f 
Ipecai 

I  of  amceb<e  after        . .     77 

Iridocyclitis  . .         . .  733 

\  Iridodialysis,  pupil  irregu- 

I  lar  from  . .         . .  551 

I  Iris,    adhesions    of,    from 

iritis     . .  . .  . .   232 

from  ulcer  of  cornea. .  733 

-  coloboma  of  . .  . .  415 
,  -  discoloured,  in  glaucoma  233 
I  -  green,  with  iritis  ..  232 
I  -  injected,  in  glaucoma  . .  232 

-  prolapse  of  . .  . .   733 

-  tremor  of,  from  dislocated 

lens      . .  . .  . .   175 

I  Iritis,  acute  {Tlate  XI)    . .  2.S0 
[  -  adh&sions  after  . .  . .   551 

I  -  atropine  in  diagnosing..  232 

I treatment  of  . .  . .   233 

j  -  black  spots  before  eyes 


Irorty  could. 

-  perchloride,     alkapton 

and       . .  . .  . .   74 

in  Bial's  test  . ,         . .  2( 

carboluria  and  . .  I't 

in  diacetic  acid  test  . .  1^ 

indican  and    . .  . .   74 

melanuria  and  . .  74 

salicylates  and  . .   11 

thirst  from     . .         . .  7S 

in  0ffelmann's  test  . .  3' 

-  phosphate,    white    pre- 

cipitate of      . .         .  .'Vi 

-  sulphide,  black  motions 

from     . .  . .        75,  38 

Iron-founders,  cramps  in . .  IE 
Irrigation     in     diagno^^ing 

posterior  urethritis   . .   51 

-  testing  for  urethritis  . .  5J 
Irritable  bladder  398.  42),  74 

-  -   Mr.niL'nrv  iti   ..  .  .    C,i 

Irritable   breast   of    Astley 
Cooper 43 

-  larynx      . .           . .  . .  15 

-  spine  . .  .  .■  . .  71 
IRRITABILITY     ..  ..32 

-  in  acromegaly    , .  . .  32 

-  alcoholism           . .  . .  3*2 

-  from  bad  ventilation  . .  32 

-  in  chorea            . .  . .  13 

-  diabetes  . .         . .  . .  32 

-  epilepsy  . .          . .  . .  32 

-  general  paralysis  . .  32 

-  Graves's  disease  . .  32 

-  jaundice  . .          . .  . .  32 

-  leukaemia            . .  . .  2 

-  melancholia       . .  . .  32 

-  from  meningitis. .  315,  32 

-  mental  deflciency  and..  62 

-  in  nephritis        . .  . .  32 

-  in  neurasthenia  323,  71 

-  plumbism           . .  . .  32 

-  rickets     . .         . .  . .  14 

-  from  tea. .          . .  . .  32 

-  with  tropical  liver  . .  36 
Irritant  poisons,  acute  gas- 
tritis from 


;disn 


afte 


Inversion  of  uterus  ..  539 

snnuiiitiiiL:   prolapse..   539 

vulval  swelling  from. .   700 

Iodide,  acne  from  . .     98 

-  for  actinomycosis  . .   458 

-  anosmia  from  ..  ..  612 

-  atrophy  of  testis  from. .     66 

-  bleeding  gums  from     72,  73 

-  bullae  from        ..  96,  98 

-  colds  simulated  by       ..  178 

-  coryza  from       . .  . .      73 

-  cyanosis  from   . .  . .   159 

-  in    diagnosing     syphilis 

560,  604 

gumma  230,  615,  619 

nature     of    ulcer    of 

tongue    . 

-  -  syphilis  403,  480,  588, 

622,  735,  738,  739 

-  eruption,  syphilide  simu- 

lating   560 

-  erythema  from  . .        98,  222 

-  foul  taste  from..  ..   705 

-  guaiacum  reaction  from     98 

-  gumma  of  liver  and      . .   253 

-  laryngeal        obstruction 

from  . .  . .   418 


injected  ii 

129  .      .    I  ..         iirs  from. 

-itis.  general  account  Of. 


379 


232 

-  -l;m.-,.i„  ,   irniu    .  .  ..761 

Iritis,  glaucoma,  and  con- 
junctivitis,    compared  232 

-  headaclie  troin  l"j4.  -JOo,  712 

-  hyperacusis  from  , .  308 

-  hypopyon  with..  ..  232 

-  iris  discoloured  with    ..  232 

-  keratitis  punctata  with  232 

-  lachrymation  from       . .  231 

-  pain  from  . .         . .  231 

in  eye  from    . .  . .  445 

face  from        . .  . .  449 

-  photophobia  from     231,  534 

-  pupil  changes  with       ..  232 
irregular  after            ..  551 

-  from  sypliilis      ..  ..  403 

-  synechia  from    . .        72,  232 

-  tenderness  of  scalp  from  712 

-  turbid  aqueous  with   . .  232 

-  from  ulceration  of  cornea  733 

-  unequal  pupils  from 
Iron,  blue  sweat  from 

-  in  chlorosis 

-  headache  from  . . 
relieved  by    . . 

-  in  intestinal  sand 


Irritant  poisons,  symptoms 
caused  by  . .  33 

Irritunt^.  dysphngia  aftor     19 

-  luflraatemesis  from    265,  26 

-  pain  in  epigastrium  from  76 

-  pigmentation  from        . .   52 

-  sore  throat  from  . .  61 

-  tongue  swollen  from  . .  69 

-  vegetable,    sore    fingers 

from    . .         . .         . .  23 

-  vomiting  from  ..  7G5,  76 
Ischaemicparalysis(/'i(7.58)  14 
(and   see   Volkmann's 

Paralysis) 
Ischiorectal     abscess    (see 
Abscess,    Ischiorectal) 

-  fossa,    examination    of, 

per  rectum     . .  . .  58' 

Italy,  malaria  in  . ,  . .  63! 

-  pellagra  in  . .  . .  22: 
Itch,  carpenter's  . .  . .  54i 
Itch,  dhobie's  ..251 

-  gardener's          . .  - .  54i 

-  grocer's,  from  sugar  . .  54i 

-  (and  see  Scabies) 
Itching      in      application 

dermatitis      . .         . .  54< 

-  from  bug-bites  . .         . .  541 

-  in  cheiropompholyi    97,  54( 

-  chilblains  . .  . .    ''4( 

-  dermatitis  gestationis  . .  541 
herpetiformis  98,  540,  71( 

-  drug  rashes        . .         . .  38; 

-  in  eczema  488,  491.  540, 

558,  560,  710,  754,  75( 

-  erythema  . .  . .   54( 

-  from  flea-bites  . .         . .  54( 

-  in  herpes  gestationis  . .     9( 

-  with  inflammatory  pap- 

ules     . .  . .  . .   481 

-  from  jelly-fish  stings  224,  54C 

-  in  lichenization  . .      491,  54C 

-  lichen  urticatus..      540.  756 

-  with   malignant  pustule  55S 

-  from  mosquito-bites    . .  540 

-  in  mouth,  from  Fordyce's 
..  366 


ITCHING    —  .  KIDNEY 


tehiiig,  coiud. 

Jaundice,  contd. 

Jaiimlicr.  cnntd. 

-  occupatioa  aud . . 

340 

-  from     cholangitis     326, 

Jaundice,  pulse-rate  in 

324 

-  in  papular  eczema 

487 

332, 

309 

-  iMzrpura  ia          . .      553, 

pediculosis          . .     490, 

540 

-  choluria  with     . . 

744 

-  ill   ]iyiemia  and  septic- 

-  perapliigus 

540 

-  from  chronic  pancreatitis 

335 

-  of  penis,  from  herpes  . . 

754 

239, 

264 

-  from  pylephlebitis    32G, 

333 

ill  pityriasis  rosea 

540 

-  from     cicatrization     of 

-  pyrexia  with     . . 

326 

-  rubra 

540 

duct 

329 

-  rectal  examination  in  . . 

326 

-  -  l)ilaris          .  .      489, 

540 

-  cirrhosis  35,  46,  51,  326, 

-  in  relapsing  fever 

336 

prickly  iieat 

540 

332,  371, 

635 

-  from    right   kidney    tu- 

prurii^o  . .          . .      489, 

640 

-  clay-coloured       motions 

mours 

330 

psoria.«is             . .      540, 

603 

with 

326 

Jaundice  with  rigors,  causes 

scabies    . .         . .      490, 

540 

-  from  colon  tumours     . . 

330 

of        

326 

seborrhcea 

540 

-  congenital  obliteration  of 

—  saliva  not  coloured  in . . 

3-'i 

from  serum  injections  . . 

223 

bile-ducts 

329 

-  with  sarcoma  of  liver 

in  small-pox 

601 

-  -  syphilis           . .      329, 

334 

52,  252, 

330 

from  tinea  circinata    . . 

249 

-  congestion  of  liver 

326 

-  in  secondary  syphilis  . . 

334 

-  marsinata 

540 

-  constipation  with 

324 

-  serous   effusions    tinged 

in    urticaria      489,  540, 

771 

-  dark  green  urine  with.. 

747 

in 

324 

-  pigmentosa    . . 

732 

-  from  dinitrobenzene     . . 

337 

Jaundice,  signs  of.. 

324 

733 

-  distoma  hepaticum 

328 

Jaundice,  skin  changes  in 

324 

vulval,  from  leukoplakia 

701 

-  in  dogs 

337 

-  ^Imw  |.ul-i    ir-Hi          329, 

518 

(and  see  Pruritus) 

-  from   duodenal   tumours 

330 

-  from  ^iiakii-  [.lOtiuu 

337 

Tory  exostoses  of  skull  . . 

671 

Jaundice,  emotional 

-  with        rhliirL'cd       gall- 

337 

-  spinal  cord  not  coloured 
in         

324 

l.l.^M.T 

326 

-  in  splenic  anaemia 

372 

rAIlOUAJTDI,     ptyalism 

Jaundice,    from    enlarged 

-  splenomegalic  cirrhosis 

iroia 

542 

portal  glands  ■ . 

329 

332, 

033 

400 


1521 


acksonian     epilepsy 

1 . 1 1 . 1 1-[  1^  V .  Jjicksoniaii) 
acquets  erythema,  simu- 
lating congenital  sy- 
philis . . 
,i.iir  ii;,,:,-:,  iii  vpilepsy .  , 
affe's  test  for  indJcan  ■ 
araaic;!,  aiilcylostomiasis  i 
apan,  distoma  pulmonale 

hinp  fluke  in       . .  . .   645 

AUNOICE  ..324 

from  abdomi  na!  aneur- 
ysm      331 

from    abscess    of    liver 

326,  330,  332,  370 

acholuric  (see  Acholuric 
Jaundice) 

from  Jicute  congestion  of 


331 


376 


aundice  in  acute  fevers  . .  335 

-  yellow    atrophy    273. 

333, 

alveolar     echinococcus 

di.'icase 
from  aneurysm  of  liepati 

artery  ..         ..Ail 

with  angina  abdominalis  115 
from    arseniuretted    hy- 

droeen  . .  . .   337 

oACJiris  lumhricoidcs     . .  328 
ascit<>s  with  46,  50,  52 

from    bile-duct  obstruc- 
tion     .,  ..      3n9,  372 
after    biliary    colic  131, 

326,  767 
black  urine  from  . .  74 '» 

brain  not  coloured  in  . .  324 
bradycardia  with  . .  329 


A-ith 


ivith 


brui 

-  from  trivial  causes  in  555 
bleeding  due  to. .  ..  274 
from  carcinoma            . .  326 

-  of  ampulla  of  Tatcr. .  239 

-  bile-duct         ..         ..662 

-  colon    . .         . .      .320,  330 

-  duodenum      . .      330,  601 

-  liver  52,  252,  326,  330, 

331,  373,  374 

-  pancreas     2311,     204, 

326,  451,  601,  602 

-  rectum           . .         . .  326 

-  stomach  . .  320,  330 
catarrhal            . .         . .  326 

-  acute  yellow  atrophy 

simulating  . .          . .  373 

-  allminosiiria  with      . .  16 

aundice,  catarrhal,  general 

account  of     . .     32B.  329 

h.mM.-r  from  174 


nulii 


334 


-  spei'itic  infectious  nature 
of 3S 

cerebrospinal    (luid    not 

coloured  in     . .  . .   3S 

from  chloride  of  sulphur  35 
cholteniia  from  . .         . .  3i 


endo- 


334 


11 
~  t";tiL-es  colour  with  . .    324 

-  familial,  spleen  enlarged  631 

-  fatal  ooziTig  due 

-  fatty  stools  with 

-  with     fungatiug 

carditis 

-  from  gall-stone  116,  25 

272,  326,  327,  328, 374, 451 

-  gastrointestinal  secretions 

not  coloured  in         . .  324 

-  green       . .         . .         . .  745 

-  from  gumma  of  liver  330,  334 

-  h£Bmatemesis  from       . .  2  74 

-  hajmorrhages  witli        . .  324 

-  in  Hanot's  cirrhosis     . .   372 

-  from   hepatic  aneurysm     51 

-  liepatoptosis      . .         . .  368 

-  Ilodgkin's  disease         . .  329 

-  from     hydatid    cvst    of 

liver  . .  328,  330,  375 
jaundice  in  infants  . .  329 
Jaundice,     infectious    or 

epidemic  ..  336 


Mtiuv 


465 


Jaundice,  from  inspissated 
bile 328 

-  irritability  from  . .  323 

-  itching  in  . .  . .   324 

-  from     leukicmic    portal 

glands  ..  ..330 

Jaundice,  list  of  causes  of  325 

-  liver  enlarged  with    326,  3GU 

-  from  local  liver  enlarge- 

ments  330 

-  in  lymphadenoma         . .   329 

-  malaria    . .  . .      273,  335 

Jaundice,  malignant        ..331 

-  with  malignant  liver  . 
port-al  glands 

-  meninges  not  coloured  : 

-  milk  tinged  in  . .         . .  324 

-  with  multiple  liver  ab- 
..  '     ..335 


.  101 
.  630 
.    330 


330 


-  from  movable  kidney  ..  331 

-  in  new-born       . .  . .  326 

-  with  nutmeg  liver    334,  368 

-  olive  green         ..          ..  373 
~  from  omental  tumour..  331 

-  ovarian  cyst       . .  . .  331 

-  pancreatic  calculus 

lesions 

new  growth    . . 

-  with    pancreatitis     lOI, 

110,  254,  326,  328 

-  in  pernicious  nniomin  . .   325 

-  perideious  nnicmia  simu- 

lating   324 

-  due  to  pho-^phorns    326,  336 

-  in  pnruinnnia    ..  ..   335 

Jaundice,  due  to  poisons 

336.  337 

-  from  portnl-vein  throm- 

bosis   . .         . .  . .     51 

-  with  i)ressuro  on  portal 

vein 272 

-  prolonged    hmmntcmesis 


-  from  stomach  tumours 

-  suppurative  cholangitis    : 
pylephlebitis  . .         ..  \ 

-  sweat  tinged  in. .         . .  3 

-  from  syphilis     . .         . .  ; 

-  tears  not  coloured  in  . .   i 

-  from  tetrachlorethane 

334,  I 

-  toluylenediamine  . .  ; 

-  tuberculous  portal  glands 

-  in  typhoid  fever      326,  ; 

-  typhus  fever      . .  . .   i 
Jaundice,  urine  changes  in  i 


JOINTS.  AFFECTIONS  OF 
THE 2 

-  Charcot's,     in     syringo- 

myelia . .  . .   1 

-  hremorrhage  into       272, 

350,  362,  i 

-  hydatid  disease  of       . .  3 

-  interphalangeal,  pulmon- 

ary arthropathy  of  . .  3 

-  -  spindled       iFig.  169)  3 
^  -  in    rheumatoid    ar- 
thritis    . .      343,  3 

spindle-shaped  35,  {Fig, 

153)  I 

-  malignant  disease  of  . .  3 

-  prominent,  in  achontlro- 

plasia  . .  . .  . .   1 

-  tuberculous  (see  Arthritis, 

Tuberculous) 

-  urate  of  sodium  in       . .  3 

-  (and    see    the    Various 

Joints) 

Jolting,  vesical  calculus  and  A 

Jordan,  Dr.  A.  C,  skia- 
grams by  209,  279, 
282,  289,  318,  4 

Judgement,  defective,  in 
general  paralysis       . .  1 

Jugular  vein  (see  Vein, 
Jugular) 

Jumpiness,  from  alcohol. .  7 


irnhit 


■irh 


Jaundice,  xanthelasmafrom  324 


-  x;iiiihui,^i:i  fruni        32(,  ' 
Jaw.  actinomycosis  of  74, 

458,  683,  ' 

-  clenching,  in  convulsions  '. 

-  dislocation  of,  ptyalism 

from i 

-  endothelioma  of,  spread 

to  nose  . .         .. 

-  enlarged,  in  acromegaly 

204,  237,  ) 

-  fixation    of,    by    osteo- 
arthritis 


fract 


of 


from 


266 


Jaw,   inflammatory   affec- 
tions of  • .  I 
Jaw.  necrosis  of    ■ .         . .  i 

-  osteo-artliritis  of,  ptv-»l- 

i.sm  from        ..      '  ..  : 

-  papilloma  of        .. 

-  sarcoma  of  1711,  r.-Kit,  I 

-  tics  aftectiiig 

Jaw.  tumours  affecting  683.  < 

microscope  in  dia- 
gnosing 

Jejunum,  obstruction  of, 
no  abdominal  disten- 
tion with        . .         . .   ] 

.relly-rish,  erythema  from 

222,  : 

-  Itching  from      . .      224,  \ 

-  trrlema  from      . .         . .  : 

-  urticaria  from  . .         . .  : 
Jerks,    anklo   («eo    Ankle- 
jerk) 

-  cltmw,  tnereascd  In  hemi- 

plegia   

-  knee  (see  Knee-jerk) 

-  KUpinator  . .  . .  < 

-  wrist   (wi'  Wrist-jerks) 
.fennerV  stain 

JowftltTs.  nail  changes  In  \ 
.rew4,  tuhrrrulous  penis  In  ( 
.luint ,  gntat  toe,  gout  and  '. 

-  looHc  hmly  lii    . .         ..  I 

-  temporo-mnndlbular,  mip- 

puration  in.  otorrh<cu 
from    . .         . .         . .  ' 

-  temporo-maxillary,  rheu- 

matoid arthritis  of  . .  : 


K 


AHLER'S    DISEASE 

Kala-azar,   confused 
with  malaria 

-  due  to  trypanosoraes    . . 

-  geographical  distribution 

of         ..  ..        29, 

-  Leishman- Donovan 

bodies  in        . .        29,  i 

-  pyrexia  in 

-  spleen  enlarged  in      29,  i 

-  splenic  puncture  in  dia- 

Kaposi's  disease ;    general 
account  of  . .  ' 

pigmentation  in        . .  i 

Kathode i 

Keith,  Dr.  A.,  on  malforma^ 

tious  of  rectum  . .  I 
Keratin-coated  capsules,  in 

detecting  pancreas  di- 


diagnosing     pyloric 

obstruction        . .  ( 

-  particles  in  fa)ces  . .  i 
Keratitis,  black  spots  be- 
fore eyes  from 

-  in  congenital  syphilis  . .  : 

-  corneal  opacity  from    . . 

-  interstitial,  in  congenital 

syphilid  .  .       3IS, 


Keratomalacia  ■  ■  i 

Keratosis  foillcularis    T.vi.  i 
Keratosis   pilaris,    general 
account  of  •4 

-  -  ichthvusis  and  . .   ^ 
keratosis    follicularis 

simulating  . .  . .   i 

nutmeg-grater  skin  in  I 

scales  in         . .         . .  C 

Kerion        . .        217,  248.  ; 

-  baldness  from    . . 
Kernig'ssikMi,  In  meningitis  3 
Kharaivan  (see  Sidvanmn) 
Kick  from  Iioinc.  panijiloglu 

after f 

-  on  kne«>.  shi^'k  rrom      . .    i 
•  -  voniitinu*  from  . .   '* 

-  urethra  Injured  liy        ..    I 
Kidnc-y.  abHces*.  In  (sco  Ab- 

w«^.  Ilftial) 

-  angioma  of,   tuiiinaturln 

[  from    ..         ..      275,  'J 

-  atrophy  of,  from  urotorie 

cali'uluB  . .  . .  £ 

-  cnlculuK  in  (hcc  CuIcuIiim^ 

llenalj 

-  carcinoma  of  (hoc  farci- 

noma  of  Kidnoyj 


838 


KIDNEY 


KNEE-JOINT 


Kidney,  contd. 

-  cloudy  swelling  in 

-  cystic,  albuminuria  from  ■' 

anuria  with   . .  40, 

arteriosclerosis  with. . 

ascites  rare  with 

Clicvno-Stokes'  breath- 

iiiL-  with      ..  ..  ] 

-  -  U;ilul.Mi,-..'  with 
Kidneys,  cystic,  general  ac- 
count of  12, 


>'.v 


Kidneys,    cystic,    physical 
signs  of  ..  z 

po!yuii;i  from         536,  t 

poreiicc'phalus    with.,    i: 

renal  tumours  with  . . 

simulating  chronic  ne- 

pluritis 
spleen  simulated  by. .  C 

-  tube  casts  from         . .  I 

unemia  with. .        42,  1 

urine  changes  with  42,  3 

a  variety  of  Bright's 

disease 
vomiting  with 

-  cysts  of,  kidney  enlarged 

from    . .  . .         . .  3 

-  displaced,  in  visceroptosis  4 

-  embolism  of  (see  Embol- 

ism, Renal) 

-  embryoma  of  (see  Em- 

brvoma  of  Kidnev) 
KIDNEY,  ENLARGE- 

MENT   OF     ..  -.3 


l.n,  ,  ■  ..354 

-  -  bik-Uu-Lpl.-uiicLL'abySSO 

from    bladder   growth  281 

from  calcuUis   .  .       41,  451 

by  carcinoma  . .    355 

carcinoma    coli    simu- 
lating . .  , .   354 

in    compensation    for 

the  other    . .         . .  355 

contralateral      aching 

from  ..  ..355 

-  -  dilatation  of  stomach 

from  . .  , .    174 

Kidney,   enlarged,  distinc- 
tion from  other  tumours 

353,  354 
in  loin  with. .   253 


-  -  fa3C( 


.ulatii 


gall-bladder  simulating  353 
liiematoma     mistaken 


for 


631 


-  "  lifematnria  with       51,  330 

-  -  hypyonephrosis      280, 

352,  355,  35u-,  536,  575 

-  -  from  injury    . .  . .   278 

-  intussusception    simu- 


u.dii 


Kidney,      enlarged,      large 
spleen    distinguished 
from 629 

liver  simulating       51, 

330,  353 
mesenteric  tunjour  si- 


ulatii 


movement  with  respi- 


354 


rati. 


bynewgrowth  7,  278,  352 

omental  tumour  simu- 
lating . .  . .   354 

pancreas  tumour  simu- 

liiting  ..  ..354 

from  papilloma         . .  278 

pelvic  tumours  simu- 
lating        ..         ..353 

-  -  pnri.iepln-ic  lesions  si- 

mulatiiitj     ..  ..353 

Kidney,  enlarged,  physical 
signs  of  . .     352,  629 


Kidney,  enlarged,  contd. 

from  pyelitis  . .         . .  451 

pyelography    in    dia- 
gnosing      . .         , .  354 

from    pyelonephritis 

355,  576 

pyonephrosis  352,355, 

356,  536,  577 

pyuria  with    ..        51,  330 

spleen  simulating  353, 

662,  664 

suprarenal        tumour 

simulating  331,  354,  630 

by  tuberculosis      282, 

352,  355,  579 

varicocele  with         . .  352 

from  vesical  growth. .  277 

-  fatty,  in  phosphorus  poi- 

sonhig  ..  ..   337 

-  floating,     Riedefs    lobe 

simulating      . .  . .    367 

-  gramilar    (see    Granular 

Kidney) 

-  growth     in,     varicocele 

with 356 

Kidney  growths,  varieties  of  355 

-  hydatid  cyst  of  . .  . .   357 

-  hypernepiiroma   of   (see 

Hypernephroma        of 
Kidney) 

-  in  iliac  fossa       ..  . .    C70 

-  infarct  of,  abscess  from     76 

albuminuria  due  to  . .        7 

in  blood  diseases       . .       7 

Kidney,  Infarct  of,  causes      8  i 
from  embolism  . .       7  I 

fungating  endocai 


diti? 


34 


-  -  liremnturia  from     275,  2S:! 
~  -  n-iial  tuhc  ra-^ts  due  to       7 
Kidney,    infarct   of,    sym- 
ptoms of  8 

from  thrombosis        .  .        7 

-  -  (and    see    Embolism, 

Renal) 

-  injury  of  (see  Injm-y  of 

Kidney)  . .  . .    278 

-  lardaceous    (see     Lard- 

-  lesions,    bladder    lesions 

simulated  by  . .  . .    575 

increased  frequency  of 

micturition  with  . .   575 

-  liver  simulating  . ,   367 

-  movable,  aching  iu  lorn 

from 280 

albuminuria  from     7,  460 

appendicitis  simulated 

by    . .  . .      460,  CG5 

bile-duct  kinked  by..  331 

biliary  colic  simulated 

by     ..  ..      450,  451 

-  -  blue  brain  and  . .    1G3 
carcinoma,  of  colon  si- 
mulating    ..  ..   663 

Kidney,   movable,   charac- 
ters of  . .  663 

chronic  nephritis  from       7 

colic  from       . .      280,  394 

collapse  from  . .    115 

constipation  with      . .   127 

Dietl's  crisis  from  115, 

280,  665,  765 

duodenum  dragged  on  280 

kinked  by  . .         , .  331 

enteroptosis  with      ..  331 

faices  in  bowel  simu- 
lating, . .         . .   663 

faintness  from  . .  115 

frequent    micturition 

from  . .      280,  394 

gall-bladder  simulating  663 

gastro-intestinal  sym- 

]irom? 


stroi.t 


■ith 


3  IS 


Kidney,    movable,    general 
account  of  . .  280 

-  -  htenKitiiria    [rniii     li:,.  I 

■-':.v  -.'SO,  460  ; 

-  -  hydatiJ  .-iiiiul.ain-   ..   063  ' 

-  -  liydi-oiiupliru.-i,  ii-um 

115,  536,  665  , 

in  iliac  fossa  . .  . .   678 

intermittent      hydro-  [ 

neplu-osis  from"      . .   451  j 

jaundice  from  . .   331  \ 

mucocele   simulating     254 


Kidney,  movable,  auitd. 

nausea  from  . .         . .  115 

noises  in  the  head  with  40G 

omental    mass    simu- 
lating . .         . .  663 

ovarian  cyst  simulating  353 

tumour  simulating     663 

pain  in  iliac  fossa  from 

454,  4G0 

loin  from    . .  . .  460 

palpation  in  diagnosing  253 

polyuria  from  . .    665 

no  pyrexia  with        , .   460 

renal  tube  casts  due  to       7 

Riedel's     lobe     simu- 
lating . .      252,  663 

simulating    enlarged 

gall-bladder        252,  253 

swelling  in  right  iliac 

fossa  from  . .  . .   G65 

-  ~  torsion  of       . .  . .   394 
with  undue  abdominal 

aortic  pulsation    . .  543 

urethral  kinking  from      7 

vomiting  from  . .  765 

without  symptoms  . ,  280 

-  neuralgia  of,  simulating 

stone  ,,         . .         .'.  426 

-  new  growth  of,  albumin- 

uria from       . .  . .       7 
cystoscope    in    dia- 
gnosing . .         . .       7 
kidney  enlarged  from  352 


278 


I tube 

j  Kidney,    new    growth    of. 
urine  changes  from 

Kidney,   palpitation,  tech- 
nique of  ..  277 

-  papilloma  of       .  .       275,  278 

-  pelvis,     carcinoma     coli    . 

opening  . .         . .-  530 

-  polycystic,  age  incidence 

of         280 

arteriosclerosis  with , .  357 

Kidney,  polycystic,  general 

account  of      . .      280,  357 

-  -  WMm:i\nvvA.  IV.. ,n     -j;:.,  280 
liyilronriilii-osi.s  di^tni- 

guisiied  from  . ,    280 

kidney  enlarged  in  . ,   355 

urine  changes  with  . .   357 

-  right,  normally  palpable  663 

-  sarcoma  of  (see  Sarcoma 

of  Kidney) 

-  scarred,  from  ascending 

nephritis         . .  . .        8 

-  sickening    sensation    on 

palpating       . .      253,  331 

-  single,  good  health  with     -ll) 

-  stone  in   (see   Calculus, 

Renal) 

-  tuberculous  (see  Tuber- 

culosis of  Kidney) 
Kink  of  colon,  constipation 

from    . .  . .         . .   126 

-  of      duodenum.       with 

movable  Iridney        ..   331 

-  ileocaical,   appendicitis 

simulated  by. .         . .  457 

constipation  from     . .   457 

heartburn  fiom  . .   297 

pain  in  iliac  fossa  from 

454,  457 

.I'-rays  and  bismuth  in 

diagnosing  . .  457 

-  of  ureter,  from  movable 

kidney  . .         . .       7 

Kirkland's  disease,  cervical 

glands  enlarged   from 

379.  615 
Kirkland's  disease,  general 

account  of     . .      615.  616 


i;acillus  Iliplitlinria;) 

Klumpke's  palsy  . .         . .  507 

-  ~  haamatomyelia     simu- 

lating . .  . .    509 

Knee-elbow  position  in  ab- 
dominal   examination  G03 

detecting  ascites  ..     44 

Knee,  housemaid's  . .  476 

-  subacromial     bursitis 

allied  to       . .  . .   476 

-  injury,  shock  from       . .    705 


Knee  injury,  contd. 

vomiting  from  . .   7C 

KNEE-JERK,         ABNOR- 
MALITIES OF  .35 

-  absence  of  one,  in  tabes  51 

-  in  chorea  . .      ;-;59.  5(j 

-  diminished,    in    anterior 

cruritis  , ,  . .   4S 
from    bronchopneu- 
monia        ..         ..35 

epidemic  diarrhoea  . .  3S 

in  infants       . .         . .  35 

-  ebb   and  flow  of,  with 

cerebral  tumour       . .  3e 

-  increased,  abdominal  re- 

flexes and       ..         ..35 

in  amyotrophic  lateral 

sclerosis       . .        62,  51 

with  ankle-clonus  39,  3a 

blue  brain  and         . .  IC 

with    brachial    mono- 
plegia ..         ..50 

from  cerebellar  abscess  51 

tumour       . .         . .  51 

in  convalescence       . .  35 

in  disseminated  scler- 
osis . .         307,  496,  51 

with  extensor  plantar 

reflex  . .         . .     3 

functional  nerve  trouble  3 

from  general  ill-health  35 

in   hemiplegia  . .     3 

hysteria  307,  308,  468, 

497,  51 

lateral   sclerosis        . .  51 

neurasthenia  . .      358,  46 

from   new  growth   in 

spine  . .         . .  71 

noises  in  the  head  with  40 

in  paraplegia . .         . .     3 

patellar  clonus  with..   35 

in  phtliisis      . .  . .   35 

plantar  reflexes  and. .  35 

with  pyramidal  tract 

lesions         . .        39,  35 

in  renal  disease         . .   35i 

in  spastic  paraplegia    51: 

syringomyelia  . .  50i 

from  transverse  mye- 
litis   6 

after  typhoid  fever  . .  351 

with  undue  abdominal 

aortic   pulsation    . .   54; 

-  lost,  from  anterior  crural 

nerve  lesion  . .         . .  49! 

cerebral  tumour        . .   35! 

in  diabetes       63,  264,  35! 

after  diphtheria        , .  35! 

from   fracture-disloca- 
tion . .  . .   35! 

in    Friedreich's    ataxy 

113.   51*i,  51! 

increased    intracranial 

pressure      . .  . ,   35i 

myelitis  . .         . .  35f 

myopathy      . .         . .  35i 

peripheral  neuritis  358.  44( 

pneumonia     . ,         . .  351 

sick  children  . .         . .  51( 

-  -  tabes    126,  315,   358. 

420,  425,  466,  514, 

650,  719,  76S 
from  transverse  mve- 

litis..  .,        ■.,     6S 

Knee-jerk,  method  of  testing  357 


-  Ironi  !:rross  intracranial 

lesion 

-  in  hemiplegia        303, 

-  poliomyelitis  acuta  . . 


lating  . .  . .   , 

■  -  spinal  caries  and 

■  -  thigh     atrophy    from 

01.  ; 

■  -  with  tuberculous  peri- 

tonitis 

■  flexed,     from     popliteal 

abscess  . .         . .  ( 

forcible  extension  of  con- 
tracted, sciatic  nerve 
paralysis  from  . .   ' 


KNEE-JERK    ^    LARYNX 


lee-joint,  mnld. 
Eorcible  extension  of  con- 
tracted, talipes  from  ] 
Foreign  body  in  . .         . .  : 
gonococcal  arthritis  of . .  i 

?out  of i 

iijemophilic  arthritis  of  ; 

fi£Bmorrhage  into  . .  ! 

tiystr-ri;i  affecting      142,  ; 
iiid  I  iiiinerit     hydrarth- 

iliritis  of      346,  i 

[I    MiMiiroocal  arthritis  of  ; 
^vpliilitic     arthritis     of 

235,  ; 
-  Umpini^  from. .  . .   ; 

hibt-rriilous.; 


■■itli 


I 'If. 


■aurosis  vulva,  leukoiilakic 
vulvitis  distlnouished 
from 7 

-  levator atiisp-Lsmfioni   1 

-  parts  afFeeted  by     . .   7 

-  vaifinal  s(<>nosis  from    l!)4 


I  Iron 


1{»3 


li  swollinp  from  fiOft 
in  adolescence.   165 

ini's  ..  ..188 

itm;  ..  ..154 

tiiital  spastic  piira- 


ckcLs 


LABIA,  condylomata  on 
-  herpes  of 
-  majora,  leukoplakia  of. . 
~  minora,  kraurosis  affect- 


ing         36Z 

jees,  lifheti  [tlaiiu-?  affect- 
in-        fi03 

li'iri    iliiicantes  on       ..  3G5 
|i     '      I      rubra    pilaris 

■•    M-i-  ..  ..489 

|ni-ii  ;.iii    iti   tetany        . .        3 
psori:isi_s   affecting    489,  • 

491,  603 
-  starting  on     . .  /.  602 

pulpy 348 

acborrhceic  eczema  affect- 
ing        401 

spurious  osteoma  above  671 
xanthelasma  of . .         ..  324 

leeting,  housemaid's  knee 
frotn     . .  . .  . .   476 

life-griiulers,  siderosis  in  288 
liinLT.    li!L*moptysis   from  286 
111'   I'    I'-r  crystals        . .  524 
in      dwarfs 
.  /    /    -:.)         ..  ,.186 

\I..,,..,,|iMn  ..  ..191 

from  ri.-kets        {Fig.  85)  186 
lot'grass,  erythema  from 

lucklcs,    pads   on    (Fid. 

160,  p.  347)  405 
Mh's  old  tuberculin,  in 
diagnosing       tubercle 

738.  740 
ichcr,  on  cervicobrachial 

|.l.-Mi-  ,.         ..  507  ' 

liiMihM  .irral  plexu-i       ..   500  I 
iplik's  Spots  (i'/a/c  VII [) 

178.  228  ' 
jrc.i.  Inn-  llukc  in  .  .    tW.'. 

srsiikow's  syndrom.-      ..      -n 

irsakow's  syndrome,  from 
ticrioheral   neuritis   • .  465 

...  .     Milv.-c,  age  inci- 


fptiosls,  general  account 
of  154.   155 

K.I   1.1  'd  spino  . .    151 


with  ..  155.  156 
t.n-nrthritirt  ..  188 
il:icla      ..         ..188 


Labium  majus,  epithelioma 

of         3 

pain  in,  from  renal  cal- 
culus . .         . .   1 

-  minus,  oedema  of         . .  7 
Labioglosso-pharyngo-Iaryn- 

geal  paralysis  (see  Par- 
alysis, Bulbar)  . .  5 
Labour,  difficult  (see  Dys- 

-  -  tieniiph-i;i   trorn         ..113 

Labour,  exhaustion  during, 
signs  of  .  ■  201 

-  pain  in  the  back  fi'om.  .  716 
pelvis  from     . .  . .  468  , 

-  pelvic  cellulitis  after  . .  691 

-  phlegmasia  alba   dolens 

in  737  : 

-  stages  of 211 

-  straining  at,  subcutaneous 

emphysema  from      . .  203 

-  (and  see  Childbirth) 
Labyrinth,  component  parts 

of  the 163  , 

-  liquor  Cotunnii  from  ..  421 
Labyrinthitis,tinnitus  from  723 
Lacey,    Dr.    T.     Warner, 

i I lu.'^t ration  lent  by  . .   195 
Laclirymal  ducts,  obstruc-  j 

tion  of  . .         . .   220 

-  glands,  enlarged  (f/j/.  3)     25 

in  chlororaa  . .   556  | 

leukaemia    . .         . .     25  j 

Miculicz's  syndrome  695 

-  sac,     excision     of,     for 

suppuration   . .         . .  220 

suppuration  of  . .   220 

Lachrymation     (and     sec 

Epiphora)       . .         . .  220 

-  from  conjunctivitis       ..  231 


glauc 

-  in  influenza 

-  from  iritis 

-  nasal  discharge  from 


amenorrhoea 


ll.i^liir.gin  ..  ..  211 

gahu'tocf^le  in    . .         . .  686 

mastitis  in 

mastodynia  in   . 

milk    How    from    nipple 


.  Lactic) 


261 


-  hi  ., ,     .11    M'.lui-i.'dby  262 

-  -"VV"-     'I'  '-. lion  by  261 

-  os!i/uM(!  crv-^tals  from 

261,  262 

-  picric  acid  test  and      . .  262 
Lnonncc.  metallic  thikling 

of,  with  pneumothorax  If'S 
Lajvulose.  fermentation  witli 

veaat 263 

Lallinq       628 

r,:irri.- ■    Limping) 

l.:u,,r    ,   ■  .   I.'..    1    11.-..  416,  .117 
I.  .n'JM.i.  ■    I ii,.-     mvo- 

,.  ,H,.,  ,-/>.  i:;.-,.  fill.  628 
Landry's  paralysis,  general 

account  of  ■  -  518 

-  -   p|..„t;.rn.(I..x  in         ..      68 


Laparotomy,  contd.  ' 

-  in  colic  cases      . .  . .   593 

-  cryptomenorrhcea         . .     18 

-  diagnosing  actinomycosis  458 

acute  abdomens       . .  436 

peritonitis       . .  . .   593 

carcinoma  cipci         ..    677 

of  sigmoid  . .         . .  676 

of  stomach         271,  769 

cicatrization    of    bile- 
duct  ...        . .  329 

diverticulitis  . .  . .   676 

double  ovarian  tumours  19 

-  -  .-liilinliHii  nf  pi.ioreas    76 

-  -    (■:,.■;  -n    I     ..-■■iir.  ..    657 


..      76 
..   253 

-  II ir-rimprung's  disease  390 
-  Iiyilitid  disease     253, 

328,  658 

■  -  malignant    peritonitis    49 

■  -  mesenteric  embolism 


thromlK 


389 


throm- 


■  Ri.-<trrslotK>  . 

■  ruptured  splei 

■  splenic    vein 

bosis  . .         . .  : 

■  suppurating  gall-blad- 

der   I 


I  gall- 


328 


iippendi- 

..   456 
..   390 


■  f.ornea  733 
rimpsin  150  I 

n.  effect 


salpingitis 

citis. . 

-  in  hysteria 

-  pneumonia  in  error      . .  593 

-  scar,    visible    peristalsis 

beneath  . .      521,  522 

-  for  twisted  spleen       ..  611 

-  (and  see  Operation) 
Lardaceous  disca.se,  Addi- 
son's    disease     simu- 
lated by        ..         ..527 

-  -  albuminuria  in   7,  35, 

.'575,  636 

-  -  aiiiiMnia  with  35.  636 

-  -  anuria  in         ..  10,    12 

Lardaceous  disease,  causes 


of 


431 


181 


from  chronic  sepsis  . . 

diarrhnea    in    8,     35, 

172,  375,  ( 

Lardaceous  disease,  general 
account  of      . . 

I  -  in'lc'.liiir    invulv.-d    bv  ' 
636,  I 

kidney     affected     by 

172,  < 

albumlimria  from.. 

anuria  from  40, 

disease  affeirting    . .  i 

renal  tube  ciusts  duo 

to 
Lardaceous  disease  of  the 
kidney,  urine  changes 


Lan.-.  Sir-  \.,  iL-Mf-a.-ul  kink 

of         457 

Lanugo-liko  hair   . .  . .     70 

Laparotomy,    after    abdo- 
minal injury  . .         . .  503 

-  ncnic        dilatation        of 

Htomach  after  . .   173 

-  for  acute  pancreatltlH  . .  661 

,  -  -  pcritoniriH        47,  425.  767 


Lardaceous  disease,  notes  on  635 
Lardaceous  disease,  organs 
affected  by     ■ .  B 

-  pornir'ionrt        untomia 

simulate  I  by  ..   527 

-  -  from  (dithlsls..         ..  375 

-  -  polyuria  from  . .  036 

from  prtoiw  ubsci'jw  ..   375 

rariT  than  fiirmcrly  . .  636 

si!verp  ari'i'inia  from  . .  527 

rtkin  colour  In  . .     SB 

spleen  affected  l»y    .,  173 

enlarged  in  35,  .175. 

632,  635 

-  from  KUppurntlon  172, 

375. 635 

-  -  syphllU    35,  172.  372, 

375,527.635 


Lardaceous  disease,    urine 
changes  In 

-  kidney,  albumimiria  from 

polyuria  from        536,  u 

renal  tube  cast*  due  to 

tnhe-casts  from         . .   ■" 

-  intestine,  dinrrlui-a  from  ;] 
Lardaceous   liver,    general 

account  of  . .  3 

-  tube-casts 

Laryngeal  crises    . .  . .  1 

-  -in  tabes  418,420,487,;] 
Larvngismu^  stridulus,  cvn- 

'n..-i--   fron,       .  .        \" .    I 

Laryngismus    stridulus, 

general  account  of    . ■  4 

-  -  larvnx   oti^tructed   hr 

157,  -1 

orthopncea  from     418,  ^1 

in  rickets       . ,      145,  A 

spasmophilia  and     . .    1 

Laryngitis,  acute,  imeumo- 

coccnl         . .      158,  < 
sputum  in      . .         . .   1 

-  -  stapliylo.-or.Ml  ..   t 


Laryngitis,  acute  suffocative  616 


of       ..        ..     lysi, 

-  bronchitis  with  .. 

-  bronchopneumonia  simu- 

lated by 

-  from  congenital  sypliilLs 

-  convulsive     movements 

of  chest  in 

-  cough  from 

-  cyanosis  from    . .       157, 

-  diphtheria  bacilli  causing 

-  dysphagia  from. . 

-  liicmoptysis  from       14H, 

-  hoarseness   from 

-  huskincss  from  . . 

-  from  irritant  gases 

-  hirvngeid     otistruction 

from     ..  ..      137, 

-  loss  of  voice  from 


fro 


-  orthopi 

-  pneumococcal    199.  418, 

-  simple,  with  phthisis  . . 

-  simulating         laryngeal 

paralysis         . .  . . 

-  sore  throat  from         . .  < 

-  streptococcal      199,  418,  ■ 

-  sucking  in  of  intercoatnl 

spaces  in         ..  ..    : 

-from  syphilis      .. 

Laryngitis,  tuberculous,  dia- 
gnosis of 

-  -  (and  sc-  nnd.-r  ■I'lihiT- 

culosis  ot'  larynx) 

-  voice  chang<!  with 

,  Laryiix,   ubscncn  of  deep 

tonderne>*s  in.  In  tahcw  i 
'  -  angioma  of  . .  287,  : 
I  -  careEnnma  of  (sen  Tftrci- 


LOf    I 


ynx) 


K-alne  in  examining  . . 

-  rpitln4inmu  of  (jteo  Cur* 

ru.on.a  ..f  Larynx) 
I   -  llhroma  of  . .       533,  ' 

-  fori-ik'n      body     In     (se*t 

l''orolgn       no<ly      tn 
I  Larynx) 

I  -  Irritable 

..  lupuH     of  . .         . .  : 

I  -  niyiutthenla    gravb    ai- 
I  'feeling  . .         . .   : 

-  obMtnielion  of.  from  ah> 
I  iluclor  paralvtdrt 

-  -  In   ItrlL'hiV  dlsoniie   .. 

I  -   -  cvanoblM  from  . .    '. 

I  -  -  friini  dlphthiTla      157,  i 
1  -  -  dy.pnn.a  from  ..    I 

-   -  from  for-i^-o  ho.iy  157. 
I  Larynx,    obstruction    of. 
general  account  of        ' 


»ilid<' 


LARYNX 


LE  [OOCYTES 


Larynx,  obstruction  of,  cotihl. 

from  laryngismus  stri- 

.lulns  ..      157,  420 

-  -  l.n-yn-iti>         ..  -.157 

Larynx,  obstruction  of,  list 

of  causes  of   418.  IJ50.  651 

-  -  ..111,.,!.:.....,  I.-..IM     as, 419 


itri.l 


ith  15 


419, 


-  -  sucking  iu  with    419,  590 

tracheotomy  for       . .   419 

up-and-down      move- 
ments of  larynx  in 

160,419,  420,  590 

-  oedema   of  (see  Oedema 

of  Larynx) 

-  papiUoma  of,  asthma  si- 

mulated by     . .  . .   535 

-  paralysis  of  (see  Para- 

lysis, Laryngeal) 

-  sarcoma  of,  hsemoptysis 

from    . .         . .         . .  287 

-  spasm  of . .  . .  - .   752 

-  syphilis    of        . .         . .  199 

-  tooth-plate  impacted  in 

{Fit;.  94)         . .  . .    195 

-  ulceration  of  (see  Ulcer- 

ation of  Larynx) 

-  vagus  supply  of . .         ..  148 
Lassitude,  in  diabetes     . .  260 

-  after  epileptic  fit         . .  143 

-  from  serum  injection    . .   554 

-  in  typhoid  fever  . .   636 
Latent  uramia,  general  ac- 
count of          . .         . .     40 

Lateral  sclerosis,  age  inci- 
dence of 
amyotrophic  (see 

Amyotrophic  Lateral 

Sclerosis) 

-  -  anemia  witli  . .  . .   140 

anaesthesia  with       . .  140 

Rabinski's  sign  with  68, 140 

-  -  some  causes  of         . .     68 

-  -  contractures  fi-om  138,  140 

-  -  drawing  up  of  legs  with  140 
Lateral  sclerosis,  primary, 

general  account  of    ..  517 

paraptegia  from     140,  514 

retention  of  urine  in..   398 

-  -  rigidity  in       ..  ..   139 

shuffling  gait  from    . .  259 

sphincter  troubles  with  140 

in  syringomyelia      . .     62 

-  sinus   erosion,   in   otitis 

media  . .  . .  . .   421 

thrombosis  (see 

Thrombosis    of    La- 
teral Sinus) 
Lateropulsion  in  paralysis 

agitans  . .  . .   725 

Latissimus  dorsi,  atrophy 


140 


of 


513 


supply  of        . .   505 

root  innervation  of  . .  509 

Laughing,  regurgitation  of 

food  through  nose  from  588 
Laughter,  explosive,  from 

double  hemiplegia  . .  234 
~  hiccough  from  ..  ..  307 
Lavage  of  bladder,   boric 

acid  for  . .  . .  575 
in  pyuria        . .  . .   575 

-  stomach,   in   diagnosing 

dilatation       ..         .-317 

gastrectasis  . .   174 

liour-fflass    contrac- 
tion        ..         ..318 

in  testing  motility     . .   320 

for  opium  poisoning. .   118 

Lead  acetate  in  Cammidge's 
h  -■     reaction  . .         . .  100 
test  for  cystin  . .  161 

-  amblyopia  from  . .  759 
ammonium  sulphide  test 


for 


lidge's 


-  carbonate  ii 

reaction 

-  central  scotoma  from  .. 

-  delirium  from    . . 

-  colic,  renal  colic  simu- 

lating   


Lead.  coHtd. 

-  medulla    oblongata    de- 

generation from         . .   197 

-  poisoning,       abdominal 

cramps  in       . .         . .  484 

abortion  from  . .     34 

acute  mania  from  119,  147 

albuminuria  from     . .     34 

amenorrhoea  from    . .     18 

anajmia  in       . .  32,  34 

anuria  from   . .  40,  41 

from  beer       . .  . .   117 

bleeding  gums  from. .     72 

bluelineongumsin  34, 

65,119,124,131,425,505 

bruit  de  diable  iu      . .  723 

cachexia  from  . .     99 

cerebral     haemorrhage 

simulated  by         . .  119 

tumour  simulated  by  119 

symptoms  from  146,  147 

colic    from     34,   117, 

126,  131,  425,  593 

simulated  by         . .  115 

coma  from     , .      118,  119 

constipation    due    to 

34,  (Fig.  51)  124,  131 

convulsions  from     34, 

146,  147 
-'-  cramps  from  ..         ..  484 

dementia  from  , .  119 

from     electrolysis     of 

water-pipes  . .     65 

<^-  epigastric  pains  in   34,  438 

epilepsy  from  . .     34 

epileptiform     convul- 
sions from  . .         . .  119 

feeces  analysis  and  . .     65 

fatty  heart  from       . .     53 

-  -  foot^drop  from  . .  113 
Lead     poison  ing,     general 

account  of     .  ■        .  ■    34 

general  paralysis  simu- 

mulated  by        119,  727 

gout  from       . .  . .     34 

granular  kidney  from     34 

from  hair-wash  . .     65 

headache  from  34, 147,  295 

infantilism  from        . .   189 

insomnia  from  . .     34 

irritability  from        . .  323 

lead  in  faeces  in      73,  119 

iu  urine  iu    34,  73, 

119,  147 
leucopenia  with        . .  361 

-  -  mania  from  . .         . .     34 

-  -  nausea  in        . .         . .     34 

neuritis  from.,  ..   140 

noises  in  the  head  from  406 

of  external  popliteal 

-  -  occupation  aiid      llV*   147 

ophthalmoplegia  from     34 

optic  atrophy  from  . .   759 

nem-itisfrom34, 119,  759 

pain  in  the  limbs  from  466 

at  umbilicus  iu       . .   484 

paralysis  from  . .   726 

of  sixth  nerve  from     34 

penile  erection  absent 

trom  ..  ..313 

Lead  pois'^ning  peripheral 
neuritis  from  34,  6t, 
65.  U.S.  443,  465,  466,  505 

punctate  basopliilia  in    23 

retrobulbar      neuritis 

trom  . .  . .  446 
saturnine     encephalo- 
pathy from             . .    119 

sight  impaired  in     . .      34 

source  obscui-o  . .     65 

tetany  from   . .  . .   151 

tremor  from  . .      724,  726 

urine  analysis  and    . .     65 

vomiting  from  . ,     34 

from  water    . ,  ■       , .  117 

wrist-drop  in    34,  65,  505 

-  in  screening  radium     , .  223  ' 

-  sulphide,  from  cystin  . .  161 
Lead  -  mind's,     ankylosto- 

Lead-workers,  plumbism  in  117 
Lent  her -bottle  stomach  , .   244 

Lecithin  in  ascitic  fluid  . .     50  . 

-  phosphates  from  . ,  522  | 
Leech  bite,  purpura  from  553  ; 
Leeks,  foul  taste  from     . .  705  , 


465 


-  Volkmann's  contracture 

of         IU 

Legs,     bent,     in     osteitis 

deformans      . .         . .  155 

-  bow         . .         . .      186,  187 

-  burn  of,  talipes  fr'om  . .  114 

-  cramps    in,    from    p 

plieral  neuritis 
Legs,      determination      of 

length  of         . .  . .   L'»3 

-  diplegia  all'ecting  - .    132  j 

-  drawing  up,  from  appen- 

dicitis . .  . .  677 

colic  . .       117,  425 

hseraatomyelia       . .  140 

in  infants    . ,      117,  321 

from  intussusception    78 

lateral  sclerosis     . .  140 

peritonitis  ..  ..   425 

transverse    myelitis  140 

-  elephantiasis  of . .         . .     28 

-  epithelioma  of    . .         . .  381 

-  erythema       multiforme 

affecting         . .         . .  489 
nodosum  of   . .  . .   404 

-  gangrene  of  (see  Gangrene) 

-  glands  draining. .  . .   679 

-  laceration  of,  talipes  from  114 
-local  fatness  of,  in  Der- 

cum's  disease. .         . .  410 

-  lupus  of  . .         . .         . .  738 

-  multiple  benign  sarcoid 

affecting  . .  . .  405 

-  mycetoma  of     . .         . .  736 

-  cedema  of  (see  OEdema) 

-  pain  in  (see  Pain  in  the 

Leg  ;  and  Pain  in  the 
Extremity.  Lower) 

-  pai-alysis  of  (see  under 

Paralysis  of  one  Leg) 

-  pigmented  scars  on,  from 

syphilis  ..         ..209 

-  position  in  tetany        2,  151 

-  short,    from    achondro- 

plasia   187 

in  dwarfs        . .         . .  186 

from  rickets  (Fiff.  85)  186  , 

-  sore  on,  inflamed  inguinal 

glands  from   . .  . .   381 

-  stiffness  of,  in  Thomsen's 

disease  . .         . .  584 

-  syringomyelia  affecting     60S 

-  swollen,  in  myxcedema     537 

-  ulcer     of     (see     Ulcera- 

tion of  the  Leg) 

-  unduly  curved,  in  rickets  635 

-  unequal,  scoliosis  from     153 
Leishman-Donovan  bodies 

(Plate  XXVIII,    Fig.  I 

H)  614 

in  kala-azar  . .  . .   633 

splenic  puncture  for..  633 

Leislunan's  stain  21,  28,  31,568 
Lemon-yellow  skin,  in  per- 
nicious anaemia  . .   569 
Lemonade,  polyiu-ia  from 

534,  535 
Lens,  coloboma  of  . .  415 

-  in  diagnosing  eczema  . .  488 

-  dislocation,  diplopia 

from    . .  . .      175,  551 

ophthalmoscope        iu 

diagnosing. .  . .   175 

pupil  irregular  from. .  551 

shallow  anterior 


cken 


of 


bones  from             . .  406 
cranial  and  face  bones 

enlarged  in            . .  670 

forehead  enlarged  in  204 

Leontiasis    ossea,    general 

account  of     ..        . .  204 
-  -  lUiVv.iAu'z  -izes  of  luit 

wirh              . .       2U4,  67U 
noises  in  tlie  bead  from  4U6 


Leontiasis  ossea,  could. 

osteoporosis  and       . .  ! 

Paget's  disease  related 

to : 

from  syphilis. .         . .  ' 

Lepidophyton,    ringworm 
from    . .  . .  . .   ! 

Leprosy,  ansesthesia  in  63, 
383,  404,  I 

in  n;i3al   discharge    in  : 

Leprosy,  bullae  in..        •  •  i 

-  cicatrization  in..  .. 

-  crusts  in i 

-  distinction   from    leuco- 

dermia  . .         . .  i 

-  erythema  in     222,  225,  : 
nodosum  simulated  by 

;  403, 

I simplex  simulated  by 

I  -  fingers  affected  by    239, 

-  forelicad  enlarged  in    . . 


■  macules  in         . .      383, 

■  mucous  membranes  af- 

fected by 


p]gn 


tati< 


250. 


rosacea  mimicked  by 
Leprosy,  skin  eruptions  of    I 

-  subcutaneous  nodules  in 

-  sycosis  mimicked  by  . .  ^ 

-  s3T)hilis  simulated  by 

403,  . 
simulating 

-  syringomyelia  simulating 

63,  ; 

-  telangiectases  in  . .  ^ 

-  tinea    versicolor    simu- 

lating   ! 

-  ulceration  in      63,  257, 

404,  ) 
of    larynx   from   158, 

199,  287,  : 
nose  from       . .         . .  : 

-  Wassermann's  test  posi- 

tive in  . .  ..    ~ 

Leptothrix  bacillus,  septi- 
caemia from    . .         . .  ! 
Leucin,    in    acute    yellow 
atrophy         273.    333,    ' 

-  crystals  (Fig.  147)       . .  : 
Leucocyte    count,     differ- 
ential (see  Differential 
Leucocyte  Count) 

Leucocytes,  abnormal  forms 
of  (Phite  ID..  22, 

-  in  a?citii-  Ihiid  . . 

-  Moud,  ill  cliildn-n  .  .    J 

-  -  Miiily  v;iri;itiuns  of    .  .    : 

in  ]ii-e.L'tKnicy.  .  -.   : 

Leucocytes,  in  cerebrospinal 

fluid ; 

-  behind  cornea,  in  iritis    : 

-  eosinophile  (see  Eosino- 

phile  Cells) 

-  gonococci  in      182,  185,  ; 

-  in  leukaemia 

-  in  morbus  cceruleus     . .  •- 

-  myocarditis       . .         . .   - 

-  normal  numbers  of 

-  polymorphonuclear    (see 

Polymorphonuclear 
Cells)     . 

-  in  pustules         . .         . .  5 

-  relative  numbers  of     . . 

-  in  stools. .         . .         . .  5 

-  tube  casts 

-  urine        . .  . .  - .    7 

in  acute  nephritis     . . 

from  bacilluria       455,  7 

carcinoma  recti 

(and  see  Pyiu-ia) 

-  in  uterine  casts . .  . .    1 


LEUCOCYTES 


LIPOMA 


■lischarKC 
of  1 


lal 


185 


tubiil  i,'estati( 


EUCOCYTOSIS    ..  ..359 

rinij  n  lite  peritonitis. .  <i9Z 
-  meumatism    . .  . .   3G0 

appendicitis  ..  UGl,  f)77 
bronnhiectasis  . .  . .  360 
carcinoma  360,  374,  630 

in  caseous  bronchopneu- 
monia . .  . .  360 
with  ceHuHiis  . .  . .  -UO 
cholangitis  . .  .  .  360 
in  cholera  . .  . .  360 
cirrhosis  . .  . .  37t 
from  cinnamon..  ..  360 
definition  of  . .  . .  35'J 
in  diphtheria  . ,  . .  360 
disappearance   of,   when 

abscess  opened  . .  360 
from  'IruiK         -  -  .  .   360 

^.I'li.  nii>vema   ..        35,  361 
ii-bladder  ..   254 

'I    ii^  ..  ..   360  , 

;r..;i:  ■  --ential  oils  ..  360 
m  fatid  bronchitis  . .  360 
gani^rene  of  lung  . .  360  | 

with  hepatic  abscess  . .  361  i 
in  intestinal  obstruction  360  j 
leak£emia  24, 25,  55, 273, 

570,  572,  632  ' 
with  liver  abscess         . .  362 
Ivnipliatic  leuka;nua  51,  330 
■■<  n.-i-l.-  ..  ..    360  ' 

,M~  .  .  ..    361  , 

■  M        ■:     :-  in;.  ..  .  .     360    ■ 

..-t:  ..■::■,. 'liris        ..  ..    688 

from  p.-ppcrmint.  ..   360 

pfhi.'^titis  ..  ..693 

in  pi. t!ii~is  with  secondary 

inf.,  t ion  ..  ..360 

1  ■    :  .   -.i,ia  3.),  361,  593 

I  i..i:irgol  ..  ..360 

'    .  .    '      . .  . .   5116 

(  ,  IMtis      ..  ..   360 

,     '.     Minx  ..  ..   361 

I    !  I  360 

■  ;.  ver       ..         ..598 

593 
360 

scarlet  fever      . .  . .  360 

septic  arthritis  . .  . .   339 

septicaemia         . .  . .  567 

after  severe  blood  loss. .  360 
irom  succinic  acid        . .  360 
subdiaphrngmatic    ab- 
scess    . .  . .      451,  658 
V  ,ih    ■iii.i.nf.,IiMri  ..    360 

.1  1  -(^ted  by  572 

I  '  mI   .  I    of  vein  360 

!■.    n-   ilhn-         ..  ..  360  ' 

(rirliiiM.Ms  ..  ..  464  I 

tiihfniilous meningitis..  360 

frotii  Turpentine  ..  360 

ill  fvrlius  fever..  ..  33r>  i 

urfTt.rili^  ..  ..  .360  1 

witli  uliitlow      ..  ..  .•i60 

ni  ulioopintr-coutrh       ..  3fi0  i 

uorirj  -uLTuested  by  ..  572 
i  '      I  ii.iinitt  (sec   liOU- 

urorinrmia  ..  ..529 

I'  '         itrophica'    simu- 

I:.tlli- 365 

nico-niplunodormia  (/•'ij^.f. 

223.  22 1)         . .  . .   528 

iKonvluH  .,  .,    -100 

iUCOPENIA  ..361 

I  ..        361,   362,  370 

I    '    I  iruis  anatmia  24,  361 
J  I.   M    fnver    76.  171, 

335,  361,  636 
JUcorrhu'd,  cachexia  with     99 
from  endomolritis     192.  387  ■ 
picrtmMitationoffiicewhh    99 
with  pyosalpinx  . .   582 

pyuria  from  ..  575,  581  j 
urethritis  from  ..  182,  478  ' 
from  uterine  congestion  387  ' 
^ukamiia,  ai>hcs  and  pains 

in         467 

albumosuria  with  10,  17 
amenorrhcea  in..  ..  18 
nm»mia  in  . .        99.  283 

nsrites  in  15,   16,  55 

hasopliili>  cell.'^  iti  . .     2-1 

bluediiiL'  L'unis  in  . .      72 


Leitkcemia,  contd. 
~  blood  per  anum 

-  cachexia  in 

-  Charcot^Leydeii  crystals 


102 


-  chloroma  related  to 

-  chlorotic  anaemia  in     . .  24 

-  chylous  ascites  from   50,  106 

-  chylous    fluid    ui   chest 

from 106 

-  chyluria  from    . .         . .  50 

-  cirrhosis  simulating      . .  273 

-  deafness  from    , .         . .  166 

-  epistaxis  from   . .      221,  273 

-  hiematemesis  in. .      266,  273 

-  htematuria  in    . .      275,  283 

-  haemoptysis  in  . .          . .  287 

-  haimorrhaEres  in             . .  273 

into  miilfUe  ear  in   . .  166 

tont'ue  in        . .          . .  698 

-  jaundice  in         . .          . .  325 

-  leucocytosis  in   04,  273, 

570,  572 

-  liver  enlarged  in         C4,  374 

-  loss  of  weight  in          . .  99 

-  lymphatic,  age  incidence 


of 


(/•/'■I/ 


25 
25,  556 


632 


556 


blood  coimt  in  dia- 
gnosing 

change  of  tempera- 
ment in 

cbloroma  allied  to  . . 

simulating  . . 

colour  index  in 

different  type? 

epistaxis  in    . . 

without  gland  enlai^c- 

ment 

hajmorrhixges  in       25, 

into  tongue  in 

inguinal  glands  en- 
larged in     . . 

irritability  in. . 

jaundice  in    . . 

lachrymal  glands  en- 
larged in     , .       25,  695 

leucocytosis  in  25,  51, 

55,  330 

without  leucocytosis       26 

loss  of  appetite  in    . .     25 

lymph  glands  enlarged 

in  25,  51,  55,  61, 
.    376,    556.   570,  632 

lymphocytes  in  25, 51, 

r>5,  61,   274,   330,   632 

in  cerebrospinal  fluid  305 

Miculicz's  syndrome  ■ 


..   330 


I'seudoleu- 


695 
26 


myelocytes  in 

nodules  in  liver  in    . .  374 

portal  glands  enlarged 

in     . .         . .         40,  51 

prognosis  in  . .         . .     25 

purpura  in     . .  . .     25 

first  sign  of  . .  556 

pyrexia  in       . .'       . .     25 

salivary  glands  enlarged 

in     ..         ..        25,  695 

serous  iDllammatinns  in   25 

simulated  by  lympho- 
cytosis       . .  . .     20 

-  -  .^pl.;.:n  li.rgc  i »_-'■'',_  f'l, 

Leukffimla.  lymphatic,  sym- 
ptoms of  . .    25 

visceral  glands  enlarged 

in     ..         ..         ..  .330 

-  malaria  simulating       . ,  273 

-  marrow  hyperplasia  in..   707 

-  nn-trorrhnu'ia  from    31)0.  302 
Leukemia,  mixed  forms  of    26 


Ul   ^'jiUld^ 


iilargcd 


rrdemn  of  legs  in        113,   115 
peripheral  neuritis  from 

Gl.  61 
pleuritic  efTusion  in  ..  106 
I'ortal  glands  enlarged  in  325 


Leukccmia   at 

-  pseudo   (se 

kiemia) 

-  purpura  in  . .  . .   553 
Leukaemia,  pyrexia  in  570,  572 

-  renal  infarct  in. .  . .       8 

-  rigors  in  . .      595,  596 

-  shortness  of  breath  from    87 

-  simulating    malignant 

peritonitis      . .         . .     51 

-  skodaic  resonance  in  ..611 

-  spleen    enlarged   in    64, 

09.  273.  283,  570,  611 

I.uif.-  ./"      ^    ^      -.273., 
Leukemia,  splenomedullary, 

blood  chanaes  in       ..    24  I 

{Plate  IV)  ..     26 

count  in  diagnosing  632 

duration  of    . .  . .     24 

eosinoplulia  in  ..  219 

leucocytosis   in       55,  632 

myelocytes  in  23,  24, 

55.  274,  632 

pyrexia  in  (Fig.  4)  . .     25 

soleen  enlarged  in  24, 

55,  631,  632 

-  tenderness  of  bones  in 

467,  707 
~  thrombosis  in    . .         . .  411 

-  thrombotic  infarction  in  640 

-  tinnitus  from   . . 

-  tongue  swollen  ii 

-  uric  acid  in 

-  effect  of  i-rays  in         . .     25 
leukoplakia,    carcinoma 

from    . .  . .       701,  739 

-  from  syphilis      ..      209,  739 

-  tongue  swollen  from    . .  698 

-  Tulvae,  age  incidence  of  701 
appearances  of  ..   194 

-  -  .l_\^[.,,r.ui,i.i    [mm      ..    193 

Leukoplakia  vulvae,  kraurosis 
distinguished  from 


698 


1  from  193 
194 


vaginismus  from       ..  193 

vulval  swelling  from     699 

Levaditi's  stain,  for  spiro- 

cha3ta  pallida  . .  701 

Levator    anguli    scapulas, 

nerve  supply  of        . .  504 

-  ani,  injury  of,  prolapse 

from 538 

-  -  r61e  in  dcfircation  127, 128 

spasm  of,  causes       . .  193 

dyspareunia  from..   193 

viiginismus  from  . .  193 

-  palpebral,  spasm  of,  in 

Graves's  disease       . .  229 

superioris.  absence  of    542 

paralysis  of  (and  see 

Ptosis)     ..  ..   511 

Leydon,  myopathy  of     . .  135 
Lice,  genital  region  affected 


by 


rilO  ' 


shoulders  affected  by  . .  510 

-  typluia  fever  spread  by  335 
Lichen    aniudaris,    fingers 

affected  by    . .         . .  239 
I  -  plaims,  arseidc  relieving  489 

I brown  utains  from  . .  ■187 

I  -  -  Ihigcrs  affected  by  239,  210 
'  Lichen  planus,  general  ac- 
'  count  of         .  •     487.  488 

-  -  it.-liini:  in       ..      -191,  .'►lo 

-  ■  lips  :.lT.-.-l.d  l.v         ..   3';'' 
-  Mi.i.ul.-  ri.     ..        ..  ;;s;; 

Lichen  planus,  pauular  ec- 
zema distlnoulslied 
from 487 

-  -  pniiulonf  1S7,  101.6(»3,  7;.6 

pityrirwis  rubra  after    601 

pilaris  distinguished       i 

from 


dl-ri 


^^hcd 


In.tri  ..    lUif 

Lichen  planus,  psoriasis  dis- 
tinpulshed  from     Ihn,  603 

-  -  ^yphili'lt-xt  Hiniulating     491 

-  -  verruca    pinna    simu- 

lating ..  ..   488 


ulittin 


'd   p> 


538 
from  563 


-  ml"  t    pi.i,,,   ,   i'>piil«  of    1H7 
Lichen  scrofulosorum.  gene- 
ral account  of  . .  488 


Lichen^  eoniii. 

-  urticatus, 

lated  by         . .         . .   756 

itching  in        . .       540,  756 

Licbenization,  itching  in. .  540 

-  in  prurigo  . .         . .  490 

Lientery     . .         . .         . .  173 

Life    insurance    examina- 
tions, albuminuria  at     l.'V 

effects  on  heart     . .       2 

nephritis  discovered 

at  ..         ..12 

polyuria  from        . .   535 

obesity  and  . .         . .  408 

preglycosuric  state  and  408 

urine  reduction  and..  743 

Lifting  loads,  orchitis  from    67 
Ligament,  long  plantar,  cal- 
cification in  . .         . .  439 

-  plantar,  ossification  of..  671 

-  round,  fibromyoma  of..  681 
malignant  deposits  in 

650.  057 

-  Poupart's,  line  of         . .  674 

-  torn,  pain  long  after 
Ligaments      affected 

osteo-arthritis 
-ossification   of    ..  ..   143 

Ligature  of  artery,  pain  on  434 

-  neurotic,  oedema  from..  411 

-  of  vessels,  gangrene  from  255 
Light,  intolerance  of  (see 

Pliuioplii.l.i:.) 

Liu'hp,,'  _■.      n-  in.ni     -55 

Lightninn   Dams,   described 

as  rheumalirs  ..   440 


476 
346 


of 


719 


in  tabes  116,  315,  466, 

515,  609,  6.'>rt 
Ligneous  thyroiditis  ..  158 
Limbs,  chromidrosis  of  . .  655 

-  leprosy  erythema  of    . .  383 

-  lichen  scrofulosorum  af- 

fecting ..         ..488 

-  piemcntation  of  . .  527 

-  pityriasis  rosea  atTecting  604 
rubra  pilaris  affecting  *189 

-  prurigo  affecting  . .  489 

-  psoriiisis  affecting         . .   603 

-  seborrlia-a  affecting     ..  602 

-  small-jiox  affecting       . .   757 

-  syphilis  roseola  on        ..  383 

-  syphilodcrms  of  ..  490 

-  tics  affecting     . .         . .  136 

-  xeroderma  affecting     . .  488 
Lime,  dermatitis  from     ..  755 
Lime-kilns,    carbon    mon- 
oxide  poisoning   from  119 

Lime-salts,  in  stools         ..  170 

-  (and  sec  un.l.-r  Calcium) 
Liin.-iM,  ,.,     ,h.  <.   .     irnni..    L'SS 
LiiiM    V    ,   ,  .  M  -t    ..    711 

LIMPING    IN   CHILDREN     362 

-  from    l.rimi.l.L'L.  ^   ..    -J.-.I 

-  infanlil.-  p:u  .l,v-i-<  .  .*  'J.-.t 

Limping,  list  of  ciauses  of. .  362 

-  from  nmnoplegia  ..   251 

-  ostooarthritift     ..  ..   .34  7 

-  osteomyelitis     . .         . .  3t;2 

-  pain  on  wnlkuig  ..   251 

-  p;.n.pUria  ..  ..    251 


-  I- 


dHi 


LINE>E  ALBICANTES 


urlri 


■d  by  Jaundiced 


324 


I.lpfns  In  ascitic  (Inid       ..     ftO 
Lipoma  nf  ikbtlomlnal  wall  6r>6 

-  In  axilla  ..      666.  667 

-  nf  ItrenMt  . .  . .   686 

-  chrordc 


IiiIinI  hy 


666.  667 


LIPOIMA 


LOBSTER 


Lipoma,  rvii/d. 

-  femoral   . .  . .         . .  075 

-  bernia  simulateij  by  Gyfj,  (jSl 

-  impulse   on  coughing  in  681 

-  lobulation  of     . .         . .   732 

-  periosteal  . ,  . ,   G71 

-  popliteal  . .         . .  G92 

-  retroperitoneal,    ovarian 

cjst  simulated  by  . .  G91 
pelvic  swelling  due  to  G88 

-  of  round  ligament        . .  G81 

-  sebaceous    cyst    distin- 

guished from. .         . .   732 

-  skiti  wrinkling  over     . .  GC7 

-  vnlval  swelling  from   . .   700 
Lipomatosis  diffusa,  general 

account  of  ..  410 


obf 


408 


LIPS.      AFFECTIONS      OF 

THE  RED  PARTS  OF  365 

-  angiotioiiiulir  >!--irnut  of  411 

-  ataxy  or . .  . .  . .      59 

-  blanching  of,  from  severe 

hsemorrhage  . .         . .   120 

-  bleeding,  fi*om  stomatitis    74 

-  blubber,  from  lymphs 


gitis 


674 


-  bluenessof,  in  pneumonia  593 

-  burning,     in     Pordyce's 

disease  . .         . .  36G 

-  capillary  pulsation  in  . ,  207 

-  chancre  of  (^Fi(/.  23)  73, 

365,  674 

-  chapping  of       . .  . .   365 

-  condyloinata  on  .  .   365 

-  congested,    from    mitral 

regurgitation  . .   210 

-  dead  feeling  in  . .         . .  365 

-  dermatitis  herpetiformis 

affecting  . .  . .     74 

-  eczema  affecting       365.  GOO 

-  epithelioma  of  179,  365, 

369,  370 

-  erythema   bullosum    af- 

fecting . .         . .     74 

-  excoriation  of,  in  nasal 

diphtheria      ..  ..179 

-  fissured,  in  Monirolisra..   238 
Lips,  Pordyce's  disease  of 

365,  366 

-  herpes  affecting         365,  754 

-  Kopllk's  spots  on      178,  228 

-  lichen  planus  affecting. .  365 

-  lupus  affecting  . .         . .  365 

-  paresis  of,  in  bulbar  pai-a- 

lysis 589 

-  pemphigus  affecting     . .     74 
Lips,  perleche  of    . .         . .  366 

-  pigmentation       of,      in 

pernicious         anmniia 
(Plate  XXir)  . .    52S 

-  pouting,  in  myopathy. .   235 

-  psoriasis  affecting        . .  3G5 

-  scars   on,    in    congenital 

syphilis  . .  . .   235 

-  seborrhoea  affecting     . .  365 

-  sore  from  picking  . ,   365 

-  swelling  of,  from  mercury    73 
stomatitis       . .         . .     74 

■^wnllnn.  in  niTxoedema-   234 
Mv,,.,.  :,irr,'ting  ..    600  I 

3G5,  739  j 
. .   490  ' 


.Llk- 


of  .. 
nig 


365 


-  tremor,,  from  lead 

-  urticaria  affecting  . .  365 
-yaws  affecting  ..  ..  403 
Liquor  ammoniie  in  acetone 

test      , ^         , ,         , .       3 

-  amnii,  deficient,  dystocia 

from    , .         . ,         . .  200 

-  Cotunnii.  albumin  in  ..  421 

escaping  from  ear      . .    421 

~  eplspasticus,  buIUe  from     97 

-  ferri   pereUloriai,   in   di- 

acetic  acid  test         . .   170 

-  potassffi,     in     Bdttgcr's 

t?st      . .  , .  . .   2G2 

examining  for  psoro- 

sperms        ..         ..730 

melanuria  test  . .  746 

methvlene  blue  and. .  747 

in  Moore*s  test         . .  262 

in  picric  acid  test  for 


safra 


I  test  , 


-  soda.'  1 ; i .    I     .  . 

Lithotorin  ,  ii-[iil  I    iii.T  .  . 
Lithotrity,     f:']iidiilymo-or- 

chitis  after     . . 
Litmus  paper,   in   testing 

stool  reaction 
Litmus,  phosphates  and  . . 
Little's     disease,     general 

account  of  132, 

-  -  kypliosis  HI     .. 
scissor  gait  in 

Liver  abscess  (see  Abscess, 

Hepatic) 
Liver,  actinomycosis  of  375, 

-  acute  yellow  atrophy  of 

(see      Acute      Yellow 
Atrophy) 

-  adenoma  of,  simulating 

hydatid 

-  albumosuria  fi-om  affec- 

tions of 

-  alcoholic,  dwarfing  of  one 

lobe  of 

-  angiomata  of 

-  carcinoma  of  (see   Car- 
■    cinoma.  of  Liver) 

Liver,     cirrhosis     of     (i^eo 


Liver,  congestion  of.  active, 
general  account  of  . .  334 

simulating     hepatic 

abscess    . .         . .   334 

pain  in  the  back  from  716 

passive     (see     Liver, 

Nutmeg) 

in  Tropics       . .  . ,   369 

Liver,  depressed    . .         . .  367 

-  dipping  to  feel  44,  371 
Liver  diseases  causing  ascites  46 

tendiTiiess      of     spirip 

from  (F/;/.   2'J4;    7ir. 

Liver  displaced  . .  368 

by   meteorism  . .   656 

renal  tumour..         ..  353 

from  tight  lacing       . .   366 

in   visceroptosis        . ,  426 

from  weight  in  nutmeg 

change        . .         . .  368 

-  dropped,     constipation 

with 127 

in  wasting  diseases  . .   367 

-  dullness,  absence  of,  with 

meteorism      . .         . .  656 

pneumoperitoneum    656 

LIVER    DULLNESS,    DE- 
FICIENT ..366 

diminished,    in    acute 

yellow  atrophy  273, 

333,  366 

cirrhosis     . .         . .  3G6 

emphysema        167, 

217,  366,  368 

gas  in  bowel      366,  368 

in  perforative  peri- 
tonitis     ..      366,  368 

pneumothorax       . .   366 

from  tight  lacing  . .  36G 

increased  upwards,  by 

abscess        . .         . .  367 

-  dyspeptic  congestion  of     369 


LIVER.  ENLARGEMENTS 

OF  THE  ..366 

from  'abscess         326,  658 

by  actinomycosis     . .  375 

from  acute  congestion  334 

in     alveolar     echino- 

coccus  disease       . .  376 

by  angioma    . .  . .    374 

ascites  with   . .  4(; 

~  -  bile-du.  ,■  ,,■,  i,.,,  ,„,., 

broiiri         ,        ■■■■:.   -Jin.' 

froni  cnrcniorna4(i    47 

.    50,  b-2,  77,  352,  326^ 

331,  373 
carcinoma     of     colon 


Lirer,  enlargements,  conld. 

-  -  in  catarrhal  jaundice 
chest  bulged  by 

from  cholangitis    333, 

in    chronic  alcoliolism 

nephritis     . . 

chronic  peritonitis  si- 
mulating    . . 

from    cicatrization    of 

hepatic  duct 

in  cirrhosis    51,    266, 

272.  326,332, 

of  childhood 

-  -  in  con-riiital  syphilis 

Liver,  enlarged,  depression 
of  liver  simulating    .  . 

from   ili.-r[<.]iii;L   lii'|.;iti- 

from  emphysema 

faeces  in  colon  simu- 
lating 

in    familial    acholm-ic 

jaundice 

fatty   


froni   !  .    ■■      ■  ,    ■!! ,     .-,:;     212 

-  -  higli  l.h...,i  p,.^- .;  212 

by  bydatid     .  .        49,  375 

jaundice  with         326,  369 

fi-om,  some  types  of  330 

Liver,     enlarged,     kidney 
I         simulated  by  ..         ..  353 

in  lardaceous  disease 

8,  35,  375,  635 

leukaemia        . .        64,  .^74 

locallv,  hv  abscess    . .   330 

carcinoma  . .  . .   330 

I gumma       .  .  . .   330 

■ hydatid  cyst  . .   330 

sarcoma      . .  . .   330 

in  lymphadenoma  329,  374 

mitral  regurgitation 

210,  211 
myocardial    degenera- 
tion.. ..  ..     90 

nutmeg  53,  334,  368 

omental  matting  simu- 
lating ..         48,  367 

tumour  simulating     331 

pain  in  the  hypochon- 

drium  with . .        . .  450 

from     phosphor\is 

poisoning    326,  336,  374 

in  pseudo-Ieukjemia. .     37 

pylephlebitis  . .         . .  333 

relapsing  fever         . .  336 

renal  tumour  simulat- 
ing . .  ..        51,  330 

rigid  rectus  simulating  659 

from  sarcoma..       52,  252 

from  single  abscess  . .   369 

skodaic  resonance  from  611 

from  suppurative  cho- 
langitis       . .  . .    369 

pylephlebitis  . .    59G 

suprarenal      tumour 

simulating  . .  . .   331 

from  syphilis. ,  . .   326 

with  tricuspid  regurgi- 
tation        . ,  . .     92 
from  tropical  conges- 
tion                     . .  369 

tuberculous  peritonitis 

simulating  . .         . .     48 

vena  caval  obstruction 

by    ...         ...         ..  749 

in  Weil's  disease      . .  336 

-  fatty,  from  alcohol      . .  375 

-  phosphorus  . .        73,  337 
Liver,    fatty,    general    ac- 
count of  . .  374 

anajmia. .  375 


[  Lirei\  conuL 

-  gumma  of  (see  Gumma 
I  of  Liver) 

1  -  hard,    from    carcinoma 


-  tu 


cle 


wasting  disease        . .  ; 

-  fibrosed,    in    congenital 

syphilis  . .         . .  ; 

-  furrowed,     from     tight 

lacing ; 

-  gas-containing    locuH  in  : 

-  Gaucher's  cells  in        . .  ( 


-  hydatid     cyst     of     (see 

Hydatid        Cyst        in 
Liver) 

-  u-regular,  from  carcinoma  37; 

in  cirriiosis     . .  . .   27: 

from  syphilis. .  , .   37: 

-  kidney  simulated  by    . .   36 

-  lardaceous    (see    Larda- 

ceous Liver) 

-  lesions,  ptyalismfi-om  ..   54; 

-  leukaemic  nodules  in     . .  37* 

-  lobulated  . ,  , .    36( 

-  lymph  adenomata  of     . .  37^ 

-  malignant,  pyrexia  witli     1\ 

-  melanotic  sarcoma  in  . .   25i 

-  new  growth  of,  pain  in 

the  back  from  . .   71( 

shoulder  from  . .  47i 

physical  signs  of  the     36( 

proportions  of  the    . .  36( 

-  nutmeg,    from    arterio- 

sclerosis . .        11,  3GJ 

ascites  with    . .         47,  33-1 

cyanosis  with  . ,   334 

from  fibroid  lung      . .   334 

Liver,  nutmeg,  general  ac- 
count of  . .  36G 

from  granular  kidnev     11 

from  heart  failure  47. 

52,  334,  694 

jaundice  with  . .  334 

liver  enlarged  with   . .     47 

tender,   pulsating  334 

from  lung  disease    . .     47 

from  mitral  stenosis. .  334 

tedema  of  legs  with  . .  334 

pain    in    epigastrium 

from  . .  . .   437 
shoulder  from     ■  . .  475 

-  primary  growth  of       . .      53 
Liver,     Prussian-blue    re- 
action in.  in  bronzed 
diabetes  . .         . .     24 

in  pernicious  anie- 

mia     ..         ..34 

in  sprue  . .  . .      24 

Liver,  pulsatile     368,  369,  694 

from  heart  failure     . .      5:,' 

mitral  regm-gitation . .   211 

tricuspid  regurgitation     92 

nutmeg  change         . .   334 

Liver,  Riedel's  lobe  of     ..  366 

-  rub  over. .  . .      388.  592 

-  sarcoma    of    (see    Sar- 

coma of  Liver) 

-  secondary  carcinoma  in 

77,  19G,  317 
Liver,     suppuration     in, 

general  account  of  . .  369 
Liver,   syphilis  of.   general 

account  of      ..      :;7i,  372 

-  tender,  from  acute  con- 

gestion . .  . .   334 

cholangitis      . .  . .   333 

gall-stones      . .         . .  272 

new  growth    . .         . .     r.^* 

nutmeg  change         . .   '■'■'.'  I 

-  -  (see    Tenderness    of 

Liver) 


Liver,  trnn 


nnestionof  369 


on  fr. 


-  umbilicateJ  Tiodules  i 

52,  253,  331,  3 

-  uneven,  from  cirrhosis. .  ? 

-  venous     congestion      of 

(see  Liver.  Nutmeg) 

-  visible  movements  of   . .  S 

-  wandering  (see  Hepato- 

ptosis) 
Lividity  (see  Cyanosis) 
Llewellyn,  L.  J.\  illustration 

lent  by  . .         . ,   '.i 

Lobar      pneumonia      (see 

Pneumonia) 
Lobelia,  asthma  relieved  by  5 
Lobster,  urticaria  from    . .   7 


LOCOMOTOR   ATAXY 


LYMPHATIC  GLANDS 


843 


)coniotor  atasj"  (see  Tabes 
Dorsalis) 

)ck-jaw     (see    TeUnus ; 
and  Trismus) 

)cke.  Dr.  Lindsay,  skia- 
grams by        . .       1-10,  531 

xAiiiff  of  joints  . .  . .   346 

)iii  filled  out  by  perine- 
pliric  abscess..      352,  451 

oedema  of,  in  acute  ne- 
phritis..        . .  9,  412 

pain  in  (see  Fain  in  Lcins ; 
Backache;  and  Acliinj; 


School  of  TrupitMl  Mf 


.  31 


)ng  plantar  litJLinietu  Hi'.  »;71. 
thoracic  nerve  51)4,  5ii5,  r>;n; 
)Ose    cartilage    in    knee, 

lintping  from..  ..   362 

jrdosis,  abdomen  promi- 
nent from  . .  . .  156 
in  achondroplasia  . .  187 
from  congenital  disloca- 
tion of  hip  . .  156,  251 
in  contortionists  . .  lofi 
)nlosis,  general  account  of  156 
with  kyphosis  ..  155,  156 
from  myopathy  iFi'j.  tlO)   150 

ricket-s" 188 

ass  of  appetite  (see  Appe- 
tite, Loss  of) 
wciffht  (see  Weight,  Loss 

"0       .  .  ... 

yzGn^cs,  eosin  m . .         . .    /  4.» 

[imbat^o,  a  form  of  my- 
algia   . .         . .         . .  407 

pain  in  tlie  back  from 

428,  438 
rectal  examination  In  . .  429 
sciatica  with      . .         . .  438 

simulated      by      pelvic 


Ie<;i 


429 


spondylitis  deformans   715 

-  tumour  . .  - .  429 
tenderness  in  the  back  in  438 

-  of  spine  from. .  ..  713 
vaginal  examination  in    429 

umbar  cushion  . .  . .  412 
pain  (?i>e  Pain  in  Loins  ; 

I'.;u-ka<h..' :     .ml    A.I.- 

inu'  ill    i>oi!iM 

umbar  plexus   498,  499.  500 

pnm-iurf.   in    di^L-nositii: 
cause  of  pain  inarm.,   412 

prolonged  i>yrexia  063 

cerebral  tumour    . .  625 

encephalitis  . .  525 

general  paralysis  . .  243 

meningitis,  147,225, 

315,     511.     on, 

525,  566,  590,  640 

pachymeningitis    . .  625 

sarcoma  of  cord    . .  305 

sciatica       . .         . .  439 

spinal       meninpitis 

417,  439 

spotted  fever        . .  554 

(and     see    (Vrcbro- 

si.Mial   Fluid) 

'"Th''M,:i"or ''''*.."'  '  :-  1''! 
umbar  region,  left,  organs 

contained  In     -  660 

umbar  renion.   rinht.   or- 
gans contained  in  660 
umbar  segments  of  cord. 

muscle  connections  of  499 
,umhri.;.l.s      nfffcf.-.l      in 

uhiiir  paralyHJH  ..   110 

of  foot,  nerve  uupply  of  498 
hand,  m-rve  supply  of  . .   501 

-  root  innervation  of  ..  509 
paralv^-i.-;  of.  talipes  from  114 
rflle  in  claw-hand         ..  190 

lUJig,  absci-ss  of  (SCO  Ab- 
scess of   Lung) 
actinomyi'OHirf     of     (see 

ActinomycoMis) 
aneurysm  nipturcd  into 

287,  290 
aspergillosis  of  (kco  As- 
pergilloHlB) 


Lung,   cirrhosis  of  (Pneu- 
monocoiiiosl^) 

-  compressed  by  aneurysm  434 
Lung-conditions,  heart  fail- 
ure from  14 

-  congestion     of,     haimo- 

ptosis  due  to  . .         ..  212 
from  mitral  regurgita- 
tion.. ,.  ..   212 
stenosis       . .  . .   215 

-  diseases,  heart  large  from    54 
pancreatitis  with      . .   100 

-  embolus  of  (see  Embol- 


ruhi 


Lung,  empyema  ruptured 
through  86,  I'.s,  -js;, 
L".pl,  :.:;l,  y.i-j,  643,  705 

-  engorgement  of,  from 
myocardial    degenera- 


over  ..  ..   216 

ascites  from   . .         . .     46 

back  pressure  from  . .     40 

bronchial    breathing 

over  ..         ..168 

bronchiectasis  and  14, 

111,  16S,  210,  292 
bronchophonv  over  . .  216 

-  -  bubbling  rales  in       . .  108 
cavernous    breathing 

over  . .  . .   210 

chest  of  atTected  side 

shrimken  from    153, 

154,  210 

movement  defective 

with         ..         -.168 
_  _  _  outline  with  (ftfir.  79)  167 

-  -  Cheyne-Stokes  breath- 

ing from     . .         . .  108 

clubbed    fingers    with 

34.  Ill,  168,  216,  643 
compensatory  emphy- 
sema of  other  lung 
with  ..  ..216 

cough  from    ..         ..  216 

cracked-pot  sound  over  216 

crackling  rales  over..  216 

cyanosis  from  . .   161 

deficient      movement 

over  ..         ..216 

distinguished    from 

phthisis      . .         . .  216 

—  dyspnoea  from  ..  216 

—  epigastric       pulsation 

from  ..         ..216 

foetid  sputum  with   . .   168 

hajmoptysis  from      . .  216 

heart  displaced  by  111, 

108,  206,  2J6,  299 

failure  from  14,  40, 

108,  161,  418 
iutercwital         spaces 

narrow  with  . .    168 

Lung.flbrold,  list  of  causes  of  292 


fihrmil.  contd. 

ng  from  . .    7 

t  test  with  2 

-  fluke        6 

LUNG,     GANGRENE     OF  2 
(and  see  Gangrene  of 

the  Lung) 

-  glanders  allecting 

-  growth     of,     aneurysm 

simulating      . .         , .  1 

bronchusohstructedby  1 

cyanosis  from  , .   1 

mediastinal      fibrosis 

simulating  . .         . .  1 

-  -  (T^dema    of    face    and 

arms  from  . .  . .   1 

jileuritic  effusion  from  1 

vena     cava     superior 

obstructed  by        . .   1 

j--rays  in  diagnosing. .   1 

Lung,  hepatic  abscess  rup- 
tured through  149,  287, 
I  291,   332,  37(t,  644,   \ 

-  hernia  of . .         . .         . .   1 

pulsation  in    . .  . .   t 

-  hydatid  cyst  of  287,  *. 

-  induration  of,  from  mi- 
tral stenosis   . .         ..  '. 

-  infarction  of  (see  Infarct 
of  Lung)' 

-  injury  of,  subcutaneous 
emphvsema  from      . .  - 

-  knift-griiider's  286,  : 
Lung,  new  growth  of      .  -   I 


-  vagus  bnincliL'S  to  ..  14S 
Lupoid,  multiple  benign  . .  405 
Ijumpus  erythematosus,  age 

incidence  of  . .         . .  710 

atrophic  scarring  in  . .  242 

atrophv  of  ears  from..  603 

-  -  haldin'ss  from  71,  710 
Lupus  erythematosus,  char- 
acters of  . .  402 

-  -  .iM.-k-  ;iir.-.(.d  l,v     ..    603 

.1    11.1  11.,-  -ii,i(il;itodby  602 

_  .     .  ..    602 

_  --  .        I  .  !  ,      r.Mil.itodby  710 

-  -  f;uM'  atb'cli'.l  by         ,.    247 

farus  simulating      . .  247 

lingers  atlocHsd  by  239.  240 

granulosis  rubra   nasi 

.li^iinu'Ni-li.'d     from  054 
Lupus  erythematosus,    le- 
sions of  ■ ■  602 

-  -  lips  ;.lT.vl<-.l  l.v  ..    305 

-  -  lupus     vukmri 


402 


palpi 
1" 


riln.,u 


CM 


484 
216 


Luna,  fibroid,  physical  signs 
of  168.  206.  292.  643 

-  -  polvcythiimiia  with  . .    533 
'  pn>cordial       pulsation 

from  ..  ..    216 

resonance       (mpairod 
over  . .      16H,  216 

-  retraction     of     chest 
from  . .      168.  109 

right  ventricle  enlarged 

from  ..       215.  216 

-  -  scoliosis  from         153,  210 

-  -  shoulder  drawn   down 


216 


cart'inoma  of 


2H7,  290 


Lung,    fibroid,    signs    and 

symptoms  of  ■  • 
simulitlod      by      now 

growth        . .         . .  KM 

Kpinul  curvature  from  168 

Kpiitum  from..         ..  216 

vcfllctilar  murmur  Im- 

palrofi  over  - .   168 

vocal     fromitui*    over 

168,  216 


-  -  parts  alfrcted  by       . .    602 
Lupus  erythematosus,  psori- 
asis distinguished  from  603 

-  -  rosacea    distiiiguish.'d 

from  .  .  .  .    212 

,  -  -  scaliri.'ss  in       212,  002.  603 

I scarring  in     71,    247, 

002,  6o:i 

I ncx  incidence  of       ..   7l*» 

lemlernesti     o(     scjilp 

from  ..   710 

17H,    102.735,  738 

Lupus  vulgaris,  apple-Jelly 
I         nodutMOt      179,402, 

601,  73H 

lione  never  cro<lc(|  bv 

402,  735 

cartitage  eroded  by  . .  402 

I trufitu  in        . .         . .  «01 

-  -  of  .heekrt  ..179 

urwl  ion  from . .  . .   220 

enlthelioma  simulating 

402.  422 

ntartlng  from        ..731 

linger  a(Ie*ted  by      •.   210 

Lupus    vulgaris,    ganeral 
account  of  -  735 

diHtirigui-dii'd  from     «;.''» 

-  -  of    larynx     158,    lUU, 

387.  293  I 

-  -oflcff 7M 

_  _  lrprof.ynilmickhiR403,40l 


Lupus  vtilfjarix^   could. 

lips  affected  by       ..  305 

j lupus     erythematosus 

I  simulating  . .  . .   402 

, lymphatic    gland    iu- 

I  volved  in    . .         . .  403 

-  -  nose  affected  by    179»  4<iJ 

of  palate        . ,         . .  2S*> 

pharynx         . .         . .  285 

rodent  ulcer  simulating  402 

' scarring  in     . .         . .  402 

scrofulodermia    simu- 
lating ..  ..402 

distinguished  from    559 

spinal  caries  and      . .  510 

syphilis  simulating 

402,  403 

tuberculoas    ulcer    of 

palate  with  . .  588 
with  tuberculous  peri- 
tonitis. .         . .         . .     4$ 

Lying,  from  alcoholism  . .  405 
Lj-mphadenoma   (and   see 
Hodgkin's  Disease) 
I  -  albuminuria  in  . .  . .     13 

-  ancemia  in  ..      329,  679 
I  -  ascites  in  ..         45,  51 

-  axillary  glands  afTccted 

by       380 

]  -  bronchiectasis  from      . .  292 

-  bronchus  stenosis  from     292 

-  cervical  glands  enlarged 

from    . .         . .         . .  371t 

-  fibroid  lung  from  . .   292 

-  general     glandular     en- 

largement in  . .       51,  376 

-  luemoptysis  in  . .         . .  287 

-  hiccough  from    . .  .  .    30< 
Lymphadenoma.  Hodgkin's 

disease  and    . .     377,  635 

-  inguinal  glands  enlarged 

-  jaundice  in        . .      325,  329 

-  lachrymal  glands  enlarged 

in         695 

~  lai^e-cellcd  hyperplasia  in37ii 

-  ieucopenia  in     ..  ..301 
'  —  liver  changes  in. .  ..   371 

-  -  enlarged  in     , .      329,  37 1 

I  -  lymphoma  an.I . .  ..    377 

I  Lymphadenoma.     lympho- 
sarcoma and  ..     377,  635 

-  Miculicz's  syndrome  in     6it.'» 

-  myelocytes  in    . .  . .      2;* 

-  occipital      glands      en- 

larged in        . .         . .  378 

-  orthpncea  in      . .         . .  419 

-  pleuritic  cITusion  in      . .  106 

-  porUd  glamis  enlarged  in 

45,  51.  325,  329 
I  -  purpura  in         . .  . .  563 

-  pyrexia  in  . .  . .   679 

-  salivary  glands  enlarged  695 
~  simulating        malignant 

peritonitis       . .  . .     51 

spleen   enlarged    in    51, 

,^29,  679 
thrombotic  infarction  In  OlU 
ulous  glands  slmu- 


latii 


idy^i^fnini  l\t:> 
Lymphangioma       circum- 
scriptum . .  756 
~  of  cord,  livrniaitinuilulcd 


by 


082 


Lymplnuigitis,  blublwr  Iip4 
from Om 

-  from  dissection  wounds    240 

-  prj'thonia  from  . .  . .   222 

-  of  penis  . .         . .         . .  473 

Lymphatic    glandx,   abdo- 

mintU,  oiilarged,  CJiw- 
ouH    tlionu'ic    Rlaudif 
with  ..  ..  308 
in  UiMgkin'* 


6r..'i 


-  -        -   lyr.iphadn .i.  .       *■  I 

Lymphatic  glands,  axillary, 
anatomy  of    .  ■  .666 

Lymphatic  glands,  axillary, 
enlarged  . .  380 


LYMPHATIC   GLANDS 


Liniiphaiic  glands,  contd. 

Lympliatic  glands,  contd. 

Li/mphatic  glands,  contd. 

Lymphatic  glands,  contd. 

-'-  axillary,  enlarged,   in 

cervical,       enlarged. 

femoral,      enlarged, 

mediastinal,    caseous. 

German  measles    . .   238 

inflammatory        . .  379 

from  pediculosis    . .  679 

vagus  nerve   irrita- 

 from  herpes      . .  431 

in  Kirklaud's  dis- 

 syphilitic           \  .  679 

tion  by    308,  703,  70' 

Hodgkin's  disease 

ease      . .      379,  615 

from  truss          . .  679 

x--rays     in     dia- 

(Fig. 168) 

lichen    scrofulo- 

tuberculous        . .  679 

gnosing           . .  70^ 

377,  5G9,  635 

sorum  with    . .  488 

hernia  sunulated  by 

Lymphatic  glands.   Medi- 

 leuksemia           . .     yl 

in  leukiemia      . .     51 

679,  680 

astinal,  enlarged       . .  381 

lichen     scrofulo- 

lymphadeuoma 

suppurating            . .   679 

ill  Hodgkin's  dis- 

sorum with    . .  488 

61,  379 

Lymphatic  glands,  general- 

ease    . .          . .    66P 

in  lymphadenoma 

lymphatic  leukje- 

ized    enlargement    of, 

pressure  signs  from  381 

31,   380 

■    mia     . .          . .     26 

list  of  causes  of        . .  376 

simulating  aneur- 

 lymphatic  lenkje- 

lymphosarcoma. .  379 

Lymphatic   glands.    Hodg- 

ysm    ..          ..381 

mia     . .          . .     25 

mumps  simulated 

kin's.  characters  of. .  377 

mediastinitis  . .   361 

from  mastitis     . .  686 

by        ..          ..617 

Lymphatic   glands.    Hodg- 

 new  growth   . .   381 

pnirigo    . .          . .   490 

from  otitis  media  379 

kin's,    distinguished 

3:-rays     in      dia- 

 from  septic  absorp- 

 pediculosis      379,  647 

from  tubercle. .        .380 

gnosing           . .  381 

tion      . .          .  .   380 

peptic  ulcers     . .   740 

iliac,  i-aleareous.  simu- 

 malignant,        vocal 

tubercle  . .      378,  380 

scarlet    ffvcT    1ft. 

lating  stone  iiiureter  455 

cord        paralysis  - 

tuberculous  breast  686 

■-■•:s,  r.T'.i.  617 

connections  of       . .  679 

from        ..         ..  495 

pain  in  arm  from  . .  443 

Lymphatic  glands.  cervicaL 

enlarged     . .          . .  676 

sarcoma  of. .         . .   761 

-  -  bronchial,  caseous,  age 

enlarged,    sources    of 

appendicitis  simu- 

- -  mesenteric,  caseous  ..     48 

ineiaeiicf  nf           .  .   385 

infection  causing      ..  617 

lated  by      459,  677 

.adhesions  from. .  13( 

Lymphatic    glands,    bron- 

 spinal   caries  and  516 

malignant      381,  480 

bands  from       . .   13( 

chial,  caseous,  brady- 

stiff-neck  from  . .  647 

swelling  in  right 

iiitestinal  obstruc- 

pncBa from     . .         81,  85 

from  tonsillitis  .  .   647 

iliac  fossa  from  665 

tion  from        . .    130 

bronchiectasis 

Lymphatic  glands,  cervical. 

tuberculous        . .  677 

Lymphatic    glands,     mes- 

from   . .          . .   292 

enlarged,  tuberculous 

inflamed. causes  of  459 

enteric,  enlarged      ..  381 

seen  with  the  bron- 

379, 378 

pain  in  iliac  fossa 

in  Ivmpliatism   .  .    382 

choscope    (Fig. 

with    tubf-rculous 

from  452,  454,  459 

tulic-rculous     381.  657 

68)       ..          ..   158 

peritonitis      . .     48 

pyrexia  from     . .  459 

Lymphatic  glands,  occipital. 

bronchus  stenosis 

inflamed,  dysphagia 

rectal  examitiation 

enlarged                    .378 

from    292,  381,  704 

from        ..         ..617 

for        ..          ..   459 

ill  ilcrman  measles 

(.Fiff.  61)..          ..   149 

sore  throat  from 

swelling    in    iliac 

228,  377,  378 

in  chUdren        . .     85 

613,  617 

fos^a  from      . .   459 

in  syphilis      377,  378 

couRh  from       . .  149 

torticollis  from  . .  142 

Lymphatic    glands,     iliac. 

pelvic,  enlarged,  from 

difficulty  in  dia- 

 lymphadenomatous. 

tuberculous    . .         ..  459 

carcinoma  of  bladder 

gnosing          . .  385 

orthopnoea  from 

-  operation   in  dia- 

472, 579,  680 

fibroid  lung  from  292 

418,    419 

gnosing            ..   459 

recti     - .          . .   58J 

general    tubercu- 

 trachea  obstructed 

tuberculous    cae- 

 malignant          . .  381 

losis  from      . .  385 

by       ..         ..418 

cum   simulated 

rectal  examination 

-  hjemoptvsis  from  287 

malignant,      ortho- 

by        ..         ..459 

in  detecting  381,  472 

hiccough  from  307  308 

pncea  fi-om     418,  419 

von  Pirquet's  re- 

  ~  from  testis  growth  696 

irruption  into  bron- 

 stridor  from      . .   651 

action  with    . .  459 

obstructed,  cbyliuria 

chus    381,  420,  644 

trachea  obstructed 

a:-rays      m      dia- 

from       . .         . .     2f 

into  trachea  . .  418 

by       ..         ..418 

gnosing           . .  459 

popliteal,  enlarged  . .  692 

marasmus  from. .  385 

vocal    cord    par- 

 inflamed,  abscess  from  381 

from  septic  absorp- 

 from  milk          . .   385 

alysis  from    ..  495 

pain  over   . .          . .   381 

tion     ..         ..382 

obstructing 

sarcoma  of            . .  380 

pyrexia  from         . .   381 

suppurating           . .  69- 

trachea           . .    157 

tuberculous,    lar3m- 

reddening    of    skin 

portal,         enlarged. 

orthopnoea  from    418 

gealparalysisfrom  496 

.mr         .  .          .  .    381 

ascites  from  46,51,32' 

■ —  phrenic  nerve  irri- 

 ulceration  of      . .   379 

Lymphatic  glands,  inguinal. 

bile-duct  obstruc- 

tation by       ..   308 

ulceration  of  malig- 

anatomy of      .           .679 

ted  bv            51,  325 

simulating    diph- 

nant       .  .          . .    380 

Lymphatic  glands,  inguinal, 

carcinomatous  45, 

theria  . .         . .  157 

LYIVIPHATIC  GLAND  EN- 

enlarged                  . .  381 

.-.1.      326.     3 -J  9, 

tachycardia  from     85 

LARGEMENT               ..  376 

by  carcinoma  184, 

:;:;ii,  :'.M,  381 

vagus  nerve  irri- 

 lilui-Hl-r.iuntiiidiffer- 

381,  585 

Lymphatic   glands,    portal. 

tation  by       . .   308 

eiitiating             .  .   37i; 

Kith  chancre  618,  700 

enlarged,  jaundice  from 

.7-r:iv5  in  diagnos- 

in   chloroma       205,  556 

from  .•pithclioMia 

60,  325.  329,  330 

in-        ..        85,149 

generally,  in  Clerman 

r.l'.l,  C-Jl.  li'.lj.  700 

leukaemic   45,  61, 

crft:iccous     hgemo- 

measles  . .         . .  228 

Lymphatic  glands,  inguinal, 

325,  330 

litvMS  from        ..    287 

in  plague            . .   378 

enlarged,   general  ac- 

 lymphadenomatous 

Lymphatic    glands,    bron- 

Still's  disease  35,  378 

count  of                    ■ .  679 

45,   51,  329 

chiaL  enlarged         ..  381 

syphilis  240,  491,  618 

in  German  measles  228 

from    lymphosar- 

-  -    -  l.rniulm^      nli- 

tuberculosis       . .  378 

from  herpes    431,  754 

coma  ..          ..329 

Mnwm\  liv    ..   376 

in  Hodgkin's  disease 

in  Hodgkin's  dis- 

 malignant,  ascites 

in  Hodgkin's  dis- 

?,7. 5.5,    64 

ease      ..      569.  635 

from    . .          45,  60 

ease     ..          ..669 

Lymphatic  gland  enlarge- 

 leukajmia          51,  679 

bile-duct      ob- 

 in  lymphatism  . .  382 

ment,  localized         . .  378 

-  lymphadeuoma 

structed  by       5( 

systolic  bruit  over 

-  T  -  Icukieniia       66,  64.  570 

51,  679 

jaundice    from 

manubrium  from  91 

lymphadenonia     , .     64 

lymphatic       leu- 

60,  325 

T-rays  in  detecting  376 

lymphatic  leukteraia  556 

k.-Emia             ..     25 

portal  vein  ob- 

 inflamed,  cough  from  149 

multiple  benign  sar- 

 melanotic        sar- 

structed    by 

-  -  carotid,  pidinjid  from 

coid        ..          ..   405 

coma   ..          ..381 

45,  60,  51 

.■|iin,,ll,,i„,<              ..   738 

in  mycosis  fungoides  731 

prurigo    . .         . .  490 

sarcomatous       . .     51 

c;),-''ii',                          ,'i.  in"  - 

pleuritic    effusion 

from  sarcoma    . .  680 

tuberculous  45.  51,330 

■    ,;::i.  385 

with        . .          . .  106 

scrotal  chancre. .  621 

posterior  cervical,  en- 

 |iiTh"i(.-  hi.!   11,1111    308 

svpliilides  and       . .  560 

septic   absorption  381 

larged    in    German 

,,yrr    -M     Ilnn,                ..      704 

from  tiii.-a  .■irLiiiata  249 

in  sleeping  sickness  28 

measles        . .          . .   562 

scr.ilnl.Kl.rniui  will.  4113 

Lymphatic     glands,     epi- 

from  soft  sores  . .  617 

mediastinal,  second- 

 a--r:ivs  ill  ilifiL-nosinu' 

trochlear,  enlarged   ..  380 

syphilis  . .      184,  377 

ary  deposits  in..   109 

S.-..    ll'.P,  .MIS.  l.".ll.  7111 

with  i.nlinti^     ..      36 

trypanosomia.sis       28 

Lymphatic '  glands,    pre- 

- -  cervirul.     carcinoma- 

  from  digital  chan- 

 tuberculous       . .  378 

auricular,  enlarged  ..  378 

tous 196 

cre       . .          . .   381 

inflamed,    limping 

from    chancre   of 

Lymphatic  glands,  cervical, 

in  Hodgkin's  dis- 

from       . .          . .   363 

eyelid  .  .          .  .   379 

enlarged                   . .  379 

ease  (Fiij.   168)  377 

from  soft  sore  . .   619 

epithelioma        ..   378 

from  boil           . .  647 

rheumatoid  arth- 

 suppurating           . .  680 

melanotic  sarcoma  379 

carious  tooth     . .   647 

ritis      ..      343,  378 

lumbar,  enlarged,  from 

rodent  ulcer      . .  37.' 

—  caseous     thoracic 

from    septic    ab- 

carcinoma 480,  585,  696 

septic  absorption  378 

glands  with     . .   308 

sorption          . .  380 

mastoid,  inflamed     . .  203 

sepsis      . .         . .  695 

Lymphatic  glands,  cervical. 

Lymphatic  glands,  femoral. 

Lymphatic    glands,    medi- 

 syphilis  . .         . .  695 

enlarged,  epithelioma- 

anatomy  of    . .           .679 

astinal,  caseous,  notes 

tubercle             . .  695 

tous 380 

Lymphatic  glands,  femoral. 

on       704 

puncture  in  diagnosis 

ill  1. . Til lliL-;isk-s -Lis 

enlarged                 381.  675 

phrenic  nerve  irri- 

of trypanosomiasis      28 

Ho.ii;kiii'5  disease 

Iron,  bites           ..   679 

tation  by        . .  308 

retroperitoneal,  secon- 

376, {Fill.  168) 

epitiieliomatous 

tachycardia  from 

dary  deposits  in  7, 

377,  569,  635 

079,   738 

703,  704 

381,  749,  750 

LYMPHATIC  GLAXUS  —  MALTA  FEVER 


ijinpl'ulif  ijlamfs.   ronlii. 

ymphatic     glands,     sub- 
maxillary, enlarged  . .  £ 

in    diphtheria    . ,   i 

epithelioma     379,  i 

lichen    scrofulo- 

sorum  with    . .  < 

from  quinsy       . .  ; 

in  scarlet  fever. .  ; 

from  septic  absorp- 
tion    ..        ..  ; 

suppuration  of  . .   i 

from  totisillitis  . .  I 

—  suppurating,    leuco- 
cytosis  with  . .  I 

-  septicaemia  from  . .  i 

-  prolonged     pyrexia 

from        . .         . .  ' 
.ymphatic   glands,   supra- 
clavicular, enlarged  . .  ', 

carcinoma  ooU  . .   i 

of  rectum 

stomach      317,  i 

epithelioma 

.ymphatic    gland,    supra- 
clavicular,   enlarged 
malignant  iJ-'"r.  ]'.).. 


left. 


11)7, 


-  thoracic,    enlarged    in 

Hodgkin's  disease. .  C 

leuksemia 

lymphadenoma 

-  tuberculous,  age  inci- 

dence of      . .         . .  3 

anajmia  with 

from  milk  . .         . .  3 

obscure        pyrexia 

from        . .         . .  5 

phthisis  rare  with, .  3 

leukn^inia  fsee  Leuksamia ; 
and  Leukasmia,  Lym- 
phatic) 
obstruction,    from    car- 
cinoma mammai       . .   4 

—  elephantiasis  from    . .  4 

—  by  filaria        . .         . .  4 

—  cedema  from..         ..  4 
of  arm  from  . .  4 

-  after  operation  . .   4 
l^ymphatics.      abdominal. 

obstructed,       chylous 

.hvluria  from 

Lymphatlsm.    general    ac- 
count of  ■■  S 
Lymphocytes.    In    cerebro- 
spinal fluid    ii".  305,   S 

-  "    -    in    :''-ii'T;i1    ].  ir..l\^is 

■-•l.'i,  3 

t.ilH.;  ..        11(1,   -1 

■  in   Ho.iL'kiii's  diseiLse   .. 
Lymphocytes,  large,  charac- 
ters of 

-  -  (Plate  If,  Fig.  j)     .. 

-  -  increased     in   malaria 

335.  381,  3G2,  530, 
096,  ( 

-  -  in  lymphatic  Icuksemla 

-  relative  numbers  of. . 

-  in    leukaimia      04,  274,  ( 

-  lymphatic  leukaemia     . .   i 

-  myelocytes  simulating. . 

-  numerous  in  children  . . 

-  in  pleuritic  efTunton      . .  1 

-  Bmal!        . .  (Plate  V) 
^   -    in   :is(iti.:   Ilitid 

Lymptiocytes,  small,  charac- 
ters of 

-  -    iTi  lLHik;«:niia   .. 

lymphatir  I«.'ukaimia  25, 

pernicious  anaimia  ... 

relative  numbers  of.. 

-  -   in  tv|-l>ni,i  U\iT     :J»11,  ) 

Lymphocytes,  transitional 


Lymphoma,    genernlizod 
iymph-gland    onlarge- 
ment  in  ..         ..  : 

-  Tlodgkin'a  disease  and. .  : 

-  lympliosarcoma  and    . .  i 
Lymphosarcoma  of  cnscum  ^ 


Lymphosarcoma,  contd. 

-  cervical  glands  enlarged 

i  from 2 

:  -  chloroma  related  to     . . 
\  -  eosinophilia  from         . .  ' 

-  generalized  lymph-gland 

<  Lymphosarcoma.  Hodgkin's 
disease  and    ..     377,  t 


-  port;U     L'l^irids     enlarged 

from    . .  . .  . .   ; 

-  swellings   in    abdominal 

wall  in  . ,         . .  I 

Lysis  in  pneumonia 

-  tj-phas  fever  (^Fig.  268)    i 


McBURNEY'sspot  451,454 
McCall    Anderson, 

psoriasis  rupioide-s  of  601 
Mackenzie,  on  extrasystoles  547 
Mackenzie    polygraph,    in 

heart  cases  . .  544 

Miicmillan  &  Co.,  Messrs., 

blocks  lent  by  . .  235 

Macrocheilia  . .  . .   698 

Macrocvtes  {Plate  11^  Fig.  B)  22 
Ma<:roglossia  . .  . .   698 

Macula,  cherry-red  . .  416 

-  white  patches  at  ..  416 
MACULES 382 

-  in  erythema  multiforme  489 
fourth  disease  . .  229 

-  Oernian  measles        228,  562 

-  hjemosiderin  in . .         . .  382 

-  in  herpes  . .         . .  383 

-  lentigo 382 

-  leprosy    . .         . .      383,  4U3 

-  Uchen  planus     . .         . .  383 

-  measles   ...         .  -      228,  562 

-  pityriasis  rosea. .         . .  383 

-  syphilides  . .  . .   560 

-  syphilis  {Fig.  170)         . .   383 

-  tinea  versicolor..         ..  .t83 

-  types  of .•582 

-  in  typhoid  fever  . .   382 

-  xanthoma  . .  . .   383 

-  xeroderma  pigmentosum  383 
Madura  foot  . .  736 
Magnan's  sign  . .  611 
Magnesium    in    intestinal 

sand 599 

-  phosphate,  deposit  of  . .  524 

needles  of      . .         . .  524 

solubility  of  . .         . .  523 

urine  cloud  from       . .       4 

-  rect.ll  concretion  from . .  718 
1  Main  bote,  in  Friedreich's 

I  dis.-:.M.  ..  ..  140 

MAIN-ENGRIFFE  ..    109 

-  r:uMl-.-i1;.u-h:ind) 
Main  snivuleiite,  in  syringo- 

'  myelia  ..  ..110 

Maize,  pellagra  and  . .  226 
Malaise,   from   abscess   of 

liver 597 

-  in  ocute  yellow  atrophy  273 

-  from  phthisis    . 

-  in  poliomyelitis. 


Malaria^  wntd. 

-  cachexia    in    4,   13,   33, 

173,  374,  313,  413,  415 

-  characters  of  attack  of    30 

-  chattering  teeth  in       . .     30 

-  Cheyne-Stokes      breath- 


. .   140 


t'uta 


509 

-  from  polymyositis        . .  464 

-  pyelonephritis    . .  . .   355 
Malar  lliish  iu  mitral  sten- 
osis     . .           53,  485,  701 

myxnedema  (Fig.  104. 

p.  234)         . .        38,  400 

-  process,  enlarged  in  acro- 

megalv  . .         •  -  237 

Malaria,    abscess   of   Uvor 

simulated  by..         ..  335 

-  acetonuria  from  . .       4 

-  acute  congestion  of  liver  331 

-  ttMtivo-autumnnI,      crcsi- 

rcntic  parasites  in  ..     31 

-  albuminuria    In    13,   31.    273 

-  olgiditv  in  ..  ..30 

-  auiumi'a  in     21,  29.  33,  037 

-  ascites  in  . .         ..     40 

-  bluckwatcr  fever  and  . .  28 1 

-  blood  chnngCH  in       271,  037 
oTaminnllon  fn         . .  273 

fllTiil  in  dlognofling  . .  335 

-  brncbiul  neurul(;laaiid..  412 


diill  i 


ol.l  st;i 
oIla,,sc 


iOf 


. .    173 


. .     30 

..30 

..    -  30,  117 

-  death    from,   symptoms 

preceding 

-  diazo-reaction 

-  double  tertian  . .         . .     30 

-  English 574 

-  eosinopliilia  after  . .  21S 

-  erythema  in       ..      222,  225 

-  exhaustion  in    . .         . .     30 

-  in  fen  districts  . .         . .  632 

-  Qushing  of  face  in  ..     30 

-  ganuTcne  frotii  .  .  . .    255 
Malaria,  general  account  of 

29,  30 

-  general  wasting  from  . .     59 

-  hfematemesis  in  265,  273,  274 

-  hsematuria  in    . .      273,  275 

-  bffimoglobinuria  in       . .  284 

-  headache  in       . .         . .     30 

-  hot  stage  of       - .         . .     30 

-  hyperacusis  in  . .         . .  309 

-  hyperpyrexia  in  30,  309 

-  impotence  from  . .  313 

-  in  Italy 632 

-  jaundice  in       273,  325,  335 

-  kala-azar  confused  with     29 
distinguished  from  . .  633 

-  large  lymphocytes  in  335, 

361,  362,  536,  .596,  037 
mononuclear  cells  in. .  568 

-  latent      . .  . .  . .     32 

-  no  leucocytosis  in    335, 

361,  536,  568,  506 

-  leucocytosis  rare  in      . .  360 

-  Icucopenia  in    .361,  362,  370 

-  kuikaimia  simulating  . .  273 

-  liver  abscess  simulating 

361,  362.  370 

-  loss  of  weight  after       . .    770 

-  meiiorrhagia  from         . .   386 

-  mosquito  bites  and       . .     29 

-  nephritis  from  . .         . .       9 

-  oedema  of  legs  from  413,  415 

-  overwork  causing  attack    32 

-  pains  in  the  back  in     . .     30 

eyes  in  446 

limbs  in  . .         . .  403 

-  panisitcs  of  (Plates  I'/, 

XXVIII)    32,  014 
absent  after  quinine. .  335 

-  -  in  blood  in    27,  29,  31, 

32,    61,     225,     334, 

630,  508,  596,  037 

-  peripheral  neuritis  in  61,  04 

-  pernicious,  yellow  fever 

simulating      . .         . .  336 

-  pigment  granules  in  urino    81 

-  pigmentation  of  skin  . .  528 

-  polyuria  in         . .      535,  580 

-  prolonged  pyrexia  in  503,  508 

-  pur|iura  in         . .         . .  503 

-  )iyn3mia       dlstingubtlied 

from    . .         . .         . .  590 

-  rvvri'xiii  in  . .      335.  574 

Malaria,  pyrexia  In.  types 
of  . .  28.  29,  30 

-  qujtrlJMi   . .  . .  . .      2P 

ring  form  of  parasite  In     81 

-  quinine  in  5.30.  590,  037 

-  -  in  diagnoHing. .        31,  508 

-  quotidian  ..  29,  30 

-  relation  of  piru  to  . .     9U 

-  rlgont     in    29,   30,   235, 

591,   595.  590 

-  ring  and  crcwx-nt  formii 
I  of     (Plnlm     VI      and 

'  XXVnt.  p.p.  32.611)    31 

-  Ktrpticniniiu  Kitntilalod  by  508 

,  Malaria,  spleen  enlarged  In 

I  273.  27  1.  5i;S.  631 .  632.  637 

-  Hph-nlc     ar.ii'mi.i     J*lniu- 

laldig 278 

-  ftwealing  in        . .        30.  508 

-  tomppraturo  rlinrt«  in  28, 

29.  80,  ni 


Malaria,  contd. 

-  tenderness  of  scalp  in 

-  tertian    . .         . .         . . 

and  quartan  parasites 

distinguished 
ring  form  of  parasite  in 

-  thyroid  gland  enlarged  iu  7: 

-  tinnitus  from    . .         . .  7; 

-  in  tropics  . .         . .  6i 

-  types  of 5! 

-  urobilinuria  in  . , 


712 


. .  30 

-  worry  causing  attack  . .  32 

-  yellow  fever  simulating  27ii 
Male  fern.  Jaundice  from.  .  .'J'.'.* 
Malformations   of   rectum 

(/■•(■//.v.  249-252)  .  .    586 

Malignant  disease,  aceton- 
uria from        . .  . .       4 

amenorrhcea  in         . .     IS 

anaemia  from..         ..     33 

cachexia  from    4,  S3,  17S 

chylous  ascites  from      50 

chyluria  from  ..     50 

diazo-reaction  in      ..  173 

(and  see  under  Carci- 
noma, Sarcoma,  etc.) 

-  peritonitis    (see    Perito- 

nitis, Maligiumt) 

-  pustule,  erythema  from  222 
Malignant  pustule,  general 

-  account  ot  . .  559 

-  -  (and  s«-e  Anthrax) 
Malin-orcrs,  pyn-xia  and. .   31^ 
Malingering,  aneurysm  simu- 
lating . .      432,  467 

-  anuria  and         , .         . .     42 

-  buIliB  in 97 

-  carcinoma  simulating  ..  407 
of    spine     simulating 


432,  714 


A'eat  and 


Malingering,  convulsive  fits 


In 


147 

.  .    IOC 


-  deafness  in 

-  epilepsy  simulated  by  . .  137 

-  erythema  from  . .         . .  222 

-  by  external  applications  223 

-  fatigue  in  . .         . .  59;i 

-  foaming  at  mouth  in  ..  147 

-  haimatemesis  and     205,  206 

-  homioptysis  and  . .  2St*. 

-  hysteria'      distinguished 

from 350 

-  insomniaand      ..      321.  323 

-  ligature  and  cedema  from  411 

-  localized  convulsions  in  144 


-  pami>Ici.'i(i  ill     . .      51' 

,   SIS 

-  perspiration  in  . . 

.    117 

-  photophobia  and 

.  riL'f. 

-  pur|>ura  from    . . 

-  (lUivcrinR  eyelids  in 

.    IM? 

-  risun  sardonicus  in 

.    f.ilK 

-  stertor  in 

.    117 

-  trismiiH  in 

.   "L"J 

Mallein,  in  ilini;nosing  (.'lui 

SO 
UatprcsentJktinntt,  dystocia 

from 200 

-  early  riiplure  of   mem- 

branes from  . .  . .  mio 
Malt  lii|ilors,  obesity  from  -lOH 
Malta  fi'vcir  (and  see  Medi- 

UTrnni'an  fever) 

-  -artlirilis  in     ..      310,  .|«(1 

bacterimmia  In  . .  oDT 

broiirhitis  in  . .  . .    inC. 

constipation  in  , .    Itit; 

continued  fever  in    . .    ItKi 

-  -  ilobillty  ill      . .         . .    lilil 
Kii-lrii'  svniplonis  in.  .    llU'i 

Milti  lever,  generil  account      ' 


-  Iieiidii.'lie  in   . . 

-  In  MeillterrnniMiii      . .  < 

-  inii'rm-occus  melltunNU 

and  . 


inil 


o-on^nlsin  of  fseu 
Mli'mcoiTuii     Mell- 

teiisis) 
nnhltlH  in  ..    1*10 

piilii  In  lliniM  In  IU»,  Inn 
liemplratlonH  In  . .  'Kin 
rik'or  rare  in  . .         . .  Mi.'i 


MALTA  FEVER 


MEIGES   DISEASE 


Mulla  fever,  contct. 

serum  reaction  in     . .   ■ 

spleen  enlarged  in  "166, 

632, 

Mamma  (see  Breast) 

Mammary  abscess  (see  Ab- 
scess*, Mammary) 

Manchester  epidemic,  ar- 
senic in  beer  in       66,  . 

Mania,  acute,  fi-om  plumb- 
ism      . .         . .        34,  '. 

saturnine  encephalo- 
pathy . .         . .  ' 

^  delirium  in         . .         . .  : 

-  dilated  pupil  from       . .  i 

-  after  epileptic  fit  . .  : 

-  hearing  of  voices  hi    . .  ■ 
~  homicide  from  . .         . .  ■ 

-  insomnia  from  . .  . .  ; 

-  nocturnal,  from  old  age  : 
Mannerisms  . .  . , 
Manson.  on  dhobie's  itch. .  : 
Manubrium,  systolic  bruit 


MARASMUS  ..  : 

-  from    caseous    bronchial 

glands  . .  . .  ; 

-  congenital  syphilis  . .  ; 

-  defective  feeding  . .  ; 

-  definition  of      . .  . .  ; 

-  from  diarrhcea  . .  . .  i 

-  dht       ; 

-  gangrene  from  . .         . .  : 

-  general  wasting  from  . . 

-  hernia  of  lung  in  . .  ; 

-  hypothermia  from         . ,  I 

-  keratomalacia    witb      ..  ', 

-  from  rickets        . .  . .  J 

-  tuberculosis       . .         . .  ; 

-  vomiting  . .  . .  ; 
Marie,  on  spondylose  rhizo- 

mfilique  . .      714,  ' 

Marriage,  anaemia  cured  by 

-  gleet  in  relation  to       . .    I 
Marrow,  hyperplasia  of  . .  ' 
Marsh  cachexia     . . 
Marsh's  test  for  arsenic   . . 
Massage,  insomnia  relieved 

by      : 

-  in  lowering  liigh  blood- 

pressure         . .         . .  ; 

-  for  ccdema  of  legs         . .  ■ 

-  in    prevention    of    con- 

tractures       . .         , .  : 

-  of  prostate,  in  detecting 

prostatitis      . .         . .  : 

-  rheumatism  relieved  by  ' 

-  in  rlieumatoid  arthritis  ; 
Masseter  muscle,  paralysis 


493, 


Masscters,  atrophy  of, 

bulbar  paralysis 
from  cerebral  tin 

Masti.-;i(iuii,aini.Mlty 


lating  . .  . .  . .   ( 

fibro-adenoma     simu- 
lating , .         . .  I 
Mastitis,    chronic,    general 

account  of  . .  I 

-  cyst  formation  with  181,  ( 

-  pain  witli  429,  430,  ■ 

-  pus  from  nipple  with  . .   : 

-  serous  discharge  from..   : 

-  tenderness  from  . .   ' 
Mastodynia           . .     430,  t 
Mastoid  abscess  (see  Ab- 
scess, Mastoid) 

disease,  cerebral  abscess 
from    , .         . .         . .  ; 

-  —  headache  from  . .  : 

-  oedema  over      ..         . .  ! 

-  process,  enlarged,  in  acro- 


tender. .         ..      202,  i 

-  swelling,  from  cavernous 

sinus  thrombosis      . .  : 
Masturbation,        priapism 

from I 

Matches,     phosphorus     in 

making 
poisoning  from  . .  : 

-  in  urethra  . .         . .  : 


Measles,  albuminuria  in  . .     13 

-  albumosuria  in  . .  . .      Ifi 

-  arthritis  with     . .  . .    340 

-  cancrum  oris  after        . .     74 

-  coma  in 117 

-  common  cold  simulated  228 

-  convulsions  from  . .   144 

-  coryza  in  178,  384,  446 

-  cough  in 384 

-  deafness  from    . .         . .  166 

-  delirium  in  . .  . .   169 

-  diagnosis    from    scarlet 

fever   . .         . .         . .     14 

-  diazo- reaction  in  . .    173 

-  diphtheria  with. .         . .  199 

-  empyema  after  . .         . .  597 

-  eosiuophiha  after  . .   218 

-  epistaxis  in        . .         . .  221 

-  erythema  m       . .      223,  228 

-  febricula  representing  . .   464 

-  fourth  disease  simulating  229 

-  gangrene  from  . .  . .   255 

-  German     (see     C4erman 

Measles) 

-  haemoptysis  in  .  .  . .   287 
Measles,  koptik's  spots  in 

[/•/a/r  VIII)    178,  228 

-  I.n\  iiL'ril  .Instruction  in  418 
'  .i\.,  -11   -    M        ..      199,  418 
360 


-  nasal  discharge  from   . .   '. 

-  oedema  of  face  from  413,  • 

-  ortliopncea  in    . .  . .   ' 

-  pain  in  the  eyes  in       . .  ' 
limbs  in         . .         . .  ■ 

-  peroneal    atrophy    after 

60,  i 

-  photophobia  m..         ..I 

-  purpura  in  . .       553,  i 
~  rash  of    . .  . .  . .   : 

-  rigor  in  and  after      595,  i 

-  scales  in  . .         . .  ( 

-  scarlatina  simulated  by  ; 

-  simulating  common  cold  '. 

-  syphilis  simulating   383,  ; 

-  talipes  after       . .         . .  ; 

-  thrombosis    of    cerebral 

veins  after     . .         . .  : 

-  tuberculous    meningitis 

after ; 

Meat,    distaste   for,    from 
carcinoma  of  stomach 

43,  ; 

-  fibres  in  faeces,  in  chronic 

pancreatitis    . .       116,  : 
Meatus  auditorius,  exosto- 


562 


Media stinitu.  contd. 

~  clubbed  fingers  from    . .  Ill 

-  hiccough  from  ..  ..   308 

-  pain  in  the  chest  from. .  430 

-  pericarditis  preceding  . .  308 

-  pleurisy  preceding         . .   308 

-  from  syphilis  (Fig.  303)    749 

-  varicose  abdominal  veins 

from  (Fig.  303)  . .  749 

-  (and    see    Mediastinum, 

Fibrosis  of) 
Mediastino-pericarditis     ..  435 

\i-  ■<■".   Mt/i.liastinal) 
■■  :ni-'ii]\  -111  lr;.king  iuto..   120 


435 


(and  see  Ear) 

-  urinarius,  reddened,  from 

gonorrhoea 

small,  enuresis  from. . 

frequent  micturition 

Meckel's  diverticulum,  in- 
testinal  obstruction . . 
Median  nerve         . .      504, 
Mediastinitis,  acute,  pain  in 
the  chest  from 

sternal       crepitations 

with 

-  from  acute  rheumatism 

-  chronic,  after  pericarditis 
with     adherent    peri- 
cardium 

adherent  pericardium 

part  of 

ascites  from  . . 

Bright's  disease  simu- 
lated by     . . 

enlarged     mediastinal 

glands  simulating. . 

fibrous,  vena  caval  ob- 

?tru<-tion  from 

Mediastinitis,  chronic,  gene- 
ral account  of 

oedema    of    face    and 

arms  from  . . 

after  pleurisy 

from  polyorrhomenitis 

rheumatic  52,  54, 

tuberculous    . . 

vena  cava  obstructed 

by    ..         ..        53, 
inferior     obstruc- 
tion by 


-  fibrosis     in,     aneurysm 

simulating      . .  . .   159 

cyanosis  from  . .  169 

growth  simulating    . .    159 

cedema    of    face   and 

arms  from  . .         . .  159 

from  . .         . .  415 

palpitation  from       . .  485 

pneumogastric  ■    irrita- 
tion from   . .       703,  704 

tachycardia  from   703,  704 

vena  cava  obstructed 

by        52,  159,  415, 

673,  751 

vocal    cord    paralysis 

from  . .  . .   495 

3--rays  in  diagnosing. .  159 

(and  see  Mediastinitis, 

Chronic) 

-  gumma    in,    vena    cava 

obstruction  by  . .  415 

~  haemorrhage  into  . .  159 

-  hydatid  cyst  in         476,  751 

-  lesion  of,  t-enderness  from  706 

of  sternum  from  . .  708 

a:-rays  in  diagnosing. .  708 

~  lymphadenoma  of,  hic- 
cough from    . .         . .  308 

Mediastinum,  growth  of  .  ■  104 
"  -  ansemiafrom  434,435 

aneurysm     simulating  435 

arthritis  simulated  by  476 

ascites  from    . .  46,  52 

blood-stained  eflfusion 

from  . ,      102,  105 

bronchiectases  from . .   292 

bronchus  obstructed  by 

104,  292,  308 

cachexia  from        434,  435 

cervical     sympathetic 

affected  by         . .   654 

clubbed  fingers  from. .  Ill 

cough  from     . .  . ,   434 

dyspnoea  from  . .   434 

effpcts  of         . .  . .   102 

eosinophile  corpuscles 

and 102 

fibroid     lung     from..   292 

hsematemesis  fi'ora  265, 267 

haemoptysis  from      . .  434 

heart  displaced    by..  104 

~  -  hiccough  from  , .  308 
intercostal     neuralgia 

suggesting  . .  . .  431 

cedema  from  . .         . .  415 

of  arm  from       267,  411 

face  and  arms  from  413 

legs  from    . .  . .     52 

neck  fi-om  . .  . .   267 

opening  aorta         265,  267 

cesophagus. .      265,  267 

orthopnceafrora      418,419 

pain  down  arm  from. .   434 

Mediastinum,    growth     in, 
pain  in  chest  from  2G7, 

430,  434,   435 

lieail  from   .  .  . .    434 


ck  fro 


434 


-  shoulder  from       . .   476 

■  palpitation  from       . .  485 
pleuritic  effusion  from  104 

■  pneumogastric    irrita- 

tion from  703,  704 

pyrexia       from      435, 

(Fig.  248)  570 

■  secondary    in    supra- 

clavicular fluid      . .  380 
simulating 


asthma 

■  -  -  Brighfs  diseasi 
bronchiectasis 


. .   535 

. .    413 


Mediastinum,  grou'lh  in,  contd. 

simulating       eidarged 

-     mediastinal  glands  38 
epithelioma  of  ceso- 
phagus   . .         . .  26 

fibroid  lung  . .   10 

phthisis       . .      104,  26 

skodaic  resonance 

from  . .         . .  61 

spine  eroded  by       . ,  43 

stridor  from  . .  . .   65 

tachycardia  from  703,  70 

tightness      in      chest 

from  . .  . .  43 

trachea  obstructed  by 

418,  419,  65 

unequal  pulses  from. .   55 

unilateral  sweating  of 

face  from    . .  . .   65 

varicose  thoracic 

veins  from  104,  308,  41 

veins  invaded  by      . .  26 

vena  cava  inferior  ob- 
structed by  . .     4 
vena    cava     obstruc- 
tion by  52,  104,  J 13, 

415,  419,  673,   75 

vocal    cord    paralysis 

from        . .         . .  49 

voice  altered  by       . .  43 

,a--rays    in    diagnosing 

52.  102,  411,  419, 

435.  461,  47 

Mediastinum,  non-malignant 
tumours  of     . .         . .  75 

-  sarcoma  of  (see  Sarcoma 

of  Mediastinum) 

-  syphilis  affecting  . .  43 

-  tuberculosis  affecting  . .  43 
Medical    Annual,    illustra- 
tions from  327,  58 

Medical  Laboratory  Meth- 
ods, illustrations  from 

519,  520,  521,  64 

-  men,    chancre  of  finger 

in         24 


Medico-legal     aspects    of 

M.'.lncil,  'iir;(,|\-|iini>a  from     S 
Mediterranean  fever,  general 
account  of      ■ .     565.  56 

prolonged  pyrexia  in 

563,  56 

temperature  chart  of  56 

(and  see  Malta  Fever) 

Medulla  oblongata,  de- 
generation of,  from 
alcohol  . .      197,  30 

arterial  changes     30 

haemorrhage  into       . .  49 

lesions  in,  ataxy  from    5 

bulbar         paralysis 

-  from  62,  589,  62 

Cheyne    -    Stokes 

breathing      from 

107,  10 

double     hemiplegia 

from        . .  . .   50 

hiccough  from   307,  30 

laryngeal     paralysis 

from        ..      495,  49 

from  lead    . .  . .   19 

senile  . .         . .  30 

from  syphilis     197,  30 

tongue'atrophyfrom  19 

softening  of,  Cheyne- 

Stokes       breathing 
from  . .  . .   10 

from  thrombosis  of 

posterior    inferior 
cerebellar  artery    61 
tumour  of,  bulbar  par- 
alysis from  . .   62 
Cheyne  Stokes  breath- 
ing from. .         . .  10 

laryngeal    paralysis 

from        . .  . .   49i 

-  sensory  impulses  crossing 

-  vomiting  centre  in       . .  76' 
Mesaloblasts         . .         . .  2: 

-  (Plate  III)         . .         . .  2. 

-  in  pernicious  amemia  . .  31 
Megalocytes           . .          . .  2; 

-  (Plate  IT.  Fig.  B)    _     . .  2: 

-  in  pernicious  aniemin  . .  6 
Meige's  disease  (Fig.  179)  41' 


MEIGES   DISEASE 


MENSTRUATION 


ige's    disease,    general 

Meningitis^  cerebrospinal,  contd. 

account  of 

226 

Cheyne-Stokes  breath- 

- .ivtlit-ma  in  ..       -jn, 

•J2U 

ing  from     . .         . .  108 

-  iri,nle  attacks  in 

414 

-  -  coma  from     . .         . .  117 

EL/ENA  (and  see  Blood 

erythema  in  222,  225,  591 

pur  Anum)     ..        76, 

385 

p:reen  vomit  in          . .  225 

n  acute  yellow  atrophy 

-  -  headache  in  . .      225,  295 

273, 

333 

hemiplegia  from        . .  303 

anaemia  from     . . 

30 

herpes  facialis  in      . .  225 

rom  ankylostomiasis  . . 

531 

hyperpyrexia  in        . .  309 

cirrliosis 

371 

lumbar  puncture  in 

diio>liMKil  ulcer     36,  75, 

147,  225 

271, 

451 

meningococci  in        . .  225 

'rem  L,';tII-stoues    • 

272 

photophobia  from     . .  525 

M-lric-  ul.ii         73,  268, 

269 

--  -  purpura   in  225,   553, 

"    11, ■ l.-s  purpura  .. 

343 

554,  591 

laena  neonatorum 

76 

pyrexia  in      . .         . .  225 

fn)!ii  purt^il  vein  throm- 

pyrcxial  crises  in      . .  566 

IJOSIS     .  . 

272 

relation    of    posterior 

in  small-pox 

272 

basal  to      . .         . .  591 

splcnome^alic       polycy- 

rigidity  of  face  in     . .  729 

thfcmia 

033 

rigor  in            . .         . .  594 

lancholia,  catalepsy  and 

598 

somnolence  iu           . .  225 

learinf?  of  voices  in 

405 

vesicles  in      . .      225,  591 

lish  blood-pressure  with 

81 

-  choroid  tubercles  with. .  307 

nsomiiia  from  . . 

322 

-  coma  from         . .      144,  566 

rrilaliilitv  in     . . 

323 

-  constipation  in  . .          . .   128 

->--  .'1  ;ippetite  and     . . 

43 

-  convulsions    from     120, 

iiiil  i-rjj  ill 

621 

141,145,146,307,511,515 

^in.  iii-  irora 

4115 

-  .l.;.fnf^s  from    ..          ..166 

M    1.  ipirdonabic  sin  in 

405 

-  .hp<  III,  'ii    mi  I  , ken  for  690 

Mil  ! !  1  urine  . . 

374 

-  <h,,         .  ~      :■..■;!            ..  566 

745 

-  ,1,  -1  ■  r  1  ■      ■:   il  iiMl  by  316 

1 1    r-ircinomaof  skiu 

730 

-   .■[,    ipl,  ilin-     -iniulating 

Mrniugitis,  contd.  ' 

-  rigors  rare  in     . .         . .  597  | 

-  simulated  by  otitis  media  202  [ 

-  simulating  sinus  throm- 

bosis     5X1  I 

-  sinus  thrombosis  simu- 

lating . .         1-20,  591,  597 

-  spinal,    atrophy    of    leg  | 

from 499  , 

convulsions  in  ..  138 

crurat         monoplegia 

from 


feve 


.\|fl;inotlc-) 

slanuria,  general  account 
of  . .     745.  746 

'  i  bodies,  in  tcno-  ' 

i(is        ..  ..  152 

lilt    III     propria,    per- 
fon.tion  in      ..  ..423 

tympatii  (see  Tympanic 
Membrane) 

embr.ines,  adherent,  dys- 
tocia from      . .  . .   200 

earlv  rupture  of,  dystocia 
from 200 

cmbranoiis  dysmctiorrhcea 
Csee    Dysraeuorrhoea; 

rhinitis     (see     Rhinitis) 

va^initLs  (see  Vaginitis) 

emory  changes  in  demen- 
tia        l£t 

-  epilepsy  . .         .  -     20 


EMORY.  LOSS  OF        ..     Is  i 

, !..')!    .hrolK.Iism       20,  I 

14G,  465  I 

-  frontal  lobe  tumour. .  727  ! 

^nitirc's  disease,  deafness 


511,  591 


-  foroi^n    body   in   larynx 

mistaken  for  . .  . .    590 

Meningitis,    general    sym- 
ptoms of  . .  590 

-  gununatous,    dysarthria 

from    ..         ..         ..  627 

pain  in  the  face  from  447 

-  headache  from  120,  294, 

315,323,515,525,711,  768 

-  hemiplegia  from  . .  306 

-  hypertension  of  cerebro- 

spinal fluid  with        . .  304 

-  irritability  in     . .      315,  323 

-  Kernig's  sign  due  to    ..  315 

-  leucocytes    in     cerebro- 

spinal fluid  in  . .  305 

-  lumbar  puncture  in  dia- 

gnosing 147,  225,  304, 
307,  315,  417,  439, 
511,    515,    525,    506,    590 

-  in  malignant  endocarditis  567 

-  malignant     endocarditis 

simulating      . .  . .   567 

meningococcal,  age 


'.  of 


304 


fron 


IOC 


•  li-om  syplnl.-.  .  .  .    IGG 

-  lintiitu^  from  . .    723 

-  vertigo  in       . .  . .  708 

-  vomiting  due  to       . .    765 
icningeal  ha)ni()rrhnge(see 

Ilmmorrhage,  Meningeal) 
Icninges,  brunch  of  vagus 

to         ..  ..         ..   14S 

gumma    of,    bradypncca 

from 84 

spinal,  gumma  of,  nllo- 

clieiria  from  . .  . .     17 

-  neoplasm     of,     allo- 

cheiria  from  ..     17 

not  tinged  by  jaundice  324 
(oningitis,   acute   bedsore 
from    . .  . .         . .  258 

albumiimria  with         ..     13 
biwal,        liyilroccphaluH 
from    . .  . .         ..511 

■  -  pupil  reacting  to  light 

hut  not  to  accom- 
modation in  ..  551 
.  blood  culture  in  . .   566 

■  cercbroHptnnl,  nretonurla 

from    . .  . .         . .       4 

•  -  acute  general  tondcr- 

nefts  In        . .  ..  501 


-  -  arthritis  with  ..   310 
Meningitis,  meningococcal, 

general  account  of  590,  591 

-  -  Ii.'T.iii.!fL'i;t  irorn     303,  3(il 

-  -  l,vi!n>fCi>li;.lN^  after..  21)5 

-  -  liypi-riifllsK  in  ..  308 

leucocytosis  with       . .  301 

lumbar     puncture     in 

diagnosing  . 


pyr 


xial  < 


iof 


-  recovery  from 

-  retracted  head  in 

-  temperature  chsfft  in  591 

-  tuberculous  simulating  590 

■  meningococci  causing  . .   305 
occipital  headache  from  296 

■  optic  neuritis  from    120, 


.^07. 


15,  52 


!  back  from. .  427 

-  parapleirla  from  510,  514,  515 

-  i>hotophubia  due  to     ..   315 

-  pneumococcal    305.  507,  51*0 

-  pr>stcrior  basal,  Cheyne- 

Stokes  breathing  from  108 

coma  from . .  ..117 

headache  from       . .  205 

hemiplegia  from   . .  303 

hyperpyfcxlft  in  309,  310 

relation  of  cerebro- 
spinal to..         ..  fiOt 
rigiditv  of  faro  in. .   720 

-  pyrexia  with     145,  511,  503 

-  pyrexial  crJHCs  in       310,  590 

-  retracted  head  from  295, 

323,  560,  589,  500.  040 

-  retropharyngeal    abi*c< 

mistaken  foi  . . 


600 


499 

138 

girdle  pajn  in. .         ..  200 

lumbar    pmicture    in 

417,  439 

meningococci  in       . .  417 

opisthotonos  in         ..  417 

optic  neuritis  in       . .  417 

pain  in  head  and  neck 

in 138 

part  of  cerebrospinal 

meningitis  . .         . .  417 

priapism  from  . .  538 

pyrexia  in      . .         . .  417 

sciatica  simulated  by  439 

simulating  tetanus  . .  138 

-  -  syphilitic        . .      260,  499 
Wassermami    reaction 

with  ..         ..499 

-  squint  due  to     . .         . .  315 

-  staphylococci  causing  . .  305 

-  stiff  neck  from         295,  649 

-  strabismus  from       323,  515 

-  streptococci  causing     . .  305 

-  suppurative,      due      to 

bacillus  coli  . .         . .  590 

diphtheria!  . .  590 

from  cavernous  sinus 

thrombosis  . .  229 

-  Cheyne-Stokes  breath- 

ing from     . .         . .  108 

coma  from     ..         ..  117 

first  sign  of  . .  118 

hemiplegia  from        ..  303 

hyperacusis  in  .  •  308 

1 hyperpyrexia  m        . .  309 

due       to       influenza 

bacillus       ..         ..  590 

leucocytosis  with      ..  361 

lumbar    puncture    ii» 

147,  611 

'  —  from  otitis  media     . .     84 
photophobia  from 

I prognosis  in   . . 

rapid  pulse  with       . .     84 

1  -  -  retmctcd  lieatl  in       ..   589 

-  -  due  to  typhoid  bacillus  590 
I  Meningitis,  '    suppurative, 

various  causes  of       . .  590 


500  I 
590 


Mtuittgith,  tuhercuious,  coiitti. 

photophobia  from     . .   525 

prognosis  in  . .         . .  590 

prolonged  pyrexia  hi    566 

pyrexia  from  147,  560, 

574,  590 

-  -  retracted  head  in   589,  640 

rigidity  of  face  in     . .  729 

squint  from    . .  . .    147 

tache  ctrC-brale  in     . .  702 

tachycardia  from     . .     S4 

typhoid  simidated  by  560 

simulating  . .  . .   565 

unilateral  convulsions 

from  ..         ..  147 

vomiting    from    574, 

590,  04(t 

-  unilateral  paresis  from. .  118 

-  vomiting  from  120,  148, 

307,    315,    323,     511, 
515,    525,    574,    59t», 

04O,  705,  768 
Meningocele,  dystocia  from  200 

-  exophthalmos  from     . .  229 

-  paraplegia  from  ..  51" 

-  pulsation  of        . .  ..   230 

-  puncture  in  diagnosing     230 

-  situation  of  (/■Vp.  102)..   230 
Meningococci,   in   cerebro- 


spinal lluid 

-  (Plate  XXV  It  I) 

-  within  leucocytes 

-  meningitis  from 


305, 


146, 


YM) 


590 


1710.711 


ractod 
■  iiicide 


>  of 


fitlung  in. . 

■  hriidycardia  from     . . 

■  bradyiHirra  in 

■  Cheyne-Stokes  breath- 

ing from     . .      108, 

-  in  children      .. 

-  choroidal  tubercloa  iu 

516,  690. 


117.   147 


..  -  duration  of     .  .  ..    500 

Meningitis,    tuberculous. 

general  account  of  . .  690 

-  -  T.oa.lach.'  in  500,  574, 

600,  OIO 

-  -  homiphuia  from        . .  So.n 

-  -  liviH-racnslH  In  ..   308 

-  -  livp<T|.vr«\iu  iu     309,  310 

-  -  irr«'giilar  f"!''"'  with..   117 

-  -  lmi>-o<-vtosiH  with  300,  361 

-  -  no  leucocytowiH  In     . .  0 10 
lumbar    piuirlure    In 

147,  611.  040 

lymphocvtwiincerohro- 

Kphuiriluid  in        ..   306 

after  moanUw..         ..  386 

meningococcal     Htmti- 

laling  ..         ..690 

!  -  -  optic  uourilU  In  600. 

ftOO,  640 

-  pnralyHla  In    . .         . .  606 


-  in  otitis  media  . . 

-  spinal  meningitis 
Meuingomyelitis,  acute  bed 

sore  from 

-  gangrene  from  . . 
Meningomyelocele. . 
Menopause,  epistaxis  at.. 

-  flushing  at 

-  hypothyroidism  at 

-  niale,  priapism  from 

-  menorrliJigia  at 

-  metrorriiagia  at 

-  nervous  symptoms  at 
*  and 


.  221 
.  211 
.  409 
.  53S 
.  387 
.  390 
.  409 


noises  I 

obesity  at  . .         . .  409 

phantom  timiour  at  45,  091 
thyroid  extract  beneficial 


MENORRHAGIA 


..  385 

32,  387 


386 


-  from  arteriosclerosis 

-  calcium  and 

-  chilblains  and  . . 

-  from  cirrhosis    . . 

-  cold  hands  and . . 

-  from  constipation 

-  dead  lingers  and 

-  distinction  from  meir 

rhagia 
metrostaxis    . .         . .  3S0 

-  from  emphysema  . .  3S7 

-  endometritis      185.  192,  3!<; 

-  oxunthemata     . .         . .  387 

-  excessive  ovarian  activity  387 

-  flbroid      ..         391.  688,  689 

-  in  fJravr«'8disen.Me       ..  3HH 

-  from  lunmophllia  . .    387 

-  heart  .liscas.-     ..  ..  387 

Menorrhagia,  list  of  causes 


of 


;nopi 


387 


SHK 
387,  302 


-  from  prevention  of  « 

ceptlon 
--  at   iMibiTty 

-  from  purpura    . .         . .  387 

-  wjtii  relroventlon  . .  3H7 

-  wdningo-iMiphoritirt  and 

387.  090 

-  from  Harcomi^  of  ntermt  387 

-  M'UTVv 387 

-  xrxuni  exi-OKS     . .      388,  392 
--  hul'Irivr.liidnn     .  .  . .   387 


MonHtnmtiuii.  im«  wf  ntnrt- 
ing 

-  enlclum  aud       . .         . .  301 

-  exceiwivo    (««     Monnr- 

rhaglii) 

-  nitHldng  with     ..  ..   '-'I 


17 


MENSTRUATION 


MICTURITION 


Mfinstnialion.  conlJ. 

Mercury    poisoning,    sym- 

Metrorrhagia, contd. 

Microscopical  exam.,  coittJ. 

-  headache  from  . . 

29U 

ptoms  of                   . .     33 

-  from  purpura    . .          . .   392 

diagnosing    sebaceous 

-  internal  secretions  and 

388 

-  in  pseudoparalyiU        . .   348 

-  ruptured  tubal  gestation  593 

cyst 

-  noises  in  ears  and 

723 

-  purpura  from    . .         . .  553 

-  sarcoma  uteri    . .          . .    391 

sloughing  fibroid  . . 

-  pain  in  the  back  from . . 

716 

-  in  rabbit-skin  curing  , .     33 

—  scurvv     . •          • ■          • •   392 

tinea           , .      223, 

breast  from  . . 

430 

~  salivation  from    33,  73, 

-  sexual  excess     . .          . .  392 

torsio  testis        480, 

-  in  pregnancy     . . 

688 

542,  726 

-  slouL'liiMi:  fibroid            . .   391 

triple  phosphates. . 

-  thyroid   gland   enlarged 

-  speech  defect  from       . .   726 

-    1  111,.  !  ^  111"- 1-  utiTi          . .   391 

tubercle 

during 

721 

-  stomatitis  from  33,  73, 

METROSTAXIS     ..          ..   392 

of  uterus 

—  vicarious 

274 

74,  266,  542,  726,  740 

■■■■11      ..          ..      32 

tuberculous  breast 

blood  per  anum  from 

79 

-  taste  loss  from  . .         . .  705 

■  1    .  ]  ...'I    h.iiu  meiior- 

glands     . . 

epistasis  from 

221 

-  tremor    from       33,  721,  726 

|-h:M_'|:i                     ..               -.386 

tongue    . . 

hasmoptysis  from     . . 

287 

MERYCISM                      ■■  388 

-  -  ni.-rn.rrha-ia              ..    386 

ulcer  of  larynx     . . 

Mensuration,  abdominal,  in 

-  vomiting  simulated  by    764 

Metrostaxis,  list  of  causes  of  392 

xanthoma  . . 

ascites 

44 

Mesenteric   embolism   (see 

Mica-Uk.'  soale^,  in  pityri- 

 distinguishing     new 

-  in  hip-joint  disease  363, 

364 

Embolism,  Mesenteric) 

asis  rubra  pilaris       . .   488 

L-nnvths       .. 

-  with  ovarian  cyst 

45 

-  glands    (see    Lymphatic 

Microblasts            ..         -.22 

-  -   .—.■iiii.ilinallmminuria 

Mental  backwardness,  from 

Glands,  Mesenteric)..  130 

-  iPlcUe  II,  Fig.  F)          . .     22 

Microscopical   examination 

cerebral  diplegia  132, 

729 

-haemorrhage       ..          ..767 

Microcephaly,        dwarfism 

of  fasces                  170, 

embolism    . . 

133 

-  plexus  lesions,  meteorism 

from    . .         . .          .  -  188 

in   pancreatitis 

-  cases,  salivation  in 

543 

from 389 

-  facies  in 188 

fowl's  blood  corpuscle 

-  changes,  in  general  par- 

- thrombosis  (see  Throm- 

- idiocy  with        . .         - .  188 

detected  by 

alysis  

120 

bosis,  Mesenteric) 

-  infantilism  with             . .   189 

for  osazone  crystals. . 

Graves's  disease 

726 

Mesenteiy,  hydatid  cyst  in. 

Micrococcus       catarrhalis, 

of  pleuritic  effusion . . 

-  defect,     in    congenital 

657,  658 

cold  due  to     ..         . .  178 

semen  in  sterility     . . 

syphilis 

235 

-  loaded  with  fat.,          , ,    A5 

nasal  discharge  due  to  178 

sputum  in  phthisis  . . 

cretinism 

234 

~  thick  contracted            . .     48 

in  otitis  media          . .  422 

in  stomatitis  . . 

Mental  deficiency  in  child- 

- tumour  of.  kidney  simu- 

- -  phthisis          .  -         . .  641 

Miprai'taivi.'ui.ii"  L'laml 

ren,  signs  of  ■■ 

623 

lated  by     . .       354,  663 

sore  throat  due  to    . .  613 

Microscopical    examination 

-  -  lallirig  and      .  . 

628 

Mesotan.  dermatitis  from     755 

urethritis  due  to       . .     70 

of  tissues,  technique  for 

~  -  with  porencephalus  . . 

144 

-  erytliema  from  . .          . .   222 

-  melitensis,    Malta   fever 

-    -     ut'   \'l)ll|jt 

priapism  from 

538 

Metacarpal,    enchondroma 

and 46G 

MicroscopL-its,  eyestrain  in 

with  spastic  paraplegia 

144 

of  (i^i:*?.  282)  ..          ..671 

in  Mediterranean  fever  566 

-  specks  before  eyes  in  . . 

speech  defect  and     . . 

623 

-  bones,   tuberculous   dis- 

_ -  rn-ine 69 

Microsomia  (see  Dwarfism) 

-  deterioration,  from  alco- 

• 

ease  of             . .          . .   668 

-  rheumaticus,  in  infective 

Microspora.  ringworm  from 

hol       

726 

Metacarpus,  node  on,  from 

endocarditis  ..         ..209 

Microsporon  Audouini,  ring- 

- disease,  insomnia  from.. 

322 

yaws 403 

-  tetragenus,  in  sputum . .  645 

worm  from    . . 

-  dullness,  in  typhoid  fever 

76 

Metallic     tinkling,     with 

Microcytes             . .         . .     22 

-  canis,  ringworm  from  . . 

-  failure,     from     cerebral 

piipumotlmrax           . .   168 

-  {Plates  II,  III)  . .          22,  24 

-  felineum.  ringworm  from 

softening 

725 

Metatarsal  neuralgia         ■  ■  439 

Microraelia 188 

-  furfur,  dhobie's  itch  from 

-  state     in     disseminated 

Mrl;il;n--U-.    I,n,ic    On,    fl'Om 

Micropsia 763 

tinea  versicolor  from 

sclerosis 

148 

v.iu< 403 

Microscopical  examination 

-  minutisamum,    dhobie's 

~  symptoms,    in    adiposis 

-  tL'H.kr,   111    Xorton's  dis- 

 for  bilharzia  . .         . .     79 

itch  from 

dolorosa 

410 

ease      439 

blood  in  stools          . .     75 

erythrasma  from 

Mental     symptoms,     from 

METEORISM                388.  389 

-  -  cystin 161 

-  tardum,  ringworm  from 

alcoholism 

465 

-  abdominal     distention 

detecting  chvluria   . .  108 

Microsporosis 

in  lead  poisoning 

119 

from    . .          . .      655,  656 

elastic  fibres          . ,  642 

MICTURITION,     ABNOR- 

- -  myxiedema    . . 

119 

Meteorism,  effects  of      . .  656 

malingering  of  ha2- 

MALITIES  OF 

from  peripheral  neuritis  46u 

-  hysterical            . .          . .   390 

matemesis          . .  266 

-  arrested,     by     bladder 

-  trouble,  from  plumbism 

34 

-  (and  see  Tympanites) 

meat  fibres  in  stools  116 

growth 

Meralgia  parssthetica     .. 

439 

Methsemoglobin,     spectro- 

 uric  acid     . .          . .   741 

calculus           . .      470, 

Mercurialism,   albuminuria 

scope  in  detecting  . .  157 

diagnosing   actinomy- 

- cessation  of,  after  injury 

in         

13 

-  spectrum  of  iFig.  35)  . .     80 

cosis    74,  375,  458, 

-  difficult,    from    enlarged 

-  occupations  causing     . . 

33 

-  in  urine 275 

677,  683,  698 

prostate 

-  taste  loss  from  . . 

705 

after  drugs     . .          . .   157 

adenoma  recti       . .  719 

Micturition,  difficulty  in  .. 

Mercury,  acute  cedema  of 

Metbaemoglobinsemia       , .  161 

antral  timiour       . .  685 

Micturition,  increased  fre- 

tongue from  . . 

698 

-  cyanosis  in         . .      157,  161 

carcinoma  180, 184, 

quency  of      . .     393, 

-  albuminuria  from 

13 

Methtemoglobimu-ia,  black 

186,  230,  390,  391, 

from  appendicitis  394, 

-  anaemia  from     . . 

33 

urine  from     . .         . .  745 

422,  430,  480,  580, 

582, 

-  anuria  from 

40 

—  from  drugs         . .          , .   533 

585,  615,  686,  687, 

bacteriuria     . .        70, 

-  bleeding  gums  from  73, 

-  polycythsemia  and       . .  533 

690,  697 

balanitis 

73, 

266 

-  spectroscope      in      dia- 

 cause  of  hfematuria  276 

calculus 

-  cachexia  from.    . . 

99 

gnosing           . .         . .  284 

chorion -epithelioma  391 

carcinoma  of  bladder 

—  chancre  healed  by 

739 

Methyl-orange  test  for  free 

cysticerci    . .         . .  405 

41,    281,    394,  471, 

-  condylomata  cured  by. . 

700 

HCl 320 

eczema  marginatum  250 

472,  580, 

—  in  congenital  syphilis  . . 

348 

Methyl-salicylic  acid         . .   222 

endometritis      387,  391 

rectum 

-  curing  rabbit  skins 

65 

Methylene  blue     . ,         . .  641 

endothelioma         . .  180 

uterus 

-  curious  results  of  taking 

542 

blue  urine  from        . .  747 

epithelioma  74,  179, 

in  children     . . 

-  deafness  from    . . 

166 

in  detecting  pancreas 

379,  381,  619,  684, 

from       chronic       ne- 

- in  diagnosing  gumma  . . 

230 

disease        . .         . .  328 

701,  731,  738 

phritis         ..      393, 

nature     of    ulcer     of 

urinary  fistula       . .   397 

erythrasma            . .  251 

coli  bacilluria 

tongue 

379 

diagnosing  pyloric  ob- 

 favus           . .          . .   247 

cystitis  194,  393,  470, 

-  -  syphilis   99,  199,  480, 

struction     . .         . .  653 

gum  tumoui-s        . .     74 

578,  581, 

560,  588.  604, 

735 

green  urine  from       . .  747 

Hodgkin's  gland  . .  379 

diabetes          . .      260, 

-  dysphagia  from 

73 

mucus  stained  by    , .  399 

hydatidiform    mole  186 

diverticulitis  . . 

-  erythema  from  . . 

222 

in  searching  for  amcebie   77 

intestinal  fermenta- 

 enlarged  prostate  281, 

-  foul  taste  from  . . 

705 

~  ^  spectroscope  band  of    747 

tion         ..         ..241 

393.  394.   396,  534, 

-  gumma  of  liver  and     . . 

253 

in  sweets         . .          . .   747 

leprosy       . .         . .     63 

after  exercise.. 

-  intolerance  to   . . 

73 

-  -  tests  for         . .         . .  747 

malignant  effusion     290 

from  fibroid  . . 

-  iodide,  in  syphilis 

63 

Methyl  xanthin,  uric  acid 

melanotic  carcinoma  730 

gonorrhcEa      . . 

-  leucopenia  from 

361 

from 742 

meningitis  . .          . .  417 

hyperaddity   of    urine 

-  necrosis  of  jaw  from  . . 

683 

Metritis,    chronic  . .       193,  194 

multiple  benign  sar- 

 irritable  bladder 

-  oedema  from 

410 

METRORRHAGIA           ..  390 

coid         . .         . .  405 

movable  kidney     280, 

-  peculiarities     of     sweat 

-  in  acute  yellow  atrophy  333 

nature  of  ulcer  483, 

ovarian  cyst  . . 

after    

655 

-  from  carcinoma  uteri  . .   391 

588,  739 

oxaluria          . .      394, 

-  peripheral  neuritis  from 

—  chorion -epithelioma      ..   391 

nepliritis     . .         . .  212 

pelvic  lesions. .      394, 

33,  CI,  65, 

505 

-  circulatory  lesions         . .   391 

orbital  tubercle     . .   230 

penile  calculus 

-  poisoning,    amenorrhcea 

-  distinction  from  menor- 

ovarian  tumoui-    . .  690 

peritonitis 

from    . . 

18 

rbagia              . .          . .   386 

oxaluria      . .         . .  218 

--phimosis 

anuria  from  . . 

41 

metrostaxis    . ,         . .  386 

Paget's  disease     . .  730 

polym-ia  and . . 

disseminated  sclerosis 

-  from  endometritis         . .   391 

polypi         . .         . .  186 

from     prostatic     ab- 

simulated by 

72G 

-  hfemophilia        . .          . .   392 

polvpus  of  uterus. .   391 

scess 

Mercury  poisoning,  general 

-  leukfemia            . .          . ,   392 

pvelitis       . .         . .  218 

prostatitis      . .      393, 

account  of 

726 

Metrorrhagia,  list  of  causes 

p'yuria         . .          . .     70 

pyelitis          393,  576, 

nct'Upation  and 

72G 

of        390 

rodent  ulcer            ..179 

pyeloneplu-itis 

-  -  paralysisagitanssimu- 

-  from  polypi        .  .          .  .   391 

.'inrcoma      391,  672, 

pyosalpinx     . . 

lated  by     . , 

726 

-  at  puberty          .  .          . .   392 

681,  731 

renal  calculus  27S.  393. 

iticlurition^  increased,  cottlil. 

-  ill  renal  colic  . .  394 

r lesions        . .         . .  575 

r  -  retrovert«d         gravid 

[  uterus         . .         . .  30 1 

salpingitis       . .  . .   394 

r  —  small  meatus. .  . .  394 
■ —  stricture         . .  . .  534 

r  —  tuberculous      bladder 

471,  534,  579 

kidney       277,  279, 

282,  355,  393,  577,  579 
ureter         . .         . .  473 

-  ulceration   of  bladder  580 

-  undue  acidity  . .    742 

-  -  ureteric  calculus  472,  57S 
r  -  ureteritis  . .  . .  472 
^  -  uric  acid  and..         ..   742 

-  -  vaginal      examination 

I  ill  detecting  cause..  394 

-  —  from   vesical   calculus 

282,  471,  579 

-  -  ivorms 391 

-  interruption  of,  by  stone 

in  bladder      . ."      181,  282 

-  -  urethral  calculus  282,  409 

-  involuntary,  in  epilepsy  143 
muscles  of,  nerve  supply 


of 


of 


393 


Vlicturition,  painful,  general 
account  of    469,  470.  471 

Micturition) 
-  iir-rji.itate,  from    spinal 


,  from  bacte 


..rrhi 


Micturition  through  fistulse  397 
Miculicz's  syndrome 

./-/.  ■■■■>  ■-■■-..  695 
Mid-brain  lesion,  facial  par- 
alysis with  . .  493 

-  luiHuur,,!.  .1.  ifric-slroni   li;i; 
Mid-brain,  tumour  of,  signs 

of        727 

Ui.MI ribral  artcrv  (sec 

.\rrcrv,    Miildlc  Cere. 

liral)' 
lliddlc-car     disease     (sec 

(llilis Media, and  Otor- 

rlicea) 

-  -  liinmorrhiigc  into       . .   I'Hl 
Kidwives,  chancre  of  linger 

in  240 

..       4  i 
. .    759  1 
.  .   fl2f! 
^  ill        . .  . .   7ti2 

cotoma  in  759,  "(!o 
I  sinuilating  . .  233 
■  in  2»B,  31«,  702 
|.sia  in  301,  302 

liu  in  . .  . .  7liO 
isis  ill  16G,  308,  3U9 
lierinetropia  .  .  441! 
.Ill  >iiniilnted  by  311! 
mnnn.'iil^ir  lilindneKo  in  759 
periodi.iiy  "i  uttacks  of  3ln 
pliolo)ilii)i>ia   ill.  .  . .   525 

polyiiri.i  from    .  .  . .   535 

(pladriiiit  hcmiaiiopin  in  75i( 
769 


ck  licailiiclir 


52<! 


Miliaria  rubra,  notes  on  . .  755 

Vliliinii  189 


[ilk,  i-ii>icous  gliinds  from 

3U8,  asfi 
colic  from  ..         ..  117 


.AlICTURITIOX 


Milk,  conld. 

~  ijoats",  Kalta  fever  and    4*16 

Mediterranean  fever 

from  . .  . .  56G 

-  ill  reiinin  test    . .         . .  320 

-  spontaneous  discharge  of  181 

-  ill  test  meal       . .  . .   317 

-  tinned  in  jaundice        . .  321 

-  tinned,  scurry  from     . .     72 

-  transmission  of  bromides 

ill         98 

ioflides  in       . ,         . .     J»8 

-  tuberculosis  from         . .   7ti8 

-  tuberculous  glands  from  379 

peritonitis  from         . .   ii31 

Milliers,  cow-pox  in  . .   i»40 

-  cramp 151 

Milky    urine,    from    phos- 
phates . .  524 

Milroy's  disease  {Fig.  17iO  414 

(tdema  of  one  Wm  in 

(Fiff.  177,  p.  411)..    4l.-| 
Miraicrv,  nervous,  of  artii-  I 

ritis 330 

Miners,  nystagmus  in      . .  407 

-  phthisis    (see    Phtliisls.  i 

iliner's) 
Mines,   workers   in,   anky- 

lostomum  in  . .  . ,     81 

ilirrnr,     in    distiniruHiing 

trance  from  deaib    , .     85 

-  makers.  merL-uriiili^m  in     33 
Mirth,   exaggerated,    from 

ienticuhtrd^'eneralion  *J38 
Miscarrioee  (see  .\bortion) 
Mitral  area,  bruits  in  (see  I 

Bruits) 
defuution  of  . . 

-  disease,  bniits  of 
gastritis  with. .  . .     43 

-  loss  of  appetite  with. .     43 
paiix    in    epigastrium 

from  . .  . .  437  | 
passive  congestion  of  i 

liver  in        . .         . .  437  | 

polycjrthjemia  with  . .     34  ■ 

pulmonary  second  sound 

with  ..         ..       2 

-  endocarditis,  distinction 

from  mitral  stenosis. .       :; 

-  rei'urgitation,   from   ad- 

herent      pericardium  j 

8!t.  ;tO.  211    I 

albuminuria  from  210,  211   j 

-  -  from  idroholism         . .    211    j 

-  -  aorrii-  .l!.vo:..-f.    4fi,  SO,  | 

*.H.    211,  212,  288,  3fi8  I 
artfrioscloro.^i-;  89.  90,  212   j 

-  -  iiscites  frcni    ItJ,  21",  211   ; 

from  athlete's  heart. .   21 1 

back-preswure  from  Iti,  212 

beticllted  by  rest  ami 

digitalis       . .  ..211 

bruit  of  89.  2lfi 

cardiac    impulse    dis- 
placed from  . .   210 
cnrdiorospirati 


MOORE'S  TEST 

Mitral  rcgurgilatioH^  coulj. 

interstitial  nephritis  89,  90 

pulsatile  liver  from  . .  211 

left  ventricle  enlarged 

from  . .         . .  20C 

liver  enlarged  from  . .  210 

loud  pulmoiiar}-  second 

soiinJ  w-ith  . .       1 

with  mitral  stenosis..     95 

from  mvocardial 

changes  .j3",  89,  90,  211 

nutmeg  liver  with    . .  3i;S 

oedema  from  210,  211 

orthopna'ii  from       ..  418 

palpitation   from  210,  -184 

with  pericarditis  211,  213 

polycytbaimia  with  . .   533 

precordial  bulging  with 

89,  210 

pulse  irregular  with..  210 

after  rheninatic  fever     89 

site  of  impulse  with..   299 

-  -  thrill  from      ..       210,  720 
tricu-|iid  rcL'iir-itatiiin 

from  . .  ..211 

Mitral  resurgitatlon,  various 
causes  of  . .    89 

-  stenosis,  accentuated  pul- 

moiuirv  secoiitl  sound 

in  ..      1,  9.i,  288,  289 

acute      dilatation      of 

stomach  in..         , .  173 

after  acute  ciidocardi- 


Mitrat  stenosis,  eoiitii. 

my.\n?demasimulating 

nephritis  siimiliiting, . 

--  nutmeg  liver  with  334,  ( 
-  -  ic.lcnmol  legs  with..  ( 

orthopiia'a  with     418,  I 

palpitation  from 

panting  from . . 

liaro.xysmHl        taclty- 

cardia  from       548,  .' 

polycvthaiinia  with 

532,  ; 

polyuria  in     . .         . .  ; 

precordial  puLsation  in  ; 

presvstolic  bruit  with 

53,  93,  210,  289,  \ 

■ Jiscudo-bradycardia  ill 

pulmonary     apoplexy 

from     '      . .         . .  ; 

enibolLsm  from      . .  I 

regurgitation     from 

93,  : 

thrombosis  from  . .  ; 

puls-'ttiiig  liver  with..  ( 

pulse  fast  and  irregular 


irregular 


14, 


tis 


211 


89  I 


acute  rheumatism  ami 

■183.  701 

—  afteracuterlieumatism    53 

age  incidence  of       . .     9G 

ante-mortem  clot     in 

heart  from . .  . .  289 
aortic  disease  with  ..  209 

-  -  apical   diastolic   bnijt 

from  ..93 

ascites  with      4fi,  53.  894 

atheroma  of  piilmoniir)* 

artery  from  215.  289,  291 
auricular  extrasvstoles 

in     ..  .."         ..   547 

librillation  ill       91,  .Vl.s 

bronchiectasis  from  . .  292 

bronchus  stciiosed  from  292 

Mitral  stenosis,   bruits  ol 


(Fi. 


39) 


94 


-  WithuUl     I. 

-  carillacdiilhii-ssiii  2lli,  289 
impulse  di.<pliiced  in  2111 

■  -  cerebral  cmholism  from 

303,  3111 


afle 


53 


nhi 
Mitral  regurgitation,  causes 


190 


~  cluireit  from   .  .  . .    701 

-  clubbed  lingers  from  1111 

-  coiigesMoiioftheluiigal" 

from  ..         ..  215 

-  ililllcnllleslndliignosliig  53 

-  digitalis  (or    . .  . .     53 

-  dis'ippfiiriincc  of  bruit  548 

-  -  thrill  of      ..         ..518 
■  -  diHtlnctlon  from  oiiilo- 

ciirdltls       .. 

-  epjgiiHtric  pulsation  in  2li'> 
fi..ii-s  1 53 


Mitral  regurgitation,  from 
dilatation  of  left  ven- 
tricle   .     90.  211.  212, 


li>.n>i.|  hiiig  from     . .  292 
l.ir.,,.im>lngbnillsln      94 

■  Mi'i.lirili^  ■-".is      ^       \u plvslsfrom   149, 

■ITS  (roiii     111  2811.  288,  2H9 

ffiu-cfruni  210 heart  failure  frntn    11. 

.  .   210  4ll.  M.  55,  418 

-  -  hoinlplivla  Inmi    3ifl,  301 

high       blooil-pri-s-ilro 

with  ..II.  55,  81 
hypothcrmln  In  (/V(/. 


reiliiplicated    second 

sound    in     95,    210, 
288,  ; 

right  ventricle  enlarged 

from  . .         , .  ; 

second  sound  inaudible 

fii'it-saw   im|iulse   with 

Mitral  stenosis,  signs  of  . . 

site  of  impulse  tvith. .   : 

slapping  first  sound  in 

2.  95.  210,  289, 

sputum  ill      . .         . .   I 

systolic  bruit  in     95,  : 

liichvcardiii  from  703,  ' 

-  -  thrill  in  . .      210. 

-  -  tricuspid  stenosis  with  I 

-  -  vo<al     cord     paralysis 

from 
Modc^lv,  blushing  from  ..   : 
Mciebin's.  myopathy  of     . .    : 

Moeblus's  sign  215.  i 

.Molar,  llnenipleil.  )>ain   ill 
jaw  from        . .         . .  ■ 

-  -  skiagram  ill  diairnrising  - 
Mole,  epilhelioina  starting 

from    . .         . .         . .    I 

-  hairy,  over  spina  biHda  < 

-  hydiitldiform,        blooil- 

stained  dlKoliiirge  from  1 

-  chorion-epithelioma 

after  ..         ..  : 

-  microscope    in    dia- 

gnosing      . .         . .   1 

-  sarcoma    starting    from 

370,  381,  ; 

-  tubal       ! 

Mnllmina     ..  ..  17. 

Mollifies    otslum.    general 

account  of       .  i 

Molluscum      conlaglosum, 
characters  of    .  i 

-  -  k.Tiii...h      r.ilii.'iiliirl. 

^inlllIatlng  ..         ..  ; 

-  -  skin  liiiniiiin.  from  . .  i 

-  llbro.iini(/'ii;.  291)      ..  ; 

-  -  of  vulva          . .         . .  ; 
MongolUm  (Fit.   I'll)    I9il,  1 

-  dntlblc-Juhiliil  thumbs  in  1 

-  lint  ni'liMil  ill    . .  .  .  1 

-  heart  di-i' uilh  .  .  1 


.'likii 


..II- 


hi.. 


r.lili^ 


ejdL'iistric    jaiLsation 

from  . .         . .  - 

-  -  from  follv  heart     89,  -J 

-  -  lil.roid  heart  ..        89.  1 
Mitral  reguroltatlon,  general  _ 

account  of 


I..I' 


r   kl.ln 
I  with 


failure  from  H. 

from     high     blis).!- 

Iircsdilre 

hydrolhnrax  fnim    . . 

from    Infet'tive    olido- 

cardllb 


■111 


IK.-i,    illl 
.It    III      VI 

..|.hy-     __ 


iiillrni     rrmirHlinlloii 


Monoplegia,  brachial    SOI. 
Monoplegia,  brachial,  hyi- 

terlcnl 
MonopleQln.  crural,  grneral 

.ircouni  ol 

ill    liil.oiir 


Moon's  tail  (or  sugar 


MOOREN'S  ULCER 


MYELOCYTES 


Mooren's  ulcer  .  ■  734 

Moorbead.  Dr.,  illustratioQ 

lent  by  .-         -.  158 

Moral  deterioration,  from 

alcohol  . .         . .  526 

]VIoran-A-xeiifeld  diplobacilli, 

conjunctivitis  from  . .  231 
Morbus  cceruleus  {Fig.  67)  157 
~  -  blood  count  in  . .   533 

clubbed  Biigers  from     111 

polycythaimia  in       . .    532 

(and     see     Congenital 

Heart  Disease) 
Morbus  cordis   sine    mur- 

mure 88 

-  coxae  senilis       . ,  . .   346 

-  niaculosus     of     Werlhof 

553,  5oG 
Morgagni,  hydatid  of,  cyst 

from 481 

Morgan's  bacillus,  ptomaine 

poisoning  from  .  .    717 

-  -  sumTiKTilinrrli.-rafrom  384 
Morisoii.  I'l'it,  KiiTinrford, 


ii65,  7 


173 


Morning  di 

-  sickness,  in  chronic  alco- 

holism..        ..        51,  267 

in  pregnancy  . .         . .  393 

Morphia,   abdominal  pain 

from    ..         ..  .'.426 

-  amenorrhoea  from         . .     18 

-  bradypnoea  from  . .     84 

-  Cheyne-Stokes      breath- 


ing from 

■  coma  from 

■  contra-indicated    in    ( 

■  —  peritonitis 

■  convulsions  from 

■  leucopenia  fi'om 

-  palpitation  from       4 

■  prick  marks  in  diagn 


48G 


acid 


-  tremor  from 

-  urticaria  from  . 
Morphine,  glycuroi 

from abi 

-  reduction  by  lu-ine  after  261 
Morphoea,  atrophic  strife  of  529 

-  baldness  from    . .         . .     71 

-  distinction   from    leuco- 

dermia  . .         . .  529 

-  lincEe    atrophica    simu- 

lating   365 

-  violet  border  of . .         . .  529 
Mortar-making,  dermatitis 

Morton's  disease  ..         . .  439 

Mortuary  attendants,  warts 


of 


2  in 


Morvan's  disease  ..        02,  257 
Morvan's  disease,  syringo- 
myelia and  .97 

MiisqnUo  lute,  itching  from  oln 

mahu-i;i.  and    . .  . .      lilt 

swelling  of  face  from    674 

vesicles  from  . .  . .  757 

Motoring,  sore  throat  from  615 
Mountaineering,     epistaxis 

from    . .  . .  . .   221 

-  noises  in  the  head  in     . .  4U6 

-  shortness  of  breath  from  89 
Mousy  smell,  of  favus  . .  246 
Mouth,  athetosis  of         . .   132 

-  bleeding  of,  fi-om  haemo- 

philia . .         . .         . .  273 

-  -  in  norli:rkin'.^  disease. .  274 
Mouth.    bleedinQ 

(Plur,    XVII 


vi   of 


bre 


:i~U'  from  ( 


Mouth,  contd. 

-  scars  round,  in  congeni- 

tal syphilis    . .         . .  235 

-  small-pox  affecting      . .  616 

-  sore,  in  pellagra           . .   225 
angles     of,     in     con- 
genital syphilis  {Fig. 
107) 234 

Movable  kidney  (see  Kidney, 
Movable) 

Mucinoid     substances     in 

ascitic  fluid    . .  . .      50 

Mucocele    of    gall-bladder 

253,  254 

Mucomembranous  colitis 
(see  Colitis,  Muco- 
membranous) 

Mucous  colic  (see  Colic, 
Mucous) 

-  membranes,  affected  by 

bullous  dermatoses  . .  99 
blanching      of,      from 

severe    hsemorrhage  120 

favus  of  . .  . ,   246 

hiemorrhage   from,    in 

blood  dil^ensos         . .   596 


■  -  (and  see  Fiijmentatiou 

in  the  Mouth) 

■  -  rhinoscleroma  affecting  7 
-  ringworm  affecting  ..    5 

syphilis  aff.-Ttin-       ..   4 


-  tel;i 
shreti^  I 


-  tubercles  m  perineum  . .   ' 

on  scrotum     . .  . .   < 

Mucus  and  blood  in  stools 

(see  Stools,  Blood  and 
Mucus  in) 

-  excess  of,  in  gastritis  43, 

317,  : 

-  from  nose 

-  shreds  of,  from  mucous 

colitis  . . 

-  stained  by  eosin  . .   i 

methylene  blue         . .  , 

MUCUS   IN  THE  STOOLS 

(and  see  Stools)      170,  ; 

-  m-ates  simulating 

-  uric  acid  with    . . 
MUCUS  IN  THE  URINE.. 
Miill.rn-v  r.<-li 

Multiple  benign  lupoid 
Multiple  benign  sarcoid    ■■ 
Multiple   serositis,    general 

account  of      .. 
Mummification 


test: 


292 

613 

bullous  dermatoses  af- 
fecting . .  74,  99 
chicken-pox  affecting  . .  616 
congenital  syphilitic  erup- 
tion round  . .  . .  400 
herpes  of  . .  , .  754 
injury  to,  ptyalisra  after  542 
Koplik's  spots  in  (Plate 

VIJI)  178,   22S 

najviin 283 

pain  in    .  .  ..         74,  267 


-  deafness  from 

-  dysphagia  from..     19S,  617 

-  earache  from     . .         . .  202 

-  epididymitis  from        . .     66 

-  epididymo-orchitis  from 

478,  696 

-  hydrocele  from  . .         . .  481 

-  leucocytosis  rare  in      . .   360 

-  lymphocytes  in  cerebro- 

spinal fluid  in . .         , .  305 

-  orchitis  from     . .         . .     66 

-  pancreatitis  in   . .         . .   100 

-  ptyalism  in        . .  , .   542 

-  rigcy  rare  in      . .         . .  595 

-  salivary  glands  enlarged 

in>        ..  ..       617.  694 

-  sore  throat  from        613,  617 


Muri 


Muses  volitantes  .  ■ 

-  -  from  plethora  . .    1 
Muscle    hbres,    in    kidney 

tumours         . .  . .  ; 

-  -StoolslOl, 170,172,241,; 


Muscle,  contd.  I 

-  intercostal,  overstrained, 

from  bronchitis        . .  432 

pain  in  chest  from    432 

stitch  from  overstrain 


of 


431 


-  lar-r-ratinii    of   .^hdominal  593 

Muscle  tone,  mode  of  main- 
tenance .  .         J.i,   137 

Muscles  of  arm,  nerve 
supply  of  ■  ■  504 

Muscles  of  arm,  root  inner- 
vation of  . ■  509 


1  of  , 


143 


-  electrical      reactions      of 

normal  . .      582,  583 

-  flabby,  with  fatty  heart    212 
in  rickets        ..  . .   714 

-  hsemorrhagic    knots    in, 

in  scurvy        , .  . .   556 

-  hyperalgia  of,  anaesthesia 


A-ith 


-  hypotonia  of,  in  tabes 
dorsaJis  . .  . .   236 

-  injury  of,  contracture 
from 143 

Muscles  of  leg,  innervation 
of  498.  499 

Muscles  of  leg,  spinal  seg- 
ments associated  with  498 

-  ossihaction  of     . .  ..113 

-  pain  in  (see  I'ain  in  Muscies) 

-  parasites  encysted  in    . .    729 

-  rupture  of.  purpura  fr-om  553 

-  stow  relaxation  of,  in 
Thomsen's  disease    . .  584 

-  swelling  of,  in  myositis 
ossificans        . .         . .  143 

-  swollen,  in  trichinosis  . .   464 

-  tenderness  of  (see  Ten- 
derness of  Muscles) 

-  trichinella  in      . .  . .   4iU 
MUSCULAR  ATROPHY  ..     59 
progressive   (see   Pro- 
gressive     muscular 
atrophy) 

-  dy.strophy,  primary  (see 
'Myopathy) 

Muscular  rheumatism  138, 

431,  443,  467 
Musculo -cutaneous  nerve  504 
Musculospiral    nerve    (see 

Nerve,  Musculospiral) 
Musiirooms,     haemoglobin- 

iiria  from       . .  . .   284 

Mussels,  urticaria  from    . .  771 
Mustard  plasters,  erythema 

from 222 

-  sore  fingers  from  . .    239 

-  vomiting  from  . .  . .    765 
Mutism  (and  see   Speech, 

Loss  of) 

-  aphasia    distinguished 
from 624 

-  in  dementia       . .  . .   623 

-  melancholia        . .  . .    624 
:\rval-i;(.      rrrvi.Ml.      li.-ad- 

.H-lir    M(lllll;itri|    1,V       ..     294 

. .  617     Myalgia,  general  account  of  467 


707 


from    . . 

-  pain  in  the  chest  from,  . .  430 
limbs  in         . .         . .  463 

-  tenderness  from        431,  706 
Myasthenia  gravis,  bulbar 

paralysis      sunulating  198 

drooping  of  eyelids  in  235 

of  chin  in    ..  .  .    235 

Myasthenia  gravis,   dysar- 
thria in  . .   627 

Myasthenia  gravis,  electri- 
cal reactions  in         . .  584 


Myasthenia  gravis,  facies  in 

(/■/V/.^.  in.  112) 

muscles  affected  in  . . 

nasal  voice  in. . 

--ptosis  in 

Iityalism  from 

rapid  fatigue  in 

regurgitation    of   food 

sneering  appearance  in 

zygomatic     muscles 


Mycetoma  . . 

Mycosis  fungoldes,  general 
account  of  . .  ' 

itching  in       . .  . .   J 

Myelitis,  acute  bedsore  from  : 

hyperpyrexia  from   . ,   : 

from  injury  ...  . .   : 

strangury  from         . .   i 

Myelitis,  anxsthesia  from    i 

-  compression,  pain  at  um- 

bilicus from    . .  . .   ' 

-  constipation  in  . .  . . 

-  contractures  after 

-  difficulty  in  micturition 

with ; 

-  gangrene  from  . .         . .  : 

-  girdle  pain  in    . .  . .    I 

-  knee-jerk  lost  after      . .  ; 

-  paralysis  of  bladder  in. .   ; 
one  leg  from  . .  . .   ■ 

-  precipitate     defsecation 

from ; 

-  pupil   reacting   to   light 

but  not  to  accommo- 
dation in        . .  . .    ; 

-  retention  of  urine  in  396,  '; 

-  transverse,      antesthesia 

with     . .  62.  140.  ; 
without  anaisthesia  . .    ■ 

ankle  clonus  from     . . 

anterior  cornual 


atrophy     of     muscles 

from 
cervical  cord  affected 

by 

from  compression  389,  5 

cystitis  from  . .         ..I 

dorsal  cord  affected  by 

drawing    up    of    legs 

with  . .  . .    ] 
extensor  plantar  reflex 

from  .  .  62, 

Myelitis,  transverse,  general 
account  of  62,  £ 

girdie  pain  from      140,  4 

hyperjesthesia  with  . .  1 

incontinence  of  urine 


xe^k  i 


Myelitis,  transverse,  Injury 

and      ..        ..     389,  51 
knee-jerk     increased 

lost  from    . .  . .     ( 

loss  of  reflexes  from. .   5] 

main-en-griffe  from  . .     ( 

from  new  growth      . .   3i 

pain  and         . .  . .    51 

paraplegia  from    514, 

515,  5] 

priapism  from  . .  5i 

R.D.  from        61,  62,  51 

retention  of  urine  in. .   51 

simulating     amyotro- 
phic lateral  sclerosis    ( 

progressive  muscular 

atrophy  . .         . ,     ( 

from  softening  . .  51 

spastic  paraplegia  from   ( 

sphincter  trouble  from 

62,  1^ 

from  spina]  caries    . .  3S 

thrombosis. .         . .  3£ 

syphilis  . .  . .   3£ 

tympanites  from      . .  3? 

wasting     of     muscles 

from  . .         61.  51 

-  urine  dribbling  in        . .  39 
Myelocytes  (Plates  IT,  I V) 

-  in  aplastic  anremia       . .     2 

-  eosinophile     (Plate     II, 

Fig.  N.  p.  22)             .  .      ^ 
Myelocytes,  general  account 
of        2 

-  in  Hodgkin's  disease  2:;, 

37,  64,  377,  63 

-  leukiemia  23,  24,  55,  64, 

274,  63 

-  lymphadenoma  . .         . .     - 

-  lymphatic  leukiemia    . .     - 

-  lymphocytes  simulating      - 


MYELOCYTES 


NECK 


fs/tlo<'>/U'.s,  coiitd. 
iieutrophile 

in  pernicious  anemia   . . 
polymorphonuclear  cells 

simulating 
ill  splenic  anaemia 
[yeloid  sarcoma  (see  P;ir- 

coma.  Myeloid) 
'velomata,     albumosuriiv 


■yhil.n..  hull;u  from 

yocardial    changes,    ac- 
count of 

-  ;%'!■    incidence  of 

-  Xrom  alcohol  . .         . . 

-  ascites  from   . . 

-  back-pressure  from  . . 

-  Cbeyne-Stokes  breath- 

ing from    ..■       ..  ; 

-  digitalis  and  . .         . .  ■ 

-  dyspepsia    simulating  - 

-  dyspnoea  from  , .  ; 

-  engorged   lungs   from 

-  lirst  sound  like  second 


-  irallop  rhvthni  with  . .  ; 

-  heart  blwk  with       .. 

-  lieartbura    simulating  : 

-  heart  failure  from  14, 

46, ; 

-  heart  impulse  displaced 

with        ..         ..    ; 
large  from  . . 

-  insomnia  from  , .   J 

-  irregular  heart  from . . 
pulse  from. .         . .  ; 

-  liver  onlar-ed  from  . . 

-  niilr:il      r</iruri.'itation 

iruiri  ■_'.  S9.  90,  i 

yocardial  changes,  mode 
of  estimating.. 

-  Xauhoim       treatment 

and A 

-  nutmeg  liver  from    . .   'i 

-  (edema  from  . .        90,  : 

-  in  old  people. . 

-  palpitation  from    300, 

484,  ^ 

-  rheumatic      . .         . .   i 

-  shortness     of     breath 

from  . .  85, 

-  simulating     adherent 

jtpricardium 
yocardial  changes,  some 
forms  of         ■  ■     484.  A 

-   -y-ii'Iii-  bruit  from  M'l,  :- 

-  from  syphilis..  ..   'i 

-  tachycardia  Irom      ..  1 

-  varieties  of    . . 

-  (and  see  Hciirt.  Fatty  : 

.iu.\   IUmit.  I''ibroi<l) 
yocardltis.    general    ac- 
count of  ••  t 

l.;.in  in  tlif  back  from   ..    \ 

pjironchyrnatous,  acute 
dilatation  of  heart 
from    . .         . .         . .  ' 

yocardium.  chronic  affec- 
tions of 

yocardium.  diseases  of. 
fieneral  account  of    ■ .  2 

.n.-  nodules  ill    ..    I 


parathyroid  glands  and 
yokyniia,  in  intermittent 
riaudication    . .  . .   ' 

yopathy,  age  incidence  of 
arm  involved  by 
atrophy  of  muwies  in  00, 
509,  r.M, 
deep  roMexes  in. . 
drooping  eyelid-*  in 


.lv-y»riliT 


•■\n|.h(liidnios  in 
yopathy.  fades  of  {FOjs. 

IH'.P.     I  1.1) 

fi.iiMlv  history  in        SOO 


Myopathy^  coiUd, 

-  Friedreich's  ataxy  simu* 

lating  . .  . .  . .     fiO 

-  infantile  . .  . .      510,  513 
paralysis  simulating. .     CO 

-  juvenile  . .  . .      510,  513 

-  knee-jerk  lost  in  . .  358 

-  Landouzy-Dejerine  type  511 

-  limping  from     ..  ..   362 

-  lordosis  from      {Fig.  06)  156 

-  orbicularis   palpebrarum 

weak  in  . .  . .   235 

-  paraple^^ia  from  . .   510 
Myopathy,  peripheral  neu- 
ritis distinguished  from 

513.  514 
simulatiML:  ..  ..     60  ' 

-  plantar  rellRx  lit  .  .      68  , 

-  pouting  lips  in  . .  ..   235  I 
Myopattiy.  pseudo-hyper- 
trophic  113,  509,  510,  513 

climbing  up  self  in  113,  251 

waddling  gait  in        . .  251 

-  no  R.D.  in  59,  509,  513 

-  reflexes  in  ..         ..513 

-  scoliosis  from     ..      153,  151 

-  shoulder    involved    by      509 
Myopathy,  some  account  of  513 

-  svnonyms  for    . .  . .   135 

-  talipes  in  ■         ..         ..113 

-  Tooth's  paralysis  distin- 

gnishcd  from..  60,  113 
Myopathy,  types  of  50,  135 
Myopia,  crescents  in    415.  416 


-.l-M'! 


703 


XIX)  416 

-  pupil  large  with  . .    551 

-  strabismus  from  . .  649 
Myositis,    from    cold    and 

damp  . .         . .         . .  475 

-  infective     peri-arthritis 

and      . .  . .  - .   475 

-  from  injury       . .         . .  475 

-  intercostal,     tenderness 

from    ..         ..      "OG,  707 

-  interscapular  pain  from  461 

-  occupation  neurosis  simu- 

lating   476 

Myositis  ossificans  ■.  143 
trismus  simulated  by    729 

-  pain  in  the  limbs  from. .  403 

muscles  from..  ..   404 

the  shoulder  from     . .   474 

-  rheumatic,  torticollis  from  112 
Myositis  of  shoulder  region  475 


ess  of  spi 

Myotonia  atrophica  (and 
see  Myopatliy) 

Myxtedema,  ailiposis  dolo- 
rosa simulating 

-  Aizt-  im-idence  of  ..  ■ 

^  :ill.iimiiiuria  in  ..       38, 

-  ;uii""norrhoea  in. .         18, 

-  broad"  features  in       409, 
hands  and  feet  in     . . 

-  cerebral    tiunour    simu- 

lated by 
toarse  skin  in   . . 

-  ryanosLs  in 


diabetes  Insipidus  and..  537 


-  cyi'brows  defective  In  ..  : 

-  eyelids  pufTy  in..  ..    \ 

MyxoBdema.  facies  of  {t^o- 


Myxoitema.  general  account 


of 


by 


di^e: 


nul.ited 


MyxcBdema,    hypothyroid- 
ism  and  . .  409 

-  iiuniisingstoiitnoiwln..  409 

-  inl.'llect  dull  In  234,  409,flR7 

-  lcucocvto-»L-*  In  ..  ..300 


Mifxosdema,  coiitJ. 

-  lips  swollen  in   . .         . .  : 

-  loss  of  strength  in       . .  • 

-  malar  flush  in  38,  iFvj. 

104)  234,  ■ 

-  mental  changes  in 

symptoms  in . .         . .  ; 

-  mitral  stenosis  simulated 

-  nephritis  simulated     38,  : 

-  nose  broad  in    . .         . .  ; 

-  cedema  in 
--of  leg  in 

-  paralysis   agitatis  simu- 

lated by        . .         . .  : 

-  perspiration  deficient  in  • 

-  podgy  fingers  in 

-  polj-uria  in         . .      536,  < 

-  sex  incidence  of         38,  • 

-  skin  thickened  in 

slow  pulse  in  . .       84,  J 

speech  in        . .         . .  : 

-  swelling  of  legs  in      414,  \ 

-  temperature    subnormal 


-  weight  increased  in      ..  • 
Myxcrdeme  fruste 
Myxoma,  parts  allected  by 


Xan-otits,    Cheyne-Stokes 

breathing  from 
Nares,  active,  in  pneumonia 

-  collapsing,  snoring  due  to 

-  occluded,  anosmia  from 

-  posterior,  rtiinoscleroma 

afTecting 

-  pruritus  of 

Nasal   bones,   necrosis    of 
(see  Xecrosis) 

-  diphtheria    (see     Diph- 

theria, Xasal) 
'  -  discharge  (see  Uiscliarge, 
Nasal) 

-  process,      enlarged,     in 

acromegaly    . . 

-  septum,  dLstocated,  anos- 

mia from 

spur  un,  anosmia  from 

Nasolabial     fissure,   scbor- 

rha?ic  eczema  affecting 

-  folds,  eczema  seborrhoci- 

cuni  of 

in  hemiplegia 

Nasopharyngeal      catarrh, 

headache  from 
Nasopharynx,  fibrosarcoma 
of  ..  ..       179, 

, suppuration  iti.  menin- 
gitis from 
'  -  recurrent  fibroma  of 
I  Natal  fold,  oblique,  with 

hip  disease 
j  Nates,  eczema  marginatum 


N 


-EVI,    buccal :    blood 
oozing  iPtate  XV If) 
292.  i 

Nievus    of     tongue      and 
moutii  . .         . .  *J 

-  urethra], hatmaturia  from  t 

ansimia  from  . .  *. 

hiumaturia  from        . .  '. 

urethroscopy    in    dia- 
gnosing     ..        ..  ; 

NAILS,   AFFECTIONS  OF 

THE 2 

Nails,  brittle  . .  ..A 
from  ringworm          . .  S 

-  capillary  pulsation  in  . .  : 

-  congenital  syphilis  affet-t- 


ing 


-  dull,  from  ringworm     . .  : 

psoriasis         . .         . .  ; 

-  ec7omii  :itTecting        250,  ', 

-  fuv-shell 

-  epidermolysis        biillocMi 

alTecling  ..  ..   : 

'  exfoliation       of,       from 

riiigworin       . .         . .  ; 

-  favus  alTecling  247,  20i>,  \ 

-  gout  affoi^tlng    . .  . .   : 

-  hypertrophy  of . .         . .  ■ 

-  orange-rind    like,    from 

-  psnriimis  affc-tiiig      250,  1 

-  rhemimti.sni  atTecting  . .   ; 

Nails,  ringworm  of    247, 
249.  : 

-  shedding  of,   from   dia- 

betes    ■ 

locomotor  atJixy       . ,  ■ 

-  from  KyphlliA 

-  pitting  of,  from  ecxeiim  : 

-  Hfilittlng  of,  from  eciemii  : 
pftoriiuht         . .         .  ■  • 

-  IIPOOII 

-  thickenoJ,     from     ring- 

-  tlmi*  of  growth  of 

-  trmi-ver'c  furrowing  of, 

from  p^orliL-i- 
Nalli.  transverse  rldoot  on 


sis  in    . .         . .         . .  ' 

-  pain  ill  shoulder  in        . .   ■ 
Kaubeim  treaiiiiont,  heart 

alTectioii  benefited  by 
Nausea,   from    acute  con- 
gestion of  liver 

-  in  acute  yellow  atropliy 

273, 

-  angina  abdominalis 

-  from  arsenic      . .       CI,  : 

-  bacteriuria 

-  carcinoma    of    stomach 

270,  ; 

-  catarrhal  jaundice        . .  '• 

-  chronic  alcoholism 

-  cirrhosis 

-  after  llushing    . .         . .  ! 

-  from  k'astric  ulcer    268,  ; 

-  ga.4trilii(  267.  317, 

-  with  iiilcstinal  colic     ..  - 

-  hi  Meniere's  disease 

-  migraine 

-  from  movable  kidnoy  . . 

-  piuicroAtilis 

-  in  pellagra  . .         . . 

-  phoHphorits   poisoning.,  : 

-  phthi«L* I 

-  plunihlsm 

-  portal  obstruction 

-  iirecedlng    hnimatomesig 

-  Ill  M'arlet   fever         Oil,  : 

-  from  rtnake-bito 

-  lubeniiUiiis   perilonitiH     i 
NauiM.  vomltlna  and  765.  1 

-  with     undue     i.bdnmiliril 

pnl-unn.. 


N. 


709     -  tTltk  ii 


,  \»>t<- 1  <  |.'.  tri>*a  MfToeting 
crninpFi  in.  In  ti'tany     . . 


s.u,. -      ailiim) 

\jti.lii]..i,   luiuiiw>;li»blfiuri» 

from 38i 

-  iierii'ltiTiil  neuritis  from 

'      '  01.  o:. 

NAPKIN-REGION   ERUP- 
TIONS 

-  _  M'l.nrrh.i'l.'   .hriiiniiii. 


(Vrvhrtl* 
.  pain  hi  (mt  I'ttlii  In  the 


400 


NECK    —    NERVE 


St'ck,  coitti 

-  stifE  (set- 

-  swelliiiL- 


Xtfjltntis,  ,o„lil. 

Nephritis,  acute,  exacerba- 
tion of  clironic 

from  exposure  to  cold 

from  fungating  enclo- 

cnrditis        .  .     7,  8,  ' 

Nephritis,  acute,  general 
account  of     . . 


in  heart  from         . .   i 

-  acute,     mistaken     for 

acute  rlieuraatism. .  : 

central,    sarcoma   simu- 
lated by  . .  . .   I 

-  pya;nij:i  from 


-  of  c 


rboM 


102,  735 
I  422 


.  .   422 


polypi  from 

-  fat  (see  Fat  Necrosis)  . .  131 

-  of     femur,     popliteal 

abscess  from..  ..    692 

Necrosis  of  jaw  •  •  683 

-  -  stomatitis  from  . .   542 

-  iji  leprosy  . .  . .      ti3 

-  of  nasal  bones,  anosmia 

from fil2 

bridge  of  nose  fallen 

in" from  ..  ..179 

foul  breath  from    . .     87 

from  injury  . .  179 

pus  from  nose  due 


to 


179 


from  syphilis     179,  210 

from  periostitis  . .   668 

of  pubic  bones,  scrotal 


Mllowomen,        acropar- 

fcsthesia  in      . .  . .   444 

?dIework,  cramps  in  arm 


|i.ii[i  HI  I  \^>-  r\i--s  from    . .  446 
\,..iiin._'  ..I    rl„.^t.,  in  dia- 
L-nn-ii!L'   riiiiiyema  35, 

103,  160 

fluid  in  chest       104,  530 

■  hEemopneumothorax 

530,  651 

hepatic  abscess 

subphren' 

pyopneumothorax 

651,  652 

hemoptysis  from      . .    28G 

subcutaneous  emphy- 
sema from      . .  . .   203 

-  of  meningocele  . .  . .  230 

-  of  joint,  in  diagnosis     . .   340 
Negro  blood,  pigmentation 

of  mouth  from  . .  528 

Negroes,  cachexia  in         . .      99 

-  dirt-eating  in     . .  . .      99 

-  perverted  appetite  in   . .      90 

-  pica  in     . .  . .  . .      ^^ 

-  ^IoM,:nl,   ,|l^(.;-.sOOf 

Neisser.  gonococcus  of      .  ■   I 

.\,  j.^rr  ^  -iiiri,  for  bacillus 
diplitheriic      ..      157,  C 

Neosalvarsan,  erythema 
from     . .  . .      222,  S 

Nephritis,  acute,  acute  di- 
latation of  heart  from  1 

albuminuria  in        42,  '. 

albumosm-ia  with 

angi(>neurotic    oedema 

simulating  (Fij?.  178)  A 

Clieyne-Stokes  breath- 
ing from      . .         , .  ] 

from  chill        . .         . .  i 

clironic    parenchyma- 
tons  nephritis  after  i 


526 


IIciKH'h' 


I  Sephritis,  chronic,  could. 

convulsions  in 

Cheyne-Stokes  breath- 
ing from 
chylous  fluid  in  cliest 


-'I      Nephritis,  chronic,  effects  of    42 


purpi 


sirnulatii 

mercurial  stomatitis  in 

mitral    regurgitation 

from  . .         . .   : 

-  -  cederaa  of  9,  281,  • 
from  beer  simulat- 
ing 

Nephritis,   acute,   without 

cedema       9,  11,  14,  : 
pallor  in 

-  -  pneumococcal  9, 
polyuria  after 

puffiness  of  ankles  in 

face  in 

pyrexia  in 

in   secondary   syphilis 

simulated    in    anajmic 

girls 
hy   carcinoma  recti 

-  -  -   ir;  iiif;iilts     .. 

Nephritis,  acute,  simulated 
by  thrombosis  of  renal 


of 

tube  casts  in  42,  : 

witliout  tube  casts     10, 

-  -  Jn.iri  typhnid  fever    .. 
Nephritis,   acute,   universal 

oedema  in  . .  * 

-  ur;rnil.i     Irnt,,  .  .  ..     ] 

Nephritis,   acute,   unrecog- 
nized     

Nephritis,     acute,     urine 
changes  In      9,   10.   14, 

Nephritis,     acute,     various 
causes  of 

-  -  \.-ti;i  .■.■n;il  thrombosis 

vimiiiiitiiig  ..  ; 


-  ascending,     albuminuria 

from 

causes  of         . .  7, 

Cheyne-Stokes  breath- 
ing from 

empyema  from 

hyperpyrexia  in 

perinephritis  from 

pleurisy  from 

uraemia  from  108, 

-  B.  coli  with 

pyocyaneus  with 

-  bulljE  in  . . 

-  cachexia  with    . . 

-  chronic,  acute  superven- 

age  incidence  of 

albuminuria  with    70, 

191,  212,  274,  298, 

a  first  sign  of 

albuminuric    retinitis 


^•ith     47 


,  212,  2: 
11,34, 


ascites  with    . .        42, 

blood  per  anum  in     . . 

blood-pressure  high  in 

10,  11,  42,  76, 


cardiac  impulse  in     . . 

causes  of 

catarrh  of  small  intes- 
tine from    . . 
chylous  ascites  from. . 


394 


dis- 


-  -  epistiiM-   1 1. 

freqtn-iii      iniitiirii 

from 

at  nighj^-ith 

gastritis  f^mu  . .   an 

general  cedema  in      . .      10 

giddiness  in     . .  . .     42 

hfematemesis'in         , .    274 

hcemoptysis  J&rom      ..   212 

hiomorrliagd?  in         . .      11 

headache  in    . .  11,  42 

heart     imppSe 

placed  with 
heart  sounds  rfith    10,  11 
high -tension '^"'""   ''"  ''''* 
liydrothorax 

hyperacusis  in 

hypothermia  i 

infantilism  fro 

infarction      ol 


mcnihraiies  in  ..      11 
iiisniiiui;i   In      .  .  .  .       11 

Nephritis,  chronic,  interstitial 
(see  Granular  Kidney) 

irritability  in  . .   323 

left  ventricle  large  in     76 

liver  enlarged  from  . .   212 

mitral    regurgitation 

from  ..  i.    298 

morningheadachefrom  294 

nutmeg  liver  from     . .   368 

-  -  obesity  from 


(,f  u-js  ; 


Nephritis,  chron 
chymatous, 
account  of 

polyuria    hi 


10,  408 

42,    191, 

274,  298 
-  -  radial  artery  thick  and 

tortuous  with         . .   212 

resultimi    from    acute 

10,  408 

retinal  changes  with  11,  42 

hsemorrhages  with     212 

ringing    aortic    second 

sound  with . .  . .   4(18 

shortness  of  breath  in     11 

simulated  by  polycys- 
tic kidneys  . .     42 

stertor  in        . .         . .     42 

thick  tortuous  arteries 

m 274 

tinnitus  from  . .    723 


■  -  tub.. 


^4, 


-  -  nni'mia   in       ..        42,  108 
Nephritis,     chronic,     urine 

changes  in     . .         . ■  10 

weakness  from            . .  76 

-  chylous  ascites  with      . .  109 

-  chyluria  with      . .          . .  109 
--  from  cold  and  damp       .  .  10 

-  ion\'ulsions  from           ..  144 

-  J'ri-'iiliinder's        bacillus 


-  oedema  with 

-  pain  in  limbs  i 

-  pleural  effusioi 


11 


simulating        38 


from    ..   104 


Sephritis,  contd. 

-  rigor  in 

-  simulated     by     chron  iu 

peritonitis 
myxccdema     . . 

-  from  scarlet  fever 

-  staphylococcus  with 

-  streptococcus  with 
Nephritis,  tube  casts  with  6, 

lO'.i. 

-  iiilurrh^  bacilli  with      .. 

Nephritis,  varieties  of  I 

-  Ill    Wrir-   ,li-r;|... 

Nerve,  anterior  crural, 
affections  of  . . 

Nerve,  anterior  crural,  dis- 
tribution of    . . 

Nerve,  anterior  crural,  par- 
alysis of 

spinal  segments  de- 
rived from 

Nerve,  anterior  thoracic, 
muscles  supplied  by.  ■ 

spinal  segments  suj>- 

plying      . . 

-  Arnold's 

-  auditory,    nci-i-    In    imi- 

due  tu  ii -mil  -it" 

tUmOUl-nli.  Ilriiini    W  Itli 


at    till- 
riniillr 


;iilV 


Nerve,  circumflex,  muscles 
supplied  by 

neuritis  of 

paralysis   of,    arthritis 

simulating  . .  . .   . 

spinal  segments  sup- 
plying 

weight-carrviug  affect- 


Nerve,     external     plantar, 
distribution  of 

riv.-l    irniii 

Nerve,    external    popliteal. 
distribution  of 

Nerve,    external    popliteal, 
paralysis  of    .  . 


spi 


ved  from 

in  Tooth's  palsy 

fifth,  hyperidrosis  in  ar 


462 


neuralgia  in  . . 

ptyalism  from       . .  54:1 

neuroses  of    . .  . .   543 

tumour  of,  anaesthesia 

from  . .         . .   711 
neuralgic  pain  from  711 

-  glossopharyngeal,    pani- 

lysis  of    . .         . .   70f] 

-  gumma  of,  muscle  wast- 

ing from         . .         . .     61 

-  -  E.D.  from      ..         ..     61 

-  hypoglossal,  paralysis  of 

63,  13.-i.  ''i:! 

-  impulses,  motor,  rate  of 

discharge  of  . .         . .    "21 

-  inferior  dental,  neuralL'in 

irj  UVl 

Nerve,  inferior  gluteal,  dis- 
tribution of    . .         .498 

rived  from  . .    IHS 

-  inferior  laryngeal  . .    1  IS 

-  intercostal,  abscess  irri- 

tating  432 

aneurysm  in'itating 

432.  434 


NERVE 


NEURITIS 


853 


iervo.  internal  plantar^  tvidd. 
spinal  segments  de- 
rived from         . .   498 
popliteal,       claw-foot 


lOf 


lerve,    internal    popliteal, 
distribution  of 

-  i„teloss.l      supplii-d 

hy 

-  luiiiliriciilei  supplied 
by 


109 


109 


lerve,    internal    popliteal, 

paralysis  of. .  .499 

-  .^[linal  set^rments  de- 

rived from         . .  498 

-  vdnar  nerve  horao- 


'.  of 


I'JS 


lerve,  long  thoracic,  mu. 
cles  supplied  by        ■ .  504 

lerve.  long  thoracic,  par- 
alysis of  i/"/.  -''i7j505,  506 

-   M,i„;,l>(-lneiltssup- 


I'l.v 


lerve,     median,     muscles 
supplied  by  ■  ■  504 

p.aralysis  of,  ischiemic 
paralysis  simulating  50G 

spinal   segments   sup- 
jilyinir  '       ..  ..   -504 

lerve,    musculocutaneous, 

muscles  supplied  by . .  504 


lerve,  musculosplral,  mus- 
cles supplied  by        . .  505 

-  ri.'Unl-ia  ..1    ..  ..    442 

-  ),.ir;ily.M.-  uf     i;.5,  ".04.  inc. 

-  spinal   segments   sup- 

plying        ..         ..  50.5 
new  ffrowth  on,  muscle 
wasting  from..  ..      nl 

-  -  I!. 11.    fr...m,.  ..     01 
;,ir,tli.  |ianil.v.-i-  of  .  .    700 

lerve,  obturator,  distribu- 
tion of 498 

geniculate    branch  to 
knee  . .         . .  363 

spinal   segments   deri- 
ved from     . .  . .  49S 
lerve,  obturator,  paralysis 

of        498 

rived  from  . .   49S 

optic,    compression    of, 

blindness  from  . .  762 
-*  connections    of    (Fiif. 

138) 300 

-  liippus     from     axial 

lesion  of      .  .  .  .   552 

-  lesion    of    one,    pupil 


proptosis  due  to    . .  330 

phrenic,  ascending  fibres 


nlil. 


■omiiression     of,     no 


pan 


nitl 


434 


-  iliapbragm  supplied  by  709 

-  irritation  of,  by  caseoua    ■ 

glands         ..         ..  308 
hiccough   from   307,  308 

-  paralysis  of    . .         . .     *••'» 

-  role  in  vomitiTig       . .   "fit 

-  roots  derived  from  .  .   ""9 
_  twi...stoliv.-rai,du-:dl- 

bla.l.lcr  ..    7"'-' 

lerve,    posterior   scapular, 
muscles  supplied  by..  504 

-  -  s|iinal  segments 

snpplving  . .  504 

pudic,    neuritis    of       ..   193 
jivriformis,    spinal    seg- 

nient.s  derived  from..   498 
(luadratUBfenioris,  spinal 

segments  derived  from  498 
rei'urrcnt  laryngeal,  com- 
pressed    l)V     th.iToid 
gland   enlat^gcment   ..   722 

-  -  i.arulvsi.;     of     (sec 

r.MviIvHis  l.nryii- 


-  roots,  sacral,   injury   of, 

claw- foot  from  . .  1 09  i 

Nerve,  sciatic,  distribution 
of        498 

injury  of,  talij.es  from  11;; 

Nerve,  sciatic,  paralysis  of 

113.  499 

spinal  segments  de- 
rived from . .  . .   49S 

~  seventh,  paralysis  of  (sec 
Paralysis,   I'aoial) 

Nerve, subscapular,  muscles 
supplied  by  . .  505 

spinal  segments  sup- 
plying .  .  .  .   ."io.S 

Nerve,  superior  gluteal,  dis- 
tribution of    . .        . .  498 

rivf.l  from       ..  ..    1'..- 

Nerve  supply  of  heart  433,  708 
Nerve  supply  of  the  scalp 

(/.',.  ■:."•■  -.710 

Nerve,  suprascapular,  mus- 
cles supplied  by         ■  -  504 
Nerve,  suprascapular,  par- 
alysis of  . .  506 

-  -  spinal    segments    sup- 


504 


Neuraltiia.  calcanean       ..  439 

-  ,.  ..477 

-  -    i  I  r  from  475 

-  flMli,     ,|,  ■    ln,.ll|  29(i, 

448,  710 

-  disseminated  sclerosis. .  009 

-  distinction    from    licad- 


290 


Neuralgia,  epileptifortn  .  447 

Neuralgia    from    error  of 

refraction  . .  449 

.M.Tiiil  .•utaiieoiis  ..   4;iU 


sujiratrochlnar,  para- 
lysis of  (see  Paraly- 
sis of  Third  Nerve) 

Nerve,  ulnar,  effects  of 
division  of  . .  606 

iiiternat popliteal  nerve 

lioniolofue    of         ..    Pi9 

Nerve,  ulnar,  muscles  sup- 
plied by  . .  504 

neuralgia  of  . .         . .  4.12 

paralysis  of  (see  Para- 
lysis, ulnar) 
spinal  segtncms  supply- 
ing    504 

Nerve  vagus,  branches  of  148 

compressed  by  th>Toid 

gland     enlargement  722 

no  pain  with         . .  434 

irritation  bv  aneurysm  703 

caseous  glands    308,  703 

hiccough  from       . .  308 

by  mediastinal  fibro- 

'sis  ..         ..  703 


by  thoracic        new 

growtli    . .         • .  703 

laryngeal    paralysis 

from  changes  in  . .  495 

neuritis  of      . .         .  •  703 

paralysis  of  (see  Para- 
lysis of  Twelfth 
Nerve) 

relation  to  cough      . .    11^ 

r61c  in  vomiting        . .   7i.  I 

Nerves,    callus    involving, 
muscular  atrophy  from 

ni,  03 
B.D.  Dom  111,  113 

-  electrical     reactions     of 

normal  •  •  583 

-  injury   of,   contrij^itures 

from    . .         •  •     1^8,  141 
muscular  atrophy  from    03 

-  -  R.D.  from     ..         til.  "3 

-  olfactory,  absence  o(  ..  1112 

-  -  nem-iiis  of     ..         ..  fil2 

Nerves,  sensory,  distribution 

of  1 1,-,.  J.VM  ,.  .605 

Nerves,  spinal,  distribution 
of  sensory  rt 

-  thick. I . 

lingl'  '  ■■' 

Ncrvou.-i- 

llrst  I. 
_  from  al..a....| 
_  alcoholism  -Irrmlalcl  b. 

-  evtrasvsloles  froin 

-  in  Oraves's  di«en«e  229. 

48n,  703,  77.1 

-  incronscd  knee-)ork  with    311 
_  frreeiilar  lienrt  from     . .  »*I| 


Neuralgia,    facial,    general 
account  of  . .  448 

-  -  ptvalLsni  from  ..   .'il2 

-  after  hcrpw        431,  415, 

448,  754 

-  irdcrcostal,      aneurysm 

simnhiting    431,"  430,   707 
Neuralgia,     intercostal, 

general  account  of   .  ■  431 


sinmhling  ..    431 

-  -  new    growth  uf    spine 

sinmlating  . .         . .   i07 

pain  on  breathing  with  431 

in   the  epigastrium 

from        . .         . .  43G 

livpochondrium  from 

450,  451 

on  movement  vvitll  431 

pleurisy  sinuilnting  . .  707 

pucumonlnsinuilating 

432,  707 
spinal    abscess    simu- 
lating ..         ..707 

caries  simulated  hy  154 

simulating         . .  431 

tender  points  with 

431,  430,  4.'iO 

tenderness  from     7(H(,  7(»7 

x-rays  before  Ufagnos- 

iug    ..         ..      43«,  707 

-  inlistinal,     colic     simu- 

lat...l  l.v  ..  ..     115 

Neuralgia,  liitestlnal,  general 
account  of  . .   1 15 


ki.hi 


ol  427 


y'itrti,tlh-nia,  t^inftl. 

-  com])lete   incapacitation 

from    ..         ..         ..715 

-  constipation  from         . .  121 

-  craving  for  sympathy  in  71ii 

-  dissetniiiated     sclerosis 

simulating       ..          ..  313 

-  dysiii.ii..rrli.l!a  from  192,  193 

-  .lyspi'psi.i  from              . .  406 

-  e.vaggeratiou     of     s.vm- 

ptoms  in         . .         . .  716 

-  fatigability  in    . .         . .  715 

-  headache  from  ..      466,  715 

-  hvperacusis  in    . .         . .  309 

-  hyiiencsthesia  in       610,  611 

-  hysteria  simulating       . .  710 

-  imaginary     .se.xual     dis- 


r.ler  i 


460 


period  of 

-  insomnia  from  321,  322 

-  irritability  in    . .       323,  715 

-  knee-jerks     exaggerated 

in  ..  ..       358,466 

-  over-work  and  . .         . .  466 

-  o.\aIuria  and       . .  . .  424 

-  pain  in  the  arm  from  . .  445 
back  from       . .         . .  715 

-  -  face  ill 449 

limbs  from      . .     463,  465 

-  palnitutioii     from    460, 

484,  486 

-  phthisis  simulating       ..  313 

-  phosphates  in     . .  . .   522 

-  plantar  retlex  lle.xor  in . .  466 

-  pol.vuria  from     . .         . .  535 

-  from  pyorrluea  . .     74 

-  rapid  pulso  from  . .     88 

-  sex  incidence  of  . .  466 

-  shortness  of  breath  in  . .     88 

-  strangury  in       . .         . .  649 

-  suicide  from       . .         . .  309 

-  tomperaturo    subnormal 

-  tenderness  of  scalp  from 

710,  712 
Neurasthenia,  traumatic  ..  715 

-  tremor  from  . .    721 

-  weakne^Wriim  ..  ..715 

-  worrv  :n..l  .  .  lOO.  716 
Xeurili-  lr..ii.  id.<.l...|i-ni .  .  --.li 
Neuritis,   brachial,  general 

account  of     . .        ■ .  443 


-  of. 


nth' 


..  426 

Neuralgia,  mammary     i:i<i.  431 

Neuralgia,  metatarsal       . .  439 
Neuralgia    minor,    general 

account  of  711,  712 

-  after  nourilis     ..  .  .  431 

-  obturator  . .         • .  439 

-  Ill  osteitis  detorinans    . .  670 

-  ovarian,    appentlieitis 

Himulated  by..  ..  666 

-  pain  in  the  liicsl  from 

4,W,  431 

-  -  Jaw  from         . .         . .  4ll'i 

-  parosvsmal         I lacho 

'    an.l 20« 

Neuralgia.  phr»nlc  .  •  481 

silallc ■IS" 

in  Inbcs '131 

leniler  spots  Willi       200, 

431,  436,  450 

I.  .i.l.rr..--  ..t  ...lip  (r^HII  710 


-  liillltiph.     (see     .Neuritis, 

r.ripli.-ral) 

-  niu.*.-ul;tr  atrnphv  from     477 

-  ri.-nralgia  alter  .'.  .  .    431 

-  (H'cnpation  noiirosLs  sim- 

ulating ..    '76 

-  olfactory,  ano«mla  from  612 

-  optic,   rilbiiinliiurle  rell- 


iiliilli. 


116 


Neuritis,  optic,  appearancn 
of  i/'/.K.  .\/.Vi        ..  418 

-  -  Ir.nii  iil..\vl    ..  ..    7.M1 

-  -  black  spots  liefiin.  eyiw 

from  . .         • ,     72 

hradypnii.a  with        ..     HI 

cembollar  tumour     . .  592 

-  -  tTrebral    at»s<'i"»s     HI, 

117,  aiMi,  5112,  626 
_  —  -  luiaiiorrliiige  . .     HI 

Imioii.    HI,  85,   146, 

2U5,  5V0 

-  —  liilnunr,      HI,     147, 

306,  315,  1211,  503, 
.in:,    r.'.'.l,  6S6,  (II 


110 


120, 


NEURITIS    —    NOSE 


Neuritis,  optlt;  conttf. 

ycnrilis.  peripheral,  contd. 

I^euroses,  contd. 

Nitroglycerijie,  angina  alj- 

—  pachymeningitis        . .  525 

from  mercury  33,  65,  505 

-  vasomotor  (see  V.tsomo- 

ilominalis  relieved  by 

—  pellagra          . .          . .  225 

muscle  atrophy  from 

tor  Neuroses) 

pectoris  relieved  by. . 

plumbism        34,  119,  759 

61,     63,    351,    440, 

albuminuria  in 

13 

Nitroprusside  test  for  ace- 

— rare  with  haemorrhage     84 

466,  512,  515,  770 

Neurosis,    abdominal    dis- 

tone  

—  from  retrobulbar  neur- 

 myopathy  simulating       60 

tention  fi-om  . . 

418 

for  melaiiuria 

itis   ..         446,   525,  7G3 

Neuritis,   peripheral,   myo- 

- aiiic^ttie^ia  in     . . 

518 

-  -  (^Plate  XXXIV) 

—  sinus  thrombosis       . .  120 

pathy    distinguished 

-  i-arii-s  simulating 

477 

Nits             

—  sphenoidal   sinus   dis- 

from   ..         ..     513.  514 

-  rlifilitis  and       .. 

365 

Nocturnal  emission         15, 

ease             . .         . .  231 

from  naphtha            .  ,      liO 

-  diarrluna  from  . . 

173 

-  enuresis  . . 

—  spinal  meningitis      . .  417 

occupation  and         . .     65 

-  disseminated    sclerosis 

Node  on  bone,  alter  injurv 

-  -  uriemia           . .         . .     85 

oedema  of  legs  in      . .  414 

smiulating      . .      617, 

518 

-  periosteal,     in     typhoid 

—  vertigo  and    . .          . .   752 

-  -  pain  in      66,  66,  440, 

-  earache  from 

202 

fever    

-  _  vomitins  witli             .  .   768 

463,  465,  466,  505,  512 

-  of  fifth  nerve    . . 

543 

-  sinn-^urinilrir      ,  . 

-  p:ifln  iiH'iiiiiL'iris  simula- 

parsEsthesia  with  440,  515 

-  hysteria   distinguished 

No.l.-.      !'.n-M,t'-'.     ii,     mil- 

nir' 477 

pai-aplegia   from   510, 

from    . . 

487 

Lr;i||:i|     -\  |i|iil|-^         ."iS.*., 

(Kiiii  111  ilir.-huuiderfrom  474 

514,  516 

-  lachrvmation  from 

178 

Nodes,  syphilitic    . . 

p;u;tlv^i.s    agiLans   simu- 

 paresis  from  . .         . .  266 

-  nil --il'ili'-.-linrc-c  from    .. 

178 

NODULES 

lating  603 

pelvic     lesions    simu- 

- '1' '1     spine 

-  apple-jelly,  in  lupus     . . 

-  peripheral,  from  alcohol 

lating           . .          . .   615 

477 

-  cutaneous,  from  bromides 

66,  113,  256,  443,  465, 

perforating    ulcer    of 

Neurosis,  occupation     445 

476 

iodides 

166,  505,  555,  770 

foot  in         . .          . .    735 

-  ui>ii>    ui:.,    txaiiiinations 

~  definition  of 

-  -  ansesthesia  from      66,  606 

in  pernicious  ansmia      64 

ill  caries  of  suspected 

120 

'  -  in  erythema  multiforme 

-  -  anlile-jerk  lost  in      . .  440 

plantar  reflex  in       . .     68 

-  orthopncea  from 

418 

-  lupus       . .         402,  735, 

-  -  from   arsenic,  34,  64, 

poliomyelitis       simu- 

-  pain  in  the  hand  from . . 

151 

-  mycetoma 

65,  66,  73,  256,  443, 

latuig           ..          ..512 

-  paraplegia  from 

514 

on  elbows 

465,  466,  506,  529 

from  pregnancy         . .     64 

-  in  pregnancy     . . 

543 

neurofibromata   simu- 

 arthritis  simulated  by  351 

purpura  with . .          . ,  553 

-  prolonged  pyrexia  from 

563 

lating 

—  ataxy  from     . .          . .     56 

■  Baynaud's     disease 

-  pseudo-angina  from 

434 

on  scalp 

bacteriological    exam- 

simulated by         . .   256 

Neurosis,  pyrexia  and 

570 

-  in  rodent  ulcer..      403. 

ination  in  . .         . .     64 

reaction  of  degenera- 

- reflexes  with     . . 

518 

-  in  skin,  age  incidence  of 

—  in  Banti's  disease      .  .>   64 

tion  in   56,   59,   60, 

-  salivation  from.. 

643 

in   acute  rheumatism 

from  beer       . .         . .  529 

61,63,440,465,477, 

-  spasm  of  oesophagus  from  435 

Bazin's  disease 

-  -  beri-beri          . .       63,  414 

512,  514,  516 

—  vaginismus  from 

194 

from  carcinoma 

bilateral    facial    para- 

 rectal  examination  in  515 

-  writer's  cramp  simulated  151 

from  cjfsts 

lysis  from   . .          . .   627 

reflexes  in      . .        63,  515 

-  (and  see  Hysteria) 

cysticerci 

blood-count  in           . .     64 

scoHosis  from         163,  154 

Neutrophilc  liivclocvtes  (se 

epithelioma    . . 

in  cachexia     . .          .  .   467 

in  secret  drinkers     . .     66 

Mv.,ln,,vt.',.| 

erythema  keratodes . . 

—  from  carbon  bisulphide   65 

Neuritis,  peripheral,  sensory 

.\.,i",„  :.     ii,-,,i,iinal   dis- 

nodosum     . . 

—  Cauda   equina   lesions 

changes  from  63,  465,  607 

,    ■!,■       ■ 1     cystic 

fibroma 

simulating              ..  515 

from  sore  throat       . .    154 

12 

glanders 

chemical     substances 

-  -  in  splenic  anajmia    . .     64 

-  li.liliio^li.liiiiiaia   in 

284 

gonococcal  artliritis . . 

I'ansing        ..          ..65 

stocking      anajsthesia 

-  intestinal  oljstruction  in 

129 

due  to  knuckle  pads. . 

Neuritis,     periplieral,     in 

from            . .          . .     56 

-  jaunrlice  of       325,  326, 

329 

in  leprosy       . .        63, 

children      ..        ..512 

symmetry  of..         ..     56 

-  malformed  rectum  in  .  . 

129 

in    multiple      benign 

clironic  (ijaamia         . .      64 

from  syphilis  64,  466,  466 

-  miliary  abscesses  in     . . 

557 

sarcoid 

cirrhosis          . .         . .     64 

tabes  simulated  by  . .  614 

-  ophthalmia  of  (see  Opli- 

from  myoma. . 

contractures  from  140, 

distinguished    from  607 

th.almia  Neonatorum) 

in  osteo-arthritis 

351 

talipes  from  . .         . .  113 

-  pemphigus  of     . . 

401 

sarcoma 

cramps  frotn            66.  465 

tenderness  with    440,  465 

-  prolonged  pyrexia  in  . . 

667 

scrofulodermia 

-  -  in   iliitln'ti-',     ."i^i,    i;:'.. 

-  -  tremor  in       . .        66,  250 

-  septicasmia  in    . . 

567 

.syphilis 

1 1".  ■:■■-..  1 1:;,  466 

trophic  changes  in  . .   256 

-  tetanus  in 

730 

varicose  veins 

-  -  aii.liili.iM.  .-.i;   1,1.  ii.-i. 

from  tuberculosis     . .  465 

-  mnbflical     inflamm.ation 

in  yaws 

li:;,  uii.  lo:;,  i.:,4, 

typhoid  fever             . .      64 

in         .  .          .  .       .i67 

656 

Nodules,  subcutaneous,   in 

362,  465,  512,  589 

unsteady  gait  in        . .      56 

—  vaginal  hffimorrha,„',^  in 

'U'l' 

acute  rheumatism    i  \. 

-  -  disturbed  sensation  iji  256 

wasting    from        266,  514 

New  Zealand,  hydati,!-  ii 

L-Jl 

In,-,,  i.-,s,  .■;:;;,  338, 

—  dysarthria  from         . .  627 

wrist-drop  from        . .     56 

Nicholson,  on  testis  grow  Lh 

f;',H) 

Noises  in  ears,  various  722, 

—  extensor  paralysis  from  56 

-  of  pudio  nerve          193,  194 

Nicotine,  tremor  from     .  . 

Tlili 

NOISES  IN  THE  HEAD  .. 

—  fixed  pupil  in            . .  514 

-  retrobulbar,  age  incidence  760 

Night    blindness   land   see 

age  iacideiioe  of 

-  -  flaccid  paralysis  from  512 

blindness   from     446, 

ViMi.ii.  li-ifcfsof)  734,763 

from  antemia. . 

foot-drop  from          . .     56 

525,  760,  762 

irulM  rcliiiilisiiigment- 

atheroma 

in  funi^ating  en-locnr- 

Neuritis,  retrobulbar,  gone- 

osa  .  . 

761 

cerebral  aneurv^m    .  . 

ilitis             ..          ..64 

ral  account  of       445,  760 

-  cramps 

150 

Noises  in  the  head,  list  of 

-  -  t-'iiN^'i'i'iie  from       ITi.'*,  256 

from  inlluciiza            ..   446 

-  starts,  fi'om  hip  disease 

363 

causes  of 

Neuritis,  peripheral,  general 

optic  nenriUs  after  .  .    526 

-  sweats  in  Barlow's  dis- 

--   Xflti^'U   with     .. 

account   of   . .  63,  64, 

pain  hi  eye  from  445,  763 

ease 

654 

-  -  W  assermamis  test   in 

65,  465 

photopliobia  from    . .  524 

-  -  phthisis         288,  476, 

654 

cases  of-    .. 

-  -  glove  anissthesia  from     66 

from  plumbism          . .   446 

rickets 

654 

-  headache  from  . . 

from  glycosuria     260,  605 

scotoma  from         760,  762 

-  terrors     .  .          . .      321, 

402 

-  hearing  better  amid     . . 

-  -  gout    . .          . .         64,  466 

from  syphilis..         ..  446 

NIGHTMARES 

402 

Noma          ' 

—  hair  analysis  in          . .  529 

waxing    and     waning 

21 

-  bleeding  gum  from 

-  -  high-steppage   gait  in     57 

sight  with  . .          . .   445 

Nil  1 '            •    1     ,  .l\  -is 

706 

Normoblasts     (P/o/e     //, 

-  -  in   Hodgkin's   disease    64 

-  sciatic 438 

430 

Fig.  2) 

-  -  hyper.-osthesia  in       . .  140 

-  of   iirrn^.-npiilnrnerve..  606 

-   Clarlv.,,!,       |,aiii       m      the 

Northumberland,  tricho- 

- -  hyperalgesia  in      606,  607 

-  ' ,       ,,'     pine  from  713 

breast  from    .  . 

429 

phyton  rosaceum  in. . 

—  from      influenza     64, 

,■  ,,     ,  i.T.s        ..    703 

NIPPLE,     DISCHARGE 

Norway,  leprosy  in 

140,  465,  466 

-       11,  In,  ,i,iM   liom      ..   703 

FROM    181,   685,  686, 

Norwegian,  leprosy  in  {Fig. 

-  -  Klebs-Loeffler  bacillus 

:Neuiuiil.iuiiiaia,  rlieumatic 

687, 

730 

173) 

in 154 

nodules  simulated  by  732 

-  eczema  of 

730 

Nose,  acne  affecting 

-  -  knee-jerk  lost  in  358,  440 

-  skui  tumours  from       .  .    732 

-  epithelioma  of  . . 

429 

-  angioma  of 

—  Korsakow's  syndrome 

-  in  von  Recklinghausen's 

-  inflamed,    p.ain    in    the 

-  bleeding  from  (see  Epis- 

with             .  ,          .  .   466 

disease            . .         . .   710 

hroast   from    . . 

429 

taxis) 

Neuritis,    peripheral,    from 

-  pain  from           . .         . .  431 

Nipple,   Paget's  disease  of  730 

-  blowing,  epistaxis  from 

lead  :;i,  65,  ii::,  ) m. 

Neuroma,  vulval  swelling 

430 

subcutaneous  emphy- 

ii:;, -ii;.-,.  ir.i;,  505 

from    . .         . .          .'.   700 

-  relrartril  liv  tarcinoma 

687 

sema  from  . . 

Neuritis,  periplieral,  list  of 

Neuromata    of    brachial 

ill  Pagels  disease     . . 

730 

-  bottle 

causes  of                       61 

Plc^s 443 

-  scabies  of 

755 

-  bridge  of,  depressed   in 

—  from        leprosy        63, 

Neuromimesis,        arthritic 

-  secondary  areola  roimd, 

achondroplasia 

(Fig.  206)  505 

form  of           . .          . .   350 

in  pregnancy.  . 

430 

congenital     syphilis 

-  -  in  leukcemia   . .          . .      64 

Neuromyositis,  pain  in  the 

Nitrate  of  =ilvcrV=cc  Silver 

iFig.  106)  234, 

-  -  limping  from . .          . .  362 

limbs  from     .  .          .  .    463 

\lllMlr) 

fallen  in,  fi'om  injury 

—  loss  of  power  in          . .    614 

-  Senator  on          .  .          . .   464 

nasal  bone  necrosis 

of  weight  from      .  .    770 

Neuroses  of  bladder        . .  39S 

Xilnir  ,,1  .iiii.vl  (~,,|,  Aiiiyl 

syphilis 

—  in   lymphadenoma    . .     64 

-  blue  brain  and  . .         . .   163 

-  broad,  in  myxcfidenia  . . 

-  -  Manchester    epidemic 

Neuroses,    occupation,    of 

-  sodium,  in    Cammidge's 

and  flat,  in  Mongolism 

of     . .         . .        66,  529 

arm 445 

reaction 

100 

-  bullous  dermatoses  afifect- 

—  in  malaria      . .         . .     64 

-  from  pyorrhoea..          ..     74 

in  diazo-reaction 

173 

iiig 

XOSE 


(EDEMA 


855 


tsc,  conlil.  ' 

cerebrospinal  fluid  from 

119,  178 
chromidrosis  of . .  . .  655 

crusts  ill.  from  atrophic 

ri.iMiH  ..  ..179 


■I     i,' 


xostosis 


20-1 


3SE,  DISCHARGE  FROM   178 

-  (.iintl     see     Discharge, 

Nasal) 
dry,    from    fifth,    nerve 

paralysis 


,  to 


..   612 
..   220 

endothelioma  of        179,  180 
enlarged,  by  rosacea     . .  2il 
epithelioma  of  179,  379 

excoriation  of,  in'  nasal 
diphtheria       . .         . .  178 

fibroma  of  . .  . .  22<t 

Toreign  body  in  87,  179,  220 
gangrene   of,   from   em- 
bolism . .         . .     34 

hemorrhage    from    (see 

Kpistaxt«) 
inability       to      breathe 
tlirongh,  from  hyper- 
trophic rhinitis  . .   179 
lesions  of,  causing  epls- 
taxis    . .          . .          . .    220 

lupus  of  . .      179,  735 

picldn?,  epistaxis  from     220 


yijsCaginus,  contd. 

-  from       anterior      polar 

cataract  . .         . .  .759 

-  in  blind  persons  . .   407 

-  from  cerebellar  abscess    517 

lesions  . .         . .     59 

tumour  407,  408,  517,  593 

-  choroiditis  . .         . .  759 

-  colour  blindness  . .  407 

-  cunj.'  :;fM    .■,!   .M.'t  ..    407 


fron 


519 
654 


1 1-,  I";,  ("',  r.it;,502, 

517,  728,  700 

-  Friedreich's  disease  113, 

140,  407,  513 

-  hippus  with       . .         . .  552 

-  after  injury        . .  . .   408 

-  from  macular  coloboma  759 

-  in  miners  . .         . .  407 

-  ophthalmia         . .  . .   761 
neonatorum            407,  759 

-  persistent  hyaloid  artery  759 

-  after  poisoning  . .  . .  408 

-  from  retinitis     . .         . .  759 

-  in  syringomvelia       110, 

408.  508 

-  from      unusual      retinal 

pigment  distribution     407 

-  varieties  of         . .  . .  407 

-  vertigo  with      ..      408.  751 

-  from    working    in    dim 

light 407 


Occupation,  acroijaraisthesia 
and 444 

-  actiiiomyces  and  . .  G45 

-  acute  yellow  atrophy  and  334 

-  ankylostomiasis  and  81,  530 

-  anthrax  and       . .      559,  674 

-  aortic  disease  from      ..  209 

-  arthritis  from    . .         . .  476 

-  aspergiilus  of  lung  and  645 

-  beri-beri  and     . .         . .  414 

-  bullae  from        . .         . .     96 

-  caisson  disease  and       . .  307 

-  cervical    rib    symptoms 

and 443 

-  chancre  of  finger  and  . .  240 

-  "hronic  pharyngitis  from  613 

-  chlorosis  and     . .         . .     36 

-  cow-pox  and      . .         . .  240 

-  cramps  and        ..      150,  151 

-  dead  hngers  from     162,  163 

-  deafness  and      . .         . .   166 

-  dermatitis  from  . .  755 

-  in  diagnosing  heat-stroke  119 

-  drugs  in  sweat  and       . .   655 

-  Dupuytren's  contracture 

and  . . 
j  —  earache  from     . . 

-  epistaxis  from 

-  epithelioma    si 


and 


pink 

polypi   in  (see   Polypus 

Nasal) 
projecting,      in      micro- 
cephaly . .         - .  188 
pruritus  of         . .         - .  540 
Raynaud's  disease  affect- 
ing       . .  . .      256,  699 
red.  with  cirrhosis        . .  371 
regurgitation     of     food 
through  (see  Regurgi- 
tation of  Food  through 
>'ose) 
rhinoscleromft  of  . .  733 
rodent  ulcer  of           179,  735 
running  at  (see  Discharge, 

Na.sal) 
sarcoma  of  . .  . .  1''9 

sepsis  in,  arthritis  from  339 
-  foul  breath  from  . .  86 
.  -  meningitis  from  ..  590 
.  syphiloderni  of  . .  . .   400 

■  tubercnktsis  of  . .  . .    179 

luclear  paralysis,  facial  . .  493 
luctein,  derivatives  of     • .  742 


OBERMEIfiH,       spiro- 
chajte  of  (see  Spiro- 
clifflta  Obermcieri) 
OBESITY 408 

-  abdominal        distention 
from    . .  45,  655,  656 

-  amenorrhcea  from        . .     18 

-  anaemia  with     . .         -  -     32 

-  from  cerebellar  tumour  410 
-constipation  w.th         ..  127 

-  witli    deficieni    ovarian 
activity  .-      409,  646 

-  in  Dercum*s  disease     . .  410 

-  after  epididymitis        . .  409 

-  in  eunuchs         . .         - .  409 

-  fattv  heart  with  53,  90,  212 

-  glycoFuria  and  . .     260,  264 

-  from  hvpernephroma  . .    109 

-  larkof  ex»-T.i>..  .  .  ..    is.-i 

-  life  insuniM.-  (ii.d 
Obesity,  list  of  causes  of 

-  at  menopauit-    . . 

-  meralgia      parresthetici 
and 

-  after  orchitis     . . 

-  pal|iitation  from 
I  -  pancreatic    apoplexy    . 

-  from  pituitary  lesions. 
I  -  a  prcglvcosuric  stAte  . 

urine   . .  . .  4,  5  I  -  shortness  of  breath  in. 

-  uric  iicid  from  . .         . .  742  ,  -  simulating  ascitis 

-  in  urine,  withoxaluria.  .^  424  ;  -  sterility  from 
»Jumbness, 


-  erythema  from  222,  224 

-  eyestrain  from  . .      -146,  524 

-  finger  numbness  and  . .  444 

-  glanders  from    . .      179,  645 

-  housemaid's  knee  and..   476 

-  itehing  and        . .         . .  540 

-  lead  poisoning  and   117,  147 

-  loft  ventricle  etilarircd  hv  2<m; 

-  inen-urialism  and  :i3.  73,  726 

-  nail  chsiTiCes  and  .  .   399 

Occupation  neuroses  445.  476 
tremor  in        . .  . .   721 

-  noises  in  the  head  from  4nfi 
I  —  nystagmus  and..  *  ..  407 
j  —  onychia  from     . .         . .  400 

-  ossification     of     tendon 

from 671 

I  -  pain  in  the  eyes  from  -.416 

-  pallor  due  to     . .  . .      21 

-  peripheral  neuritis  anjl 

-  pharyngitis  and 

-  phosphorus,   powoning 


GuJcma.  tiiifjhneumiic,  conUl. 

electrical  reactions  in    584 

erysipelas  simulated  in  226 

-  -  erythema  in  . .       223,  220 

-  -  of  face  . .         . .  673 

familial  nature  of  226,  699 

family  history  in      . .  699 

febrile  attacks  in     . .  414 

hiemoelobinuria    with  284 

legs  affected  by         . .  414 

limb  pains  in. .  ..  226 

CDdema  of  hands  and 

arms  from  . .         . .  413 

ptosis  from    . .         . .  54 1 

pyrexia  in      . .      226,  699 

rigor  in  . .         . .  699 

tongue  swollen  in     . .  699 

tracheotomy  in        . .  699 

-  -  urticaria  simulating  ..  673 
vomiting  in    . .  . .   226 

-  from  antitoxic  sera      . .  410 

-  of    arm    (one),    from 
aneurysm       . .         . .  411 

from   carcinoma  of 

breast     . .         .  -  411 

142 from    mediastinal 

203  growth    . .  ..411 

221 x-rays  in  diagnosing 

cause  of  . .         ..411 
695     -  arms,  from  aneurysm  ..  159 

224 opening    superior 

,  524  vena  cava  . .     92 

444 angioneurotic    cedcma  413 

growth  of  lung         ,.   159 

hajmorrhageintointra- 

tlioracic  sarcoma  . .  159 

mediastinum         ..  159 

thvmus       . .         . .  159 

heart  failure  ..  -.413 

mediastinal  fibrosis  ..  159 

-  -   Ravnau.l's  disease    ..    413 

(Edema' of  arms,  from  vena 
cava  obstruction    !''>'.•. 

413.  751 


616 


408 


409 


p)M 


nd.. 


336 
73 
o'l-lMtbia  from     521,  525 

I'.'-'iTand'     "..  .'*    151 


-   II,  ,rn-l.ru.sj'inal  llu 

ii.'phritis 

lucleoproteid,  reactions  in 


!  -  umbilical  hernia  and 


67 


epilepsy 

-  in  disseminated  sclerosis  609 

-  of    fingers,   iu    acropar- 

ffistliesia  . .         . .  444 

.  _  occupation  and  . .  444 

-  after  Hushing     , .         . .  241 

-  in  sciatica  . .         - .  438 

-  sense  of,  in  paroxysnuil 

ta<,'hycardia    ..  ..   703 

-  from  peripheral  neuritis  466 

-  in  tabes 609 

S'umnnilar  sputum  149,  611 
[^urseniiiids,     hypertrophy 

of  bre:tst  in    .  -  . .   685 

-  scoliosis  in  - .  . .  l'»* 
Nurses,  chancre  of  linger  in  240 
Nutmeg   liver   ^see   Liver. 

Nutmeg) 

Nntniog-crater    skin,     in 


Obstipation  (see  Constipa- 
tion) 

Obstruction.  intfNtinal  ("see 
Intestinal  Obsirfiction) 

Obstruction  to  urine  out- 
flow, causes  of 

Obturator  evtertiu?,  nerve 
iupply  of 


horn 


FTcrtiiu,  Ob- 


supply  of  498 


Nyctalopia,  causes  of 


turator) 

-  intcrtiu^,  n 

-  nerve        •»" 

-  ncuralk'ia  - .         ■  ■    ^-"^ 
Occipital       lobe       legion-;. 

hemianop'iia  from  3ir.',  552 

pupil  retlcx  and    . .    552 

tumour  of,  visual  nuru 

with  ..  ..      «8 

-  lymph  gland**  (see  I^ym- 

nliuticr.lands.Ocripitan 

-  rc.-i..Ti.ll:a.lT.  MonK0lii»m    190 

) .  eyelid 


-  scrratus     magnuM     par- 

alv><is  and       . .  .  ■   506 

-  sore'tingers  from  . .  239 
thront  from   ..  ..   613 

-  subacromial  bursitis  and  476 

-  tendertifss  of  spine  from  715 

-  tinnitus  from     . .  . .   724 

-  torsio  t<'«tiH  and  . .  480 

-  tremor  and        ..      151.  724 

-  vesicular  dernnidtis  from 

07.  224 

-  wnriM  from  . .   240 

-  WVil'.  .Ii^e,w.  und  ..    336 

Octironosls.  notes  on   528.  746 

-  iri'it.-  .v.v.v///t         ..  716 

0»-ulo-pni'MIiirv    llhn-^.    in 

1st  .lorwd  n-Tve  rcMit  5n9 
Odontoma  . .        .  ■     ««3<  MJ 

-  trimnuH  dinnilatwi  by  . .   729 

-  niUro«'«pe  In  diagnosing     74 
(Edema  of  alHlominal  wall. 

from  tuberctdous  perl- 


-  from  ;isi)irin 
(EDEMA,     ASYMMETR 

CAL     ■■ 

-  of  back  from  vena  ca 

thrombosis  7,  t 

-  bladder,  in  cyst  His 

-  from  bromides  . . 

-  buUtn  with 

-  from  cellulitis    . . 

-  chyluria  with     .. 

-  congenital 

-  from  drugs 

-  in  eczema 

-  of  eyelids.  In  cavernous 

sinus  thrombosis 

from  crying  . . 

In  glaucoma  . . 

Graves'*  dlseaso 

-  -  nephritis        . .         9. 
ptosW  from     . . 

-  -  from  trachoma 

-  -  In  trirhlmwi*  . . 

-  face  from 


nil 


..   410 
96,  07 

..   410 


idnvici 


nitb 


031 


-  from    ocnle    nephrill* 

281,  413 

-  anmioti."  bands..  ..  410  , 

-  in  aminnic  liirU  ..  ..  412 

(Edema,  angioneurotic  410.411. 

(Fi-r  17M)  112 
(Edema.        anoloneurollc, 
acute  attacks  In        ■ .  226 


-  -  cellulitiM 
coughing 

—  cohU  . . 


-  -   lir»rl   iltax'itM).. 
mivliMtincil  flbr 


Nylanrier's  test  for  sugar    282 
NYSTAGMUS  -.407 


-  iilbumhiurln  in 

-  niiglna  T.udovlcl  *imu- 

lato<l  by     . . 

-  (iKplrin    crTo*'tA    simu- 

lating 

-  dentil  (mm 

-  dlnrrlMi-n  In    . . 


13 


.<lt.|«  413 
..  673 
.,    410 


(EDEMA 


OPERATION 


(Edema,  contO. 

-  of  feet  in  chlorosis    ^7,  : 

with  cirrliosLs  . .  ; 

in  crythromelalgja    . .  • 

polymyositis  . .         . .  ■ 

-  from  filariasis    . .         . .  ■ 

-  general,  in  infants         . .  • 

fungating  endocarditis 

--  -  gastro-enteritis  . .  • 

nephritis        . .  0, 

snake-bite       . .  , .   ; 

-  of    genital    organs,     in 

acute  nepliritis 

-  hands,    from    angioneu- 

rotic oedema  . .         . .  < 

heart  failure  . ,         . .  < 

myxoedema  simulating 

from    Raynaud's   dis- 
ease . .         . .  ' 

-  head,  from  vena  caval 

obstruction    . .         . .  1 

-  innor    side    of    eyelids, 

iMHii  ■■i-[iin[ictivitis  . .   1 


I'hritis 


(Edema    of    larynx,   acute 
bacterial         . .      410. 

-  -   ill   ;iti,L'i!i;i   J.iulovici    .  : 
from  Bright's  disease 

159,  420, 

-  -  iodism  159,  418, 
laryngeal    obstruction 

from 
"  -  from  laryngeal  ulcera- 
tion 

-  -  orthopiicea  from 
stridor  from  . . 

suffocative,    laryngeal 

paralysis  simulatmg 

-  leg(onp)  ill  Milror's  .lis- 


with  ..  ..411 

thrombosis   8,   410,    749 

vaginal  examination 

with        ..  ..411 

—  legs,  albuminuria  with..  412 
from  anasmia. .         . .  413 

—  angioneurotic    cedema  414 

—  ankylostomiasis        . .     54 

—  from  aortic  regurgita- 

tion .  .         . .  ...  207 

—  with  arteriosclerosis. .     11 

—  ascites  . .         . .     52 

—  from  back  pressure  52,  212 

—  in  beri-beri    . .        R3,  414 

—  Bright's  disease    105,  412 
cachectic  states         ..   413 

—  from     carcinoma     of 

kidney        . .  . .  750 
recti            . .  . .       7 

—  chlorosis  . .         . .  413 

—  chronic  nephritis       . .   212 

—  in  convalescents       . .  414 

—  after  duodenal  ulcer. .  414 

—  from  emphysema     . .   217 

—  after  fractured  femur  414 

—  after  gastric  ulcer    . .  414 

—  with  granular  kidnev      11 

—  -  after  Imtniorrhn^e     ". .    413 
from  Im.iii    1  mIiii  ■■   Ti-j. 


■  high  I. 

-  HodL'k 
inter  ill 


[Edema  of  legs,  list  of  causes 
of         415 

—  from  malaria..         ..  413 

—  malignant  cachexia  . .  413 

—  massage  for  . .  . .   414 

—  -  in  Meige's  disease     . .  414 

—  from  mitral  regurgita- 

tion ..      210.  211 

—  myocardial  changes  90,  300 

—  mvxcedema    . .  ^      . .  414 

—  -  nephritis         . .      412,  413 

—  -  with  nutmetr  liver    . .  334 

—  in  old  people  . .  414 
~  -  peripheral  neuritis    ..   414 

—  pernicious  anaimia  . ,  413 

—  from  portal  obstruction  272 


(Edema  of  h(is,  could. 
pseudo-lcukjemia     in- 
fantum       ..  ..   41.S 

ill  Raynaud's  disease    414 

from  renal  growth  . .       7 

ulated     by     myx- 


oede 


537 


413 
414 
410 


from  splenic 

starvation       . .  . .   413 

syphilis  . .  . .   413 

with  tricusjjid  regurgi- 
tation . .  •        . .      92 

tube  casts  with         . .  412 

from  tuberculosis 

-  -  after  typhoid  fever 

-  -  varicose  veins 

-  -  vena  cava  obstruction 

749,  750 

■  from  iignture     . .  . .   410 

■  hneje  aibicantes  from  . .  365 
over  liver  abscess  . .  370 
of  loins,  in  nepliritis  9,  412 
lungs,  acute,  in  Bright's 

disease            . .          . .   420 
from  lvm])hatic  obstruc- 
tion"      410 

\\  ji  h    itiiili'jii.itit    pustule  559 


from  near 

nutmeg  li- 

-  of    palms. 


I  ligature..   411 


■Jtis 


nd 


^\  Mil   jiii|\ii  -lie  kidnevs    42 
[inhun.i   atlLT    ..       535,  530 

-  of  prepuce,  from  balanitis  617 
from  chancre. .         . .  C19 

-  retina      . .  . .  ..   41G 

-  scalp,  in  nephritis        . .  412 
from    superior    longi- 
tudinal sinus  tlirom- 
bosis  . .  . .   597 

wound  infeption  ..    410 

-  scroliiin,   ill    nepliritis    ..    412 

til. Ill    prt  i-mvtliral  ab- 


p  ricks 


-  of    soles, 

keratodi 

-  solid,     fro 

ohstniPl 
(EDEMA.  SYMMETRICAL  411 


eryth 

..405 
lyniphatic 


-  of    trunk,    from    renal 

growth 

-  umbilicus  in  tuberculous 

peritonitis 
(Edema,  universal..        ..  ' 

from  nspirin  .  .  .  .   ' 

beer  swillinir  . .  . .  - 

-  -  in  Bright's  disease   . .    ] 

from  drugs     . .  . .    ■ 

infusion  . .  . .   -. 

(Edema,  universal,  list  of 

causes  of  . .  ^ 
from  snnke-bite         . .   ~. 

-  from  venous  ohstruction  ■: 

(Esouhaqismus  . .  ^ 

(KM.pl,:iL-'n-ro|,r         ..  lil.",,     ] 

-  in       dijgnusni-      foreign 

body  in  oesophagus  . .  : 
Oesophagus,  aneurysm 

opening  into  267,  120, 
2fi5,  < 

-  bean  in  . .         (Fig.  95)  ] 

-  bone  impacted  in         . ,   ] 

-  bullous  dermatoses  affect- 

-  cardiac   end   of,    site   of 

sensibihty  of . .         . .   1 

-  chicJken-pox  affecting  . .  (' 


haematemesis  from  affec- 


i  of 


2G5 


-  idiopathic  dilatation    of 

(Fig.  98)  198,  7G3 

-  opened  by  foreign  bodv 

2fi5,  2G7 

mediastinal  new  growth 

265,  2G7 

-  obstniction    of,   by   ab- 

norma  I     subclavian 
artery  . .  . .   196 

acetonuria  from       . .       4 

anaemia  fi-om. .         . .     33 

by  aneurysm..      195,  434 

bougie  in   diagnosing     7G3 

cachexia  from  . .     33 

by  carcinoma  ..   195 

constipation  from     ..    123 

-  -  after  nnrmsives  ..    194 
ij.iiii   111. mil-  stricture  194 

-  ■     i..niL'i,  l.,..h-   ..  ..194 

-  ■     |.u.-M|.,i,],i  with         ..   361 


(Esophagus,  obstruction  of, 
list  of  causes  of        . .  763 

oesophagoscope  in  dia- 
gnosing      . .  . .  195 
(•  r)ie>t  from  4MI» 


-  p; 


. .      74 

. .    G45 

■vlon     . .   645 

iiluted  by  G45 

. .    G45 

<  ina  from  222 

l;i-  from. .      96 

ind  Age 


..69 
. .      20 
,  definition    20 
uhLiu-^permia.  sterility  from 

646,  G47 
Oliguria  (see  Anuria) 
Olivo-ponto-eerebellar  atro- 
phy     . .  . .  . .    727 

Omentum,  abscess  of  fsee 
Abscess,   Omental) 

-  evst  of 661 

-  fat  necrosis  in  . .         . .   767 

-  in  hernia. .  . .      675,  G82 

-  hydatid  cyst  in  . .      657,  658 

-  lesions  of,  pelvic  swelling 


]..Tiio!uti-      . .     171.  :;(;7 

MMuiLiLin-  fiilar-cd  liver 

48,  367 
thickened  by  carcinoma    49 

-  colon    growth     simu- 

lating . .  . .   425 

-  stomach  growth  simu- 

lating . .  '. .   425 

■  tumour  of.  bile-duct  ob- 

stnirtinn  bv    ..  ..331 

■  -     l;.MfHllr..     lr<.lll  ..     331 


Ollirn/llin.   Cnil/d. 

spleen  simulated 

tuberculous    . . 

-  in  umbilical  hernia 
Omphalo-mesenteric 

cyst  of 
Onions,  foul  breath  fr 

taste  from 

Onychauxis 

Onychogryphosis  . . 
Onychomycosis 

Onychorrhexis 
Ooplioritis.    pain    in 

fossa  from 

lielvis  from     . . 

Opaque   nerve  fibres, 

(PhU'  XfX)   .  . 


331,  ' 
duct. 


-  aciile  iliiaUUiun  of  Stol 

ach  after 
peritonitis  after 

-  for  angioma  of  tongue 

-  anuria  from 

-  in  appendicitis  . . 

-  aspiration 


-  .h. 


afte 


■  nf  t 


;  fron 


omyc 


-  -  antral  tumour  ..    685 

appendicitis    . .  . .    450 

apijendicular  adhesions  458 

brciist  tumour  . .   181 

calculus  . .  . .     41 

carcinoma317,459,68G,687 

cause    of    fteces    per 

urethram    . .  . .   238 
intestinal     obstruc- 
tion         . .  . .   241 

cholecystitis  . .  . .  450 

diaphragmatic  hernia    652 

duodenal  ulcer  . .   450 

hiematocele    ..      4S1,  482 

hydrocele    of    liernial 

sac 681 

681 


lipoma  of  cord 

mucocele         . .  . .   254 

nature  of  pelvic  swell- 

new  growth  of  testis. .  69G 

submammary   abscess  686 

torsio  testis    . .      480,  696 

tuberculous  abscess  of 

liver  ..  ..375 

breast  . .  . .   686 

iliac  glands  ..  459 

ureteral  calculus       . .  455 

ureteritis         . .  . .   455 

-  distinguishing  empyema 
from    abscess    in    the 


suhdiai^hrag- 


oliMi 


"  Imi-  :iftC 


.'90 


lot 


-  for    empyema    of   gall- 

bladder ..         ..  254 

-  enuresis  cured  by         . .  218 

-  epididymo-orchitis  from  478 

-  epistaxis  from 


1  tabc: 


484 


;ifrr- 


.  in   jaundice   cases,   fatal 

oozing  after    . .  . .  555 

-  neurasthenia  after         . .  715 

-  cedema  after       . .          . .  411 
pain  in  pelvis  after       . .  4G8 

■  paralysis  of  palate  after 


■  -  pharynx  after 

■  pleurisy  after    . . 

■  for     pneumococcal 

thritis 


588,  589 


OPERATION    —    OSTEOSARCOMA 


nftor    . .      335,  ^ 

ifter  ..  ..  i 
ttion  of  food 
-'li  nose  after  . .  i 
ii  of  urine  after  : 
\  iiiphaticus  and  '. 
11  ic  abscess  from  i 
riiilous  caicum. .  ■ 


nil  of  larynx  from  : 

iMf  diverticMlIitis  • 

iL'iilnted       hernia  - 

till  ovariaTi  I'edicle  ■: 


Oplic  disc.  mini. 

-  -  il'lales  XIX.  XX)  41C,  J 18 

-  -  white  and  excavated, 

in  glaucoma  . .  233 

-  nerve  (see  Nerve,  Optic) 

-  neuritis    (see     Neuritis, 

Optic) 

-  radiations,     lesion    of. 

hemianopsia  from  iFtg. 
IH)     ..         ..      3111,  302 
pupil  reaction  and . .  302 

-  thalamus,  athetosis  from 

lesion  of         . .         . .    133 

ha^morrha{;e  into        . .   309 

lesion,  hemiantosthcsia 

with  . .         . .  GIO 

pain  in  limbs  from  GIO 

tremor  from  . .  72S> 

-  tract   connections   ^Fig. 

138)     .. 

lesion,    bcmianopsi 

from  iFig.  140) 


-  perforation  of  cornea 

-  uherntioii   with  '.'. 


riuuii-     .iiu-  thrombo- 

phthalmoplegia  (and  see 
Paralysis :  and  Stra- 
hismiis)  with  l.nOtar 
paralysis 

interna    , . 

from  plMnd>istn .  . 

PHTHALMOSCOPIC  AP- 
PEARANCES 


,\  /  ' 


i»ISTHOTONUS 


■lie,  118 

..  417 

138,    117 

..    117 

strychnine  . .      417,  599 

in  tetanus  138,  417,  599,  730 
from  nrmmia  ..  ,.417 
pium,  bradypn<L'ft  from  84 
Chevne-.Stokcs  breathing 

from 108 

coma  from  . .  . .  118 
constipation  relieved  by  124 
headache  from  . .  . .   295 

hypothermia  from     119, 

310,  311 
poisoning,    alcoholism 
simulating      . .         . .  310 

-  coma  in  . .         . .  310 

-  heat-stroke  simulating  310 

-  laviige  of  stomach  for  118 

-  pin-point  pupils  in 

119,  310 

-  pontine     limmorrhiM^c 


uhitod  In 
nuhiti 


(and  sec  iforphia) 
ppler-ltoas'   bacilli,  with 
gnstrii;  carcinoma  3111, 

320.  7(lti,  707 
pponcns    minimi    digiti, 

nerve  supply  of         . .  504 
pollicTS,  iiervo  supply  of  504 
psonic  iixlex.  in  diagnosing 
gonococcal  infection..  310 

-  -  phthisis       . .  . .  7fi8 

-  -  tubercle      ..     479,  077 
ptic      chiasma      lesions. 


blinilnci 

hr 


I  from 

nil' 


-  from , 


..   300 


301,  StW,  761 

pupil  Inaction   and 

302.  552 
Oral  sepsis,  anicmia  from      32 

—  dyspepsia  from        . .  319 

foul  breath  from      80,  87 

gastritis  from  . .  317 

peripheral  neuritis  from  01 

(and  see  Caries,  dental ; 

and    Pvorrlicea    Al- 
vcolaris) 
Orange,  sore  fingers  from     239 
Orange-rind  nails  . .         . .  399 
Orators,  pharyngitis  in     . .  010 
Orbicularis  oris,   weak,  in 

myopathy  [Fig.    109)  235 

-  palpebrarum,  cramp   of, 

in    watchmakers       . .  151 

hysterical        ..  ..141 

ptosis  from    ..         ..   141 

spasm  of,  in  paralysis 

agitans        . .  . .   236 

weak  in  myopathy  . .  235 

Orbit,  abscess  of  . .  . .   177 

arteriovenous   aneurysm 


of 


dermoid  cyst  of . . 
growth  of  . .         . . 

■  -  microscope    in    dia- 


Orbit.    lesions   of.    causing 

exophthalmos  . .  229 

Orbit,  pulsatile  tumour  of    694 


uppi 


,  headache 


291 


meningitis  from         . .   600 

-  swelling    in,    from    eth- 

moidal cell  distention  230 

-  tubercle    of,    cellulitis 

simulated  by..  ..  230 
•  -  exophthalmos  from..  229 
microscope  in  diagnos- 


ing 


230 


-  nasal  sinus  distention 

simulated  by         . . 

tumourof,  exophthalmos 

from    . .  ■■  ,      ■■ 

-  headache  from 

'  varicose  veins  in.  inter- 
mittent exophthalii 


Organ-idayiug,        plantaris 

longus  rupture  during  554 
Orientation,  visual  process 


pticdisc.  In  hypermetropic 

astlamalism    . .  -  417 

ptIc  disc.  In  glaucoma  417.  7i',i 

-    iH.iniiil    (/■/„(,      .V/Al    1li; 

ptIc  disc.  In  optic  neuritis  416 


ptIc  disc,  various  appear- 
ances of 


-  -!i.  1,111  'M'ci  cansltlg 

Orchllts.  lyphllltlc, 

--   ,.-(i.Mllar    ..trophy    nl 


of 


175 


ORTHOPNCEA  . .  4ia 

-  from  abductor  paralysis  419 

-  aneurysm  . .      4 19,  420 

-  with  arteriosclerosis     . .     11 

-  from  asthma      . .         . .  323 

-  in  Bright's  disease       . .  105 

-  bronchitis  160,  323,  420 

-  bronchopneumonia       . .  420 

-  diphtheria  . .         . .  419 

-  emphysema        . .      100,  323 

-  enlarged  cervical  glands  419 

heart   . .  . .  . .   420 

thymus  gland  ..  419 

thyroid  gland  . .  419 

-  foreign  body       ..  ..419 

-  with  granular  kidney  . .     11 

-  from  heart  failure    105, 
420,  094 


from  . .         . .  322 

-  from  irruption  of  caseous 

gland  into  trachea   ..   420 

-  larvneeal  obstruction   ..    119 

-  laryngismus  stridulus  ..   42n 

OrthopncBa,  list  of  causes  of  418 

-  from    mediastinal    new 

growth  ..         ..  419 

-  phthisis 323 

-  pleural  effusion  and     . .   104 

-  from  postpharyngeal  ab- 

scess    ..       ■  ..  ..   419 

-  pulmonary  embolism  . .  289 
Orthostatic  albuminuria  . .     15 

Orthotoinis.  in  tetanus  ..    138 
Os  calcis,  spine  on,  painful 
heel  from        ..      439,  071 

skiagram  of  . .   440 

x-rays  in  diagnosing 

4.39.  071 

-  uteri,      stenosed,      dys- 

menorrhoea  from       ..   192 

-  -  (anil  sec  rierus) 
Osaxone  crystals  iti  Cam- 
midge's  reaction       ..   100 

from  glucose  . .         . .  262 

-  -  glycuronic  acid  . .  262  [ 

lactose  ..      261,  202 

pentose  ..      201,  202  ! 

Osier,  on  nicvi  of  mouth. .  283 

^  ivphoi.l  iaunilice  ..  .335  ] 

o^lirs  •  Modern  Medicine," 

I'ig.  fnnn        . .         . .  607 
Osniic  acid  (see  .\cid,  Osmic) 
<  Issiclcs  ul  ear.  t'lirhs*  of  422,  423 
Ossification  of  ligaments..    143 

-  milsclts 143 

-  plantar  ligament  ..   671 

-  premature,  in  infantilism  188 

-  oft«ndon  ..      671,  6113 

OnlHtd  man  . .  143 

Osteitis  ileformans,  ago  Inci- 
dence of     . .          . .  670 

-  ~  hone  chniiKra  in     400,  6711 

-  -  (Fm.  03  and  (14)      . .  156 

--         ilv  .|.liir>    in     ..             ..  670 

..  166 

..  166 


Orbital  ridge,  thickened, 
from  frontal  sirnis  dts- 
tcnlion  ..  ..    '. 

Orchitis  (and  see  Epidldy- 
ino-orchills) 

-  atroliliv  of  testis  frotn. . 

-  bacillus  coll  causing     .  .      '■; 

-  bacterial  diagnosis  of  . .     07 

-  from  a  blow  .  .  .178 
Orchitis,  causes  ol  68.  478 
Orchitis,  general  account  of 

477.  478.  479 


2.30    Osteitis  deformans,  notes  on  670 


0.itro-arlIiritis,  omitt. 

-  joints  affected  by    345, 

340,  347 

-  knee  affected  by  . .  347 

-  knuckle    pads    confused 

with 347 

-  kyphosis  from  . .         . .   188 

-  lameness  from  . .  . .   347 

-  limping  from     . .  . .  252 

-  loose  body  in  joint  in  . .   350 

-  nippingof  synovial  fringes  350 

-  nodules  in  skin  in         . .  338 

-  in  osteitis  deformans  . .    155 

-  pain  in  the  limbs  in    . .  463 

-  popliteal  bursa  in         . .   092 

-  no  pyrexia  with  ..   346 
Osteo-aVthrltls.  rheumatoid 

arthritis   distinguished 
from    . .  "i  ■•.  346 

-  sciali.i.  caUMil  l.v  ..    347 

-  simulating      . .         . .  ::  ii; 

-  of     spine,     appendicitis 

simulateil  by..         ..  401 

pain  in  iliac  fossa  from 

452,   451 
ureteral  calculus  simu- 
lated by  ..  401 

-  spondylitis   ileformans 

and      . .  . .  . .    714 

-  stethoscope  iti  diagnosing  347 

-  swelling  of  bones  in      . .  670 

-  s>*tdulis  simulating       . .  348 

-  syringoinvelic jointsimu- 

Inting  '. 348 

-  ulnar  detlcction  in       ..  317 

-  wet  sand  in  bag  sensa- 

tion in  ..  ..    317 

Osteo-arthropathy.       pul- 
momiry(see  i'ulmonary 
Osteo-arthropathy) 
Ostoochon«lritis.     in    con- 


nilal  I 
«ipi 


Osteogenesis       Imperfecta 

(Fig.  87)    1S7.   188 
Osteoma  of  bone  . .  ..  070 

-  criuiium,         bradypiuca 

from 81 

-  frontal  bone       . .         . .   23tt 
•  ilium,  pain  in  iliiu;  fossa 

from    . .  . .      464,   I6ii 

-jaw          . .  . .   683,     OS  I 

-  spurious  . .  . .  tl7l 
Osteomalacia,  dwarfism 

from    ..  ..      180,  187 

-  eosinnphilia  from         ..   219 

-  kyphosis  from   . .  . .    188 

-  muscles  weak  In  ...  187 

-  relation      of      fragllitu 


Ostoon»yelltis,   acuto   pain 


187 


vlth 


008 


-  nciitt',  suppurative  nrtli- 

rll  is  frniu  ..311 

-  nininnia  wllh      ..  ..     35 

-  cndoi'Jirdltls  In  . .         ..   283 

-  eosiimphiliii   from         ..   219 

-  crvlhema  noilosnmttimu- 

'intlng  ..  401,  008 

-  from  giinuint 

-  of  Ilium  . . 

-  Infective,  rigon)  In 

-  li'Uco<'Vto«U   villi 
--  llni|ilng  from     .. 

.,(  |.cl 


669 


.'    vpblllx  ..711 

-  rir,'l\inc.   in   i*onguidtal 

svphilis  ..711 

-  Mtn'omn  nlmuliiMng       . .  693 
_  icniliTiniR^  from  . .   7ii7 

II- .i.nlirllU.     Chari-ot'- 

l.,ii,l    -liiiiitiiling  .  .    3111 

Osleo-arthfltis,  general  10- 
count  of  ■  346 


HUppI 


.  .  668 
302,   363 

..  678 
ith     1168 

..  1168 
i>   ullli      ..  ..    AOH 

.  iind-«i'llinuwlth  668 
111  .liniilallng  ..  672 
I  blliilenil  ..    401 

-allvi>,  iilliuniofiiirlii 


Till- I   ab< 

friini 


•  11  h 


10 


-  Ilbin  nlTn'tnl  liy  . .   411 

-  •w<-lllng  on  n  linnn  fmm  66 
I  lnliKiplivK',  I'liuiiarl'ii  llga- 

minit  biilgiHl  liy        . .   A7c 

l>«l(>4ipll 


li'iilllllUlK 


21)1 
runt    lOII 


OTALGIA 


PAIN,    ABDOMINAL 


OTHER-HANDNESS         ..      17 
Otitis,   acute  hemorrhagic  421 


Otitismedia,  bacteriology  of  422 

-  -  broiichopiieumoiiia 

from  . .  . .    289 

cerebellar  abscess  from  592 

cerebral   abscess  Ironi 

84,  306,  752 

cervical  glands  enlarged 

from  ..  ..379 

chorda    tympani   par- 
alysis from . .  . .    706 

Otitis  media,  complications 


of 


84 


convulsions  with 

deafness     from      165, 

308,  422,  423 
-  -  delii-iumwith..  ..  202 

earache  from. .         . .  202 

eczema  from  . .         . .  422 

empyema  from         . .  106 

granulations  fi-om  421,  423 

haemoptysis  in  . .  106 

hEBmorrhage  from  ear 

in 421 

headache  from  . .  295 

hearing  impaired  with  202 

hyperaisthesia  acustica 

in 166 


infarction     of      lungs 

from  ..  ..    lOG 

in  influenza    . .      ^    . .   564 

internal  carotid  artery 

eroded  from  . .  421 

jugular    vein    throm- 

106 
421 


menintritis  from        . .  59U 

noises  in  the  head  from  406 

optic  neuritis  from  . .  202 

■  otorrhoea  due  to       . .  421 

■  otoscopic  appearances 


of 


202 


pain  in  hyoid  area  from.  449 

-  ear  from    165,  422,  423 

-  over  occiput  from     202 

-  on   opening   mouth 

with         ..  ,.202 

■  4)leurisy  from  . .  100 
•  pneumococcal  . .  339 

-  polypi  from    . .      421,  423 

■  prolonged  pyrexia  from  567 

-  pulmonary    embolism 

from  . .  . .   159 


pyp 


vith  . 


202 


from  {Fig.  244)  56' 

after  scarlet  fever  10,  617 

screaming  from         . .  202 

septicaemia  from       . .   567 

simulating  meningitis    202 

suppurative  meningitis 

from  . .  . .     84 

swelling  of  meatus  from  422 

tenderness     of     scalp 

from  ..  ..712 

tinnitus      from      165, 

422,  423,  723 

tuberculous    . .         . .  422 

in  typhoid  fever       . .  595 

unilateral       headache 

from  . .  . .   294 

vertigo  from  423,  752,  753 

vomiting  with        202,  765 

Otorrhagia  (see  Hreraorrhage 
from  E;ir) 

OTORRHEA  .421 

Otorrhoea,  albuminous  dis- 
charge in        . .  . .  421 

-  arthritis  from    . .  . .  339 

-  cerebellar  abscess  from  517 

-  from  cerebral  abscess  . .  423 

-  from  diphtheria  of  ear. .  422 

-  diphtheria  of  skin  with  558 

-  from  eczema       . .  . ,  422 

-  epithelioma        . .  . .  422 

-  foreign  body       . .  . .  422 

-  furuncle  . .  . .      202,  422 

-  mastoid  abscess  . .  423 


Olorrhcsa,  contd.  ' 

-  necrosis  of  bone  . .  422 

-  noises  in  the  head  from    406 

-  from  otitis  media     421,  422  ' 

-  parotid  abscess. .         . .  423 

-  rigors  from        . .         . .  597 

-  from  scarlet  fever        . .  227 

-  sinus  thrombosis  from. .   597 

-  from  suppurating  lymph 

gland  . .  . .  - .   423 

sebaceous  cyst  . .  422 

temporomandibular  ; 

lolnt  . .  . .   423 

-  syphilis   . .  . .  .  -   422 

-  tuberculous        . .  - .   422  , 

-  from  wax  in  ear..  ..  421  | 
Otosclerosis,  deafness  from 

166,  753 

-  iiMi^r-;  i,i  tin-  head  from  406 

-  |.;ii,i.-i)si-    Willisii    with     165 

-  TMihim-  ii-un,       ..       723,   753 


■  bilharzia 


iFig.  217)  5 
(^Fig.  26) 


-  -  urine    . .         282,  472,  \ 

-  distoma,  in  faeces         . .  \ 
in  sputum      . .         . .  i 

-  in  fEEces  . .         . .         . .   I 

Ova    in   faeces,    mode   of 

examining  for  . .  ! 

-  in  sputum  . .         . .  i 

-  of     ttenia    solium     519, 

{Fig.  21G)  ; 

-  trichocephalus        dispar 

(Fig.  28)  80,  520,  {Fig. 
219)  \ 
Ovarian  abscess     . .  . .   i 

Ovarian  activity,  deficient, 

general  account  of   ■  ■  I 


obesity  from  40S.  409,  646 

-  cyst  (see  Cyst,  Ovarian) 

-  secretion,    menstruation 

and  ..         ..        18,  388 

-  tumour      (see       Ovary, 

Tumour  of) 
Ovaries,    absent,    sterility 

from    . .  . .  , ,   64  6 

-  defective,  in  ateliosis  . .  191 

-  destruction     of     both, 

amenorrhoea   from    . .      18 

-  prolapsed  tender,  dyspar- 

eania  from     ..      193,  194 

-  ■ levator  ani  spasm. .    193 

vaginismus  from   . .   193 

-  th3rroid  relationship  to     409 
Ovaritis,  appendicitis  simu- 
lated by         456,  665,  678 

-  generally  bilateral  457 

-  pain  in  Iliac  fossa  from. .  456 

-  simulated  by  undue  ab- 

dominal aortic  pulsa- 
tion     . .  . .  . .   543 

Ovary,  affections  of,  etl'ect 

on  menstruation      , .     19 

anaemia  with  . .         . .     32 

appendicitis  simulated 

by    ..  ..      456,  665 

eosinophilia  with      ..  219 

pain  in  the  back  from  428 

ureteric  calculus  simu- 
lating ..         ..578 

-  cai'cinoma  of  (see  Carci- 

noma of  Ovary) 

-  cystic,  felt  per  rectum  587 

-  fibroma  of  . .         . .  6S9 

-  functionless,    with    uni- 

cornuate  uterus        . .     19 

-  by  per  aesthetic,  in  hysteria  611 

-  impacted      tumour      of, 

backache  from  . .  4GS 
pain  in  thigh  from    4GS 

-  inflammation    of    (see 

Ovaritis) 

-  neuralgia  of        . .         . .  665 

-  new   growth    of,   pelvic 

swelling  due  to         . .  6S8 

,  felt  per  rectum     . .  587 

I  -  papilloma  of       . .  . .     49 

j  -  prolapsed,   pain   in    the 

pelvis  from    . .  . .  4GS 


Ovary,  contd. 

-  sclerosed,    pain    in    the 

pelvis  from    . .         . .  4G8 

-  sensory  skin  area  of     . .  468 

-  small  cystic        . .  . .   193 
dysmenorrhcea  from  192 

-  tumour  of  (and  see  Cyst, 

Ovarian),  albuminuria 

from 13 

amenorrhoea  with     . .   689 

aniomia  from. .  . .      35 

ascites  from    . ,         . .  331 

bearing  -  down       pain 

from  . .         . .  427 

bilateral         . .  . .     19 

bile-duct  compression 

by 331 

dyschezia  from         . .  129 

dystocia  from  . .  20O 

enlarged  splee 

lating 

jaundice  from  . .   331 

Ovary,  tumour  of,  kidney 
simulated  by  353.  354.  663 

triiosiiii.'        . .  . .   690 

pancreatic  cyst  simu- 
lating . .         ' . .   688 

rectal  examination  in 

diagnosing  . .  . .  331 

secondary  portal  glands 

from  . .  . .   331 

Ovary,  tumour  of,  some 
signs  of  630.  631 

sterility  from. .         . .  646 

swelling  in  hypochon- 

drium  from  . .  629 

tenaculum  in  dia- 
gnosing 

twisted  pedicle  of,  ap- 
pendicitis simulated 


Oxaluria,  contd. 

-  nocturnal       micturition 

from    . ,         . .  . .  : 

-  nucleoproteid  with       . .  •; 

-  after  oxalic  acid  poison- 

ing        - 

-  pain  in  testis  from       . .  -: 

-  with  pancreatic  affections  '. 

-  and  phosphaturia  alter- 

nating ..      424.  ; 

-  powdered  -  wig     pheno- 

menon from  . .  . .  - 

-  priapism  from  . .         . .  ' 

-  renal  ralciihis  with        . .    - 


630 


689 


by 


rinalexaminatif 


Ov 


dia 

r-catii 


331,  631 


cute 


from..    334 

-  obesity  from      . .  . .   408 
Over-exertion,  acute  dilata- 
tion of  heart  from  211,  214 

-  cramps  from     . .         . .  150 

-  left     ventricle    enlarged 

from 206 

-  mitral  regurgitation  from  211 

-  ruptured     aortic     valve 

from 210 

Over-strain,  mental,  impo- 
tence from     ..         . .  313 

-  pain  in  the  limbs  from. .  4G3 
and  stiffness  from     . .   464 

-  subacromial  bursitis  from  47G 

-  tenderness  of  spine  from  715 
Over-study,  nightmare  from  402 
Over-use,  cramps  from  . .  151 
Over-work,  dyspepsia  from  319 

-  evening  headache  from     294 

-  insomnia  from  . .  . .   321 

-  malarial  attack  from  . .      .^2 

-  neurasthenia  from        . .   4G6 

-  pain  in  the  back  from  . .   428 

-  twitching  from  . .         . .  136 
Ovum  (see  Ova) 
Oxalate  of  calcium  crystals 

{Fig.  181)       . . 
in  intestinal  sand     . .  59' 

-  crystals  in  urine  9,  21; 

-  uric  acid  with  424,  741,  74: 
Oxalates,    amount    passed 

normally 


Oxalic  acid  (si 

alic) 
OXALURIA 

-  aching  in  lo 


'.  Acid,  Ox 


of 


.,  424 
..  281 
..  424 

..281 

from  endogenous  sources  424 
frequent  micturition  from 

394,  424 


■  aftr 


oselit 


..  424 

IM ■M,:".    iiMia  275,  281 

■  \  ;  . .  j.u'    I'  I  i-:is  and    . .  424 

irnf..i.lr  i.l.i.ider  from..  424 

nervous  dyspepsia  and  424 

neurasthenia  and  . .  424 

nocturnal  enurRsis  from  424 


42. 


423 


423 


Oxybutyric  acid  (see  Acid. 

Oxybutyric) 
Oxygen,  convulsions  stopped 

■  by        14 

Oxyhiemoglobin,   hEemato- 

porphyrin  simulating  74 
-  spectrum  of  {Fig.  30)  . .  S( 
Oxyuris  vermicularls       • .  52< 

anal  irritation  from . .    .J2( 

no  blood  changes  with    2 

blood  in  stools  from. .     7 

in  children      . .  . .   52( 

eosinophilia  rare  from  21 

no  eosinophilia  with . .    52 

gonorrhcea    simulated  53 

grinding  of  teeth  from  26 

priapism  from  . .  53i 

vulval  irritation  from  52 

OzEena,  from  atrophic  rhi- 


nitis 


-  foul  breath  from           . .  S 

-  from    hypertrophic   rhi- 

nitis    . .          . .          . .  17 

-  syphilis   . .          . .          . .  17 

Ozonic  ether,  in  blood  test  28 
effervescence  with  pus  57 

PACHYMENINGITIS, 
cervical,      claw-hand 
from  ..         ..      109.  11 

pain  inarms  from  110, 

443,  44' 

tenderness     of     spine 

from  . .         . .  44 

-  cervico-dorsal,    pain    in 

the  shoulder  from    . .  47 

simulating     myofibro- 

sitis  . .  . .   47 

iisyphmJi;-^    ::     ::  47 

Pachymeningitis,   chronic 
hypertrophic    hsemor- 
rhagic  515,  51 

-  headache  from  . .      294,  52 

-  hyperacusis  in  . .         . .  30 

-  lumbar  puncture  in  dia- 

gnosing . .  . .  52 

-  noises  in  the  head  from    4C 

-  optic  neuritis  from       . .  52 

-  root  palsies  from  . .  50 

-  syphilitic  . .      406,  50 

pain  in  shoulder  from  47 

photophobia  from    . .  52 

-  voniiting  from  . .  . .   52 
Pacific  Islands,  elephanti- 

Pads  on  fingers  {Fig.  160) 


Dii 


contr; 


Paget's     disease,     general 
account  of 

leontiasis  ossea  and.. 

psorosperms  in 

Fain,     abdominal,     acute, 
from  appendicitis 

colic 

dysmenorrhcea 


embolism,    of     p:in- 
creas 

■  f ungating    endocar- 

ditis 

-  haemorrhage    into 

Graafian  follicle 

-  -  into  pancreas    . . 

■  pancreatitis 


PAIX,   ABDOMINAL 


PAIN  IN  EPIGASTRIU.M 


ain,  alnlominal,  ojiitd. 

—  acute,  perforated  gas- 

tric ulcer    , . 

vn 

raptured    ovarian 

cyst 

lilS 

pyosalpinx 

Iil» 

tubal  gestation 

193, 

593 

twisted  ovarian  cyst  193 

-  from  aneurysm     115, 

271, 

sal 

-  anffina  abdominalis  . . 

311! 

-  appendicitis    . .       115 

Ill; 

Pain  in  thr  arm.  cnnhi. 

left,  from  heart  disease  -i 

lumbar    puncture    in 

diagnosing  cause  of  - 
from  mediastinal  new 

growth        . .         , .  -: 

neuromata      , .  . .   ■ 

oecupatioti  and         . .  r 

Pain    in    the    arm,    from 
occupation  neuroses.,  t 


ajn,     abdominal,     btood- 
pressure  changes  with  437 

-  fr(^iii      vAV-Uiom:x      of 

bowel  ..  ..    115 

-  colitis  . .  . .  . .   llo 

-  constipation  from     . .    124 

-  from  corrosives         . .  268 

-  in  diabetes     . .        85,  389 

-  from  duodenal  ulcer      271 

-  gastritis           . .          . .    766 
AIN.  ABDOMINAL,  GENE- 
RAL     424 

ain,   abdominal,   general, 
from  colic      . .         . .  425 

dysentery    . .  . .   459 

gaslric  crises  . .  425 

intestinal     obstruc- 
tion . .  . .   425 

-  -  morphia      . .  .  .   426 
Bin.   abdominal,   general, 

from  neuralgia      425.  426 
pfituinti:;   .  .  . .   425 


ulcerative  colitis  . . 

visceroptosis 

-  from  gout 

~  in  Henoch's  purpura 
343, 

-  in  influenza    . . 

-  intense,   from   perito- 

nitis 

-  from    intestinal    neu- 

ralgia 
obstruction         1.31, 

-  intussusception      115, 

-  movable  kidney 

-  raucous  colitis       115, 

-  pancreatitis    . ,      115, 

-  perforated  gastric  ulcer 

-  perforative  peritonitis 

-  pleurisy  . .      115, 

-  plumbism 

-  pneumonia     . .      115, 

-  Pott's  disease 

-  pyloric  obstruction  . . 

-  in  relapsing  fever     . . 

-  from  renal  colic    115, 

-  spasmodic,  from  colic 

-  from  spinal  caries     . . 

-  spondylitis  deformans 

-  tabes  dorsalis 

-  tuberculous  bowel    . . 
peritonitis  48, 

-  typhoid 

all  over,  in  rat-bite  fever 

-  in  poliomyelitis  acuta 
in  antnstlietic  area 

anal  region,  from  vesical 

carcinoma 
at  angle  of  ri^'ht  scapula, 

from  gall-stono 
the  ankle,  from  syno- 


ttcropar- 


vitii 
arm,       from 
OMthesia 

-  adiposis  dolorosa      . .  ■ 

-  aneurysm        . .  . .   • 

-  -  of  siil.rl:ivi:m  artery  ■ 

-  axillary  Lrlatids  ..   • 
aIn    In    the    arm.    from 

brachial  neuralgia    .  ■  * 

-  -  neuritis       . .  . .  ■ 

-  carcinoma  of  liver 

-  cervical  caries  . .  ■ 

-  -  p  achy  meningitis    . .  ■ 

-  -  rib   110,  443,  608,   i 

-  cystic  breast  . .  . .  ' 

-  herpes  . .      440,  ' 

-  Ieft,from  aortic  disease  • 
angina  pectoris  31(1, 

433,  476,  i 

aortic  incompctenco  ■ 

[^ regurgitation     . .  : 


■itis 


Pain  in  the  arm.  radicular  < 

skiagram  in  diagnosing 

cause  of       ..  .:   ■ 

--  -  from  spinal  caries     . . 

gliosis 

tumour       . .         . .  ■ 

syringomyelia  . .  : 

vertebral  growth      . .  ■ 

writer's  cramp,  etc.. .  ■ 

I  -  as  an  aura  of  epilepsy  . . 
-  in  theaxilla,  from  abscess  i 

from  abscess  of  liver    . 

PAIN  IN  THE  BACK  (and 


Ba.-k:Kllf') 

ahdonii 


abs( 


acute  rheumatism    . .  < 

, aneurysm     195,     271, 

290,  428,  429,  664,  1 

aortic  incompetence..  • 

appendicitis   . .         . .  • 

biliary  colic    . .         , .  ■; 

bladder  lesions  . .  • 

carcinoma      . .         . .  i 

Cauda  equina  tumour 

debility  . .         . .  ■: 

duodenal  ulcer  . .  •; 

dyspepsia        . .  . .  -i 

fevers  . .         . .         . .  - 

fibrositis         . .         . .  • 

gall-stone       . .         . .  '. 

gastric  ulcer  269,  428,  ' 

herpes  . .         . .  ' 

hyperjBsthesia  with  . .  ^ 

from  infective  arthritis  < 

injury  . .         . .  • 

kidney  affections      . .  ' 

local  blush  with       . .  ■ 

lumbago  . .      428,  ■ 

malaria 

mediaatinitis  . .         . .  ' 

meningitis      . .         . .  ■ 

myositis         . .         . .  ■ 

neurasthenia  . .         . .  ' 

new  growth    . .         . .  ' 

-  -  ovarian  lesions          . .  ' 
over-work       . .         . .  ■ 

I pancreatic  calculus  . .  : 

I psychalgiu      . .  . .   * 

I  -  -  roctal  lesions..  ..  ■ 

'  Pain  in  the  back,  referred 

areas  of  {Fi/j.  2yi)  ] 
:  -  -  ill  n-lupsi.iL,'  finer     ..  ( 

! from    renal   craboUbni 

' sciatica  . .  . .   ■ 

serum  injection^       . .  : 

skin  lesions    . .         . .  * 

spinal  caries  156,  304, 

428,  429,  510, 

growth        . .         . .  ■ 

stono  in  kidney 

typhoid  spine  . .   '. 

uterine  lesions  . .  • 

i  ~  -  vesicuLo        seminales 
lesions         . .         . .  - 

Weil's  disease  . .  '. 

x-rays    in    diagnosing 

cause  of      ■ ■         . •  ' 

-  -  In  yellow  fever     273,  I 

-  at   back   of  <'ve,    in    In- 

(Inen7.a         "  . .  . .    I 

-  in    back   of   right  chcHt, 

from  gall-stonos         . .   '. 
PAIN.  BEARING-DOWN     * 

cyK(<wcope     in     diiig* 

nosing  caiue  of      . .  • 

from  Impacted  fibroids  i 

ovarian  tumoura       . .  -i 

pelvic  nbwTcss  . .    i 

diwrdrrs     . .  . .    l 

hunnalot-'cio  . .  -i 

^ pressure  on  bladdfr. . 


Pain,  bearing-tloirn,  contd. 

pressure  on  rectum  . .  42G 

rectal  examination  in 

diagnosing  cause  of  427 

from  retrovcrted  gravid 

utenis         . .         . .  427 

sigmoidoscope  in  dia- 
gnosing cause  of  . .  427 

tenesmus  with  . .  426 

from  uterine  displace- 
ment ..         . .  426 

vaginal  examination  in 

diagnosing  cause  of  427 

-  in  big  toe,  from  exostosis  671 

-  bladder,  from  calculus..   742 

-  carcinoma      , .         . .  394 

retention        , .         . .  395 

(and  see  Strangury) 

-  in  the  bones  in  infantile 

scurvy  . .         . ,     99 

leuktemia       . .         . .  707 

osteomyelitis  . .  668 

pernicious  ansQmia  . .  707 

rickets  . .         . .  364 

from  sarcoma        671,  673 

in  scurvy  rickets      . .  670 

secondary  syphilis   . .  669 

-  -  syphilis  ..  ..463 

-  boriiiE'.  in  i-\W< .  .  ..609 
PAIN  IN  THE  BREAST  ..  429 
--::.■■■:        ■....■,  1  ..429 

---':■..'.:    .1    ,    .'■  ..     429 

-  -  ..V    :u;   .:i.v,i..  429,  686 
u£  nipple  429 

..429 


epithelium 

galactoceli 

hysteria 

injury 

mam'militis 

mastitis  429,  685,  686 

menstruation  . .  430 

neuralgia        . .  . .  430 

pregnancy      . .         . ,  429 

stays 430 

submammary   abscess  429 

tuberculous  breast  . .  429 

-  on  breathing,  from  inter- 

costal neuralgia    . . 

-  -  liver  abscess  . . 

phrenic  neuralgia     . . 

pleurisy 

pneumothorax 

calf,  coming  on  during 


..  430 


431 


:ilkii 


PAIN  IN  THE  CHEST     ..  430 
Pain    in    the    chest,    from 

aneurysm      i".'".    lii", 

1:;l'.  434,  435,  7Ti> 

angina  pectoris 

aortitis 

biliary  colic  . . 

bone  di.soft.sc  . . 

bronchiectasis        43i 

carcinoma  of  breast. 

spine 


430 


,  435 


*  of  rib 


ob- 


430 


430,  432 


xlvida 


inv 

■  Ik-Ill 

rllllH 

1 

riiiiflti 

r..rriiir  i 

pcrforiitlon 
nirvHUi    . . 
perlrnrditi* 


Pain  in  thf  rficst,  contJ. 
~  -  in  phtliisis      . .      432, 

from  pleural  adhesions  ■ 

pleurisy  . .     430,  ■ 

pleurodynia   . .         . .  • 

pneumonia     . .     430.  • 

pneumotltorox       168, 

430,  - 

pulmonary  embolism 

159,  289,  290,  'i 

pyemic  abscess        . .  • 

skin  inllammation    . .  • 

.spasm  of  oesophagus    - 

spinal  cord  disease  . .  • 

splenic  infarct  . .  ( 

spondylitis  deformans  ' 

stitch 

stomach  lesions        . .  ' 

strained       intercostal 

muscle        . .         . .  r 
subdiaphragmatic  ab- 
scess . .         . .  1 

syphilitic  aortitis      . .  : 

tabes  . .         . .         . .  • 

-  cord  patlis  for  . .         . .  ( 

-  on  coughing,  with  phrenic 

neuralgia        . .         ..  i 

-  -  from  pleurisy  . .  * 

-  cramps  and        . .  . .  ] 

-  on  defalcation,  from  anal 

fissure  . .         ..  i 

ulcer  . .         . .  I 

colitis  . .         . .       77,  ] 

(and  see  Tenesmus) 

-  delirium  from    . .         . .  ] 

-  in  the  ear  (and  see  Ear- 

ache)    : 

from  furuncle  . .  < 

gtauconm       . .         . .  5 

hiemorrhagic  otitis  . . 

-  -  otitis  merlin  I«.i,  422.  ■ 

-  about    nir,     from    siims 


441 


PAIN    IN   THE    EPIGAS- 
TRIUM ..  < 

front  abdominal  anginii  -1 

acute  paticrcatitis  389,  I 

aneurysm       . .         . .  -1 

arsenic  . .       78,  i 

atheroma       ,.         . .  4 

-  from  biliary  colic     . .  •) 
corrosive  poisoning  . .  'i 

-  -  rnutfhing  . .  ..4 

dihiriiiiitii  of  heart    . .   ^ 

~  -  .lixM.tud  ulcer      437,  -i 

-  -ly-pn'^i'v       ..         ..  ^ 

-  -  ..-ntcruspimm  ..  ..  ^ 

epigastric  hernia       . .  4 

llatulcfue         . .       435,  4 

gall-stones     327,  437,  4 

gangrenous    appendix  '1 

gaatralgia       . .     319.  I 

gastric  carcinoma  270, 


,(30 ulcer    36,    206,  268, 


coronary    artery 

struction     . . 

coughitig 

empliyscmi 

empyema 

flatulent  dyspepsio  . .  433 

-  -  fractured  spine      431,  430 

-  heartburn 

-  -  heart  disease 

-  -  hepatic  abscess 

herpes  zoster. . 

hydropnoumolhorax      052 

lenionsof  bones  of  client  432 

liver  abivcss  . .         . .  709 

-  ~  mastitU  ..      430,  431 


Raslrllfs 

hnjmorrliago  Into  pan- 
creas . .         . . 
hcpallr  Hbscc:<4      -137, 

hrpatiti-* 


430,  431      - 


KM) 


ppfUpiBlrle  odhwlori" 

phuNphorun  polM)nliii>[    '. 

plourlny  . .         ■ . 

jilumbwrn       . .       34,. 

—  rheumatism   ..         .. 

—  nipturod  (luo<lonn| 

UlWT  .  .  .  • 

ffuitrir  ulcer 

iininll*pax        . .  •  •   ' 

-  -  oplnnl  cnrle*  . .         . .  ' 

-  -  (iibw 


PAIN  IN   EPIGASTRIUM 


PAIN   IN    LIMBS 


rill-,  r    .,;.  ■  ..    478 

-  -     lirrt.llr   .-.ilr ^  ..     472 

PAIN  INTHEEXTREMITY 
(LOWER)  .438 

PAININTHEEXTREMITY 
(UPPER)  ..442 

PAIN  IN  THE  EYE         ..  445 

ill  nmite  fevers  . .   4  Hi 

-  -  conjunctivitis         231,  41.5 

from  electric  light    . .  44G 

entropion        . .  . .   445 

error  of  refraction    . .  446 

eyestrain         . .  . .   446 

foreiijii  body  . .  . .   445 

-  -  glaucoma      231,    233, 

445,  525 

intluenza         . .  . .   44(1 

interstitial  keratitis  . .   445 

-  -  iritis    . .         . .      231,  445 

ocular  herpes. .         . .  445 

retrobulbar       neuritis 

445,  762 

-  -  snow 44G 


Pain  iv  the  hand,  could. 

from  neurosis. .         . .  151 

pachymeningitis        . .  477 

rheumatism    . .         . .  151 

rheumatiod  arthritis. .  151 

tenosynovitis 

tuberculous 

writers'  crar 

-  head,  from  t;Ui 


L'itis. 


564 


446 


ulceration  of  i 

445,   733 
(and  see  Photophobia) 

-  over  eyebrow,  from  frontal 

sinus  distention         . .    230 
PAIN  IN  THE  FACE       ..  446 

-  -  from  :intrat  tumour..    685 

cerebral  tumour         . .   447 

conjunctivitis  . .    446 

decaying  tooth  . .   448 

error  of  refraction    . .  449 

frontal  sinus  lesions. .  449 

glaucoma        . .  . .   449 

gumboil  . .  . .   446 

gummatous  meningitis  447 

■ —  herpes  zoster..         ..  447 
inflamed  parotid  gland  446 

-  -  iritis 441) 

nose  lesions    . .  . .   449 

periostitis        . .  . .   447 

psychaigia      . .         . .  449 

tabes  dorsalis  . .   449 

tongue  lesions  . .  449 

-  feet,   from   exposure 


Pain     in     head,     various 
visceral  causes  of     ..712 

-  round    tlie    heart,    from 

palpitations    . .  . .    435 

-  in    the    heel,    from    cal- 

canodynia       . .  . .   439 

inflamed  Achillis  bursa  362 

OS  calcis  spine        439,  671 

rubbed  heel  . .  . .  362 

.T-rays    in    disignosing 

cause  of       . .  . .   671 

-  hip,  from  hip-joint  dis- 

ease      321 

osteo-arthritis  . .   346 

sciatica  , .  . .   346 

-.-  spondylitis  deformans  715 
~  hunger  (see  Hunger-pain) 


di>ea>i-  ..  ..449 

PAIN     IN     THE     HYPO- 

CHONDRIUM  ..  450 

from      acute     yellow 

atrophy      .-  ..  333 

from  appendicitis      . .  451 

-  -  carcinoma     of     gall- 
bladder       . .  . .   450 


ches 


224 


erythromelalgia         . .  441 

Raynaud's  disease    . .   441 

-  fingers,     from     angina 

pectoris  . .         . .  433 

-  -  cervical  rib     ..  ..508 

-  after  fooil.  from  carcin- 

oma of  stomach         . .    630 

with  duodenal  ulcer     75 

from  gall-stone      . .   437 

-  -  -^  gastraigia    . .  . .   437 

gastric  ulcer  75,  26'j,  437 

gastritis      . .  . .   267 

-  food  relieving,  in  hyper- 

chlorlivilria    ..  ..   437 

-  -  (and  see  Hunger-pain) 

-  in    foot,    from    anterior 

crnritis  . .  ..439 

-  -  calcaiiodvnia  ..  ..  439 
--  cerebral' tumour        ..     68 

flat-foot  . .  . .   438 

gonorrhnea      . .  . .   340 

gonorrhceal   bursitis..   439 

fibrositis      ..  ..  439 

Pain   in   tlie  foot,   list  of 

causes  of  . .  362 

-  -  in  Morton's  disease  . .  439 

-  frontal,  from  frontal  sinus 
180 


-  over   ^'all-bladder 

Pain,  general  considerations 
regarding  . .  427 


ir;::'^"';;:;; 

l~r :,^,-.  .     410 

HI  I.ea  Jin 
r:nri)     200 

-  -  coli.- 
hami  from  cervi 

-  choiulromu     . 

"1-      ..   070 

..   27S 

.       151,  707 

al  rib..   551 

..   071 

■  of  li\ 


pancreas      ..  .  .    4.n 

cholecystitis   , .  . .   450 

colon  growth. .  . .   450 

-  -  congestion  of  liver  334,  450 

distoma  hepaticum  . .   328 

enlarged  spleeu  . .   450 

fa3cal  accumulation  . .  450 

flatulence       . .         . .  450 

-  ~  gall-stone       116,  327,  450 

-  -  gastric  .carcinoma     . .   450 

ulcer  . .         . .  450 

hepatic  abscess      450,  597 

hepatitis         . .         . .  450 

hepatoptosis  . .         . .   368 

Iierpes  aoster         450,  451 

intercostal  neuralgia 

450,  451 

intestinal  obstruction    450 

movable  kidney        . .  451 

new  growth  of  colon. .   451 

perinephric  abscess  450, 

451 


_ 

-  perisplenitis   . . 

450 

- 

-  pleurisy    '      . .      450, 

451 

— 

-  pyelitis 

451 

_ 

-  renal  calculus         450, 

451 

- 

-  ruptured  ectopic  gesta- 

tion 

451 

_ 

-  salpinfjitis 

451 

_ 

-  from  splenic  injury  ., 

041 

- 

-  5uMnphlv>-ii.:aic    ;d,- 

451 

_ 

-  tni>i^M.n  HMii  |,r,lirle 

451 

- 

liypo^M>lriuni  fi-c.in  l.iic- 

teriuria 

70 

- 

-  cystitis  2S2,  470,  578 

581 

— 

—  duodenal  ulcer 

402 

_ 

-  gall-stones 

462 

_ 

-  gastric  ulcer  ._. 

462 

_ 

-  hepatic  abscess 

402 

- 

-  prostatitis 

581 

- 

-  retention  of  nrine     .  . 

3n 

I 

-  froni'iiiM.  h.il  I'lM      . 

666 

- 

iliac  f.i^^.^lniiii, -inr, 

■,458 

'"""nl'vT    ."'     '  T 

400 

_ 

appendicitis 

354 

_ 

ciecal  distention    . 

457 

- 

carcinoma  cffici     . 

459 

_ 

of  rectum       453 

459 

_ 

of  sigmoid  colon 

453 

459 

_ 

coli  bacilluria 

455 

- 

dysentery   . . 

459 

- 

herpes  zoster 

400 

- 

ileocecal  kink 

457 

Pain  in  iliac  fossa^  contd. 
from  inflamed  glands  45 

intestiniil     obstruc- 


Paln  in  the  iliac  fossatleft). 
list  of  causes  of         . .  452 

from  ni(,v;.hl.-k)(lnev  460 

ovaritis        . .  . .    456 

pleurisy       . .  . .   460 

pneumonia  . .  460 

pyelitis        . .  . .   451 

retained  testis        ..   457 

PAIN      IN      THE      ILIAC 

FOSSA,  RIGHT         ..  454 

- from  appendicitis 

110.    lL»4,  2S3,  665.  677 
colitis       ..  ..116 

Pain  in  iliac  fossa  (right), 
list  of  causes  of        . .  454 

at     menstrual 

periods  . .   678 


rectal 

tion  in  . .   116 
fron\  spastic  con- 

stipatiou         . .  124 

typhlitis  . .   116 

fi'ora  salpingitis     . .   456 

spinal  lesions        . .  461 

stercoral  ulcers     . .  459 

stitch  ..  . .   457 

tuberculous  ciecum    458 

kidney     . .  . .   460 

tumour  of  iliac  bone  459 

typhoid       . .  . .   459 

twisted  ovarian 

pedicle    . .  . .   456 

ulcerative  colitis   .  .   459 

volvulus      . .  . .   459 

—  insomnia  from  . .  . .   321 

—  intense,         hypothermia 

from 573 

—  intercostal,  from  aneur- 


(and     see    Neuralgia, 

Intercostal) 
PAIN,  INTERSCAPULAR    461 


rbori 


relit 


462 


from  biliousness  461,  462 

calomel  relieving  . .  462 

from  carcinoma  of  gall- 
bladder      . .  . .  462 

of  liver       . .  . .  462 

duodenal  ulcer  . .  462 

flatulence       435,  461,  462 

gall-stones      . .  . .  462 

gastric  carcinoma     . .  462 

ulcer            . .  . .  462 

gastritis           . .  . .  435 

hepatic   abscess  ..  462 

-  -   iiidiLT-iinii       135,  461.  462 

Pain,  interscapular,  list  of 

causes  of  . .  461 

PAIN  IN  THE  JAW  ..   462 

from  alveolar  abscess  683 

antral  lesions. .  . .   462 

dental  caries  . .  . .  462 

-  -  uneru|.ted  molar  ..    462 

.■:ili   '    ■■■  .'   462 

Pain  hi  ii ■    -  ■  ■■    -■<■ 

ArtliMl'-.      ..'nl      I'^rn- 

arthriti-i 

-  -  in  acute  rheumatism 

iMo.  228,  463.  614 

cln-onic  rheumatism.,  466 

dengue  . .  . .  466 

erythema  nodosum  . .  404 

IleiiocliVpurpiu-a343,  556 

-  -  hvsterical        . .  . .  350 

-  -  in  leprosy       . .         . .  404 

peliosis  rheumatica  . .  556 

puerperal  fever         . .  596 

rheumatic  fever        . .  338 

from  serum  injections 

223,  554 
tuberculous  disease  . .  347 

-  kidney,     from     bladder 

growth  . .       281,  472 
pvelonepliritis  ..   355 

-  -  stone   .  .  . .         41,  277 


Pain  in  kidney,  conid. 

ureteric  calculus 

(and  see  Colic,  Renal) 

-  in  the  knee,   from   hi])- 

joint  disease  252,  34^.  ; 
sj-'.novitis         . .  . .   - 

-  like  a  knife,  from  pleurisy 

-  in  labium  majus,    from 

renal  calculus 

-  lancinating,  in  syringo- 

myelia . .         .  .  t 

-  leg,  from  anterior  cruriti> 
bladder  lesions 

carcinoma  uteri         . .   I 

cauda  equina  tumour 

embolism        . .  . .  i 

epiphysitis     . .  . .  f 

hip  disease     . .         . .  .' 

intermittent  claudica- 
tion and     . .         . . 

Morton's  disease 

multiple  neuritis       . .   - 

meralgia  paraesthetica  ■ 

obturator  hernia       . .  - 

phlebitis         . .         . . 

popliteal    aneurysm..   ( 

prostate  lesions 

psoas  :il.si(-> 

rectum  legions  . .   i 

Pain    in    the    leg,    from 
sciatica  . .       63,  i 

-  -  spondylitis  deformans 
in  tabes 

from  tumour  of  Ion;; 

bone  . .         . . 
uterus  lesions 

-  on  ligattu"e  of  artery    . . 

-  lightniug,      spontaneous 

cessation  of    . .  . . 

Pain  in  the  leg  in  tabes  116, 

315,  440,    -166,  515, 
609.  I 

-  in  tlxe  limbs,  from  alcohol  ■ 

from  alcoholic  neuritis 

in  angioneurotic  oedema' 

from  arsenic  . .        64, 

in  cachexia    . .  . .  ■ 

diabetes  . .        63, 

erj-thromelalsia 

PAIN     IN     THE     Lir/IBS, 

GENERAL     .. 

in  acute  coryza     . . 

bronchitis   . . 

from  chill   . . 

chronic  rheumatism 

:  in  don-ue    . . 

febricuhi 

Pain  in  the  limbs,  general. 

list  of  causes  of 
Malta  lever 


■asles 


ositi? 


pleurisy      . .  . . 

rat-bite  fever 

scarlet  fever 

small-pox   . .         . . 

tonsUlitis    . .  . . 

tuberculosis 

from  gout       . .  . . 

hysteria  . .         . . 

influenza        . .         . . 

lead 

leuksemia        . .         . . 

in  Meige's  disease 

neurasthenia  . . 

from    optic   thalamus 

lesions         . .         . .  ' 

pernicious  anfemia   . .   ■ 

peripheral  neiuritis  56, 

from  serum  mjections 

in  severe  ansemia 

iii  yellow  fever     273, 

"Weil's  disease  . .  ^ 

—  in    liver,    from   nutmeg 
change 


-  perihepatitis 

-  suppurative   pyle- 

phlebitis 
L  loins,  from  appendici- 


■  bacteriuria 

■  carcinoma  coli 
-  contra-lateral 


PAIN   IN  LOINS 


PALLOR 


357 


276,  ; 


plBi«  in  loins,  (rmtti. 

-  -  in  dengue       . .         . .  4(10 

-  -  from  epididyrao-orchi- 

tis  ..  ..  478 

-  —  in  iiifluenzii   . .  . .   504 

-  -  with    invagination    of 

rectum        . .  . .    129 

-  -  movaDle  kidney        . .   46(J 

-  -  pancreatic  calculus  . .  HC 
-  perinephric  abscess  . .  451 

-  polycystic  disease 

-  renal  calculus  40,  117, 

colic 

disease 

-  —  embolism 
growth        . .  . .   355 

-  -  tuberculous  kidney  . .  460 

-  (and  see  Backache ; 
and  Pain  in  the  Back  ; 
and  Aching  in  the  Loin?) 

-  loss  of  weight  from       . .   7611 

-  at  lower  end  of  sternum, 

from  pericarditis       . .  433 

-  in     lumbosacral     region 

from  pyosalpinx        . .   582 

-  masroiil.  from  abscess..    202 
Pain  on  micturition 

from  .tppf-ndicitis  582,  t» 

carcinoma  uretlira; 


396 


:  ]>hi.h\v 


11 


vstil 


Pain  on  micturition,  aeneral 

account  of    469,  470,  47  i 

in  e-onorrha-a         182,  700 

from  prostatic  abscess  182 

proi^tatitis       . .  . .  182 

strangrury  and  . .  649 

from  stricture  . .  390 

ulceration  of  bladder  580 

ureteric  calculus       . .  H97 

urethral  sores  . .  184 

urethritis        . .  . .  390 

-  in     the     mouth,     after 


505 


466 


stomatitis 

-  in  muscles,  in  acute  rheu- 

matism 
dengue 

-  -  hysteria 
nmltiple  neuritis 

-  myositis  o^^ificaiis 

from  over-strain       . .  464 

polymyositis 

-  -  rheumatism 
s-enim  injection         ..  554 

-  -  trichinosis       . .      404,  729 

-  nnck,  from  aneurysm  . .  431 

anpina  pectoris         . .   433 

caries  . .      429,  618 

cervical  rib    . .  ..  110 

in  delicate  patients  . .  429 

-  -  from  fractured  spine    i!l8 

infiamerl  t:lands         . .   .179 

mediastinal  new t,'rowthl34 

menin^fitis      . .  . .   138 

new  irrowtli 

pachymenid 

phthL'iis 

pyorrhrea  alvcolari: 


..   «'I8 


648 


rheumatoid  artliriti.' 

spinal  < 


Pain  in  thf.  peh'ift,  eontd. 

from  hysteria            . .  468 

labour              . .          . .  468 

local  conjiestion         .  .  463 

after  operation         ..  468 

from  peritonitis         . .  468 

prolapj^ed  ovaries     . .  408 

pyelitis            . .          . .  451 

retroflexed  utenis     . .  468 

retroverted  uterus    . .  468 

salpingo-ouphoritis 

193,  468,  690 

sclerosed  ovaries       . .  468 

Pain  in  the  pelvis,  spasmodic  468 

-  -  t\vUr.f.I.r.  .P-ii-i;..'  iii-!.-    168 
PAiN      IN      THE     PENIS 


(and 
Mic 


467 


itis     ..   474 
..   473 
..   473 
-  of  bladder  281,  397, 

470,  472.  580 


recti 

-  cavernitis 

-  chordee 

-  cystitis 

■  -  gonorrhoea 
•  -  iiout    . . 

■  -  iicrpes 


Pain  in  the  penis,  list  of 
causes  of        . .      469.  471 

from  lymphantritis   ..   473 

papilloma  of  bladder    472 

paraphimosis  . .   473 

phimosis         . .         . .  473 

piles 473 

prostatic  abscess  470,  473 


afTecttons 

calculus 

prostatitis 

rectal  fissure 

-  -  renal  colic 

stricture 

trigonal  lesic 

tuberculous 


..   397 

..   473 

470,  473 


IS         ..   396 
bladder 
397,  579 


..  473 


kidney 

ureter 

nreterie  calculus  472,  578 

ureteritis         ..  ..472 

uretliral  calculus  184, 

283,  396 

urethritis        ..         ..473 

vesical  disease  . .  277 

calculus     282.    397, 

470,  379,  580 
PAIN  IN  THE  PERINEUM  474 


from  !•; 


fro 


648 
616 


(and  see  Stiff  Neck) 

-  neuralgic,  from  herpes,.  754 

in  osteitis  drformaiM    070 

(and  see  Xcuraljjia) 

-  of  ol>scureor(t.'in,sjltliilis 

and 477 

-  occipital,      from      otitis 

media 202 

-  osteocopic  . .         . .  463 

-  ovarian,  ureteric  calculus 

simulatiiits'      •  •         .  •  I>78 

-  pelvic,     from     crypto- 

menorrlMi-a     ..  ..17 

PAIN  IN  THE  PELVIS 

-  -    from    ;.!...rfiM,, 


-  app. 


after  chiltlbirth 

-  -  from     extra-uterine 

Kestation     ..      468,  690 

fibromyoma   . .         . .    168 

gauze-packing      '     . .  468 

-  -  limmorrhngic     corpus 

luteum  cyst  . .  -168 


468 
468 
469     Pain,  referred 


.titi- 


lie    heart 
-o-iliac  Joint     .. 
ri,  from  carcinoma 


70 

578 

474 

397 

581 


reux 711 

-  scapular     re?ioii,     from 

cervical  rib    . .  . .   444 

-  scrotum,      from      peri- 

urethral absce?-*         . .   697 
Pain-sense,     loss     of    (=ee 

Analu'esia) 
PAiN  IN  THE  SHOULDER  474 

from   abscess  of   liver  , 

597,  709 

aneurysm       ..         ..  476 

angina  pectoris      433, 

476,  535 

aortic  regurgitation  . .  207 

arthritis  . .         . .  476 

biliary  colic   . .  . .  450 

carcinoma  of  liver    . .  373 

congestion  of  liver   . .  334 

diaphragmatic  pleurisy-  709 

duodenal  lesions       . .  476 

-  -  galK^tone       ..      110,  327 

gastric  lesions  . .  470 

hemiplegia      . .  . .   477 

Pain  in  the  shoulder,  list 
of  causes  of  . .     474,  475 

from  media-stinitis    , .  435 

occupation      . .  . .  476 

pachymeningitis        . .  477 

-  -  phthisis  . .      432.  470 

-  -  pleuri^v  ..      432,  476 

pneumonia     . .         . .  476 

pneumothorax  . .   476 

subacromial  Iiursitis..   476 

-  -  Wassermann    test    in 

cases  of      , .         ..  477 

from  weight  carrying  163 

x-rays    in     detecting 

cause  of      . .         . .  470 

-  between    shoulders   (see 

I*ain,  Interscapular) 
I  -  in  side,  in  pneumonia  . .  335 
sole,  from  gonorrhnea  . .  3 10 

somatic 706 

spine  after    tj'phoid 


toe.  from  anterior  cruritis  439 

-  ;rout     . .  . .      344,  438 

-  intrrowini:  toe-nail    . .   438 

-  .\I..rioM-~  Jj^.M^c        ..    439 


738 


PAIN  IN  THE  UMBILICAL 

REGION  ..483 

from  ecsema  intertrigo  483 

483 

nllainod  sebaceous  cyst  483 

425 


-  he 


intestinal  colic 

-  new  groivtU  . . 

plumbism 

spinal  lesions. . 

-  -  tabes  . . 
tulwrctdous  peritonitis  4S3 

-  over  ureter,  from  calculus    4 1 
urethra,    from    epi- 


484 
484 
484 


-  -  pro>i;.riti>      .. 
vesical  carcinoma     . .   397 

-  precordial,  in  acute  rheu- 

matism ..         ..211 

angina  jiectoris     476,  535 

aortic      incompetence 

j  207,  433 

I nrtcriosclerosii*        . .       U 

' endocrtrditls  . .         . .  211 

cxcilemcnt     . .  . .    133 

--  on  exertion     ..  ..    133 

from  (Ibroid  heart    ..   213 

flatulence        , .  . .   433 

graindnr  kidney        . .     II 

heartburn       . .         . .  297 

; heart  disease. .         . .  433 

\ myocardial  afTeclions      II 

I myocarditis    ..         ..  212 

i over-strain  of  heart  . .  211 

;  -  -  pericarditbi     ..         ..    133 
!  -  prostate,  from  prostatitis  581 

-  in    rectum,    from    anal 

fissure 


heli( 


097 


fev 


-  at  luretlu^l  orifice,  female, 

from  cystitis  ..   397 
vesical  carcinoma  397 

-  in  vnlva,  from  canuicle    702 

-  -  cystitb:  ..  ..397 

kraurosis         ..  ..701 

jirolapse  of  urethra  . .  702 

varicocele       . .         . .  701 

vesical  carcinoma     . .  397 

Painful       erections      (sec 

Priapism) 

-  fatness      (sec      Adiposis 

l)oloros:i> 
Pains,  growing  ..  464 

Painters' cnimp    ..  ..    l.'»l 

Painters,    plumbism    in  . .   117 
Patntini:,   deterioration    in 
ipiality  of.  in  general 


Palate,    bleeding   nsvi   of 

(I'laii  XVll)..  ..   2 
from  stomal  it  is 

-  bullous  dermatoses  affect- 

ing        

-  carcinoma  of  (see  Car- 

cinoma of  Palate) 

-  cleft  (see  Cleft  Palate) 

-  dermatitis  her|>etifonuls 


585 


-  beliiriti    :«tcniiiiii,    from 

nlleoliiiL' 

71 

clironie     mnliiistiiiilLs 

I.V. 

-  enrlotticliomii  of 

:.»s 

dalulcnci*    . . 

435 

-  c|>itlio]ionm  of  (-;oe  Car- 

licartbiirn  . . 

I3U 

rinoniii  of  I'ltliitc) 

me<Jiiwtiiinl        now 

-  cry(hemahuIlt>snniaffcot- 

prowth    . . 

431 

int:        

74 

mcdiastiriitia 

■I3r> 

-  piniiiui  nf           .  .       (>l:t. 

7.*in 

opHopllflfiCiil  lesions 

43.'i 

-   tMTJMS  of 

T.-.l 

-  supra-orbital,  in   ani^nn 

Palate,    Inflamed,    general 

Iicctoris 

433 

account  of 

615 

from  errors  of  retrac- 

 «oru  throat  from 

ni3 

tion 

410 

-   Koplik'x  Kpols  on     178, 

•.'•-■s 

-  suprii|iiil>ic  (see  I'nin  in 

-  lupilB   of.    blmnl-spillint! 

Mv|>o(;.i>*triuni> 

line  to 

•js.-. 

Pain  oh  swallowing 

IBS 

-  new  tTowtli  alTectlnc  .. 

S8H 

-  Ir-ariiiu.  fnirii  pli-iirwy. . 

I3'.' 

-   nariilv-i«ci((^ecl'un.l.»i» 

pneuriiotlif)rii\ 

432 

ol  ii.e  IVllule) 

-  ill  tlie  teetii  fr(nn  uluii- 

-  pt>nipliit.'tLs  alTii'tink'     .  . 

74 

ronin 

233 

-  perfonitioiiof,  eotiiienital 

■■188 

-  teniponil,     from     otitis 

~  -  nialik'iiiinl 

,-■88 

liii-.ll;. 

SII'J 

re*.nirKH»tion   of   f«Ml 

Pain,  tenderness  with   427 

ini 

llintu^'li  ncNMi  fniln 

Pain,  wllhoul  tenderness 

«7 

178, 

PAIN  IN  THE  TESTICLE 

477 

-  -  from  »)|ililll»  17.S,  I'll). 

-  -  Imunmlle 

Ml 

i;i< 

tlibcn'uioii'*    . . 

—  hydroTclu 

4K1 

-  piirmentnlioil      of      (mh' 

tlCW  KfOWtll    . .       -180, 

IIOII 

l*iL'inelita(loil     In     tlie 

-  -  r.n.il.iliii'ii"  117,  ars 

4S3 

XtltM'lll 

711 ; 

-    - >"-    loitimiia 

I'nt    .. 

483 

'  / 1 

■128 

|.0»il.. 

470 

i    leria 

4n8 

482 

'Miliar 

ryuin  ol 

4(111 
49» 

862 


PALLOR 


PAR.iilSTHESIA 


Pallor^  contd. 

t-  in  angina  pectoris         . .  433 

-  distinction  from  anjemia     21 

-  in  infantile  scurvy        . .  556 

-  of  foot,  from  intermittent 

claudication  . .         . .  441 

-  in  Meniere's  disease     . .  752 

-  nephritis  . .         . .     42 

-  night  workere    . .  . .     21 

-  pericarditis        . .         . .  433 

-  pernicious  aniemia       . .     24 

-  pyonephrosis     . .         . .  357 

-  from    ruptured    tubal 

gestation         . .  . .   593 

-  sudden,     from     haemat- 

emesis  . .         . .  268 

-  of    toes,    in    Baynaud's 

disease  . .         . .  441 

-  with  tuberculous  arthritis  348 

-  in  underground  workers     21 
Palms,  cheiropompholyx  on 

97,  756 

-  congenital  svphilitic  erup- 

tion on    "        . .  . .  400 

-  eczema  of  . .         . .  491 

-  horny     ovei-growth     in, 

from    erythema  kera- 
todes 405 

-  hyperkeratosis  of,  from 

arsenic  . .         34,  73 

-  pink        . .  . .         . .  654 

-  pityriasis    rubra    pilaris 

affecting  . .  . .   604 

-  pruritus  of         . .         . .  540 

-  small-pos  not  affecting    561 

-  syphilis  of  . .         . .  491 

-  syphiloderm  of  . .         . .  490 

-  xanthelasma  of..  ..  324 
Palmar  fascia,  contracture 


of 


142 


Palmaris     brevis,     nerve 

supply  of        . .         . .  504  I 

-  longus,  nerve  supply  of    504  j 
Palpebral     fissure,     dimi- 
nished,  from   sympa- 
thetic paralysis         . .    217 

small,  from  cord  lesion  501  i 

paralysisof  arm  with  501  ' 

from  spinal  lesion. .  507  i 

-  fissures,    imequal,    from  I 

habit 540  I 

PALPITATION  .484 

-  from  absinthe    . .  . .   48t!  ; 

-  from  absinthe    . .         . .  486 

-  in  acute  rheumatism    . .  211 

-  from  alcohol      . .         . .  486 

-  anaemia  . .  . .      484,  487  [ 

-  from  aortic  regurgitation  207 

-  athletes'  heart  . .         . .  214  , 

-  chlorosis  . .  . .    274  j 

-  chronic  nephritis  . .     11  i 

-  cocaine 486  , 

-  coffee 48G 

-  definition  of      . .         . .  484  i 

-  from  d^italis     . .         . .  486 

-  drugs 484  i 

-  livspepsia  ..      435,  485  ! 

-  ■' lion 486 

..    211   ' 


rditis 


Palpitation,    fear   of   heart 
disease  caused  by     ..  485 

■ -^Mii^     ..  ..   435 

!  I    .         Ii-r;ise    722,  726 
.      297,  322 


Ptilpitation,  contd. 

-  in     paroxysmal     tachy- 

cardia . .  , .    703 

-  in    Stokes-Adams     syn- 

drome        •    . .  . .  486 

-  from  tea. .         . .         . .  486 

-  tobacco  . .         . .      485,  486 

-  thyroid  extract. .         . .  486  , 

-  valvular  heart  disease. .  484 
Palsy,  crutch         ..         65,  504  I 

-  Saturday  night  . .         . .     65  I 
Pampiniform  plexus,  throm- 
bosis of,  priapism  from  538  ! 

Pancreas,  affections  of,  co-  j 

eflicient  of  urine  hi  . .  100  i 

-  calculus  in  (see  Calculus, 

Pancreatic) 

-  carcinoma  of  (see  Carci- 

noma of  Pancreas) 

-  cirrhosis    of,    no    Cam- 

midge's  reaction  in  . 
fat  globules  in  fteci 

with 
fatty  acid  crystals  : 

faaces  with  . . 


100 


■ith 


Pancreas,  disease  of,  indi- 
cated by  Cammldge's 
reaction 

indigestion  due  to  . . 

jaimdice  due  to 

keratin     capsules     in 

detecting    . . 

-  hiemorrhage    into     (see 

Hsemorrhage  into  Pan- 
creas ;  and  Pancrea- 
titis)   . . 

-  lesions  of,  fatty  diarrhosa 

with 437 

glycosuria  with         . .  437 

pancreatic  reaction  in 

urine  with  ..         ..437 

-  new  growth  of,  pain  in 

epigastrium  from     . .  437 

-  tumour  of.  ascites  from     40 
Pancreas,  tumours  of,  general 

account  of  630,  681 


100 


264 


-  \.i. 


on  in 


creatic   artery,   opened 
by  gastric  ulcer  . .   2 

colic  (see  Colic,  Pancrea- 
tic) 
diarrhoea  . .         . .  1 

extract,  infantilism  im- 
proved by      . .         . .  1 
■  incompetence,  fatty  stools 


40 


infantilism  from       . .  191 

Sahli's    capsules    in 

tpstin?         . .  . .    191 

PANCREATIC  REACTION, 

CAMMIDGE'S  ..    100 

r:iiMf,.,,,iM^.   :nmr..   abdo- 
204, 


cideii 


;  of 


131 


484 


-  with  hepatoptosis 

-  from  heredity    . . 

-  high  blood-pressure 

-  in  hysteria  . .  . .   486 

-  insomnia  from  . .  , .   322 
Palpitation,  list  of  causes  of 

484.  485 

-  from  lung  affections  484,  485 

-  mitral  regurgitation     . .  210 

-  morphia  . .         . .         . .  486 

-  myocardial        affections 

213,  300,  484,  485 

-  myocarditis        . .         . .   212 

-  nervousness       . .         . .  484 

-  neurasthenia      . ,      466,  486 

-  overstrain  of  heart       . .  214 

-  with       parenchymatous 

goitre  . .         . .  . .  722 


in  alcolioUc  persons. 

collapse  from  264,  436,  601 

constipation  with  131, 

264,  661,  767 

Pancreatitis,  acute,  diagnosis 

of        436 

epigastric  pain  from. .  661 

fat  necrosis  with  131» 

389,  661,  767 

in  fat  persons             . .  131  | 

flatus  with      . .          . .  LSI 

-  -  L'lyrn-iiiKi  from          .  .  201 

Pancreatitis,  acute  hamor- 
rliagic  . .  389 

Pancreatitis,  acute  hemor- 
rhagic, symptoms  of. .  594 

hiccough  from  . .  307 

intestinal    obstruction 

simulated   by    131, 
264,  389,  594,  601,  767 
laparotomy     in     dia- 
gnosing    389,     436, 

5U4,  601,  767  . 

meteorism  in..      389,  594 

nausea  from  . .         . .   707 


Pancreatitis,  acute,  contd. 

pain    in    epigastrium 

from  . .         . .  436 

perforated  gastric  ulcer 

simulated  by         . .  389 

peritonitis     simulated 

by    ..         ..      594,  661 

pyrexia  from  . .   661 

shock  from    . .         . .  436 

tenderness  over  pan- 
creas with  . .         . .  767 

vonuting    from     594, 

661,  765,  767 

-  bile    pigment    in    uriue 

from 101 

-  Cammidge's  reaction  not 

pathognomonic  of    ..  100 

-  with  carciaoma. .         . .  100 

-  chronic,    bile  duct     ob- 

struction from  . .  326 
buliiy  offensive  stools 


101 

101 

-  undigested    muscle- 
fibres  in  fffices  with  101 
■  cyst  of  (see  Cyst,  Pan-  I 

creatic)  [ 

acid    fasces 


fro 


116 


Cammidge's     reaction 

from  117,  254,  328,  661 

chemical    analyses   of 

stools  in  diagnosing  116 

clay-coloured    stools 

from  . .      32G,  661 

-  -  colic  from      116,  328,  329 

cysts  from      . .  . .   661 

diagnosis  from  carcin- 
oma . .         . .  339 

gall-stones  . .         . .  239 

epigastric  pain  from 

116,  254,  329,.  661 

fatty  stools  from  116, 

239,  264 

gall-bladder    enlarged 

from  116.  253.  254 

gall-stones    simulated 

by 328 

Pancreatitis,  chronic,  gene- 
ral account  of        100,  328 

-  -  glycosuria  from    264,  601 
jaundice     from     116, 

239,  254,  264, 
325,  326,  328,  661 

meat  fibres  in  stools  in 

116,  204 

pigmentation   of  skin 

from  ..      116,  264 
rigors  from     ..      116,  204 

-  -  sugar  in  urine  in       . .   110 

-  -  wastingfrom  ..      116,  264 

-  colic  simulated  by        . .   115 

-  cyanosis  in        . .         . .  157 

-  from  duodenal  ulcer    . .  101 

-  epigastric  pain  from     . .   437 

-  excess  of  pancreatic  juice 

with 101 

-  fcecal  fat  with  . .      101,  328 
-gall-stones  and..         ..  437 

-  from  gastric  ulcer         . .   101 

-  jaundice  with    . .         . .  101 

-  microscopical    examina- 

tion of  fffices  in         . .   101 

-  occult  blood  with  . .   101 

-  oxaluria  with     . .  . .    100 

-  ptyalism  from    ..  ..    513 

-  saponifu^d  fats  with      .  .    101 

Pancreatitis,     secondary, 

various  causes  of      . .    100 
l-.M    1.  ■■  ..134 


-  gonorrhoea  . .  . . 

-  ulcer  of  cornea  . .  . .   ' 
Papilloma  of  bladdei*,  car- 
cinoma simulated  by  J 

cystitis  from  . .         . .  ! 

cystoscope    in     dia- 
gnosing   281,     396, 
471,  472,  I 

detected  per  rectum. .  : 

fragments  in  urine    . .   '. 

frequent    micturition 

from  ..         ..  ; 

hcematuria  from  275, 

276,  281,  471,  ^ 

kidney  enlarged  by.,  i 

pain  in  kidnev  from. .   '. 

penis  from  469,  471,  ^ 


pyu 


ifro 


Papilloma  of  hladdcr,  contd. 
' —  strangury  from  . .   049 

ureter  obstructed  by    281 

urethra  obstructed  by  472 

-  gum,  microscope  in  dia- 

gnosing . .  . .     74 
(and  see  Epulis) 

-  jaw,  bleeding  gums  from    72 

-  kidney,  hjematonephrosis 

from 278 

haematuria  from  275,  278 

hydronephrosis     from  278 

renal  enlargement  from  278 

-  larynx,  asthma  simulated 

by        535 

-  ovarian 49 

-  rectum,  age  incidence  of     79 

blood  per  anum  from      79 

speculum  in  diagnosing    79 

-  scrotum,epithelioraa  from  021 
hernia    testis    distin- 
guished from         . .  623 

ulceration  of  . .         . .  021 

-  ureter      . .  . .  . .   278 

Papillomata,  peritoneal  . .     49 

-  urethral 184 

discharge  from  ..   184 

endoscope      in      dia- 
gnosing      . .         . .   1S4 

-  vulval  swelling  from  . .  (;it9 

PAPULES 487 

Papules  of   acne    vulgaris 

487,  489 

-  in  chicken-pox  . .  . .   (;u; 

-  defiintion  of       . .  . .   4S7 

-  in     dermatitis     herpeti- 

formis . .  . .   755 

-  eczema    . .         . .      487,  755 

martrinatum   . .  . .   250 

Papules  of  erythema  multi- 
forme   489 

-  fMlhrul.!!^    .Ir,-:,|x;,h-       .  .        71 


-  glandere  . ,  . .  . .   . 

-  goose-skin  . .         . .  ■ 

-  granulosis  mbra  nasi  . .   ( 

-  herpes  zoster     . .         . .  ' 

-  impetigo  . .         . . 

-  infiammatory,       itching 


vith 


lofi; 


9  fro 


•  simulated  by  ureterit 
calculus 


-  in  keratosis  pilaris        . .  ■ 
Papules  of  lichen  planus 

487.  488.   I'.'l,  0IJ3,  ' 

Papules,  of  lichen  scrofulo- 

sorum  ..     487,  ' 

Papules,  in  lupus  . .         . .  ' 

-  with  malignant  pustule  J 


-  in  pityriasis  rubra  jiilaris 
Papules  of  pityriasis  rubra 
pilaris  4S7,  488, 

!  Papules,  of  prurigo       187,  . 


-  seborrhcea  . .  . .   602 

-  seborrhceic  dermatitis  . .   401 
^  sniall-pox  554,  560,  616 

-  strophuhis  ..  ..771 

Papules  of  syphilis       401,  487, 
490.   '<'>0.  500,  756 

-  urtir;.n;i  ..  ..487 

-  vaccinia 757 

-  varicella  . .  . .    756 

-  verruca  plana    . .  . .   487 

-  xanthoma  . .  . .   487 

-  xerodermia        . .         . .  488 
Paracentesis       abdominis, 

chronic  peritonitis  from  47 
perihepatitis  from    . .     52 

-  recurreTit,      for      poly- 

orrhomenitis  . .  . .   107 

-  thoracis,     fluid     blood- 

stained after  . .         . .  102 

hiemoptysis  from     . .  280 

hydropneumothorax 


-  pu]Ml  n-:„Ti,Hi  lo  light..    553 
Pancsthe-sia,  from  alcohol     726 

-  of  arm,  from  cervical  rib  551 


PAR.^iSTHESIA 


.  PARALYSIS 


'.ffhfuia,  contil. 
>!i!  '■ombineddegenera- 
^  iMi-  of  cord  . .         . .  ■ 
.1    iiiiinated  sclerosis  . 


;  agitans  . .   1 

:il  neuritis       ..  ■; 

IX,  in  histology    : 

carcinoma    of 


-  ta?te  from      . .  . .  : 
Etralysis     of     abdomiDal 

miLscIes,    from    diph- 
theria .  .         .  .'        .  .  : 
abductor,  asphyxia  from  ; 

-  functional       . .         . .  • 

-  laryngeal    obstruction 

from  ..      418,  ■; 

-  orthopnoea  from   418,  ' 

-  from  syphilis. .         . .  ' 
of  accommodation  in  dis- 
seminated sclerosis  . . 

acute  ascending        514,  { 

ni^itans,  bilateral  cortical 

,,,frf.|(i>t9'  =!fnnl;iting. .    ' 

.  .  ...1..  ,1  ■■:..-..iplegiain  i 

■  :il..sviug  in  I 

analysis  aoitans,  facies  of 


analysis  agitans.    general 
account  of  --  i 

-  liystena  simulated  by  i 

-  insomnia  from  . .   I 

-  lack  of  expression  in. .  i 

-  mercury        poisoning 

simulating  . .         . .  ' 

-  myxoedema  simulating  : 

-  neuritis  simulated  by    i 

-  ptvalism  in    . .         ..  i 
rr-ilpxps  normal  in  498,  t 


"  ^NiiiMg  appearance  m  . 

-  tremor  in        ..      724,  : 

-  without  tremor         . .  i 

-  woakncse  of  one  leg  in  ■ 

-  uinking  defective  in. .   : 

-  untf'is'    cramp    simu- 

!;it.-.l  by      ..  ..    : 

aralysis  of  anterior  crural 

nerve  . .  • •  ' 

aralysis     of     one     arm. 
atrophic,  causes  of  ■  ■  ! 
iiMnibr;.cliialpl<-xus 

cerebral  abscess  . .  ■ 

embolism  . .  ■ 

hemorrhage  . .  • 

thrombosis  . .  ' 

tumour  . .  . .  I 

chorea         . .  . .  ' 

disseminated  sclero- 

-  I>tKhnm..-'^"palsy.. 

-  -  ,-H-.-pl.alih.. 

aralysis  of  one  arm.  from 
Erb's  palsy    • .         ■■  • 

analysis  of  one  arm, 
hysterical  ■•  < 

IrMMi    injiirv    at  birtll    . 

analysis  of  one  arm,  from 
Klumpke's  palsy 


-  -    Volkni:niii'scontri«> 

triicture  . .         . .  i 

-  -  yawtiing  and      .   •  •  ' 
arm," from  cervical  rib. .  1 

-  from  myopathy        . .  J 

-  jiiTononl   atrophy     ..  ! 

-  •<nudl  palpebral  fissure 

with  .,  ..  '• 

--pupil  with.  ..  i 

-  from  tumour  of  cord  i 

-  frotn  birth  injur}'      ..  i 

-  Landry  ".s  paralysis   ..  1 

-  lepro;*y  .-         •■  J 

-  poliomyelitis  acuta  ..  J 

-  proirressive    muscular 

atrophy       .. 


Parah/sis  of  arm,  contd. 

s.vringomyelia  . .  008 

talipes  with    . .  . .    112 

Paralysis,  ataxy  simulating  500 

-  of  b;ick  muscles,  scoliosis 

from 153 

-  bladder,  from  fractured 

spine 398 

haemorrhage  into  spinal 

meninges    . .         . .  398 

myelitis '         . .  . .   398 

paraplegia      . .         . .  398 

retention  of  urine  from  398 

from  labss     . .         . .  398 

urine  dribbling  from    398 

-  bowel,  from  perltoititts    425 
spinal  lesions..  ..   389 

-  brachial     plexus,     pain 


with 


progressive  muscular 

atrophy       distin- 

Paralysis,    Brown-Sequartf. 
general  account  of  58. 

496.  497 

-  bulbar,  u-e  iiieiac-ia*;  oi  OhU 
allied    to    progressive 

muscular  atrophy. .  62 
atrophy  of  hand  mus- 
cles with     ..          ..  627 

masseters  in          . .  493 

tongue  in  197,  493, 

543,  589,  627 

aspiration  pneumonia 

from             . .          . .  259 

cell  degeneration  in..  63 

difficulty  in   articula- 
tion in        . .         . .  135 

mastication  in       . .  135 

phoimtion  in           ..  135 

swallowing  in        ..  135 

—  dribbling  of  saliv 


542 


589 


dysarthria  in..      135,  627 

dysphagia  from     197, 

543,  589,  627 

fibrill'ir  contraction  in  135 

librillation  of  tongue  in  627 

lesions  causing  . .   627 

due  to  medulla  changes  589 

nivastheniaK'mvissimu- 

'lating  ..  ..108 

nerves  piiralyzcd  in  . .  135 

Paralysis,  bulbar,  notes  on  627 
ophthalmoplegia  with  130 

-  -  i.alatc  alTectcd  in  588, 

089,  627 

paralysis  of  massclcra  493 

tonL'UC  in  493,  689,  70ti 

_  _  jmresis  of  lips  in       . .  589 

j.harynx  atTwtcd  in..   688 

jirou'ressive    muscular 

atrophv  and  . .   589 

-  -  pseudo-simulatlng  197,493 

-  -  ptyalism  from  . .   543 

regurgitation  of  food  in  704 

through  nose  from 

178,  088,  580 

speech  changes  in  135,  627 

tantc  loss  from  . .   705 

tendon     retlexcs*     ex- 
aggerated in  ^      ..  027 

-  tongue  like  a  bag  of 

worms  in    . .         . .  13'» 

unilateral       . .  .  ■  6'JS 

vocal  cord  pal^y  In..   627 

-  of  cervical  svmimthetic, 

Murthing  absent  from  '-'i: 

iMiophtlmlmtM  from 

217.  511. 
|„s^  nt  pwyrhic  pupil 


crh-x  fro 


511 


,.u,-.U,>.:.lllnm.-.M7. 

Paralysis  of  cervical  sym- 
pathetic, signs  of     ■  ■ 

small    palp.-bnd    i\>- 


•  froi 


lit  If 


hiiftliiil  in  . .    ''•'•-' 

uiUN|uid  i«upllH  from  fif»*J 

-  chord»lvnii>aiil,t!xcefciof 

gj'ilivu  from         . .   700 

with  facial  paUy  . .  403 

from  mlddle-oardlH- 

cawj  . .  t  •    *'**' 


Paralysis,  cfmtd. 

-  chorda    tympuni,   saliva 

defects  from      . .  • 

taste  impaired  with 

■    493,  705,  : 

-  ciliary  muscle    . .         . .  i 
after  diphtheria  64, 

197,  \ 

-  circumflex  nerve,   arth- 

ritis simulating         . .  J 

-  cranial  nerves,  from  cere- 

bral syphilis  . .         ..  '. 

-  deltoid     . .  . .  . .   i 

-  detnisor,    retention     of 

urine  from      . .         . .  : 

-  diaphragm         . .         . .  : 

-  -  aspliyxia  from  ..  i 

from  diphtheria 

in  Landry's  paralysis  i 

-  dilatator  pupiti®  . .  • 

-  eleventh  nerve,  in  bulbar 

I>:tralysis         ..  ..    : 

i.ir-rimHis   from 
Panalysts.    Erb's,    general 
account  of  . .  b07 

-  crut.--et.),uith facial  para- 

lysis 493 

-  of  e3'e  muscles,  double 

vision  from    . .  . .   251 

-  -  ran-l  =^c  Strtbi-inus) 

ri.'oMr.lin.itinii  from  251 

Paralysis  of  extennal  popli- 
teal nerve  . .  499 

icvUJi.   uii'lujiia   from 

{^Fuj.  83)  177 

ottects  of    ..  ..176 

with  facial  paralysis  493 

frn,n    l^ad     .  .        '    ..       34 

PARALYSIS  OF  ONE  EX- 
TREMITY aOWERi    496 

PARALYSIS  OF  ONE  EX- 
TREMITY  (UPPER*     500 

PARALYSIS,  FACIAL     ..  491 

atrophv  from  63,  493 

-  -  bilateral         iFifi.  2ul)  493 

in  myopathy  ••   628 

peripheral  neuritis    627 

with    brachial    mono- 
plegia ..         ..  502 

in  bull)ar  palsy  . .    135 

cerebral  diplegia        . .   493 

contracture  from  140,  491 

corneal  reflex  in        . .    192 

crossed  paralysi;*  with  193 

dilllctdt       swallowing 

from  ..         ..  543 

dribblingofsaliva  from  403 

epiphora  in    . .      220.  403 

external    rectus    i»ar- 

alysis  witli.. 
from    Fallopian   canal 

lesion  , .  . .    194 

-  -  (Fig.  197-20l»)       491,  492 
Iiemiatrophy        simu- 
lating ..  ..  491 

-  -  with  hemiplegia    302,  492 

\\vT\tv»  of  tar  from  . .  40.1 

hyrx-rarusis  frrim       . .   403 

ii'iipair«il  hearing  from  403 

krratitis  from  ..   731 

Paralysis,  facial,  midbrain 

lesion  and  ■  493 

-  -   t.Lst..  h."   frnni        l!>:t,    _ 

Paralysis,  facial,  nuclear-     493 


i^\%  facial,  peripheral  ' 

Mb     ..  ..   i 

Ki-hnlbrtr  pani- 


-       Sfaprdiu^  u(T.-ct.-d   In 

Paralysis,     facial,     supra- 
nuclear •  •  ' 

llillW^l!/.  23'l)' 
.Ihxl     tMHOtlun 

Paralysis,  facial,  variattos  of  ' 

of  fa.-ft  (rum  . . 
—  -      tongiio  fn>'» 
•  —  nnoMnln  from        . .  < 
In  bulbar  pnrnlyilii 


Parnliisis,  cvnid. 

-  of  lifth  nerve,  dryness  of 

nasal  mucosJi  from  612 

keratitis  from        . .   731 

from  mid-brain  tu- 

muscles  affected  by  70i; 

taste  loss  from      . .  70r» 

-  general,    of    the    insane 

(see  General  Paralysis 
of  the  Insane) 

-  of  glossopharj'ngeal  nerve  706 

-  hands,    in    amyotivphic 

lateral  sclerosis         . .  62 

progressive    muscular 

atrophy       ..  ..  61 

Tooth's  peroneal  palsy  6u 

transverse  myelitis  . .  62 

-  hypoglossal  nerve,  diffi- 

cult swallowing  from    543 

in  bulbar  paralysis  135 

ptyalism  from       . .  543 

tongue  atrophy  from  63 

-  hysterical  . .      134,  141 
■  (and  see  Ilj-sleria) 


due 


ntra- 


al  pressure         . .   590 

-  infantile.        Friedreich's 

ataxv  simulating      ..     GM 

Paralysis.'  infantile,  o«neral 
account  of  ..512 

liinjiin^'frnni  ..       251,  362 

-  -  invopatliy  sinmlating      6n 
--  parts  alTtvtc^l  by       ..    11." 

plantar  retlex  in       . .     68 

from  poliomyelitis 

113,  510.  612 

-  -  n.D.  in  . .  . ,     6)) 
scoliosis  from. .         . .  153 

-  -  shoulder  wasting  from 

{Fig.  19)   50 

talipes  from   ..  ..   113 

Tooth's  peroneal  palsy 

dtstinguLsheil     from  113 

simulating       . .     6n 

ulceration  from         ..    737 

wasting  in       ..  ..60 

-  of  inferior  oblique,  dip- 

lopia from      {Fig.  83)  177 

-  rectus,  di|ilopiu  from 

{Fig,  83)    ..         ..177 

-  of  tnfriispiiuitus  . .  fiiMi 

-  intercostal   muscles,  as- 

phy\ia  from  . .  . .    51S 

Paralysis  of  Internal  popliteal 
nerve 


of 


.l.p- 

.  s:\)  17 


PARALYSIS   LARYNGEAL494 


uplmnia  fr .        104,  628 

-  -  nrvtoimlil  llxntiontiimn- 

lallni;  ..    401 
axpir.tilon    pniMinxtnln 

fn.iu  .  .    250 

Paralysis,     iaryngaai,     bi- 
lateral ■ .  495 

in  billl.ir  prtU 


of 


721 


friun  irn-bralHitflonhig  lO'i 

-  -   .nuk'h  utth  119.   401 

-  ^   Irnin     •■|.llh<-n..iiiii     uf 

.|-n,.hai:u^,.  ..     11.,. 

Itbrold  |>b(hi^K  ..    It'.'. 

Paralysis,  larynpial.  func- 
tional   494 

-  -  iflv'-muria  with         .,   -Ili:' 

-  (rum  Kununa. .  . .    Il>'> 
lM..,....rlMtfo    liil»   m..- 

■     490 

hiiuliilliiif      lot 


•  ll>i- 


PARALYSIS 


PAROVARIAN   CYST 


Paralysis,  conld. 

-  laryngeal,  stridor  from      651 

suffocative- uili-inasiniu- 


tracheotoin\' 
fromtuberrii 


628 


■  of  I 


500 


-  IiinilirK-ile^.  t;ili|..-.  irom  114 

-  masseters,  iti  bulbar  par- 

alysis . .  . .  . .   493 

from  fiftli  nerve  lesion  706 

-  median  nerve,  ischaemic 

paralysis  simulating. .   506 

-  of  masculospiral    nerve    506 

from  crutch  . .   504 

fracture       .  .  . .   504 

wrist-(hoji  from    . .      65 


aly^is 518 

Paralysis  of  obturator  nerve  498 

-  ocular  muscles,  diplopia 

from     ..  ..      176,  177 
in  disseminated  scler- 
osis         .,         ..760 

ptosis  with  . .  541 

from  syphilis         . .  541 

.3rd  nerve  lesion  . .  541 

(and  see  Strabismus) 

-  l>ainful  affections  simu- 

latiner 501 

-  palate,  in  bulbar  paralysis  589 
Paralysis  of  oalate.  causes  of  588 


nstlu 


Paralysis  of  palate,  contd. 
after  removal  of  ade- 
noids . .         . .  580 

stertor  from  . .         . .  647 

from  syphilis..  ..   589 

after  tonsillectomy  . .   589 

-  -  unilateral.         without 


cause  of       . .  . .   495 

-  of    one    leg,     Brown- 

Stiquard  type         496,  497 

from  Cauda  equina 

tumour    . .         62,  515 
in  disseminated  scler- 
osis ..         ..496 

epiphysitis       simu- 

latini,'        ..  ..    G70 

rn.iiiLTrowth  in  spine  499 

-ununa,  of  cord      .  .    406 

Paralysis  of  one  leg,  from 

hysteria  . .  497 

myelitis       . .  . .  496 

new  -jrowth  of  cord  496 

paraly.sis  a^itans  . .  498 

poliomyelitis  acuta  500 

spinal  caries 

meningitis 

syphilis        . .  . .  499 

syrinKomyelia        . .  500 


Paralysis  of  pharynx,  causes 


-phreuirnrr^r,  fn.au  diph- 
theria . . 

~  pseudo-bulbar,  age  inci- 
dence of         . .         . .  \ 

-  -  no  atrophy  of  tongue 


■  due  to  ( 

■  emofioii 


rtical  soften- 
1     nxprpssion 


pahltr    ,UlV,|r>l     III        ..     , 

--  pharynx  airi:..-u-a  in..    , 

regurgitation   of  food 

through  nose  from 

178,  I 

spasticity  in  . .  . .   i 

starchy  facies  in       . .  i 

-  pseudo-hyper  trophic  (see 

Myopathy) 

-  of  pupil,  roniplftp  .  .    ; 

Paralysis  of  sciatic  nerve.  ■  ' 


Wassermann  reaction 

with        . .         . .  4 
.r-rays  in  diii^nosing 


type'^  .".'■  ■'"  ..    135  ' 

-  levator  palpebrae  superi- 
oris  (and   see    Ptosis) 

(Fia.   227)  541  , 
Paralysis  of  long  thoracic 
nerve  (//.  -'u    505,  506 


from       Intvihlr      cx- 

tciisioN  of  knee..  1\Z 
fracture  of  femur. .  499 
-  pelvis      . .  . .   499 

gait  witli     . .  . .   499 

from  hip-joint  injury  499 
Hodgen  splint       . .   113  I 
injury     to     lumbar 
spine        . .  . .   113 


pelvis  lesions 

•  -  splint 

-  ~  talipes  from 


-  seventli   n.iAr  , -rr     I  ■,.,■- 

alysi^,  racK.l) 

-  shoulder,     from     polio- 

myelitis acuta  . ,   509 

-  simulated  bv  arthritis. .   501 

-  of  sixth    nprvr.,  .liplonja, 


589 


rih- 


\)  177 
.    176 

Ulth  \:u-\a\  lMl.il\-i<    49.3 

from  jilunibi.iu      ..      34 

-  spastic,  of  arm  . .         . .  502 
one  leg,  from  syringo- 
myelia       ..         ..110 

-  of      sphincter      vesicae, 

incontinence  from    . .  218 

-  spinal  acce^isory         135,  142 

-  from  splint         . .  . ,    141 

-  of  stapedius        . .  , .   493 
from    Fallopian   canal 

lesion  ..  ..494 

-  stomach,  acute  dilatation 

of  stomach  from      . .   173 

-  superior  oblique,  diplopia 

from     ..  (Fig.  83)  177 

rectus,   diplopia  from 

(Fh.  831  177 
Paralysis,  supranuclear  . .  492 
Paralysis  of  suprascapular 

nerve 506 


ten>,,c 


fro 


■-'7.   764 

■.Ml 

.  .    706 
•is    627 
nasal  voice    from  64, 

154,  512,  627 
regurgitation   of  food 
through  nose  from 
64,  154,  512,   588,  7G4 


fifth  nerve  lesion 
of  third  nerve  (and  see 
Ophthalmoplegia  ;  and 
Strabi«mn=>    .  . 


speech  Ue 
■  trunk   in   Lam 
alvsis  . . 


'06 


Paralysis,  contd. 

-  twelfth  nerve    63,    135,    513 

-  ulnar,    adductor  poUicis 

affected  in     . .         . .   110  , 

claw-hand  from    109,  110 

flexor     carpi     ulnaris 

affected  in  . .         . .  110 
hypothenar      wasting  j 

from  . .         . .  110  I 
ischaemic        paralysis  i 

simulating  . .  . .   506  | 

lumbricals   affected  in  110  | 

progressive    muscular 

atrophy  distinguished 

from    '  . .      61 


nr 


Paralysis,   unilateral,   from 
gross  intracranial  lesion  118 

-  of  the  vuL-u...  death  iruni     iJ.j 

after  diphtheria         . .      65 

tachycardia  from      . .      65 

-  vocal  cord  (see  Paralysis, 

Laryngeal) 
~  Volkmann's       ischaemic 

114,  {Fig.  58)  141,  506 

-  -  from  splint      .  .  .  .     61 


Paramyoclonus     multiplex 
136, 

retracted  head  from. . 

PARAPLEGJA  V.  \ 

-  ankle-clonus  in  . . 

-  ataxic  (see  Ataxic  Para- 

plegia) 

-  from    bilateral    cerebral 

softening         . .  . .   i 

-  cases  of  sudden  onset  . .  J 

-  from  Cauda  equina  tu- 


Paraplegia  in  children,  list 
I         of  causes  of    . .         ..I 

113  I  -  from  coiiil.mcl  scleroses  I 

113  ,  -  eunipie.^iuii,  girdle  pain 

499  1  in         . .  . .  . .   ; 

113  j  -  congenital  spastic,  talipes 


r  refle 


-  itoiii  fotvc|.s  at  birth    ..   , 

-  fracture  uf  spine        243,  ■ 

-  Friedreich's  ataxy 

-  functional  . .         . .  , 

-  from  general  paralj^is..  . 
hysterical  59,  141, 

-  incontinence     of    faeces 
with    . .         . .  . .   , 

-  after  kick  from  horse  . .  . 


nsed  i 


Paraplegia,  list  of  causes  of, 

in  adults  ..  I 

"  malingering  of  . .  . .  J 

-  from  meningitis  . .  • 

-  meteorism  with  . .  i 

-  from  myelitis     . .  . .  '. 

-  new  growth  in  spine   . .  i 

-  paralysis  of  bladder  in. .  ; 

-  from  peripheral  neuritis 

512,  I 

-  poliomyelitis      . .      512,  I. 

-  primary  lateral  sclerosis  J 

-  primary    spastic,    penile 

erection  absent  in     . .  .' 

-  from  progi-essive  muscu- 

lar atrophy    . .  . .  f 

~  I'etention  of  ui'ine  in    . .  .' 

-  from  scarlet  fever         . .  I 

-  spastic,  in  amyotrophic 

lateral  sclerosis 

ankle-clonus  in  .,  I 

athetosis  in    . .         . .  1 

bladder    and    rectal 

trouble  in  . .         . .  I 

from  caries    . .         . .  1 

after  cei'ebral  embolism  ] 

hsemorrhage  . ,  1 

thrombosis  . .  1 

from     combined     de- 
generations of  cord  4 

congenital,  kyphosis  in  1 

contractures  in  . .  1 


Paraplegia,  spastic,  to/Ud. 

in  disseminated  scler- 
osis . .         . ,  . .  , 

— -  from  encephalitis 

-  -  extensor  plantar  re- 
flexes in      ..      314,  . 

after  fevers    . . 

from  hsematomyelia . .   , 

infantile 

from  injury    . . 

instruments  at  birth 

Icnee-jerks      increased 


from  lateral  sclerosis 

from  meningeal  hae- 
morrhage   . . 

mental  defect  with  . . 

new  growth    . . 

polio-encephalitis 

precipitate  defaecation 

with 

micturition  with   . . 

-  -  no  R.D.  with.. 

from  sinus  thrombosis 

-  -  spinal  caries  . . 

tendon-jerks  brisk  in 

from  transverse  mye- 
litis . . 

tumour  of  cord 

no  wasting  with 

-  from  spinal  caries 

-  syphilis    ..  . .      516, 

-  syringomyelia    . . 

-  thrombosis    of    superior 


-  bile-duct  obstruction  by  : 

-  causin£7  blood  changes  . . 

-  (■l,:i,vni-|,,.v-lM,  crystals 

HI    -iomI-    n,il,  ..  ] 

I  PARASITES    INTESTINAL  j 

I    -      -    rrhitinr,   of  pir;,    tO        .. 

I  -  inu-iiiialr.i-i  .Miuulating  : 

I  -  jaiuidiee  from     .  .  .  .  ; 

I  -  ieucocytosis  from         . .  ;' 

-  i'l  lung f 

-  malai-ial     (see    Malaria) 

-  oedema  of  legs  from      . .  -I 

-  ova  of,  in  faices  . .  . .  ; 

-  severe  anaemia  from    . . 

-  in  sputum  . .  . .  : 

!  -  stools      . .  . .         . .  ] 

j  -  toxEemia  from  . .         . .  ". 

j  -  in  trachea  . .  . .  i 

-  trichinosis,  in  muscles  , .  i 

-  (and  see  Worms) 
Parathyroids,  calcium  and  1 

-  myoclonus  and  . .         . .  1 

-  tetany  and         . .          . .  1 
I  Paratji-plioid  bacilli        69.  ( 

-  fever,  agglutination  test 

for        . .  , .      565,  (' 

influenza  simulating . .  •" 

pyrexia  from  . .         . .  ." 

spleen  enlarged  in  632.  * 

tuberculosis    simulat- 


rarkuJui!'^"!ue!^e     (see  ' 
Paralysis  Agitans) 

Paronychia  (and  see  Wliit- 
low) 

Parotid  gland,  abscess  in 
(see  Abscess,  Parotid) 

carcinoma  of . .         . .  ' 

swollen,  in  Kirkland's 

Parotid  tumours    .  . .  ( 

Parotitis,  Infective,  notes  on  I 

-  pain  in  the  face  from  . . 

-  periostitis  of  jaw  simu- 

lating . .  . .  . .   I 

-  salivation  with  . .  . .    ' 
Parovarian  cyst,"simul:itiiiL.' 

ascites  . . 


PAROXYSMAL  H.EMOGLOBINURIA    —    PERICARDITIS 


iroxysmal     hsmoglobin- 


iroxysmal  tachycardia, 
general  account  of  547, 

548,  703 

-  (and  see  Tiicliycunlia, 

Paroxysmal) 

-  palpitation  from       . .  484 
irrot's  nodes,  in  congeni- 
tal syphilis     . .      ,?8o,  C69 

irticles  of  new  growth, 
in  ascitic  fluid  48,  40 

in  pleuritic  fluid  102, 

11)5,  290 

serous  eSusion      . .  107 

sputum       . .         . .  644 

urine  ..7,  27C,  5S0 

-  -  vomit  . .       7B6,  767 
[irturition  (see  Childbirth 

and  Labour) 

assion,  cerebral  vein  rup- 
ture from       . .         . .   113 

itellar  clonus      . .         . .  S58 

reflex  (sec  Knee-jerk) 

ileiit  ductus  arteriosus, 
bruits  with       91,  150,  157 

no   clubbed   lingers 

91,  111,  333 


>  cy 


ivith 


91,  111,  15B,  333 

-  no    polvcythieniia 

with  ■      . .  . .   533 

-  without  symptoms    720 

-  thrill  with  . .      157,  720 

-  T-ray  appearances  in    91 
iramr-n  dvaic.  no  svni- 


137 


jtent    septum    ventrlcu 
lorum.  bruit  of  ;>l,l3i;, 

157,  215,  533 

-  -  cardiac  impulse  dis- 

placed with       . .  215 

-  -  clubbed  flnijers  witli 

111,  215 
toes  with  ..    215 

-  -  cyanosis    with    111. 

15li.  215 

-  -  dyspnaM  with       ..  215 
epigastric  jiulsation 


ivith 


21.- 


large  heart  with  . .  215 

polycyth:l!inia    with  215 

—  pulmonary  stenosis 

with      "  ..      Ill,  215 

-  -  thrill  with  . .      157,  215 
avor  nocturnus   . .         .321 

..p,l..,.<v  ali.l  ..  ..322 

iiinly  lii^rory  ai.d  ..  :;■.■■-■ 
avy's  disease  15 

avy's  solution  In  estimat- 

inn  sugar  . .  263 
avy's  test 261 


.1...  fal^c  ilUCStiil 

after    . . 
19,  inhaled,  gatig 
luntr  from 


ijid 


599 


..  424 

(jinyelia  110 


409 


■,,  i,h.  N  .  11.  I  ..     iipply  Of  498 
'ecloi.*li.-  m.ijui ,  .itropiiy  of  513 

-  nerve  supply  of         . .   504 

-  root  irniervatioTi  of  , .   509 

-  wasting  of,  in  phthisis     «1 
mliiur,  nerve  supply  of. .  604 

•ectorilo(|uy,  with  bronchi- 
ectasis..        ..      292,043 
over  llhroid  lung      2U«,  21« 
iji  phthisis         . .         . .  2H8 

■  jineumonia        . .      160,  012 
'ediculosis    capitis,    anoi- 

inia  from        . .         . .  378 
.  -  cervical     glands     en- 
larged from  . .  379 
•  -  Goflinuidiilia  rare  from  219 

■  -  irritalion  of  neck  with  378 
*-  nits  with        ..         ..378 
t  -  occipitJil    glands    en- 
larged in     . .      377,  378 

■  —  pyre.via  from..         ..  37S 
-  -  BtilT  neck  from         ..  (117 

■  carbolic  acid  in  treating    740 

■  corporis.cosinophilla  rnro 

from 219 

■  -  jinrpura  from  . .   553 


Pnlit:uhgis,  contd, 

~  it.-liiii-  in  . .      490,  340 

-  iii.'uiii^-itisfrom. .  ..   590 

-  j.rmiu'o       distinguished 

iroiii 490 

-  pubis,     bathing-drawers 

area  aflected  by       . .  401 

eosuiophilia  rare  from  219 

gliinds  enlarged  in    . .  079 

other  parts  affected  by  401 

-  purpui-a  from    . .         . .  353 

-  tenderness  of  scalp  from  710 

-  vestimentorura,  purpura 

from 553 

Peeling  after  scarlet  fever  10 
Peliosis  rheumatica  in  acute 

rheumatism  . .  . .  105 
age  and  se.K  incidence  of55(l 

-  -  arthritis  with  .  550 
erythema  with  . .   530 

Peliosis  rheumatica,  general 
account  of  . .  556 

haimorrhage  iato  ankle 

from  . .         . .  302 

into  hip-joint  from    303 

into  knee  from     . .  302 

Henoch's     purpura  i 

simulating  . .         . .  550 
not  influenced  by  sali- 
cylate        . .         . .  550 

limping  from. .      302,  303 

purpura  in     . .         . .  553 

Ijyre-xia  from . .         . .  550 

sore  throat  with       . .   550 

systolic  bruit  and     . .  550 

Pellagra  (Pto/M  IS,  X)  226, 228 

-  desquamation  in  . .  220 

-  erythema  ui  . .  102,  223 
of  hands  in     . .         . .  220 

-  dead  fingers  ir.  . .         . .  102 

-  gastro-intestinal      sym- 

ptoms in        . .  . .   225 

Pellagra,  general  account  of  225 


Italy 
opti( 


liri 


VIS  .symptoms 
.trophy  in 


..  5711 


iieuriti> 

-  pigmentation  of  skin  i 

-  pyrexia  ' 

-  salivation  in      . .  . .   1 

-  simulating         ptomaine 

poisonitig       . .         . .  225 

-  skin  changes  in         225.  226 

-  sore  tongue  and  month  in  225 

-  temperature  chart  in    . .   225 

-  I  heorifs  of  causation    ..   220 
j'l-lli-rli.-r.  illufitmtion  sup- 

l.h.il  l)y  ..  ..   619 

i'llM..  .l.-ccss  (see  Abscess, 

-  a.lhcioiis  (sec  .Vdhesioiw) 
-  bone  loinh.;.  i.clvicswel- 

liML-  due  I"     ..  ..   08S 

IVlvic  lioiic  l.-M..ns.  pelvic 

-n..|l]h-   .li".   1..  ..    08« 

Pelvic  cellulitis,  notes  on  ..  691 
Pelvic  floor,  prolapse  of   .  ■  538 

pain  from       . .         . .  420 

-  glands    (sec    Lymphatic 

(Hands,  I'elvic)  ' 

-  httimatocelc  (see  llnjmato- 

cele) 

-  inllammation,     nmcnor- 

rha'a  from. .         18,  19 
inllamcU    lilac   glands 

from  . .         •  ■    159 
paralysis     of     sciallc 

nerve  from  . .    1119 

Pelvic    leiloni,    condlllons 
tlmulatlng     ■.        ..  46S 

-  -  frei|uent     micturition  _ 


from    .  . 
}ir|itiratinf'>  fnjm 

-  swelling    (  .  '■    .Swelling, 

I'elvic) 

-  tumour,        albuminuria 

from 

-  -  dlfflcully    In    micturi- 

tion with    . .         .  • 


Privic  funiour,  contti. 
frequent     Miicturitiou 

from  . .         . .  394 
iliac  veins  obstructed 

by 411 

muscle  wasting  from      01 

oedema  of  leg  from  . .  411 

paralysis    of     sciatic 

nerve  from  . .  499 

paraplegia  from        . .  514 

p.VOsaIpinx  causi?tg  . .   582 

retention  of  urine  with     39 

-  -  U.l).  from      . .         . .     01 
simulating         Cauda 

equina  tumour      . .     03 

-  -  vaginal     e.xaminatiou 

in  diagnosing        . .  394 

Pelvimetry 301 

I'elvLS,  beaked,  in  rickets. .    187 

-  contnu^ted  in  achojidro- 

pliisia 187 

dystocia  from  . .  200 

mode  of  detecting  200,  201 

-  chondroma  of    . .         . .  678 

-  fracture  of        278,  470,  499 

-  hour-glass,  in  rickets    . .  187 

-  osteoniyeiitls  of . .  . .   678 

-  pain  in  (see  Pain  in  the 

Pelvis ;      Dysmenor- 
rhcea) 

-  rostrate,  in  rickets      . .  187 

-  sarcoma  of  1 13, 078, 68 1 ,  09 1 

-  spleen  in  . .      028,  030 

-  tumour  in,  dystocia  from  200 
Pemphigus,  acute  eedcma 

of  tongtic  from         . .  098 

-  albuminuria  in  ..         ..     13 

-  bleeding  gums  with     . .     72 

-  bulllB  in  ..  ..  96,98,558 

-  ciiciropompholyx    simu- 

lating . .         . .         . .  756 

-  colon  allected  by         . .     74 

-  colour  of  . .         . .  001 

-  dysphagia  from . .         . .   198 

-  eosinophilia  in  ..        99,  219 

-  lingers  alTe._-lc.l   l.v        ..    239 

-  foliaccn- OOl 

Pemphigus,  general  account 


of 


-  itching  in 

-  mouth  alTccteU  by       . .     74 

-  mucous  surfaces  aflected 

by        74 

Pemphigus  neonatorum  98,  401 

-  -  ba.ilhn       iiymyancns 

-  -  hullai  in          .  .          . .  90 

-  -  congenital  syphilitic.  97 

impetiginous  form    ..  97 

poverty  and  .  .          . .  97 

-  -  rolJitioii  of  midwife  to  97 

staphylococci  causing  97 

types  of         . .         . .  97 

-  pyrexia  h 75 

-  relation  to  urticaria  ..  99 
~  nitiiaria  ..imulating     ..  771 

-  vagina  alTcctcd  by        ..  71 

-  vru'ilaiis 001 

-  vnl^-aiis.  ImllO!  in  ..  Ool 
-  -  cnisis  ill  . .  . .  601 
Pciiiclllium     glaucuin,    In 

sputum  . .  645 

Penguin-llkc  .Iwarf  .  .    188 

Penis,  absence  of  arecllont 

of.  list  of  causes  of  . .  313 


-  guiiinia  ol.  carli'"  of  |aili|.« 

sllnnliiling      ..  ..   i 

Ptnli,  gumma  of,  general 
account  of  -  ' 

-  liifMliatolna  of    .  . 

Ponli,  hentti  of    . . 

-  Ilcliliigof.  fnimheip-.. 


•mil.  miilJ. 

•  lupus  of < 

'  malformed,     impotence 
from    . .         . .         . .  ', 

pain  in  (see  Pain  in  the 


Penis,  painful  erections  of 


182 


537,  338 


98 

5411 


-  painful  erections  of,  from 

gonorrhoea     . .         . .  182 

-  Raynaud's    disease    af- 

fecting ..         ..  099 

-  sarcoma    of,    caries    of 

pubes  simulating      . .   60S 

-  scabies  atlecting  . .  401 

-  sore  on  (see  Soi"es,  Penile) 

-  ulcenition  of  (see  Ulcer- 

ation  of    Penis;    ami 
Sores.   Penile) 
Pentose.  Pial's  i«.st  for    ..  201 

-  bismuth  salts  reduced  by  202 

-  in  Canunidge's  reaction    100 

-  copper  salt  reiluctioii  by  201 

-  osazoiic  crystals  from 

•201,  262 

-  phloroglucin  test  for    . .  201 
Peppenuiiit,  heart-burn  re- 
lieved by       . .         . .  297 

-  oil,  Icucocytosis  from  . .  360 
Pcrchloride  of  iron,  iu  dia- 

cetic  acid  test  . .   170 

thirst  from     . .         . .  720 

in  Utielmann's  test  . .  320 

Percussion,  abdominal,  in 

ascites 44 

-  heart  mapped  out  by   . .  200 

-  of  stomach,  little  value  of  '244 
Perforation    of    bowel,    in 

typhoid  fever        674,  595 
Perforating  ulcer,  in  taboi  257 

(and  sec  I'lceration  of 

the  Foot,  Perforat- 
ing) 
Pericardial  elTusion,  bron- 
chiectasis after         .  .  292 
tallest  bulged  by        . .   10'.' 


iiiblewilh   297 


Pericardial  rub.  bruits  dis- 
tinguished from         .  433 


Pel 


105 


ilii'il. 

,  404,  014 

-  adherent       pericardium 

alter    ..  53,  64 

-  angina  p«'torls-llko  pain  433 

-  anxious  look  in  . .         • .  43.1 

-  with  arleriosdenisls     . .      II 

-  hi  llrighfs  illsvase        ..    In.'. 

-  caiiler  rhvlhin  with   21.1,587 

-  canliii..  Ii'iipi with    ..   213 

~  cliihl.!"!  Ilin-'.-rs  from    ..    Ill 
Pericarditis,  friction  sounds 

of                   ..      213.433 
Pericarditis,  general  account 
of        213 

-  with  cniiiiiliir  kl.lncv   ..      II 

-  heart    faillliv  (nnil         ..    lis 
.-  liiti'n'iKlal    spai'i-t    l)lh.<l 

up  In 213 

-  misiliistlnltlrt    after    62, 

.1118,  751 

-  mltnil  ri'guivltnllon  Imni 

211,  31.1 

-  inyocnnllllH  with  ..    212 
Mrthopniea  from  . .    IIH 

.  itlioul  1     ■ 


1  from 


130,  433 
,.,....or<lla  Irriln  ..   433 

lit  lower  end  of  ulrrnum 
fnilii  ••  <33 

-  pallor  III 4SJ 

-  pnlpllitl'"!  from        1HI,  186 


866 


PERICARDITIS 


PERITONITIS 


Pericardilia^  conid. 

-  suppurative,  in  pyiemia    596 
(and  see  Pyopiieumo- 

pei'icardium) 

-  systolic  bruit  from  89,  91,  213 

-  -  thrill  with      . .         . .   720 

-  tenderness  from  . .   706 
Pericardium,         adherent, 

after  acute  rheumatism  53 

pericai'ditis. .  . .      53 

angina   pectoris   from  709 

apical  systolic  bruit  in     89 

ascites  from  . .         . .     46 

back  pressure  from  . .     46 

cardiac    impulse    dis- 
placed from  . .    213 

-  -  in  children      ..  1^,  54 

clubbed  fingers  from      111 

diastolic    collapse    of 

veins  with  . .        90,  213 

shock  with..         90,  213 

Friedreich's  sign  with     90 

Pericardium,         adherent, 
general  account  of.  53,  213 

ln-art      ciilaru'-'ii      with 

14,  54,  213 

failure  from  46,  418 

impulse      displaced 

from        . .  . .   299 

-  -  liicc.Mmh   fi 


xed 


64 


from       y-.i,  -HI.  I'll,  214 

-  orthopncea  from       . .   418 

-  palpitation  from        . .   484 


littU'    rrlirr    f 

talis  «ith 


Pericardium,  adherent,  signs 


of 


90 


simulated  by  myocar- 
dial changes  . .     54 

-  -  systolic  murmur  with  213 
i-etraction  with     54. 

90,  213 

unsuspected   . .  . .   213 

varieties  of     . .  . .      53 

without  signs  or  symp- 
toms . .  . .     53 

-  aneurysm  ruptured  into 

•Xi.  li'O,  434 

-  bacillii-  >  ..h  M  ii'>  T..'    . .   652 


op. 


-  fibri 

fn.i I    ■■■'    ■■■-  Mitis  107 

-  fort'iL-i.      ■'■<  ■  ■■  .i^-u- 

pl.: I  .    ..■      ,  .   652 

-  SUbi!i:i[ilii    ijiri.il  )  ■  ;il.t- 

scess  opc'iiirig  into    ..   652 

-  vagus  branches  to  . .  148 
Perichondritis  of  ear,  ear- 

aclie  from      . .  . ,   202 

--  of    larynx,    sore    throat 

due  to 613 

-  from  syphilis     . .         -  -  203 

-  thyroid 721 

Pericolitis,  abscess  from  . .  663 

-  from  diverticula  . .  125 

-  vesico-colic  fistula  from  125 
Perigastric  adhesions  . .  437 
Perihepatitis  . .    52 

-  ascites  with  IG,  47.  52 

-  clu-onic 373 

-  from  chronic  peritonitis      47 

-  with  ciiThosis    . .         . .  371 
enlai-ged  with      . .     47 


edg 


vith 


ultiple  tappings  with        52 
~  pain  due  to       . .         . .  371 

-  from  paracentesis         . .      52 

-  in  polyorrhomenitis     . .  107 

-  simulating  cirx'hosis     . .     52 

-  syphilis  and       . .  . .     52 
Perimeter,     in     detecting 

cause  of  blind  spots  . .     72 
scotoma         . .         . .   760 

-  mapping  focal  blindness  301 
Perineum,  abscess  in  (see 

Abscess,  Perineal) 


Perineum, 

contd. 

Perineum, 
Pain 

acliing 
n  the  Pe 

in   (see 
riiieum) 

-  boils  affecting    . 

-  bromidrosis  of  . 

-  carbuiu 

e  ;iirect 

-  condvl" 

-  diah.n. 

-  epitlirh: 

-  extrav:i 

at  ion     ( 

'    u'niie 

into 

-  fall  on, 

by 
~  gouty  e 

urethra  injured 
nzema  affecting 

spasm 


-  injury  of,  prolapse  from 

-  intertrigo  affecting 

-  Jacquet's  erythema  of.. 

-  lacerated,      dyspareunia 

from 

levator 

from 

vaginismus  from 

--  pain  in  (see  Pain  iu  Peri- 
neum) 

-  rigid,  dystocia  from 

-  sinus  in  . .         . .         . . 

-  -  (and  see  Fistula,  Ure- 

thral) 

-  sores  in  (see  Sores,  Peri- 

neal) 

-  syphilis  of 

-  testis  in  . .      482, 

-  ulceration  of  (see  Sores, 

Perineal) 

-  urinary  fistula  in  . .  . 
Perinephric     ..bseess     (see 

Al.-r..-..     l-,.ri„rphnc) 

Perinephric  lesions,  general 
account  of      ..      106,  ; 

Teriodic  breathing  (see 
Cheyne-Stokes  Breath- 


Periosteum,  abscess  of  (see 
Abscess,  Periosteal) 

-  fibroma  of  . .      179,  i 

-  fibrosarcoma  of . . 
Periosteum,  gumma  of   .  ■  i 

-  hsemorrhage  beneath  38, 

72,  99,  ) 

-  lipoma  affecting  . .  i 
Periostitis,  abscess  from.,  i 
iu    heart    from         . .  i 

-  antemia  with 

-  of  femur. .         . .         . .  i 

popliteal  abscess  from  i 

-  gummatous,  pain  iu  the 

face  from       . .         . .  ^ 

-  of  ilium. .  . .      452,  • 

-  infective,  scurvy-rickets 

simulating      , .         . .  l 

-  from  injury        . .  . .    ' 

-  of  jaw I 

parotitis  simulated  by  ( 

-  leucocytosis  from  . .   I 

-  limping  from     . .      3G2,  ; 

-  mastoid,  pain  and  teuder- 

-  necrosis  due  to . .         . ,  I 

-  orbital,       exophthalmos 

from    . .         . .         . .  \ 

skiagram  in  diagnosing  : 

-  pyiemia  from    . .         . .  i 

-  in  pyiemia         . .         . .  : 

-  pyogenic,  syphilis  simu- 

lating . .         , .  i 

imulating      . .  I 
due  to  . .  . .  < 

-  of  spine  . .         . .         - .  ' 

-  suppurative,      albumos- 

uria with 

of  ilium,  appendicitis 

simulated  by         . .  * 

pain    in    iliac   fossa 

from        . .      452,  ' 
pericarditis  from       . .   i 

-  swelling  on  a  bone  from  ( 

-  syphilitic  362,  363.  622,  i 
— ■"  forehead  enlarged  from  : 

-  tenderness  from 

-  traumatic  . .      362,  ; 

-  tuberculous  3G2,  303,  668, ' 


Periostitis,  contd. 

-  in  typhoid  fever        595.  707 

-  of  ulna  {Fig.  27S)  668 

-  .T-rays  in  diagnosing     . .   6G8 
Peripheral     neuritis     (see 

Neuritis,   Peripheral)  j 


719 


Periproctitis,  general  account 
of 

Perisplenitis,   pain  in  \ 
left      hypochondrium 
from 450 

-  in  polyorrhomenitis     . .  107 

-  rub  from  . .      450,  640 
I'eristalsis,  absent  in  perito- 


nitis 


PERISTALSIS,  VISIBLE..  521 

-  visible     . .         . ,         . .     44 

under  abdominal  scar  521 

iu  ascending  colon    . .  663 

-  -  carcinoma  coli  77,125,126 

of  duodenum         . .   G61 

dilated  stomach        . .  660 

divarication  of  recti. .  521 

duodenal    obstruction  521 

gastrectasis    . .  ...   174 

from      Hii-schsp  rung's 

disease        . .         . .   127 
liypertrophic    stenosis 

of  pylorus  . .  . .   767 

with  intestinal  colic. .   425 

obstruction         130, 

241,  316,  388,  522, 

660,  661 

ladder-rung  type       . .  522 

laparotomy  and         .  .   522 

from  pyloric  obstnic- 

tion  "245,  317,  521, 

653,  660 

strangulated  hernia  . .   452 

ventral  hernia  ..    521 

vertical  type  . .  . .   522 

from  volvulus  . .   452 

Peritoneum,  aneuiysm  rup- 
tured into       . .  . .   434 

-  carcinoma  of  (see  Perito- 

nitis, Malignant) 

-  fibrous     thickenins     of, 

from  )...lyorrlioni.-iiitis  107 

Peritoneum,    hydatids   in 

49.    i.'1't'.  •iO:,  658 

-  miliary  tul^.-ivlrs  un     ..     47 

~  palpable  iliirkriiin^'  ni.  . 

-  retrosiL'niMi.i  i.Dnrii  .>i. , 

-  secondary  >i\  ;iii  ui  LTuutli 

Peritonitis,  abdominal  dis- 
tention with  . . 

-  after  abdominal  injury 

-  acute,  ;nii[i'  I'M'.  I  '-..I  His 


49 


131,  388,  453,  592 

ascitesfrom    ..  45,  47 

in  Bright's  disease  46, 

47,  55 
Peritonitis,  acute,  colic  simu- 
lating   593 

-  -    ru,i^tip:.tl..M   With     i:;i.  592 

-  -  cffrct  of  iiiiiirv  simu- 

lating .  .  . .    593 

empyema  from  . .  100 

from  fungating  endo- 
carditis       . .  . .   3S9 
Peritonitis,    acute   general, 
colic  distinguished  from  425 


425. 


with        ..         -.388 

from     diverticulitis  453 

dry    furred    tongue 

With        ..         ..388 

from  duodenal  ulcer 

47,  388,  592 

dysentery   . .  . .     47 

foul  breath  in       . .     86 

from  gastric  ulcer  47,  388 

impaired     note     in 

flauks  with         . .   383 


Prri'o/iifis.  r<uihl 

Peritonitis,  acute  general, 
intestinal  obstruction 
distinguished  from      .  38t 

mor[ihi:i.  ;,vni,h-d  iti  a'i: 

motionless  rigid  ab- 
domen with       . .  38! 

pain    increased    by 

pressure  in         . .   42i 

from  perforated  uloor 

131,  59: 

perirectal  abscess..     41 

pleurisy  from  . .   lOi 

pneumonia  simulat- 
ing ..      425,  59; 

prognosis  in  . .   42-: 

from  prostatic   ab- 

pyosalpinx. .  . .     4' 

pyrexia  with       131,  42^ 

rigid  abdomen  from 

131,  425,  592,  76] 

rising    pulse     from 

425,  59: 
septic,    after    abor- 
tion        . .         . .  59: 

from    abscess    of 

kidney  . .  59; 

liver    . .         . .  59: 

spleen  . .         . .  59: 

after  childbirth. .  59: 

dullness  in  flanks 

with    . .         . .  59; 

endometritis      . .  59' 

frequent  micturi- 
tion with        . .  59' 

from  gall-bladder 

perforation     . .  59' 

Hippocraticfacies 

with    . .      388,  59; 

leucocytosis   with  592 

liver  dullness  dis- 
appearing with  592 

after  operation. .  59:! 

from  parametritis  59:: 

pneumococcal    . .  59- 

pulse-rate      with 

388.  592 

from    pyosalpinx  592 

retention  of  urine 

with    . .         . .  592 

rub  with  388,  592 

tympanites    with 

388.  592 

from      ulcer      of 

bowel . .  . .   592 

from  wound       . .   "ly:- 

simulated  by  ruptu- 
red tubal  gestation  59;^ 

simulating  . .         . .  59." 

-  -  -  sordesin      ..  . .     8U 

from  stercoi-al  ulcer 

of  colon  . .     47 

strangulated  hernia  452 

suppurative  nephritis 

simulating  . .   594 

tenderness  with    . .   131 

tlurstfrom..  ..    7'JO 

from       tuberculous 

ulcer  of  bowel  . .     47 

in  typhoid  fever  47, 

388.  .V.'j 

urgent     laparotomv 

for  ..         ..    I'J.j 

from  volvulus        . .   452 

vomiting  with  3SS. 

425,  592.   767 


Peritonitis,      acute      non- 
suppurative . .     47 
from  duodenal  ulcer    47 


pyosalpinx 

stercoral     ulcer    of 

colon 

tuberculous 

from    typhoid    fever 


PERITONITIS 


PHLOROGLUCIX  TEST 


erjtonitis.  acute,  vascular 

lesions  simulating     . .  i 

'M„lM,rv.'rni    ;,l.-eiit   with 

in   i;i-i^')if-  .ii.-ease 
from  carcinoma  of  colon 
over  carcinoma  of  liver 
chronic,    abdominal   tu- 
mours from    . .         . .  ' 

-  albuminuria  in 

-  ascites    with    11,  45, 

47,  373, 

-  in  Bri^ht's  disease    46, 

-  constipation  in 

-  dullness  with . . 

-  encysted   ascites  with  ( 
'eritonitis,  chronic  general, 

general  account  of  ■  ■  ' 

-  hydatid  cyst  simulating 

-  liydronephrosis    siniu- 

-  intestinal    obstruction 

from  . .         . . 

-  liver  enlargement  simu- 

lated by      . .  . .  : 

-  loculated  ascites  with 

-  masses    of    thickened 

peritoneum  felt  in     ■ 

-  omentum  matted  in. .  ; 

-  pancreatic  cyst  simu- 

lating 

-  from  paracentesis     . . 

-  perihepatitis    and  47, 


eritonitis,  chronic  simple 

-  simulating  nephritis. . 

-  from  syphilis. . 

-  tube  casts  in  , . 

-  from  tubercle  . .  ■ 

-  vomiting  in    . . 
coated  tongue  in  . . 
collapse  from     . .         . .  : 
diaphragmatic,     phrenic 

neuralgia  simulating 
from    gall-bladder    r^ip- 

ture     . .         . :         .  -  : 
foul  taste  in 
hiccough  from    .. 
hypothermia  in. .  . . 

inclicanuria  from 
intestinal        obstruct  io[i 

with    ..  ..      388,  . 

local,  adhesions  from  . . 

-  from  duodenal  ulcer. . 

-  irall-stones 


.01.  I 
from  mesenteric  embolism ; 

-  thrombosis  . .  . .  < 
pain  in  the  pelvis  from. .  ' 
jiclvic,      dysmcnorrha-a 

from    . .  . .         . .  ; 

-  empyema  from         . .  ' 

-  pleurisy  from            . .  i 
lierforativc,  colic  simu- 
lated by          . .         . .  J 

-  liver   dullness   dimin- 
i:4hed  in  . .      3G6,  : 

peristalsis  absent  in     . . 
pneumococcal,  umbilical 

listula  from     . .  . .  1 

phMiri?.y  sinniiating       . .  ' 

pvloph'lebitis  sinudating  J 

|.yre.\lu  witli      . .  . .  : 

rurely   due  to  infection 

from  above  diaphragm  : 
■  tubeivutous,    abdominal 

lumps  with  47,  -18,  130,  ( 

swelling  from     0**5,  i 

wall  iidiltratcii  by 

-  acute  asi-ites  from    . . 

-  adluf?<ions  from         . .  ' 

-  age  incidence  of      48.  ■ 

-  anfflmia  with..        32,  i 

-  ascites  from  M,  45,  47, 

4«,  130,  420,  I 

-  hands  from    . .         . . 

-  Cnlmette's       reaction 


caseous  glands  ii 
■  -  portal  glands  i 


Peritonitis,  tiihercuhits^  ronftl. 

cirrhosis  simulated  by  057  , 

simulating  . .         . .  570  i 

constipation  with     . .   657  | 

-  -  diiMno^^  with..  ..      48  I 


48 


Peritonitis.        tuberculous, 
general  account  of    47,  48 

-  -  ytitiidi  aircL'tod  too  ..    631 
guinea-pig  inoculation 

in  diagnosing      48,  657 

iliac  glands  involved  In  459 

infiltrated  omentum  in    48 

intestinal    obstruction 

from  . .         . .   130 

jouits  affected  too  . .  031 

leucopenia  in. .         . .  3G1 

matted  intestines  with    48 

from  milk       . .         , .  031 

-  -  nausea  with   . .  . .   657 
Peritonitis,       tuberculous, 

notes  on                  . .  657 

obstruction  from       . .  657 

cedema  of  abdominal 

wall  from  . .  631,  657 
"  -  other  organs  affected 

with            . .         . .  48 

pain    in   abdomen    in  48 

peculiar  dullness  with  44 

pigmentation   of  skio 


•ith 


657 


pyrexia    in    48,    570, 

631,  657 
redness  of  abdominal 

wail  from    . .         ..  631 

simulated  by  malignant  49 

simulating  cirrhosis. .     48 

enlarged  liver        . .     48 

malignant  disease 

48,  51,  GGl 

ovarian  cyst  . .     48 

swelling  in  hvpochon- 

drium  from        G29,  631 
tenderness  of  abdomen 

m 48 


types  of  . .         47,  48 

umbilical    discharge 

from  . .  . .   631 

listula  from  . .   656 

inflammation    from  650 

umbilicus  affected  by  483 

reddened  in  43,  48,  425 

urachal  cyst  simulating  666 

von  Piniuet's  reaction 

with  ..         ..631 

-  in  typhoid  fever  . .  254 


Perleche,  general  account  of  366 


vphHtK 


son's  disease  sinuilated 

by  520,  (,PltU€  XX/f)  528 

—  age  incidence  of       . .  34 
amyloid  disease  simu- 
lating         ..         .,  527 

I aplastic    anoinna   dis- 
tinct from  . .         . .  24 
I nnkvlostomiusis  simu- 
lating         ..-       ..  521 
!  -  -  arsenic  in  33,  00,  520,  717 
'  -  -  iiscitc^t  in        . .          40,  55 

atypical  in  early  stogcs  32 

IIiibinRki's  sign  in      . ,  69 

hlecilintr  gums  In     ..  72 

-  -  bl(»od  chant-'f^  in       . .  22 


031, 


Pernicious  aneemla.  blood 
picture  In  ii'faic  ///)    24 

-  -  r,one.n.arn)W     liypcr- 

iropliv  fn  ..         ..  107 

-  -  earlier  rhythm  fn     , .  587 
colour  index  high   In 

21,  24,  55»  0*,  317,  569 

vuriatiotm  in     . .     24 

deafness  from  . .   166 

dlarriia'a  with  ..   172 

dllatalton  of  heart  In  587 

4'pifttaxis  from  ..   221 

-  -  fftltv  heiirt  from    53.  587 
funguiing  endoenrdill.t 

Himnhited  by  . .  21 
giutric  carcinoma  Hlrnu- 

hithig  21,  274.  317 
n<*l  dendent  iti     ..2iii 


hiomatemesis  iu    266, 

liaemoptysis  in 

hicmorrhage  into  middle 


ear  i 


160 


hypenesthcsia  in      . .  610 

lymphocj'tosis  iu      . .     04 

increasing  pallor  in  . .     24 

jaundice  simulated  by 

324,  325 

lemon  yellow  skin  in    509 

Pernicious  aneemla,  leuco- 
cytes in  24,  361 

leucopenia  in  . .     24 

loss  of  muscle  power  in    24 

-  loss  of  weight  in       21,  770 

marrow  hyperplasia  in  707 

megaloblasts  in         . .  317 

megalocytes  in  . .     64 

myelocytes  in  . .     23 

nerve  symptoms  in  . .     24 

noises  in  the  head  with  406 

cedema  of  legs  iu  413,  415 

pains  in  . .         . .  467 

in  the  limbs  in       . .  463 

palpitation  from       . .  484 

penile  erections  absent 

in 313 


■  -  peripheral  neuritis  from 

CI,  04 

■  —  pigmentation    of    the 

mouth  iu  33,  (Pla/e 

XXliy  528 
skin  in        . .         . .  527 

-  pleuritic  effusion  in  . .   106 

-  poikilocytosis  in       . .  509 

-  primrose-yellow    skin 
64 


Prussian-blue  reaction 


purpura  in     . .  . .   553 

Pernicious  ansemia.  pyrexia 

In     25,  563  {Fig.  240)  569 

-  -  rerud  infarct  in          . .  8 
rigors  in          . .          . .  590 

-  -  salvansan  in  . .          . .  026 
shortness    of     breath 

from  , .         . .     87 

spinal  cord  changes  in 

64,  09,  610 

spleen  enlarged  iu  632,  634 

stomatitis  in  . .         . .  512 

-  syphilis  simulating  . .  527 
tenderness  of  bones  in 

407,  707 

tinnitus  from..         ..  723 

uric  acid  and. .         . .  742 

urobilinuria    in     274, 

324,  743 

-  -  yellow  skin  in  . .  770 
Peroneal  muscular  atrophy  50O 

-  type  of  progressive  mus- 

cular     atrophy      (see 
Tooth's  I'oroneal  Atro- 
phy) 
Pcroneus     hrevis,     nerve 
supply  of        ..         ,.  408 

-  longus,  nerve  supply  o(  498 

-  tcrtius,  ncn-e  supply  of  498 
Perspiration,  dcliciont,  in 

myxoedoma    . .         . .  537 

-  in  nialinKercr    ..      117,  417 

-  .Malta  fever        . .  . .   400 

-  after  pneumonia  . .  042 

-  during  sleep  In  Infantile 

st^urvy  . .  . .      99 

-  thirwt  from        ..  ..    720 

-  ill  Irichinwls      ..  ..401 

-  (uiid  ^iT  .Sweating) 

I  *es  ciivHH,  from  Hpina  blllda  1 13 

-  -  tight  bootf 


In      rric-Jreich's 


>liK< 


-  -  (and  see  Talipw) 
Pt-HHarifis,  difwlmrgo  iluo  to 
185, 
Pe-wary  felt  jn'r  r»vtum  . . 
peti-ch'lin  Cmh)  PurpunO 
p,-tit   t,i  .1      .  ..        •■■■<. 


h.  IvrnplixilMn           ..   382 
MhniL'h^  nf.  In  ly[>hnfil 
j,.v,.r «S« 


Pfeiffcr's  bacillus,  in  influ- 
enza   . .  . .      465, 

Pbage<lajna  . .         . . 

-  oris,  bleeding  gum  from 

Phalanges,  tuberculous  dis- 
ease of  ..         ..  I 


fnm 
Phantom  tumour  45,  142,  ; 

-  -  ab<loniinal    distention 

swelling  from         . .   < 

age  incidence  of        . .   i 

amenorrhnea  with     . .  i 

anaesthetic     In      dia- 
gnosing      . .       45,  I 

diaphra^'ni  and  . .   ' 

Phantom  tumour,  general 
account  of  . .  i 

-  -  pelvic  swcllinj,'  dii.-  to  < 


idon. 


I  of 


Pharyngitis,  acute,  bacteria 
causing  ..  i 

sore  tliroat  from       . .   i 

tonsillitis  and  . .   < 

-  blood  spitting  from     . .  : 

-  chronic,  from  occupation 

613.  i 

sore  throat  from       . .  ( 

from  smoking       013,  I 

-  from  syphilis     . . 
Pharynx,  branch  of  vagus 

to        ..         ..         ..  ; 

-  cluckeii-pox  affecting  613,  i 

-  diphtheria  membntnn  on  ■ 

-  dermatitis  herpetiformis 

affectitifr 

-  epithelioma  of  379.  380,  ( 

-  erythema  l)ullosum  of  . . 

-  lupus  of,  blooil -spitting 

due  to  ..  ,.   : 

-  paralysis  (see   Paralysis 

of   Phiu-ynx) 

-  pemi>hi;,'us  affecting     . . 

-  red,  in  scarlet  fever      ..  : 

-  rhinoscleroma  affectini; 

-  small-pox  affecting  613,  i 

-  stenosis  of 

-  ulceration  of  . .  202,  i 
Phenazone,  glycuroiuc  acid 

from    . .         . .         . .  : 

-  reduction  by  urine  after  : 
Phenol,  gangrene  from  . .  : 
Phenolphtliniein  ..  ..  : 
Phcnylalanin,  nikuptomirlu 

and      . .         . .         . . 

Plienvlglucosaxono  crystals 
(Fi(f.  127)      ..         ..  ; 

-  melting  point  of  . .  : 
Phenvlhvdmaino   in   Cam- 

r"ni.iL'<-*s  n-ictimi 

-  hii^niM-Iol.it.uriii  (r..iii  .. 

-  osazo ■rv^t;ih  from.. 

Phenylhydrazlne    test    for 
sugar  .■  262. 

PhcnyllaotoftOKono 

-  melting  point  of 
Plioityl|M>nt«s>tKone,    molt- 
ing point  of    . .         . .  ' 

Phlmortirt.  chancre  obsu-nrwl 

bv        ..         ..      617.  I 
^  c<nivMt-i..ii-  fn.M, 


frmn 
rrlor 


PHLYCTENULAR   CONJ ITXCTIVITIS 


PIGMENTATION 


Plllvctenular  conjunctivitis 

I'fwtujifiohia,  coiitil. 

PhUmls,  contd. 

Physical  signs  of  ascites  43,  4- 

{Plate  XI)      ..         ..  330 

Photophobia,  list  of  causes 

-  lichen  scrofulosorum  with  48S 

Physical  signs  of  bronchi- 

rhoconielus          . .         . .  ISS 

of                  ..     524, 

525 

-  loss  of  appetite  in       . .  28S 

ectasis.  .         . ,      -.'-,  643 

Pbonation,    defective,    in 

—  from  meningitis 

316 

-  -  weight  in        . .      288,  768 

Physical    signs     of    cystic 

bulbar  paralysis        . .  135 

-  occupation  and .  . 

625 

-  malaise  from     . .         . .  572 

kidney                       .354 

Phosnliates,  acetic  acid  test 

-  from  sick  headache 

526 

-  mediastinal  tumour  simu- 

Physical   signs    of    dilated 

for       524 

-  ill  -iiiiw  hliiiilness 

762 

lating  267 

stomach                 521,  522 

iill.uniiiniria  siinulatiHUiy  521 

-■   111'  iliiiiliiiiii'ii\    .  . 

447 

-  micrococcuscataiThalisin641 

Physical   signs    of    emphy- 

Phosphate,   ammoniomag- 

-  ir iliiaiiiiin  of  cornea 

733 

Phthisis,  miner's  ..        ..288 

sema  217 

nesic 524 

I'hiviiii'  ill  rxr  i^cc  Nerve, 

haemoptysis  in          . .  288 

Physical  signs  of  enlarged 

crystals  of       .  .          . .   524 

I'hiviiin 

skiagram  of  {Fig.  70)  159 

heart 206 

~  ammonium,  solubility  of  523 

Phrenic  neuralgia  .  ■ 

431 

syphilis  and  . .          . .    288 

Physical      signs     of     en- 

- calcium  deposit  of       . .   524 

Plitli.-iriasi-.    iiiumcntation 

-  -  syphilitic        . .         . .  169 

larged  kidney  352.  •■;■•;.  629 

in  intestinal  sand     . .   599 

in 

627 

no  tubercle  bacilli  in  159 

Physical   signs  of  enlarged 

—  solubility  of  . .         . .  523 

Phthisis,   abnormal  apical 

-  nausea  in           . .         . .  315 

spleen  . .        "•■■'■<.  628,  629 

stellar  crystals  of     . .  524 

signs  in 

159 

-  neurasthenia    simulated 

Physical   signs,   of  fibroid 

urine  cloud  from       . .       4 

-  without  abnormal  physi- 

by         313 

lung     , .         . .      -':i-'.  643 

-  iron,  white  precipitate  of  170 

cal  signs 

286 

-  night   sweating   in  288, 

Physical     signs    of    gall- 

- magnesium,  deposit  of . .   524 

-  albuminous  sputum  in. . 

644 

470,  054 

bladder  enlargement   .  35! 

—  needles  of      . .         . .  524 

-  albuminuria  hi  . . 

13 

-  offensive  sputum  from..  260 

Physical  signs,  hepatic        366 

solubility  of  . .         . .  523 

-  albumosuria  witli 

10 

-  opsonic    index    in    dia- 

-   -   III    hi'iiiiliijil y-.],^            ,  .     :a■.^ 

urine  cloud  from      . .       4 

-  adhesions  in 

632 

gnosing           . .         . .  768 

Physical  signs  of  lobar  pneu- 

- potassium,  solubility  of  523 

—  aniemia    due    to  21,  32, 

—  orthopnoea  from           . .  323 

monia 642 

-  sodium 523 

35, 

572 

-  osteo-arthropathv    from 

Physical    signs    of    mitral 

-  -  dihydric          . .          . .   623 

—  aneurysm  simulating  . . 

291 

{Figs.  164,  165)        .  .   351 

stenosis                             2 

monohydrio    . .          . .   623 

-  anorexia  nervosa  simu- 

- pain  in  chest  from    432,  435 

Physical  signs  of  pancreas 

Phosphate,  triple  . .         . .  524 

lating  , 

771 

-  -  neck  in           . .          . .  432 

tumours                    . .  661 

.  n-sl;,l~  .il  (Fig.  221)    524 

-  apical  mottling     in     . . 

104 

-  -  shoulder  in    433,  471,  470 

Physical  signs  of  pericar- 

i'liu^lih:ili-^, rlrared  up  by 

— •  signs  with 

476 

Phthisis,  physical  signs  of  288 

ditis       .         ..      213.  433 

;i,i-fi,-  iirid          4,  183.  674 

-  bacillus  prodigiosus  sug- 

- pigment  in  mouth  from 

Physical  signs  of  phthisis.     288 

.liMolouicil      by      blood 

gesting 

644 

527,  528 

Physical    signs  of    pleural 

inu'nierit            .  .           .  .        9 

-  bronchial     glands     not 

-  pleural  adhesions  in     . .  432 

effusion                  168.  299 

Phosphates,  effects  of  heat 

caseous  in 

385 

-  pleuritic  effusion  from. .  104 

Physical  signs  of  pneumo- 

on        523 

-  bronchitis  simulated  by  644 

-  pneumococci  in. .         ..  641 

thorax            168.  432.  530 

Phosphates,  litmus  and  . .  523 

-  bronchopneumonia  from 

159 

-  pneumonia  simulating.,  2H9 

--Sawyer's          ,,          ,,     HI 

-  normal    amounts    of,    in 

-  cachexia  from     13,  173, 

313 

superposed  on           . .  389 

illustrations  from  ,  .    \t,l 

urine 522 

-  calcareous    particles    in 

-  pneumothorax  from  169, 

of   stenosed    bronchus  390 

-  potash  not  dissolviiic!  ..    740 

sputum  in    (Fig.  273) 

644 

631,  632 

Physical    signs    of     sub- 

-   i.u^  sinuil:il.-d   l.y     524,  574 

-  Oalmette's  test  in 

768 

-  prognosis  in,  diazo-reac- 

diaphragmatic  abscess  658 

Phosphates,  solubilities  of    523 

-  carcinoma  of  tonsil  with  616 

tion  and         . .         . .  173 

Physical  signs  of  swellings 

M)itrr.'<  III"            .  ,          . .   522 

-  caseous  mass  in  sputum 

-  pulmonary  aneurysm  in  287 

of  abdominal  wall          655 

■    uniti'~   siniulitini,'          ..   740 

in 

644 

-  pyogenic    organisms    in 

Physiological    albuminuria 

-  in   urine,   dinlinished   in 

-  catarrh  of  small  intestine 

cavities  of      . .         . .  641 

15.  537 

ne|)liritis         . .          . .     10 

from    . . 

172 

-  rarity  in  children         . .  385 

Physiological  cup,  appear- 

- urine  turbid  from          . .   183 

~  catarrhal  latyngitis  with 

199 

-  ridging  of  nails  in         . .  769 

ances  of         ..        .415 

Phosphatic  deposits,  physio- 

~ cavitation  in     . . 

643 

-  secondary  infection  in 

PhTsostigniiiip,    unequal 

logical  chemistry  of  . .  523 

-  chest  in 

106 

35,  86,  104,  641,  643 

■  |iii|iii-  fr.iiii    .,         ,.  :.:■: 

Phosphatic  diabetes     522.  523 

-  chronic,  clubbed  lingers 

-  skiagram  of  (Fig.  41)  . .   103 

Piaii.-l--  II  ii,i|i      .,           ,.    l.U 

PHOSPHATURIA             .     522 

from    . . 

111 

-  shortness  of  breath  early 

I'iaiiii.[i|.i\  IIIL-,      ili'teriora- 

iii-i-llr  ail.l  in  ill:iL'li,.-il||_|    luS 

-  with  cirrhosis    . . 

266 

in         88 

II. Ill    111    i|ilalltv    of.    ill 

-  clilorides  and      . .          . .   523 

-  congenital  heart  disease 

-  simulated  by  hydatid  of 

general  paralysis       .  ,    13i 

-  cliyluria  simulating      . .  108 

and 

288 

lung 291 

Pica                     .  -        4:;.  99 

-  deiinition  of       . .          . .   622 

-  cough    in   88,  150,  150, 

infarction  of  lung     . .  100 

-  alternative  names  for  . .     HU 

288, 

476 

oidium  tropicale       . .  645 

-  relation     to    intestinal 

-  nocturnal       micturition 

-  -  early 

149 

-  simulating  bronchiectasis    86 

worms            . .         . .     9S 

from 218 

-  cyanosis  from   . . 

150 

-  without  signs     . .         . .  288 

malaria           . .         . .     91 

-  and  oxaluria  alternatini* 

-  in  diabetes 

264 

Phthisis,    sputum    in    104, 

Picking  of  lips       . .          . .   365 

424,  524 

-  diarrtitea  from  .  . 

172 

149.  388,  641 

Picric     acid      (see      Acid. 

-  spermatorrhea  suggested 

-   (lla/.u-reartiun  ill 

173 

-  without  sputum            . .  104 

rii-rii-l 

by       524 

-    ili-iniira    llMlil    .. 

322 

-  staphylococci  in            . .  641 

PIED  EN  GRIFFE             .      109 

-  sulphates  and    . .          . .   523 

Phthisis,    elastic   fibres   in 

—  stench  from       . .         . .  290 

I'l-i  ..■    .  1,1  -I    -  /■..;.   7S|  1(17,    1S7 

-  urine  milkv  on  passing..   108 

sputum    In    159,   260 

-  streptococci  in  . .          . .  041 

l'li,'i>iiii-,   1 lia>  III.  asiier- 

rii.i-|iliiini^.'anuriafrom40,  41 

280, 

642 

-  succussion  in  cavity  in 

gillns  01  lung  in          .  .   111.) 

l.lir.hii-  u-inijs  from     ..     73 

-  emphysema  blebs  with. . 

532 

651,  652 

Pigment,     blood,     carriei  1 

iIiMlli  ti.iiii          ..          ..73 

-  empyema  from  . . 

104 

-  syphilis  of  larynx  witli    199 

down   by    phosphate^      9 

ratt\-  ili-L:riiiiration  from     7.1 

-  family  histoiy  in     104, 

768 

-  tenderness  from         708,  709 

-  granules   in   malaria 

-  heart  from     ..         63,  212 

-  fatal  hsemoptysis  m     . . 

288 

-  tiredness  from  . .         . .  572 

parasites         . ,         . .     '■'•' 

liver  from       . .         . .  374 

-  fatty  heart  from 

312 

-  tubercle  bacilli  in  sputum 

urine    ,  .          , ,          .  .      ,'il 

-  gastritis  simulated  after  766 

-  fever  in  .  . 

672 

with  86,  159,  286,  288, 

Pigment  patches  in  retina    416 

-  hiematemesis  from    366,  268 

-  fibroid  lung  from 

392 

293,458,476,632,642,643 

scotoma  from        .  .    7i;0 

-  janndiii.  li.nii    ■:■■:'■.  :;36,  336 

distinguished  from 

316 

not  found  in  sputum 

-  producing    micro-onran- 

-  large  In.  i    iinni         .;--'il.  374 

-  fibroid,  vocal  cord  par- 

641, 044 

isms 386 

-  pOiSOTllliL-.      II  lllr     iilli.u- 

alysis  from    . . 

496 

-  tuberculin  in  diagnosing  768 

Pigmentation  of  eyelids,  in 

atri.|ilii     -. nig  336 

-  fcetid    bronchitis    simu- 

- tuberculosis  laryngis  with  293 

Graves's  disease     216.  230 

-  -  allinniiiiniTi  ,11           ,:      13 

lated  by 

643 

-  tuberculous  arthritis  rare 

PIGMENTATION  IN  THE 

-  allnnnosnna    with      ..      16 

—  foul  breath  from 

86 

with 348 

MOUTH                    .526 

Phosphoruspolsoning,  gene- 

 sputum  with            86, 

643 

Cfficum  with  . .          . .   458 

in  Addison's  disease 

ral  account  of          . .  336 

tai.tc  111 

705 

glands  and     . .         . .  379 

33,     (Plate    XXI 1 

post-mortem     appear- 

513 

stomatitis  from         . .  542 

526,  628,  76.''.   i  ~'(. 

259 

-  -  tonsil  witli      . .          . .   615 

am,yloiil  disease        . .  537 

urine  changes  in        . .  336 

.,i. .           'rji 

290 

-  -  ulcer  of  palate  with . .  688 

from  arsenic  . .         . ,     33 

-  priapism  from  . .         . .  538 

Phthisis,  (leneral  account  of  288 

ulceration  of  bowel  in     76 

in  cachexia    .  .          .  .   527 

-  in  matcll-mnking           . .      73 

-  gingivitis  witli   .  . 

74 

-  ulcer  of  tongue  with    . .  740 

from  carcinoma        . .  537 

-  necrosis  of  jaw  from     . .  683 

-  gumma  of  tonsil  with  . . 

615 

—  vomiting  in        . .      316,  766 

malignant  disease     . .  ^^-^ 

Negro  blood  . .      526,  528 

—  ptyalism  from    .  .          . .   542 

-  hlEmoptysis    from    149, 

-  von  Pirquefs  test  in    . .  70S 

-  stomatitis  from.  .          ..     73 

159,  280, 

288 

-  wasting  in  169.  (Fig.  165)  361 

in  pernicious  anEemia 

-    vDinitin-  liiim  .  .          .  .   766 

-  headache  from  . . 

296 

above       and       below 

?,'i.(Plate XXII) 526.  52S 

I'hi.-iihiituirj-tii-  acid       ..      16 

—  hernia  of  lung  in 

169 

clavicles  in,.          ,.   169 

-  -  phthisis          . .       627,  .>2S 

1  hii-i-v  iaw               .  .           ..73 

-  hydropnenmothorax  iron 

1662 

-  -  of  deltoid  in  ,  .          . .      61 

from  syphilis..          ..   537 

PHOTOPHOBIA    ..         ..524 

-  impotence  from 

313 

infraspinatus  in        ,,     61 

Addison's  disease'  S3.  538 

-  from  biliousness            ..   526 

-  indicanuria  from 

315 

pectoralis  major  in  .  .      1)1 

-  conjunctivitis    . .         . .   231 

-  indigestion  simulated  by 

315 

supraspiiuatus  in       ..      61 

PIGMENTATION  OF  THE 
SKIN 527 

-  electric  blindness           . .   762 

-  insomnia  from  . . 

322 

-  weaknes,s  from  . .         . .  673 

-  erythropsia  with           . .  762 

-  knee-jerks  exaggerated  ii 

368 

-  .r-rav  examination  in 

from    abdominal    tu- 

- from  glaucoma  . .      331,  525 

-  lardaceous  disease  from 

104,     150,    387.    288, 

bercle          . .         - .   "'-"^ 

-  hysterical           . .         . .  536 

8,  375, 

635 

458,  476,  76S 

Addison's  disease    82, 

-  from  iritis          ..         ..231 

-  leucocytosis  in  . . 

360 

-  (and  see  Tuberculosis) 

526,  528,  765,   : 

PIGMENTATION 


PLELRISY 


PifjinrntatUm  of  the  skin,  cottttl. 

—  -  from  aisenic  ita,  {Plate 

ril)   G4,    73,      528, 

(_Fig.   2-J5)  529 

—  -  in  bronzed  diabetes 

—  cachexia         . .         . .  528 

—  chloasma        . .         . .  527 

—  cliromidrosis        simu- 

lating . .  . .   529 

—  in  cirrhosis     . .  35,  51 

—  from  endometritis    . .     99 

—  after  erytliemapapula- 

tum  ■  . .         . .  489 

—  from  fibroids  of  uterus    99 

—  ill     Graves's     disease 

215,  23C  {Fig.   222) 

.      527,  722 

—  from       ])a)mochroma- 

tosis  ..         ..  528 

—  after  herpes  . .         . .  710 

—  in  Hodglcin's  disease    527 

—  -  from   iniesthial  stasis  528 

—  irritants  . .         . .  527 

—  in  Kaposi's    disease 

528,  731 

—  leprosy  . .     250,  528 

—  -  with  leucodermia      . .  529 

-  from  leucorrhoea       . .     99 

-  alter  lichen  planus    . .  487 

-  in  malaria      . .         . .  528 

-  from  malignant  disease  G57 

-  in  ochronosis. .      528,  746 

-  )»ancreatic  disease  116,  2G4 

-  pellagra  (Plales  IX,  X) 

220,  228 

-  pernicious  anffimia  . .  527 

-  jihtheiriasis    . .         . .  527 


preg 


223 


from  radium 

-  in  rheumatoid  artliritis 

35,  342,  527 

-  round  scars  of  syphilis 

580,  737 

-  from  silver    . .         . .  529 

-  solar  plexus  irritation  527 

-  in  Still's  disease        . .  378 

-  from  syphilis  209,  219, 

4!>0,  aiS,  529,  5liO,    737 

-  tinea  versicolor     250,  529 

-  with  tuberculous  peri- 

tonitis        . .         . .  fi57 

-  in  urticaria  nij^ricans    528 

-  from  uterine  disorder  527 

-  round  varicose  veins    554 

-  from  vesicants  . .  527 

-  with  vitiligo  . .         . .  529 

-  in    von    Reeklinc- 

hausen's  disease  710,  732 

-  xanthoma       . .         . .  732 


fro 


--niys 


233 


vulva,  in  Addison's  dis- 


ease 


pigmented  crescent  at  disc 
margin  . .         ..415 

Piles,  aching  in  perineum 
from    . .         . .         .  •  474 
backache  from  . .  . .  4fi9 

bearing  down  i>ain  from  42IJ 
l>lood  per  anum  from  . .  78 
from  carcinoma  of  rectum  584 
in  cirrhosis         . .  . .     51 

inllnmed,  dysclioiia  from  12S 

-  d>'(*pareunia   from 

-  levator  ani 

-  rectal  examination  in 

diagnosing  . .  .  •    194 

-  spasm    of     sphincter 

from  . .  ■ .   I'-8 

-  speculum  ill  diagnosing  191 

-  strangury  from         . .  049 

-  vaginismus  from  . .  193 
pain  in  penis  from    471,  473 

-  rectum  from  . .  . .  78 
periproctal  abscess  from  719 
prill!'        '  "'"' 


I  from  193 


Piles,  could. 

-  sometiiing  coming  down 

rectum  iu       . .         . .     78 

-  tenesmus  from  ..         ..718 
Pilocarpine,  erj-thema  from  222 

-  ptyalism  from  . .         . .  542 
Pin,  aorta  opened  by      . .  2C7 

-  in  knee,  limping  from..  3fJ2 
*-  tesophagus  perforated  by  267 

-  in  rectum  . .         .".  584 

-  in  testing  analgesia     . .  606 

-  in  urethra  . .         . .   184 
Pins  and  needles,  sense  of, 

in  paro.vysmal  tachy- 
cardia . .         . .   703 

periphenil     neuritis  465 

Pink-eye 231 

Pit  workers,  noises  in  the 

liead  in  . .         . .  406 

I'its,  from  small-pox    561,  001 
Pituitary  body,  acromegaly 

and"      . .  3IJ2,  409,  537 
dystropliia      adipo; 


I'ifi/rinsis  rubra  /tilaris,  eonttt, 

scales  in  488,   001,   604 

on  soles       . .  . .  604 

-  veisicolor    (see    Tinea 

"      '     lor'i      ..  ..250 


n. 


201 


Placenta  pravia,  diagnosis 


of 


393 


itali!i 


409 


Pituitary   deficiency,  sym- 
ptoms of  . .  410 

-  gland    defects,    delayed 

sexual   development 

from 190 

fatness  from       190,  409 

-  —  glycasuria  from    . .  190 

headacliG  with       . .  190 

infantilism  and  189,  190 

polyuria  from       . .  190 

vomiting  with        . .    190 

-  lesions,  high  blood-pres- 

sure and         . .         . .  388 

-  secretion,    menstruation 

and 388 

-  tumour,  hemianopsia  from 
{Fig.  139)  3110,  302 


Pitj'riasis,    ringwo 
tinguished  from 

-  scalp  aflccted  by 

-  rosea.  ervthra.sma  j 

l.i 


dis- 


249 


'251 


604 

. .   Ii04 
..   540 


Pityriasis    rosea,     general 
account  of 

-  -  liwal.l  J.iil.li 

itching  in 

macules  in     . .  . .  383 

parts  affected  by     . .  00^1 

psoriasis  distinguished 

from  ..         ..004 

scales  in         . .         . .  604 

seborrlia-a  distin- 
guished from        . .  C04 

syphilide  distinguished 

from  ..         ..  004 
tinea     circinata     dis- 
tinguished from    ..  604 
versicolor  simulating  250 

-  riibm,   after    dermatitis 

lierpctifornii.<  ..   604 

-  -  des(|Uanmlioii  in       . .  604 
lifter  drug  eruptions. .   604 


.rythiMria    iiiullifornie 

Pityriasis    rubra,    general 

account      of      (««/»• 

XXI  I') 

itching  in 

-  -  after  lichc 

psoriiisis 

icalcs  in 


planus  . .  not 


601,  602 
pilaris,  cnists  In    604,  488 

-  eczema  simulated  by  604 

-  cxfollalivo     derma- 
list  inguislicti 


frm 

-  -  -  ntigers  iiff.rte.l  by     2 
Pityriasis  rubra  pllarh,  gene- 


489 


lllfi'. 


1,1  l..'..ltll 

-.1  bv 


from 

rectal     exanii 

diagnosing 

retention   of 


ition     in 


hair  loih.li-s  and  ..  4« 

itching  In  . .         .  •  >■>' 

sliglil.  in  . .         . .  48 

lichen     pliinus    dl»- 

thiguislM-'i  from      IH 

on  palms    ..         ..Oil 

papule  of    487,  48(1.  on 

purls  iillivled  hv  .  .    "' 

plll,kcd-f.»vl»kirilii 

Pityriasis  rubra  pilaris, 
psoriasis  dltllngulshcd 
from    ..  ■     489. 


ISH 


f.r,i 


Plants,  dermalltli  from     .  755 
Plates,  coloured,  list  of  «o 


Pleiades      . .         . .         . .   75S 

Plethora 221 

Pleura,  actinuntycosisaffcct- 

-  aneuo'sm  nipturcd  into  43 1 

-  librous     thickening     of, 

from  polyorrhomeuitis  107 

-  gas    in     (sec    Pneumo- 

-  nialiniianl      dLsoase     of, 

blooilstiiiried    effusion 


liteinorrhuge  from 
Plague,  gangrene  from    . .   255 

-  l3-niph-gland  enlargement 

in         ..  ..      370,  378 

-  purpura  in         . .         . .  553 

-  rigor  rare  in      . .         . .  595 
Plantar  ligament  (see  Liga- 
ment, Long  Plantar) 

-  nerve,  external..         ..  498 

-  -  iiitcrniil  .  .  498 

-  ivll.-v.  u-c  riii.l   .  .  .  .      O'.l 
PLANTAR  REFLEX,   EX- 
TENSOR ..68 

abdoniiniil  rellex  lost 

with         ..  ..   35S 

in  alcoholism        . .     69  I 

in  amyotrophiclateral 

sclerosis    02,    68, 

508,  517 

under  anasthetics       69  . 

with  ankle-clonus  . .     39 

in  ataxic  paraplegia    68 

brachial  monoplegia  502 

Jtrown-S6qunrd  par- 

al^-sis      . .         . .  497 
from  cerebellar  ab- 

_ tumour  . .        08,  517 

cerebral  abscess    . .     08 

embolism  . .     68 

-' liasmorrhage       . .     68 

thrombosis         . .     68 

in  chorea    . .         . .     69 

coma  . .         . .     09 

from  combined  de- 
generations of  cord  444 

in  concussion         . .     69 

dissemiiiatwl    scler- 

osLs  68,  148,  307, 

496,  502,  017,  728  ' 

cpileiJSy      . .         . .     69  j 

evidence  of  organic  | 

diBea.se    . .         . .  358  i 

in  Pricdreicli's  ataxy         I 

68,  512  , 

hemiplegia  39,  68, 

139,  303  1 
with  increased  knee-  | 

jerk        . .         . .     3ft  ' 

in  infants  . .       69,  510 

newgrowtli  In  sjiine  714 

pamplcgia  . .         . .     39 

[lemicious  annimla      69 

primary  latcnd  scler-  ' 

osis         . .         . .     68 
witli  pyramidal  tract 

lesions  39,  68,  140,517 
in    tMttiirnInu    cncc- 

phalopatliy        . .     09 

during  sleep  . .     09  , 

in  Hpastlc  piirnpltvla 

314,  512 

syringomyelia      68,  508 

tulipiwand..  ..    112 

in  ImnsvenM!  niyn- 

lltis  . .  02,  08 
urmmia                 . .     69 

-  -  noxor.  In  hystiTlii    6U.  197 

Intnnllle  panil.vsls. .     OH 

Ijinilry's  piimlysis      08 

neunwthenla  . .  400 

periphenil  nmirlllH       08 

prinniry      muwulitr 

dyslmpby  . .     08 
Mclattcn        ..  ..   438 

-  —  labm  donuillH       . .     08 
Toalll'K        pcronCMl 

atmpliy  . .  . .     08 

Piinlar    rellei.    modi    of 
testing  ..     8S 


Pleura,  new  growth  of 


1112 
104 


PLEURAL  EFFUSION     ..  104 

albuminuria  and      ..  liil 

in  Itright's  disease  . .  I»i5 

broncliiectasis  after  . .  292 

-  -  dii,l.hlM:.-m     depressed 

l.y 6.".S 

Pleural  effusion,  expansile 

pulsation  of  . .         . .  694 

-  -  libroid  liiiiL-  after     .  .  '^92 

-  -  heiirt  displace.1  by  298,  09 1 
from  heart  failure  104,  105 

liver  do|iressed  by    . .  367 

from  rnctliastinal  sar- 
coma ..         ..  312 
nephritis 


llM 


cede: 


nil 


tliopiiini  and         . .  l<i| 

-  -  |ial|iiliilioii  from       ..  4NI 

-  -  purlUb-s  of  frowtli  in  lii; 

Pleural   effusion,   physical 

signs  of                    . .  299 

-  -  fnnn  pica 99 

--  with   i.iieiimothorax..  432 
Pleural  effusion,  pneumo- 
thorax from  tapping  of 

■:..'1I.  532 

-  -  |.„l>ur,:,   ..fi.-i-            .  .  .•.:i.-. 

-  -  slM>rlii>'^~     of     brciilb 

lirst  sign  of             . .  8S 

-  -  skmliiic  resonance  with  Oil 

-  -  in  sr.leiionuiridic  |«olv- 

cvlhn^mia   ..         ..  0.13 

-  -  tinged  in  jnlindice    ..  321 
Plcuri.sy,   abdominal   pain 

from 115 

-  acute,  bloodstained  elTu- 

sion  from       . .         . .  lo2 

-  in  acute  rheumatism  105, 

404,  on 

-  adherent  perlcardhrm  after  54 

-  from  nneurvsin..         ..  4.14 

-  appendicitis       . .         . .  4011 
-in   broncliopnctimonla. .  105 

-  diaphnielnntjc,  appendi- 

citis   sImillaliHl    by  432 
choIc<'ys(itlssiniulat«l 


by 


432 


-  -  dliiplmiL-mslill  wilh..  367 

-  -  lirer  ili'iin-sMil  with..  307 

pain  in  slnntlder  from  70U 

periloiilliK     simulutivl 

by 432 

plin'nlciiennili.'laslniu- 


lalin 


431 


rub  Willi   ..  ..132 

Piturlsy.      diaphragmitic 
silts  of  pain  wllh      . .  432 

-  rinpvi'iii  I  >ill>'r  .  .  .  .   597 

-  In  •■ii.l...,ii.hli.  ..  ..31 

-  friclioii    ...nil. I.   Ill    IM.   133 

-  In.bK.^li'. Ill il...!  bv   .116 

-  friilii  lilt. II.  11. til  111  liiin.-     Iiul 

-  Inl.Hlloiilrol limiKii- 

pliragin  .  .    inn 

-  IntenHMtalnmimUilawltnu- 

lalnl  by         . .         . .    i"? 

-  (rnni  Ingiilnr  vein  llinnn- 

bo. 100 

-  lult.nil  >liin>  llimniboplii  IIHl 

-  liver  i.l~ .~      .  .  . .  .17" 

-  In  Inbnr  piieiimiinin     . .  lUd 

-  lm.<lliuilliilllii      and     Vi, 

3IW,  ;.M 

-  after  oiMTillona  . .    106 

-  Imin  nlllla  mnlla         .  .    lim 

-  piiln  In  back  fnmi  ..    7  In 
'    .  nn  brvnlliliig  Inmi    . .  4.13 

III  llie  I'liixl  iTtini  130,  433 


PLEURISY 


PNEUMONIA 


Pleuris}/,  conld. 

-  pain  on  cougliingfrom. .  432 
at   crest   ol   shoulder 

from  . .  . .   432 

-  -  in  the  epigastrium  from  436 

-  -  liypochoiidrium  from 

450,  451 

-  -  iliac  fossa  from      454,  4G0 

-  -  like  a  knife  from       . .   432 

-  -  in  limbs  with. .  ,.  465 

-  -  shoulder  from        474,  476 

-  simulating  pericarditis 

433,  593 

-  from  phthisis    . .  . .  104 

-  pleurodynia  simulating    431 

-  pleuropericardial     adhe- 

sions from       . .  . .     54 

-  pneumococcal    . .      105,  432 

-  in  py.Tmia 

-  pyrexia  in 

-  quiet,  couah  f rom 

-  referred  pain  in. . 


34,  102 


afte 


597 


-  shortness  of  bi'eath  from 

-  stabbing  pain  from       . .  432 

-  from  subphrenic  abscess 

370,  451,  659 

-  subphrenic  abscess  simu- 

lating   658 

-  systolic  bruit  from       . .     90 

-  -  thrill  with       . .  . .   720 
*  tearing  pain  from         . .  432 

-  tenderness  of  chest  from 

432,  706,  708,  709 

-  in  typhoid  fever  . .    595 
Pleuritic  effusion 

rheumatism 
aigoplK 


acute 


,vith. 


106 


from  appendicitis     . . 

100 

with  arteriosclerosis.. 

11 

-  -  from  osceiidiog  neph- 

ritis 

106 

baculiis  coli  in 

100 

—  from  blood  diseases.. 

106 

bloodstained  . . 

290 

breath  sounds  dimin- 

ished with  . . 

168 

-  -  in  Bright's  diseai5e    . . 

105 

bronchiectasis  after. . 

292 

-  -  cancer  cells  in 

290 

cardiac    impulse    dis- 

placed by  . . 

200 

cbest   bulged  on   one 

side  by 

168 

shrunken  after     . . 

168 

from  cholangitis 

100 

Pleuritic  effusion,  chylous 

106 

from  injury  to  tho- 

racic duct 

106 

lenkremia    . . 

106 

nephritis     . . 

IOC 

;^■th 


106 


104 


clubbed  fingei-s  from 

distinguishing  feature; 

dullness  over. .      168,  206 

from  duodenal  ulcer. .  106 

fibroid  lung  after  ■    . .  292 

from  gall-bladder  in- 
fection       . .         . .  106 

gastric  ulcer  . .  . .  106 

with  granular  kidney    11 

from  growth  of  lung. .   159 

guinea-pig  inoculation 

from  ..      104,  105 

from  gumma  in  liver  I'li; 

heart  displaced  by  . .    l':s 

from  hepatic  abscc.-^.s     Ion 

in    Hodgkin's    disease  luG 

from  hydatid  cyst  of 

liver  . .  .  .    106 

-  -  hydatid  of  liver  simu- 

'latinEJ  ..  ..    375 

Pleuritic  effusion,  from  in- 
fection from  below  dia- 
phragm ■ .    (06 

-  -  ill  leukitiuiia  . .  . .   lot; 

-  -  liver  jiushed  down  by  168 

-  -  in  lymphadenoma     . .   lOB 
lymph-gland    enlai-ge- 

nient  with  . .  . .   106 

from  mediastinal  now 

growth        . .  . .   104 

-  -  microscopical  examina- 

tion  of        . .      104,  290 
nt     of     chest 


Pleuritic  effusion,  wntd. 

from  new  growth     . .  ; 

in  liver  . .         . . 

palpitation  from       . .  • 

from  pelvic  peritonitis 

perinephritis  . .         . . 

peiitonitis      . .         . . 

-  -  i^hrifi^i^'    .. '   ;.  ■ 

Pleuritic  effusion,  physical 
signs  of 

Pleuritic  effusion,  pneumo- 
thorax from  tappinq  of  I 


fantum 

pylephlebitis  . . 

pyosalpinx 

from  renal  calculus  . . 

-  -  rPtrartio„nt\-lii'~t.  after: 

Pleuritic  effusion,  rheu- 
matic, diagnosis  from 
tuberculous    . . 

Pleuritic  effusion,  simple,  ■ 


ab- 


■  in  splc 
splenic    enlai^ement 

with 

■  from    subph: 


tinged  in  jaundice    . .  ; 

from  tuberculous  kid- 
ney   : 

tuberculous,  simulated 

by  mediastinal  new 
growth        . .         . .   . 

tubular  breathing  with  : 

unilateral        . .  . .    : 

vesicular  murmur  de- 
ficient over  . .  : 

vocal  fremitus  dim- 
inished with  . .  : 

voice  sounds  dim- 
inished   with        . .  ; 

Pleurodynia,  a  form  of 
myalgia  . .         . .  ' 

-  pain  in  the  chest  from. .   ' 

—  pleurisy  simulating      . .  ^ 

—  pneumonia  simulating 

431,  '. 

-  tenderness  with  431,  706, ', 
Pleuropericardial  adhesions, 


deficient  with 


Pleuropericarditis,  pericar- 
ditis simulated  by    . .  ' 

Plexus,    brachial,   cervical 
rib  affecting  . .  . .  . 

compressed  by  thyroid 

gland     enlanrement 

effects     of    fall     on 

shoulder  on  . .  J 

fibroneuroma  of        . .  ■ 

paralysis  of    . . 

-  cervical",  compressed  by 

thyroid  gland  enlarge- 
ment  .  .'        .  .  .  .   ' 
Plexus.      cervico -brachial. 

diagram  of  . .   ! 

Plexus,  lumbar,  diagram  of  i 
Plexus,  lumbar,  distribution 
of  498,  ' 

-  mesenteric,      meteorism 

from  lesion  of  . .  : 

-  pnnipinifofm.  thrombosis 

of.  ,.i-i.n'i-"i  'I'OTn        .  .    ; 

Plexus,  sacral,  diagram    of  i 
Plexus,  sacral,  distribution 
of  . .      498.  ' 

-  -  growth  invading       . .    : 
Plexus,    solar,    meteorism 

from  lesion  of  . .    : 

pigmentation         from 

irritation  of  . .   i 

Plucked-towl  skin,  in  pityri- 
asis rubra  pilaris      . .  •; 
Plumbism(sce  Lead  Poison- 


Plum-stones.  colic  from  ..    117 
PNEUMATURIA  .■      529,  530 

-  from  carcinotfla  recti    . .   582 
Pneumobacilli.  in  cerebro- 
spinal fluid      . .  . .   305 

-  sore  throat  due  to        . .  613 

-  in  sputum  . .  . .   643 
acute  ascites 


-  in  ascitic  fluid  . .         . .     48 

-  bacteriuria  from  . .     69 

-  bronchopneumonia  from  568 

-  in  cerebrospinal  fluid  . .   305 

-  empyema  from  103,  104,  105 
-gastritis  from    . .         . .  267 

-  in  infective  endocarditis 

209,  567 

-  laryngitis  from  158,  199, 

418,  419,  616,  650 

-  meningitis  from  305,  567,  590 

-  nasal  discharge  due  to  178 

-  nephritis  from   . .  9,  69 

-  in  otitis  media  . .  . .   422 

-  in  phthisis  . .  . .   641 

-  pleurisy  from     . .  . .   105 

-  pneumonia  from  . .   105 

-  recovered  on  blood  cul- 

ture    ..  ..  ,.   597 

-  rheumatoid  arthritis  from    35 

-  septicsemia  from       425,  590 

-  sore  throat  due  to  . .   613 

-  in  sputum  . .         . .  643 

-  suffocative  laryngitis  from 

158,  616 


lOi 


-  pyelitis  from     . . 

-  pyelonephritis  due  to  . . 

-  ulcus  serpens  from 

-  ureteritis  due  to 

-  urethritis  due  to 

Pneumogastric  nerve  (see 
Nerve,  Vagus) 

Pneumonia,  acute  abdomi- 
nal pain  from        115, 

dilatation  of  stomach 


nflu 


173 
465 


fro 


-  acute,  : 
i  -  acute  nephritis  from    ...  10 

-  albuminuria  in  . .  13,  14 
I  -  albumosuria  in  . .  . .  16 
I  -  appendicitis  simulated  by  460 
j  -  arthritis     due     to         . !    339 

'  Pneumonia,  aspiration, gene- 
ral account  of  . .  259 

-  -  after  immei-sion  . .  260 
I  -  bacillus  influenza  in  290,  643 

-  bacteriaemia  in  . .         . .  597 

-  bleeding  gums  in  . .      72 

-  blistering  in  . .  . .  14 
I  -  blueness  of  lips  in  . .  593 
j  -  bromidrosis  after         . .  654 

-  broncho-  after  anaesthe- 

I  tics 289 

age  incidence  of        . .  289 

' a4bumiauria  in  . .      13 

bacillus  influenza  in. .  290 

I bronchiectasis  from  . .  292 

caseous,  cyanosis  from  159 

-  -  in  children  . .  160,  289 
convulsive  movements 

of  chest  ill,.         ..  160 

cough  from     . .  . .   149 

I  -  -  cyanosis  from  159, 160.  420 

i dyspnoea  from  . .  590 

I empyema  from       103,  160 

gangrene  of  lung  in 

259,  G52 

general   tuberculosis 

I  simulating  . .  . .   310 

I hemoptysis  from  2S6,  289 

liyperpj'Vexia  in        . .   309 

I from  influenza  . .  289 

knee-jerk  absent  in  . .   510 

diminished  in         , .   358 

hirvngitis  simulating..   160 

leucocytosis  with    35,  361 

, orthopna^a  from    418,  420 

' from  otitis  media     . .   289 

pleurisy  rare  in         . .  105 

pneumococcal        105,  568 

prolonged  pyrexia  from 

563,  568 

j i-etracted  head  from 

I  589,  590 

shortness     of    breath 

from  . .         . .     88 

from  siu\is  thrombosis  28ft 

sticky  rales  in  . .   290 

streptococci  causing. .  &GS 

sucking    in    of   inter- 
costal  spaces   from 

160,  420 

-  caseous  broncho,  cyanosis 

from    . .  . .  . .    159 

leucocvtosis  in  . .   360 


-  chlorides  in  urin 

-  coated  tongue  in  . .  70i 

-  convulsions  from  . .  14r 

-  cough  from        . .  149,  :i3i 

-  crisis  in  . .          . .  . .  07- 

-  delirium  in        . .  . .  16! 


-  diazo-reaction  in  . .   17; 

-  empyema  with  35,  103. 

104,     (^Fiff.     71)    160, 

291,  574,  597.  lU; 

-  ending  by  lysis  (Fig.  71)  161 
"  endocarditis  in  . .  90,  I'S; 
~  eosinophilia  after  . .  21f 

-  febricula  representing  . .    16^ 

-  foul  taste  in       . .         . .   70-! 

-  in  Friedreich's  ataxy  ..  oli 
~  gangrene  of  lung  in     . .  I'Ol 

-  gastric  HCl  deficient  in    *J7( 

-  heart  block  from         ...    '>U 

-  herpes  facialis  in  . .  33t 

-  hot  dry  skin  in  . .   33{ 

-  hypothermia  after        . .  31] 

-  infective  parotitis  in  . .  69^ 

-  influenza  complicated  by  56i 

-  intercostal  neuralgia  simu- 

lated by  . .      432,  TOi 

-  jaundice  in        . .         . .  32s 

-  laparotomy  in  error  in. .  59i 

-  leucocytosis  in  . .         . .  59i 

-  from  liver  abscess        . .  37( 

-  lobar(audseePneumoniat 

without  abnormal  signs  16C 

acute  onset  of  . .  28S 

bronchial  casts  in    . .  64J 

chlorides  absent  from 

urine  in      . .      160,  285 
crepitations  in  . .   G4S 

-  -  crisis  m        (Fig.  272)  (US 

cyanosis  from  . .   16C 

diplococci  in  sputum  in  283 

duration  of    . .         . .   16C 

ending  by  crisis        . .   16C 

lysis  . .  . .   16C 

libroid  lung  from      . .   29S 

gangrene  of  lung  fron:i 

644.  652 
Pneumonia,  lobar,  general 
account  of  .642 

haemoptysis  from  286,  '.'ss 

herpes  facialis  in       . .   lil: 

high  respiration  i-atio  ill  2r^fl 

hyperpyrexia  in         . .   303 

knee-jerks  lost  in     . .   359 

leucocytosis  with    35,  361 

pain  in  iliac  fossa  from  45^ 

perspiration  after     . .  642 

physical  signs  with  160.  642 

without  physical  signs  6 12 

pneumobacilli  in        . .   iU3 

pneumococci  in         . .  643 

pungent  skin  in         . .  'ilii 

pyopneumothoraxfroniti''- 

ridges   on   nails  after 

iFiff.  306)  769 

rigor  ill  . .      594,  595 

simulating  phthisis  . .   28fl 

skiagram'of  (Fig.  136)  2S9 

sputum  in     149,  289. 

335,  641,  (-.12 

stridor  in        . .  . .   495 

sudden  onset  of    160.  t;42 

superposed  on  plithisi^  289 

temperature  chr 


lOi.i 


642 


urjite  deposit  due  to  741 

vocal    cord    paralysis 

from  . .         . .  495 

-  lobular  (see  Pneumonia. 

Broncho-) 

-  nares  active  in  . .  . .   593 

-  nephritis  from  . .  9,  43 

-  paux  in  the  chest  from 


432 


460 


iliac  fossa  from 

shoulder  from        474,  476 

-  -  side  in  . .  . .   335 

-  peiitonitis  simulated  br 

435',  593 

-  pleurodynia  simulated  by  432 
,  simulating      ..         ..  431 

-  pleurisy  with     ..         ..  432 

-  pleuritic  rub  in. .         .  ^35 

-  polymorphonucle:ir  cells    35. 


PNEUMONIA    —    POPLITEAL  SPACE 


,  coittd.  \ 

polyuria  after    . .         . .  530  , 
pulse-respiration  ratio  in  i 

335,  G3f; 
pylephlebitis  simulating  5G7 
pyrexia  from  . .  . .  574 
raoid  respiration  rate  in  425 
rigor  in 335 

-  after    . .  . .  . .   597 

septic,  abscess  from     . .  28fi 

-  hiemoptysis  from  . .  28G 
shortness  of  breath  from  88 
without  signs  . .  . .  432 
skodaic  resonance  with  611 
sordes  in  . .  . .  72 
speech  loss  in  . .  . .  623 
spleen  enlai^etl  in  632,  637 
from  subphreiiic  abscess  370 
ii!  typlioid  fever  . .  595 
tj'plioid  fever  simulated 

i.y        (J37 

'neunionoconiosis  . .  288 

IHtioiii   Inn.'  from  .  .    292 

-  !,,.■„, ..prvM-   tn.m        2SC,  288 

*neumoperttoneum,  list  of 
causes  of  """ 


l.>st  with  U5(i 

.  .    G52 


PNEUMOTHORAX 

-  ,iKnw  .y.uio:.!:,  ffo         m 

-  -  dvsiHicea  from 

-  bruit  d'airain  over 

-  chest  bulged  on  one  side 

by        

-  movement   deficient 


ivith 


1C8 


-  from  cuts  or  stabs 

-  cyanosis  from    . .  . .   432 

-  diaphragm  immobile  with  432 

-  dyspncea  from  . .  . .  432 

-  from  gangrene  of  lung. .   532 

Pneumothorax,  general  ac- 
count of  ..432 

-  lK;ut  displaced  bv    KlS. 

20G,  (i52,  659 

-  -  iiilurf  from    .  .  ..418 

Pneumothorax,  list  of  causes 
of        531 

~  liv.rdullMess  diminished  366 
depressed  by..  ..   307 

-  metallic    tinkling    with  168 

-  onset  during  coughing..   432 

-  orthopncea  from  ..  416 

-  pain  in  chest  from  1G8, 

430,  432 

-  shoulder  from       474,  476 

~  partial 531 

~   fn.ni   ptithi^is     .  .       531,  532 
Pneumothorax,    physical 

signs  of         168.  432.  530 

-  pleural  eirn^ion   with    ..  432 

-  prostration  from  ..  432 

-  rapid  feeble  heart  from  432 

-  ran?  from  fractured  rib  532 

-  sense  of  tearintr  at  onset 

<.r  432 

Pneumothorax,  subphrenic 
abscess  simulating 


>^.  659 


531 


Pneumothorax,    symptoms 
at  onset  of     •  ■ 

-  without  -symptoms       ..   53 

-  from  lapping  an  etTiision  53 

-  tubercle  bacilli  in  sputum 


nth 


(lim- 


-  vesicular  murmur 

inished  witli  . .         . .   1 

-  vocfilfremitusdiminished 

xvith 1 

-  voice  sounds  diminished 

with 1 

-  i-ruys      in      dia!;no>*hig 

432,  {Fui.  226)  5 
PoikiIocytc3(P/a/M  //,  ///) 

Poikilocytosis 


nalysis 


Poisoning,  conld. 

-  gastric  contents 

in  diagnosing. .         . .   il*J 

-  by  lead  (see  Lead) 

-  mercurial  (see  Mercury) 

-  by  morphia  (see  Morphia) 

-  nystagmus  after  ..  408 

-  phosphorus    (see    Phos-  | 

phorus) 

-  ptomaine     (see     Pto-  ' 

maine  Poisoning)  i 

Poisons,  hi-adypna;a  from  84, 85  \ 

-  Cheyne  Stokes  breathing 

from 108 

-  diagnosis  of        . .  . .   108 

-  foul  taste  from  . .  . .   705 

-  haimoglobinuria  from  . .  284 

-  hypothermia  from         . .   311  , 
Poisons,  jaundice  due  to  335, 

336.  337 

-  purpura  from     . .  . .   553 

-  vomiting  from  ..  ..   765 
Polarimeter,  in  estimating 

sugar  . .  . .  . .   263 

Polio-encephalitis  (sec  En- 
cephalitis) 
Poliomvelitis    acuta,    in 

adults  ..       61.  515 

atrophy  of  leg  from  . .  500 

musdesfromGl,509,512 

claw-hand  from        . .   109 

conditions  arising  from  135 

contractures  after  138, 

140.  509 

convulsions  in      MIO,  509 

electrical  reactions  in    509 

fever  in  , .      110.  512 

gastric  upsetsimulatcd 

br 512 


.  -  he.ulache  in    .  .  .  .    llO 

■  -  infantile  paralysis  from 

113,  140,  510,  512 
-  Landry's  typo  ..  518 

■  -  lympliocvtcsincercbro- 

spinal'fluid  in       ..  305 
-  -  malaise  in      . .         . .  140 


Polyeythtcmia^  conld.  I 

-  from  drugs         . .         -  -  533 

-  emphysema        . .      532,  533 

-  fibroid  lung        . .      532,  533 

-  heart  disease     . .         ..31 

-  methn^moglobinuria  and  533 

-  mitral  regurgitation  and  533 

-  from  mitral  stenosis  532,  533 

-  with     patent    interven- 

tricular septum        ..  215 

-  from  pregnancy  toxiemia  533 

-  ptomaine  poisoning     . .  533 

-  pulmonary  stenosis  217, 

532,  533 

-  renal  disease     . .      532,  533 

-  restricted  fluid  intake..  533 

-  severe  diarrhoea  . .  533 

-  -  thirst 533 


I 

-  -  all  ove 

r  in  .' ." 

.; 

80!l 

_ 

-  paralysis 

from 

500 

_ 

-  1  of  one 

lea  from   .. 

500 

_ 

-  paraple^i 

a   from 

510, 

512. 

511, 

5>5 

_ 

-  periphera 

[neuritis 

simu- 

latinK 

512 

_ 

-  pyrexia  1 

1 

110, 

508 

- 

-  n.D.  in 

01, 

612 

509 


531 


renoxcs  in      . .         . .  500 

rJL'or  in  . .         .  •  594 

no  sensory  clmnRes  in  509 

sbouliler  wa«tiiiff  from 

(Fia.  1!P>    ..         ..     59 
Paliomyelllls  acuta,  some 
effects  of 

talipf^  from   ..  ..   51'_' 

iinc(|n:il   liiiee-ierks  in  .150 

vasomotor  (;lningts  in  509 

-  -  vomitlrw  in         ..110,  509 

-  anterior  elironii^a  . .   135 

-  anterior     corruial     rellrt 

allooleil  1>\'   ..         ..132 

-  clironiea.atreiiici.leneeof  II" 

-  -  r-onlrai-lnri-  from  13H,  1 10 
lilirillarcontniLllonslfi  110 

-  claw-foot  from  . .  . .   109 

-  iiolio-eneeplmlitis  rclalcti 

to         132 

Politrer's  neonmf-ler  (Fig. 

7.1) 11' 

I'olyiliromato|ihllla  (/Vn/M 

//,  ///)  ■-'•-•.  21 

Polycystic  kidney,  general 

account  of  • •  357 

_  .  (,,,,.!  ...  k,. v.rvsil'-i 

POLYCYTH>EMIA  ••  532 


Polycytlixmia.  sDlenomega- 
lic.  main  features  of..  534 

-  -  PlaU  XXIX)  ..   631 
(.see         Splenomegalic 

Polycythajmia) 

-  from  "slimmer  {liarrhrea    533 
Polygonum  avicularo,  ery- 
thema from    . .         . .  222 

Polycraph  tru-iner.  in  dia- 
cnosintr  cause  of  total 
irresularitv  of  heart . .  550 

llbrillation  . .         . .  5 18 

heart-block  83, 

(.Fig.  233)  54C,  549 

Polygraph.  In  heart  cases. .  544 

in  paroxysmal  tachy- 

pulsus  biceminus   . .     550 

bisferiens  (Fi7.  235)  550 

-  vcntricularextrasystole 

(Fig.  231)  . .  . .  547 

Polymorphonuclcar  cells,  in 
*  ascitic  fluid    . .         . .     48 

cerebrospinal  fluid 

30.5,  511 
characters  of . .         . .     22 

-  diminished    in    per- 

nicious anffimia     . .     21 

-  in  Hodjikin's  disease..     37 

-  increa.sed  in  emp.vema  301 

with  liver  abscess. .   3C2 

suppuration         35,  SnO 

-  mvelwvtes  simulating    28 

-  ( Plair  It    Fig.  K^      . .  22 

-  in  iilenrilic  effusion..   102 


35 

reliuive  nuniliors  of..     23 

'  PolymyoiltIt  acuta  ..  464 

-  er^'lhenm  in       ..         ..  223 

-  pain  in  tlie  limbs  from. .  403 

-  trii'liinosis  simulated  by  404 
Polyopia,  from  ratnniot  ..  175 

Poliforrhomenltit,    general 
account  of      ■ .      106,  107 


.  hvdri 


■rie   fro 


of 


ISl 


J*olilt>us  oj  rceium.  wntii. 

intussusception   simu- 

latim:  ..717 

-  -  mnltiplc  . .         78,  585 
periproctal        abscess 

protrusion  of..         ..     78 

-  -  sense    of    fullness    in 

rectum  from          . .  78 

simulating  prolapse. .  78 

speculum  in  diagnosing  585 

tent^snuis  from           ..  718 

-  urethra,  discharge  due  to  183 
seen  with  endoscope. .  183 

-  utenis,  blood-stained  dis- 

charge from  . .         . .   186 

carcinoma  simulating    391 

mctroiThagia  from  390,  391 

nietrx)staxis  from      ..  392 

Polypus  of  uterus,  general 

features  of     ..         ..391 


Polyplasmia.  .Ivlli 

Polvpns.  cardiac    .  .  .-    laO 

-  of     cervix.     pn))ecting 

from  vagina  . .         . .  539 

-  of  ear.  from  carles       . .  422 
fleafncMi  from  . .   105 

-  -  frfun  otitis     ..     421.  423 

-  -  lliinltiwfrom..         ..   723 

-  malignant.  In  heart     ..   750 

-  nasjd,  anosmia  from 

-  -  i-pliitaxls  from 

-  -  heaila.ho  fnnn 

-  -  with  hyperlniphlc  rhl- 


fllS 


nllls 


-  It'll  lima   . . 

-  bronchlectnsi*  and 

-  bronchitis  nrid   .. 

-  from  cholera     . . 

-  clininli'  lironi'hltia 


index  In  . 


-  with     congonltal     heart 

dlseasu  215,  632,  533,  ' 

-  delirium  from    .  • 


.•iOl 


mulating..  391 

sterility  from..         ..  fi4<; 

POLYURIA  .534 

-  in  acromegaly  . .         . .  537 

-  albuminuria  and  . .  537 

-  in  arteriasclerosis  12,  90,  537 

-  azotic  diabetes  . .         ..  537 

-  chronic    nephritis      10, 

12,  191,  274,  298 

-  convalescence    . .  . .   63t» 

-  cystic  disease    . .        12,  537 

-  diabeti-s  .  .  260,  531,  719 

Polyuria    In    iliabetes    In- 
sipiilus  . .     533,  537 

-  -   III  Hini,  ..  ..   .'.33 

-  fevci-- 6311 

-  trerpiency  uf  micturition 

and      . .         . .         . .  53 1 

-  from  granular  kidney 

533,  530,  537 

-  hydronephrosis  . .      63«,  1105 

-  in  hysteria         . .         . .   719 

-  interstitial  nephritis     . .     90 

-  lanlaceons  disease  8,  337,  636 
Polyuria,  list  of  causes  ol  534-7 


179 
nl3 


Iroi 


III.'  ki.ln 


537 


-  nephritis  . .         . .      12 

-  after  oedema      . .         . .  53*1 

-  from  pale  gmnular  kidney  537 

-  periodic  . .  . .  S36 

-  in  phosphalic  diabetes 

523,  537 

-  pitiilMry  infantilism    . .  190 

-  aft4?r  pneumonia  . .  536 

-  in  pregnancy     . .         . .  264 

-  from  pyonephnwLs       . .  536 

-  renal  inflammation      ..  577 

-  thirst  and  ..  "lU 

-  from  tuberculous  kidney  577 

-  nfUT  typhoid     ..  ..   536 
liilTInorrll'ure   int<i  (r-ei- 

llamiorrhage,  Ponllliel 
Pons  varolii,  lesioliK,  ataxy 

from  . .     ftS 

rnisKiHl     hemiplegia 

from        ..-•..   302 

double     hemlploglu 

from  ..  502 
pria|iUni  fmni       . .  538 

-  -  -  pyiTXlii  from         ..  311 

-  -  lunioiir    of,    Chevne- 

.•^loki-s        lirenthlng 


In.i 


lOK 

inn 


-  -  snoring  due  to 
from  sphi'nolihd  sinus 

disease        ..         ..231 

-  -  laslelmpalnnent  from  7on 

loss  fnini     . .  . .   705 

-  nvl.d.  blood  per  nnum 

from ''* 

and    mucus    stooK 

from 

cnrrinoma    ■Imulntr'l 

hr  " 

-  -  In  ehlhlnm     ..         .■     :- 

felt  by  linger. .  . .      (H 

f  reipient  di-slre  to  defnj- 

cale  frran    .  .  "'^ 

Polypus  ol  roctum,  goneral 
account  ol  585 


Popllloal  ipaoe.  tumour  In  691 

",!'„'•""  III,'."; 


872 


POPLITETS     —     I^RIMARY    LATERAL   SCLEROSIS 


Poi)Iiteus,  nerve  supply  of  198 

Poreiicepbalus       . .          . .  132 

-  contractures  from          . .  139 

-  convulsions  from          . .  146 

-  diplegia  from     . .         . .  139 

-  dwai-lism  from  . .          . .  188 

-  infantile  diplegia  from. .  511 

-  mental  defect  with       . .  Hi 

-  muscular  atrojiliy  with  144 

-  paralysis  with   ..          ..  144 

-  parapleiri;i  from             . .  510 

-  spasm  with         . .          . .  144 
Pork,  colic  from    . .          . .  117 

-  ptomaine  poisoning  from  717 

-  trichinosis  from         4G4,  729 

-  urticaria  after    . .          . .  673 
Portal   j^laiids   (see   Lym- 
phatic Glands.  Portal) 

-  pyffimia,  rigors  in          . .  595 

(and  see  Pylephlebitis) 

Portal  vein  obstruction     50,  51 

\,y  ,.,|,-^.,:.ss  of  liver  330 

fi-on.  adhesive  pyle- 
phlebitis            ..  272 

albumituu'ia  from..  272 

in  appendicitis      . .  51 

ascite?  from  45,  51,  272 

by  carcinoma      51,  330 

causes         . .         . .  45 

from  cirrhosis        . .  272 

by  colon  tumours..  4G 

-  -  -  congestion    of    sto- 

mach from          . .  705 
dilated    abdominal 

bv    duodenal    tu- 


..  4R 
-bladder  (132 
-lands  . .  632 
t  liver  . .  330 
obstruction. 


haematemesisfrom  " 


by  liepaticaneurysni 

46,  51 

-  hydatid  cyst  of  liver  330 

-  -  kidney  tumours    . .     46 

leukemic  glands  45,   51 

liver  tumours       46,  632 

lymph  adenomatous 

glands      . .  45,  51 

malignant  glands  45,  51 

nausea  from  . .   272 

cedema  of  legs  from  272 

by    pancreatic     tu- 

pressure    on    portal 

vein  . .  . .    272 

-  -  by  s;.ivoni:.  ..    330 

.51 
-I.I.  .:.-■;,,  .1  'n.m632 
M'l-M-   •■■'I.H  ■ 'rit  272 

-  -  stomach  tumoius  40,  C32 

suprarenal  tumours     46 

thrombosis..  45,  51 

tuberculous  gland  45,51 

varicose  gastric  veins 

from        . .  . .    272 
CESophageal  veins 


ML'  in 


Portal  vein,  thrombosis  of 


Portei"s,  arthritis  of  shoulder 
in         476 

-  bursa  over  spine  in  155, 

(Fig.  65)  156 

■::■:  hliosisin        ..         ..155 
I  ■  M  ii.'ii.      Mediteri'aneau 

.^er in  ..  ..   566 

I  "ii-witie,   priapism  from  538 
I'osition,    sense    of,    cord 

paths  for        . .         . .  G07 
Post-hemiplegic     athetosis 
(^oe  Athotosis) 

-  .-i  -!■- 134 

I  .        I-    :    I  .[>i-m  from. .   538 

'   i.  ■■!   '  :  I    '■\amination 

!  I   li  I  -itiL'aneurysm291 

carcntoma    of    duo- 

,  denum     . .  . .    602 

: congenital     absence 

of  bile-ducts       . .   320 
syphilis  . .  . .  329 


-  -  encephalitis 

-  -  heat-stroke 

phosphorus    poison- 

-  -  primnry  neoplasm  of 

spuie 
sinus  thrombosis  . . 

-  -  splenic  vein  throm- 


X^ost-partuni 

hjcmorrhage 

(see  Haemorrhage,  Post- 

partum) 

Post-phai-yng 

■'al       abscess 

i,ee     Ah 

^cess,      Post- 

pharynge 

al) 

Post-puerpera 

breath  fi 

sepsis,  foul 

SO 

,.|,lr~    ill 

in!- cerebellar 
ri.rombosis) 

jG 

Posterior  scap 

lar  nerve  . . 

504 

Postural  albuminuria 

15 

"^^'l!inul'Vn 

1     . . 

*44 

iiiL,'  for  tubercle  bacilli  642 
■  in  cystin  test     . .         . .  161 
examining     for     psoro- 
spernis  ..  ..   730 


-  carbonate,  in  Bang's  pro- 


-  chlorate,  erythema  from 

hiemoglobinuria   from 

methiemoglobinieraia 

from      '      .. 

ptyalism  from  . .   . 

purpura  from  . .  ; 

sulphbtemoglobinEemia 


fro 


Perl's 


ferrocyaiiide 

test 

indoxyl  sulpliate 
iodide,  for  actinomycosis 

-  anosmia  from  . .   ' 

-  in  diagnosing  gumma 

230.  615.  I 
nature   of   ulcer   of 


-  -  noi'^es  ill  the  head  from 

-  -  a?d.'ma  from  413, 
of  face  from 

of  larynx  from  418,  ' 

nasal  catarrh  from  . .  i 

orttiopnoea  from 

peculiarities  of  sweat 

after  . .         . .  i 

photophobia  from     . .    . 

purpura  from 

stridor  from  . .         . .  i 

syphilitic   bone   pains 

relieved  by  . .   i 
pyrexia  checked  by  i 

-  -  (and  see  Iodide) 

-  |,lHK[,lia(r.   ^(.hibility  of  i 


I  Bang's 


shortness     of     breath 

from  . .         . .     89 

-  -  from  spinal  caries  364,  516 

-  <lts.-a--;iMVri-  ^pinnl  Caries) 

~     llMctm-r 114 

Pouches,  cesophageal       ..   196 

-  -   aLT  iiMaJ.Mice  of  ..    196 

dys|jliagia  due  to     . .   763 

vomiting  due  to       ..  763 

.r-ravs    in    diagnosing 

(Fiff.  96)  196 
Poultices,  erythema  from    222 
Poupart's  ligament,  fullness 
below,  from  psoas  ab- 
scess     364 

line  of  . .  . .   674 

Pouting  of  lips  in  myopathy  235 
Poverty,  pemphigus  neona- 
torum and      ,  .  . .      97 

-  typhus  fever  and 
Powdered-wig  ph 

Pozzi,  cochleate  uterus  of  645 
.ly^ni.-norrlKca  with  192 

Pozzi's  syndrome,  of  endo- 
metritis . .  387 


■•>nhl. 


335 


f:rressive  muscular  atro- 
phy      iin 

syringomyelia  . .  110 

Pre-auricular  lymph  glands 
(see  Lymphatic  GMand, 
Pre-auricular) 
Precipitin  reaction,  in  hy- 
datid disease  226,  658 
Precocity,     sexual,     with 

suprarenal  tumour  . .  064 
Precordium,   bulged,  with 

adherent   pericardium  213 

in  children     . .         . .     89 

by  large  heart  . .  206 

from  mitral  regurgita- 
tion . .        89,  210 

-  pain  in  (see  Pain,  Pre- 

cordial) 

-  tenderness  of    . .  . .   7(KS 

-  veins  distended  in       . .  213 
Preglycosuric  state,  obesity    - 

and ■.   408 

Pregnancy,  acetonuria  in        4 

-  acute  yellow  atrophy  and  273 

-  albuminuria  from      7,  9,  13 

-  albumosuria  in  . .         . .     16 

-  amenorrhoea  during  18, 

393,688,  689 

-  appendicitis  in  . .  . ,  691 

-  appetite  increased  in  . .  264 

-  -  perverted  ht  . .  ..     43 

-  .,^.-,!:.liiiL'  iic|,|,ritisfrom     13 


latiiiL'  . .      665,  688 

-  Braun's  sign  of  ..  ..393 

-  breast  changes  with     . .  6S9 

-  lnown  nipples  in  . .   430 

rlinn-a    if,  ..  ..     133 

^■iMMinii  r|uilirlioma after  391 

•  111. ■  Mr|iiiriti:^  from..       7 

mil   iKM'HImaa  in         12,  452 

-  coma  ill 144 

-  constipation  after         . .  127 

-  convulsions  in  137,  144,  146 


■  decidual  casts 

■  dysmenorrh 

■  eclampsia  ic 
ectopic      (s( 


cured  by  192 
..146 
Ectopic 


ana  from     IS 

iLT  ..    688 

lit;    201,  690 


Pregnancy,  herpetic  derma- 
titis in..         ..         96, 

-  hydrops  amnii  with 

-  hypogastric  swelling  from  f 

-  hysteria  simulating  142,  2 

-  impetigo  herpetiformis  in 

-  indigestion  simulated  by  J 

-  leucocytes  in  blood  in..  J 

-  lineie  albicantes  from  . .  t 

-  mastitis  in  . .  . .   ( 

-  mastodynia  in  . .         ..4 

-  menstruation  in  . .   ( 

-  milk    flow   from    nipple  ] 

-  mollities  ossium  and  . .  i 

-  Montgomerv's  glands  in  4 

-  moniiri-  si('kne^s  with..   ; 

-  iiri'il      Un-     cxaniiiiation  i 


lactation 
viiriaii  cyst  simulating  i 
ain  in  the  breast  in  . .  ■ 


-  :,rii,Mi^     l.-Mii  61,    61 

-  phantom   tumour  simu- 

lating,'              . .      659,  691 

-  phlegmasia  alba  dolens  in  737 

-  pismentation  from       ..  527 

-  polyuria  in          . .          . ,  20 1 

-  ptyalorrhoea  in..         ..  5i'A 

-  pyelitis  in           . .        12,  451 
relation     to     Bright's 

disease        . .         . .  ^ 

-  pyelonephritis   in        12,  570 

-  renal  tube  casts  due  to. .  7 
Pregnancy    in    retroverted 

uterus                      . .  689 

-  secondary  areola  in       -  .  l;ii 

-  severe  vomiting.' ill        ..  ''^-^ 
Pregnancy,  signs  of  19,  4.).  393 

-  suporinvolution  of  uterus 

after    . .          . .          . .  I'.i 

-  swelling  of  breasts  in  . ,  680 

in  iliac  fossa  from   . .  678 

Pregnancy,     technique     of 

examining  during      --  200 

-  Irl.niV     VMtll            .  .                ;l.  l.-.l 

-  Ilin>l  in 201 

-  thyroid    gland    enlarf,'ed 

during            ..         ..  721 

-  toxaemia,  polycythaemia 

Pregnancy,  with  tumours  689 


(■.,,.M..Mn,,  ,.r  i'enis) 

-  herpes  of    ISl,   473,   753. 

Presentations,  abnormal 
foetal : 

Pressure,  jirolonged,  gan- 
grene from     , .  . .   : 

-  ulceration  from.. 
Presystolic  bruit  (see  Bruit, 

Presystolic) 

-  thrill    (see    Thrill,    Pre- 

systolic) 
Presbyopia,  eyestrain  from 
^  increased    by    glaucoma  J 


.  the 


of 


gia  frui 
PRIAPISM 

Priapism,  list  of  causi 
-  from  gonorrhcea 
Pricking    sensation, 
miliaria 

I'rirklv  heat,  itcliin- 


PRIMARY   .MUSCULAR    DYSTROPHY 


PSORIASIS 


iniary  muscular  drstropUy. 

(see  Myopathy) 
iniula    obconica,     hull^ 

from KG 

-  ciermatitis  from         . .    755 

[inn  inis  from  . .  i'l-IO 

...  iMi-..  ahscesri  from  ..  :!38 

i-I.hI.Ii  r  opened  bv  . .  238 

lyia-^iims  from  .  /  ..  718 
octoricope,  in  diagnosing: 

adenoma  recti  ..  71'J 

-  rrircinoma  recti  . .  120 
IT' -fill  ulcerations  ..  121) 

■    Mins        ..  ..    718 

i   ^  il  cramps         . .  151 

Doerta  {Fig.  93)  191 

.    in  acute  ence- 

I     .;i:i.  ..  '      ..  120 

III   peritonitis   . .  425 

I.  r. i;i  of  liver        ..  374 

.■uii:,'L-iiiiid  heart  disease  157 

-  uLihteration    of     bile- 

ducts  ..  ..329 

;;jIieyne-Stokes      breath- 
ing and  . .  . .   lOS 
in  chlorosis        . .         . .     3i; 

chorea 133 

^in-ho'^is  with  ascites  . .  52 
I.-liMiirn   and      ..  ..    109 

I,  .li  .l-.-t.-s  ..  3,  2ti4 

Aiih  L-.!iital  delusions..  013 
i-i  i.r  .r-^troke    ..  ..120 

iieinipir^ia  .  .  .  .    303 

ttii-schsprunff's  disease. .  127 
Huntingdon's  chorea  . .  134 
leukfcmia  ..  ..24 

lymiihutic  leukjomia  ..  25 
jgnosis  of  meninsitis  . .  590 
il  1 1 1 1 1- »-.     diuzo-reaclion 


PROLAPSE  OF  THE 
UTERUS 

albuminuria  from     . . 

asceniling       nephrites 

from 

backache  from 

cystocele  simulatinc:. . 

extroversion  of  bladder 

simulating  . . 

hypertrophied    cervix 

simulating  . . 

inversion     of     uterus 

simulating  . . 

from  levator  ani  injury 

perineal  injury 

reetocele  simulating. . 

retention  of  urine  from 

strangury  from 

viiginal  tumour  simu- 
lating 

vulval  swelling  from. . 

Pronator  quadratus,  nerve 
supply  of 

-  radii  teres,  nerve  supply 


iikaimia 


37 


:  poisouing     730 
-.730 


110 


ogre^sive  muscular  atro- 
phy, abductor  poUi 
affected  in 

—  age  incidence  of    . .     Ul 

—  anterior  coraual  cells 

atlectcd  in  . .     62 

—  ape's  hand  in        . .  110 

—  with  bulbar  paralvsis 

62,  589 

—  claw-hand  from     . .  109 

—  contractures  in     . .  138 

-  -  distinguished     from 

brachial     plexus 
palsv        . .  . .     fi2 
ulnar  paralysis  ..      Gl 

-  -  librilliirfoiitraftions 

in 135 

ogressive  muscular  atro- 
phy, iieneral  account  of    61 

-uiiuro.val    arthritis 
mi-staken  for       . .    3  10 

hand-wasting  in  01,  109 

hypothenar  muscles 

affectwl   in  ..    110 

latei'al  sclerosis  with     02 

nuiin-en-i^rilTe  in  ..     01 

muscle  wasting  in. .      01 

paralv.«is  of  one  leg 

fro'ni         ..  ..300 
paraplegia  from     . .   500 

-  -  plantar  rellcx  in   . .     08 

-  -  preacher's  hand  in     110 
simulated  bv  syringo- 
myelia    *02.  lln,  257 

transverse  mvelitia  02 

-  -  tliemir   muscle*  x\l- 

fpctcd  in  ..    lin 

-  -  types  of  ..  ..  135 
ojection, visual  process  of  175 
Olapsc  of  bbid.If 


-  polypus  simulating 


P  roil  a 


oot-innerration 


PROPTOSIS  ..  1 

-  opiphon  from  . .         . .  : 

-  frotn    sphenoidal    sinus 

-  tumour  of  optic   nerve  : 
(and    see    Exophthal- 
mos) 

Propulsion,  iu  paralysis 
itgitans  . .         . .   ' 

Prostate,  abscess  of  (see 
Abscess,  Prostatic) 

-  calculus  in  (see  Calculus, 

Prostatic) 

-  carcinoma  of  (see  Car- 

cinoma of  Prostate) 

-  cidarged,abscteiS  of  testis 

from    . .  . .         . .  < 

aching     in     perineum 

from  . .         . .  ' 

by  adenomata       470,  . 

age    incidence    of    8, 

281,  394,  396, 

albumiimria  from       8, 

anuria  from   . .        42, 

-  bladder  distended  from 

45,  277,  I 

growth  simulating 

by  calculus    . .         . . 

calculus  behind 

-  -  by  carcinoma        470. 
rhronir  jn-pbriti?;  fix>m  3 


Pms 


1  detecting 


,  pen- 

..   474 
70,  182 


733 


Prostate,    entarged.    cysto- 
scopic  appearance   of 

(piatr  xvi)  ..       ..  : 

dillicult    micturition 

from  ..      28 1,  : 

-  -  fn'.pn'Ut.   mi.-turitinn 

rroin   3113.  :;im;.  531. 
Prostate,  enlarged,  general 
account  of 

liiiimaturia  from    270, 

nocturnal    micturition 

no  pain  during  mictu- 
rition with. . 

priapism  from 

at  puberty     . . 

pyelonephVitia   from.. 

pyonephrosis  from   . . 

-  -  pyuria  from      8,  270, 
rectal  exandnntlon  for 

277.  2S1,  391,  390. 

-  -  iviiul  tub.-  .M^l^  with 
Prostate,  enlarged,  retention 

of  urine  from   ''''.  396.  ' 

-  -   l,\    -  .n.-tii  .     .  . 

Min-am  from 

unrinia   from. . 

-  -  urine  dribMinu'  ilue  to 

-  legions  of.  pain   in  ana! 

n-gion  from   . .         . . 

iiiTineiiin  from 

natinii    in 


-  massage  of,  i 

prostatitis      . .         . .  IS3 

-  rectum  opening  through 

iFiff.  249)  580 

-  felt  per  rectum. .         . .  5S7 

-  residual  gonorrhoea  in. .     07 

-  sarcoma  of        . .         ..587 

-  secretion    of,    refraetile 

globules  in     ..         ..  183 

-  suppuration    of,    ulcera- 

tion of  perineum  from  019 

-  swollen,   from   prostatic 

abscess  ,.  ..   1S2 
prostatitis      ..         ..  ls*.» 

-  tender      . .  . .  . .   1S2 

-  tuberculous  (see  Tuber- 

culosis of  Prostate) 
Prostatectomy,  epididymitis 
from    . .         . .         . .  <■.:■ . 

-  fistula  after  ..  ..  0-'" 
Prostatic  ducts,  gonococcal 

infection  of    . .  . .    18:i 

Prostatic  threads  . .  . .  399 
Prostatitis,  aching 

neum  from     . 

-  due  to  B.  coli  . 

-  chronic,  massage  of  pros- 

tate in  detecting      . ,  183 

-  ditTicultv  in  micturition 

with  ". 395 

-  frequent  micturition  from 

393.  470 

-  due  to  gonococcus     7o,  473 

-  homiatogenous  infection  470 

-  non-gonococcal  urethritis  182 

-  pain  ill  legs  from  . .   442 

on  micturition  with..   182 

iu    penis    from    409, 

470,  471,  473 
rectum  from  . .         . .  578 

-  perineal  pain  from       ..   581 

-  prostate  swollen  in      . .  182 

-  pyrexia  with     . 

-  pyuria  from 

-  rectal     examination     in 

diagnosing    182,    470, 

578,  581 

-  retention  of  urine  from 

182,  390,  581 

-  from  septic  urethritis  . .  173 

-  due  to  sUipiiylococcus. .  70 
streptococcus  . .     70 

-  suprapubic  pain  from  . .   581 

-  tenderness  with . .         . .    182 

-  from  urethritis  470,  578,  5KI 

-  vesiculitis  with..  ..  473 
Protargol.  leucocytosis  from  30O 
Protein,  defect  of,  rickets 

from 115 

-  metaboli-itn,      rclampsia 

from  distnrbcrl  ..   110 

Protopathic  sensibility     ■  ■  606 

I    Pruri-o.  cn.sts  in..  ..    489 

-  IHirii-r  tm  .  .       4S9,  490 

-  ec'/.ema         dislinguisliod 

from 490 

-  enlarged  glands  in        . .  490 

-  ferox,  of  Hebni. .  . .  489 
nutmcg-grnler  skin  In  190 

-  itching  in  ..      489.  540 

-  lichen     planus    distlii- 
L'uij*hiHj  from..         ..  490 


182.  470 


licheidncatif 


oeneral 


-  papule  of  ..       487.  189 

-  parts  alTocted  by  . .  489 

-  pr-dicutosis  diatlnguished 

from •*"*' 

-  |..ovia«i'^     dlKtlnguinIied  49  0 
|,.i-firl.-,  in  ..  ..    190 

-  ,  ,i.ji    di-tlngulMheU  fn)iiil90 


PRURITUS  (anil 


Pseudo-angina  pectoris    . .  434 
Pseudo-bulbar    paralysis 

i:>.    11' 7.    493.    .-.13. 

Pseudochylous  ascites    ■  ■    SO 

{■-.■ii.lo-,  \,-M-  ..        112.   059 

Pseudo-elephantiasis        .  ■   ill 

-  VMlv:...   ^viph.lm.-  ..    7H1 

-  vnlv;.l  -u-llir,-  lr..m     ..   Cim 
P>^i-u.lt)-h.nii;iphnHiiti-ni       i;iO 

Pseudohypertrophic  muscular 
paralysis  ■  ■   513 

^  -        (.LM.l   -v  Myopatl.y) 

Pseudo-leukiBmia  infantum    37 
Pseudoleukemia  infantum, 
account  of  ..634 

M       ..  37.  55 

37,  46,  55 

iNU'CS  iu      . .     37 

lisvplulisand  G.35 

.//./.  J.n     *  ..         ..37 

Iiicmorrliages  in        ..     37 

-  -  liver  enlaigevi  in       . .     37 

(cdoma  of  legs  in  413,  415 

pleuritic  effusion  hi..   100 

prognosis  in   . .  . .     37 

purpura  in      . .  . .   553 

pyrexia  in      . .         . .     37 

rickets  and  37,  035 

spleen  enlarged  in  37, 

55,  631 

syphilis  and   . .  . .     37 

Pseudo-leuksmia  Infantum, 
various  conditions  in- 
cluded in  . .  634 

-  -    \\:.-,IMi:nii,    u-l    ir...    0;j| 
Pseu.lu-n<-iin.k'i;i  .  .  . .    449 

Pseudo-nystagmus  •  •  407 

Psendo-panUvsis,  mercury 

ill  ..'         ..  ..   348 

-  syphilitic  ..  ..318 

Pse'udo -pelade  of  Brocq  . .    71 

-  -  tenderness      of      s*atp  _ 

fixnii  . .  . .    710 

Pseudo-reminiscenctsa       in 

alcoholism      ..  ..20 

Pseuilo-tabes,      iliritinction 

from  tahos  51; 

Pseudo-trlctilnosls  ■ .  464 

Psoas  al>sces8  (s<'*'  Ahsces.-*, 

Psoas) 
Psoas  bursa  (sec  Bursa) 

-  muscle,  nerve  suiiply  of  499 
suppuration   of,   from 

spinal  carles  . .   150 

Psoriasis,    aiddrosis  with  65  i 

-  biddnc^s  from    . .  . .     71 

-  bathing  -  dmwers  area 

udeited  bv     . .  . .   401 

-  blue  eves  and     . .  . .   On;i 

Piorlasli  eczema  dittln- 
Quished  from..        ••  608 

-  cllums  .IIT.-.I.-.I  bv         ..    191 

-  .■oshiuphilian.T.-'in        ..    219 

-  uxten.'iorsnrfacesalTcctfsl 

by        191 

-  fair  hair  ami      ..         ..  «'•:» 

-  favus  sinniliithig  ..  217 

-  linger*  afTi'<'te«l  by        . .  2  in 

Ptorlatlt.  general  account  of  603 

heiitlh 


490  t 


ili'hi 


5Pt 


;.IT.'. 


Psoriasis,  lichen  planus  dis- 
tinguished from      i-*^.  603 

-  m-  ..:l..H  M  - .  ■  ■'^•■■ 
Pcorlasis,  luuus  erythema- 
tosus disllngulthed  from  603 

-  iiiiih  t.lTr.  i.-.l  liy  ..    ■-'■•" 


-  l"»l" 

-  part 


■•\    hs 


dia 
from 


»slni;  . 
•thrills 


Psorlails.    pllyrlaiU   rubra 
pilaris   dlitlnguUhed 
from  469.  ' 


.,  .|...   )i.  -iW*,  f"*,  r-i. 

not,  no2,  6" 
-  iM'alp  ofTnle^l  by  ..    21' 


PSORIASIS 


PUPIL 


Psoriasis,  mtttd.                            1  Pulmonary     abscess     (see 

Pulsation,   contd. 

Pulse,  conld. 

-  staiiiiiii;  of  skin  from  .*.  603 

Absce^  of  Lung) 

-  of  veins  in  neck            02.  369 

-  relatively    slow,    in    ty- 

- syphilide  simulating 

-  area,  bruits  in  . .         . .     91 

-  violent  arterial,  in  aortic 

phoid  fever    . .       564, 

491,  003,     CW 

-  -  definition  of  . .          ..91 

regurgitation             . .  694 

-  rising     rapidity*   of,    in 

-  tinea     circinata     distin- 

-  artery  (see  Artery,  Pul- 

 exophthalmic  goitre  694 

acute  peritonitis  425. 

Ruished  from. .          ..   249 

monary) 

Pulse,  alternating. .          . .   545 

-  slow,    from    alternating 

Psorosperras     in     Paget's 

-  embolism  (see  Embolism, 

-  anacrotic,  in  aortic  sten- 

extrasystoles. . 

ilisease             ..          ..730 

Pulmonary) 

osis      208 

from  bile  salts 

1  '-yclialiifja,  facial  pain  from  449 

Pulmonary     incompetence 

-  collapsing,    with    aortic  ■» 

cerebellar  abscess     . . 

-  |i  till  in  the  arm  from    ..   445 

93.   215.  217 

regurgitation          217,  485 

cerebral  abscess 

J'-vili:i-^tlienia,    aerophagv 

-  infarct    (see    Infarct    of 

-  delay  of  one,  from  aneur- 

 tumour 

with '.   240 

I.Ull-l 

ysm      . .          . .          . .   550 

in  convalescence 

PsTciiic  reflex  of  pupil  651,  552  ( 

Pulmonary  osteoarthropathy, 

-  diminished     radial,     by 

cretinism 

Pterygium 399 

general  account  of '  /■'('/.«. 

cervical  rib    . .      110,  444 

from  heart-block  546, 

Ptomaine  poisoning,   bac- 

li;i.  Kio)  352 

-  dropped   beat   in,   from 

548. 

teriology  of    . .          . .  717 

lingers  enlarged  in    ..  Ill 

extrasystole    . .          . .   547 

increased   intracranial 

diarrlitt-a    from     171, 

-  -  spelling  of  bones  in  . .   070 

pulsus  alternans    . .   546 

pressure 

234,  717 

-  second  sound,  accentuated    1 

-  high  tension,  in  chronic 

-  -  jaundice          . .      324. 

epiilemie         . .      554,  717 

with    mitral    re- 

nephritis     (and      see 

mysoedema    . . 

erythema  in    . .      222,  224 

gurgitation     . .   210 

Blood-pressure,   High)  274 

in  relation  to  tempera- 

 froniG;iertiicr'.sbaciIiiisri.:»l 

Pulmonary  second  sound. 

-  imperceptible,  from  snake- 

ture, in  yellow  fever 

Ptomaine  poisoning,  general 

reduplicated   . .                2 

bite      337 

Stokes-Adams'  disease 

account  of                . .  224 

wilih     mitral    re- 

Pulse, intermission  of  the. 

146. 

-  ~  general    wasting    from     59 

gurgitation     . .   210 

general  account  of   . .  549 

-  -  typlioid  IV-v,.,- 

Ptomaine  poisoning,  notes 

-  stenosis,  acquired         91,  92 

-   -    in     Kiikl,:,,!'^     .|,-.-.^,.    t;ili 

on       717 

ascites  from  . .          . .     46 

PULSE,  IRREGULAR           544 

Pulse,  slow,  various  causes 

a-Jema  from  . .          .  .   415 

back  piessure  from  . .     46 

uirh    :i<>Mli'    lf_'U!.-ll   1- 

of                     --      548. 

pellagra  simulating  . .   225 

-  -  bruit  cf         111,  150,  157 

tion              . .          . .    207 

Pulse,  summary  of  peculi- 

 in  children     ..         ..91 

from  arsenic  . .        ' . .     78 

arities  of       548,  549. 

-  —  from  pork       . .         . .  717 

— '-  clubbed    finger;    and 

athlete's  heart          . .  214 

-   sTii;ill.   in   iiiitrd  striu.sis 

purpura  from         553,  554 

toes  ui  91  (.Fill.  46) 

auricular  fibrillation      548 

-  si-la^liiiiL'.    iM   aortic  dis- 

 severe  diarrhoea  in    . .   533 

111,  217 

cerebral  disease          . .   295 

ease 

fromsllclinsh              ..   415 

toes  from   . .          . ,   :J  1 7 

-  -  in  children      . .          . .    549 

Pulse,  totally  irregular    . . 

.  summer  diarrhoea  allied 

congenital       ..          ..   217 

-  -  from  dropped  beats..   549 

-  variations  with  respira- 

to  717 

-  -  cyanosis  from  111,  150,  217 

Pulse,  irregular,  from  extra- 

tion 

-  -  vertigo  from  . .          . .   752 

dVspncea  from          - .   217 

systoles           ..     547,  549 

swallowing      . . 

vomiting    from     171, 

--{'Fig.  G7)         ..         ..  157 

fatty  heart     ..          ..   212 

-  waterhammer,  in  aortic 

224,  717 

heart  failure  from     . .     40 

fibroid  heart  . .          . .   213 

reguigitation    93,    91, 

PTOSIS       540 

incompetence  with  ..217 

-  -  heart-block     . .      545,  549 

207,  208, 

-  congenital           . .          . .   542 

palpitation  from       . .   484 

Pulse,  irregular,  main  types 

-    11,    vIImW   frvrr    .. 

-  from  conjunctivitis       . .  541 

patent  interventricular 

of        545 

PULSES.  UNEQUAL 

-  hysteria 141 

septum  with       111,  21."> 

from  meningitis         . .    147 

-■    -■    ;  iiiKi   .11   .iriiiiiiral  ciill.-^O 

-  myasthenia  gravis        . .  541 

polycYtha^mia  from 

mitral  regui^itation . .    210 

Pulses,  unequal,  from  aneur- 

- myopathy          . .         . .  235 

217,  532 

stenosis  14,  53,  55, 

ysm      208,   550,  551, 

-  oedema    . .          , .          . .   541 

ritjht  ventricle  enlarged 

81,  210 

axillary       . . 

-  paralysis     of     cervical 

from             ..      215,  217 

myocardial  changes  14, 

atheroma        . .      550, 

sympathetic  541,  552,  722 

Pulmonary  Stenosis,  systolic 

212,  300 

cervical  rib     . .      5">0. 

of       seventh       nerve 

bruit  of          91,  217,  533 

in  nervous  subjects  . .  549 

-  -  embolism 

(^Fiqs.  -I'll,  229,  230)  541 

-  -  thrill   with    91,     111, 

from  overstrain  of  heart214 

--  mediastinal  -rowth  .. 

-  -  tliird  nerve    . .         . .  640 

157,  217,  720 

pulsus  alternans       . .   549 

new  i-'rowtii   .  . 

-  simulation  of     . .         . .  540 

-  systolic  bruit  (see  Bruit) 

with  toxic  diarrhoea. .  171 

Pulsus  alternans   . .     546, 

-  from  syphilis  <_Fig.  229)    541 

-  thrombosis         . .         . .  289 

(and  see  Heart,  Irregular) 

Pulsus  bisferiens 

-  in  tabes  dorsalis           . .  23G 

-  rein,  anein-ysm  ruptured 

-  obliteration     of,    from 

549.  ^Fig.  2:;-.l 

-  from  thyroid  gland  en- 

into  434 

embolism        . .         . .   551 

Pulsus bigeminus  . .      547. 

largement       . .          . .  722 

Pulpy  knee            . .         . .  348 

-  in  pneumonia    . .          . .   636 

-  p,MMi!'i\i.s.  with  adherent 

-  trachoma            . .      231,  541 

Pulsatile  liver  (see  Liver, 

-  pyrexia  and        .  .           . .    573 

pericardium    . . 

PTYALISM                       ..542 

Pulsatile) 

Pulse,  paired,  from  partial 

Puncta        

-  definition  of       . .          . .  542 

-  tumour     ("see     Swelling, 

heart-btock    ..        -.550 

Punctate    basophilia    (see 

-  from  drugs          .  .          . .    542 

l^dsatile) 

-  rapid,  in  acute  rheuma- 

B-asophilia. Punctate) 

Ptyalism.  from  gastric  re- 

Piil>:iriti- iH.ises  in  head..  406 

toid  arthritis..         ..'342 

Puncture,  lymph  gland   .  . 

flex    543 

L'lils  itmii.  ;i!.,lnminal  aortic. 

in  appendicitis      454,  677 

-sptenir     :.           .".         2'., 

Ptyalism.  list  of  causes  of  542 

uiiilu..-              ..          ..   fi64 

! with  auricular  fibrilla- 

PUPIL. ABNORMALITIES 

Ptyalism.    from    paralytic 

-  ovrr;.M..inv-rn  ..           ..208 

tion              . .          . .   548 

OF  THE 

dysphagia                  . .  54:; 

-  eai.ill.M-.   11.   .it,:t-nna     ..      flS 

-  -  from  corrosives          . .   268 

Pupil,     ArqyII     Robertson. 

-  stoiii:ititi^             .  .           ..542 

-  -   ill  ;nii  I  ii    1 1 1-,    I-.            ,  ,    211 

in  dengue       . .          . .   466 

definition  of    ■  ■ 

Ptyalorrhffia.    general    ac- 

 ir-in  L'li  ii  mil          ;i;j,   207 

diverticulitis  . .          . .   453 

iu   ta!M-   in;.   .i-(i. 

count  of                   . .  543 

nictliMil    nt"    -linwiliL'    ..        93 

excitement     . .         . .  549 

iM,  p;(;.-">u.  "..'.1. 

-  (and  see  SalivatioiO 

-  -  in  Tnrki.^li  bath    '^   . .     93 

feeble,  in  phosphorus 

650.  719. 

Puberty,  acne  at          4.S9,  569 

-  cessation  of,  in  arteries     34 

poisoning    . .          . .   336 

simulated  in  neuritis 

Puberty,  albuminuria  of  . .     15 

-  ear  in  detecting        208.  693 

pneumothorax       . .   432 

-  charges,  from  optic  nerve 

-  breast  cluuiges  at           .  .    686 

-  epiiiastric,   from   fibroid 

in  fevers          . .          . .   702 

lesion 

-    delilVr.l,    II,    ;i.,.ll,,-H        ..     191 

lung 216 

■' Graves's  disease       ..  549 

paralysis    of    cervical 

-  enurr.;^  .Ii-  ii.i.,    iiHL-  at  21S 

from  large  heart       . .  206 

from  hsematemcsis  . .  268 

sympathetic 

-  epi<t;i    1^    ,,                      ..    221 

mitral  regurgitation. .  210 

-  -  in  infections  . .          . .   549 

-  from  cerebral  tumour  . . 

-  e.Wf^-ii.M.v^uiaiiiH  livity 

stenosis       . .          . .  216 

1 with      lateral      sinus 

-  constricted,    in    accom- 

at          3S7 

ovei-strain  of  heart    . ,   214 

tlirombosis              . .     84 

modation 

-  monorrhagia  at..      3S7,  392 

patent  interventricular 

mastoid  abscess         . .     84 

from  cerebral  tumoiu- 

-  metrorrhagia  at            . .  392 

septum        . .          . .   215 

-  -  mitral  stenosis         53,  216 

cervical     sympathetic 

-  milk  flow  from  nipple  at  ISl 

when    right    veitricle 

myocardial    affections     14 

lesion 

-  pain    ill   r.  lopir   tr^tis  at  482 

enlarged      . .          . .   215 

from  nervousness     . .     88 

cord  lesion     . . 

-  priain-iii   1 1    .  -          ..538 

—  expansile,  from  aneurysm 

j  -  -  in  ueui-asthenia         . .     88 

encephalitis    . . 

-  pn.si.i...  .iilnvML-  .11    ..  218 

664,    067.  674,  676, 

overstrain  of  heart    . .    214 

hypernietropia 

Pubic  -,  iHvr,,~i-  of  ..   697 

078.  681,  692,  693,  714 

paroxysmal         tachy- 

 in  infants 

-  hair,     precocious,      with 

hernia  cerebri            . .   694 

cardia          . .          . .  -^49 

from   intracranial  ab- 

liypernephroma   {Fit/. 

putmonalis              . .   694 

in  rheumatoid  arthritis  341 

scess 

174)   jnS.  409.  630 

meningomyelocele       ..694 

from  smoking            . .   486 

with  iritis 

-  region,  absence  of  hair  on     71 

of  pleural  effusion    . .  094 

with  suppurative  menin- 

 by  light 

sycosis  art'ecting         ..   558 

-  -  in  sarcoma     . .         . .  693 

gitis              ..          ..84 

-  -  in  old  age      .  - 

Pudic  nerve,  neuritis  of  193, 194 

-  precordial,  from  fibroid 

in  tuberculosis           . .   549 

paralysis  of  arm  with 

Puerperal  fever,   endocar- 

lung  216 

(and  see  Tachycardia) 

from  pai-alysis  of  cer- 

ditis in            . .         . .     90 

-  -  mitral  stenosis           . .   216 

-  rate,     after     abdominal 

vical  sympathetic. . 

-  -  pain  in  joints  in        . .   6911 

-  transitiiti..!.    1.^     r.irrin- 

iniurv              ..          ..593 

spinal  lesion  . . 

riieumatisni  simulateil  ."'9(; 

oTu..   ..■    !■  ■■  .  1.   .-       .M,   330 

in"  acute  peritonitis  . .   592 

sympathetic  paralysis 

PULSATION.  UNDUE  AB- 

- -  exercise  and    88,  485,  486 

in  tabes  doi-salis    236. 

-  -  vaginal  di^ciiarge  with  591; 

DOMINAL  AORTIC.  543 

in  general  tuberculosis  636 

thyroid       gland       en- 

-  infection,  infective  paro- 

- -  blue  brain   ;mi4           ..    Ifi.'i 

-  -  over  200  . .             703,  704 

lai-gement    .  . 

titis  with         ..          ..    094 

-  -  noises  in  head  with  . .   406 

-  -  in  typhoid  fever       . .   335 

-  -  ur.euiia            . .         40, 

PUPIL 


PYELONEPHRITIS 


iia 


tpil,  contd. 

PURPURA 

552 

dilatation    to    li^'Ut,    in 

554 

taoes 

oo2 

yellow  atrophy 

273 

dilated,  from  alcohol  . . 

170 

-  albumosuria  with 

16 

-  aneurysm 

55^ 

-  from  alcoholism 

-  by  atropine    . . 

232 

—  anaemia  from     . . 

32 

-  beliadouna     . .      170, 

705 

-  from        antidiphtheritic 

-  from  catalepsy 

552 

serum  . . 

554 

-  epilepsy 

552 

-  bacteriology  in  diagnosing         1 

-  by  fright 

551 

cause  of 

557 

-  ill  glaucoma  332,  233, 

-  bleeding  gums  in 

72 

7C1, 

762' 

-  from  blood  diseases     . . 

55ti 

-  Graves's  disease 

236 

-  in  Bright's  disease 

555 

—  mania 

552 

-  cerebrospinal  fever 

554 

-  by     sudden     sensory 

meningitis 

591  ' 

stimuli 

551 

-  cirrhosis 

C35 

double,  from  accident. . 

175 

-  diphtheria 

-  congenital 

175 

-  from  drugs 

554 

-  diplopia  from 

175 

-  in  epilepsy 

554 

-  from  operation 

175 

-  epistaxis  from  . . 

221 

eccentric  from  mid-brain 

-  in      familial      acholuric 

tumour 

727 

jaundice 

332 

in  epilepsy         . .      137, 

552 

-  fulminans            . .      553, 

55G 

lixod.  from  alcohol 

170 

-  in  fungating  endocarditis 

-  belladonna     . . 

170 

(Fuj.  23C)  555  | 

—  in  glaucoma  . . 

233 

-  general  tuberculosis     . . 

555 

-  peripheral  neuritis   . . 

514 

-  gingivitis  and    . . 

557 

—  uncmia 

170 

-  hcematemesis  in 

366 

in  hysteria 

137 

-  hfematuria  in     . .     275, 

283 

immobile,  in  general  par- 

- hsemorrhage  into  tongue 

alysis  

140 

in         ..         ..      fiJtS, 

609 

-  to  light,  in  tabes 

315 

-  haemorrhagic  erosions  in 

269 

inactive,  with  iritis 

232 

-  haimorrhagica    . .      553, 

536 

-  afterconieal  ulceration  551 

blood  per  anum  in  . . 

76 

-  dislocation  of  lens    . . 

551 

counts  in  diagnosing 

273 

-  injury 

551 

culture  in  diagnos- 

-  iridodiatysis  , . 

551 

"IB 

273 

-  iritis    . .         . .    -     . . 

551 

hajmatemesls  iu 

273 

-  from  persistent  pupil- 

- hjemoptysis  with 

287 

lary  membrane 

551 

-  in  Hanoi's  cirrhosis     . . 

372 

-  after       rupture       oi 

-  Henoch's  (see  Henoch's 

sphincter    .  . 

551 

Purpura) 

jpil.  Irregular  shaped    . . 

551 

-  in  hysteria 

554 

large,  from  t>riiih  lesions 

552 

-  idiopathic 

557 

-  in  myopia      . . 

551 

-  in  jaundice         . . 

555 

loss  of  convergence  refle.\ 

-  leukaimia            . .        2o 

536 

in,  in  alcoholism 

551 

Purpura,  list  of  causes  of-  • 

553 

diphtheria 

tabes 

551 
551 

-  malingerini:  of  . . 

-  in  measl.-; 

554 
554 

-  psychic  reflex  in       . ,  552 
non-reaction   to  accom- 
modation  in  dissemi- 
iiuted  sclerosis  . .  760 

paralysb*  of,  complete..  551 
pin-point,    from    opium 
poisoning        . .      ll'J,  310 

-  pontine     liaimorrliaee 

119,  310 
n|i:t     KMctions,     altered 

■.ifUr  diphthcriiv         ..      G1 

upil  reactions,  in  heml- 
anupsia  .302 

upil  reflexes,  general  ac- 
count of  551 

upil.  reacUnn  to  llflht  but 
not  to  accommodation  551 


-meningitis  ..         ..  225 

-  menorrhagia  from    386,  387 

-  metrorrhagia  from    390,  392 

-  from  muscle  rupture  . .  554 

-  ptomaines  . .  . .   554 

-  pyaimia  . .         . .         . .  555 

-  pyorrhcea  alvcolaris  74, 


lifte 


upil  reflex,  hemlanopic.  552 
upils.  uM('<ju:il,  from  cere- 
bral disease    ..  ..   295 

-  -  diplegia       . .  . .    729 

-  gro!*<iiitra<-raniul  lesion  118 
upils.     unequal,    general 


account  of 


;.lv-i< 


552 


-  glaucoma 

-  iritis    . . 

-  paralysis    of 

sympathetic 

-  -  thir-l  ntrvc 

-  physosdL'ininc 

-  without 


siu'nilU'ii 
doivalis 
III  nouni 


urin  tiodies,  list  of 


in  saroomatosis. .  . .   fi.«5 

scarlet  fever      . .  273,  654 

scurvy          38,  72,  273,  556 

v,.ptiea!mia          ..  ..655 

^iin[.li'\    ..          ..  553,  556 

-   iii.rl^  alT.Mt.-d  by  ..    662 

Purpura  In  small-pox      . .  554 

-  ^iiiiill-pox  siumlating   . .   602 

-  in    w|)l(Miomegalic    poly- 

cythicmia        , .  . .   633 

-  tongue  swollen  witfi     . .   698 

-  tonsils  and  . .  .  •   657 

-  from  toxaimia  . .         . .     76. 

-  in  tvphus  fever  335.  654,638 

-  vellow  fever  . ,  273,  336 
m's.  litll.-iilbunun  in  ..  12 
^  :.,,,  1  ,,  I  i  .  ..loured  369 
PUS  IN  THE  CHEST       .-    103 


con»i 


/'((A-  in  the  xtooh,  roiitU. 

sigmoidoscope  in  dia- 
gnosing cause  o£  . .  i 

from     ulceration     of 

bowel  . .         . .  '. 

-  tube  casts  of     . .         . .  . 

-  urates  simulating 

-  in  urine,  characters  ot. .  i 
phosphates         distin- 
guished from         . .  < 

urates  distinguished 

from  . .         . .  . 

-  -  (and  sea  Pyuria) 

-  vomit      . .         . .         . . 

Pustule,  malignant  . .   ■ 

ervthema  from  . .  : 

PUSTULES 


utes  i 


!  489. 


-  bacillus  pyocyaneus 

causing 

-  from  bromides  98,  559,  I 

-  contents  of        . .         . .  { 

-  crusts  from        . .         . .  i 

-  in     dermatitis    hcrp3li- 

formis  . .         . .  ' 

-  from  dissection  wounds    '. 

-  ecthvma  . .         . .  ! 

-  eczema    . .         557,  560,  : 

-  furunculosls       . .         ..  i 

-  granulosis  rubra  nasi  . .  < 

-  herpes  progenitalLs       . .  ( 

-  impetii;o..         557,  55K,  J 

-  from    iodides    y8,     559, 

56t»,  i 

-  in  lichen  scrofulosorum    • 

-  new-born  . .         . .  • 

-  prurigo   . .         . .         . .  • 

-  rhinophvma       . .         . .  ' 

-  scabies  '  . .         558,  COO,  ' 

-  scrofulodermia  . .         . .  J 
Pustules  In  small-pox 

554,   558,  559,  561, 
GOl.  616, 

-  staphylococci  causing  . . 

-  in  svcosis  . .      557,  ■ 

-  svpliilis   490.    557.    658, 

659,  560,  562, 


-  varicella  . .         . .  ' 
Pntrcfnclion,  alkaline  stool 

from    . .  . .  . .    : 

-  of    food    particles,    foul 

brfath  from  . . 

-  inte-tinjil        lKirl)orvi:mi 

with 

Putrefaction.       intestinal, 
characters    of    stools 

with : 

distiiiguisiliwl  from  fer- 
mentation ..         ..   : 

Ilatus  from     . .  . . 

iiidican  from  lOl,  314, 

743, 

tetany  from  . . 

urinurj'  Hulphaten  in. . 

-  in  lunus.  foul  breath  from 

-  nioutli,  font  bn'ath  from 
PultiliL'    ih.-    vvrik'hl.    HUb- 

urTotiiiiil  bnr^iiis  froni 
Pvminiii,  iil»-.'i->s  ill  luNirt 
'in  J 

-  -  lu.ik'  h.  ..  ..   ' 
Pyamla.  bacteriology  of.. 

-  hronchitlM  h(     '.'. 

-  blood    cultures    In    dia- 
gnosing 


-  dinn 


t  in 


•iatinn  from 
-  etnbnti  in  

_    t..„^..r, i.t    iM-.r    III  .   . 

PynT"'-*  f*«-^i«rrounlof  ! 


-  from  ear  (^w  otorrbccu) 

-  from  nipple        ..  •  •   "J  ' 

-  from  nose  ..  . .   17** 

-  phoHphates  mistaken  for  524 

-  i.pr  rf»-tum,  from  abscttw  5H5 
-iterile 369 

-  in  -tools IJO 

PUS  IN  THE  STOOLS     ..  857 
from  al)S<i's«i  ruptured 

into  bowel  . .  ■'''•' 


Pijitmia,  fonld. 

-  with  periostitis  59G,  707 

-  peripheral  neuritis  from 

61,  64 

-  pleurisy  in         . .         . .  596 

-  portal,  rigors  in . .         . .  595 

-  prolonged  pyrexia  from 

{Fig.  244)  567 

-  prostration  in    . .         . .  696 

-  pulmonary  emboli  in  . .  260 

-  purpura  in  . .      553,  555 

-  from  pyorrhcea..         ,.     74 

-  quinine  ineffective  in  ..  596 

-  rash  in    . .         . .         . .  597 

-  rigors  in  335,  iFuj.  244) 

567,  594,  595,  696,  597 

-  and  septicaemia,  relation- 

ships between       696,  597 

-  spinal  abscess  in  . .   714 

-  subcutaneous  abscesses  in  596 

-  suppurative   pericarditis 
696 


-  sweating  in        ..      336,  59rt 

-  tenderness  of  chest  in  . .  707 

-  thyroid  abscesses  in    . .  722 

-  typhoid  fever  simulated 

by       596 

-  vomiting  in        . .         . .  596 

-  after  wounds     . .      335,  69G 
Pyelitis,  aching  in  loin  from  576 

-  acute,    amount   of    pits 

small  in  . .  . .     12 

-  in  acute  fevers  . .  . .   576 

-  nlttuniiniiria  from     576,  .'i7S 

-  from  bacillus  coli  12,  182,  576 
proteiis  . .         . .  57<i 

-  calculus  . .      676,  577 

-  carcinoma  of  bladder  . .  576 
of  uterus        . .         . .  57r. 

-  coli  bacilluria  simulating  56ti 

-  fi-om  cystitis      ..         ..  57ii 

-  cystitis  simulated  by    . .   57S 

-  c'vslos'ope    appeamnets 

*in    {Plate    XV)    282. 

576.  57S 

-  from  enlan:ed  im>^taie. .  57<"» 

-  Ire«piei»t  miiiuritionfrom 

393.  578 

Pyelllls,  general  account  of  576 

-  front  hmniutogenous  in- 

feetion  . .  . .   67" 

-  hyperniHhesia  with      ..  4'>! 

-  hvpon^vre'^''*  *"  ••  •'"  ' 

-  kidnev  enlarue.1  with  451,  57- 
-   Iiurm-vlostrt  ^lil:h(  with     3'. 


h».:il  1 


....   :uritionfn-.,n..nt  with:.:' 
~  iitMlurnal        niiituritioii 
iron* 21S 

-  pain  in  hypochnmlriuni 

from <61 

iliac  fow*a  from         . .  4M 

polvU  from    ..         ..  J51 

-  puri-uroteric   lymi>hatlcH 


576 
576 


-  from  pnmmiwoccuH 

-  pouting  of  ureter  in      ..   576 

-  in  pregnancy     ..      I'M.  676 
relation     to     Ilright'i* 

dlKOiute         . .  . .        9 

-  pyrexia  with      ..      451,  57*1 

-  pyuria  from       . .         . .  575 

-  nmni  tfthdemoNi  from  .  .    576 
II1-..1-   tr..ni  ..       676,  ftll5 

.1  harnh  with  576 


Pyelitis,  urine  changes  with 
Pyologrtphy  In  diannoils 

Pvrhvni.hv         xfv,.  KWii 
I'v,.|iMH.,.l.rHI..    ut.^--    h. 


PYELONEPHRITIS    —    PYREXIA 


~  fromcarcin 

ymn  of  bladder 

uterus 

-  cystitis    .  . 

-  cy=titi^'  sini 

ilato-i  hv   .  .    . 

-  from    enlar 

_'eil    ]. restate  . 

-  frequent  mi 

-■t.iiritionfroin  . 

~  Friedlaiuler's  bacillus  with  69 
Pyelonephritis,  general  ac- 
count of  . .  576 

-  from  h hematogenous  ia- 

fection  . .  , .   576 

-  kidney  enlarged  in    355,  576 

-  leucocytosis  slight  with  360 

-  malaise  from      . .  . .   355 

-  peri-ureteric  lymphatics 

and    - 576 

-  pneumococcus  with      . .     69 


tenderness  from        . .   . 

-  skiu  dry  and  harsh  with 

-  staphylococcus  with     . . 

-  from  stone  in  kidney  . .   . 

-  streptococcus  with 

-  from  stricture    . .  . .   . 

-  tonsue  tilazed  iii  . .    , 

-  tube  raPts  with..  ..    i 

-  t-nb.'tvlf  b:iL-illus  with  .. 


-  hsBmatenippi^  from         . .   265 

-  obscun-   i.ytv\i;i    .hi.:,   to  573 

-  proloiiL'i'.l  pyir\ 


sept 
-  suppi 


nni  ..    637 

ib^UL-.^=CS  of 

liver  from  . .  332,  596 

albumosuria  with      . .     16 

from  appendicitis  326, 

333,  507,  596 

appendicitis  simulated  567 

diarrhcea  w'ith  . .  59G 

empyema  from  . .   106 

hectic  fever  with      . .  596 

jaundice      from    326, 

333,  596 

leucocytosis  with      . .   560 

liver  enlarged  from 

333,  596 

often  overlooked       . .  333 

pain  over  liver  from. .    591! 

peritonitissimulatedby567 

pleurisy  from  . .  106 

pneumonia    simulated  567 

prolonged  pyrexia  from  5G7 

pvrexia  from. .         . .  333 

rigors   from  326,  333, 

567,  595 

septicemia  from        . .  5G7 

tender  liver  with      ,.  596 

—  typhoid    fever    simu- 

lated by      . .          . .  567 
Pylonis,  adhesions   round, 

from  duodenal  ulcer. .  174 

gall-stones  . .         . .  17-1 

gastric  ulcer          . .  171 

peritonitis  . .  ..171 

-  carcinoma  of  fs=pe  r?)rciii- 

,.in;i    of  ^itoniiirh) 

Pylorus,  congenital  stenosis 


of 


384 


Pylorus,  hypertrophic  sten- 
osis of..         ..      765,  766 

-  in  iliac  fossa      . .  . .  678  I 

-  uormal,  palpable  in  chil- 

dren      660  I 

-  spasm  of,  dyspepsia  from  319  ; 
in  infants       . .         . .  660  ' 

-  stenosis  of,  from  adhe-  I 

sions 174 

bismuth  and  a:-rays  in  ' 

diagnosing  174,  241, 

245,  653  , 

from  calcified  cyst    . .    174 

carcinoma      174,  270, 

297,  318,  C53,  6G0 


!  Pi/hn/s,  contd. 
Pylorus,  stenosis  of,  causes 

colic  simulated  by    .  . 

copious  vomiting  due 

to ; 

dilatation  of  stomach 

from  171,  317,  653,  ' 

flatulence  with  . .  : 

from  gall-stones 

gas  in  stomach  from. .  : 

gastric   juice    changes 


nth 


■111  I  iii-rnatcd  capsule; 
iu  diaL^nosint:: 
fthvlene  blue  in  dia- 


on       

from  old  ulcer 

-  <-  renal  tumour, . 

-  -  sarcinffi  with  241,  320, 
by  spasm 

stomach  tube  in  dia- 

gnosincj        ..      124, 

-  -   aff-Tiilr-.M- 


Pylorus.  stenosis  of,  without 
vomitino  . .  653 

w  eakness  from  . .    123 

without    many    sym- 
ptoms ..         ...   123 

yeasts  with    . ,      241,  320 

Pyodermia,       leucocytosis 

slight  with     . .  "      . .  360 
Pyometra,  age  incidence  of  186 

-  from  carcinoma         186,  392 

-  endometritis       . .  . .   186 

-  foul  discharge  due  to  186,  392 

-  metrostaxis  from  . .   392 

-  sound  in  detecting       . .   186 
Pyonephrosis,  from  carci- 
noma of  bladder       ..   577 

uterus  . .  . .  577 

-  cystitis    . ,  . .  . ,  576 

-  diarrhcea  with   . .  . .  357 

-  from  enlarged  prnstntp  Tur. 

Pyonephrosis,    general   ac- 

countof  .  .      356.  576 

-  kidney  i-nl.iivcd  ironi 

-  leucocytosis  slight  with  360 

-  normal  urine  with  . .    577 

-  pallor  with         . .  . ,  357 

-  pelvic  swelling  due  to  . .  688 

-  polyuria  from    . .  . ,   536 

-  pyrexia  with      . .  . .   357 

-  jiyuria    from    357,  536, 

575,  576,  577 

-  without  pyuria         357,  575 

-  from  renal  calculus  279, 
576,  577  I 


Pyorrhasa  alveohins,  contd. 

aniemia  from  32,   74 

arthritis  from  74,  648 

bleeding  gums  from  72, 

73,  74 

blood-spitting  due  to    285 

death  from    . .  . .     74 

dyspepsia  from  . .     74 

foul  breath  from       74,  87 

Pyorrhcea  alveolaris,  general 
account  of     . .         73,  74 

gum  recession  from. .     73 

hoemorihages  due  to. . 


llirlrlon 

iniiit  Ir-sinii?  from      .  . 

74 
2S2 

1"  -  i>i  '.'.^'i-tit  from  . . 

709 

•  ■■Ill  i-ii  ■■■II, (  fi'om   . . 

74 

I'll iM-  neck  from 

64« 

,  557 


pyiemia  from 

retraction  of  gums  from  589 

septicaemia  from       . .  637 

stiff-neck  from  . .   648 

stomatitis  from         . .  542 

teeth  loose  from       . .     73 

Pyosalpinx,  aching  in  lumbo- 
sacral region  from    . .  583 
-  acute  ascites  from       . .     47 
peritonitis  from.         . .   592 


vith 


16 


-  anaemia  fr 

-  appendix  abscess  simu- 

lated by  . .  . .   678 

-  bacillus  coli  in  . .  . .   530 

-  cystitis  from      . .  , .   582 

-  diverticulitis    simulating  453 

-  empyema  from  . .  . .   106 

-  frequent  micturition  from  394 

-  leucocytosis  with       360,  361 

-  leucorrhoea  from  . .  582 
~  opening  into  bladder  . .  575 

-  pain     in     lumbosacral 

region  from    . .  . .   5S2 

-  after  parturition  . .    678 

-  pelvic  pain  from  . .   468 
swelling  due  to  . .   688 

-  periods  profuse  with    . .   582 

-  pleurisy  from     . .  . .    106 

-  pus  in  stools  from  . .   557 


575 


-  felt  per  rectum. 

-  rupture  of  . .         . .  468 

into  bladder  . .      581,  582 

simulating   dysmenor- 


iinm 47 

-  suL-iliiig     in     Douglas's 

pouch  from    . .  . .   587 

-  vaginal  discharge  with . .  678 
examination  in  detect- 
ing  .  .         582,  587,  678 

Pyramidal  tract,  facial  fibres 


of 


■  fro 


357 


ilhi^coli  .. 
Hinds  with  .. 
ima  of  oeso- 


652 


-  frumcpitheh 

phagus             . .          . .  652 

-  foreien  body      . .         . .  652 

-  subdiaphragmatic  abscess  652 

-  snccnssinit  in  rlir^t  from  651 

Pyopneumothorax,   general 

account  of     . .         . .  652 


■dlu 


lof 


:,\,  652 


Pyopneumothorax, 
phrenic 

-  snccussion  with 
Pyorrhoea  alveolaris 
gastritis  from 


lesions,      ankle-clonus 

with  . .  . .     39 

Tiabinski's  sign  in. .      68 

Pyramidal     tract     lesions, 
effects  of  . .  496 

tlex  with..  39,  68 

mcreased  knee-jei"k 

with         ..        39,  358 

result^  of    ..      501,  303 


pancreaunri     .  .  ,  .    i 

peritonitis       . .  . .   . 

-  -  pleurisy 

rheumatism    . .         . .   : 

rheumatoid     ai-thi'ltis  I 

yellow  atro]>hv  . .    ; 

-  from  alveolar  abscess  . .   ( 

-  in  alveolar  echinococcus 


-  angioneurotic  oedema 

226,  414, 

-  appendicitis     115,     283, 

454,  460,  582,  665, 

-  from  bacteriuria 

-  bad  night 


Pi/rexia,  conUl. 

~  in  blood  diseases  . ,  ; 

-  bullous  dermatoses 

-  from  carcinoma  . .  f 
of  bowel 

of  liver  77  {Fig.  145) 

326,  373,  374,  , 

-  caseous  glands  308. 

-  with  catarrhal  jaundice    I 

-  with  cellulitis    .. 


-II. 


Pyrexia,  in  rlvldren         . .  5 
Pyrexia,  in  children,  with- 
out apparent  cause  ■ .  5 

-  cliolecy^^titis       . .  . .   4 
Pyrexia  in  cirrhosis  of  the 

liver     (Fid.     12)     35. 
326,    {Fig.    167)    371.  _ 

-  colibacilluria   455,   {Fiq. 

193)  4; 

-  colic         5 

-  colitis      . .  . .  , .   6 

-  congestion  of  liver        . .  3 

-  from  convulsions       144.  5 

-  corresponduig  pulse-rate 


of 


57 


- —  respiration -rate  of 

-  in  coryzal  cold  . .  . .   171 

-  crises    of,    in    cerebro- 

spinal meningitis  566,  59i 

-  from   cystitis   282,   470,    57! 

-  diarrhoea  with  . .  . .   17 

-  delirium  with    . .  . .    16: 

-  in  dengtie  . .         . .  46i 

-  dermatitis  herpetiformis     7, 

-  diphtheria  ..         .,  57< 

-  from  distoma  hepaticum  32! 

-  diverticulitis      . .  . .   45i 

-  Egyptian    splenomegaly  ('>3- 

-  empyema  . .  . .   57- 

-  encephalitis        . .      502,  51! 

-  endocarditis       . .         . .   57- 

-  erysipelas  . .         . .     91 

-  erythema  bullosum      . .     V 

nodosum         . .  . .  40' 

scarlatiniforme  . .   22 

-  from  excitement  . .  57^ 

-  e.\:ertion  . .  . .      464,  57] 

-  in  exhaustion  of  labour    20l 

-  fourth  disease  . .         . .  22i 

-  fungating  endocarditis  7, 

34,  334,  566,  57^ 

-  from     gall-stones      252, 

254,  327,  437,  575 

-  gangrene  of  lung  . .   251 

-  gastritis  . .      2(17,  76( 
Pyrexia,  general  considera- 
tions regarding         ..  571 

-  in  ^landere         . .  . .     91 

-  iTont         ..         339,  344,  41i 

-  gumma  of  liver         334,  5(:t: 

-  Hanot's  cirrhosis  . .  37: 

-  Henoch's  purpura        . ,  34.1 

-  hepatic  abscess  291,  369,  597 

-  hip  disease  . .  . .   363 

-  nodgkin's  disease        . .     25 

-  increased       intracranial 


m 


-  infective  parotitis         ..   694 

-  inllamed  glands  380,  381,  45tl 

-  inQuenza  . .  . .   46-5 

-  int&stinal  colic  . .  . .   435 

-  jntrarranial  lesions        ..    311 


33/i 


I  Pyrexia  in  malaria,  charac- 
ters of  . .         29.  30 

-  malignant  pustule         . .  baM 

-  in  Malta  fever    . .           . .  466 
~  mastitis  . .          . .          . .  6S5 

-  mediastinal  growth       . .  435 

-  Jleige's  disease         226,  411 

-  meningitis       138,     145. 

147,  225,  511,  .Vti' 
ng    hypothermia 


vith 


PYREXIA 


REACTION* 


,||. ,_■!.. .-![,■_■  .■all-e  of  6i),  ■ 

-  hli.o.l  cultiin's  in  dia- 

gnosing cause  ot  . .  ■ 

-  from  deep  tuberculous 

glands         . .         - .  ■ 

-  faaces  examination  in 

diagnosing  cause  of  . 

-  from  gall-stones        . .   . 

-  infected     ei^docarditis 

-  ovarian  abscess         . .   . 

-  phlebitis         . .         . . 

-  pylephlebitis  . . 

-  tiiberculiTi  te?t  in  dia- 

L'nn-iiii.'   c.in-e.of    ..    ■ 

fREXIA  WITHOUT  OB- 
VIOUS CAUSE 


otitis  media  . . 

with  psiroxysmal  hajmo- 

globinuria 
from  pediculosis 
peliosis  rhcumatiea 
pellagra  . .      2J5, 

pemphigus 
periodic,     in     relap^ng 


fev 


115 


nth  peritonitis 

i-i-tii.ious  anicmia        . .     'JO 

III     1^  suggested  by  ..  57;; 


I  m|i  I  II  ,<-litis  acuta  IK), 

110,  500,  512 

polymyositis      . .          . .  -lU  I 

pontine  hajmorriiage    ..  110 

portal  vf'iri  thrombosis  51 

rREXlA,  PROLONGED  563 

-  from  ;i|i|"iiiti.  It  I-         .  ."(t;7 


Pyrexia,  contd. 

-  m  severe  anajmia         . .  572 

-  simple  colitis     . .         . .     78 

-  from    sinus    thrombosis 

511,  567 

-  in  spinal  meningitis     ..  417  | 

-  from     subdiaphragmatic 

abscess  . .      451,  fi58 

Pyrexia,  sudden  drops  in . .  574 

-  with     suppurative     ne- 

I  phritis  . .  . .   594 

i pylephlebitis  . .      333,  590 

I  -  syphilis   , .         33-i,  5G2,  G14 

-  (and    see    Temperature 

'  Chart)  ..  ..591 

i  -  from  testicular  abscess    fi22 

-  tonsillitis  ..        34,  574 

-  tremor  from       . .  . .   724 

-  in  trichinosis      . .      404,  729 

-  from 'tuberculous  kidney  117 

-  -  raeninsitis      . .         . .  574 
peritonitis48,  570,631,  657 

I  -  ulcerative  colitis  . .     7S 

I  -  after  urinary  operations  42 
I  -  from  various  bites  . .  598 
I  -  visiting  dav       ..  ..   573 

-  Weil'sdisease    . .  - .   336 
[  -  yellow  fever       . .  . .   273 

Pyriform  cells  in  urine    . .   742 
Pyriforrais,  nerve  supply  of  498 
I  Pyrogallic      acid,      luemo- 

globiimria  from  . .  284 
I  Pyrosis,  with  heartburn  . .  43G 
I  -  meryeism  and    . .  .  .   388 


-  from  i_-i_ri.lir.il 

-  in  cerebrospin;) 

gitis 

-  coli  bacilluria 

-  empyema 

-  erysipelas 

-  glandular  suppuration  5fi7 

-  Hodgkin's  disease    . .  5r>j( 

-  jnllucii'/a        (Fiq.  210)  564 


567.  5tJS 


L'll 


yrexia.  prolonged,  list  of 
causes  of  .563 

yrexia,  prolonged,  from 
malianant  disease  570 


-  Me(litcriam.'an  fe 

lm;;j 

5G5 

-  otitis  media   . . 

567 

-  pelvic  suppundio 

n  .. 

507 

-  pernicious  aniemj 

H    .  . 

509 

-  jiyajmia        {Fig. 

244) 

507 

-  pylephlebitis  . . 

607 

-  aeptiwomia     . . 

607 

-  syphilis 

508 

-  throat  alisrnsses 

507 

-  tuberculosis    . . 

soil 

-  tuberculous  meni 

IRitis 

500 

-  typhoid  fever 

504 

-  umbilical  sepsis 

567 

-  Wassermann  test  In . . 

508 

with    prostatic    abscess 

182, 

470, 

581 

prostatitis 

18i, 

4711 

pscudo-lcukicmia 

37 

pyemia  . . 

33;;' 

5!I0 

pyelitis    .. 

451 

pyelonephritis    . . 

570 

pyonejihrosis 

3:.7 

rat-bite  .. 

•leri 

570 

in  renal  colic     . . 

451 

rheumatic,  effect  of  sali- 

vintfs*  on 


674 


in  fhiunintoicl    iirtliritia    35 

in  riKois •''»4 

from  siil|iiiit'o-i».pl>orilis  (IBO 
'yrexia,  from  sarcoma    . 


ot. 


in 


570 

005 
■>-n.  273 


socondnry  sypliilis 

8C[)tic  FtrthritU  . . 

ecpttciuniin 

from  scrum  iiijoft  ionK  223, 


334 


574 


-  relation  to  iiearthurii 
PYURIA     .. 

-  albuminuria  willi  ..   ST-i 
Pyuria,  from  appendicitis. .  582 

-  a|.|i.-:iiii./iil.ii  .,li,.--css    ..   283 

-  l.a.illil-  foli  .  .  . .  12 
i  -  bacteriuria  . .  . .  70 
'  —  bilttarzia             . .     580,  581 

-  carcinoma  of  bladder  41, 

471,  580,  582 
Pyuria,    catiieter    in    dia- 
gnosing cause  of       . .  575 

-  timii  iv.-liti-   IS.',,   lal, 

:;>-j.  470,  578 
Pyuria,  cystoscope  in  dia- 
gnosing cause  of      . .  575 


-VI  1 


282 


-  drUL'S  for  .  .  . .   0511 

-  srowtb  of  bladder     376,  281 

-  he.xametlirlenetetramine, 

etc..  for  . .  . .   05U 

-  l.vM.'c  iif  Idadder  in  dia- 


:  of 


rorrlK 


581 


Pyuria,  list  of  causes  of  ■  ■  575 

-  niicroscope  in  disignosinff 

12,  70 

-  not  oi>vioHS  to  chemical 


nalted  e.ve  . .         . .     12 

-  from  pliiraosis  .,         ..  581 

-  pneumatnria  witii         . .   530 

-  from   i)rostatic   cnian,'e- 

-  prostatiti.s  . .         .  •  581 
Pyuria,   from  pyelllB  12, 

-  pyelonepiiritis   . .        12,  366 

-  nyoncplirosis  357,    530, 

<       "  670,  677 

-  ronai  calculus   270,  278,  577 

-  -  ninicnr  ''1.  330 
Pyuria,    from    rupture    of 

abscess  Into  bladder..  581 

-  «ill,  Mri.liuv     ..  ..    ••,81 


Qtiadrirt'/jx  rxt.  fetii'iris,  cmlj. 

nerve  supply  of  498,  49!) 

paresis  of  . .         . .  512 

«a.stiu|,'  of  . .  . .  433 

Quarriers,  silicosis  in       . .  288 
Quartan  malaria  (see  Ma- 
Quarterly  .iournal  ot  Medi- 
cine, (injure  from       . .  347 

Mciire's  di-sease  and  414 

Quincke's  disease  ..  ..411 
Quiiiitio,    amblyopia    from  7.'i'.) 

-  blackwatcr  fever  and  . .  284 

-  dejitness  from  . .  .  .  100 
Quinine,  effect  In  malaria 

31,  530,  5liS,  5!10.  037 
on  malaria  parasites     335 

-  etytlieniH  front  . .         . .  222 

-  hxmoclobimiria  from  . .  284 

-  headaclie  from  . .         . .  295 

-  noises  in  the  licad  from    40G 

-  nyctalopia  from  . .  703 

-  puri)UrH  from     . .  . .   553 

-  pynimia  uninlluenced  i)y  590 

-  retinal  vessels  constricted 

by        759 

-  scales  from        . .         . .  002 

-  tiinntus  from     . .  . .    72S 

-  urticaria  from  . .  . .  771 
Quinsy  («a/c  XX  Vt)  . .  610 
Quinsy,  asymmetrical  as  a 

rule 014 

-  dysphagia  from . .  . .   198 

-  I>tvalism  from    . .  . .  542 

-  sore  throat  due  to        . .   013 

-  stertor  from      . .         . .  647 

-  submaxillary  inlands  in- 

llamed  from  . .  . .   379 

-  trismus  simulated  by  . .  729 
Quotidian      malaria      (sec 

Malaria) 


RABBIT,    opaque  optic 
nerve  fibres  in        . .  416 

-  skin-curers,      peripheral 

neuritis  in     . .         . .     05 

-  skins,  hats  from  . .     33 

nien;ur>-  in  curini;  33,   05 

Babi(S  (see  Ilydropiiobia) 
Uadiouraphy  (see   x-rays; 

and  Skingnini) 
Radium,  burn  from         . .  2'-':: 

-  erythema  from  222,  223 

-  Iciid  or  silver  screens  for  223 

-  for  Mooren's  ulcer        . .   734 

-  pigmentation  of  skin  from  223 

-  rodent  ulcer  cured  by  ..  180 
Radius,  myeloid  sarcoma  of 

072.  {Figii.  280,  287)  073 

-  in  rickets  . .  . .    155 

-  sarcoma  of,  skiaKnim  ot  072 

-  .syiiiiilis     of,     nkiBKnim 

showim;  ..         ..009 

-  thickeneil  in  rickets  . .  154 
Railway  spina  7Ki,  715 
~  -  t  rcnior  from  . .  ..721 
Rainbow  vision     . .  .762 

from  kdallconia         . .   23.1 

If  ales,  from  aneurysm     . .  2U I 

-  bubblinif,  Willi  bronchi- 

ectasis       . .         . .   108 

-  -  hronchltl.H  ..  ..107 
Ilbrold  luiiK    . .         . .   108 

-  conHonutini;,  over  llhrolil 

lun« 200 

-  -  in  phthisis     ..         ..  288 

-  cnirkilihf.  from  nnoiir>-»ln  1U6 
with  bronchiectasis 

292,  III3 


plirills. 
.In 


Milipnmtii 


Hash,  could. 

-  of  fourth  disease         , .  229 

-  German  measles  .'.  228 

-  measles  . .         . .         . .  228 

-  ratbitc  fever      . .         . .  598 

-  scarlet  fever      . .         . .  228 

-  septic       . .  . .  . .   597 

-  in  small-pox      . .         . .  272 

-  typhoid  fever    . .  . .   335 

-  typhus  fever      . .      335,  038 
Rat-bite  fever  . .  598 

-  -  ervtlicnia  in    ..      223,  59S 

headache  in   . .  . .   598 

Iiiph  fever  in . .         . .  405 

leucocytosls  in  . .  698 

pain  in  the  limbs  in 

403,  405 

pains  all  over  in        . .  59S 

pyrexia  in      ..         ..  57" 

rigors  in         . .     505,  59S 

rashes  in         . .  . .   5;ts 

swelling;  of  muscles  in  59s 

tomper.iturc   chart   of  5;»s 

urticaria  in    . .         ..  59> 

Rat  fades,  in  microcephaly  iss 

-  paste,  phosphorus  poison- 

ing from  . .  . .  3.10 
strycluiinc     poisoning 

from  . .  . .  5ic.t 
Ray  funpi  ..  ..  74,  37.' 
in  actinomycosis       . .  4.',^ 

-  -  (Plate  XXVI lit      ..   Oil 
Raynaud's   disease,   acute 

ledema  of  tont^lo  in . .  698 

aire  incidence  of       , .  441 

albumiiniria  in  . .      13 

black  cyanosis  in     . .  899 

blue  bmin  and  . .   163 

-  -  bullai  in  . .         90,  97 
cervical  rib  siniulatint;  444 

^^  of  toes  in    . .         . .  44 1 

dead  fincers  in  . .  102 

-  -  ears  alT<>cte>l  in      203,  099 


M    ■■■    .il.vtf.l    bv  210.   O'.c.l 

Raynaud's  disease,  fingers 

in  (flail  XIII)       ..  256 
-  -  fro.-l-bil,-i,nnlal,vl  by   102 


,.r  liiirrr-  n. 

Raynaud's  disease,  general 
account  of 

hienink-lobitinna  with 

Iiands  ultivled  by      .. 

Iiitrh       bluod-pressuru 

wilh 

Raynaud's  disease.  Inter- 
mittent clnufllcation 
dillerentlatPd  trom 


594 

676  I 


-  tubcnnlous  bladder  270, 

282,  397,  471.  57!l 

kidney  117,  270,  279. 

282,  366,    400,  577,  .[.79 

-  ureteric  cjilcuius       472,  578 

-  urethritis  . .         . .  681 

-  vesical  calculus  270,  282, 

471,   680 

QUAnU.\TU.S  lunibonim. 
ncrie  supply  of      . .  4flU 
QuailricepH  extensor  feniorls. 


In   cerohnisplluil   nienni 

Vitis 

dnii?  («'e  linii;  Hash) 


IJ.'i 


-  necrosis  of  iin«en«  in 

(fi!7.  120)  267 

-  -  nose  n(Tecti-l  bv       . .  «99 

-  -  ichini.  from  in.  III.  II.', 

^    -  |.,dl..r.i(l.,.-i"  111 

Raynaud's   disease,    parts  •-' 

BifectHi  by  256 


REACTIOX 


REGURGITATION 


/:,ar/io,K    roN/J. 

lii'ctal  crises,  contd. 

Recfiim,  could. 

Red  coipuschs,  coitld. 

Reaction    of   degeneration. 

in  diagnosing  intestinal 

-  catarrh  of,  diarrlicea  from  172 

in   urine          . .      9,  12, 

conditions  causing     ..     61 

obstraction         . .   459 

-  colibacilliu'ia  after  opera- 

 various  sizes  of 

Ill                                ...'>'.• 

obturator  hernia  . .   681 

tions  on           ..          ..70 

Red  currant  jelly  sputum. 

-   -    W  :                                       -I-.  .     -I'M'. 

ovarian  tumour     . .   331 

Rectum,  concretions  in  ..  718 

from  new  growth     . .   S 

-  -   l"r ciii,  ■   <  ■!    tiiTre      111 

piles             ..      194,  584 

tenesmus  from           . .   718 

-  nucleus,  lesion  of,  tremor 

ill   infantile  paralysis       (iO 

prostatic        abscess 

-  enterolith  in      . .          . .   584 

from ' 

infraspinatus              . .   50G 

182,  470,  581,  587,  620 

Rectum,  fibrous  stricture  of 

-  vision       . .          . .          . .  ' 

from  injury    . .           61,  63 

affections            . .   397 

585,  586 

Reduplication  of  first  souiul. 

mvelitis           . .          . .   515 

calculus           470,  473 

dysche7i:i  from      . .   129 

from    acute    endocar- 

-  -  neuritis            . .          . .   477 

prostatitis  182,  470, 

in  women    ..           ..    129 

■    ditis i 

-  -  new  ^Towtli    . .          . .     61 

578,  581 

Rectum,  foreign  bodies  in    584 

arteriosclerosis       . .   . 

partial             .  .          . .   583 

rectocele     . .         . .  539 

absro^due  to          .  .    584 

granular  kidney   . . 

from  pelvic  tumours. .     61 

tuberculous  bladder  471 

tenesmus  from       . .    718 

hypertrophy  of  heart  I 

-  -  peripheral  neuritis  56, 

kidney  280,  282, 

—  gumma  of           . .          . .   585 

REDUPLICATION  OF 

59,     60,     61,     440, 

355,  577 

-  hsemorrlmge    from    fsee 

HEART  SOUND        ..  E 

465,  512,  514,  515 

prostate  . .      479,  620 

Blood  per  Animi;  and 

caiin-iTlivtliiiisiniu- 

peroneal  atrophj      . .   513 

seminal  vesicles . .  479 

Melfcna) 

latin;;  '      .  .              .  .    ^ 

-  -  poliomyelitis  . .       509,  512 

ureter      277,  471, 

-  hair  ball  in        . .      584,  718 

mid-diastolic     bniit 

projrressive     muscular 

473,  579 

-  insensitive,  in  dyschezia  121 

simulating            ..    . 

atrophy       . .          . .     61 

ureteric  calculus  41, 

-  invagination    of,     blood 

Reduplication  of  pulmonary 

-  -  sciatica   '        . .          61,  63 

472,  578,  587 

per  anum  from     . .   129 

second  sound.. 

-  -  syringomyelia             . .     61 

urethral  calculus  . .  395 

constipation  from     . .   129 

with    mitral    re- 

 talipes     '       . .         . .  112 

in  diarrhcea  . .         . .   170 

defjECrttion  misatisfied 

gurgitation                . .  S 

Tooth's  peroneal  atro- 

 diseased  ovary  felt  on  587 

in 129 

-  second  sound,  accentua- 

phy               60,  61,  113 

ectopic  gestation  felt 

dyschezia  from          . .   129 

tion  and     . .         . .  1 

ti'ans\ei-se  myelitis    61,  62 

on 587 

lumbar  pain  from     . .   129 

from  arteriosclerosis 

tumour  of  caiida  equina   61 

with  growth  in  liver. .     52 

-■  -  mucus  from   . .          , .   129 

granular  kidney    . .  i 

REACTION.  DIAZO         ..    173 

-. —  iu  bajmaturia  cases  . .  277 

felt  per  rectum          . .   129 

hish  blood-pressiu-e 

-  Easoi.-s 285 

-  -  hydatid  felt  ou         . .     49 

-  irritation   of,  by  pelvic 

298,  * 

Reaction  of  stools. .           .170 

-  -   ill    intestinal   obstruc- 

abscess            ..          ..427 

mitral  stenosis      . .  k 

-  vol, in 766 

iini,               ..      129,  130 

-  loaded,  dystocia  from  . .  200 

Redux  crepitations  iu  pneu- 

Reaction,     Wassermann's 

-  iiitn-Mi^ceptionfelton 

priapism  from           . .  538 

monia               ..      160.  { 

(scr     W  :i— iTiiiariii  1 

:s,    ll(i,    127,    130, 

-  lesions  of,  pain  in  legs 

Reeling,    from    cerebellar 

Reaction.     Widal's     (see 

585.  717 

from    . .          . .          . .   442 

lesions 

Midal) 

for     invagination     of 

tenderness     of     spine 

Reeling  gait  (and  see  Ataxy)  S 

Reactions,     electrical,     in 

rectum        . .          . .    129 

from           {Fi(j.  294)  716 

-  in  tabes ' 

tetany               ..           ..        3 

ischiorectal  abscess  felt 

Rectum,  malformations  of 

-  from  vertigo      . .         . .  ' 

Reading,  book  seeming  to 

on 587 

{Figs.  249-252)  586 

Reflex,  abdominal,  absent. 

recede  during            . .   763 

in  jaundice     . .          . .   326 

intestinal    obstruction 

from  lateral  sclerosis    i 

-  eye-strain  from..          ..   446 

lumbago          . .          . .   429 

from             . .          . .   129 

with  brachial  mono- 

- headache  from  , .          . .   449 

Rectal  examination,  malig- 

- occluded  by  fcetal  head  ,587 

plegia      . .          ..  i 

-  pain  in  the  eyes  from  . .    446 

nant  '  shelf '    felt    on  587 

-  opened  by  carcinoma  of 

in  amyotrophic  lateral 

Receptaculum    chyli,    ob- 

Rectal examination,  method 

bladder          ..         ..238 

sclerosis 

structed,  chylous  ascites 

of  making                   .584 

uterus          . .          . .   238 

lost    extensor   plantar 

from 50 

-  -  for  new  groutli           ..    172 

-  -  caseous  glands          . .  238 

reflex  with . . 

clivluria  from        . .     50 

papilloma  recti  and. .      79 

-  oxyuris  vermicularis  in       79 

_  _  _  i-vidcrico  of   or^ranic 

rupture  of       .  .           . .    109 

parametric  abscess  felt 

-  pain  in.  from  piles        . .     78 

lil-IM-^l- 

Recession  of  gums            .  .   589 

on .587 

-  papilloma  of       . .          . .      79 

Reflexes,  abdominal,  changes 

Rectal  crises,  from  tabes 

pelvic  adhesions  and    130 

-  polypus  of  (see  Polypus 

in         4 

173,  515,  650,  719 

glands  felt  on        . .   381 

of  Rectum) 

in  disseminated  scler- 

- examination,     in     acute 

for  pelvic  tumour     . .     63 

-  pressure  on,  bearing  down 

osis  . .          . .          . .   ' 

constipation  . .          . .   129 

in  peripheral  neuritis    515 

pain  from        . .          . .   426 

-  Achillis  (see  Ankle-jerk) 

anal  fistula  and         . .      78 

pessary  felt  on           . .   587 

by  carcinoma  uteri  . .   129 

-  centres  in  cord  (Fig.  211)  * 

aneurysm  felt  on       . .   587 

pyosalpinx  felt  on   , .   587 

-  -  distended  tubes       . .  129 

-  corneal,  in  facial  paralysis 

in  appendicitis      IIG, 

rectal  polypus  and  . .      78 

dyschezia  from          . .  129 

-  deep,        increased        in 

283,  434,  587,  677 

-  -  sacral  disease  and     . .   587 

-  -  by  fibroids     ..          ..129 

hysteria          . .         . . 

appendix  felt  ou      . .  587 

-  -  in  sciatica      . .      438,  439 

ovarian  tumour         . .   129 

-  lost,  in  epilepsy.. 

in  ascites        . .          . .     49 

-   -    of   M'lmnal    vrnrles      ..     587 

-  prolapse  of  78,  79,  717,  718 

-  palate,  absent,  in  hysteria 

for  carcinoma  of  colon 

--  in  MH,Hr,ol,i,^          ..      78 

-  retention  of  urine  after 

impaired,    in     bulbar 

130,  172,  330 

Rectal  examination,  struc- 

operations on             . .   396 

palsy 

recti    78,   129,  130, 

tures  palpable  on      ■ ,  587 

-  sense  of  fullness  in,  from 

-  patellar  (see  Knee-jerk) 

453,  587,   718 

-  -  in  tenesmus   . .          . .    718 

carcinoma  . .          . .   129 

-  plantar  (^ee  Plantar  Re- 

cases  of  bearing-down 

thickened  ureterfclt  on  280 

piles            . .         . .     78 

lIi'Vl 

pain            . .         . .  427 

in  thieves        . .          . .   584 

weight  in,  from  piles      78 

Reflexes,  pupillary,  general 

iliac  fossa  pain      . .  116 

vaginal  growth  felt  on  587 

sometliini:      coniing 

account  of            551. 

tpdema        . .          . .        S 

for   venereal   ulcer  of 

d(l\\  I;      I'lli-    1    iil-:'r'     ,  .        78 

-  -  (and  see  Pupil  Reflex) 

of  one  kg           .  .   411 

rectum         . .          . .     79 

-  tub.'!-/...         ■    ■■■  .i.pina 

Refraction,  error  of,  diplopia 

-  -  -  ]tns  in  stools           ..   557 

-  -  vesical  calculus  felt  on  587 

^inu.i    ■■   .    ■                  -.585 

from 

in    Cauda    equina    tu- 

- -  vc'^ioulre  seminales  felt  377 

-  ulcMM'  :>'■■  ,'i  1  -!■.■  I  li-ura- 

eye-strain    from    446, 

mour            ..          ..-63 

(aii-l  MT  l;,.riinii.  Ab- 

tion  ..f    i:.'rruTn  ;    and 

524, 

chyluria          . ,          .  .    109 

Carcinoma  of  Rectum) 

headache    from     295, 

ooccydynia  and          . .   587 

Rectal  shelf,  in  abdominal 

-  v.Miereal  ulcer  of           . .      79 

446,  449, 

ciyptomenorrhcea     ..      17 

malignant  disease     . .  587 

-  villous  tumour  of         . .      79 

neuralgia  from 

-  -  detecting          bladder 

Recti  abdominales,  divari- 

Rectus abdominis.on  guard  592 

photophobia  from     . . 

growth  41,  277,  281, 

cation  of         , .          . .   483 

rigid,  over  liver  abscess  370 

l>ricking  of  eyes  from 

471,  472,   579,  580 

Recto-abdominal  examina- 

 tumour  simulated  by  659 

strabismus  from 

enlarged           pelvic 

tion  m  vir-ins            .  .    192 

Recurrent  fibroma  of  naso- 

 supra-orbital  pain  from 

glands     ..          ..   472- 

Rec(nr<|..,  I..  ■  ,.  .   .  Miiina- 

pharynx          . .          . .   179 

tenderness     of     scalp 

polypus       . .          . .    585 

tiM                              I-'    ..    539 

-  laryngeal  ]ierve,  paralysis 

from 

retroversion       of 

-   Sitnn!  .                            ;    -.         .  .    539 

of      (see       I'aralysis, 

visual  defect  from    . . 

uterus        ..          ..587 

Recto-vadinal  fistula        ..  586 

Laryngeal) 

-  -  (and  see  Astigmatism  : 

sutimucous  abscess    585 

Eecto-v.-..J  ii^nil  1        238,  5SG 

Red  corpuscles  in  amosbai      77 

liypcnnctroi-iia  ;    Myo- 

 uti  line  enlai^ement  587 

RECTUM.     ABNORMALI- 

 crenated     {Plate     II, 

pia! 

in     .ha;:iiosing      anal 

TIES  FELT  PER       ..  584 

Fiq.  D)        . .          - .      22 

Regeneration  of  nerve,  sen- 

llssure         ..          ..194 

-  ahsc.--  o,M.,un_'  into     ..    581 

-  -  fragility   of   f=ee   Fra- 

sory recovery  after  . . 

ascites         . .          . .   587 

-  adenonKi  of        . .          . .   718 

gility  of  Red  Cells) 

time  required  for     . . 

carcinoma   of   pros- 

- affections  of,  pain  in  the 

insignificance   of   '  oc- 

Regional  anatomy   of  ab- 

tate        ..          ..   470 

back  from      . .          . .   428 

casional  '  in  urine. .        6 

domen             . .          . . 

cause  of  swelling  in 

-  ballooned            . .          . .   131 

normal  numbers  of  20,  532 

Regurgitation,   aortic   (see 

iliac  fossa           . .   665 

-  bilharzia  affecting         . .     79 

nucleated        . .          . .     22 

Aortic  Regurgitation) 

diverticulitis          . .  453 

-  bullous  dermatoses  affect- 

in  Hodgkin's  disease    64 

-  of     food,      in      bulbar 

dyschezia   ..      121,  128 

in? 99 

-  -  oval,  in  birds..         ..  266 

paralysis 

enlarged       prostate 

-  blood  per  (see  Blood  per 

in  pleuritic  effusion..  102 

-  -  in  infants        . .          . . 

277,281,587,  394,396 

Anum ;  and  Melajna) 

punctate  basophilia  in     2.'^ 

-  -  luvasfi ia    i:ravis    .  . 

impacted  faeces  172,  718 

-  carcinoma  of  ("see   Car- 

- -  size  of            . .         . .     22 

REGURGITATION  OF  FOOD 

inflamed  glands     . .   459 

cinoma  of  Rectum) 

in  tube  casts  . .         . .       6 

THROUGH  NOSE 

REGURGITATION 


RHEUMATISM 


879 


'tijurgilalion  of  joiid,  mnki. 
-  tlirougU  nose  I'rom  bul- 
bar paralysis     178,  589 

cleft  palate         ..   178 

diphtheria       151, 

17S.   liin,  :,V1,  764 
liy-triii  .  .  ..    r,S9 

legurgitation  of  food  through 
nose,  list  of  causes  of  58S 

from    myasthenia 

gravis..  ..   178 

paresis  of  palate    512 

perforated  palate  178 

syphilis  . .  . .  178 

mitral  (see  .Mitral  Eeiriir- 

gitation) 
pulmonary     (see     Pul- 
monary Incompetence) 

■  tricuspid  (see  Tricuspid 

Resunjitation) 

U'iiifori-(-ment       .  .  . .   357 

;.  I      ■,'- test  for  arsenic.     78 

-•  fever,  chills  i[i..  637 

..nd  ..  ..637 

lelapsing    fever,    general 

account  of  27,  28.  336,  637 

■  -  geosraphical   (iL=trihu- 


of 


50G 


-  livperpyre.\ia  in        . .  309 

-  hypothermia  after    ..  311 

-  jaundice  in    . .         , .  325 

-  pains  in  back  in        . .  G37 

-  parasites  in  blood  in      27 

-  pyrexia  of     . .      336,  637 

-  rigor  in         391,  595,  590 

-  spirillum     of     i^Flate 

XXVI 11)   ..  ..014 

-  spirochiBtes  in       M6,  637 

-  spleen  enlarged  in  032,  037 

-  sweating  in    . .         . .  637 

-  temperature  chart  in 

(Fir,.  5)  27 
Remittent  fever,  purpura  in  553 
ftenul  abscftvi  (see  Abscess, 

•  ■  ii.  iiliis    fsee    Calculus, 

■  I;    c.-e  Colic,  Renal) 

-  >  r '-.-  ill  tabos   ..         . .  515 

-  ciiiiticlialcoll.^,  from  acute 

liriu'lit's  .li-ease         . .  -112 

-  tul»o-.;a*ts  (sf>rr  Tube  Casts) 
Kidney, 


Knla 


..Ir,l    by 


Renal  veins,  thrombosis  of. 

diagnosis 
Renal  veins,  thrombosis  of. 
simulating    acute    ne- 
ohritls 


Uesiii.  bulUG  from. . 

-  ei-ythcmii  from  . .  . .  S 

-  in  uriiio,  whire  riii^  from 
Eesoriaiice,       in      femoral 

-  impaired,  from  aneurvi'm 

l'J5,  208,  i 
Mti,  bus  obstruction     1 
'   libroid  hini;  IBS, 

UKI,  L'92,  299,  ( 
i  lithi'is  ..  ..  1 
uiMoi-i:i     .,  ..   ] 

I    p.ilmonary   om- 

■iiis         ..       ..  : 

iiioriary  infan-t    ..   1 
I.  [in-.i>,  of  bronchus. .  : 

-  iiHi' M-i*'l,  111  cinijhyscma 

J67,  ; 

Resonance,  skodalc  1G8, 29i>,  { 

,  li   ■  k  iiriiio  from 

■I, '  <-'  \  rtc-Slokes, 

<  ii-  \  iii'-Stokca 


M  i^<^<cd,  in  tetany    151 
I  itc  and   ..  ..   .'>4U 

H,f.noumonin.'»35,  125 
Mow,  from  pneumo- 
iM.nix  ..  ..    531 

n  pneumonia      ..   \VM\ 
;     irsiii  jind   ..  ..   573 

Respiration,  slow  ..         ..84 

-  ■   fnan  cerebral   abscess  5U2 

-  siipi*r(irinl,  with   pcrito- 

Piitis 592 


Respiratory  blood-pump,  in 

heart  failure  . .         . .  420 
Rest  in  bed,  in  chlorosis  . .     3G 

effect    with,    adhereiit 

pericardium       ..  214 
mitral  regui^itation  214 

-  pain  and  stitlness  after    4G3 

contractures  from     . .    114 

talipes  from   . .  . .   114 

Restlessness,  in  acute  yellow 

atrophy  . .       273,  333 

-  from  alcohol       . .  . .    720 

-  with  anuria        , .  . .      42 

-  in  children,  from  colic.   425 

-  eclampsia  . .         . .  146 

-  from  hrematemosis       . .  2G8 

-  hysterical  pyrexia         . .    310 

-  at  night  in  rickets       115,  711 
Retching     . .  . .  . .   7G4 

-  with    undue    abdominal 

aortic  pulsation         . .   543 
Retention  of  urine,  alcohol 

and 305 

from   bladder  growth 

281,  39G 

Madder    felt    above 

pubes  with  . .  :f95 

~  -  from    carcinoma    of 

ovary  . .  . .   G49 

prostate      . .         . .  G49 

cold  and         . .         . .  395 

cystitis  from  . .      578,  G50 

-  distinction  from  anuria 

-  -  ilribblinswith  .!  395 
from  enlarged  prostate 

395,  39G,  G49 
Retention  of  urine,  general 
account  of     . .      395,  396 

-  -  fi-oin  i:uii..,-rlir..M         ..  lillt 

-  -  in  liy^tt-ria     ..          ..  :VM\ 
incontinencesimiiiated  395 

-  -  from  inflamed  urethral 

caruncle     . .  . .   649 
in  lateral  sclerosis  398.  517 

-  -  myelitis         39G,  398,  578 
; after  operations        . .     42 

from  ovarian  cyst    . .  G49 

pain  from       . .         . .  395 

above  pubes  with. .     39 

from      paralvsis      of 

I  bladder      ". .      39G,  398 

paraplcijia       . .  . .   39G 

fielvic  tumour  . .      39 

p<ripro>;fatic      abscess  649 

-  -  pr.-nr"i-tul  abscess       ..    649 

peritonitis       ..  ..   592 

prolapse  . .  . .   649 

prostatic  abscess  182,  39R 

-  -  prostatitis     182,   396,  581 
I retrovei-ted         gravid 

I  uterus  39,  649,  689 

i sphincter  spasm        . .  398 

j spinal  disease  . .     39 

■ strangury     from     39, 

395,  nin 

' stricture  39,  395,  396,  619 

I in   tabes  dorsalis  396, 

398,  578,  650 

-  -  typhus  . .         . .  638 
Irom  urethral  j;alculus 


Retinal    artery,   spasm    of 

blindness  from  . .    Tfil 

embolism  of  (see  Km- 

bolism,  Retinal) 

-  changes,   with   nephritis     42 
uncmia  . .  . .   146 

-  examination,  with  growth 

in  liver  . .         . .     52 

-  hpemorrhage    (see    Hai- 

morrliage,   Retinal) 

-  vein,    thrombosed    (si^e 

Thrombosis,  Retinal) 
Retinitis,  albuminuric,  ap- 
pearances   of   416, 

iPlcae  XX)  418 

with  arteriosclerosis..       1 

-"-  black  spots  before  eyes     72 

cerebral     hajmorrhage 

and 119 

in    chronic    nephritis 

11,  212,  274,  408 

granular  kidney        1,  106 

heart  failure  with     . .       1 

blood-pressure 


Retroversion  of  uterus  f-^ee 
Uterus,  Ketroverted) 

Retroverted  gravid  uterus 
(see  I'terus,  Retro- 
verted Gravid) 

Rhabdomyoma    ot    kidney  356 

Rheumatic  tever(see  Rheu- 
matism, Acute) 

Rheumatism,  acute,  acute 

endocarditis  in  ..  211 

necrosis  mistaken  tor  338 

adherent   pericardium 

alter  ..  53,  54 

age  incidence  of       . .   106 

albuminuria  in  ..      13 

albumosi 


vith 


1,  212 
212 


-  With  liiL'h  hl'Mnl-pressure  485 

-  interstitial   nephritis    . .     90 

-  nephritis  . .         . .     47 

-  nenro-.  in  (ungating  endo- 

-  lilint()pltobia  from        ..  524 

-  liru'iiiciitosa,  familial     ..   761 
ni'^l  It -blindness  from 

761,  763 
ophthalmoscopic     ap- 
pearances of       761,  763 

visual  field  constricted 

m     ..         ..      760,  761 

-  uncmia  and       . .         . .   759 

-  of  yellow  spot,  nystagmus 

from    . .  . .  . .    759 

IU-truiioii..flh.-Al.aoni.',i 


AImIo 


RETRACTION     OF     THE 
EYEBALL      .. 

-  ev.lids  111   <lr:iv..s's  dis- 

217 

RETRACTION     OF     THE 

GUMS 
RETRACTION     OF     THE 

HEAD 

589 
589 

capillary  bronchitis  . . 

—  cerebellar  lesions 
dyspncea 

590 
590 
592 

590 

iisr.l 


urelhrili! 


Retraction  of  the  head,  list 
of  causes  of    . .  .  ! 

from    nieninpitis    295, 

323,  500,  590,  010,  I 

'    282,  019  I tuberculous  meningitis  I 

0-(9     -  nipple,   from   carcinoma  I 


V.fji' 


Retina,     in     albuminuric 

retinitis  .416 

Retina,  detached,  appear- 
ances    of     416, 

(Plttlr  XX)  lis 
black      spots      beloie 

blindness  from  . .  702 

by  irrowtlt     . .  ..-117 

-  embolism  of  (see  Em- 
hnlism.    Kelinal) 


Retraction  of  ribs,  systolic, 
with  adherent  peri- 
cardium 90, 


Ihi 


rtiTus.  H.^tnillcviiMi  of) 
Retroperitoneal  cyst,  dilata- 
tion of  stomach  from 

171,  0 
Retroperitoneal  cyst,  notes 


ara?mi:i  froni  .  .      34 

i.iif,     li  I  !-."■  from  40,  209 

-  -  . .    337 
Rheumatism,  acute,  associ- 
ated conditions  of  14 

bromidrosis  in  .  .    0."»1 

cerebral  embolism  and   119 

in  children     .  .  .  .    404 

chorea    in    105,    133, 

537,  404.  014 

chronic     niediastinitis 

from  . .         . .   751 

-  -  coma  in  ..  ..117 

delirium  in     . .  . .   109 

does    not    affect    one 

joint  only  . .      341,  304 
drenching  sour  sweats 

in 33S 

endocarditis  in  90,  90,  105. 

209,  283,  404,  574,  014 

eosinopllilia  after      . .  218 

erythema  in  . .      223,  337 

murdforme  from  . .  105 

nodosunt  from  105, 

228,  014 
simplex  in  . .  . .    228 

-  -  family  history  and 
133,  337,  404,  OU 

fauces  inflamed  in    . .  015 

fpbricula   representing  404 

fixation  very  rare  after  339 

'  flitting 'of  joint  pains 

Rheumatism,  acute,  general 
account  of  . .  337 

L'Oijuci.ccal        arthritis 

mistaken  for      338,  340 

growhig  pains  and 

303,  404,  40li 

heart-block  from       . .   540 

disease  and   35,  40, 

89,  93,  105,    209, 
337,  404.  485,   704 
Henoch's  purpura  simu- 
lating ..  ..343 

in    history    of    heart 

disease        . .  . .     11 

hydrocele  from  .  .   481 

al  hyperityrexia   in   109, 

.    .'.90  309,  310,   574 
infantilism  from        ..   1K9 

joint  pains   with   105, 

2'J8,  014 
Kirkland's  disease  simu- 
lating ..  ..  010 

.leucocytosis  in  ..   30(i 

limping  from..  ..  302 

mcdiiistinitis  from  52, 

,'i4,  308 
menorrhagia  from    . .  380 

-  -  mitral  disea.so  in       ..  337 

regurgitation  after      S9 

stenosis    after     35, 

485,  701 
cle    atrophy 


.•ith 


338 


Retina,    alter    retinal  em- 
bolism .416 
Retina     after     thrombosis     of 
of  retinal  veins        . .  416 
-  white     patches     in,     in 

110 
410 


Chimin  Itelropcritonca!) 
hernia 452 

-  tis.sue,  aneurysm  leaking 

into 120 

Ilctrophiu'yngeal  abscess 
(see  Abscess,  Post- 
pharyngeal) 

Hetropulslon,  in  porelysls 

agitnns  . .         . .  725 


-  -  mvocardial       chang 

'lifter             ..        of,  704 

-  myocanlltis  in           ..  212 

-  nightmare  and           ..  4n2 

-  nodules  and  . .      337,  33s 
.  -  pain  in  the  back  from  127 

-  -  -  opigiistrium   from..  430 

foot  from  . .          . .  302 

joints  in     . .         . .  403 

limbs  from..         ..  403 

-  —  muscles  in  . .         . .  lo.'l 

-  -  palato  inllamod  in    . .  0iI5 

-  -  palpitation  in            . .  211 


RHEUMATISM 


RIGORS 


nhi. 


■mkl. 


irtliti; 


54, 


105,  337,  404,  I 
permanent    stillness 

r.iie  after    . . 
pleurisy   in      54,  G14, 
-  witli  effusion  from 
polyorrhomenitis  from 
precordinl  pain  in    ..  : 
puerperal  fever  sirau- 

pulmonary       stenosis 

after 
purpura,   of,   aije  inci- 


aiicylates  and  34,  iSS, 


nev'cr  su'|.puratrs  SsV,  : 
suppurative     arthritis 

mistaken  for      33S,  : 
tacliycanlia  from      . . 
tlivroid  gland  enlarged 


traumatic  arthiritis  mis- 
taken for    . .  . .  ; 

tricliinosis  simulating  • 

tuberculous     arthritis 


braL 
chro 
-  ii 

,,     ,1       : 

,U|..l     |.    II 

-  V 

iiri"' 

!;,''l"iin'i!l 



loints 

from 



limbs 

in 

_    - 

muscles  from 

-  'ia 

vcoma 

simulat 

-  w 

ealher 

and  .. 

-    \Y 

■iteK' 

cramp 

latcJ 

bv      .. 

rnii 

ractui 

es  from 

epii 

idvnio 

-uivliitis 

al(^ 


■it  is, 


;U) 


Rheumatism,  muscular  431,4 
brachialneuralgiasimu- 

lating  .  -         ..A 

simulating  tetanus  . .  ] 

stiff-neck  from  . .   1 

tenderness    of    muscle 

insertions  in  . .  A 

-  nails  affected  by  . .   ' 

-  scarlatinal  . .  . .  ; 
Rheumatism,  tabetic  pains 

mistaken  for  . .      43(i,  ^ 

-  tenderness  ui  M'alp  in  .  .  'i 
spine  from      . .  . .    ^ 

-  urethritis  from  . .  . .  ] 
Eheumatoid  arthritis,  acute 

(see  Arthritis,  Rheu- 
matoid) 

Rhhie      valley,      molHties 

ossiura  in        . .  . .  : 

Rhinitis,  atrophic,  anosmia 

from    . .  . .  . .  1 

crusts  in  nose  from  . .  ] 

-  -  nasal  dischai-ge  from  ] 

oztena  from   . .  . .  ] 

taste  loss  from  . .  ' 

-  caseosa,  not  tuberculous  ] 

-  chronic,  from  syphilis . .  '. 

-  diphtheria  of  skin  with  { 


179 


-  foul  breath  from  ..     87 

-  hypertrophic,     adenoids 

from 179 

anosmia  from  .,  G12 

inability    to    breathe 

through  nose  from    179 

nasal  discharge  from    179 

ozffina  from  ..  ..  179 

polypi  from    . .         . .  179 

snoring  due  to  . .   til3 

taste  loss  fi*om 

tonsils  large  fi'om     . . 

-  membranous,  not  always 

diphtheritic    . . 

-  purulent  (see  Dischai-ge, 

Nasal) 

-  rhinoliths  from  . . 

-  taste  impairment  from 

-  tuberculous 

-  ulcer  of  cornea  from    . . 
Rhinoliths  . . 

Rhinopliyma  ..      241. 

Kliiriorrhagia(seeEpistaxis) 
lihiiioscleroma,  epithelioma 

simulated  by. . 
Rhinoscleroma,  general  ac- 
count of 


Rickets,  could. 

-  bow-legs  from    . .  . .   18G 

-  bronchitis  in      . .  . .   145 

-  cachexia  with    . .  . .     99 

-  carpopedal   contractions 

and      .  .  .  -       152,  420 


old  i 


145 


733 


iiiiOl.ls, 


of 


supply 


-  root  innervation  of     . .  50: 
Rhonchi,  with,  bronchitis 

1G7,  21 
~  typhoid  fever    . . 
Rhubarb,  chrysophan 

in  ..  ..      744,  745 

-  erythema  from  . .         . .   1322 

-  heartburn  relieved  by..    297 

-  oxalate  from     . .  . .   424 

-  oxaluria  after    . .  . .    2S I 

-  pink  urine  after  . .    745 

-  yellow  urine  from  . .  744 
;  Rhus,  sore  Angelas  from  . .  239 
j  -  toxicodendron,     blisters 

I  from    . .  . .  . .      97 

buUas  from 

I dermatitis  from 

I ei-ythema  from 

pniritus  from 

Rib,  carcinoma  of. . 

-  caries    of,    pain    i 
I  chest  from 


G3G 


9G 


rvical  Rib) 
Fracture 


431 


-  ptjriosiiris    of,    after   ty- 
phoid fever    . .  . .    fiSG 
!  -  resection  in  empyema..  103 
I  -  retraction,  systolic,  with 
I           adherent   pericardium 
j                                        54,  90,  213 
I  -  sarcoma  of         . .  . .   707 
:  -  tuberculous   -     . .       668,  686 
I  Ribs,  beaded,  in  rickets 
I                                   155,  167,  635 

-  eroded  by  aneurysm    . .  434 

-  everted,  from  emphysema  36G 
I  -  -  in  rickets         . .   "       . .   635 

Ribs,  lesions  of.  tenderness 
due  to 


707 


from 


370 


-  overlapping^ 

fibroid  lung 
I  -  periostitis  of      . .  . .   707 

-  pushed  out,  by  ascites. .     43 
I  -  syphilitic  nodes  on       . .  669 

Rice,    decorticated,    beri- 
beri  and         63,    226,    414 

in  cholera        . .  . .   717 

Rice-water  stools  .  .      268,  273 
I  Ricin.hiemoglobinurialroni  294 

Rickets,  age  incidence  of 
'  154,  242,  3G4 

-  ankle-joint  disease  simu- 

j  lated  by         . .         . .  304 

I  -  ankles        large        from 
I  (Fig.  85)  186 

;  -  anterior  fo7itanelle  in  . .  145 

-  baldness  in        . .         . .  711 
[  -  Barlow's    disease   simu- 

I  lating  . .  . .  . .   556 

-  beaked  pelvis  in  . .   187 

-  bending  of  bones  from. .  242 
I  -  bones  unduly  curved  in  G35 


Rickets,  chest  in  (Fifj.  76)  167 

-  coma  ill 144 

-  coMsti[.ation  in  123,  145 

-  convulsions     from    144, 

145,  420 

coryza  in  . .  . .  145 

■  craniotabes  from       152,  205 


deic 


Rickets,  distinguished  from 
achondroplasia  --    188 

Rickets,  distinguished  from 
osteogenesis  imperfecta  188 


-  eosinophilia  in  . .  . .    219 

-  epiphyses  large  in         . .  635 

-  fat  heavy  child  in         . .  385 

-  flahbiness  of  muscles  in  714 

-  Hat  feet   from   (Fiff.  85)  186 

-  fontanelles     delayed    in 

closing  in        ..  ..635 

-  forehead  bulging  in       . .   187 

-  -  large  iii  .  .  .  .   204 

-  gastro-intestirial     upsets 

in  145 

Rickets,  general  account  Of  145 

-  greenstick  fracture  from  242 

-  Harrison's  sulcus  in  145, 

167,  187,  635 

-  head  large  in  145,  205,  511 

-  head-rolling  hi  . .      145,  711 

-  hip-joint    disease    simu- 

lated by  ..  ..364 

-  hot-cross-bun  head  in 

187,  205 

-  hour-glass  pelvis  in      . .   187 

-  hydrocephalus  simulating  204 

-  infantile  scurvy  and 


321 


-  irritability  in     . .  . .    145 

-  knee-joint  disease  simu- 

lated bv         .  -         . .  364 

-  knock-kneefrom(/'i(7.85)186 

-  kyphosis  from    . .      155,  188 

-  laryngismus  stridulus  and 

145,  420 

-  limping  from      . .      362,  363 

-  liver  depressed  by        . .  367 

-  long  bones  curved  in    . .   145 

-  lordosis  from     . .         . .  188 
from . .         . .  385 

stools  in  . .   145 

-  muscular  debilitv  in     . .   145 

-  night  sweats  in.".         . .  654 

-  pains  in  the  bones  in  . .   364 

-  paraplegia  from  ..   510 

-  pieeon  breast  in  . .   187 

-  t.ot-bfllv  in        ..      G35.  G60 

-  i.-rN.in  ;.  Ill  .iMni:iand37,  635 
635 


-  !     I fH'.l  in  154,  155 

-  1,  -1.  --■T--    ni       ..  ..  711 

-  -  at   nJL'ht   ill      ..  ..  145 

-  ribs  beaded  in  155,  167,  G35 

-  rosaiy  in  . .  . .  145 

-  rostrate  pelvis  in  . .  187 

-  sabre  tibiie  from  . .  186 

-  sacro-iliac  joint  disease 

simulated  by. .         - .  364 

-  scoliosis  from    . .      153,  154 

-  screaming  in      . .         . .  145 

-  scurvy-      (see     Scurvy- 

-  short  legs  from  (Fig.  85)  18G 
Rickets,  signs  of     ..  145,  635 

-  spasmophilia  and  . .  420 

-  spinal  caries  simulated  by  714 
curvature  from      187,  714 

-  spleen  enlarged  in  632,  G35 

-  sweating  of  head  in     . .  145 

-  teeth  delayed  in  . .  155 

-  tender  bones  in. .      145,  714 

-  -  scalp  from     . .      710,  711 
spine  in           . .          . .  714 

-  tetany  with  3,  145,  151 

-  transverse  colon  visible 

in         660 


tubcrcnlo 


par- 
alysis   ] 

-  wrist.slargefrom(Fw7.85)  ] 
Ricketts      on      small-pox 

561,  5G3.  : 
Rickety  girdle       . .         . .  :! 

Riedel's   disease,   cyanosis 
from    . .         . .         . .  ] 

dyspnoea  from  . .   I 

-  lobe         ( 

age  incidence  of        . .  ; 

floating  kidney  simu- 
lated by     .".  . .  ; 

-  -  gall-bladder  simulated 

by    . .  663,  t 

gall-stones   ami  . .    ; 

Riedel's  lobe,  general  ac- 
count of  ■ .  : 

kidney  simulated  by    ; 

laparotomy     in     dia- 
gnosing       . .  . .   : 
movable  kidney  simu- 
lated by      . .          . .   ( 

sex  incidence  of       . .  ; 

simulating       enlarged 

gall-bladder  . .  : 

movable  kidney    . .  : 

tight-lacing  and       . .   '■ 

Rigg's  disease  (see  Pyorrhaa 

Alveolaris) 
RIGIDITY   OF  THE   AB- 
DOMEN 

from  acute  peritonitis 

131,  388,  425,  oii'2. 

appendicitis   . .         . .  i 

appendicular  abscess 

colic    . .         . .      425, 

diverticulitis  . .         . . 

-  -  in  infants       . .  . . 

after  injury  . .         . .  . 

from  nervousness     . .  . 

pleurisy  . .  . .  < 

]nieumonia     . .  . .  . 

pyelitis  . .  . . 

ruptured  tubal  gesta- 
tion . .         . .  I 

suppurative    nephritis 

-  of  the  back  from  aneur- 

arthritis  of  spine 

librositis 

infective  arthritis     . . 

myalgia 

myositfe         . .         . . 

spinal  caries  364,  429, 

461,  ' 

new  growth 

spondylitis  deformans 

461, 

-  in    combined    degenera- 

tions of  cord  . . 

-  decerebrate 

-  in  Friedreich's  nta\y   .. 
Rigidity,  hemiplegia  and 

139.  : 

-  iliac,  in  appendicitis    . . 
from  ureteral  colic    . . 

-  in  lateral  sclerosis 

-  muscular,  from  bilateral 

cortical  softening 
in  disseminated  scler- 

epilepsy 


polymyositis  . 

-  of  7ieck,  from  ca 
fracture 

-  in  pai-alysis  agi 

-  of  spine,  from  c 


Rigor,  description  of  tyiiical  i 
RIGORS i 

-  in  angina  Ludovici       . .   ' 

-  angioneurotic  cedema  . .  > 

-  abscess  of  liver. . 

-  after  appendicitis     320, 

-  from  bacteriiiria 

-  blood    cultures    in    dia- 

gnosing cause  of       . .   ■ 

-  in  blood  diseases 

-  bronchiectasis    . .  . .   i 

-  after  child-birth 


RIGORS 


SALIVATION 


881 


jors,  conid. 

irom     cholangitis     254, 

326,  333,  369, 597 

iholecystitis       ..     450,  597 

'hronif  pancreatitis     ..  264 

n|i-|.,,illnria     ..  ..   569 

iinis   in   children 

II        .riting   ..  ..594 

■i  III]  HI  simulating   ..   594 
irom   empyema. .  . .   597 

jpileptiform  convulsions 

simulated  by. .  . .  594 
in  erysipelas  . .  598,  G74 
jrythemascarlatiniforme  227 
iuntratin^  endocarditis. .  34 
Erom      ijail-stones     254, 

327,  374,  595 
'onorrha?a  . .    ■      . .   597 


Ri  HO  Ivor  III,  conld. 

-  pityriasis     distinguished 

from    . .  . .  . .   249 

-  psoria^iis   distinguished 

from 249 

Ringworm  of  the  scalp  247,  248 

-  seborrhoea  distinguished 

from 249 

scalp  from 


;out 


597 


iepatic  abscess  291,  32G,  370 
in  Hodgkin's  disease    . .  596 
tiysteria  simulating       . .   594  I 
from  infective  parotitis    694  I 
influenza  , .      598.  639  ' 

jaundice  with    . .  . .  326 

from  lateral  sinus  throm- 
bosis   ..       {Fig.  244)  567 
in  leukaemia       . .         . .  596 
|ors,  list  of  causes  of  594,  595 
in  malaria  291,  568,  596 

mastitis 685 

meningitis,  rare. .  ..   597 

\%  onset  of  fevers 

Erom  otorrliuea  . . 

pancreatitis 

with  jjiiroxysmal  hEemo- 

giobiriuria 
in  pernicious  anemia  . . 
pneumonia 
[rom  portal-vein  throra- 


594 


bosi 


abso. 


51 
182,  581 


prostati 
in  puerperal  fever  . .  596 
pulmonarv  tuberculosis  598 
pyajniia  .'135,    (FUj.  244) 

567,  596,  597 

pyelitis 576 

pylephlebitis      . .  . .   326 

rat-bitr  fever  . .  . .  598 
relapsiiiu'fever  ..  596,  637 
relation  to  convulsions  143 
from  renal  calculus       . .    597 


sinus  thrombosis  .  .  597 
small-po.v  ..  ,.  272 
aubphreriic  abscess  . .  608 
suppurative  pylephlebitis  333 
testicular  abscess  ..  622 
tremor  in  . .  724,  727 
Ln  typhoid  fever  595,  598 
fcypiius  fever  . .  . .  637 
anemia  simulatitig  . .  594 
-  aft(M- urinary  operations  42 
In  yellow  f.-VL-r. .  273,  336 
ng-fomi  of  malaria  para- 
site        31 

ngs.  brown  urinary,  with 
nitric  acid      . .  . .        5 


ngs,    white,    in    urine, 

causes  of 

S 

rit-'untrii.  alopecia  areata 

,i.aul;iting       ..         71, 

2111 

jal.l          

'.Mil 

)al<li.i-<s  frniii    ..         71. 

?M 

K'ar.l  air.-.t.-.l  In- 

-\: 

Jlack-ilol 

■J  IS 

ngworm    of   Ijody   skin. 

general  account  of  247 

248, 

24!) 

ngworm.  cultural  differ- 
entiation of    . .         . .  248 

faMi    ill  liiiuMiMifd  from  2lil 
.■.■■/,.„,  ,  -11, Mil. 1  by  ..   2'l!l 


iif- 


the  nails 
217,  249,  S'.iii 
lilating  ..  2.'>0 
iting  ..  250 
inulatinR. .  250 
t  simulating  250 


250 


Rinoworm,  Tokelau 
Ringworm,    various    para- 


Hire  en  travcrs  (,Fig.  110)    2.35 
Eising  to  the  tliroat,  as  an 

aura  of  eliilepsy         ..     67 


,•■,118 
.5118 
508 


RISUS  SARDONICUS 

-  -  hysteria  .  . 

malingering    . . 

sclerodermia        si 

lating  . .  . .  599 

from  strychnine   417, 

698,  599 

-  -  in    tetanus    1.38,   417, 

B98,  699,  730 
Rivetters,    noises    in    the 

head  in  . .  . .  406 
Roarings  in  head  . .  . .  40G 
in  insanity     . .         . .  405 

Roast  beef,  taste  of  . .  70G 

Robin,        hajmoglobinuria 

from    . .         . .  . .  284 

Roburite,  dinitrobenzene  in  334 
Rochelie  salt  in  Fehling's 

te.st 201 

Rock  drillers,  silicosis  in  . .  288 
Rodent  ulcer,  age  incidence 

of        179 

-  -  bone  destroyed  by  . .  179 

-  -  cartiliwc  destroyed  by  170 
Rodent  ulcer,  characters  of 

402.  403 

-  of  cornea  , ,  734 
Rodent     ulcer,     cured    by 

radium  . .   180 

-  -  diagram  of  {Fig.  301)    737 
distinction    from   epi- 
thelioma     .  .      179.  735 

epithelioma  sinmlated 

by 422 

Rodent  ulcer  of  face        . .  735 

-  -  of  leg 7.38 

long  duration  of       ..179 

-  of  nose  . .         . .  179 

lupus  simulated  by  . .  402 

pain  in  . .  . .  179 

preauricular  gland  en- 
larged troni  . .  378 

-  -  of  skin  . .  . .   179 

-  syphilis    distinguished 

from           . .  . .  40.3 

Rods  In  retina  ■ .  758 

Romanowsky*s     stain  for 

malaria  parasites  . .   66S 

Romberg's  sign  . .    57 

in  tabes           .  .    ■,   . .  609 

Root  pnlsv 500 

H„sii,-iM,  iH-iie  vulgaris  di.s- 

ii,iL-iii~lied  from        ..  211 

aL-,-  in.i.l.-nce  of        242,  489 

~  ironi    aliiihol      51,   241,  726 

-  with  cirrhosis     . .          . .  61 

-  corneal  ulcer  with       . .  734 

-  dyspepsia          . .         . .  211 

-  flush  area  nUcctcd  by  . .  489 

-  flushing  in          . .          .  .  211 

-  gmnulosis  rubra  nasi  dis- 

tinguished from        ..  651 

-  hypersecretion   of  seba- 

'ccoTis  glands  in         ..    211 
l,|.n,sv  mimicking        ..    103 
lii„itali.„i  lo  face         ..   211 
lui'ii-;  rryf  hematosus  dis- 
tiiiL'uisliod  from       ..  2-12 

•  rliii Iiyma  from         ..  241 

sy|, hills       disthiguished 


Rose     Bradford     kidneys, 
general  account 

after  unsuspected 

scarlatina  . .  1 

Roseola,  in  dengue  . .  - 

-  small-pox  . .         . .   J 

-  syphilis  73, 334  (F«7. 170) 

383,  ( 
Rose  spots  in  typhoid  fever 

76,  335,  564,  ( 
Rosette  crystals    . .  . .  1 

Rostrate  pelvis      .  .  . .   '. 

Rotheln    (see    German 

Measles) 
Rothera's  test  for  acetone 
Round      ligament,     fihro- 

m.yoma  of      . .         . .  * 

malignant  deposits  in 

656,  1 
Round-worms  . .  I 

Round  worm  (see  Ascaris 

Lumbricoides) 
Rowing,     enlarged     heart 

from    . .         . .         . .  1 

Rowing  men,  albuminuria 


242 


Sacro-iJiac  pint  dis'j'jse,  contd. 

difficult  to  detect. .  348 

hip  disease  simulated 

by  ..  ..361 

lameness  from     347,  363 

muscle  wasting  with    63 

pain    in   iliac   fossa 

from        . .  . .   45 1 

on    jarring    hips 

with    . .  . .  364 
simulating    cauda 

equina  tumour  . .     6M 
swelling  in  iliac  fossa 

from        ..      665,  678 
Sacrum,    abscess    of,    felt 

per  rectum     . .         . .  587 

-  bedsore  over       . .  . .   257 

-  examination  of,  per  rec- 

tum     . .  . .       584,  587 

Sacrum,  fracture  of        .  ■  608 

-  new  growth  of,  felt  per 

rectum  ..  ..587 

-  pain  over  . .        78,  680 
Sadness,  appearance  of,  i 


tab. 


dois;alis 


236 


01           10 

cramps  in       . .          . .  l,''i' 

111    -1  .1 L-    lal    .lro),lets 

108 

occupation  neurosis  in  47i; 

Safranin  test  for  sugar    . . 

262 

pain  in  shoulder  In  . .  47i; 

s.iliir-  ,.i|.  iili~,  ill  Icsting 

tenderness  of  spine  in  715 

1-    1 '■'•'"■  -li^e.ase 

191 

Rowlands,  R.  P.,  illustra- 

St.  l.lnlli.ml    ■Iniilirl.    auky- 

tion  lent  by   . .          . .  141 

521 

Rub,  in  pericarditis          . .  213 

St.     \irii---     il.iii,',-     (see 

-  perltonitic  34,  373,  388,  592 

flhorea) 

-  -  over  liver       . .      388,  592 

Salicylates  in  acute  rheu- 

 over  spleen    . .      388,  592 

matism    34,    228,  339, 

over    splenic    infarct 

464, 

614 

629,  640 

-  anfemia  from     . . 

34 

in  pneumonia            . .  335 

—  black  ux'ine  from       745, 

747 

over  pulmonary  infarct  160 

-  brad.ycardia  from 

84 

-  over     subdiaphragmatic 

-  deafness  from    . . 

166 

absce-ss           . .          . .  G58 

-  delirium  from    . . 

169 

-  (and  see  Friction-sounds) 

-  effect  on  pyrexia  in  acute 

Rubber     workers,      acute 

rheumatism  89    {Fiq. 

atrophy  in     . .          . .  334 

149)  338, 

674 

-  -  chlnijile     of     sulphur 

-  erythema  from  . . 

222 

us,^,l  I.T            ..          ..334 

-  ferric    chloride    reaction 

Uulii-f:i,;i,ai'ts.  various      ..  222 

after    

170 

Kubclla  (500  Measles) 

-  growing  pains  relieved  by 

363 

Rubrospinal  tract,  lesion  of. 

-  headache  from  . . 

295 

tremor  from  . .         . .  729 

-  ineffectual  on  pyrexia  in 

Rumination  (see  Merycism) 

gonococcal    arthritis 

Running,  as  an  aura  of  epi- 

(I'iii. l.-,li) 

338 

lepsy   67 

in  gonociv  il  iiiiliiin^ 

::il 

-  enlarged  heart  from     . .   214 

-  -  peliosi,=  III,  iiiii  III.  1 

.1 .",(.; 

-  at  eyes  (see  Coryza) 

-  -  rheumatiii.l      .i-ini-- 

-  at  nose  (see   Discharge, 

(       /',!/.             1       'l- 

.Ill 

Xasal)              ..          ..    17S 

-  -  various  forms  of  arth- 

Rupla, in  syphilis          ooo,  601 

ritis 

339 

Rupture  (sc    llornial 

-  noises  in  the  head  from 

406 

Rupture    of    aortic    valve. 

-  tinnitus  from     . . 

723 

general  account  of  208,  210 

-  urine  after 

1711 

-  I,la,ld..r 278 

-  urticaria  from  . , 

771 

-  lu:i,l         213 

Salicylic  acjid 

5.",  a 

-  spl.Tii 641 

Saliva,    hlood-stamed,     in 

Rlliilui.J     nihil      '.-station 

convulsions    . . 

143 

(-.■l-"H -tation) 

-  curious  effects  of  mercury 

Rus-i:.,  .  i-i.li :/aiiL'rene 

on 

542 

1 2.')9 

-  deliripnl,   frnlil  paralysis 

Rusty  nail,  tetanus  from 

i.r   ,'Imi,iI:,    I  Mn[.:i,ii"    .  . 

404 

699,  730 

-  ihiiililiT'    ni    ,   ,  r    Drih- 

-  sputum       149,  289,  641,  642 

l,l,i.  •   n!    -,.lr,  1  ;    and 

Rye,  ergotism  from        . .  259 

I'l  1     ill-  III! 

Sacral    senments   of   cord. 

muscle  connections  of 
Sacralnia.      from      pelvic 

lesions 

SlUTO-.ha>         i.l........       (M'v 

Abs.v--;.s  Siicro-iliac) 

-  joint  disease,  nbsces 
(iroiri  from 

backache  from 


218 

-  glai.il.  .  ,  ,,1  „::i.|    (Fig.  3)  25 

250 

from  calculus         .  .   694 

530 

in  chloroma           . .  556 

453 

gont.            . .         . .  095 

663 

-  --       iiir,,.-tivc  parotitis..   694 

500 

l,.„ka.„i,,        .            ..25 

lv'ii|.lii.li 1      ..   698 

498 

lwM|.l,.,ii,   l.ukiL-mia  096 

11.3 

.Mil  nil. ./.':> ,  \  lulromc  695 

mumps       '. .      617,  691, 

499 

syphilis       . .          . .  095 

489 

tuberculosis           . .  G95 

Si,ii\.;,ti,,n      from      chorda 

499 

l\  ,..|.:.„i  paralysis     ..    70n 

I.I  1. ,  .'I.-.      .'.          ..   543 

4G8 

1 1    ii...,-.nry      33,   73,   726 

680     -  tii^  ihiiilmireux  . . 
409     -  (and  see  I'tyalism) 


SALLOWNESS 


SCALP 


Sallowness,  from  abscess  oE 

Sarcoma,  con/iL 

^Sarcoma,  melanotic,  contd. 

Saundei-s,  Dr.  P.  "VT.,  illus- 

liver    . .          . .          . .    332 

Sarcoma  of  bone,   general 

in  inguinal  glands    . .    381 

tration  supplied  by  . .  S 

-  ill  cachexia         . .          . .      99 

account  of                .671 

-  -  in    liver          253,  374,  746 

Savour        ' 

-  ciiThosis 371 

metastases  in  lung  from  071 

secondary  to  eye  . .  374 

Sawdust,  dermatitis  from    ' 

SaloK  binck  urine  from    . .  745 

microscope      in      dia- 

 melanuria    from    ."74, 

-  pruritus  from     . .          . .   5 

-  carboluria  from             . .   746 

gnosing        . .          . .   672 

745,  746 

Sawyer's  Physical  Signs.. 

-  ferric    chloride    reaction 

-  -  fn.nMi-tciii-,|riMnnaus670 

from  mole       . .      379,  381 

illustrations  from  . .  1 

after 170 

-  -  u^t.in^  Mil, Ml  iiiir.'    ..   693 

of  pre-auricular  gland  379 

Sawyers,  serratus  magnus 

-  jrlycuroiiic  acid  from    . .  261 

-  -  oslcuiuvliii-  -ununited 

secondary  in  spine  . ,  714 

paralysis  iu        . .          , .   S 

bv 672 

of  skin            . .         . .  680 

Scabies,  buU^  in  . .         . .  ( 

-  urine  after          . .          . .   170 

-  -  pain  in            . .      671,  672 

of  toe          . .         . .  381 

-  eczema  simulated  by  . .  ' 

Salpiiifjitis,    appendicitis 

rheumatism  simulated 

-  microscope  in  diagnosing 

-  eosinophilia  rare  in       .  .   : 

simulated  by..          ..   456 

by 672 

74,  .H91,  588,  615,  672,  731 

-  face  not  affected  in      . .  " 

secondary  in  spine    . .  714 

-  mycosis  fungoides  simu- 

- linsers  affected  bv        . .   I 

-  genorillv  l.il:i<ri-;,l         ..   457 

spontaneous    fracture 

lating  731 

-  itcliniL'  ill             .  '.       Ulii.   " 

-  hrr^m.iMni.i   Imn,         1^75,  283 

from             . .      242,  243 

Sarcoma,  myeloid..        ..  672 

Scabies,  notes  on  . . 

-  p;nii    in    la|..>.- Irium  451 

syphilis  simulating 

of  bone            . .          . .    243 

Scabies,   parts  affected   in 

ili:ir  !(]--, 1   jium 

669,  672 

jaw,  bleeding  gum  from    72 

401,  563.  7 

lo'2,  454,  456 

.-r-rays  in  diagnosing 

ptyalism  from       . .  542 

-  prurigo    distinguished 

pelvis  from    . .         . .  468 

668,  672,  693 

(Figs.  286,  287)  673 

from ' 

Salpingo- oophoritis,  ameu- 

-  brain,  hemianopsia  from  301 

spine 648 

-  pustules  in         ,.      55S,  ) 

-  breast,  age  incidence  of    687 

-  of    neck,    pyrexia    from 

-  scabs  in 6 

-  dysmenorrhoea  from     . .   19*2 

blood  discharge  from  181 

(/■w.  I'lS)  570 

-  vesicles  in           . .      60(i.  ' 

-  dyspareunia  from     103,  194 

fibro-adenoma     simu- 

- nos.-'.  iIi-.i.:iiL-i'  iH-iN     .  .    179 

and  burrows  in          . .  a 

-  ectopic  ^'estation  simu- 

lating          . .          . .   687 

-  C8deiu:i  Ml  \,-j^  iiMiii    113,  415 

SCABS        S 

lating  690 

-  cachexia  from   . .      413,  415 

-   of   pahitr.    l„l,Tu-rnp,.    in     _ 

-  in  anthrax          . .          . ,   i 

-  endometritis  with         . .  387 

-  of    cjccum,    swelling    in 

-  dermatitis  herpetiformis  7 

Salpingo-oophoritis,  general 

riglit  iliac  fossa  from    665 

-  parotid  gland     . .          . .    095 

-  eczema    . .         . .         , .  ( 

account  of                . .  690 

7-  Cauda  equina     ..          ..62 

-  pelvic 678 

-  over  epithelioma          . .  ( 

-  levator  ani  spasm  from  193 

-  cervical  glands  . .          . .   380 

aneuiysm  simulating     681 

-  in  erythema  u-is            . .  7 

-  menorrhagia  from     3S6,  387 

-  cord,  diagnosis  by  lumbar 

sacral  plexus  invaded 

multiforme  . .           . .  G 

-  pelvic  adhesions  from  . .   193 

puncture         . .          . .   305 

by 113 

-  herpes     ..         ..      431,  4 

-  pelvic  bone  tumours  simu- 

- crus  penis,  caries  of  pubis 

salpingo-oophoritis  si- 

-  impetigo             . .      558,  ( 

lating  691 

simulating      . .          . .   698 

mnlnted  by             ..   691 

-  scabies 6 

pain  from       . .         . .  193 

Sarcoma,  endosteal         . .  672 

siniiil  11  ;!■_■  .   Mi.|  1  .-.(nina 

-  from  scratching             . .   ( 

swelling  due  to         . .  688 

-  of  eve,  stvund;iiv  in  liver  252 

ti;' ..      63 

-  in  seborrhcea     . .          . .   6 

-  sterility  from     . .          . .   640 

-  femur,  limping  Troiu     ..   363 

-  perin-i.  .1.  ■■■  !■-.   1  .1  i-ni,e204 

-  small-pox           . .      561,  6 

-  swellings  behind  utems 

pojiliteal        aiH'urvsm 

-  proldii'j.  ■!    i\  ii\i.i    irum  563 

-  syphilis ( 

from 193 

simulated  by     '   . .  692 

-  of    prostate,    rectal    ex- 

- yaws        . .          . .          . .   6 

--  vaginismus  from           . .    193 

skiagram  in  diagnosing  692 

amination  for            . .   587 

Scalding    on    micturition, 

Salpiiigopharyngeus.  click- 

- fibula,  limping  from    . .  362 

-  pulsation  in        . .          . .   693 

from  bacteriuria 

ing  ill  ear  due  to       . .   723 

-  general  wasting  from   . .     59 

-  of  radius,  skiagram  of. .   672 

gonorrhoea      . .      1S2.  7 

Salt,  taste  of         . .          . .  706 

-  of  groin  glands  . .          . .  680 

-  rib  tenderness  from      . .    707 

Scalds,  albuminuria  from 

-  thirst  fiom        . .         . .  720 

-  heart,  heart-block  from     83 

-  Scarpa's  triangle           . .   676 

-  bullfe  from 

Salvai-san.        condylomata 

-  ilium,  pain  in  iliac  fossa 

Sarcoma  of  skin    ..      680,  731 

-  hyperpyrexia  after       . .  : 

curi'd  \>Y          .  .           .  .    700 

from     .  .          . .      454,  460 

papules  from.  .          .  .    487 

Scales  from  belladonna  . .   ( 

-  dc.'ilH.  ■■    iM.ni                   .  .     It.r, 

iM.n,   M.MiM'          ..            ..480 

-  Spilir.    1  M'l"-i^    ",,i,i    .  .     i:,| 

-  carbolic  ac-id       . .          . .   ( 

-   in  ill  1    ■  ■     '                '        _■'.''■  1   . 

i.iie    bone. 

V-y.w                     ■,:■•■         I :,  1 

-  drugs       6 

.^  |,            1  ■<■■     1  -       -,,,,.. 

iniulated  by  438 

-sph^i'M,,    ..     ■ ,  i;::- 

-  in  eczema  488,  001,  602,  6 

1. 1  '1     p,.i  1 .   i.jj.    ;■;•-.    ::::• 

Sarcoma  ot  jaw    ..      683,  684 

-  steriiiiiN.  '.■-  .u  !■  >  ■-  iH.1,1  m; 

-  -  maivinatum  . .          . .   ; 

-  ervtlii'iii  (    tt ■'■'■'     T2  I 

-  -  odontoma  simulating    684 

—  stomach.    ?[i!efri     simu- 

- eiytliemascarlatiniforiiK'  i 

-  gnnniM  m  lu.i   ;,]id      ..   253 

spread  to  nose           . .   179 

lated  by      , .          . .   630 

simplex            . .          . .   t 

-  in  [...■i-niri.Mi-.  ;,M;riiiia    ..    526 

-  kidney,    aching   in   loin 

tumour  in  epigastrium 

-  from  fevei-s        . .          .  .   1 

SAND,   INTESTINAL       ..  599 

_.   from             . .          . .    278 

from            . .          . .   660 

Scales,  general  account  of  6 

-  -  (Plale  XXnn          . .    598 

Clieyne-Stokes  breath- 

- suprarenal,  secondary  in 

-  from  ichthyosis . .          . .   6 

-  under  skin,  sense  as  of, 

ing  from     . .         . .  lOS 

cranial  bones. .          ..  711 

-  iodine 6 

from  cocaine  . .          . .   611 

colic  from       . .          . .   278 

simulating    enlarged 

-  keratosis  pilaris         601,  6 

haematuria  from    275,  278 

gall-bladder            . ..  252 

-  lidien  scrofulosorum    . .  4 

from    . .          . .          . .   232 

rarity  of          . .          . .   355 

Sarcoma  of  testis  . .     480,  696 

-  lupus  erythenaatosus  242, 

Santonin,  alkali  test  for  . .   744 

renal  enlai^eraent  from  278 

-  thymus,  vena  caval  ob- 

602, C 

-  convulsions  from          . .  144 

secondary  deposits  in 

struction  by  - .          . .    751 

vulgaris           . .          . .  •! 

-  pink  urine  after..          ..    745 

luns  from  . .          . .    105 

-  tibia,  limping  from       . .    362 

-  pemphigus  foliaceus     . ,   ( 

-  urticaria  from    ..          ..771 

simulating       enlarged 

skiagram  of   . .          . .   671 

—  mica-like,    in    pityriasis 

-  yellow  urhie  from         . ,    711 

gall-l. ladder            ..   252 

-  tongue     . .          . .       698,  099 

rubra  pilaris  . .-         . .  4 

-  xantliopsi;i.  from            .  .    Ttl'J 

-  -  nnemi;i.  from..          ..   108 

-  tonsil       . .          . .      285,  615 

-  in  mycosis  fungoides  . .  1 

Saphena  varix,  general  ac- 

- larviix,  hmmoptvsisfrom  287 

-  ulna,  skiagram  of         . .   672 

-  pityriasis  rosea  ..         ..6 

count  of                   ■ .  675 

-  leg",  ulceration  of           . .    738 

-  uteri,  from  fibroid    391,  690 

-  -  i*ubra  . .         . .      601,  6 

hernia  simulated    675,  680 

-  leucocytosis  with          . .  360 

-  -  in  girls            . .         . .  387 

pilaris         483,  OOl.  C 

impulse  on  coughing  in 

-  of  liver,  ascites  with 

menorrhagia  from    . .   387 

-  prurigo    . .         . .          . .  ^ 

674,  675,  680 

46,  47,  52,  330 

metrorrhaijia   from 

-  psoriasis  249,  488,  491.  r.Ol 

-  -  reducible        674,  675,  680 

-  -  jaundice  with           52.  330 

;>90,  391 

-  from  quinine     . .          . .  C 

-  vein  tlu-ombosis            8,  749 

liver  enlai"ged  with  47, 

-   -    ini.Tn^rn,.h:il  .  1  i:  I -|  lOSlS  391 

~  in  ringworm      . .          . .  S 

Saponin,     h33moglobinuria 

52,  252,  330 

peh  i<-  -NVi'IliM-  A\u-  to  688 

-  scarlatina            . .          . .   6 

from 284 

primary           ..          . .   374 

-  -  polypu-  -iiiiuliitin-  ..    391 

-  seborrhcea         600,  601,  6 

Sapraamia,  loss  of  weight 

secondary  to  eye       . .   252 

rapid    enlargement   of 

-  seborrhoeic  dermatitis  . .  4 

from 769 

—  loss  of  weight  from      . .   768 

uterus  with             ..   391 

-  -  eczema            . .          . .   2 

-  rigor  in 595 

-  of  lung,  hsemoptvsis  from 

-  of  vertebne,  interscapular 

-  syphilis   490,   491,   601.   6 

-  -  with     carcinoma    of 

287,  290 

pain  from        ..          ..   461 

-  tinea  circinata  . .         . .  2 

stomach      , .      630.  767 

secondary  to  bone    . .  671 

-  vulval  swelling  from    . .    700 

imbricata       . .         . .  2 

Sarcime       ventriculi      115 

to  kidney  . .          . .  105 

-  x-rays  in  diagnosing  105, 

tonsurans       . .         . .  6 

(Fig.    121)    241,    318, 

to  various  primary 

1.54,    668,     671,    672, 

versicolor  250.  529,  OUl 

320.  653,   766 

growths  . .         . .  290 

681,  692,  693 

-  urticaria             . .         . .  6 

Sarcoid,  multiple  benign..  405 

skiagram  of  (Fig.  42)  105 

Sarcomatosis,        chloroma 

-  xeroderma         . .         . .  6 

-  mediastinum,    bronchus 

allied  to          ..          ..556 

-  (and  see  Desquamation  i 

ueplu-oni;i  and            ..    356 

ulcerated  by  . .         . .  287 

-  puipura  in          . .      553,  555 

Scalp,     cii-soid     aneuiysiu 

-  of  antrum           . .          .  .   685 

hEemoptysis  from     ..  287 

Sartorius.  nerve  supply  of 

of  (Plate  XXXI)      .  .    0 

-  basisphenoid.  blood-spit- 

 hypothermia         with 

498,  499 

-  eczema  scborrhceicum  of  4 

ting  due  to    . .          . .    285 

(Fit/.  143)  312 

Satin-wooil,  bulla?  from  . .     96 

-  epithelioma  of   . .          . .  3 

-  blood  cysts  in    . .          . .   673 

interscapular  pain  from  461 

-  dermatitis  from. .         ..  755 

-  favus  affecting  . .          . .   2 

-  of  bone,   abscess  simu- 

 pleural  effusion  from    312 

-  eiTthema  from  . .          . .   222 

-  hypei-iesthesia     of,     in 

lated  by     . .          . .  672 

pyrexia  from  (is'ii?.  248)570 

~  pruritus  from     .  .           . .    540 

neurasthenia  . .               6 

callus  simulating      . .   672 

vena    caval    obstruc- 

S:iturd;iy niL-ht  (.:.Nv        .  .      65 

-  inflammation,  hyperacusis 

-  -  central  necrosis  simu- 

tion by       . .         . .  751 

Saturnine     encephalopathy 

from 3 

lating           . .          . .   668 

-  melanotic,    in    eye  253, 

?A.    119.    140,  147 

-  multiple  benign  sarcoid  4 

enchondroma   simu- 

374, 379 

-  -  Babinski's  sign  in     . .     69 

-  nerve  supply  of  (Fig.  290)  7 

lating  (f/f/.  282)671,672 

black   spots   before 

coma  in          ..      US,  144 

-  pityriasis  of       . .          . .   2 

-  -  eosinophilia  from       . .   219 

eyes  from       . .     72 

convulsions  with       . .  144  , 

-  psoriasis  of        .  -      249,  Gi 

SCALP    —    SEBAOEOUS   CYST 


i7/».  con'il. 

Scarhi  jcvcr,  could. 

Sciatica,  cotitii. 

Scrotum,  affections  of  skin 

rheumutic  iiojules  on 

malignant,  eiiistaxis  in  273 

-  retroverted  uterus  simu- 

of          095 

405,  7S2 

headache  in           . .  273 

lating  439 

-  chancre  on          .  .          . .   621 

alp.  ringworm  of  217,248,  Gij2 

haematemesis  from 

-  sarcoma   of    innominate 

-  epithelioma  of  621,  623,  693 

sebaceous  c^^st  o£                732 

205,  273 

bone  simulating         .  .   438 

-  extravasation    of    urine 

seborrlioeic  eczema  affect- 

 hematuria  in         . .   273 

-  simulated      by      cauda 

into 470 

ing       ..          ..      401.  003 

purpura  in. .          . .   273 

equina  tumour          . .     02 

-  fistula   in   (see    Fistula, 

=c2niental  areas  o£  {Figs. 

pyrexia  in  . .          . .   273 

-  skiagraphy  in     . .          . .   439 

Scrotal) 

292,  293)  712 

measles  .simulating  . .  228 

-  .s|ihiMi-t(-rs  ill      .  .          .  .   439 

-  mucous  tubercles  on    . .  021 

some  skin  affections  of    710 

menorrhagia  from    . .  386 

-  s|iiri;il  ili>i-:i-r  -iiimliitin^'    lilS 

-  niv.-t.t..ina  of      . .          ..730 

syphilides  affectins?      . .  .500 

-  -  nausea  in        . .      614,  765 

-   iiivM.iiii  of         ..          ..732 

lender    ("see    Tentierness 

nephritis  from    9,  10, 

-    SIi(il|i|\  III  1-           ilrliulllllll-. 

-    iiiij.ill.iiii.i  of      ..       621,  623 

!i)    r\\f    S<-;t|pt 

14,  42,  614,   017 

^Illlul.illliL,'          ,   .               .  .      71-J 

-  |ii-iiriui-  of              ..      ..   5-lp 

-  scabies  affecting           . .  4(71 

:„-..|l,         .■l.,.|,M,-      the.       7.ir, 

the  sole  evidence  of    10 

-    SVI-lllll-    iMUMIIL-                       ..      407 

..    .'.00 

otitis  media  after    10,  617 

-  t.-ml.T  -|"'l-  iii-  .          ..   438 

-  sebaceous  cyst  of         . .  623 

ALY    ERUPTIONS        ..   601 

otorrhcea  from          . .  227 

-  teri-l.iiii-.  ill  III.-  Ii-gfrom   63 

-  sinus  of  . .         . .       622,  690 

pain  in  the  limbs  in  . .  465 

-  -  on  ia-t-^--urc  in             . .   346 

Scrotum,  sores  of  . .        . .  62 1 

'"i'j'.'fLcl.;    tocamiinK) ' 

pale  granular  kidneys 

-  urine  examination  in  . .  439 

Scrotum,  ulcers  of  479,  621,  otio 

apulu,    pain   nnder  (see 

after            . .          . .     14 

-  vaginal  examination  438,  439 

-  sweep's  cancer  of         . .  731 

I'ain  in  the  .Shoulder) 

pai-aplegia  from        . .  516 

-  a--rays  and         . .         . .  438 

-  swelling  in  (see  Swelling, 

>osition   of,   in   serratus 

peach-blossom  facies  in  228 

Scissor  gait           132,  139,  729 

Scrotal) 

mat'nus  paralysis  505,  50G 

-  -  peeling  after  . .        10,  614 

Sclerodennia,anidrosiswitli  654 

Scrotum,  syphilis  of     621,  096 

systolic  bruit  below  left      89 

purpura  in    273,  553,  554 

-  distinction  from    leuco- 

Scurvy,  albumosuria  with      10 

Bint-ed 506 

pyrexia  in      . .         . .  227 

dermia            . .         . .  529 

-  anemia  from       38,  72,  273 

ar,  epithelioma  develop- 

 ra.sh  of             . .          . .   228 

-  ectropion  from  . .         . .  220 

-  bleeding  gums  in        72,  200 

ing  in 020 

without  nish           10,  617 

-  of  face    . .         . .          . .  599 

-  bromidrosis  in  . .         . .  03  ] 

Dtt  head,  in  Jacksonian 

red  throat  in  . .         . .  227 

-  finger  affected  by         . .  240 

-  bulla;  in             ..         96,  97 

epilepsy           . .          . .    147 

rheumatic  fever  simu- 

- risus    sardoin'cns    simu- 

Scurvy,  In  children  72,  99,  556 

ir-.  '"'itrncture  from  ..   143 

lating          ..          ..014 

hito.l  bv                       ..599 

-  diet  and             . .        72,  27;i 

■!  .;   "H  from  ..          ..   220 

rigor  in            ..      595,  597 

-  tr-n.l.-iii.--  i.f  -.lip  from  710 

-  epistaxis  from  ..          ..221 

>us         ..          ..    247 

Rose  Bradford  kidney 

Scli-i-.i-i  .,.llll.l-,..|.llil.■late- 

-  from  no  fresh  vegetables  330 

.M,i.  Hiiu- decalv.ans    ..     71 

after            ..          .■.  228 

^.|l    ...      \ irophic 

-  hpsmatemesis  in        200.  273 

..■..l.-.|^'umma  (/?!</.  227) 

scales  in         . .      601.  C02 

!.  II.  .   .1     --■  .  1  1  .-!-) 

-  htematuria  hi     . .      273,  283 

541,  737 

simulated    by   cheiro- 

-  i-iini     -.   ■  ..iiiliined 

-  hiemoptysis  in  . .         . .  287 

sfter  herpes  zoster  431,  707 

pompholyx           . .     97 

-.   -  - ■  1  ..III) 

-  hemorrhage  into  tongue 

n  leprosy           . .          . .  404 

after  enemata.        . .  224 

-  di--.  II...    .1-   i     1   ....     Dis- 

in         69S 

upus 402 

small-pox  simulating    560 

.-1  lilll,..l  .  .  1    .-.  Irr.i^is) 

-  hremon-hages  in             . .      3S 

upus  erythematosus  71, 

softening  of  cord  from 

Sclerosis,    primary   lateral. 

-  Iia^morrliagic  swellings  in 

212,  247,  002,  603 

516,  317 

general  account  of    . .  517 

calves  UL         . .          . .   330 

nuUipIc  beniu'n  sarcoid  405 

-  -  sore    throat    in    224, 

-  (.-CI-  l,..l.^.l.^.l..l■.lsl^J 

-  inf.antile.  anffimia  in    . .     99 

pigmented,  from  syphilis 

613,  617 

Sclerolic.-..      bl.iekciied     hi 

bleeding  gums  in      . .     99 

209,  5(i0 

spinal  thrombosis  from  516 

oclironosis      .  .          . .   528 

bones  painful  in        . .     99 

round    mouth,    in    con- 

 spleen  enlarged  in  632,  037 

-  blue,  with  brittle  bones  242 

cachexia  in    . .          . .     99 

genital  syphilis          . .   235 

strawberry  tongue  in    562 

-  bluish,  in  chlorosis       . .  274 

night  sweats  in         . .  034 

nim    ^mall-pox..          ..   561 

submaxillary     glands 

Scoliosis,  cause  of . .          . .  188 

subperiosteal    haemor- 

,| 1  .hlf-s            ..      560,  701 

inflamed  from        . .  379 

-  from  fibroid  lung      168,  216 

rhages  in    . .         . .     99 

III,.     lr..m        ..          ..114 

testicular  abscess  in. .  622 

-  in  Friedreich's  disease  ■ 

-  menorrhagia  from    386,  387 

(i.  '    :■■..■!•.  acute  endo- 

-  -  tongue  in       227,  862,  617 

140,  512 

-  metrorrhagia  from    390,  392 

,  ,,.h!i^  from  ;i0.  2nn.  2U 

tonsillitis  in    . .         . .  614 

-  from  short  sight            . .   155 

-  nyctalopia  from           . .   763 

riet  lever,  acute  nephritis 

toxaemia  in    . .         . .  214 

-  in  syringomyelia  110,  350,508 

-  periosteal    haemorrhages 

in                     1".  14.  014 

—  typhoid    fever    simu- 

- with  wry-neck  . .          . .  647 

in          . .          . .    38,  72,  99 

-    ii,ciuii,.ci.'    .•.vUi.-lnu 

lated  by     . .         . .  037 

-  (and  see  Spine,  Lateral 

-  purpura  hi  72,  273,  553,  550 

sininlatMit-'.  .          ..    228 

urticaria  simulating. .  771 

Curvature  of) 

-  rarity  of . .          . .          . .   550 

-  adenilisf  rom   10,  227, 

valvular  heart  disease 

Scorbutus  (see  Scurvy) 

-  on  ships             . .         39,  72 

379,  617 

from            ..      209,  485 

Scotoma,  black  spot  before 

-  spongy  gums  in  38,  273,  55(; 

rIet  fever,  albuminuria 

vomiting  in  224,  227, 

eye  from        . .         . .  760 

-  stomatitis  in      . .        72,  542 

with    13.  14,  224,  227,  617 

614,  765 

-  central,  from  alcohol  . .   700 

-  subcutaneous  indurations 

.11 .osuria  in         ..     16 

"weak  first  sound  in  . .   214 

from  atoxyl  . .         . .  759 

in         . .         . .          . .   273 

Scarpa's   triangle,   hollow, 

in  disseminated  scler- 

- tender  bones  iu..          . .     72 

LIT  II,-  diacasc  after  ..  209 

with  congenital  disloca- 

osis . .          . .      617,  760 

-  tongue  swollen  in         . .   09S 

.nihiilis  after            ..   340 

tion  of  hip      . .          . .   156 

Scotoma,   central,  general 

Scurvy-rickets                38,  670 

-  atypical  rasli  in         . .  227 

s^velling  in  (see  Swell- 

account of    . .        . .  760 

-  age  incidence  of            ..  fwii 

-  Ijald  tont'ue  in           . .   017 

ing,  Femoral)        . .  674 

in     hereditarv     optic 

-  anicmia  ii;          . .          . .  07') 

-  .-onia  in           ..          ..117 

Sceiila,  erytliema  from    .  .    222 

atropliy       .  .          .  .    700 

-  class  incidence  of          ..   07n 

,  uKiona  from       ..   M4 

Sch'dnlein's  disease,  general 

--  hippus  with   ..          ..   ii.52 

-  diet  and             . .        39,  07u 

!i  .iiii--;  from            . .   100 

account  of               . .  556 

from  lead       . ,          . .  759 

-  luemorrhages  in           ..  070 

-Si-liolfs     .Niiiilir-ini     Irout- 

in  migraine     . .      759,  760 

-  painful  bones  in          . .  07n 

1'    ,|U;iniation  after  . .   227 

ni(-iil.    hnilt    alTi-ctioil 

retrobulbar  neuritis 

-  j.eriostitis  simulated  by  670 

-  •lia;.'MOsisfrom  mca-tles     14 

henelited  by  . .          . .   485 

760,  762 

-  sjioiiL'^-  '.'iim--  in  .  .          .  .   670 

-  -  (iermaii  measles  14, 

Sciatic  nerve  (see  Nen-e, 

-  -  tobacco           . .      759,  760 

-  s|ii)iit:iii.  .-11  -    ii-i.-lin-c   in  11711 

22S,  377 

Sciatic)                  't 

-  negative             . .          . .   760 

~  swi-lliii--'  ..1.   Iiiiii..   in         .  .    070 

-  diazo-reaction  in       . .   173 

Sciatica,    acute   bracheitis 

-  perimctiT  in  locating  .  .    700 

-  ten. 1.  Til..--  1.1   li.i.i.--  ill.  .      3S 

-  dilTlcultv  in  din^nosing 

allied  to          . .          . .  477 

-  from    pigni.-nl   in  retina  760 

Scybalii.  iip|.cii.lu-il  is  ^inm- 

nish  of         . .          . .   226 

-  ankle-jerk  lost  in          . .  438 

-  retinal  liinniorrliiige      . .    700 

lated  bv           . .          . .   665 

-  dilatation  of  lieart  in    214 

-  anterior  cruritis  with  . .  439 

—  ring,  ill  niiu'i-iiiiif           .,    759 

-  felt  in  bowel      121,  057, 

-  empyema  after          . .  597 

-  caufla     equina     tumour 

.Scott.  Dr.  S.  (iilliert,  skia- 

661, 660 

-  eosiiiophilia  after      ..  218 

siniulalin-.-      ..          ..    439 

grams  I)y       . .         . .  443 

-  at  h.-piti.-  !l,-\-iii-.'          ..    059 

-  opididvmo-orcliitis 

Sciatica,  general  account  of  438 

Scratch,  erj-sipelns  from . .  568 

-  fn.li .-n    -..l-ii-        ..    113 

f roni            . .         ..178 

-  L'.-ri.-nillv  uiiil;.l.-nd       ..   439 

Screaming,  in  hysteria    . .    137 

-  in  -1'  1   1  1' 1-  iiHiii.  .    121 

-  cpistaxis  from        220.  221 

-    hi|.    .li-.-l-.-   HlllUlllliTlg..      138 

-  infants 321 

Sca-.-:il      l-n.  L  .     .  iMlielna 

kii.-.-i.Tk   iin;,ir.-,-l.-d  ill      13S 

-  -  from  colic       ..          ..117 

from     .  .          ..      222,  221 

irlet  fever,  erythema  ex- 

1.-/  iTi.n.-iii.-ril,  with      .  .      03 

-  from  intussusception    ..      78 

festering  sores  from..   22  1 

loiiativum  simulating    227 

1 lll.L-.l   uitii       .  .               .  .     .|3« 

-  at  nitdit.  from  tuberculosis 

headache  from          . .  2"-'  1 

,iii]ili-\  -innilatiriL'     -"J7 

-   lunil.iir  |iMT„-niii-  ill      ..    439 

arthritis          ..          ..   3-17 

(ctlema  from  . .          . .  22  I 

uli    re|>respnliii(?  401 

-  muscle  wasting  from  61, 

-  from  otitis  media         ..  202 

vomiting  from           . .  22  1 

1  lisca.sc    simii- 

03,  438 

-  in  rickets           . .         . .  115 

Seal-like  rlwart      ..          ..188 

..229 

-  nuinhne.«.s  i?i      . .         . .  438 

Scrofula 735 

Seamen,  beri-beri  in       ..  411 

II'-  from          . .  255 

-  ostco-arthritLs  causing..  347 

-  bruit  de  diable  in          .  .    723 

Seamstresses,  actinomyccs 

liihinuria  from    284 

simulating      . .         . .  346 

Scrofniod.-niiia.    clsi-ous 

in         643 

1  ■■  re.xiu  in        ..  .1(19 

-  pain  in  the  hip  from    . .  340 

Ldiin.N  v\illi     ..           ..    403 

-  critmp  in            . .         . .   151 

h^m  from       ..   189 

leg  from         ..       03,  438 

-  di>.liii.-li.Mi  rniiii  lii|.us..   403 

-  sporotrichosis  in           ..  29ii 

•  artliritis  after  648 

-  pelvic  disease  simulating 

Scrofulodermla,  general  ac- 

Sea-sickness          . .          . ,  705 

-   KirKliind's  disease  simu- 

438,  139 

count  of                   . .  659 

-  headache  from  . .          . .  296 

latlni;          ..          ..616 

-  plantar  reflex   flexor  in  438 

-  lupus  simulated  by           402 

Sebaceous  cyst  (see   C.V8t, 

-  ieucocvtosis  in           . .  360 

-  ll.n.  from         ..         61,  63 

-  syphilis       distinguished 

Sebaceous) 

-  Ivsis  in             . .          . .    227 

-  rectal  examination  in 

from 103 

-  -  of  face              .  .           .  .    673 

-  niidiL-nant,  delirium  in  273 

-138,  139 

-  Wasscrtnann's  test  with  .'..19 

-  -  scrcliun           ..          ..    623 

SEBACEOUS   CYST 


SEXUAL  PRECOCITY 


Sfbaccous  ci/st^  coiUd. 

suppui-ating,  iu  ear  . . 

at  umbilicus  . .         . .  ■ 

-  glands,  acue  vulgaris  and  ■ 

-  -  in  ear  ..      421,  ■ 
hypersecretion   of,   in 

-  -  lichen     scrofulosorum 


Sensory  area,  ovarian     . .   408 
I  Sensory  areas  corresponding 

to  tongue  . .  449 

1 face,   head,   and   neck 

I  (Figs  188-191)  418 

!  Sensory   areas   of   human 

body  (/'M/,'  XXV) 


-  lupus     erythematosus 


nd. 


seborrhoea  and  . .  ( 

syphilis  affecting      . .  ■ 

Seborrhcea,  baldness  from 

-  capitis,  face  affected  by  : 

-  cnists  in  . .  . .   < 

-  .eczema  mai^inatum  dis- 

tinguished'from    250,  : 

-  favus  distin^iished  from 
Seborrhoea,  general  account  i 

-  itching  ill 

-  lips  affected  by..  .. 

-  occipital  glands  enlarged 

from    . .         . .         . . 


-  papules  in           . .          . .  602 

-  parts  affected  by           . .  602 

-  pityriasis    rosea    distin- 

guished from. .         . .  604 

-  ringworm    distinguished 

from    . .          . .          . .  249 

-  scabs  In 600 

"  -  scales  in..        600,  601,  602 

-  sicca        602 

-  sypliilis  simulating       . .  384 

-  tinea    clrcinata    distin- 

guished from..          ..  249 

sycosis     distinguished 

■  from             . .          . .  249 

-  -  versicolor  simulating  250 
Seborrhoeic  eczema  of  in- 
fants     401 

Secret  drinking     . .          . .  555 
neuritis  from . , 


Section ,  abdominal  (see 
Laparotomy  ;  and 
Operation^ 

Segmental  areas  of  pain 
refpiTPd 


Of^r 


(  F/', 


Segments  of  cord,  lumbar. 

muscle  connections  of 
Segments   of   cord,    sacral. 

muscle  connections  of 
Segments,  nerve,  cardiac. 


MU.l.- 


Semieii'cular  canal,  has: 

rhage  into 
Senator,  on  neuromyositis 
Senile     changes,     cei-ebral 

hemorrhage  ai 

Senile  tremor,  general  ac- 
count of 

Senilism     . .  {Fig.  9.S) 

Senility,  gangrene  fi"om  . . 

-  penile    erections    absent 

from    . . 
Senna,    chrysophanic  acid 
in  ..  ..      744, 

-  pink  urine  after 

-  vpIIow  nviiip  from 
SENSATION.     SOME     AB- 
NORMALITIES OF 

Sensation  disturbances,  with 
cord  lesions    - . 

Sensation  disturbances  in 
peripheral  nerve  lesions 

Sensation,  normal  mechan- 
ism of 

-  perversion  of,  from  alco- 


hol 


-  retarded  . .  . . 
Sense  of  fullness  (see  Full- 
ness, Sense  of) 

-  movement,  disturbed  in 

tabes   . .  . .  . .   ' 

-  position,     disturbed     in 

tabes    . .  . .       444, 

Sensibility,  deep    ■ .         . .  i 

-  di-l:iyo.l,  in  tabc-s  .  .    ■ 

Sensibility,  epicritic 

-  loss  of.  ill  Brown-Seqnard 

■^     paralysis         . .  .  .   ■ 

Sensibility,  protopathic    ..  i 


41'.) 


Sensory  impulses,  paths  of    55 

-  loL-aliiiatiou       in       cord 

(Fig.  210)  518 

-  loss,  in  circumflex  palsy  506 

-  tracts  in  cord  (Fig.  258)  607 
Semen,  examination  of,  iu 

sterility  . .      645,  647 

Semicircular  canals,  audi- 
:  tory  nerve  ending  in      103 

'  Semicircular  canals,  lesions 

of  individual  ..     751,  752 


Sepfic(emia.  conid. 

-  sweating  in        . .         . .  338 

-  from  throat  abscesses  . .  567 
~  typhoid  simulating       . .  565 

-  from  umbilical  sepsis  ..  567 

-  whitlow 637 

-  wonriJs 637 

Septicopyemia,      bacterio- 
logy of  . .  597 


JK* 


vertigo  and    . .  . .    7ol 

Semilunar  cartilage,  dis- 
placement of  . .         -  ■  350 

Semimembranosus,     bursa 

under  . .  . .  . .   692 

-  nerve  supply  of..  ..   498 

Seminal  vesicles  (see  Vesicu- 
las  Seminales) 

Semitendinosus,  myoclonus 


of 


137 


supply  of. .  . .   498 

Sepsis,  albumosuria  from       16 

-  chronic,  anaemia  with  . .     35 
lardaceous  disease  from 

8,  35 
Sepsis,    cbronic.    various 

causes  of  . .    35 

-  gangrene  from  . .  . .   255 

-  headache  from  , .         . .  296 

-  oral  (see  Oml  Sepsis,  and 

Pyonhoea  Alveolaris) 
Septic  states,  hremorrhagic 

"269 


66 

-  -  hj-rerpyrexia  in 

674 

■|U4 

Septicaemia,  some  accouni 

of       

.%/ 

-  acboluric  jaundice  from 

33b 

-  from  acne 

63/ 

-  acute  rlipiimatism  simu- 

,16 

lated  by 

310 

.1-1 

-  anemia  from 

.i!)/ 

-  from  appendicitis 

.i67 

499 

Septicaemia,  bacteriology  of  597 

-  blood    cidtiu-es    in    dia- 

499 

-iiosin-           555,  567, 

637 

7U8 

-  from  cen-lir.il  abscess  .. 

-  cereln-Ob]iinal    fluid    cul- 

567 

0o3 

ture;s  ill  diagnosing  . . 

567 

-  after  cliildbirth. . 

637 

752 

-  from  cholangitis 

637 

464 

-  coated  tongue  in 

705 

-  from  cuts 

5!)7 

Dlo 

—  empyema            . .      567 

63  V 

540 

-  endocarditis  in  . . 

!)() 

-  foul  taste  in 

70.') 

Tih 

-  from  glandere    . . 

567 

lai 

-  glandular  suppuration  . , 

66V 

255 

-  hsBmoglobinuria  from  . . 

2S4 

—  hyperpyrexia  in 

309 

313 

-  iiifectire  endocarditis  and  637 

—  jaundice  in 

336 

745 

-  from  leptothrix. . 

667 

745 

-  leucocytosis  with 

66  V 

,44 

-  malnrin  =imulating 

668 

..    567 


al     .. 


..   425 

-  -  menin;^-uL5  in..  ..    590 

-  from  pneumococcal  arth- 

ritis      340 

-  prolonged  pyrexia  from 

.  563,  567 

-  purpura  in         . .      553,  555 

-  and    pyaemia,    relation- 

ships between        596,  597 
~  from  pylephlebitis    567,  637 

-  pyorrhcea  alveolaris     . .  637 

-  pyosalpinx  . ,  . .   637 

-  pyrexia  from     . .         . .  555 

-  rash  in 597 

-  rigore  in  r,55,  504,  595,  597 

-  from  septic  teeth  . .   597 

-  spleen  enlarged  in     632,  637 

-  due  to  staphvlococci    . .  335 

-  -  streptococci    . .  . .  335 

-  from   suppurative   arth- 

ritis      341 


•spi.t 


Serositjs.   multiple,  general 

account  of  -    106 

SEROUS     EFFUSION     IN 

CHESTc^uia;:L-L'.  i'k'ural 
Effusion ;  and  Pleu- 
ritic   Effusion) 

-  membranes,  inflammation 

of,  in  chronic  nephritis     11 

leukfemia    . .  . .      25 

Serratus  magnus,  atrophy 

of  '.    513 

nerve  supply  of         . .  504 

paralysis  of  505,  {Fig. 

207)  506 

root  innervation  of  . .  509 

Serum  disease  ..  223 

-  hfemoglobmuria  from  . .   284 

-  htemolytic,  hicmoglobin- 

uria  from        . .  . .   284 

-  horse,  anaphylaxis  from  223 

-  injections,  acute  oedema 

of  tongue  from  .  .   698 

Serum  injectious,  effects  of  554 

erythema  from       222,  223 

fatal  result  from        . .  224 

furred  tongue  from  . .    223 

giant  ui'ticaria  from. .   698 

headache  from  . .'  223 

itching  from  . .  . .   223 

loss  of  appetite  from    223 

cedema  from..         ..  410 

pains  all  overfrom  223,  554 

purpmra  from         553,  554 

pyrexia  from..      223,  554 

urticaria  from  223, 554,  771 

vesiculation  from      . .   223 

vomiting  from  . .   223 

-  iodized,  in  examining  for 

psorosperms  . .  . .   730 

-  ioint  pains  from  . .   554 

-  lassitude  from  . .         , .  554 

-  oedema  from      , .         . .  410 

-  in  pustules  . .  . .   557 

-  reaction,  Eason's  . .   285 
hydatid  49,  226,  253, 

291,  376,  658 

in  Malta  fever  . .   466 

Serum  reactions,  phenomena 
■  of    (and   see    Wasser- 
mann ;     and    Widal's 
test)  ..         -.223 
in  whooping-cough  . .   645 

-  testforGaertner'sbaciIlus554 
of  ptomaine  poisoning  554 

-  treatment  In   fungating 

endocarditis  . .         . .     34 
Servants,    acroparaesthesia 

in         444 

-  arsenic  administered  by  718 

-  chlorosis  in         . .  . .      36 

-  gastric  ulcer  in. .         . .     36 
Seventli     nerve     paralysis 

(see  Paralysis.  Facial) 
Servia,  typhus  fever  in    . .  335 
Sewers'  cramp       . .  . .   151 

Sewers,  sore  throat  and  . ,   615 
Sewing,  headache  from  . .   449 

-  machine,      menorrhagia 

from    . .  . .      386,  387 

Se.x  incidence  of  abdominal 

anemysm       . .         . .  544 
acute  rheumatoid  arth- 
ritis . .         . .  342 

yellow  atrophy  273,  333 

adiposis  dolorosa     . .  431 

acroparesthesia        . .  444 

aerophaffy      . .  . .   240 

alcoholic      peripheral 

neuritis       . .         . ,     66 

aneurysm      435,  437,  664 

angina  pectoris         . .  434 

anorexia  nervosa      . .  770 

aortic  disease . .        14,  210 


Sex  incidence,  contd. 

appendicitis   . .         . .  41 

asthenic  dyspepsia  . .  31 

bacteriuria     . .         . .     ( 

bath  pruritus  . .  5-; 

carcinoma  of  breast. .  6^ 

stomach      . .         . .  31 

thyroid  gland        . .  7t 

tongue         . .  . .   7; 

chlorosis         . .         . .     ; 

chorea  . .         , .  1.- 

chronic  glossitis        . ,  7'. 

cirrhosis         . ,         . .  3' 

congenital   dislocation 

of  hip  . .         . .  1- 
obliteration  of  bile- 
ducts       . .         . ,  3: 
dermatitis        herpeti- 
formis        . .         . .     ' 

diverticulitis  . .         . .  4 

duodenal  ulcer  75,  271.  4! 

erythema  nodosum  ..  4' 

erythromelalgia         . .  4 

false  angina  pectoris    4. 

femoral  hernia      674,  6; 

filariasis  . .         . .  1' 

Friedreich's  disease  . .  1 

functional  aibiuninuria 

hiccough     . .         . .  3- 

gall-bladder  disease  . .  4- 

gall-stones   116,    316, 

328,  4; 

gastralgia       ,.  . .  4. 

gastric   ulcer   36,  75, 

268,  4: 

gastrostaxis   . .         . .  2i 

glaucoma        . .  . .   2; 

Graves's  disease       . .  7: 

haamophilia    . .         . .  5i 

Hanot's  cirrhosis       . .   3' 

hepatoptosis  . .  . .   3< 

hypersthenic  dyspepsia  3 

hysteria  . .         . .  4* 

inguinal  hernia         . .  Gi 

intermittent  claudica- 
tion . .     440,  4- 

hydrarthrosis         . .  3- 

intestinal  neuralgia  . .  4; 

lupus  erythematosus     1' 

-  -  mysoedema    . .        38,  4] 

neurasthei.ia  . .  . .  41 

Paget's  disease         . .  7: 

paroyssmal    hfemo- 

globinuria  . .  . .  2t 

tachycardia  . .  7( 

peliosis  rheumatica  . .  51 

phantom  tumour      . .     ^ 

pseudo-hypertrophic 

paralysis     . .  . .  51 

Raynaud's  disease    , .  i~. 

renal  calculus  . .     ■^ 

-  -  Riedel's  lobe  . .         . .  3( 

sarcoma  of  breast    . .  6S 

secret  drinking  . .     ( 

spondylitis  deformans  7] 

sterility  . .         . .  6^; 

stone  iti  bladder       . .  2S 

sulphonal  poisoning. .  7- 

symptoms    from    cer- 
vical ribs    . .         . .  4-1 

syphihtic  aortic  disea; 


51 


tropical  abscess 

typhoid  spine  ..  T 

umbilical  hernia       . .  4! 

undue  abdominal  aortic 

pulsation    . .         . .  5' 

urethral  calculus       . .  21 

venereal  ulcer  of  rec- 
tum . .         . .     ' 

-  -  "Weil's  disease  . .   3: 
Sexual    development,    de- 
layed, in  pituitary  in- 
fantilism        . .  . .   11 

-  disorder,   neurasthenia 


-  excess,  impotence  from     3] 

-  -  menorrhagia  from  3SS,  3£ 
metrorrhagia  from  390.  3t 

-  excitement,     Barthohn's 

gland  active  in  . .  IS 

pain  in  testis  from  . .   4S 

priapism  from  . .  5J 

-  feeling,  absence  of,  ster- 

ility from       . .         . .  Cii 

-  precocity,    with    supra- 

renal tumour. .  . .   i>i 


SHALLOTS    —  ■  SKIAGRAM 


haltot^,  foul  taste  from. 
liame.  bUishio^  from 
bei'p,  distomii  hepaticuc 


32S 


helf,  rectal,  in  abdominal 
malignant  disease     ..  587 

hell,  in  larynx     ..  ..   157 

hell-fish  poisoning,  redema 
from    . .  . .  . .   415 

berreu,    on    ansesEoesia 

(Fig.  257)  606 

herrinizton,     decerebrate 

ruridity  of       . .  . .    139 

higa's  bacillus,  in  dysen- 
tery     . .  . .      173,  716 

hintrles  (see  Herpes) 

bins,  erythema  nodosum 
affectin^r  ..  . .   66S 

hips,  beri-beri  on 


'  Sfiortness  oj  breath,  conltl. 

pleurisy  . .         . .     89 

polycythsemia  . .     87 

from  Pott's  curvature     89 

renal  affections         . .     88 

splenomegalif     poly- 
cythemia  . .         . .  633 

subphrenic  abscess  . .  658 

in  uitemia      . .         . .     87 

Shoulder,  athetosis  of      . .  133 

-  atrophy  of  muscles  of,  in 

amyotrophic   lateral 
sclerosis  . .  . .   50S 

-  blade,    pain    under   (see 

Pain  in  the  Shoulder) 

-  chorea  electrica  affecting  134 

-  definition  of       . .  . .   475 

-  depressed,   from   fibroid 


216 


hivering    . . 
from  biliary  colic 
f iTom   trall-stone . . 
(and  see  Rigor?) 

tiock.  from  acute  pane 


39, 


594 


436 


anuria  from       . .          . .     42 
r,fl,.t,.-i^  after  ..          ..132 
—  from    . .          . .      71 
'W  on  epigastrium  765 
:,va.  from          84,  85 
a  ion  from         ..   124 
.  from    ..          ..169 
insipidus  from     537 
,  with  adherent 
,.:.  ;.^.irdium   , .         ..  213 
UvopLpsia  from..          ..  319 
Jrom  i,'angreuous  appen- 
dix  436 

311 


shrug 


tic 


136 


1,  inflamed  axillary 
glands  from    . .         . .  380 

-  Sprengel's,  scoliosis  from  153 

-  tuberculous  disease  of..   317 

-  wasting  of,  from  polio- 

myeUtis  (Fig.  19)     o9 

Shoulder-joint,  arthritis  of 

475,  476 
neuritis  simulated  bv    5(i6 

-  eff^.-t  of  hru^heitis  on  "  .    477 
Shoulder-joint,    method   of 

testing  movement  in. .  475 

~  •-  >:        345,  347 

1  ..    345 


from  perforated  duodenal 

ShouMcrs,  asyiimietry  of 

153 

ulcer 

136 

-  hi«h     and '  square,     in 

-  trastric  ulcer  . . 

436 

emphysema    . . 

167 

fityalorrbcea  from 

543 

-  lice  affecting     . . 

540 

from  semilunar  cartilage 

-  linese  albicantes  on 

365 

injury 

765 

-  local    fatness    of.    in 

SU'Men"  nervous,    coma 

Dercum's  disease 

410 

from 

118 

-  multiple  benign  sarcoid 

from  testis  injury 

765 

aflfectint; 

405 

vomitini,'  from  . . 

765 

-  pain  between  (see  Pain, 

orr,  I>r.  A.  Bendle,  illus- 

Interscapular) 

,....i,,.,„  I,..,,   ,.y     234 

711 

-  syphiloderms  of 

490 

10RTNESS  OF  BREATH 

87 

Slmipnell's  membrane,  per- 

87 

foration  in     .. 

423 

521 

Shreds  in  stools    172,   399, 

438 

-  jiiii-^l-iiciii- i.wii*Jitions 

Shrugging  tic 

136 

ST 

89 

Shuffling  gait  iu  paralysis 

-  bad  air 

89 

agitans 

498 

-  bronchitis       . .         8  j 

88 

Shvness.  blushing  from  . . 

241 

-  bronchopneumonia  . . 

88 

Sicily,  kala-azar  in 

633 

-  in  caisson  work 

89 

Sick  headache,  g:istric  ab- 

- from  chest  deformities 

89 

sorption  stopped  during 

526 

-  chronic  mcdiastinitis 

435 

Sick     headache,     general 

-  -  nephritis     . . 

11 

account  ol    .  ■ 

526 

-  in  convalescence 

88 

glaucoma     simulating 

233 

-  cousjh  and 

150 

—  heredity  and  . .  '     . . 

526 

-  from  deformity  of  chest 

87 

—  hypetacusis  from  308, 

309 

-  in  diabetes     . .          87 

88 

migraine  and. . 

526 

-  from  emphysema      85 

89 

photophobia  in     525, 

526 

-  fatty  heart'   . . 

53 

rigor  in 

595 

-  in  fevers 

87 

vomiting  from 

526 

-  Ilrst   sign    of    pleural 

Sickness  (see  Vomiting) 

effusion 

88 

Sickness,  sleeping  (see  Sleep- 

- from  fungating  endo- 

ing  Sickness) 

carditb 

7 

Siderosis 

288 

87 

Siegle's  speculum,  in  Gellc's 

-    isri-i-  !i,iTnitrr!i:tv'e     .  . 

87 

test 

169 

ortness  of  breath,  from 

Sight,  impairment  of,  from 

heart  conditions       78, 

88 

plumbism 

34 

-  in  li-ukiunnii  .  . 

87 

-  loss    of,    from    cerebral 

—  lobar  pneumonia 

88 

tumour 

68 

—  luin:  conditions 

87 

retrobulbar  neuritis.. 

445 

—  on  mountaitts 

89 

-  short,  kyphosis  from  . . 

155 

-  with  myocardial  allec- 

-  (anil  sec  Blin<lness ;  and 

tions            ..   U,  85 

90 

Vision.  I)efc<'ts  oO 

—  nervousness   . . 

83 

Sights,  repulsive,  x'omiting 

-  in  neurastlienia 

88 

due  to 

765 

-  from  obesity  . . 

53 

Sigmoid  colon,  carcinoran 

-  partial  asphyxia 

89 

of  (SCO  Carcinoma  of 

-  in  pericarditis 

133 

Sigmoid) 

-  pernicious  ainemiu    . . 

87 

-  -  .lil.il.-.l 

676 

-  phthisis 

88 

676 

Erb's  palsy  from  507 
Shoulder,  fibrositis  of      . .  475 

-  lowered,  from  fibroidluug  168 

-  mycetoma  of     . .  . .    736 

-  myopathy  of      . .  . .   514 
Shoulder,  myositis  of       . .  475 

-  occupation  neurosis  of..  476 

-  pain  in  (see  Pain  in  the 

Shoulder) 

-  pneumococcal  arthritis  of  339 


Sigmoid  colon,  conttl. 

palpable         . .      666, 

scybala  iu 

thickened  in  colitis  . . 

tuberculous    . .         ; . 

-  sinus,  thrombosis  of    . . 
Sigmoidoscope  in  ascites. . 

-  diagnosing  adenoma  recti 
carcinoma    of    bowel 

77,    78,     126,    129, 
172,  585, 

-  —  —  of  sigmoid  . . 

catarrh  of  colon 

cause  of  obstruction 

241, 

-  -  -  pus  in  stools 

coUtis        76,  78,  172, 

diverticula 

drschezia 

intestinal  obstruction 

-  in  diarrhoea 

-  cases    of    bearing-down 


Sign,  Braun's.  of  pregnancy 
Sign,  Chvostek's  . . 
in  tetany 

-  DalrymDle's 

-  Erb's  iti  tetany..  3, 
Sign,  Hegar's.  of  pregnancy 

-  Kerniii's.  in  meningitis 
Sign,  Magnan's 

Sign.  Moebius's  . .  215, 
Sign.  Romberg's  .  57, 
Sign.  Stellwag's    -15.  229, 

-  Truu.-..ars         ..3,  151. 
Sign,  von  Graefe's      229, 
Sigii^.    proper    names    as- 
sociated with  (*ee  end 
of  Index^ 

Silica  in  intestinal  sand.. 

Silken  crepitus 

Silver  nitrate,  alkapton  and 

argyria  from  . . 

in  irrigating  bladder. . 

for  chlorides. . 

•esical  styptic     . . 

radium     . . 

Sin,  the  unpardonable     . . 

Singing    in    the    ears,    in 

arteriosclerosis 

-  head  in  insanity 

-  (see  Noises  in  the  Head) 
Siuo-auricular  node 

-  rhythm,  slow     . . 


Sinus  arrhythmias 


..  545 

tii.ii.i...u..i.    AiUt        ..    694 

emiSf^ary  vein  from  . .   229 

thrombosed  (see  Throm- 
bosis of  Cavernous 
Sinus)  . .  . .   229 

-  of  bre:ist.  from  tubercle  686 

-  from  empyema..         ..  635 

-  ethmoidal,  blood-spitting 

from  lesions  of  . .  2S5 

distended  orbital  swel- 
ling from    . .         . .  23U 

infected,     foul     taste 

from  . .  . .   705 

intltunmation  in,  antral 

diseiise  simulating     463 

foul  taste  from      . .   705 

nasal  dtsi'harge  from 

179,  181 

suppuration  in,  head- 
ache from  . .         . .   394 

meningitis  from     . .  590 

-  of  fool,  from  mycetoma  736 

-  frontal.       bloml-spitting 

from  lesions  of  . .   285 

diseJise     of,     cerebral 

abs4'ess  from      117.  '"O:.* 

pus  from  nose  due  to  179 

db!tend*Ni.ori>itaI  ridge 

thickeriiHl  from,.   230 

front         ..'      23n.  U9 

Sinus,  frontal,  empyema  of  180 

enlarged  with  .ice     . .   2<43 

-  -  esoslosLsof    ..  ..671 
infected,  antral  disease 

simulating  . .  . .    463 
foul  taste  from      . .   705 


Sinus,  frontal,  <ontd. 

infected,         headache 

from  . .         . .  294 

subjective     smells 

from         . .  . .   612 

-  infection,  foul  taste  from  705 

-  lateral,  eroded   . .  . .   421 
thrombosed  (see  Throm- 
bosis    of     Lateral 

-  mastoid,  suppuration  in, 

headache  from  . .  294 

-  perineal,  from  prostatic 

abscess  . .         . .  620 
tuberculous  prostate     620 

-  from  periostitis..         ..  668 

-  scrotal,   from    testicular 

abscess  . .         , .  622 
from  tubercle         622,  696 

-  sigmoid,  ttux>mbosis  of. .   597 

-  sphenoidal,  blood-spitting 

from  lesions  of  . .   285 

infected,     foul     taste 

from  ..  ..705 

294 

from        . .  .  /  231 

meningitis  from    . .  590 

nasal  discharge £rom 

179,  181 

optic  atrophy  from  231 

neuritis  from     ..  231 

polypi  from  ..  231 

proptosis  from       . .  231 

-  from  spinal  caries        . .  635 

-  superior       longitudinal, 

emi^ary  vein  from  . .  220 

thrombosis    of   (see 

Tlirom  basis) 
Sinuses,  bone,  an%mia  with     35 

-  joint,  anaemia  with      . .     35 

-  nasal,  distended,  blind- 

ness from      . .         . .  763 

exophthalmos  from 

239,  230 
orbital  tubercle  simu- 
lating     ..         ..  330 

suppurating,     earache 

from  . .         . .  202 
thrombosis  from  . .  229 

-  in  neck,  from  actinomy- 

cosis     683 

Sixth  nerve  paralvsis  (see 

riinlvsis      of      Sixth 

Nerve) 
Size,  abnormal  sensations  of  763 
Skeletal  dwarfism . .         . .   186 
Skene's  tubes,  gonococci  in  185 
Skiagram  of  aneurrsm  (Fig. 

iOO)  209,  435 

-  of  bean  in  bronchus      . .   195 

-  bismuth  above  carcinoma 

of  oesophagus  . .   196 
in  normal  colon        . .  436 

-  bone  rareftujiion  in  rheu- 

matoid arthritis        . .  344 

-  carcinoma     of     splenic 

llexure            . .  . .  125 
stomadi          . .  269,  270 

-  Charcot's  hip      . .  . .   350 

-  chronic  periostitis  . .  668 

-  cen-ical  rib  (Figs.  186, 

187)  443 

-  dropped  stomach  . .   318 

-  enchondroma  of  hand..  671 

-  exostosis  of  femur       . .  670 

-  gall-stones  . .  . .   327 

-  gouty  hands      . .  . .   346 

-  hands    in    :u:ute    rheu- 

matoid arthritic        ..  342 

-  hour-glass  stomach  (Fig. 

12S)  368 

-  hydatid  cyst  of  lung  , .   391 

-  idiopathic   dilatation   of 

(psoplnigus     . .  . .   1 98 

-  lobar  pneumonia  . .   289 

-  normal  stoni:wli  . .   269 

-  piid^  on  lingeni.  .  ..347 

-  plitlib;is  ..         (Fig.  41)  103 

-  pyoloirraphy    iu    liytlrtK 

'  nephrwL-i        . .  . .   356 

-  pyopneumothora.x         . .   331 

-  renal  calculus    . .         . .  279 

-  sarcoma  of  lung  . .   105 
radius              ..      672,  673 

-  -  til.i.i 671 

-  -!  ■  ..no 


SKIAGRAxM 


SORUES 


cesophagus      . .  . .   197 

-  sypliilitic  radius  . .   GGO 

-  thymus  gland,  enlarged    419 

-  tuberculous  kidney      . .  280 

-  vesical  calculus..  ..   282 

-  ureteral  calculus  , .  ibo 
Skiagraphy    (see    .r-rays ; 

and  Skiagram) 
Skin,  appearances  in  jaun- 
dice       324 


Skin,  benign  tumours  of  . . 

732 

-  brown  paper,  in  prurigo 

190 

-  blood    crusts    on,    from 

jaundice 

324 

-  capillary  pulsation  in  . . 

207 

-  coarse,  in  cretinism     . . 

2.S4 

myxosdema    . . 

234 

-  cold  and  clammy,  after 

abdominal  injury     . . 

693 

-  crystals  in 

655 

Skin,  diplitlieria  of 

558 

-  discoloration,  from  snake 

Wte 

337 

-  diseases,  eosiiiopliilia  in 

219 

-  dry,  in  cretinism 

334 

-  -  myxcpdema    . .      334, 

537 

and    hai-sh,    with    cir- 

rliosis 

371 

-  -  -  pyelonephritis   .    . . 

S76 

shrivelled,    with    car- 

cinoma 

374 

-  epithelioma  of  (see  Car- 

cinoma of  Skiu) 

-  flushed   and    dry,    from 

belladonna     . . 

170 

glossy,  in  svrinL'omvelia 

110 

-  s?reeiii.-li,  m   .■1,Imi',,-i~   .  . 

274 

-  hot  dn  .    •    |.'  .  ■,:■ 

335 

-   melaiiDl  \r  -,nr. 

ii;i  ni  ;.;,si 

nso 

-  moist,  in  I  ;i;i\  r 

■^'  '.li.SL^ase 

rM\ 

-  nodule-s*  in  (sf?e 

Xodules) 

-  nutmeg-grater. 

in  kera- 

tosis  pilaris 

4HH 

prungo 

41)0 

-  pale  and  sweaty,  from 

poisons 

!70 

-  pigmentation 

of     (see 

Pigmentation 

of    the 

Skin) 

-  plucked-f owl,  in 

pityriasis 

rubra  pilaris 

-  primrose  yellow,  in  per- 

nicious aneemia       64,  770 

-  pungent,  in  pneumonia     642 

-  ringworm  affecting       ..  247 

-  rodent  ulcer  of  . ,         . .  179 

-  sallow,  in  rayxoedema. .    234 
Skin,  sarcoma  of  487,  680,  731 

-  scratch   marks  on,  from 

jaundice  . ,  , .   324 

-  stains  in  syphilis  . .  384 

-  tense  and  shining,  from 

ascites  . .  . .     43 

-  thickened,  in  myxoedema    38 
SKIN  TUMOURS  ..         ..730 

-  ulceration    (see    Ulcera- 

tion) 

-  yellow,  in  cretinism     , .  234 

lardaceous  disease   . .     35 

from  picric  acid        . .  529 

Skins,  mercury  in  curing. .     65 

-  in  stools. .  . .        \      30;* 

-  rabbit  i-,r  i;.,i.i.m  -Un-i 
SKODAIC  RESONANCE     .611 

-  -    OV.-l-    ]■!■■ ■■     .     iM.IUil     itiS 

Skull,  in  a,iomeg:i]y        ..   237 

-  anosteoptasia     . .         . ,  187 

-  big,  in  rickets     . . 

-  enlai^ed,  in  acromegaly 

-  flat  occipital  region  of, 

in  mongolism  . .    ; 

fracture  of  (see  Fracture) 


hot-( 


;  bun,  fro 


genital  syphilis 

rickets 

ivory  exostoses  of     204, 
230, 

■  natiform.  from  congenital 

syphilis 

■  osteoma  of         . .        84 


.s'/«//,  coiud. 

-  secondary  carcinoma  of  204 

-  syphilitic  nodes  on       . .    669 

-  tender,  in  rickets  . .  145 
Skutsch's  pelvimeter  . .  201 
Slaughterers,  warts  in  . .  240 
Sleep,  Babinski's  sign  in   .     69 

-  excessive,   in   hypopitu- 

itarism ,".  . .  410 

-  lack  of  (see  Insomnia) 
Sleep,      requirements      at 

different  ages. .         ..320 

-  urine  amount  and  ..  534 
Sleepiness  after  epileptic  fit  143 
Sleeping  on  back,  priapism 

from 538 

Sleeping  sickness  . .  28 
enlarged  lymph  glands 

geographic  distribution    28 

lymphocytes  in  cere- 
brospinal fluid  in  . .  305 

spread     by     glossina 

palpalis       . .  . .    -28 

trypanosonies  in  cere- 
brospinal fluid  in..  305 

tileeplessness,  loss  of  weight 

from 769 

-■trom  pruritus    ..  ..   540 

Sling,  bracheitis  requiring    477 

-  brachial     neuralgia     re- 

lieved by        , .          . .  442 
Slipping    through     one's 
hands,  in  pseudohyper- 
trophic paralysis       . .   513 
Slobbering,  in  idiots,  etc.    543 
Sloughing 255 

-  fi"om  erysipelas..  ..  674 
Slouglis instools,  in  typhoid 

fever   . .         . . "       . .  636 
Small     lymphocytes     (see 

Lymphocyte's.  Small) 
Smail-po.x,  acne  simulating 

559,  563 

-  acute  oedema  of  tongue  in  698 

-  albuminuria  in  . .  . .      13 

-  albumosuria  in  . .  . .     16 

-  arthritis  with     . .  . .   340 

-  bathing-drawcre        area 

affected  by    . .         . .  401 

-  bromide  rash  simulating  563 

-  chicken-pox  simulating 

561,  563 

-  confluent  . .     (Fig.  238)  561 

-  copaiba  rash  simulating  563 

-  discrete      . .     (Fig.  237)  561 

-  eczema  simulating        . .   562 

-  eruption    . .     (Fig.  305)  757 

-  erythema  in  . .  . .  223 
multifomie  simulating  562 

-  gangrene  from  . .  . .  255 
Small-pox,  general  account 

of  560-63 

-  hfematuria  in     . .  . .   275 

-  hsemoptysis  from  . .   287 

-  ha3morrhages  in  . .   561 

-  hydrocele  from..         ..  481 

-  impetigo  simulating  . .  562 
~  iodide  rash  simulating. .   563 

-  itchint?  in  . .  . .   GOl 

-  h'urnryto-^'.-^  rare  in  ..  360 
Small-pox.  malignant   265,  272 

-  niniuiTlia-ia   I'roin  ..    386 

-  mouth  allLvtea  by        . .   616 

-  mucous  membranes   af- 

fected by        . .  . .  561 

-  pain  in  the  eyes  in  . .  446  1 
limbs  in  . .  . .   465 


i  -  stomnt 

I  -  sypliibi 

I  ~  tiiyroii. 

;  -  typlioi. 


Sodium,  conkl. 

-  bicarbonate,     heartbur 

relieved  by    . . 
in  inflating  stomach 


by        

G37 

interscapular  pain  re- 

- ulceration  of  larynx  from 

lieved  by    . . 

158,  199,  287 

292 

-  cacodylate,    erythema 

-  vaccinia  simulating  562 

757 

from    . .         . ,      222. 

Smali-pox.  varicella  distin- 

- carbonate,   dead   fingei-^ 

guished  from . . 

757 

757 

from    . . 
-  chloride,  thirst  from    . . 

SiihII-,   vuimli.iL-  dii.'  to.. 

765 

-  dihydric  phosphate 

SIVIELL.  ABNORMALITIES 

-  hydrate  (see  Caustic  Sod.-\ 

OF       

611 

-  monchydric  phosphate 

Smell,   sense    of.  deficient. 

-  nitrite,    in    Cammidge'.^ 

list  of  causes  of 

612 

reaction 

-    Iii-^   i>|.   HI    |i\  -tcl  i;l 

610 

diazo-reaction 

liiiiii-i  .   M'    |:i\  IK 

246 

-  nitropmsside,  melanuria 

S I1-.     i~     jii)  ,1    (it  cpilcpsv 

67 

and 

Smells,  subjective  sensation 

-  -  tests    (Plate  XXXIV) 

of        

612 

-  phosphate 

Smells,  undue  sensitiveness 

-  salicylate,  in'acute  rheu- 

to         

612 

matism 

.Smile,  nasal,  in  myastlienia 

235 

bradycardia  from     . . 

-  sardonic  (see  Risus  Sar- 

deafness  from 

donicus) 

delirium  from 

-  transverse,  of  myopathy 

effect  in  acute  rheu- 

(Fig. lid) 

235 

matism 

SmokinjT,  chronic  glossitis 

-  (and  see  Salicylates) 

from    .  . 

738 

-  theocin-acetate,  polyuria 

pharynsritis  from 

613 

from 

-  cough  from 

148 

-  urate        . .          . .       344. 

-  foul  breath  from 

86 

Soft  sore,  balanitis  simu- 

 taste  from     . . 

705 

lating  

—  heart  faihire  from 

418 

bubo  from     

-  irregular  heart  from     . . 

486 

chancre    distinguished 

-  loss  of  weight  from 

769 

from            . .      61S. 

-  low  blood-pressure  from 

82 

condvloma  pimiiiatin-' 

-  noises  in  eats  and 

723 

Soft  sores,  general  account 

-  orthopnoea  from 

418 

of                    ..      618. 

-  palpitations  from 

485 

on  glans  penis 

-  pharyngitis  from 

616 

herpes  simulating     . . 

-  pulse-rate  and  . . 

486 

inguinalglandsinfectP'l 

-  variable  incidence  of  ill- 

from            . .      617. 

effects  of 

485 

on  scrotum    . . 

Smoky  urine 

9 

-  -  syphilis  and  . . 

Snail-track  ulcers  in  syphilis 

615 

ulceration  of  penis  from 

Snake-bite,       albuminuria 

617, 

from    . . 

413 

of  urethra 

-  erythema  from  . . 

223  1 

urethral  discharge  dup 

Snake-bite,  general  account 

to     .. 

of        

337  1 

stricture  from 

-  .TiU-m:-|  from        .  .       413, 

415  ! 

-   imrpio-i  fi-(i?ii     .  . 

553  1 

SfittffiiiiL.'  ijf  1  III'   lir.iih  (-(■.■ 

-    ^  H,  ■_-  HI  ocne  from. , 

255 

1    i'I'cIt..1      .-nMrlilli    '1 

-    -   lMiiio^l,,i,iiiiiria    from 

284 

--     -■nr.l       l~ff       ~|.li|:i|       (    .,!■.]. 

U-gita. 


of     iuod 


paiMll. 


;  ot 


Smallpox,  parts  affected  by  757  i 

-   ph;  -      .     -   - 


a  tiff  ■ 


■ll  b) 


613 


.  .       561,  601 

-  prodromal  rash  in         . .    554 
Small-pox,  purpura  in  272, 

553,  554 
simulating      , .  . .    562 

-  pustules    in     558,    559, 

561,  601,  753 

-  Ricketts   on      561,  563,  757 

-  rigor  in 594 

-  roseola  preceding         , .  560 

-  scabs  in  . .  . .      561,  601 

-  scarlatina-like  rash  in..   560 

-  septic   dermatitis   simu- 

lating . .       (Fig.    239)  562 

-  sore  throat  in    . .      613,  616 

-  spleen  enlarged  in    632,  637  ' 


Sneezing 
I  -  regur( 

through  nose  from 

-  subcutaneous        emphy- 

sema from       ..  :.    203 

,  Snellen's  tvpe,  in  detecting 

hysteria  ..         ..760 

Sniffing  tic 136 

SNORING 613 

-  stertor  and        . .  . .  647 
Snow  blindness,  erytbropsia 

in         ..         "..  ..762 
hemeralopia  from     . .   763 

-  pain  in  the  eyes  from  . .  446 

-  workers  in,  photophobia 

in         524 

Snuff,  anosmia  from  . .   612 

-  nasal  dischai^e  from  . .  178 
Snuffles     in     congenital 

syphilis  385,  400,  635 

Soap,  dermatitis  from     . .  755 

-  erythema  from  . .  . .   222 

-  pruritus  from    . .  . .   540 

-  in     relieving     constipa- 

tion in  infants  . .   128 

Soda,  caustic  (see  Caustic 
Soda) 

-  fingers  affected  by       . .  239 
Soda-water,    regurgitation 

of  food  through  nose 

after 588 

Sodio-potassic  tartrate,  in 

Fehling's  test  . .   261 

Nylander's  test  . .    262 

Pavy's  test     . .  . .    261 

Sodium  acetate,  in  phenyl- 
hydrazine  test  '..    262 


pigmentation  from  irri- 
tation of         . .  . .   ; 

Solei,  pseudohypertrophy  of  •. 

Soles,  antesthesiaof,  vertigo 
and      . .         . .         , .   ; 

-  cheiropompholyx  on  97.  i 

-  congenital  syphilitic  erU|i- 

tion  on  . .  . .  4 

-  eczema  of  . .  . .  -1 

-  gout  of  . .        . .        . .  ;: 

-  horny     overgrowth     in. 

from   erythema   kera- 
todes 4 

-  hyperkeratosis  of,  from 


34. 

-  pityriasis    rubra    pilaris 

affecting         . .         . .  i 

-  pruritus  of  . .  . .   ■ 

-  syphilis  of  . .      490. 
Soleus,  nerve  supply  of  . .    ^ 
Solitai-y  follicles,  enlai^ed 

in  lymphatism  . .  .' 
Somnolence,  in  meninsitis  i 
Sordes,    in    acute    yellow 

atrophy 

-  astlienic  states  . .  72. 

-  bleeding  gums  from 

-  in  cachexia 


-  general  paralysis 
peritonitis 

-  intestinal  obstruction 


SORE    —    SPINAL  CARIES 


3re,  dissecting-room,  epi- 

'S/xcsm,  contd. 

SjHCuluin.  wnkl. 

Sphygmomauoraeter,     in 

trochlear    gland     en- 

— of    colon,    with    muco- 

-  Pergusson's,  in  examining 

detecting  high  blood- 

larged  from    . .          . .   381 

membranous       colitis 

for  gonococci. .          . .  185 

pressure          . .          . .  485 

finger  (see  Fingers,  Sore) 

iFig.  52)  124 

-  Siegle's,  in  Gelle's  test. .   105 

Sphyginograph,  in  diagnos-       * 

IRE  THROAT    ..         ..613 

-  from  gall-stones            . .  310 

-  in  tenesmus        .  .          .  .    718 

ing  pulsus  aUernans. .  550 

^  in  acute  rheumatism 

-  hysterical,  of  face         . .   494 

SPEECH,      ABNORIVIALI- 

bigeminus  . .          . .   550 

228,  4(14 

-  of  larynx,  coma  from  . .   752 

TIES  OF                   .623 

Spiders,     liEemoglobinuria 

-  .ill.uminaria  with      .  .      14 

epileptic         . .          . .   752 

-  blurred,  in  general  para- 

due  to             . .          . .   284 

re  throat,  bacteriological 

vertigo  from  . .         . .  752 

ly.sis     ..          ..      140,  720 

.Spina  bifida  occulta,  lum- 

diagnosis of  ..     379,  614 

-  levator' ani,  cau-ses  ot  . .  193 

-  centres  (Fig.  260)          . .    624 

bar  mole  suggesting. .  511 

-  bad  ventilation  and..   (>15 

palpebraj,  in  Graves's 

blood  supply  of        . .  625 

palpation     in     dia- 

- blood-spitting  from  .  .   28.5 

disease            . .          . .  229 

-  cerebellar           . .          . .     59 

gnosing  ..         ..  .511 

-  from  cervical  adenitis  fil7 

-  muscular,  in  occupation 

-  in  chorea             . .          . .    133 

paraplegia  from     . .  510 

-  common  cold  and    . .   111.5 

neuroses         ..          ..445 

-  defective,  from  cerebral 

paraplegia  from        . .  510 

-  contlylomata  and     . .   700 

-  of  cesopliagus     . .          . .   435 

embolism       ..         ..133 

pes  cavus  from         . .   113 

—  in  dengue       . .          . .  4()tj 

-  -  vomitiTig  due  to        . .  703 

with  diplegia..          ..  132 

talipes  from  . .          . .   113 

-  diphtheria      . .          . .     04 

-  orbiculares,  in  paralysis 

in  disseminated  scler- 

Spinach, oxalate  from     . .  424 

re  throat,  diphtheria  and  614 

agitans            . .          . .  230 

osis  148 

Spinal      accessory     nerve 

-  -  .liagnosc.l  from  other 

-  pylorus,  dyspepsia  from  319 

Huntingdon's     chorea 

paralysis         . .         . .  135 

forms  of.  .          .  .      14 

in  infants       . .         . .  600 

and 134 

torticollis  and       . .  142 

mistaken  for  simple  589 

-  retinal  arteries,  blindness 

-  delayed  development  of  023 

-  artery,  thrombosis  of  (see 

-  dust  acid        ..         ..  015 

from 701 

-  interference    with,     in 

Thrombosis,  Spinal) 

-  dysphagia  from         . .  198 

-  sphincter  ani,  anfesthetic 

mercury  poisoning  . .  726 

Spinal     canal,     aneiirysm 

-  febricula  representing  404 

in  diagnosing  cause  of  128 

-  loss  of,  from  alcoholism  023 

ruptured  into            . .   434 

-  foul  breath  from       . ,     87 

cocaine  in  diagnosing 

pneumonia     . .          . .  623 

Spinal  caries                  ..154 

-  hospital  wards  and  . .  015 

cause  of  . .          . .   12$ 

typhoid  fever            . .  623 

abdominal  pain  from     110 

-  in  Kirkland's  disease 

dvscUezia  from      . .  128 

-  -  (and  see  Aphasia) 

abscess  iu  back  from  169 

015,  610 

vesiciB             . .          . .   395 

-  mechanism  of    .  .          . .   620 

abscess  in  groin  from    080 

re  throat,  list  of  causes  of  613 

retention    of    urine 

-  moTiotonous,    in    Fried- 

 age  incidence  of       . .   713 

-  motoring  and             .  .   015 

from        . .          . .   398 

reich's  ataxy. .          ..   313 

allocheiria  from        . .     17 

-  from  nnimps  .  .          .  .   017 

-  sternomastoid    . .         . .  648 

-  physiology  ot     . .          . .   624 

aneurysm    simulating 

-  with      peliosis      rliou- 

-  in  strvchnine  poisoniu'-'     599 

-  scaintiiig.  from  cerebellar 

516,  714 

inatica        . .         . .  550 

-  tetaiuis 599 

abscess             .  .           .  .    517 

angular  curvature  from  713 

-  from     postpharyngeal 

Spasmodii:  contractions    . .   136 

tumour       . .          . .  517 

appendicitis  simulated 

abscess        ..          ..  010 

-  nfiir..-niii-rHl:,i-;.lV.vliHi,s, 

disseminated  sclerosis 

by 461 

-  peripheral  neui-itis  from  1 54 

^H.-r,„„-h.-nr  >  b:ii.d  m         2 

517,  627,  728 

backache  from          . .  469 

-  in  scarlet  fever    224, 

Spasmodic  tics                ..136 

-  slow,  in  myxcedema     . .   234 

Spinal  caries,  cervical     . .  648 

227,  017 

-  torticollis,  retracted  head 

jerky,  in    Friedreich's 

pain    in    arm    from 

-  seweis  and     . .         . .  015 

from .689 

ataxy  . .          . .          . .   027 

443,   1 1 1 

-  syphilides  and           . .  500 

Spasmogenic      zones,      in 

-  slurred,  in  disseminated 

tenderness  of  spine 

-  in  svplulis     334,  4!11, 

l,v  =  trrin             ..            ..707 

^,l,.i-,i=is          ..         ..307 

from        ..          ..  444 

5I1».  01  1 

>;i.:,--;iM|.'  ill  ,.    i  ,    ri.-kets..   420 

^  -    r,,..[|...i.  1,'-  ,li<ease  ..  113 

colic  simulated  by    . .  113 

-  weather  and  ..          ..   Ol.". 

^l--'i'       1 i"--'^'     (see 

-  :-t  ,,.,,,,.  ,11  .|i--,.iiiinatcd 

curvature  with         . .  048 

re    throats,     illustrated 

i    ,,  .,'i--ii.    -I'astic) 

M.|..|.,i-i-          Ml.  027,  728 

-  -  debility  simulating   . .  429 

(/>/«(«  A.V  17,  A- .vr//) 

Spasticilv   1"   arin..            ..    .502 

-  svilabic.    m    Friedreich's 

deformity  of  back  from  110 

610.  612 

-  in  disseminated  sclerosis  307 

"  disease           . .         . .  140 

without  deformity  364,  516 

-  syphilis  causing  (I'tafp 

~  pseudobulbar  jialsy      . .   627 

Spermatic    cord    compres- 

- -  gait  due  to     .  .      154,  713 

.V.YIV)        ..          ..   CIO 

Specific  gravity  of   ascitic 

sion,     testis     .atrophy 

Spinal  caries,   general  ac- 

)RES. PENILE  ..         .617 

fluid     ..          ..          48,  60 

from fiO 

count  of                  . .  364 

i-.lli.nr.l            ingnirnd 

blood,  in  collapse     . .  534 

Spermatic    cord,    encysted 

-  -  h,.a,l  k..|,l  li\,.,l  from    429 

jl,u.\^  Ir.Ni,              ..    381 

diabetes  insipidus. .  337 

hydrocele  of  .           .695 

l,v|„.nr>ili,.-ia  from  .  .    010 

)RES.  PERINEAL        ..  619 

itifttsion  and           . .   534 

-  -  sinnc  lesions  of           .  .     ISL' 

ni,h-,'Sti.)ii     snnulated 

-  a,.hn,s,'     in      iierineum 

Specific  gravity  of  blood. 

-  -   tliickened,   witli   testi- 

by  310 

from            ..          ..474 

measurement  of       . .  534 

cular  abscess          , .    622 

intercostal     neuralgia 

-  iiillamed  glands  from  381 

normal         .  .      534,  537 

Spermatocele          . .          ..481 

suggesting..       1.54.431 

in  prurigo          . .          . .  490 

_  _  rricl.rofpinal    Uuid    ..    304 

-  achin..'  in  groin  from   .  .    481 

interscapular  pain  from  401 

IRES.  SCROTAU          . .  621 

-  -  uriTie       ( Urine, 

lin,il,.,r  !,.._•!,. 11  from  ..   481 

-  -  kyphosis  from        154,  188 

-  from  abscess  of  testis  022 

>],vilir  liravitv  of) 

-       I,    ,1-  l,,,iii      .  .          ..   .181 

lardaceons  disciise  from 

~  sviiliilis           021,  022,  090 

SPECKS     BEFORE     THE 

-  .Ill  ,ii  i,.-ii-  from..     66 

8,  035 

-  tuberculous  testis  479,  022 

EYES 71 

-  s|...in,,,ti,.  ,1  ..omprcs- 

lateral  curvature  simu- 

from  sea-cat  pricks      . .  224 

Spectra,  various,  ilhistrated    80 

sion   by            .  .          . .     00 

latitlg          . .          . .  439 

soft  fsec  Soft  Sores) 

Spectroscope,  in  detecting 

Spermato-cystitis,      acute. 

limping  from. .          . .   303 

in  syringomyelia           . .  510 

blood 81 

litematuria  from       . .  275 

lordosis  from..          ..   150 

various,  inllamed  axillary 

hasmatoporpliyrin     . .  744 

SpcnnatorrhcL'a,      oxaluria 

-  -  local  rigidity  with     . .  429 

glands  from   .  .          . .   380 

-  diagnosing  hajmoglobin- 

;,i„l 424 

milk  drinking  and    . .  510 

inguitial  glands  from  381 

uria      .  .          . .      284,  285 

-  pli.i  1.1,  ,T,i|.  1  -,,._'-usting    624 

new   growth   simulat- 

from   weever-Iish    pricks  224 

methrcmoglobiu         . .  157 

.Si... Ill,  ,11,  .  ,1.  iiliii-.    pain 

ing  ..         516,  048,  711 

ouiui.  in  diagnosing  cysto- 

methvlene  blue         . .  747 

I.I  |,..|ii-ln,ii,..          ..   171 

pachymeningitis  simu- 

oele  539 

-  -  urobilin          321,  325,  743 

SpermatoKoii,    m    cyst    of 

lating          . .          . .  310 

-  fibromyoma   . .      380,  387 

-  as  test  for  blood           . .     10 

testis 481 

—  pain  in  the  back  from 

-  hypertrophy  of  cervix  539 

in  stools     . .'»       . .     75 

-  urine,  with  ox.aluria    . .  424 

1.56,  304,  4'.>8,  510,  713 

-  inversion         . .         . .  539 

Spectrum  of  acid  hfcmatin 

Spermin,    Charcot-Leydeii 

epigastriinn  from  . .  430 

-  pyometra       . .          . .   180 

{Fin.  34)     80 

crystals  and   . .          . .   102 

,,..,1.  f 129,  016,  648 

-  vesical    calculus    282, 

-  alkaline   hajmatin   {Fi(j. 

Sphacelus 255 

-li,,i,l.l..i    !,. 1,111       ..  475 

471,  580,  719 

33)     80 

Sphenoid  sinus  (sec  Simis, 

,,  iiiniih.i,    from..  484 

normal  distance  for     . .  387 

-  carboxvhaimoglobin  (/■«;. 

Sphcnoi.lal. 

-       |,.,i  ,h   1-    ,,i    one    leg 

uterine,  in  din^'nosis    . .     19 

32)     80 

S|,l,i,i.  1,  ,   11,1.  1,1  ,\,.,1  after 

from             ..          ..    499 

ounds.    uniluc    .seimitivc- 

-  mothaemoglobin  (Fig.  35)     SO 

iury  ..   314 

—  paraplegia   from    113, 

n(W.s    Ut    (see    ITyper- 

-  oxylmmoglobin  (Fig.  30)     80 

1 1      1  ,  'ia  from  128 

151,  243,  510,  311 

acusis)            ..          ..  308 

-  reduced  haimoglobin  (Fvj. 

-  i.iih  .  ,i,,,,il,,-,-  „f         ..   651 

—  post-]iharyngeal      ab- 

OUth  .\fricii  (see  .\frica) 

31)    80 

-  -    rupture  of      ..          ..   551 

scess  from  ..          ..647 

outh  KiLsliTii  Fever  Hospi- 

- urobilin   . .         (Pyi.  30)    80 

-  trouble,  in  amyotrophic 

simulating          . .  010 

tal,  charts  rrom    03S,  039 

Speculum     in     dingnosing 

lateral  sclerosis         . .     63 

Pott's  curvature  with 

pade  users.    I)u|.uylren's 

anal  fissure    ..          ..   194 

from  cerebellar  tumour  517 

364,  510 

contracture  in           ..  142 

carcinoma  recti         . .     78 

cerebral  diplegia       .  .    729 

—  prominence    of    back 

pain,  Mediterranean  fever 

cause  of  anostnia      . .  012 

softening    . .          . .    725 

from            . .          . .   109 

in         lino 

—  foreign  bodies  in  ear 

combined  sclero.ses    . .    MO 

—  psoas  abscess  from 

plaiirhnic  veHsels,  artcrio- 

105,  422 

in  convulsions          . .   143 

1.56,  364.  682,  680.  7l:> 

.l.n.^isof      ..            ..         1 

-        mil, 1,1.. ,|  |,il,..              ..    191 

dis.scminated  sclerosis 

rickets  sinuilating  304,  714 

1  !  '  1      ■.      gastric      (sec 

,,,,   ,      111.  '  ,  I,,,,.;               ,       179 

148,  490,  .502,  617,  728 

rigidity  of  back  with 

.,  -n.sion) 

-         ,.l,r    .   ,,,,.!,,     ..            ..    202 

from  hutmatom.yclia. .   110 

164,  301,  461,  OSll 

|Ki  in  n\  I.MWcKsee  Kntero- 

-    -  |,,,|,ill.iiii  ,  i,...|i           ..      79 

new  growth  in  spine. .    714 

neck  from  . .          , .  tits 

^li.Klnl 

-  -  polypus           ..          ..   .586 

-  -  in  tabes          173,  400,  610 

spine  from          116,   713 

pasm,  carponedal          . .      3 

wax  in  ear     ..          . .   104 

transverse  myelitis  62,  140 

-  "  root  iialsies  from      . .   509 

-  iniMf;inls         ..           ..    152 

-  ear  cxnmitiatlon            . .  421 

typhoid  spine            ..    715 

-  -  s.-oliosis  Witll..          ..    131 

rickels               ..           ..    1.52 

-  epistaxis              .  .          . .    221 

-  vesica!,  paralysis  of      .  .    218 

sirnulal ing  neurosis  . .    177 

-  tetany  ami     ..          ..    152 

-  CNamining  ri.clnm         .  .    584 

spiisni  ot    ■    . .          . .   395 

_  -  -  lorticollis    . .          . .    1 12 

Spiital  carii's,  co>i/d. 

-  -  sinus  from      ..  . .   G35 

skiagram  of    . .  . .   460 

spastic  paraplegia  from 

113,  512 

spontaneous    iracture 

from  . .         . .  2,43 

stiff  neck  from         . .  648 

swelling  in  iliac  fossa 


in  back  from 
154,    364,    680 

ai  116,516,713 
myelitis 

389,  516 


spine  frc 

transverse 

from 

other  tuberculous   le- 
sions and    .  .  ..   516 

with  tuberculous  peri- 
tonitis        , .         . ,     48 

ureteral  calculus  simu- 
lated by     . .         . .   461 

a*-rays    in    diagnosing 

116,   154,   364,  429, 

461,   477 

-  cord,  amyotrophic  lateral 
sclerosis  of  (see  Amyo- 
trophic Lateral  Scler- 


als) 


of 


432 


-  -  central    canal    of, 

syringomyelia        . .     62 

■  -  changes,  from  anaemia  610 

pernicious  aneemia       64 

transverse  myelitis       62 

after  typhoid         . .    715 

-  combined   sclerosis  in 

(see  Combined  Scler- 
oses) 

-  compression    of,    allo- 

cheiria  from  . .      17 

paraplegia  from  510,  514 

penile   erection   ab- 
sent from  . .    313 

transverse    myelitis 

from         . .      389,  516 

-  contusion  of,  priapism 

from  . .  . .   538 

-  disease,    pain    in    the 

chest  from..  ..   430 

-  -  retention     of    nrinf 

with        .  .  .        :;:■. 

-  diSi^Pinin:Hr,|      ...|,tm~i~ 

Of(>-,.   hi-,.n,n,;,tr,l 
Scleio^i^.) 

-  double  hemiplegia  from 

lesion  of      , .  . .    502 

-  embolism  of  . .         , .  517 

-  gumma  of,  allocheiria 

from  . .  . .      17 

-  haemorrhage  into  140, 

509,   514,  515,  538,  608 

-  hemisection    of,    allo- 

cheiria from  . .     17 

-  -  priapism  from       . .    538 

-  insular  sclerosis  in  (see 


Spinal  cord  lesions,  ataxy 
from 

constipation  ^ith.. 

difficultr  in  micturi- 
tion with 
Spinal  cord  lesions,  effects 
of  cervical    . .  . .  . 

gangrene  from 

hemiplegia  from    . . 

-  -  -  paralysis    of    bowel 


fi-nn 


deffeca- 


Spinal  cord  lesions,  sensory 
disturbances  with      . .  i 

small   paliiebral  fis- 
sure from  . .   ; 

pupil  from         . ,  ; 

-  —  in  tabes 

tympanites  from  . .  ; 

urine  stream  changes 

from        . .  . .  ; 

neoplasm     of,     allo- 
cheiria from 


SPIXAL   CARIES 

Sf)inal  cord,  contd.  Sf 
neoplasm     of,      ataxy              - 

from  . .  .".      58 

Brown-S6quard 

phenomena  from 

paralysis  of  one  leg 

from        . .  , .   496 

pachymeningitis  of  . .    516 

reflex  centres  in  (Fig. 

211)  ..  ..518 

-  -  sarcoma  of      . .  . .   305 
sensoiT  localization  in 

(Fi^.  210)    ..  .,518 

tracts  in  55,     {Fig. 

258)  607 
softening  of,  allochei- 
ria from      ..         . .     17 

from  enteric  . .  516 

from  injury  . .   310 

paraplegia  from    . .   516 

penile    erection    ab- 
sent from  , .    313 

from  scarlet  fever. .  516 

syphilis       . .         . .  516 

thrombosis  . .   516 

not  tinged  by  jaundice  324 

tumour    of,     atrophic 

palsy  of  arm  from    509 

-  - —  paralysis  of  one  leg 


fro 


-  gliosis 

latPi 


of. 


-  memnges. 

hypersBSthesia  from  610 

-  segment,    5th    cervical, 

effect  of  lesion  of. .  507 

Cth  cervical,  effect  of 

lesion  of     . .         . .  507 

7th  cervical,  effect  of 

lesion  of     .  ■.         . .  507 

8th  cervical,  effect  of 

lesion  at     . .      501,  507 

1st    dorsal,    effect    of 

lesion  at      ..      501.  507 

Spinal  segments,  cervical, 
muscle  distribution  of  509 

Spinal  segments,  cervical, 
muscles  supplied  by  . .  504 

lumbar,  muscle  con- 
nections of . ,  ..   498 

hunbar  plexus  and   . .  498 

sacral,  muscle  connec- 
tions of       . .  . .   498 

sacral  plexus  and     . .  498 

-  thrombosis  (see  Throm- 

bosis, Spinal) 

-  tumour,  pain  in  arm  from  443 
Spinati,    paralysis    of,    in 

Erb's  palsy    . .  . .   507 

-  root  imiei-vation  of      . .  509 
Spindled  fingers,  in  rheu- 
matoid artlu~itis  (,Fig. 

153)  342,  378 
Spine,     actinomycosis     of 

713,  714 

-  aneurysm  eroding 

516,  664,  670 

-  carcinoma  of     154,  467,  648 

-  r;.ri.-     ,.f     f.M.....     fipinal 


III  .!.■ 


chest 


SPINE.  CURVATURE  OF 

angular,    from 

rysm 

new  growth 

tubercle      . . 

asymmetrical 

from  . .         . .  : 

from  caries     . .  . .  i 

dwarfism  from  . .  : 

liver  depressed  by    , .  ; 

Pott's,     shortness    of 

breath  from 

psoas  abscess  with    . .  ) 

in  rickets       . .      187,  : 

syringomyelia         257,  < 

(and    see     Kyphosis ; 

Lordosis ;     and    Scoli- 

Splne,  entassement  of  . .  <j 
-  eroded  by  aneurysm  434,  't 
pain  in  testis  from    -i 


713 


SPLEEN 

'I'ine,  eroded,  contd. 
~  by    mediastinal     new 

growth        . .  , .    434 

fracture  of  (see  Fracture 

of  Spine) 
growth  of,  kyphosis  from  154 

-  pain  in  the  back  from  428 

-  prominence    of    back 


from 
-  hydatid  of  154,  15 

kyphosis  from 

tenderness     of 


169 
, 032, 714 


611 


Spine,  hysterical    . 

Spine,  infective  arthritis  of  648 

interscapular     pain 

from        . .  . .   461 
pain   in  iliac  fossa 

from         . .       452,  454 
Spine,  injury  of.  effects  of  7f5 

-  -  (and  see  Injury) 

-  invaded  by  new  growth  713 

-  irritable  .  .  .  .  .  .    715 

Spine,  lateral  curvature  of 


(and  >.. 


from  caries 

caries  simulated  by    429 

from  diphtheria  153,  154 

empyema    . .  . .   153 

fibroid  lung  . .  153 

in  Friedreich's  ataxy  154 

from  hysteria        . .  153 

infantile  paralysis     153 

myopathy  . .      153,  154 

in  nursemaids       . .  154 

occupation  and     . .  154 

from     paralysis     of 

back  muscles     . .  153 

peripheral     neuritis 

153,  154 

rickets         . .      153,  154 

sore  throat. .         . .  154 

Sprengel's  shoulder    153 

unequal  I^s         . .  153 

weak  back  . .   153 

wfiL'lit  carrying  153, 154 

ujy-n.-.k      ..       153,154 

-  IuuiIku-.  iiiiiirv  to,  sciatic 

norv.-  i.aralysis  from     113 
talipes  from  . .   113 

-  malignant     disease     of, 

pain  in  arm  from     . .  443 
testis  from         . .  483 

-  necrosis   of,   swelling  in 

iliac  fossa  from         . .   678 

-  new   growth    of,    aneu- 

rysm simulating       . .   714 

angular    curvature    714 

backache  from      . .  469 

caries  simulating  ..   51G 

girdle  pain  from    . .   714 

intercostal  neuralgia 

simulated  by      . .    707 

-  -  -  malingering     simu- 

lated by  ..  ..714 

pain  in  back  from. .   714 

neck  from  . .   648 

shoulder  from    . .   475 

imibilicus  from  . .  484 

paralvsis  of  one  leg  499 

paraple-ia  from  514,  714 

post-mortem       dia- 


Spine,   contd. 

-  on  OS  calcis        . .        440,  67 
skiagram  of  . .   44i 

-  osteo-arthritis    affecting 

345;  34fi 

pain  in  iliac  fossa  from 

452,  45^ 

-  penetrating    wound    of. 


•  beds. 


I  fro 


25i 


71J 


pnmary  very  rare. .  0I6 

from  prostate        . .    714 

rigidity  of  back  from  461 

■ root  palsies  from  . .   509 

■ from  sarcoma        . .    714 

■ secondary  to  breast 

516,  648,  714 

thyroid    . .      648,  721 

■ simulating   neurosis  477 

spastic     paraplegia 

from        ..         ..lis 

spinal   caries  simu- 
lated by. . 

simulating 

-  -  stiff  neck  from 

from  testis. . 

transverse    mveliti 


fro 


-  rlifumatoid  arthritis  of. 

-  rigidity  of,  with  caries. .   15^ 

from  Pott's  disease  . .   llf 

spondylitis  deformans  64E 

-  sarcoma  of         . ,  . .   15^ 

-  tender   (see   Tenderness 
in  the  Spine) 

-  tuberculous  disease  of  . .  341 

anaemia  from        . ,     3i 

(and  see  Spinal  Caries) 

Spine,  typhoid  . .  34C 

S|>ino-cerebellar        ataxy, 

153  SPIRALS,  CURSCHMANN's'^' 

428  153 

154  Spirilla,  in  Vincent's  angina  (il-l 
Spirillum  of  relapsing  fever 

{Plate  XXVIIf)       . .  GU 

-  of  Vincent's  angina  (Plate 
XXVIII)       .,  ..614 

Spirochsetes,  in  chancre 

618,  674 

-  sjTahilis 739 

Spirochjeta  obermeieri,  in 

I'lood  lilnis     ..  ..    037 

-  l..il1M'i  \I'lii!r   XXVIII)  014 

Spiro"hsta     obermeieri. 

characters  of-  ■  28 

ligure     of     (Plate 

XX\T[I)  614 

Leishman's  stain  for. .     28 

in  relapsing  fever   28, 

336,  596,  637 

-  palhda,  in  cerebrospinal 
fluid 305 

from  chancre  619,620,  701 

fixing  method  for     . .    701 

rheumatoid     arthritis 

from  . .  . .     35 

sore  throat  due  to    . .  013 

stains  for       . .         . .  701 

-  -  in  syphilis        73,  334,  097 

ulcer  of  palate         . .  588 

Spitting     of     blood     (see 

Hcemoptysis) 
Spleen,     abscess    of    (see 
Abscess  of  Spleen) 

-  carcinoma  rare  in        . .  032 

-  dipping  over     . .         . .     44 

-  dislocation  of     629,  630.  041 

-  embolism  of  (see  Em- 
bolism of  Spleen) 

Spleen,     enlarged,     heart 

disease  and  .  ■  632 

Hi   Uodijkius  <li.sea,sf 

;;7.  55.  04,  ;-;7t;.  3so,  5H9 

I impacted  in  pelvis    . .   023 

I from  injury    . .  . .   041 

Spleen,  enlarged,  kidney 
simulated  by  ..     353,  663 

simulating  . .   004 

laparotomy  in  dia- 
gnosing      .  .  . .   062 

I in  lardaceous  disease 

8,  35,  375,  035 

I leukemia,  24,  55,  64, 

99.  273,  283.  570,  611 
Spleen,    enlarged,    list    of 
causes  of       . .     03i,  632 

-  -  in  Iviupliadenoma  51, 
329,  679 

lymphatic  leiik;tmia 

malaria    273,  274.  5(;S,  037 

Malta  fever    400.  500.  037 

movement  with  rt-ipir- 

Spleen,  enlarged,  notes  on 

662,  664 

omental  tumour  simu- 
lating . .  . .   664 

ovarian  tumour  simu- 
lating ..  ..630 


648 


51G 


SPLF  EX 

— 

I)i€cn,  enlarged,  confil. 

S/)!een,  enlargement,   cuntd. 

-  pain  in  the  left  hypo- 

in  general  tuberculosis 

640 

chondrium  from    . .   450 

htematemesis  from  265 

-  pancreatic        tumour 

-       272, 

273 

simulating  . .         . .  630 

haematoma    mistaken 

-  in  paratyphoid         . .  637 

for 

632 

-  pelvic  swelling  due  to  6SS 

in  Hanot's  cirrhosis  . . 

371 

-  in   pernicious   anajinia  63-4 

-  Giiucher's  cells  in 

634 

-  |.ho,-.i.honis    i,uU n-  y.W 

Spleen,  great  enlargements 

gleen.   enlarged,   physical 

of  the 

632 

signs  of        ::'■:;.  628.  629 

-  ■.-lunni.i  r.ivr  iti   .  . 

032 

l.l.'lintir  clTll-hMi  «itli      111.; 

-   ii;i-iiiorr}iaL'i"'   iTiro 

041 

-   Ill  im.inn.iuri              .  .    Ii:i7 

-  liydatid  cyst  in  . . 

667 

pleen,    enlarged,    polycy- 

- -  rare  in 

632 

themia  with         Vit,  633 

-  infarction  of  (see  Embol- 

- |i<.!-t;t!(»ii-rrui-tiuii  from  liTl' 

ism    of   Spleen ;     and 

~  irom  portal  vein  ob- 

Infarct of  Spleen) 

struction     . .          . .  030 

-  lardaceous  disease  of  35» 

thrombosi.s         . .  274 

172,  632, 

635 

-  in      pseudo-leukiemiii 

-  Leishman-Donovan 

inf.intuni        .'iT.  ij.?,  634 

bodies  in 

29 

-  redncc-d  by  r-niys    . .     25 

-  normal,  palpable  in  child 

034 

-  in  rel.ipsirii'  fever  330,  037 

-  pedicle  twisted  . . 

032 

ileen,     enlarged,     renal 

-  in  pelvis 

030 

tumour    distinguished 

-  rub  over..         592,  629, 

040 

from 629 

from  general  perito- 

- ill  rliHiliuiitoid  artliritis    35 

nitis 

388 

-  ric  k«s                          .  .    635 

-  rupture    of,   laparotomy 

-  sarcoma    of    stomacli 

in  diagnosing 

641 

simulatinR              . .   030 

—  sarcoma  rare  in . . 

632 

-  in  scarlet  fever         . .  037 

-  strangulation  of 

641 

-  .septiciemia     . .         . .  037 

~  wandering,    swelling    in 

-  i^kodaic  resonance  from  611 

iliac  fossa  from 

678 

-  in  small-pox  . .         , .  637 

Splenectomy,  familial  acho 

-  splenic    anaimia,    37, 

luric  jaundice  cured  by 

55,    64,    273,    372, 

332, 

034 

CPiy.  267)  033 

Splenic  anemia  {Fig.  267) 

633 

-  splenomegalic  cirrhosis  033 

albuminuria  in 

13 

polycytliajmia       . .  101 

ansemia  in 

5S 

-  Still'.s  dLse.-i.se           35,  378 

ascites  in          46,  55, 

372 

-  -(.mi:.,l,  tiiiM.iur-iiiiii- 

Banti's  disease  and  37, 

1, IT. Ill-                    .;.1J.  664 

64,  372 

033 

pleen.  enlarged,  suprarenal 

basopUile  cells  in     . . 

55 

tumour    distinguished 

bleeding  gums  in      . . 

72 

from    ..        ..     629.  630 

blood  changes  in 

633 

simulated  by     . .  662 

cirrhosis  and,   37,  55, 

simulating,'          . .  664 

64,    111,    372,   633, 

635 

-  thrombosis  of  splenic 

clubbed  Untrers  iti     .  . 

111 

STAIX 


Sjilnionwih  poh/ci/rhcvmia,  contd. 

heart  disease  simulated 

by 033 

enlarfjed  in  . .    633 

-  -  hiirh  hlnod-l.rr?sur<-  in  271 
Splenomegalic    polycythae- 

mia.  main  features  of    534 

-  ~  {I'hitv  A.V/.Vi 


ellu 


033 


shortness  of  breath  in  633 

from  summer  diarrncfia  533 

Splenomegaly,    infantilism 

with 189 

Splint,  bulto  from  . .     96 

-  gangrene  from  . .  . .   255 
--muscle  atrophy  from  . .     61 

-  paralysis  (,Fig.   58)  141 
of  sciatic  nerve  from    113 

-  tjilipes  from       . .  . .  113 

-  vesicles  from      . .         . .   757 

-  VoUanann's  contracture 

from  . .  . .  01,  506 
.Splinters  of  wood  in  rectum  584 
Spondylitis  deformans 

{Fig.  274)  648 

appendicitis  simulated 

by 401 

contnacturcs  from  142,  143 

Spondylitis  deformans,  gene- 
ral account  of  . .  714 

-  -   ii,i..|-^ii.ulir|i:iin  from  461 

-  -  kviih.i-i-  III. Ill  ..    155 

rigidity  ol  Ijack  from    401 

tenderness     of     spine 

from  ..      713,  714 
ureteral  calculus  simu- 
lated by     . .  . .  461 

a:-rays  in  diagnosing, .  461 

Spondylose  rhizom^lique  of 

Marie  . .      714,  715 

Spontaneous     fracture     (see 

Fracture,  Spontaneous) 
Spoon-nails  . .  . .  400 

Spores,  in  erythrasma     . .   251 

-  favus       . .  . .  . .   247 

Spores,  ringworm  . .         . .  247 

-  in  tinea  circinat.a  . .   223 


636 

with  tropical  liver    . .  309 
■  in  typhoid  fever,   70, 

171,  335,  564,  629,  630 
typhus  fever  . .         . .  637 
vena    caval    obstruc- 
tion by       ..  ..   749 
.laksch's  disease  634 


id  lu 


250 


I's  di.- 


il-_-.-l     111 


IPLEEN.  ENLARGEMENT 
OF  THE  ..628 

-  in  acute  fevers  . .   630 

-  aneurysm  mistaken  for  031 

-  in  Jjantj's  disease     . .     04 

-  blood-count    essential 

with  ..  ..634 

-  bronchiectasis  from  . .  292 

-  bruit  over      . .         . .   629 

-  carcinoma  of  stomacli 

simulutinsf  . .  . .  630 

-  in  catarrhal  jaundice    329 

-  chihircn         . .         . .  634 

-  cliloroma        . .         . .  205 

-  cirrhosis.  51.  266,  272, 

273.  332.  371,  374,  635 
o(  childhood  . .   332 

-  colon    tumour    stmu- 

latini;  . .  . .    664 

-  in  eouKenital  syphilis  035 

-  iliphthiTiii       ..  ..637 

Ipieen.  enlarnement  of  the. 
disliniiuislied  from 
things     simulatinii     it 

629,  630,  631 

-  -  in    Ki,.ypl        .  .  .  .   034 

■  -  erysipelas       . .         . .  637 

-  -  ficcal       accimiiilation 

simulnlinK  ..         ..  631 

■  -  in    familial    nclioluric 

jaundice      . .      332,  034 

•  -  felt  in  iliac  fossa      . .  070 

-  -  llbroiil  lunK  from      . .  292 

-  -  fraijility   of    red   cells 

and 634 

•  -  in  fun^atin^  endocar- 
34.  03" 


(f:, 


nin 


•J73,  274,  372 

1 ,,.|,.i  .;.    in.ni      .. 

287 

hiEmorrhages  in        . .  372 

Sp...  i.  .   !■    .....    .Menin- 

-  -  jaundice  in    . .      325,  372 

. ,  ,  .  .  .,  ......j.inal) 

-  -  myelocytes  in           . .     55 

Spr......   -  ■!•■    .in.phy  in 

01 

Splenic  ansmia,  notes  on    633 

-  l.nipuni  f.„m     .. 

.553 

-  -  rfd.>nia  of  legs  in    413,  415 

-  talipes  from 

114 

peripheral     neuritis 

Spreiigel's  shoulder,  scolio- 

from            .  .          01,  04 

sis  fn>iii  .  .          . .       ■   .  . 

153 

pleuritic  effusion  in  . .  106 

Spi-.i.-.  .h.i.l,....  Iiom  172, 

239 

purpura  in     . .         . .  553 

-1.11.     .  i.i.i    .1    .  . 

239 

simulating  cirrhosis..  273 

--   I'll.     .  ..,-M... lion  in 

24 

leukaemia    . .         . .   273 

-  M.,....i,ii-i..        ..      172, 

542 

malaria      . .         . .  273 

-  stools  in .  . 

172 

spleen  large  in,  55,  04, 

Spur    on     nasal    septum. 

273,  372,  631,  633 

anosmia  from 

612 

splenomcgalic  cirrhosis 

-  OS  calcis..          ..      440, 

671 

and  . .         . .     372,  633 

;r-ravs  in  diagnosing 

440 

von    .faksch's  , disease 

SPUTA 

641 

and  . .         . .«        . .  634 

Sputum,     abundant     foul. 

Splenic  artery,  opened  by 

sii.liliMi  ciiugliing  uj)  of 

86 

gastric  ulcer  . .         . .  268 

~   ;..■.  !....iii\  .-.•-   i.i   .  . 

645 

-  flexure,  carcinoma  of  125,  630 

-  1..   ...m.'   1  1.  1  .iL-ilis 

149 

-  puncture    m     kala-azar 

-  ;.ii..i..,..i.,i.  ,  I'l  phthisis 

644 

29,  633 

-  ;i...  I.... .  -. ....  .■    .-oloured 

Leishman-Donovan 

149, 

644 

bodies  found  on    . .  633 

from  hepatic  abscess 

291 

-  vein,     thrombosed    (see 

-  in  aneurysm 

149 

'riiroml.osis.  .Splenic) 

-  aspergilliis  in     . . 

045 

.-|il..ii., III. •.lull. .i-v       leukie- 

-  bacillus  inllucnzo)  in  290 

Oil) 

.111.    .   I.-     Linkmniii; 

pyocyaneus  in 

oil 

I.I.I  l..-.ik;i'....;...Slili,Miu- 

-  I.lai'k 

-  blo.i.l     in    (sec     Hemo- 

01 1 

Splenomeqalic  cirrhosis     .  332 

ptysis) 

Splenomegalic    cirrhosis. 

-  -  linge.l 

ii;i 

general  account  ol      .  633 

-  blue          

(ill 

-          .|.l.-.i|.'  :...;.■.. .1.1  .111.1    .  .     372 

-   Itordel-lW.ngon     bacillus 

-  polycythiemia    ..       llll,  533 

ill 

045 

apical  bruit  in          . .  033 

-  in  lirotK'liiectasis 

149 

-  -  hie  spleen  with         ..    101 

Sputum,  in  bronchitis  ll». 

644 

Itlood-pressnre  high  in  633 

-  calcareous    jiartides    in 

-   ■  .  V.II...M-  (I..III  i:.;.  i.;l.633 

(.Fig.  273) 

044 

Splenomegalic    polycythe- 

- coscoiut  moss  in        420, 

644 

mia,  general  account  of  633 

-  Chnrcot-Levden  crystals 

-  -  1... III...!. 11. .1-1,  II.         ,  .    271 

in         ..          ..      1112, 

153 

Sputum,  contd. 

-  Curscbmanu's  spirals  in 

102,  153 

-  disgusting,  from  gangrene 

of  lung  , .  . .    259 

-  distoma  in  . .  . .    292 
Sputum,  elastic  fibres  in 

159,  259,  iFig.  271)  642 

from  bronchiectasis 

260,  598 

empyema   . .         . .   260 

foetid  bronchitis   . .  260 

gangrene  of  lung  86, 

260,  290,  644 

mode  of  examining 

for  ..         ..  642 

soda  in  detecting.,     86 

from    phthisis    159, 

260,    286,    288,    598 

-  eosinophile  corpuscles  in 

102,  153,  219 

-  fcetid,from  bronchiectasis  290 

empyema        . .  . .    29n 

fibro'id  lung    ..      168,  216 

gangrene  of  lung       . .   29i> 

-  -  phthisis  ..  ..  29(1 
Sputum,  foul  abundant  ..  643 

with  bronchiectasis  14,  613 

empyema        . .  . .  »'>43 

foetid  bronchitis        . .  643 

gangrene  of  lung       . .  643 

hepatic  abscess         . .   644 

phthisis  . .  . .   613 

-  in  gangrene  of  lung      . .   149 

-  green 644 

-  in  influenza        . .  . .  465 

-  micrococcus  tetrageuus  in  645 

-  in  mitral  stenosis         . .   149 

-  new  growth        . .  . .   149 

-  nummular  ..      149,  641 

-  offensive,  from  bronchi- 

ectasis . .      260,  598 

empyema       . .         . .  260 

foetid  bronchitis        . .  260 

phthisis  . .  . .   260 

-  oidium  albicans  in        . .  645 
tropicale  in    . .  . .  645 

-  ova  in 645 

-  Parogonimus  Westermani 

-  particle  of  new  growth  in  644 

-  penicilliuni  gluucum  in     045 
Sputum,  in  phthisis  119,288,641 


Sputum,  in  pneumonia  149, 

289,  335,  642 

-  red,   from   bacillus  pro- 

digiosus  ..      286,  614 

-  red-currant    jelly,   from 

new  growth  . .  . .   290 

-  rusty       . .  . .  . .   149 

in  pneumonia  289,  641,  642 

-  sudden  gush  of  purulent  532 
Sputum,  tubercle  bacilli  in 

159.  l:i9,  -jss.  i:.s.64l,  642 

-  visci.i,      m       I inri....iii 

2S9.   lill.  642 
Squalor,  typing  fever  and  335 
Squames,   in   vaginal   dis- 
charge ..  ..   1S5 

-  from  viiginitis    . .  . .   185 
Squint,  amblyopia  from..  759 

-  from     cavernous     siiuis 

thrombosis     . .  . .  597 

-  cerebral  disease  . .  295 

-  meningitis  . .         . .  315 

-  (and  see  Strabismus) 
Stab,  cervical,  ht^miplcgia 

from 303 

-  of  for.l.  Mllochciria  from  17 

-  Ii:i-ni;ii<'iiicsis  from       . .  271 

-  h;fniorrliiigi!    into    cord 

-  licmiplci.'ia  from  ..   306 

-  iMiruinoIhorax  from  531,  532 

-  suhcntaneouscmiihysema 

from 203 

-  transverse  myelitis  from 

389.  516 
Stabbing  pain,  from  pleuri.'iy432 
Stable-s,  bacillus  nndlei  in 

workers  in      ..  ..615 

StJiggcriiitr,  in  tabes         ..   751 


fro 


l-tiKO 


Stain.  carhoI-fuclL- 


alaria   pax-asites  oG8 


eczema        . .  , . 

brown  (see  Pigmenta- 
tion of  Skill) 

rjftnr  hrrpr^    ..       600,   ' 


-Mil,-,  i^i'  I., I  ^mplets    .. 
Stammering  . .         . .  i 

Stammering  bladder 
-I  ij'F  iliu<  muscle,  paralvi^is 

oi  ..  ..      493. 

.■^Utpcs,  loot  fixed,  sounds 

heard  better  in  noise 

with : 

test  for       . .         . .  '. 

-  pressure    on,     giddiness 

from    . . 
Staphylococci  (Plate 

xxvffr)      ..       ..I 


III  fluid   ..    ? 
iiitisdueto  -1 


STAIN 


status  lymphalicus,  general 
account  of 

Stays,  breast  irritated  by 
Steam  enpiiies  blowing  oil 


- 

STO(  T,S 

Siiff  jiech:   contd. 

Stomach,  t/as  in,  contil. 

382 

in   tetanus   138.    417. 

gas  in  siileiiic  flexure 

430 

599,  649,  730 

simulating  . . 

torticollis       . .         . .  647 

a'-i*ays  in  di:ii,'noi-int,'. . 

40G 

Stigmata,     venous,     from 

Stomach,    hamorrhagic 

U13 

alcohol            . .          . .   726 

erosion   of     :'i;.5,  269. 

Still's  disease,  ancemia  in 

pyelitis  from     . .  . .   , 

recovered  by  blood  cul- 
ture    . .  . .  . .   I 

rhrumatoid  arthritis  from 

I]. I  i,:)Mnia  from  . .   ; 

- tliroat  due  to        . .  i 

I'll  iiiive        laryngitis 


aphylococcus     pyogenes 
atbus,  in  furuncles    . .  < 

in  normal  urethra. . 

in  otitis  media      . .  < 

urethritis  due  to  . . 

-  aureus,  cystitis  due  to 
in  furuncles 

infective      endocar- 
ditis 

nephritis  due  to    . . 

in  otitis  media 

-  --  prostiU.itis  due  to.. 

-  -  i>y.-I plirili-.l.irto 


lined   by 


Staphyloiriii,  I 
Starch  grams, 

iodine  . .         . .         . . 

in  stools         , .      170,  : 

from   pancreas  dis- 

Staring    appearance,     in 

Graves's  disease        . .  : 
paralysis  agitans      . .  : 

-^tiiit-  tin  going  to  sleep  ..   \ 
-I  n\  iiion,  acetonuria  due 

iiiiii-inin  from 

-  cachexia  from     33,  413,  ■ 

-  diacetic  acid  in  urine.. 

-  general  wasting  from  . . 


Status  epilcpticus. 

-  lymphaticus,  con 

from    . . 


-  of  pharynx         . .  . .   V 

-  pulmonary      (see      Pul- 

monaiy  Stenosis) 

-  pylorus     (see     Pylorus, 

Stenosis  of) 

-  tricuspid  (see  Tricuspid 

Stenasis) 

-  of  urethra  (and  see  Stric 
e)    ..  ..  7, 


094 


Sten^on's  duct,  calculus 
Stereobilin,  absence  of,  in 

carcinoma  of  pancreas  101 
Stercoral  ulcer  of  bowel  47 
-  -  Ciccuni  .  .  .  .   459 

STERILITY  ..645 


Sterility,  list  of  causes  of.. 


Ste 


of 


seborrhoeit 
Sternomastoid,  callus  in 

—  injury  of.  wry-neck  frc 

—  myoclonus  of    . . 
~  ruptui'e  of 

—  spasm  of.  hysterical 


.   141 


■ticollis  from      141,  14'J 

StfTinnn.  .-rndr-a  by  aneur- 
ysm      .  .  .\       16S.  434 

Sternum,  lesions  of,  tender- 
ness due  to     . .         . .  707 

-  node  on.  from  yaws      . .   403 

-  periostitis  of 


of 


707 


STERTOR 647 


StetiK 


abdominal 


-  detect i 

deaf  I 

-  diagnosing       hour-glass 

stomach  . .         , .  318 

osteo- arthritis  . .  347 

'  -  testing  knee-jerk  . ,  357 

-  succussion  detected  by    651 
Stiff  back  (see  Rigidity'of 

the  Back) 
STIFF  NECK  ..847 

after  burn       . .  . .   648 

from  cold        . .  . .  647 

from  draught  . .   429 

fractured  spine         . .  648 

infective  arthritis     . .  648 

inflamed       lymphatic 


nds 


gitis 


194 


-  -  (Fi,i.  ir.9)      .. 
StilPs  disease,  general  ac- 
count of 

iunpnig  from.  .  .  .    . 

-  —  lymphatic  glands   eu- 

"  larged  in      35,  376, 
Still's  disease,  main    sym- 
ptoms of    . . 

pain  in  foot  from    . .   ; 

pigmentation  in        . .  ; 

spindled    finger-joints 

spleen  enlarged  in  35, 

378,  I 
Sting,  bee-,  dysphagia  from  '. 

-  jelly-fish,  erythema  from  : 

itching  from  . .      224,  i 

oedema  from  . .         . .  : 


lated  by 

-  in  athletes         . .         . . 

-  pain  in  the  chest  from. . 
iliac    fossa   from   452, 

454, 

-  from  overstrain  of  inter- 

costal muscle,  i  . . 

-  tenderness  from 

I  Stockbrokers,  chronic  phar- 
yngitis in       . .      G13,  ' 
I  Stocking     anaisthesia     in 
j  hysteria  . .         . . 

peripheral  neuritis    . . 

Stocking  and  glove  anes- 
thesia (Fig.    256)     . . 
I  Stokers.  crani|.s  in 


.■1- 


a  form  of  i 

from  new  growth      . .  648 

pyorrhoea  alveolaris. .  648 

rlieumatism    . .         . .  138 

rheumatoid  arthritis  648 

spinal  caries  . .  . .  648 

spondylitis  deformans  648 


Stokes  Adams's  disease  .. 

i|...|.|.  .  r.      iftiicks   in 

-  -   liraih-nnrdi;r  from   S3,  : 
bundle  of  His  in 

-  -  coma     in         83,  118, 
convulsions  with  144, 

146, 

cyanosis  in     . . 

electrocardiogram     in 

diagiiosinE'  . . 

s:;.  m;. 

Stokes- Adams's       disease. 

general  account  of  146, 

heart-block  and     48G, 

simulated     by     shio- 

auricular  changes. . 

stertor  in 

syncope  in     . .        S3, 

palpitations  in 

Stomach,    aneurysm    rap- 
tured into  76. 120.  265. 

-  atonic,  iliijim-i-  nf  i?ll. 


-  carcmoilia  <'l  (-re  l  'nr.'in- 

oma  of  the  >;tomach) 

-  congestion  of,  vomiting 

from 765 

-  contents     (see     Gastric 

Contents) 

-  defective     motility     of, 

gastric  contents  with     319 
STOMACH,    DILATATION 
OF  i.ni.l  ~rr  DiI;itation 

SI .Nil  .Ii-r,-,    in  negroes     99 

ti'iid.Tiir-.-     of     spine 

from  (/"iV?.  294)  7lG 

-  fermentation  in. .  . .    241 

-  gas     in,     from     pyloric 

obstruction     . .  . .   245 


riihi 


Inflation  of  Stomach) 

—  injury   of,   haimatemesis 

—  insomnia  and    . . 

-  lavage  of  (see  Lavage) 

-  leather  bottle  (see  Cai-- 

cinoma    of    Stomach. 
Diffuse) 


absci 


nptu 


Stomach,   methods  of  ex- 
amining 319,  : 

-  Tiiol  ility,  currants  in  test- 

-  iKtrnial  capacity  of       . .   : 

perpendicular  position  : 

site  of . .  . .  . .  I 


Stomach  succussion.  general 
account  of    174.    -'tl. 
'lU,  S-J-J,  651,  »i.v_'.  ( 
-  size  of,  modes  of  deter- 


Stomatitis,  aphthous 

-  i,ar(.-rJolo-vnHlia-iiusinLr 

nature  of 

-  bleeding  from    . .  72. 

-  blood-spitting  from 

-  witli  dermatitis  herpeti- 

formis 

-  dysphagia  from  74. 

-  with  erythema  bullosun^ 

-  foul  breatli  from  74. 
,  -  -  tastf  frniii        .  . 

Stomatitis,  general  account 


perleche  with  . 
with  ppniphigus 
from  [.linsphoru; 


from  syphilis  . . 
taste  loss  from  . . 
toiiLMic  swollen  fn 


Stomatitis 
Stomatitis 

-       W.I  .■! 


STOOLS 


SUGAR 


lools^  COItttl.                                            ' 

.Sfciols    cinkl. 

Slrcplococci,  coiittl. 

^Iri/cliitint;  cuiifiL 

alkaline,  from  putrelac- 

-  panisites  in  (see  Parasites) 

-  laryngitis  from  199,  418, 

-~  poisoning,  chemical  ana- 

tion  170 

-  potato  particles  in        ..   170 

419,  650 

lysis  in  diagnosing     417,  599 

amopba  coli  iti   . .          . .   172 

-  pus  in  (see  Pus  in  the 

-  meningitis  from            . .  305 

convulsions    in     138, 

■Stools) 

-  nasal  discharge  due  to. .  178 

144,  729,  730 

i.,.i  irnolO'jy    ofi'iii    ZJ-- 

Stools,  reaction  of..         ..   I7Q 

-  nephritis  from  . .            9,  09 

from  hypodermic   in- 

iiiMii," iliarrhcca         . .  384 

-  rice-water,  from  arsenic  2118 

-  orchitis  due  to  . .          . .     07 

jection        . .          . .  599 

l.il.'  Hi 170 

in  ciiolera       . .          .  .   273 

-  in  otitis  media  . .          . .  422 

liyperacusis  from     . .   309 

Ijlack  Cin.l  .^oo  Wo,,,!  ,..■■■ 

-  in  rickets             . .          . .    145 

-  perleche  from    . .          . .   360 

hysteria  simulating 

Alllllll   :    :ilnl   \rrl;,.|;,|      75 

-  shreds  in,  in  ulcerative 

-  in  phthisis         . .          . .   641 

417,  398,  729 

-  from  liilli-iTir            .  .     75 

colitis 172 

-  prostatitis  due  to         . .     70 

localized     convulsions 

-  from  l.i-iiiiiil,  -idi.lii.lf     75 

-  skins  in 399 

—  pyelitis  from      . .          . .  570 

fi-om            ..         ..  144 

-  sloughs   ill,    in    typhoid 

-  p'yelonepliritis.lneto     ..      69 

-  -  no  lockjaw  in           ..417 

-  from  charcoal            .  .     75 

fever 630 

-   1I-...  .1  .T...  1    l.\-    l.lnnd   cul- 

mind  clear  in           ..418 

blood  ill 170 

-  small  dry  hard,  due  to 

lin.. 597 

opisthotonos  in     417.  59'.i 

-  with  ulcerative  colitis  172 

greedy  colon  . .         . .   123 

-  ill  ill.. n..  ...IV  throat  613 

from  rat  p.aste          . .   -199 

-  and   mucus   in,   from 

-  in  sprue  . .          . .          . .  172 

-  rli.  .11!.  .1 ihrilisfrom    35 

retracted  head  from. .  JS'.i 

arsenic        . :         ..78 

-  starch  grains  in . .          ..  170 

-  Ill           ..II-  throat  013 

risus  sardonicus  in 

carcinoma  of  bowel  453 

from  pancreas   dis- 

 1  .;.    .  a         :. 335 

417,  598,  599 

-  -  colitis    77,  7S,  124, 

ease         ..         ..   172 

-  -..1. 1...   1..        ..  013 

spasm  in         . .          . .  599 

171,  «C3 

Stools,  tarry                    . .     75 

-  »ullu,aiue         kirvngitis 

Strychnine  poisoning,  teta- 

 dysentery    . .          . .  172 

after  hsematemesis    . .  280 

from    . .         . .      158,  610 

nus  distinguished  from 

-  tough  white  particles  in  171 

-  in  typhoid  fever            ..  341 

152.  599 

Henoch's  purpui":i,      556 

-  trichinellsB  in     . .         . .  464 

-  ureteritis  due  to           . .     09 

simulated  bv          . .    138 

intussu-sception    78, 

-  with  ulcerative  colitis. .  172 

-  urethritis  due  to           . .     70 

trismus  from.'.          ..   730 

127,  171,  585,  OeS,  G78 

-  yellow  lumps  in            . .  170 

-  urine 09 

from  vermin  destroyer  417 

-  -  polypus       . .          . .  585 

Stoutness  (see  Obesity) 

Streptococcus    brevis,     in 

-  priapism  from   . .          . .   538 

bulky  Tialc  offensive,  with 

Stoves,  slow  combustion,  car- 

normal nretlira          ..      69 

Stupor,  bradypnoea  with . .     84 

.■u'lil,,    ,li..-.-,-       .      ..171 

bon  monoxide  poison- 

Strepfotrichosis  of  liver  ..  375 

-  from  choL-emia  . .          . .  324 

-  fi-,,i,i  |.,iii,iv:,ti,-,ii<..i.i-  nil 

iiiu'  from         ..          ..119 

srri.  .,■....■   .'11.  aching 

-  in  diabetes         . .          . .     86 

tools,   characters  of  fer- 

STRABISMUS                 ..649 

1  .                 :...in      ..   474 

-  epilepsy  . .          . .          . .     85 

mentative                 . .  246 

-  :uiihIvopia  from            .  .    759 

-  -  ....  ..III. r. 1  i.iin     . ,      13 

-  (and  .see  Coma) 

tools,  characters  of  putre- 

- troni"    cavernous     sinus 

Stylomastoid  foramen,  le- 

factive                      .246 

tliromtio^is                  .      597 

ascending        nephritis 

sion  at           ..          ..  494 

(■|i;.lvi.t.|,cv.lon  iTVslals 

-  -  o-Tohn,!  .li>cise         .  .    295 

from           . .          . .     13 

Styptics  for  bladder         ..   580 

Ml           ..'          ..   ■        ..    I'i2 

-  c,,r„c.inifant        ..           ..    649 

bougie  in  diagnosing 

Subacromial  bursitis       . .  476 

-.  c,.in-.-r-.-iit  U'lfl.  81)    ..    170 

394,  470 

Suhrlavi-pi       ai-ffl'V      (see 

clayey,  from  pancreatitis  (jljl 

-  ,li|.l.,|,i,.   liiiiii     ..          ..   649 

calculus  behind     395,  620 

\.i....   -  il.livian) 

comma  bacilli  in           ..  717 

-  .lu.rj.tii  1  /-■,v.  S2)       ..   170 

from  carcinoma        ...  184 

-  x.i.  .....   1            ..239 

<-oinif.-livo  tissue  in  170,  172 

-  fn.Tri  erinr  .il  n-fraction     049 

catheter  in  diagnosing  394 

Snl..aii  ....■  .  .      ....  ..-s  (see 

ili.'l     I..f.l,V    l.-liN-              ..      17(1 

-  illustrated  i.Fi<j.  83)     ..   177 

cystitis  from          378,  581 

.M........  -NLiilaneous) 

!ools,  dyspeptic    . .         ■ .   171 

-  laryngeal  paralysis  with  495 

difficulty  in  micturition 

-  11, ..lull-     (-.-..     \i..lule.s, 

tools,  examination  of.  gene- 

-  from  meningitis  147,  315, 

with            ..          ..  395 

,<Ni..  Ill    |......1|.  1 

rat  account               ■ .   170 

323,  515 

-  -  discharge  due  to       . .   183 

Suli.il.il.lil  .-'111  11  1..     abscess 

TOOLS,      FATTY          ..  239 

-  paralvtic            . .         . .  649 

dribbling  due   to   39, 

(.....   .\l.. snhdia- 

-  with      carcinoma     of 

-  from'syplul's     -.      495,589 

394,  390,  470 

|,li|..iLaii.iii..l 

pancreas     . .        51,  330 

Strain,  aortic  disease  from  209 

endoscope     in     dia- 

Suhiliiril         l.iaairrhage. 

-  pancreatic  disease  116, 

-  atrophy  of  testis  from. .     07 

gnosing     183.     394, 

,.,.iiviil-i.iN.  limn       ..    110 

172,  191 

-  ossification     of     tendon 

396,  470,  020 

Subinvolution,  en. lometritis 

fatty  crystals  in            ..170 

from 671 

epididymitis  from     . .  697 

with 387 

from   pancreas  dis- 

-  rupture  of  aortic  valve 

epididymo  -  orchitis 

-  menorrhagia  from   380,  387 

ea.se        ..         ..  172 

from 210 

from            ..          ..478 

-  metrostaxis  from          . .  392 

frothy  sour        . .         . .   171 

-  tenderness  of  spine  from  713 

from  epithelioma      . .  697 

SnliliiiL-iial    L-I.ni.l.    chorda 

fruit-stones  in    ..         ..117 

Straininf^    at    stool,    from 

fistula  due  to        397,  020 

niN|.N.:   .....I..          ..   494 

(?reen,  sij,'nillcance  of  . .  171 

colitis 171 

frequent     micturition 

SnI.i 11.1, n     .1.^.-.-^  (see 

-  slimy,     from     simple 

(and  see  Tenesmus) 

from             . .          . .   53  f 

.\i...  .  ...  -iii.iN.iiiiniary) 

colitis          . .          . .     78 

Stramoninm,    asthma    re- 

Stricture of  urethra,  general 

-  r,i!.l-.  .1 1  1  III  .  Ill,  of    . .   251 

leucocytes  in     . .         . .  557 

lieved  by        . .          .  .   535 

account  of                   .396 

Sul.11,,,1  N...  .  :,i.|..  i..|>airing. 

lime  salts  in       . .          . .   170 

Strangulation     of     fibroid  391 

-         Ii\  .ii..ia.|.lini-i..    fl-oni       2S(I 

IN. 1.1111    11.     ihva,  and  542 

meat  fibres  in,  in  pancrea- 

- liernia       (see        Hernia, 

-  -  ,.aii,  ,1.  |ii.ni-  lmni.109.470 

Slll.liiaMllarv    -lallil    duct. 

titis     110 

Strangulated) 

painful        micturition 

calculus  m     ..          ..691 

tools,  mucus  in  . .      no.  398 

-spleen      ..          ..      632,041 

from            ..          ..  396 

chorda  tympani  and. .    19  1 

-  from  arsciii.'   .  .          .  ,      7a 

STRANGURY                   ..649 

—  pyelonephritis  from  . .  570 

swollen  in  Kirkland's 

-  .-arc-inoma    of    bowel, 

-  from  calculus  ui  ureter. .     40 

-  -  pyuria  from  575,  578,  581 

disease       ..         ..  6ir, 

129,   354,  398,  453, 

-  eVNlili- 2S2 

renal  tube  casts  with       7 

Subphrenic    abscess     (sec 

5S.'),  G30 

-  .iriiiiitioii  .if     . .        . .  cm 

retention  of  urine  from 

Abscess,    Subdiaphrag- 

- ciitnrrh  of  small  intes- 

Strangury, from  drugs     . .  650 

39,  390,  049 

matic) 

tine 172 

Strangury,  list  of  causes  of  849 

-  -  scrotal  fisHila  from  ..   621 

Subscapular  nerve           . .  305 

-  OTiitLs  ..          ..77,  7.S,  124 

-  from  retention  of  urine 

II.. Ill      -.111      ...ITS                ..      181 

Snbscapularis,  nerve  supply 

-  constipation   . .          . .   :i;(S 

39,  395 

I .Ill     [1  ..IN           .  .    6-19 

of         505 

-  in  Uy.scntcrv  . .          . .     7'- 

Strangury   from  tahs     ..  650 

III  I'll. 1  .    1 1  ,  .           .  .    MO 

--  root  innervation  of       .  .    3ii9 

-  from  fistula   . .          . .     7S 

.straw,  actinomycosis  from     74 

1 Ir.nn  .  .        8 

Subthalamic  region,  tumour 

-  intussu-sception        78, 

-  sporotrichosis  from       . .  290 

11.  111,.  1,  ii.u'.-sfrom  391 

of.  signs  of     . .         ■  ■  727 

lao.  398 

Strawberries,        erythema 

-       III. .1.1 t.-liiM.l      ..   478 

.Sucfilili-    a,  1,1,    l..ll,.,i,.yl.i^is 

-  with    invagination    of 

from    . .         . .         . .  225 

-       iii.i-iiii  1   li  ..111 .  .          .  .    MO 

rectum        . .         . .  129 

-  pruritus  from    . .         . .  540 

-  .     urelliiili-.  uilli             .  .    581 

SUCCUSSION  SOUNDS    ..  651 

-  from  mucoraembranous 

-  urticaria  from   ..      22.5,  771 

STRIDOR 650 

Succussion     In     abdomen. 

colitis          . .          . .  438 

Streptococci  (Plate  XX  Vlll ) 

-  definition  of       . .          . .  O.Vi 

general  account  of        653 

614 

-  hysterical            ..          ..   051 

Succussion  in  chest,  general 

-  in  rickets       . .         . .  145 

-  in   aiiL'ina    l.udovici       ..    099 

-  with    laryngeal    obstnic- 

account  of              651.  652 

-  spastic  constipation       125 

-■    aithi  III-    It. .Ill       .  .              .  .    341 

lion     '.  .          157.    119.  .V,)o 

Succussion,  gastric  174,  522. 

-  duo  to  tlili-acl-worins        79 

-    ,■             1         ■'!!  ...             ..48 

Stridor,   list  of   causes  of 

651,    652.   653 

-  ulcerative  colitLS     172,  4.'>9 

1  ■"         ■  .  ;',       ii'iin       .  .   007 

650,  851 

-   -    ullliali.iiv       .  .        211.    21  1 

muscle  lihres  in         170,  172 

-    1...      '  .1     .    .■■a.nia  from   50M 

-   fli.Mi  p.i.ill.a.iiia               ..    495 

-  ill  pli'lJl-al  .luilr             .  .    5;ill 

occult      bloo.l     in     (sec 

.1      il  lluid  ..  305 

■-    1 .  ...  1   1 1-is      ..    495 

-  with   piii.uiM.illi.irax-      .  ,    lllS 

lilood.  Occult) 

1  I.       ...          . .      70 

.>^lii.         .    ...Ill           ..    411 

Sucking  discs  of  tape-worms  519 

olTonsive,  from  pancreatic 

:...■• 104 

.•ini'kliMi.'..liu..,'^lraiisniill...l 

disease             ..      110,  191 

•  T'  !.  '■  lisdueto478 

.^li..! 1  I.N  .  liilvcardiii 

hv        M5 

pale    bulky,    from   pan- 

■  II 1  .         .  .           ..98 

rr.iiM 84 

.fudamiim   . .          .  .      328,  654 

creas  lesions          . .  601 

1.. Is       ..   613 

Stroiihulns,  papules  in     ..  771 

Sudan  in    in  staining  fat 

-  from     bile-duct     ob- 

- .  .          ..   207 

-  simulating         erythema 

droplets          ..          ..  108 

stniction     . .      329,  372 

-  ill  ...rill  Ml  iii..i~les  sore 

multifonne     ..          ..489 

Sudden  death  (see   Death, 

-  frothy,    cojiious,    in 

Ihroal               ..          ..   013 

-  varicella  sinnilated  by..  757 

.-Su.l.len) 

hill  dinrrhina         ..173 

-  with  gonococci  . .          ..341 

-  vesicles  In           . .          . .   750 

SulTocaiion.  sense  of,  after 

sprue       ..          ..    173 

-  In  impetigo       . .         . .  fi-'iS 

-  wheals  hi            ..          ..771 

Hushing           ..          ..211 

-  olTensive,    from    pan- 

-  infective  endocarditis  . .  209 

Strvchnine,    hannoglobin- 

Sugar  in  cerebrospinal  fiuid  3m  1 

ileiLS  ilise.LSi.         172     191 

-  Kh-klan,rs  disease         ..   016 

■  nria  from         .  .              .    2S 1 

SUGAR 


SWELLING 


-   HnL'fT--  nir.x'tpfl  by 


I'stimatiiig  2G3 


t:is 


'  of 


^fuggestioii,      amenon-hoea 
Iroin    . . 

-  tj-eatmcnt,  of  functiODal 

aphonia  . .         . .  - 

ill  hysteria      . .      308,  I 

neurosis  . .         . .  ■ 

photopliobia  cured  by  I 

Suicide,  by  ai-senic  . .  ' 

-  from  melaiicliolia  . .  - 


pl 


Sulpliute,    ammonium,    in 

acetone  test  . . 
-  eoppor  (see  Copper  Sul- 


Ill  ii.^iiuciiii,'  oxyliaemo- 

globiii..    "     ..         ..  s 

-  of  iron,    black   motions 

from S 

-  lead,  from  cystin  , .   ] 
Sulphides,    bacillus    aero- 
genes  capsulatus  pro- 
ducing           . .         . .  i 

-  foul  taste  from  . .         . .  1 
Sulphocyanate    of   potash, 

in  Bang's  process     . .   S 
Sulptional,  hrndvpnceafrom 
''hfvnn-^tnkps  hreatliingl 


-  lui-iiiKiiupurphyrinuria 

from    . .  . .  . .   ' 

-  htemoglobinuria  from  . .  : 
-  meth.-nmoglobiiiuria  after  1 

Sulphonal,  poisoning  by  ..  : 


"''I"',i'h" 

-.iilistances 

ulpluii"". 

I'/'n'i,     ■        „u 

(lio.xi.li. 
ulphur.i  n 

,„'  ';;3r 

Acid, 


r^ulphuric    acid  fsi 
SutplmricJ 

Summation      of      painful 
stimuli  . .  . .  ' 

Summer,  cheiropompholys 
and      . .         . .  . . 

-  diarrhoea  in        . .      171,  . 

of  infants        . .  . .   ; 

Sunburn,     pellagra    simu- 
lating . .  . .  . .    ; 

Sunshine,     deficiency     of, 
rickets  from  ..  .. 

-  cvr-tiTiiii  from  .  . 

~nii~i M>L.'.   iir.iii;iche  from  : 
iui-i|i\  Mvi.,  after      ..  ; 

^iiiiliL.-lit.  w.irki-i^  in  strong, 
pliotoitliobia  iri  , .    I 

Superciliary  ridges  in  acro- 
megaly . .  . .   I 

Superficial  circumllex  iliac 

Superinvolution  of  uterus  l^^. 
Superior  gluteal  nerve 


r  vein  from 
u'omboisis      (see 
Thrombosis) 


Superior,  could. 

-  oblique    paralysis   {Fig. 

83),  177 

-  rectus  paralysis  {Fig.  83)  177 

-  vena    cava    (see    Vena 

Cava,  Superior) 
Supinator     brevis,     nerve 

supply  of        . .  . .   505 

~  jerk,  increased  in  brachial 

monoplegia     . .  . .   502 

-  longus,  escape  in  pUimbic 

wi'ist-drop       . .  . .      65 

myoclonus  of . .  . .    137 

nerve  supply  of         . .   505 

paralysis  of,  in  Erb's 

palsy  . .         . .  507 

root  innervation  of  . .   509 

Suppnsifnrics,       dyschezia 


with     ..  -.34 

-  lardaceous  disease  from 

172,  375,  635 

-  Icncocytosis      witli     35, 

Suppuration  in  liver,  general 
account  of  . .  369 

-  polymorplioiiuclear  cells 

increased  in   . .  . .      35 

-  prolonged,    amenorrhoea  ' 


fron 


I  Sweating,  could. 

-  in     acute       rheumatoid 

arthritis  . .  . .   ; 

!  -  from  biliary  colic  . .  ; 

-  clammy,  from  snake-bite  ■ 


-  m  pyaemia 

-  pyonephrosis 

-  relapsing  fever  . 


-  Ii'om  sinus  thrombosis. . 

-  sour,    in  acute  rheuma- 

tism  . . 

-  sudamina  from  . . 

-  from  suppuration 

-  thii-st  from 

-  unilateral,  in  hysteria.. 
from  sympathetic  irri- 
tation 

-  urate  deposit  due  to     '. . 
Sweats,   in  blood  diseases 


\i' 


Sweats) 


Suprarenal,     high     blood- 
pressure  and  . .         . .  ; 

-  rests,       hypernephroma 

and      . .  . .         . .  ; 

-  sarcoma  of         . .       252,  ' 

-  secretion,    menstruation 

and ; 


Sweets,  blue  urine  after  . .  747 


Addison's 


Suprarenal  tumour,  enlarged 
spleen  distinQuislied 
from     .  629,  6 

-  -    lKCMi:ituri;i  Jii.'  U;      .  .    i] 

Suprarenal  tumour,  kidney 
simulated    by     ;i3l, 
354,  6 

laparotomy     in     dia- 

liver  enlargement  simu- 
lated by     . .  . .   2 

portal  obsti-uction  from 

sexual  precocity  with  ( 

spleen  simulated  by. .  ( 


iiula 


ellh 


llJ'pOClK 


Suprascapular  nerve    504, 


Swallowni^'.  arrliythmia  of 
heart  and 

-  difficulty    in    (see    Dys- 

phagia) 
Swallowing,  pain  on 

Sw.Mf,    Iilark 

Sweat,  bloody 

-  blue  . .  . .      fi54,  I 

-  foul  smelling 


-  tinged  in  jaundice       . .  3 

-  urinous C 

-  Viut.'t (i 

-  vclluw 6 

SWEATING.  ABNORMALI- 
TIES OF  ..  6 

-  from  abscess  of  liver  . .   5 

-  absence  of  . .  . .   6 
from  sympathetic  par- 
alysis          . .          . .   2 


aneurysm        . .  . .  ; 

appendicitis    . .  . .  ( 

ascites  . .  . .  ) 

~  carcinoma      317,  318,  ( 

~  -  constipation  . .       127,  ( 

distended  bladder     . . 

diverticulitis  . .  . .  ■ 

gastric  ulcer  . .  . .  ; 

heart  impulse  displaced 

by : 

from  hydatid    disease  i 

intussusceiition       78, 

115,  127,  i 

-  -  lineaallicantesfi-om..  ; 
Swelling,  abdominal,  list  of 

causes  of  . .  I 

liver  pushed  up  by  . .  '■ 

from  meteorism        . .  ) 

obcsitv  . .         ..  < 

-  -■   p.ilpIi.itiMM    from        ..  ■ 

-  ■        |.  nirlr  II  !■■    rvst  ..  i 

I'll  I fiu'iiuur      ..  I 


IH.     ]„ 


Swellingsof  abdominal  wall  i 
SWELLING.  AXILLARY  i 
SWELLING  ON  A  BONE.,   i 

from  callus     . .  . .   ' 

in  chlox'oma  . .  . .   . 

gout    . .  . .  . .   ' 

from  injury    .  .  . . 

in  osteo-arthritis       . .   ■ 

osteomyelitis  . .   ■ 

periosteal  liiumori-hage  ' 

periostitis       . .      ("t67,  > 

pulmonary  osteo- 
arthropathy . .  I 


scurvy- rickets 

syphilis 

tubercle 

-  -  typhoid  fever 


pyosalpinx 

epigastrium,  from  aneiu*- 
ysm 


Swelling,  epigasirium,  could. 
from      carcinoma     of 

stomach      . .     317,  i 

gastric  ulcer  , .         . .  i 

hypertrophic    stenosis 

of  pylorus  . .         . .  ; 

due  to  pancreas    630,  i 

sarcoma  of  stomach . .  < 

scybula  in  colon        . .   i 


SWELLING  OFTHE  FACE 

-  -  from  insect,  bites..    .. 

-  feet,   from   exposure  in 

trenches         . .         . , 

(and  see  OHdema) 

SWELLING,   FEMORAL.. 

from  abscess 

aneurysm        . .  .  .   ' 

bursa  . ,  . .  . .   < 

ectopic  testis. .         . .  i 

enlarged  glands        . .  i 

hernia  . .      G74,  < 

hip  disease     . .  . .   ' 

Swelling,     femoral,      new 

growths  causing    675,  i 


Swelling  in  hypochondrium. 


left 


from    carcinoma    of 
colon        . .      G29, 

of  pancreas        . .  ' 

stomach  . . 

eyst  of  pancreas  . .   > 

fieces  in  colon 

kidney  tumour 

ovarian  tumour    . . 

perinephric  abscess 


tub( 


Swelling  in  hypochondrium. 
right    . .         . .     659,  e 

from      intussuscep- 
tion . .         . .  ( 
liver  abscess  . .   i 

Swelling    in    hypogastrium  E 

-  -   from  di-lriHlr,l  bladder  ( 

jtregnancy      . .  . .   < 

urachal  cyst  . .         . .  t 

-  in  iliac  fossa,  from  aneur- 

ysm of  iliac  artery    . .    1 
appendicitis        354,   1 

distended  cavum  . .   -J 


SWELLING    IN    ILIAC 

FOSSA.   LEFT  .  .   I 

Swelling  in  Iliac  fossa,  left  I 

carcinoma  of  sig- 
moid colon     . .   ■: 
SWELLING       IN       ILIAC 

FOSSA.  RIGHT         ..   I 
Swelling  in  iliac  fossa,  right 


■  from  appendicitis 

582,  665,  (!77 

-  carcinoma  ..   (>77- 

■  -  of  cascum       . .  (i(J5 

■  chondroma         . .   G7S 

-  enlarged  glands. .  (liJS 

■  ffeces       . .         . .  f>77 
due  to  gall-bladder  07S 


SWELLING    -^    SYPHILIS 


SicfUing  in   Uiar  fossa,  ron'd. 
right,  from  hip-joint 

disease        6G5,  C78 

hydatid  . ;  . .   678 

iliac  abscess       . .  665 

impacted  fa3ces      665 

intussusception       678 

kidney    . .         . .  678 

local  peritonitis. .  665 

movable  kidney     666 

osteomyelitis     . .  678 

phantom   tumour  639 

psoas  abscess    . .  665 

Riedel's  lobe     . .  078 

sacro-iliac     joint 

disease         665,  678 
sarcoma  . .         . .  678 


SWELLING.  VULVAL 


of  c 


665 


spinal  disease    . .  678 

stomach  . .         . .  678 

-  -  -  -  tuhprrulous  r.Ttc\im677 

-|:ITmN  ..     677 

"    \v:.iMirnn..'    -).Ir.-!i     678 

SWELLING.  INGUINAL  .  .  678 
Swelling,  inguinal  582.  664, 

665.  666.  679,   680 

-     tr-r.-   rauMnL'  ..     081 

SWELLING,         INGUINO- 

SCROTAL  .682 

SWELLING  OFTHE  JAW, 

LOWER  .683 

SWELLING  OFTHE  JAW. 

UPPER  ..685 

ill    liiiiihiLr   re;;iori,    from 

.■I, Linked  spk-nn  . .   628 

Swelling  in  lumbar  region, 


(eft 


864 

SWELLING.  MAMIVIARY     685 

-  ~  ifi  niiisin.lvni;t  ..    431 

^  of    mus<U-^    ill    nit-biti 


ffv 


598 


-  neck,  from  thyroid-gland 

etilaruenient  . .         . .  7-'l 
SWELLING.  PELVIC       ..  688 

-  -  iti  cryptoTnenorrhcea       18 
from      f.vtra  -  uterine 

t-'cstation    . .  . .    393 

Swelling,  pelvic,  list  of  causes 


of 


rectal  examination    in 

diag^nosing  . .  . .   678 

rising  into  iliac  fossa      678 

from  salplngo-oopho- 

ritis  ..         ..  193 

vaginal  examination  in 


-  r;. 


-  U'proM-  niiniiekiiig        . .  403 

-  lips  affected  by..         ..600 

-  pustules  in         . .         . .  557 

-  ringworm    distinguished 

from 249 

-  vulgaris,  acne  simulating  559 

crusts  in  , .  . .   559 

Sycosis    vulgaris,     general 

account  of  • •  558 

no  itching  with        . .  559 

parts  affected  by       . .   558 

pustules  in     . .         . .  5.'»s 

staphylococci  in        . .   558 

syphilide  distinguished  559 

from 
Sympathetic,  paralysis  of 
cervical  (see  Paralysis 
of  Cervical  Sympathetic) 

-  pigmentation  from  irrita- 

tion of  . .  . .   527 

Symptoms,   proper  names 
associated    with    (see 
end  of  Index) 
Syncope  in  Addison's  dis- 
ease     ..  ..       33,  770 

-  with  fatty  heart      212,  213 

-  from  hjematemesis       . .  268 

-  heart-block  . .  546,  549 
~  myocardial  changes     . .  300 

-  in  Stokes- Adams  disease 

83,  546 

-  thymic  infantilism  . .  189 
Synechiie  from  iritis  72,  232 
Synovial  membrane,  gumma 

of        348 

Synovitis   of    ankle,    pain 

from 438 

-  crepitus  from     . .         . .  152 

-  gonorrhceal    (see    Arth- 

ritis, Gonococcal) 

-  infective,  ansemia  with      32 
epitrochlear  gland  en- 
larged from  . .  381 

from  pyorrhoea         . .     74 

-  of  knee,  limping  from  . .  362 
pain  from       . .  . .  438 

-  pain  in  the  shoulder  from  474 
Svplin-!-,  -it-'^'ircofiU'h- 

..560 

I'-ombling  560 

Sypliihdes.  acneiform        .'.  560 


rof       491.  560 


"!•[■' 


Syphilidescorenes 
Syphilides.  ecthymatous 


'.rj.    ■.(.■;.     li;s.    I'ns. 
271.  ;i:i!.   liiH.   |-j;t. 

437.  46lt,  516,    H93, 

7i'i,  i 

egg-shell  crncklinR  with! 

menlneocclc     causing  i 

tr.n.  ] 
SWELLINGOFTHESALI- 
VARY  GLANDS        ..   6 

-  (aiMl        s...-        >^.hvary 

Cliiri.JM 

SWELLING.  SCROTAL  ..  6 

-  -   fn.tn    hviln.<-..U!  ..    -1 


lis.     Kn- 


-ipcrrii 
-    -  f;ui.l 


SWELLING       OF      THE 
TONGUE  .     I 

-  umbilical,    from    can-iti- 

from  cyst  of  omphnlo- 

mcHenteric  duct     . . 

-  -  divarication  of  recti.. 
ifmnnlation  tiHsuo    ., 

-  -  hernia 


bling i)60 

-  itching  rare  in    . .         . .  510 

-  large  acuminate  . .   560 

-  lichen  planus  simulating  491 
scrofulosorum  simula- 
ting ..         .,488 

:  -  miliary    . .         :*         . .  660 

-  papular,  fingers  affected  239 

-  pigmentation     of     skin 

from    , .         . .         . .  219 

-  pit^'rijisis    ro-sea   distin- 

guished from  . .  601 

-  polymorphism  of  . .  491 

-  psoriasis    distinguished 

from    . .  . .      603,  604 

siituilating      . .  . .   491 

Syphilides,  pustular,  general 

account  of  . .  560 

-    r;i\v  li.uii  roli.urof  ..    5i;(l 


4R3    Syphilides,  small  flatpustu- 


SijphilideSy  cotifit. 

-  variola  resembling        . .  . 

-  Wassermanu's  test  with 

559,  . 
Syphilis,    abductor    para- 
lysis from 

-  acetonnria  from 


-  albumosuria  from 

-  alopecia  from    . .         . . 

-  anjemia  due  to  . .  21, 

-  aneurysm  from  196,271, 

291.435,437,516,664, 

of  cceliac  axis  from  . .  : 

heart  from     . , 

-  angina    pectoris    from 

53,  ; 

-  anosmia  from     . . 

-  aortic  disease  from     14, 

46,  209, 

regurgitation       from 

53,  93,  207,  : 
valve  rupture  from  , . 

-  aortitis  from      . . 
Syphilis,  arthritis  from 


to        669 

-  of   bone,   osteitis   defor- 

mans simulating        ..   670 

pyogenic     periostitis 

simulated  by         . .  669 

simulating  . .  . .  672 

skiagram  showing     . .  669 

therapeutic  test  for  . .  G69 

tubercle  of  bone  simu- 
lated by     . .  . .  669 

-  -  W.issei-mann  test  for    669 

-  bony  swelling  from       ..  667 

-  bridge  of  nose  fallen  in 

from 179 

-  bronchiectasis  from      . .   292 

-  bronchus  stenosis   from 

259,  292,  535 

-  bruit  de  diable  in  , .   723 

-  bubo  with  . .         . .  679 

-  buUro  in  . .  96,  97 

-  cachexia  from  4.  8,  13, 

33,173,313,413,415, 

527,  559,  604 

-  carcinoma  of  tongvic  from  739 

-  cases   of   obscure   pains 

due  to  . ,         . .  '177 

-  cavernitis  from  . .  473 

-  central  nervous  s^-stem, 

lymphocytes  in  cerebro- 
spinal fluid  in  . .   305 

-  cerebral,  aphasia  from. .   146 

-  -  coma  from     ..       117,  M4 

convulsions  from  144,  1'16 

cmnial  nerve  paralyses 

from  . .         . .  146 

dementia  from  ..  146 

headache  from  . .   146 

hemiplegia  from        . .   146 

insomnia     from    146, 

321,  322 


..    515 
1  IT,  :iin 


cirrhosis  of  liver  from  32'.t 

-  -  coma  from     ..         ..144 

condylomata  in     385,  4()(i 

convulsions  from       ..   144 

coryza  from   . .  . .  400 

craniotabes  from  152, 

205,  711 

deafness  from        166,  235 

depressed  nasal  bridge 

in       {Fig.  106)  234,  235 

diplegia  and  . .  . .   132 

ear  affection  from      . .    7'rJ 

epiphysitis  from        . .   6i>'.t 

Syphilis,  congenital,  facies 

of         235 

familial  acholuric  jaun- 
dice and      . .  . .   332 

family  histoiy  and    .  .o635 

forehead  large  in  204, 

(Fig.  106)  234,    235 

frontal  bosses  in        . .   235 

head  enlai^ed  in   205,  511 

hip-joint  disease  in  . .  363 

hot-cross-buu  head  in 

205,  711 
intei*stitial  keratitis  in 

348,  75 L' 

Jacquet's       erythema 

simulating  . .  400 

jaundice  from       329,  334 

keratitic  opacities  in. .  235 

lardaceous  disease  from 

375,  527 

laryngitis  from  . .  40U 

limping  from. .         . .  362 

liver  changes  from    . .  372 

enlarged  fro 


385 


mental  defect  i 

mercury  in     . .  . .  34s 

nails  affected  by       . .  40m 

napkin    region    erup- 
tions from  ..  . .  400 

nerve  deaf ness  in      ..  348 

notched  teeth  in  {Fig. 

107)  234 

optic  atrophy  in        . .   205 

osteochondritis  in     . .  34S 

Parrot's  nodes  in  385,  669 

pemphigus  neonatorum 

due  to         ..         ,.     97 

pseudo-leukffimia  and 

37,  6.S5 

sallow  complexion  in  235 

scare  round  mouth  in  235 

seborrhceic        eczema 

distinguished    from  401 

senile  facies  in  , .  -loit 

separated  epipliysis  in  .'i  is 

skin  eruptions  from  . .  635 

snuffles  in     385.  400,  635 

sore  angles  of  mouth 

in  (Fif/.  107)  2.".! 


Syphilis.  conQenital.  teeth  in  235 

testes  alleclcd  hy       .  .  47H 

tibial  defonnities  in. .  235 

von   Jaksch's   disease 

and  . .  , .  634 
Wassei*mann    reaction 

in  235,  348,  385,  635 
wasting  due  to          . .  33  I 

-  corona  veneris  in  ..  490 

- N.n\    ;,,I.T\'   nl.strUC- 


-   (:i 


SweMlna  In  umbilical  replon  i 

from  nnlanrerl  spleen  i 

—  -  -  due  to  pancreas    . .  i 

—  -  -  from  Kebaceous  cyst  ■ 
tuberculous       peri- 
tonitis    . . 


lar      . .  . .  560 

-  soro  throat  with  ..  5iiii 
torii^Mie  with    . .  . .   560 

-  staining  of  skin  from    . .  S60 

-  tinea     cin.'inata    distin- 

gnifilied  from..         ..  219 

, sycosis     distinguished 

I  from  ..  ..   219 

j versicolor    simulating  250 

I  -  tuberculides  distinguished 

from    . .  . .  . .   559 


Syphilis. 

choroiditis    from 

-  ilii.U.k-iii  f 

■om     . . 

1  /'/./ 

1  ,V/.Vi  ..         ..416 

-  ■iistilirlio 

1    troiii 

-  I'll) 

■I.I    11  i-  from  ..  7:is 

(lenniiL 

■  iiiiHi    imm     ..    7M 

-  livsphiifii 

from 

;.i  1 

.11,111    irc.m         ..      M 

-  of  oar,  til 

nilus  fro 

llih 

1  iiiii  ■     .il'    boiian  4(l(i 

-    Oi-/.[.|llil   si 

iMlIiililii; 

I'liliil' 

.1    .  1.  i.i-i'sfrom   017 

-      ''IkI.II  I.'I  i 

i    (,..111  1 

-  ■       1     1  1  1  M  1  1 

.11. .lOO 

-'      I'|.|.|  I.I  .     1. 

,     1  ,..111 

.1  .1  ..iii...^isdolo- 

-    r    1  1 

1 

III 

11. .1. -110 

-     I.ll    1    1,   1. 

,  nil 1 

SYPHILIS    —    TABES 


St/pltilis,  fonhl. 

SlJ/fllili}!,    could. 

'Si/pMlis.  secomlary,  contd. 

Syphiloderms                   . .  490 

-  extrafjeuital   chancre   in 

-  necrosis  of  jaw  from     . .  683 

epididymis       affected 

-  -  (aii.l    see    Sy]iliilide.sl 

{Fi>j.  23)  73 

nasal  bones  from  179,  210 

in 479 

.•syriiiL-'iiie  ear.  M'rtigofrom   ".>;: 

Syphilis  of  face     . .        . .  735 

-  nephritis  from   . .         . .       9 

generalized       lymph- 

SvriiiL-omvelia.  ai.e-hand  in  110 

-  facial      ]>aralvsis      froni 

-  noises  in  the  bead  from  406 

gland     enlargement 

Syringomyelia,  arthritis  in  349 

'(Fii/.  230)  541 

-  obscure  nerve  cases  due 

in     . .         . .      376,  377 

-  ataxy  in               .  .           .  .      58 

1  r-  ,ir..-ir.|  by         ..   018 

to         . .          . .      309,  407 

herpes  zoster  simulat- 

- atrophic   palsy   in 

ill 1   li.'.ni   Iram      53,  213 

-  occipital  glands  enlarged 

ed  by           . .          . .    756 

'(Fid.  202)  609 

-■  ..          ..292 

in        378 

hyperacusis  in           . .   309 

-  Babinski's  sign  in        . .     68 

niiL'r,.  :,ilcri..,lby     239,  240 

-  oedema  of  legs  from  413,  415 

jaundice  in     . ..          . .   334 

-  brittle  bones  in  . .         . .  257 

-  follicnlai-  tonsillitis  simu- 

- onychia  from     . .          . .  400 

mercurial  stomatitis  in  542 

-  Brown-S6quard     pheno- 

lated by         ..         .:  C14 

-  ophthalmoplegia  interna 

mucous  patches  in  . .  739 

mena  in          ..         ..58 

-  fu-sifomi  aneurysm  from  210 

from 552 

osteocopic  pain  in    . .  463 

-  bulla;  in              . .         96,  97 

-  i,Mni:rene  from  . .          . .   255 

-  orchitis  from      .  .          . ,     66 

pam  in  the  limbs  in  . .  463 

-  central  canal  changes  in     62 

-\|'!iili-.  ^'eneral  paralysis 

~  otorrhoea  from  . .         . .  422 

periostitis  m  . .         . .  711 

-  Charcot's  joints  in    257,  516 

!  .1                   ..      243,  4D5 

—  ozjena  from       . .         . .  179 

pyrexia  in      . .         . .  334 

-  claw-hand     from       109 

1-1  ni?  from            ..     50 

-  pachymeiUngitis  from 

roseola  iu       . .          ...   334 

(Fig.  45),  110,  257 

.1     K.tisfrom  ..         ..     73 

4116.  477,  509.  516 

simulating  catarrhal 

-  cold  sensations  in         . .  609 

- I  from     ..        52,  403 

-  paiii  ill  linil-  from        ..   406 

jaundice     . .         . .  334 

-  -  sense  lost  in  . .         . .     97 

-   Ill  li\er  from  . .          ..   527 

-  [Mii.-n  iiiii-  h'.ini            .  .    ItlO 

sole  tliroat  in             ..331 

-  cord    segments    affected 

[nil  -oe  Gumma) 

Syphilis,  papular  forms  of  490 

Syphilis,  secondary,  tender 

by 110 

lii.inutemesis  from    2CG,  275 

-  papules     111     .101,     487, 

bones  in                   . .  669 

-  dissociative     antesthesia 

-  iKBnioglobinuria  from 

559,  700,  756 

tenderness  of  scalp  in  711 

in          . .         110.  257,  516 

284,  285 

-  paralysis  of  palate  from 

thyroid  gland  enlarged 

-  etythromelalgia  with  . .  441 

-  headache  from  . .         . .  294 

588,  589 

in 722 

-  gangrene  from  ..      255,  257 

-  heart-block  from        83,  54a 

of  pharynx  from      . .  588 

vesicles  in       .  .          . .    750 

-  gliosis  in             . .         . .  110 

-  heart  effects  of  . .         . .     83 

Toeal  cords  from    495,  651 

-  ,...i|.i_-i  ...11-  iil..-rs  in    ..   403 

-  glossy  skin  in     . .         . .  110 

-  hemianopsia  from         . .  301 

-  paraplegia  from        516,  517 

- in.un     .  .    527 

-  heat  sense  lost  in           ..      97 

-  hemiplegia     from     119, 

—  paro.vysmal   htemoglobin- 

-  -1..   1  .,    _        ..  .il-  in      ..   400 

—  main  succulente  in       . .  110 

303,  304 

uria  from       . .         . .   284 

-   Ml. ml, J  l..i.,-.,>v          ..      03 

-  Jlorvan's  disease  and  62, 

.1 -  from        ..          ..184 

-  perforating  ulcer  of  foot 

-  skin  stains  in     384,  490,  756 

97,  516 

1 lefrom  . .         . .  47!) 

from    . .         . .          . .  735 

-  sm.all-pox  simulating   . .  562 

-  muscle  atrophy  in    61, 

1  1  lice  from             .  .   313 

-  -  palate  from    17S,  210,  588 

—  snail-track  ulcers  in     . .  615 

110,"257,  608,  009 

iM  iii'iiiiori  period  of    . .  fil8 

-  iicriclioiiilrilis  from      ..    203 

-  soft  sore  and      . .         . .  679 

-  nystaL-nms  in    110,  408,  508 

-  infantilism  from            . .  18a 

-    |.i  Mi.i'i.  II  11  1-   (roll!           .  .       52 

-  softening  of  cord  from. .  516 

—  |iaiii  in  1 !...  ..nil-,  in         .  .    50S 

-  inguinal  glands  enlarged 

-  1  .       .    111.  1  ..lis  due  to  620 

-  sore  throat  in  491,  568, 

-  -  ....  1  ...  .iii|.     II,            !!   609 

in         184 

-  !•.  ....  '.I.     I...III..      204,  622 

613,  014,  700 

-.■...[..■..;,      .  .               .  .        97 

~  intermittent  claudication 

-  ].i  1 11  li.  .  .1   ...  .ii-iti.s  from 

-  (Plate  XXrr)  ..    ■       ..010 

-  I.iir..!i-i-  ..1    iiiii-  ill        '.'.    508 

and 440 

(;l,  64,  465,  460 

-  sore  tongue  in   . .         . .  491 

one  leg  from  . .          . .   500 

Syphilis  Of  internal  ear    ..752 

-  perleche  simulating      . .  360 

-  spinal    meningitis    from 

-  paraplegia  from        514,  510 

-  iodide  in  diagnosing  63, 

-  pernicious  antemia  simu- 

200, 499 

-  parts  affected  in           . .   608 

480,  568,  588,  604,  622 

lated  by          .  .          . .   527 

thrombosis  from  389,  510 

-  preacher's  hand  in        ..    110 

-  iritis  from           . .          . .   403 

-  pharyngeal  stenosis  from  198 

-  spirochajtaj    in    73,   334, 

-  precipitate  defalcation  iu  314 

-  no  itching  in      . .          . .   756 

-  pharyngitis  from          . .     73 

079,  739 

-  R.D.in 61 

-  Jacksonian  epilepsy  from 

-  pigmented     scars    from 

--  (Plare  XXVIID      ..  014 

-  reflexes  in          . .          . .  508 

137,  147 

209,  360 

-  stenosis  of  trachea  fi-om  650 

-  scoliosis  in          .  .      110.  3.VI 

-  jaundice  from    . .         . .  326 

~  pigmentation   of  mouth 

-  stomatitis  from           73,  542 

_  seii-e  of  -ueariiiL'  in       .  .    fai'.l 

-  lachrymal  glands  eidai-ged 

from 527 

-  strabismus    from- 

Syrinqomyelia,         sensory 

in         ..         ..         ..  695 

skin  from       . .      528,  529 

495,   (_Fig.    228)    541,  589 

changes  in  62.  63.  508. 

-  lai-daceous  disease  from 

—  pre-auricular  glands  en- 

- stridor  from      . .      650,  651 

608,  (/-i;;.  2i;2i  609 

8,  35,  172,    372,    375,  635 

larged  in         ..          ..    695 

-  tabes  and          440,  495,  515 

—  simulating    amyotrophic 

-  lai-yngeal  paresis  from. .  589 

Syphilis,   primary,   general 

-  tachycardia  from          . .   704 

lateral  sclerosis     . .     02 

-  laryngitis  from             73,  613 

account  of                   . .  618 

-  tenderness    of  bones  in  015 

leprosy           . .        63,  383 

-  of  larvn.v.  distinction  from 

-  jiriinary  lateral  sclerosis 

-  -  -..all.   in            ..      615.   710 

progressive     muscular 

carcinoma      . .          .  .   199 

from    ..          ..          ..    517 

Syphilis,  tertiary,  lupoid  ..  403 

atrophy        62,  110.  257 

Syphilis  of  larynx,  notes  on 

-  pseudo-elephantiasis  vul- 

Syphilis  of  testis           479,  696 

-  sk-in  lesions" in  62,  96,  97,  110 

616.  617 

TiB  from         . .         . .   701 

ii..m  ..  021 

-  sores  in 516 

-  -  i.l.tlijsis  with..           ..    199 

-  pseudo-paralysis  in       . .  348 

-  11...1  .1...  ,.    i.-i   and  63, 

-  spastic  paralysis  in       ..   110 

II  \  h-  III.  .  Ill  ion  from..  293 

-  ptosis  from       (Fiff.  229)  541 

71.  I',i9.  ISO,  .160,568, 

-  spiiiiil  rair\"attire  in    257.  508 

1  from    ..   204 

-  pupil   reacting   to   light 

•588,    604,    019,    022, 

-  spoiii  .11...I11-  liMiIni'e  ill      257 

!  ■■■  fiing    403,  404 

but  not  to  accommo- 

690, 735,  738,  739 

-  sni...iileiil    liainl  III          .  .    257 

.  1 II  1 Iirniiafrom 

dation  in         . .         . .  551 

-  thrombosis  from          ..   119 

Syringomyelia,  symptoms  of  257 

1/  ../v.  L'::;.  224)  528,  529 

-  pustules    in    490,    557, 

-   tinea  silMlllatiil!,'               ..    384 

-  trophic  changes  in     110,  257 

1.  iik(i|il.iki.i   li-oin       209,  739 

558,  559.  562.  756 

-   toii-il-  alle.n.l  l.y          ..    618 

-  ulcer  of  foot  with         . .   736 

i|.-  ,,ir,vi,,l  liv..          ..   365 

-  pyrexia  in  562,  563,  568,  014 

Syphilis  of  tongue            ..  739 

-  vasomotor    disturbances 

of  liMT,  ii^ntcs  with     46,  47 

-  rarefactionof  skull  bones 

-  traii-veive  myelitis  from  389 

in        110 

rare  from    .  .          .  .   371 

from 152 

-  tubercle  associated  with  293 

—  whitlows  in         .  .          .  .    1  In 

—  cirrhosis  distin-^uished 

-  raw  ham  colour  in       . .  490 

-  ulcers  from        . .         . .  304 

Systolic  retraction  of  ribs 

from             ..'         ..   371 

-  regurgitation     of     food 

-  ulceration    of    bronchus 

90.   -l: 

tlu-ough  nose  from    . .  178 

from    . .         . .         . .  287 

account  of               . .  372 

-  ret robulbarnem-itis  from  440 

larynx  from   158.  199, 

'pAni.:?,  cervical            .  .      .-.7 
-L      Tabes  dolorosa        ..  468 

-  rhinitis  from      . .         . .  179 

287.  419,  C.iO 

rare  from    . .          . .   371 

-  rosacea        distinguished 

Syphilis,  ulceration  of  leg 

-  ilorsalis,  Achillis-jerk  lost 

-  -  liver  enlart'ed  with  47,  326 

from 242 

from    ..         ..     403,  737 

in 51.-. 

liver  lolic  dwarfed  by  ..   366 

-  roseola  in             73,  015,  618 

tiose  from       . .         . .  220 

acroparaasthesia  in    . .  444 

lii|.ii<  -inmh.tpd  by        .  .    402 

changes  with  temper- 

 palate  from    . .      210,  588 

acute    cystitis    simu- 

Syphilis, lymph-gland   en- 

ature         . .         . .  384 

perineum  from           . .   619 

lated  by     . .         . .  650 

largement  in  240,  376, 

Syphilis,  rupia  in         600,  601 

scrotum  from            . .  621 

acute  dyspn(Ea  in    . .  159 

377,  491,  618,  679 

-  ruptured  aortic  valve  and  210 

tongue  from  . .      209,  738 

allocheiria  in..        17,  609 

heart  from     . .         . .  213 

tonsils  in         . .          . .   383 

ansemia  from. .          . .   650 

-  measles  simulated  by  . .  383 

-  salivary  glands  enlaiged  695 

vlilv'a  from     . .          . .   701 

-  -  ansesthesia  in. .      466,  514 

-  -  simulating      . .         . .  384 

-  salvai^sau  in  diagnosing 

Syphilis,  urethral  effects  of  184 

analgesia  iu    56,  440, 

-  mediastinitis  from    435, 

480,  588.  604.  019,  022 

-  valvular    heart    disease 

607,  609 

-  scales  in    400,  491,  601,  002 

from 485 

anomalous  cases  of  . .  515 

-  medulla  oblongata  degen- 

- scarring  from    . .          . .  701 

-  varicella  simulated  by. .  756 

anosmia  in     . ,          . .   612 

eration  from  . .         . .  197 

of  face  from  (Fin.  227)  5-tl 

-  varicose  abdominal  veins 

ArgyU-Kobertson    pu- 

- Mtniire's  diisease  from. .  16G 

-  -   lialat.-  from     ..            ..210 

from             iFig.  303)  749 

pils     in    116,    420, 

-  meningitis  from            . .  147 

-  B,.iati..:i  .111..  In    .  .            .  .    407 

-  vesicles  in           . .      490,  502 

444,   450,  514,  551, 

-  mercury  in  63,  99,  480, 

Syphilis  of  scrotum          ..  621 

-  vulval  swelling  from    . .   699 

050,    719,  76S 

588,  604.  622 

-  ."Cborrlia-a  simulating  .  .   384 

-  Wa.s.scrmann-s  test  in  33, 

astereognosLs  ui         . .   609 

Ml.  ulh  ■  ■  -1  ii.lrome  in     695 

-  second  infection  with  . .  619 

52.63,71,73,93,179, 

-  -  ataxy  m  57,  116,  251, 

.1     Mill  i-is  and     ..  288 

-  secondary,      acute     ne- 

184,    197,    199,    210, 

466,  515 

1  1  r.lcs  from     620 

phritis  in        . .          . .   542 

292,    304,    377,    403, 

bedriddenness  from . .     59 

.,iiilii|il,      ii.o.ial    nerye 

alliuminuria  in           . .   334 

480,    491,    541,    608,           I 

bladder     atid     rectal 

paralyses  from       541,  589 

Syphilis,  secondary,  condy- 

604,    615,    622,    679,           | 

trouble  in  . .         . .  515 

-  myocardial  affection  from 

lomata  of                .700 

696,  735,  738 

bone  atrophy  in        . .   349 

14,  704 

in  ear  ill      .  .          .  .    I--"-' 

-  yaws  simulating            . .   403 

brain  wear  and         . .  515 

TABES    .—    TEA 


895 


rt^jf:.*  tlorsaJis.  coii'.tl. 

—  -  carcinoma  of  bladder 

simulated  by         ■  ■  650  . 
bowel  simulated  by  719  ] 

—  -  cardiac  crises  la        . .  487 

—  cessation  of  crises  in . .  650 

—  Charcot's     joints     in 

(,Fig.  162)  349,  515 

—  colic  from      . .         . .  593 
simulated  by        . .  115 

—  constipation  iu  . .  128  ' 

—  -  crises  early  in  . .  G50 
(and  see  Crises) 

—  cyanosis  in    . .         . .  159 

—  -  cjTilitB  in       . .      578,  650 

—  deafness  in    . .         . .  166 

—  deep  tenderness  absent 

in 515 

—  -  delk-iency  of  fat  in  . .   :.'3G 
Tabes  dorsafis,  diarrhcea  in 

173,  713 

—  diilicnltv  in  micturition 


iVitU 


395 


-  dilatation  of  pupil  to 

light  in       ...     . .  so:; 

dyspepsia  simulated  by  315 

einotional    reflex    de- 
ficient in    . .         . .  237 

erythromelalgia  with    441 

Tabes  '  dorsalis,   facies   of 

(Fiq.  115)  236 

-  -  nail  joint  in  . .         . .  349 

-  -  LMit  in  . .  .  .     67 

Tabes  dorsalis.  aastric  crises 
in  iiv  11.;.  17:;,  :;i.-i. 
r-'.-..    437.    !■ 


768 


nhilic 


ulcer  simulated  by    315 

gastro-entcrostomy  in 

mistake  in . .         . .  484 
general     abdominal 

crises  in      . .  . .   515 

pain  ill    .  .  . .   425 

Tabes     dorsalis,     general 

account  of  ..      514,  SIS 
girdle  pain  in       260,  436 

-  -  -  sensation  in        116,  609 

gout  simulated  by  . .  436 

high-stepping  gait  in    252 

history  of  syphilis  in    515 

-  -  hvpentistliesia  in       . .  610 

of  chest  in..  ..   708 

hyi)Otonia  of  muscles  in  236 

inco-ordination  in     . .  609 

-  incontinence  of  faces  719 

intestinal  crises  in 

115,  lie,  187,  009 

intolerance      to     hot 

water  in     . .         . .  009 

knee-jerks    absent    in 

llfi,  315,  358,  420, 
425,  437,  460,  514, 

650,  719,  708 

still  present  in  359, 

437,  515,  050 
one     knee-jerk     per- 
sistent in    . .         . .  515 

laryngeal  crises  in 

159,  418,  420.  487,  515 

paralysis  with        . .  495 

lar>'n.x  insensitive   in    515 

lightning  pains  in  110, 

315,  400,  515,  609,  050 

no  loss  of  power  in  . ,  SIS 

loss  of  sleep  from     . .  650 

lymphocytes  in   cere- 
brospinal   fluid    in 

116,  .305,  440 

-  -  mamma  insensitive  in  515 

-  -  mistaken     for     rheu- 

matism      ..         ..  440 

ncurnlgin  In  . .         . .  431 

neuritis    of     external 

l.nr'liti'il  iicnc  ill..  499 

iiliiiil'i in  .  .  ..  0119 

<.i'lliu|iiMi'.i  ill  ..  lis 

Tabes  dorsalis.  the  pains  of  440 

-  -  piiinsin  the  fiU'C  in  ..   449 

limbs  ill      . .  . .   403 

spontaneous    cessa- 
tion of    ..         ..719 


484 


palpitation  from       . .  481 

pamlysLs  of  bladder  in  398 

paraplegia  from        ..  511 


313 

perforating    ulcer    in 

257,  515,  735,  737 
peripheral  neuritis  simu- 
lating . .         . .  514 

distinguished  from  607 

plantar  reflex  flexor  in    68 

posterior  column   de- 
generation in        . .     57 
pseudo-tabes      distin- 
guished from         . .     56 

ptosis  ij.       (Fiij.  115)  236 

—  pupils     immobile     to 

light  in    ..         ..315 
not  reacting  to  con- 
vergence in        . .  551 

small  in      . .      230,  551 

~ unequal  in  236,  552 

without  pupil  changes  437 

Tabes  dorsalis,  rectal  crises 

in    173,515,519,650.719 
E.D.  in    ..         ..   r.ir, 


nal< 


retention  of  urine  in 

390,  398,  578,  050 

rheumatism  simulated 

by 430 

Tabes  dorsalis,  Romberg's 

sign  In  . .       57,  009 

-  -  sallow   complexion    in  236 


of 
disturbed  : 


609 


posit 


I  impaired  in 
444, 


Tabes    dorsalis,    sensory 

changes  in  (.Fit,.  203)  609 

sex  incidence  of        . .  515 

shedding  of  nails  in  . .  400 

spliincter    trouble    in 

173,  466 

staggering  in. .         . .  751 

strangury  in  . .         . .  649 

sweating  crises  in  515,  654 

-  ^vpliiUs  and    .  .      440,  495 
t.n,i..ii  i.rks  absent  in  444 

Tabes  dorsalis.  tenesmus  in  719 

-  ^  t.st.s  iiisr-asitive  ill  ..    515 

-  -  tingling  in      .  .  . .   609 
tongue  insensitive  in     515. 

-  tuberculous      bladder 

simulated  bv         . .  650 

-  -  ulnar  analgosii  In  111,  009 
^  -  nrotlind  rrisM  in        .  .    515 

-  -  urini-.lril.lilniL'  in      ..   398 

Tabes  dorsalis,  vesical  crises 
of  049,650 

vomiting  in    315.  437,  706 

Wa.s.sermann   reaction 

in     . .         . .      116,  440 

negative  in        . .  305 

wasting  in      . .        09,  050 

no  wasting  in  . .  515 

weakness  only  apparent 

in 515 

weather  and  pains  of  440 

wrinkling  of  forehead 

in     ..       {Fig.  ll.'i)  236 
writeis'   cramp  simu- 
lated by     .^         . .  151 

-  mescnterica,     auOrexia 

nen'osn  simulnting  . .     771 


Tachycardia,  coiilil. 

-  hysteria 

-  after  influenza  703, 

-  from  lack  of  training    . . 

703, 

-  mediastinal  fibrosis 
new  growth   . .         . . 

-  mitral  stenosis  . .      703, 

-  myocardial  changes 

-  nervousness 

-  with     parenchymatous 

goitre 

-  paroxysmal 

auricular  only 

fibrillation'   simula- 
ting 

---  from  cardiosclerosis 
518, 

c.vanosis  with 

electrocardiograms   in 

518,  iPig.  289) 
Tachycardia,     paroxysmal, 
general  account  of 

547,  548. 


Talipes  eqnimis,  conttl. 

-  Hodgen  splint    . .         . .   11.'; 

-  hysterical  . .       114,  141 

-  in  infantile  hemiplegia. .  112 

-  —  paralysis        . .         . .  113 

-  from  injury  to   lumbar 

spine   . .         . .         . .   113 

-  limping  from      . .  . .   362 

-  in  myopathies    . .         , .  113 
~  from  necrosis  of  tibia   . .   114 

-  paralysis  of  ai-m  with  . .  112 

-  from  paralysis  of  iuter- 

I  ossei    ..         ..         ..114 

1 lumbricales    . .         . .   114 

I  Talipes,  paralytic,  general 
I         account  of  ..112 

-  from  pa.ssion      ..  ..   113 

-  peroneal  atrophy  ..   513 
I  -  peripheral  neuritis     113,  140 

-  poliomyelitis      ..      140,  512 
I  Talipes,  postural    . .         ..113 

-  from  prolonged  rest 


703 


54S,  549 

palpitations  from     . .   484 

polygraph  tracings  in  548 

pulse  rapid  in  . .  549 

regular  in  . .   548 

-  from        pneumogastric 

irritation        . .         . .  703 

-  severe  haemorrhage     . .  120 

-  thyroid     extract      703, 

704,  705 

-  tobacco  . .         . .      703,  704 

-  tuberculous  meningitis       84 

-  vagal  neuritis    . .         . .  703 

-  vagus  paralysis. .         . .     65 
diagnosing 


:  of 


704 


:ing 


171 


Tactile  sensibility,  loss  of, 

paral.vsis  simulated  b.v  501 

-  vocal    fremitus,    absent 

over      pneumothorax 

108,  432 

decreased  over  fibroid 

lung  108,  292,  299 

from    growth    of 

bronchus        . .  290 

pleuritic  effusion  168 

increased,  from  em- 

ph.vsema  ..  217 

over  fibroid  lung 

168,   216 

in  phthisis  . .         . .  288 

Taenia  echinococcus,  in  dogs  058 
geographical   distribu- 
tion of         ..  ..   6.58 

-  -  hy.latid  .liscase  from  658 
Tsnia  mediocanellata  -.519 
eosinopliilia  from      ..  219 

1  -  -  head  of  (Fir,.  214)  519 

I  Tainia  solium,  eosinophilia 

i  from 219 

;  -  -  headof(Fi!7«.  212,  21.3)510 
Tsnia  solium  ..519 

--ovum  of        (/-fy.  216)  .V.'ii 
Tailors,  actinomyces  in    ..  015 
I  -  sporotrichosis  in  . .   290 

Tailors' cramp       ..  ..    151 

TALIPES Ill 

Talipes,  acquired,   general 
account  of  .112 

-  froiH  ;irlhriti-     .  .  ..Ill 


glands   involved  459     Talipes  calcaneus,  definition 


113, 


11 
703 

-  nuriculur  fibrillation     , .  704 

-  belladonna         ..      703,  701 

-  with  bnulyiincca  . .     85 

-  from    caseous   bronchial 

glands  . .  . .     85 

-  -  glands  .  .      703,  701 

-  in  children 


^\M»i 


112 


701 


-  fr rligilalis     . .  703,  704 

-  iitlr.r  .liphtlicria  703,  704 

-  from  c.xcitt'iiieiit  . .  702 

-  exertion              . .  . .  704 

-  in  Omvcs's  disease  215, 

229,    486,    702,  703, 


Talipes  equlnus,  definition 
of       Ill 

-  -  lengthening  of  leg  from  l.-.:i 
from  long  stay  in  bed  I  1 1 

-  extensor   plantar    reflex 


lith 


IIJ 


726, 


-  from     fibrosis     of     calf 

muscles  . .         ..lit 

-  f i*acture  . .         . .         ..114 

-  Friedreich's    ataxy    60, 

U3,  MO,  512 

-  from  hicinnto-nichis    . .  113 


:  injn 


114 
113 


-  thrombosis    of    cerebral 

veins 113 

-  tight  boots        . .         . .  113 

-  in  Tooth's  peroneal  palsv 

00,  113 

-  tuberculous  ankle  ..    114 

-  after  tvphoid  lever        ..    114 

-  ulcer  (if  foot  ivifli  .  .  73r. 
Talipes  valgus,  definition  Of  112 
Talipes  varus,  definition  of  112 


u:i 


Talking  (»ee   .-|,cccl.  J 

Tannic  acid  .  .  . .    720 

■Tannin,      iKGmoglobinuria 

from 284 

Tapp  Ti-orm-.  nnainia  from  519 

-  :i|i  .  ■:!■    ^'  .  I-  ir.l  In-   ..      43 

-  iM     -  <■■    from  519 

Tape-worms,  general  account 
of        519 

-  nincoincniliranuns  colitis 

suuulatiiig      115,  399,  519 

-  nose  picking  from         . .  519 

-  ova  of     . .         . .         . .  51;i 

-  types  of 51:i 

-  (and  see  Tainia) 
Tapping     (see      Paracen- 


Tar  products,  bullffi  from . 

erythema  from  . .   222 

Tai^us,  tubei-culoiis  disease 

of         068 

limping  from  . .  362 

pain  ill  foot  from  . .   362 

Tartar,  bleeding  gums  from 

72,  73 

-  foul  breath  from  ..      87 

-  rc'li-Mli .f  -ju 

•I':nl;ilir    :u;,l  :;I7.   318,   31 

•rarlr;ilr-,|,.,liiin;,  !i-om  ,.    53 
TASTE.  ABNORMALITIES 


96 


■89 


OF 


705 


nal  h-. 


1-^ Mian 


l:il 


-  -   .VStcria      ..  ..    01(1 

Taste,  loss  of,  list  of  causes 
of       705 

-  metaUicin  tic  douloureux  117 

-  oITensive,   vomiting  due 

to        705 

Taste,  perverted,  causes  of  705 
rMl.'<.r..lr.(rt,,rv  nerve  in    70>: 
■|'a\l..r,  hi.  liv.|.Ti,-k,  illiw- 


alVc 


■|31 


iiin-iipation  from 
dl^|..•|.sia  from  3IB,  321 

-  t:dM'      angina     iiectoris 

from 431 

-  gastritis  from     ..      207,  317 

-  heart  irregular  from     . .    isi; 

-  insomnia  from  S'.'O,  321,322 


TEA    —    TENNIS-PLAYERS 


Tea,  cotllil. 

-  irritabilitv  from 

321 

-  oxalate  from 

424 

-  palpitation  from        484 

486 

-  polyuria  from 

634, 

b3b 

-  rosacea  from 

241 

-  in  test  meal 

319 

Tears,  excess  of,  in 

Graves' 

. 

-  first       appearance       at 

seventh  day   . .         . .  i 

-  not  tinged  by  jaundice. .  ; 
Teeth,  carious  (see  Caries, 

Dental) 

-  chattering,  in  malaria  . . 

-  defective,  dyspepsia  from  c 
gastritis  from 

loss  of  appetite  from. . 

-  delayed   eruption   of  in 

rickets  . .         . .  ] 

-  dropping   out   of,   from 

TEETH.  GRrNDING  OF  ! !  S 

-  HutcliiM^nrii;iii.     in    ran- 

geiiiti.l    svpliiii-    {FiQ. 
ii'S)  t':u,  i 

-  looseniiiij  of,  from  pyor- 

rhcea    . . 

-  notched,    in    congenital 

syphilis         (Fig.  107)  i 

-  segmental  sensory  areas 


num  ..  ..570 
showing  effect  of  sali- 
cylates    in      acute 
rheumatism  . .  33S 

-  -  tviilioia  U-'Vi'i-  ..    oGo 
~  -  Typliii-    iCv.T           i;:',S,  639 

Temperature,      mechanism 
of  maintenance  of    . .  571 

-  sense,  cord  paths  for    . .   607 
in         Brown-S6quard 

paralysis     . .  . .  497 

syringomyelia    508,  516 

in  cretinism  . .         . .  234 

-  subnormal    (see    Hypo- 
thermia ) 


i.Me 


of 


-  septic,     acute     gastritis 

from    . .         . .         . .  ' 

arthritis  from  . .  : 

septicaemia  from        . .   i 

(and     see     Pyorrhcea 

Alveolaris) 

-  wide  apart  in  acromegaly  1 
Teething,  convulsions  from 

144,  : 

-  insomnia  from  . .  . .   '. 
I  '^  111  I  Hits,  cirrhosis  in  . . 

Ill  inn,      lesion      of, 
i  mnr  from  . .  . .   ' 

in   chronic  alcoholism 
cirrhosis 


-  of  mucous  membranes  . . 

-  multiple  hereditary,  epis- 

taxis  from 

ininnl    trunk,  from  cir- 


Telephone  ear  . .  203,  7 
Telling's    disease,    abscess 

from    . .         . .         . .  2 

Temporal     bone     growth, 

deafness  from  . .  1 

-  lobe,      sensory      speech 

centre  in         . .  , .   G 

-  muscle,  atrophy  of,  from 

cerebral  tumour        . ,  4 

paralysis  of    .  .  . .   7 

Temperature  chart,  in  acute 

gout    . .         . .         . .  3 

carcinoma  of  liver    . .  3 

cirrhosis  . .       35,  3 

-  -  coli  bacilluria  . .   4 

erysipelas        . .  . .   5 

gonococc;xl  arthritis. .   3 

iEodgkin's  disease     . .   5 

of      hypothermia      in 

malignant  cachexia  3 

mitral  stenosis       . .  3 

in  influenza    . .         . .  5 

-  Kirkland's  disease    . .  6 

-  leukaemia 

-  -  malaria  28,  29,  30, 

malignant  endocarditis  a 

Mediterranean  fever. .  5 

meningococcal  menin- 
gitis . .         . .  5 

otitis  media  and  lateral 

sinus  thrombosis  , .  5 

-  -  pellagra  . .         . .  2 

pernicious  anaemia    . .  5 

pneumonia    and    em- 
pyema       . .         . .  I 

rat-bite  fever  . .  5 

relapsing  fever 

rheumatoid  arthritis . .   3 


:■  of,  menor- 

..  3SC 
,  tortuous  406 
1-  ..   706 

Ilia 


jomt, 

;irtliritis    of,    earache 
from    . .  . .  . .   202 

trismus  simulated  by  729 

osteo-ai-t.hritis  of       . .   347 

fixation  of  jaw  by. .   542 

ptyalism  from        . .   542 

Temporosphenoidal  lobe, 
abscess  of,  noises  in 
the  head  from  . .  406 

tumour  of,    olfactory 

aura  with  . .     68 

Tenaculum,  in   diagnosing 

ovarian  tumour         . .   689 
Tenderness,        abdominal, 

absent  in  colic      . .  115 
from  acute  peritonitis  131 


317 


colitis  . .  . ,  115 

duodenal  ulcer  . .  271 

gastric  ulcer  . .         . .  115 

local    spot    of,    from 

ulcer 

from  phantom  tumour  659 

in  relapsing  fever     . .  336 

from  tuberculous  bowel  76 

peritonitis  . .         48,  657 

-  in  back,  from  fibrositis. .   461 

infective  arthritis     . .  461 

myositis  . .  . .   461 

spmal  caries  . .     364,  680 

-  of     bones    in    infantile 

scurvy  . .  . .     99 
leukaimia         . ,      467,  707 


rickets  . .         . .  1 

scurvy 

scurvy-rickets 

secondary  syphilis    . .   C 

-  -  severe  anaemia  . .  4 
syphilis           . .  . .   6 

-  of  breast,  from  mastitis 

685,  (i 

-  -  mastodvnia    . .  ..A 
TENDERNESS     IN     THE 

CHEST  ..   7 

-  -   liMinWi:M'ht,iL'ni  lesions  7 

from  stomach  lasions  7 

-  over  colon,  in  colitis    78,  € 

-  along  diaphragm   inser- 

tion, from  neuralgia..  4 

-  of  car,  from  furuncle     . .  4 

-  epididymis  . .  . .  6 

-  epigastrium,  diffuse, 

from  gastralgia  . ,   4 

with  duodenal  ulcer. . 

with  gastric  ulcer   75,  2 

gastritis  . .         . .  2 

liver  lesions    . .         . .  7 

local,  from  gastric  ulcer  4 

from  pancreatitis      . .   6 

in  phosphorus  poison- 
ing 


-  eye,    from    retrobulbar 

neuritis  . ,  . .   ' 

-  eyeball,  in  glaucoma  . ,  : 

-  over  eyebrow,  from  fron- 

tal sinus  distention  . .   : 

-  of  feet,    in   erythroinel- 

algia    . .         . .         . .  • 


Tenderness,  could. 
~  frontal,    from    frontal 
sinus  empyema 

-  of  gall-bladder,  from  gall- 

stones . .     254, 

from  cholecystitis     . .   ■ 

if  inflamed 

-  general,  in  cerebrospinal 

meningitis  . . 

-  gluteal,  in  sciatica 

-  of     gum,     with     antral 


I  Tenderness  in  the  scalp,  ami 

from  meningitis 

middle-ear  suppura- 
tion . .  . . 
j neuralgia        . .         . . 

in  neurasthenia 

rheumatism   . .         . .  ' 

rickets 

from  stomach  lesions 

-  -  in  syphilis      . .      615, 

1  Tenderness  of  scalp,  various 

visceral  causes  of 


-  ill  .<■,  I'l    M'l'-'  ■Ii''itis454,  677 
Tenderness,  interrostal     ..  707 

-  lei;r^.     froni      peripheral 

neuritis  . .         . ,  465 
sciatica  . .         . .     63 

-  liver,  from  cholangitis 

333,  369,  597 

gall-stones      . .         . .  272 

nutmeg  change  . .   368 

suppurative         pyle- 
phlebitis    . .         . .  596 
tropical  congestion  . .    369 

-  in  loin,  from  pyelitis     . .   576 
^"-  with  suppurative  neph- 
ritis . .         . .  594 

-  f-  from  tuberculous  kid- 

ney . .  . .   579 

-  lumbar,  in  sciatica        . .   438 

-  over     McBurney's    spot 

from  appCMiiIicitis  451,  454 


202 
Mor- 


of   metatai-sus. 

ton's  disease  . .  . .   439 

mid-orbital,  from  astig- 
matism . .  . .   449 

of  mouth,   from  stoma- 
j  titis     . .  . .  . .      74 

-  in  muscles  in  hysteria  . .  141 
multiple  neuritis       . .  505 

I myalgia  . .         . .  431 

I from  overstrain         , .'  464 

j in  peripheral  neuritis 

I  440,  465 

I polymyositis  . .   464 

I rheumatism   . .         . .  443 

I tetanus  . .         . .  152 

' tetany  . .  . .   151 

-  over  musculospiral  nerve, 

in  brachial  neuralgia    442 

-  of  neck,   iu    Eirkland's 

disease  . .         . .  616 

posterior    triangle,    in 

brachial  neuralgia      442 
Tenderness,  pain  with      . .  427 

-  of    palms,    in    erythema 

keratodes        . .  . .   403 

-  over  pancreas,  from  pan- 

creatitis . .  . .   7(i7 

-  of  periosteum,  in  infantile 


urvy 


556 


from  peripheral  neuritis  60' 

■  precordial,     in      angina 

pectoris  . .  . .   70! 

-  -  heart  disease..  ,.   70! 

■  of  prostate        . .         . .  18; 

■  rectal,  from  abscess  ..  58; 
-  in  appendicitis  . .  45. 
renal,  from  pyelonephri- 


tis 


IN 


576 

..451 

. .      355,  473  I 

ioint    .  .   680 

THE 

.  710 


31i;.  438 

-  st.Ti.riil.        fT'ii[ii        peri- 

uretliral  abscess        . .   697 

-  in   shoulder,   from   dia- 

phragmatic pleurisy . .  709 

from  liver  lesions       . .    709 

from  subacromial  bur- 
sitis . .  . .   476 

-  skin,     from     peripheral 

neuritis  . .  . .   405 

-  skull,  from  cerebral  dis- 

ease    . .  . .  . .   295 

-  soles,  in  erythema  kera- 

toses  . .  . .  . .   405 

TENDERNESS     IN     THE 

SPINE  ..  712 
from    abscess    forma- 
tion             ..  . .    714 

-  -  from  caries     . .      154,  444 

from  hysteria  . .    715 

Tenderness  of  spine,  after 

injury  . .  715 

Tenderness  of  spine,  list  of 

causes  of  ..713 

from  Pott's  disease  . .   116 

in  rickets        . .  . .    714 

from  spondylitis  defor- 

714,  715 


after  typhoid  fever 

from   visceral   disease 

vertebral  growth 

-  sternum  . . 

-  behind    sternum,    from 

cesophageal  lesions  . . 

-  over    superior    maxilla, 

from  antrum  disease. . 

-  of  testis,  from  epididymo- 

-  in  the  thigh,  from  ante- 


-  over  tuberculous  bone. . 

brachial  neuralgia    . . 

-  over  ureters,  from  bac- 


516 

-  in  vulva,  from  kraurosis  701 
Tendon,  injury  of,  contrac- 
ture from        ..  ..143 

-  ossification  of    . .         . .  671 

-  reflexes  absent  early  in 

hemiplegia      ..  ..303 

-  sheaths,  gonococcal  in- 

fection of       . .         . .  340 

gout  of  . .  . .   345 

rheumatic  nodules  over  405 

TENESMUS  .716 

-  in    acute   infective  diar- 

rhoea   . .  . .  ..717 

-  atheroma  . .  . .   437 

-  bearing-down  pain  with  426 

-  from  carcinoma  of  sig- 

moid    666 

-  in  cholera  . .  . .    717 

-  from  colitis       ..        171,  717 

-  drugs       . .  . .  , .    7 1> 

-  dysentery    76.  172,  716,   717 


from  cerebral  tumour  711     Tenesn 


Tenderness    In    the    scalp, 
list  of  causes  of 

from  lung  lesions 

in  malaria 


rupture  iluriri?  .  .    -i 

Tennis-players,  subacromial 

bursitis  in      . .         . .   4 


TENOSYNOVITIS 


THERAPEUTIC  TEST 


tenosynovitis,  creiiitus  from 

Test,  could. 

Testis,  imury  lo,  conltl. 

Tetanus,  cmilj. 

150,  152 

-  for  occult  blood         ."SI, 

171 

—  -  shock  from     .  .          .  .    765 

~  from  soil             . .          . .    730 

-  melon-seed  bodies  in    . .   152 

-  ozoiiic  ptiier,  for  pus     .  . 

575 

vomituiL-  (lom            .  .    765 

-  spasms  in           . .          . .  599 

-  pain  in  the  hand  from  . .  151 

Test,  Pavy's 

261 

Testis,  malignant  growths  of 

-  stiff  neck  in     138,   417, 

-  writer's  cramp  simulated 

-  Perl's 

34 

480.  696 

599,  649,  730 

by       151 

Test,  phenylhydrazine,  for 

-  misplaced,  aihiiiL'  in  pel  i- 

Tetanus,  strychnine  poison- 

Tensor     fasciae      femoris. 

sugar  ..               262, 

743 

iie.nii  linn,      ..           ..471 

ing  distinguished  from  599 

nerve  supply  of    498,  499 

-  phloroglucin 

261 

air.i|ih\-    III      .  .           .  .      66 

-  I'                       .     ailfrom  152 

Teratoma  of  parotid  gland  695 

-  for  phosphates  . . 

524 

Testis,  misplaced  or  retained. 

..138 

Peres  major,  nerve  supply 

-  phosphotungstic,         for 

general  account  of  . .  482 

-  iriiiiii.    11            l.TJ,  649,   Kl\ 

of         505 

albumose 

16 

-  neoplasm  of,  hematocele 

-  from  a   uouinl            138,  417 

root  innervation  of  .  .   509 

Test,  picric  acid,  for  sugar 

262 

sunulating      . .         . .  481 

Tetany,  accoucheur's  hand 

-  minor,  nerve  supply  of. .  505 

-  Prussian  blue,  for  melan- 

hydrocele  simulating    481 

in        151 

root  innervation  of   . .   509 

uri.a 

746 

after  injury  . .         . .  481 

-  age   incidence   of          .  .    151 

I'crror.  |iii,iil  dilated  hv  ..   351 

-  ReiiLScIi's,  for  arsenic  . . 

78 

tubercle   simulating..  480 

-  calcium  salts  and          .  .   152 

JVrtini    lu.ihiria   (see  Mal- 

- for  reninn 

320 

-  pain  in  (see  Pain  in  the 

-  c.arpopedal   contractions 

aria  ) 

-  Riniii-'s    ..          ..      164, 

165 

_     Testicle) 

ill         730 

rest,  acetic  acid  and  boiling. 

Test,     Rothera's    (Plate 

-  painless,  syphilitic        . .  622 

Tetany,  causes  of  . .                3 

for  albumin    ..        ..      4 

xxxiri   .. 

748 

Testis,  relationship  to  hydro- 

Tetany, characteristic  hand 

l.ii-    i.lif.sphutes     ..   524 

Test.  Rothera's.  for  acetone 

3 

celes    695 

in        2 

rest    for    Acetone    (Plate 

Test,  safranin,  for  sugar  . . 

262 

-  n-taiiieil,         .appendicitis 

-  from  chloroform            .  .   151 

XX.Y/V)        ..          ..748 

-  silver  nilrali-,  for  alkap- 

simulated  by          .  .   457 

-  Chvostek's  sign  in       . .  152 

-  alkali,   for  chiysoplianic 

ton 

746 

limping  from . .         . .  363 

-  cramps  in           . .      139,  161 

acid 741 

-  two-glass 

183 

pain  in  iliac  fossa  from 

-  from  diarrhcea  and  vomit- 

 santonin          . .          . .    744 

in  gonorrhcea 

182 

452,  454,  457 

ing       151 

-  -  uroervthrin    . .          . .   7i'^ 

urethritis 

581 

swelling  in  iliac  fos,sa  457 

-  electrical  reactions  in    3,  384 

-  anunoriiinn  sul|.liidp,  for 

Test.  Trommer's  . . 

261 

Testis,  sarcoma  of       480,  696 

-  epidemics  of       ..          ..151 

ifa.l i;.-. 

Test.  Uffelmann's,  for  lactic 

Testis,  syphilitic    . .     479,  696 

-   KrI.'s  sign  in      .  .          .  .    |52 

rest     for     Bence-Jones's 

acid 

320 

-    -.  r.ilil    n-Mila    (l-OMl    .  .     (J-.'l 

-  (roni  ei-.;o(          ..          ..151 

proteid           . .            .'.  16 

Test  for  urobilin      . 

325 

-      -    rhelM|iilllli-    h-1     of     ,  .     iVl'l 

-   (I'Vei^        .  .            ,  .            .  ,    l.al 

rest,  benzidin.  for  blood  . .    171 

-  -  (Plan   .Y.Y.V/  V) 

748 

Testis,  syphilitic,  tuberculous 

-    L-a-tlv,  t.,-1-            .  .              [\     l.-,l 

rest.  Bials                      ..261 

-  von  Pirquet's,  in  tuber- 

testis       distinguished 

Tetany,  general  account  of  151 

rest,  for  bile  nioment  (I'taie 

culosis 

573 

from           . .      IMi,  622 

-  liv~l.aa.Ml              ..            .,    1.52 

.v.v.vi  1                  ..750 

-  watch 

164 

-  toivion    of,    srranL'uliite'l 

-  ililriia,-  lartatioii              ..    151 

fiM    l.ili-  ill   -ImmU                    .  .     170 

-  -Weber's 

165 

hernia  siinuKatiiig      .  .    C!i2 

-  from  lead            .  .          .  .   151 

lillllr..   l..ra|l.ll!MOSC        ..        10 

-  whispered  voice 

164 

-  tuberculous  (see  Tuber- 

- localized  convulsions  froml44 

rest,  bleaching  powder,  for 

-  AVidal's  (see  Widal) 

culosis  of  Testis) 

-  muscle    excitability   in- 

indican                      . .  314 

Testes,  excision  of,  obesity 

Testis,  various  affections  of 

crea.sedin        ..   "  151,  152 

'est.  boiling,  for  albumin  ■ .       4 

from    . . 

408 

the                           477-81 

~  miisries  render  in          . .    151 

rest,  boiling,  for  albumin. 

-  in     groin,     in     pseudo- 

Tests  for  acetone  . .                 3 

-  Iiarathyroiils  and           ..    152 

precautions  in           . .  424 

hennaphroditism 

646 

Tests  for  albumin            .4 

-  position     of    arms     and 

Jul  Ihi'ii hi.  Tioii  li;l,  li;.-, 

-  inequality     of,     physio- 

Tests, for  albumose     5,  |5,  |6 

legsiu 151 

rest.    Bottger's.  for  sugar  262 

logical 

66 

Tests  for  ailtapton . .        . .  746 

-  during  pregnancy         . ,  151 

liniliii.i.'.    lor    laiillria   746 

-  undescended,  in  ateliosis  191 

-  clinical,  too  great  delicacy 

-  good  prognosis  m         . .       3 

I'alliH-lli-'H,     ill     InlK-rru- 

Testicular  sensation,   lost. 

of  some          . .          . .       4 

-  re-spiration    embarrassed 

losK 573 

in  neoplasm  of  testis 

481 

-  for  evstiii             ..           ..    161 

in         151 

-  Cont'o  red           . .          . .   320 

Testis,     abscess     of     (see 

Tests  for  dextrose.                261 

-  in    ri.  kets          145,  151,  420 

-  corrosive   sublimate   for 

Abscess  of  Testis) 

Tests  for  haematoporphyrin  744 

Tetany,  signs  of  . .            2,  3 

urobilin           . .          . .   170 

-  absence  of  deep  tender- 

Tests, for  hearing.  -           .164 

-iiaaltniiie  poisoning  dis- 

rest,  for  diacetic  acid       ..   170 

ness  in,  in  tabes 

515 

Tests  for  indican  . .           .745 

guislied  from..          ..   152 

-   1  /'/.;(,•   .V.V-V/  1')          .  .     (t.S 

Testis,  atrophy  of  66,  313, 

-  (or  iiirlaiiuria      .  .           .  .    745 

-  tetanus     simulated     by 

rest,  diazo 173 

408, 

479 

-  (or  111.  tin  leu,.  Iilue        .  .    747 

138,  152 

rest.  Fehllng's                 .281 

-  -  after  gonorrhcea 

313 

Tests  for  nucleoproteid    . .      5 

-  after  thvroidcctomy     . .  151 

hi  III. Illation,  f.,r.,'lucose  74:i 

-  -  after  injury    . . 

313 

-  lor  peiilo.su         . .          .  .    201 

-  trismus  in           .  .          . .   730 

rest  fermentation,  for  sugar  262 

obesit.v  from  . . 

408 

-  proper  names  associated 

-  Tr.ii„.,.a„-    .i,.i,  in  151,  152 

1 ,  lorliilc-     ..          ..743 

after  orchitis. . 

313 

with 912 

-  fniiii  up 1  li'ver        ..    151 

I'M'          165 

penile  erection  absent 

313 

-  tuning-fork         .  .          .  .    164 

Teti  1.  hlia.aii  IIM-.        acute 

■.nuliii's,    for    liile    pis;- 

-  carcinoma  of  (sec  Car- 

Tests for  urates               .740 

M-Ilou    .uiophv  from     334 

mcnt 743 

cinoma  of  Testis) 

Tetanic  contractions        . .   137 

-  in  acioi.laiie  varnish    . .   334 

-  goaiacum,  for  blood     ..     10 

-  chronic   torsion    of   (see 

\  rr-iis  loiiii-        .  .            .  .    l:i7 

-  epii:astric  pain  from     ..   334- 

-  -  iodine  in  urine  and    . .     98 

Torsio  Testis) 

'retanu-:.   a.plu  \ia   ill         .  .    13S 

■    llatiilniit  .Ivspeiisia  from  331 

rest,     Gunsberg's     (Plaie 

Testis,  cysts  of  the 

481 

■  haeilli  of            13S,  590,  730 

-  iaiiii.li.e  (rnni   325.  334.  337 

.V.V.VI)     ..        ..750 

hydrocele    simulating 

481 

-  bacteriological  examina- 

- ios.  nl    i|,|„.t,l,.  (rom    ..    334 

rest.  Heller's                          5 

-  ectopic,        appendicitis 

tion  in  diagnosing    . .  599 

-  voiiiii  ill"  iiiiiii   .  .          .  .   334 

f,.r  all.nTnos,-.  .          .  .      15 

simulated  by. .      482, 

681 

-  cliloroform  in    . .          . ,   730 

Tetn.h  il.  In  all  1 a  from     84 

-  Ilofnieistur'.s,    for    albu- 

in  at<;liosi6     . . 

191 

-  convulsions  in    .  .      138,  729 

-  conn    11 ..118 

moso 16 

gangrene  of  . . 

182 

-  drumstick  baiilli  in      ..    417 

Tliap  1  1.     ,1.^  from  239 

-  Holmt'ren's,    for   colour 

hernia  with    . . 

183 

Tetanus,  general  account  of 

Tliiii a,    1  1  (rom  ..  322 

blindness        . .         . ,  762 

simulated  by 

681 

138,  730 

Till  11  1 ■'  1*  -.   iirophvof 

rest,    Huppert's,   for  bile 

in  inguinal  canal 

681 

-    li  iliil    -pa-Ill   MIMulatillg      138 

l.-.e  un.ler  .U  l<.ph>) 

pigment         . .     743.  744 

intestinal   colic  simu- 

-   Inn'    f la    .  .              ..     138 

loot  innervation  of  . .   509 

-  lor         indicaui         (/'laic 

lated  by     .•.. 

081 

-.    In.lii.|.l,nl.i  1     iniiilalillg     138 

Theocin   iieetate,   polyuria 

.V.V.V/l)                     ..    748 

liable     to     malignant 

-    Ii\  |i.  1  I,  11    1      .  .    309 

from    . .          . .         . .  535 

ioili,,,..   (or  l.il,.  |,iL..„i,.„t   743 

disease 

483 

-  I.>i..i|.,u..ii.,  IN             ..   309 

Therapeutic  test,  foractino- 

loiliidini.  (or  a...aoii,.     ..         3 

pain  in 

482 

~  hysteria  simulating  138, 

mycosls          . .         . .  438 

rest.  Jaffe's,  for  Indican  . .  314 

—  in  perineum  . . 

081 

417,  729,  730 

acute  rheumatism  164,  014 

rest.  Legal's.  for  acetone . .      3 

Scarpa's  triangle 

676 

-  localized  convulsions  froml44 

adherent  •pericardium    214 

nqllor  (luIasNO.  lor  liu..,.  .    575 

stningulated       hernia 

-  lockjaw  in         138,  417,  599 

angina       abdominalis 

-  Marsh's,  for  arnenic      . .     78 

simulated  by 

483 

-  mind  clear  in    . .         . .  417 

115,  310,  438 

Test  meal,  in  clu-onic  diar- 

in    thigh 

081 

-  in  new-boni       . .          . .   730 

pectoris       .  .          ..476 

rhrea    ..          ..       170,   172 

torsion  of 

183 

-  without  obvious  wound    699 

asthma           . .         , ,  535 

-  -  bvperchlorhydrin      ..     43 

Testis,  embryoma  of    480 

696 

-  opisthotonos  in  417,  099,  730 

chlorosis         . .         . .     36 

■Hiililc              ..          ..319 

-  enlarged    by  abscess  . . 

022 

-  pain  in 138 

cretinism        ..          ..511 

III'  '1-.  importance  of    ..   270 

from  epididymo-orcbi- 

-  from  penetrating  wound 

diagnosing    cause    of 

III!  H,,l  nnintre  ..          ..   320 

tis 

478 

609,  730 

intei^'apular  pain      402 

\liiia..--.  alkr.l.loM  mid..    2(12 

by  gumma     . . 

022 

-  priapism  from    . ,          . .  538 

type  of  constipation  122 

iiiliiii.  and     .  .            .  .    2(!2 

frommalignantdiseast 

480 

-  retracted  head  in         . .  589 

distlngulstiing     cretin 

Test.  Moore's,  for  sugar   ..  262 

Kyiihilis 

479 

-  rigor  in  . .          . .          . .  595 

from  Mongol         . .  238 

Test,  nitric  add.  for  albu- 

- epithelioma   of  scrotum 

-  risus  sariloniciis  in  138, 

—  einlopsy         . .         . .  636 

min     4,5 

invading 

621 

417.  698,  699,  730 

-  -  gumma           230,  015,  019 

■     alhumosr     ,  ,           l.'!,    II! 

-  gangrene  of        .  . 

482 

-  from  nisty  nail  , .         . .   730 

of  liver        . .      263,  33 1 

bile  pitfment          . .   713 

-  gonocTOial  infection  of 

1S2 

-  sinuilnted   by   impacted 

hypothvroidism        , .  409 

inrlii'an        .  .          ..311 

Testis,  gumma  in  ..     4io, 

823 

tooth  .,          ..      138,  730 

lichen  planus. .         . .  489 

Test,      nitroprusside,     for 

-hernia  of        .. 

622 

meningitis      . .         . .  138 

—  malaria  530,  508,  600,  037 

acetone                            3 

-  in  inguinal  canal 

00 

-  -  muscular  rheumatism    138 

myocanllal  disooso  . ,  485 

iiK'l  iiiiii  1  1                   .7  |i; 

■  injury   to,   neurastlicnia 

stryclmino     iioisoning 

—  my.veedeina 

Test.  Nylander's.  for  sugar  262 

ofler    

716 

138,  729 

38,  119,  235,  41.5,  539 

1) 

57 

THERAPEUTIC   TEST    —    THROMBOSLS 


Therapeutic  Ust,  coiitd. 

for  pernicious  aiiEemia  526 

rodent  ulcer  . .         . .  180 

svphilides       . .         . .  560 

-  -  syphilis    63,   71,  199, 

588,   604,  622,  696, 

735,  738,  739 

of  bone       . .  . .   669 

syphilitic  testis         . .  480 

ulcers  . .         . .  403 

thyroid  infantilism  . .    190 

ulcer  of  palate  . .   588 

tongue         . .  . .    379 

Thermo-anaesthesia,  defini- 
tion of 606 

-  from    posterior    inferior 

cerebellar  arterv 

thrombosis  iFiff.  264')  610 

-  in  syringomyelia  . .   608 
Thermometer,  in  diagnosing 

pontine     hemorrhage 
from  opium  poisoning     31 

-  -  trance  from  death    . .     85 

-  inakiiN.  mercurialism  in     33 
ii.  >tninacU  ..  ..271 

Thermometpy  in  ctiildren, 
notes  on  . .  573 

Thermometry,  general  con- 
siderations  regarding 

071.  572 

Chart) 
Thieves,  rectal  examination 

in         584 

'r!n"h-     i-nrn1rlnnif\ta  On. .    70U 
,  I. mil.-    Ill   ■  ..  ..    150 

■I  HI. I-    ih  iitiniL'..  ..    679 

.i,n-,|,i,M'~  riMljemaof..   401 

-  \MiKM  HlL.ii.-a.iaes  on        ..   365 

-  local  fatness  of,  in  Der- 

cum's  disease  . .  410 

-  pain  down  (see  Paiu  in 

the  Thigh) 

-  pain  in  (see  Pain  in  Thigh) 

-  pemphigus    neonatorum 

affecting          . .  . .  401 

-  position  in  tetany  . .  2 

-  scabies  affecting  . .  401 

-  seborrhoeic    eczema  af- 

fecting ..         -.401 

-  sore  on,  inflamed  inguinal 

glands  from  . .  . .   381 

-  testis  in 482 

-  wasting    of,    from    hip 

disease  . .         . .  156 

-  with  knee  disease  Gl,  363 

-  xerodermia  affecting    . .  488 
rhird  nerve  paralysis  (see 

IViralv^i^  of  Third  Nerve) 

riiii-l.   in   i!i;il>rtf.S  ..     264 

|,lM,~|,li;ihr  Jialietes     ..    522 
THIRST,  EXTREME       -.  719 

-  -  in  diabetes     . .       260,  719 

-  fevers  . .  . .         . .  719 

-  from  gastrectasis 


720 


rlivlo 


effii 


Thorax,  covfd. 

—  pediculosis  pubis 

atreot- 

mg 

-  syrinpnrtM  ^i-  .    .i 

■,  III,.' 

-  tenderin      

1  .    ■      I.T- 

nes^  '"  ■'■ 

Veins,  \'ancos 

Thor- 

acic) 

-  (and  see  Chest) 

Tiinrniu  font,  limpi 

-  knr,..  Ij, ,iL'  fro 

Tlion,-a|,|,|,.  .rv-ra 

ig  from 

Threads,  prostatic - 

Thread-worms 

-  blood  and  nmcu^ 

stools 

from    . . 

Thrill,  with  ascites 

-  congenital  heart 

disease 

-  diastolic,  with  aortic  re- 

gurgitation    . 

207, 

mitral  stenosis 

-  liv'l'itii!    ,  . 

—  having  nothing  to  driak  719 

-  -  in  hysteria     . .         . .   719 

—  from  ingestion  of  salt  720 
loss  of  fluid    . .         . .  720 

—  phosphorus   poisoning  336 

poisons  . .  . .   720 

polycythcemia  from  . .  533 

-  polyuria  and  ...  ..719 
ill  p(eL,'iiancy  . .  . .  264 
I.      1^       ..        *..  ..   594  I 

I .      Mr.     ThelwaU,  I 

M|Hration  by..         ..  455  I 

-  oiivo-ponto-cerebellarat^ 

rophy  of  . .  . .   727 

Thoma-Leitz     htemocyto-  j 

meter  . .         . .         . .     21 

Thoma-Zeiss      hffimocyto- 

Thomsen's    disease,    chief 
characters  of  . .         .  ■  584 


THRILLS.  PRECORDIAL    720 


in  njin.il    irii.,-i-     ',<!.   ' 

-  -  from  in.  ii-iml  -i.-iim^-^ 

-  ptilmoiiai  \    -\  -u.\\<- 

~  systolic,   Iluiii   aiiifLir.vsui 

207,  208'   ' 

atheroma       . .         . .  ' 

congenital  heart        . .  ' 

dilated  aorta.. 

functional       . .         . .  1 

from  mitral  regurgita- 
tion    . .      . .      210,  ' 
patent  ductus  arterio- 
sus   ■ 

interventricular  sep- 

pericardial  friction    . .  ' 

pleuritic  friction 

pulmonary  stenosis 

111,  217,  : 
tricuspid      incompe- 

Tbroat,  burning  in,  from 

waterbrash     . .  ..  '. 

-  erysipelas  of      . .  . .  ) 

-  foreign     body     in  (see 

Foreign  Body) 

-  Klebs-Loffler    bacilli    in  : 

-  pain  in  (see  Pain  in  the 

Throat,      and  Sore 
Throat) 

-  swabbings  from  ..  " 

-  ulcerated       (see  Sore 

Throat) 
Throbbing,      from     aortic 

regui-gitation  . .   '. 

Thrombosis,    ante-mortem 

cardiac,    from    mitral 

stenosis  . .         . .  1 

cerebral      embolism 

from        . .      133,  : 
pulmonary     embol- 
ism from  . .    ; 

-  arterial,  gangrene  from    : 


5  of 


ofc 


of 


106 


distinguished    from 
orbital  cellulitis     : 

-  exophthalmos  from  1 
-.  eyelids  red  from    . .  : 

-  frontal     veins     en- 

goi-ged  from       . .  : 

-  mastoid        swelling 

from        . .  . .   : 

-  ccdema    of    eyelids 

from        . .         . .  I 

-  ophthalmic       veins 

engorged  from  . .  '. 
■  -  squint  from  . .   i 

-  suppurative  menin- 

gitis from  . .  : 

erehral.  age  incidence  of  '. 


Thrombosis,  cerebral,  contd. 

headache  from      294,  295 

hemianopsia  from     . .  301 

hemiplegia    from    68, 

258,  303 

onset  of  . .         . .  147 

premonitory  symptoms  147 

sinus,  cerebral  abscess 

simulated  by         . .  597 

headache  from      . .  768 

hemiplegia  from  303,  304 

meningitissimulated 

by  ..         ..  597 

optic  disc  congestion 

from        ..         ..  597 

from  otorrhoea      . .  597 

pain  about  ear  from  597 

rigors  from. .      595,  597 

vomiting  due  to 

7G5,  768 

spastic  paraplegia  after  132 

from  syphilis..     147,  304 

unilateral  paresis  from  118 

veins,   after  influenza  113 

measles       . .         . ,  113 

talipes  from  . .  113 

vertigo  preceding     . .   752 

-  femoral,      difficulty      of 

detecting        . .         . .  411 

oedema  of  one  leg  from  749 

vena  cava!  thrombosis 

from  . .         . .  749 

-  gangrene  from  . .  . .   255 

-  iliac,  from  appendicitis     106 
difficultv  of  dctpcting  411 


Thrombosis  of  inferior  vena 
cava?,  4G, 52,  41^.410,749 

albuminaria  from       7 

ascites  from       . .     46 

from      carcinoma 

recti    . .         . .       7 

extension  from  leg      8 

cedema  from      . .       7 

peritonitis    simu- 
lated by         . .   594 

renal    tube    casts 

from    . .  . .        7 
Thrombosis  of  inferior  vena 
cava,  simulating  acute 
nephritis        - .         7,  749 
spleen     not     en- 
larged by       . .   632 
varicose    '   abdo- 
minal veins  from  52 

-  innominate  vein  . .   751 

-  of  jugular  vein,  extension 

from  sinus     . .         . .  597 

infarction    of    lung 

from        ..         -.106 
from  otitis  media  . .  106 

-  lateral    sinus,    broncho- 

pneumonia from       . .  289 

embolism    of    lung 

from  106, 159,  259, 644 

gangrene     of     lung 

from         . .      259,  644 

from    otitis    media 

84,  106,  150,  289,  567 

pyrexia  from^  (-^«?. 

244)  567 

rapid  pulse  -with    . .     84 

rigors  from  ..   567 

-  mesenteric,  constipation. 


THORAX.  DEFORMITY  OF  166 

-  herniutioii  into  . .  . .   652  i 

-  pain  hi  (see  Pain  in  the 

Chest)  I 


vith 

haematemesis  from  . .  131 

from  heart  disease    . .  131 

intestinal    obstruction 

simulated  by         ..  389 
laparotomy  in  diagnos- 
ing ..   '     ..         ..389 

melaena  from  . .  131 

meteorism  from         . .   389 

peritonitis  from         . .  389 

-  cedema  of  one  leg  from. .       S 
--  pampiniform        plexus, 

priapism  from  . .   538 

-  popHteal,  difficulty  of. . 

detecting        ..  ..410 

Thrombosis  of  portal  vein     51 


lluid  ill    . . 
liEematemesis     fro 
iaundice  with 


Thrombosis  of  portal  vein,  aw/d. 

melseiia  from         . ,  272 

piles  from  . .         . .     51 

pyrexia  with  . .     51 

rigors  with  . .     51 

spleen  enlarged  with 

272.  6:^2.    iVM', 

Thrombosis     of     posterior 
cerebellar  artery,  effects 

of        58 

inferior  cerebellar 

artery,  ataxy    from  61n 

sensory  changes 

from       (.Fig. 

2G4)  Glu 

-  post-partum,  white    leg 

from    , .         . .  ■        ..111 

-  pulmonary,  from  mitral 

stenosis  . .  . .   289 

-  renal,  albuminuria  from 

7,  749 


Thrombosis  of  renal  veins, 

diagnosis  of    ■  . 
Thrombosis  of  renal  veins, 

simulating  acute  neph- 


Thrombosis,  retinal,  appear- 
ances of  .  ■  • 

blindness  fi'Oni 

black  spots  before  eyes 


oedema  of  one  leg  from  ' 

-  of  sigmoid  sinus  . .  i 

-  spinal,  allocheiria from. . 

in  enteric       . .         . .  f 

injury  and      . .  . .   I 

paraplegia  from        . .  { 

softening       of       cord 

from  . .         . .  I 

in  scarlet  fever  . .  I 

from  syphilis         389,  J 

transverse        myelitis 

from  . .         . .  i 

-  splenic,  autopsy  in  dia- 

gnosing      . .         . .  : 

in  blood  diseases      . .  ( 

haematemesis  from   . .  : 

infarction  from         . .  ( 

laparotomy     in     dia- 
gnosing      . .         . .  ; 
splenomegaly  and     . .  : 

-  of  superior  longitudinal 

sinus,  coma  from      . .  1 

convulsions   from 

120,  I 
encephalitis  simu- 
lated by         . .  ] 

simulating     . .   f 

headache  from  . .   1 

. meningitis    simu- 
lated by     120,  a 

simulating      . .  £ 

cedema    of    scalp 

from    . .         . .  £ 

optic  neuritis  from  1 

paraplegia     from 

510,  511,  2 
post-mortem  dia- 
gnosis . .  ] 

pyrexia  from     . .  ^ 

retracted       head 

from    . .         . .  I 

vomiting    from 

120,  5 

-  systemic  venous,  pulmo- 

nary embolism  from . .  :; 

-  of  vena  cava,  cedema  of 

back  from 

inferior,  ascites  from 

superior      . .         . .  7 

Bright's  disease 

simulated  by. .   4 

cedema     of    face 

a'  d  arms  from  -1 
from  whitlow     . .   4 

-  venous,  in  cachexia      . .  -1 

gangrene  from  . .   £ 

-"-  in  leukffimia  . .         . .  4 

leucocytosis  with      . .   ^ 

limping  from  . .         . .  3 


THROMBOSIS  .—    TONGUE 


Thrombosis,  venous,  could. 

in  malifjnant  disease      411 

oedema  from  . .         .  -    H" 

pulmonary    embolism 

from  ..  ..159 

in  typhoid  fever       . .  411 

Throwing,  subacromial  bur- 
sitis from        . ,  . .   476  , 

Thrush        74  , 

Tliumbs.      double-jointed,  | 

in  Mongolism  . .   191 

-  pink        *i54 

Thumping  of  heart  . .   486 

Thymol,  for  ankylostomia- 


521 


Thymus  gland,  asthma  si- 
mulated by    . .         . .  535 

enlarged,  coma  from     144 

convulsions  from  144,  145 

dullness  over         . .  419 

in  lymphatism       . .   382 

orthopnea     from 

418,  419 

-  -  -  skiagram  of  . .  419 

stridor  from  . .   651 

tracheal  obstruction 

by  . .      418,  651 

haemorrhage  into     . .  159 

sarcoma,    vena   caval 

obstruction  by      . .  "51 
Thyroglossal  duct  . .   698 

Thyroid     cartilage,     peri- 

chondritLs  of  . .         . .  613 

-  extract,    benefit    of,    in 

thyroid    infantilism  190 

-  in  cretinism   . .         - .  511 

-  enuresis  cured  by      . .  218 
for  hypothyroidism  . .  409 

-  menopause  conditions 

benefited  by  . .  409 

-  in  myxcedema  ..  537 

palpitation  fron»   484,  486 

tachycardia  from  703, 

704,  705 

-  weight  reduction  by. .  770 

-  gland,    abscess    in    (.see 

Abscess,  Thyroid) 
adenoma  of   . .         . .   721 

-  -  bruit  over,  in  Graves's 

disease        . .         . .  215 

-  carcinoma  of  204,  648, 

672.  711,  714.  721 

-  -  cyst  of  . .  . .  721 

-  -  defer-t.  atf-Uosi<  ;md..    190 

-    cn-tiriiMii  in. in        ..    190 

-  -     -  iiif;iMti!ivii,  iumI    IHM,  190 

THYROID     GLAND     EN- 
LARGEMENT ■  ■  72r 

from  abscess  . .  722 

in  acute  rheumatism  722 

adenomatous  . .  721 
ill  cholera  . .  . .  722 
1  mm  cystic  goitre. .  721 
fibrous  goitre  ..  721 
in  ftnivns's  disease 
229.     486, 


691 


703, 


.__,  736,  770 
irvngeal    paralysis 

from        ..         ..  495 
rom  ligneous  goitre  721 


722 


irom  malignant  di- 
sease      ..  ..721 

iluring  menstruation  721 

movement  on  swal- 
lowing    . .         . .  721 

ortlioima'a    from 

418,  419 

|.;»renchymatous 


I  pr 


721 


Thyroid  gland,  rou/d. 

-  -  Riedel's  disease  of    . .   158 

-  secretion,    menstruation 

and      . .         . .         . .  388 

-  treatment,  no  benefit  in 

adiposis  dolorosa      . .  410 

in  diagnosis    . .  . .     38 

in  distinguishing  cretin 

from  Mongol         . .  238 

mysoedema   119,  235,  415 

Tliyroidectomy,        tetany 

after    . .  . .  3,  151 

Tibia,  arrested  growth  of, 

from  injury    . .  . .    114 

-  bedsore  over     . .         . .  257 

-  deformed,  in  congenital 

syphilis  . .         - .  235 

-  enlarged  by  tuberculous 

abscess  ..  ..609 

-  epiphysitis    of,    limping 

from    . .  . .  . .   362 

-  epithelioma  invading  . .  672 

-  greenstick  fracture  of  . .  362 

-  myeloid  sarcoma  of      ..  672 

-  necrosis  of,  talipes  from     114 

-  node  on,  from  yaws     . .  403 

-  osteitis  deformans  affect- 

ing        670 

-  osteomyehtis  of. .      362,  404 

-  overgrowtli  of,  from  in- 

jury    . .         . .         . .  114 

-  periostit^     of,     limping 

from    . .  . .  . .   362 

-  sarcoma    of    362,    (Fig. 

283)   671,  693 

-  syphiJitic  nodes  on        . .   669 

-  tuberculous  abscess  of . .  669 
TibitB,     sabre-shaped,     in 

rickets  . .  . .   186 

Tibial  artery,  cessation  of 

pulsation  in   . .  . .     34 

Tibialis  anticus.  nerve  sup- 
ply of  . .      498,  499 

-  posticus,  nerve  supply  of  498 
Tic,  convulsive,  simulating 

chorea..         ..         ..  133 

~  douloureux,     age     inci- 
dence of         . .         - .  447 
cerebral  tumour  simu- 
lating ..  ..447 

Tic     douloureux,    general 
account  of     ■  ■        .  •  447 

hypr-nicusis  from  308,  309 

pain  in  scalp  from    . .   711 

photophobia  in         . .  525 

ptyalorrhoea  related  to  543 

tenderness     of     scalp 

from  . .         . .  711 
trophic  changes 

-  habit,  effect  of  v 

movements  of 
Tics,  spasmodic 


/ill  on 


TirkI 


gh  fro: 


I''.V^ 


tved  liver 


307 


286 


Thyroid    fliand.    enlarged, 
pressure  symptoms  of  722 

-tri.lnr-  Irnrx  '.[    (ir.I 

-«<-lliiiL'of  iiPckfrom721 
in  syi.hilis  . .  . .   722 

t  nichca    obstructed    • 
by  .,      418,  651 

. in  typhoid  fever    . .  722 

' variola        . .  . .   722 

►  -  -  hcomorrhago  into,  acute 

dyspncca  from      . .  721 

death  from  ..  721 

hydftti<l  of      . .         . .  722 

-  -  ovarian  relationship  to  409 
rapid  onlnrgcment  of  158 


Tightlaciiig,  fun- 

from ;i(W 

-  -  liepatoptosis  from  360,  368 
liver   dullness    dimin- 
ished from  . .         . .  366 

depressed  by         . .  367 

menorrhagia  t*om  386,  387 

-  -  Riedel's  lobe  and      . .  366 
Tightness  in  chest,  in  bron- 
chitis   432 

chronic  mediastinitis    435 

from  mediastinal  new 

growth       ..  ..  434 

from  overstmin  of  in- 
tercostal muscles  . .   432 

Tilbury  I'ox,  impetigo  ( 


tat 


I  of 


rtli 
li|.S  nil. 


-.1  }<\ 


lymph-glands  etdarged 

with 
microscope  in  diugnos- 


Tinea  ciraiiafa,  coiitd. 

pityrisisis     rosea    dis- 
tinguished from    . .  604 

psoriasis  distinguished 

from  . .  . .    249 

scales  on        . .  . .  249 

simulated  by  carbolic 

acid  ..         ..223 

spores  in         . .         .  -  223 

syphilides     disting- 
uished from        249,   384 

T.  imbricata  simulat- 
ing   ^50 

-  dernlvans  .  .  . .   249 
Tinea    imbricata,    general 

account  of  • ■  250 

i.'htlivusis  :.iinul:itink'     -'50 

lopiUuphvtuii  of         . .   250 

-  -  scales  in"         . .  . .   250 
T.  circinata  simulating  250 

-  marginatum,      bathing- 

drawers  area  affected 

by       

itching  in 

-  sycosis,  carbuncle  simu- 

lated by 

eczematous  folliculitis 

distinguished  from 
Tinea     mycosis,     general 

account  of    .  ■ 
microscope  in  diagnos- 


Tobacco,  coiKd. 

-  heart  failui-e  from 

-  hemeralopia  from 

-  infantilism  from 

-  insomnia  from  . . 

-  inteniiittt'iit        claudica- 


Tincture  of  arnica,  derma- 
titis from        . .         ..  755 

-  iodine,  test  for  bile  pig- 

ment  . .         . .         . .   7 13 

Tinea  (and  see  Ring^vorm)  247 

-  circinata,     eczema     dis- 

tinguishcil  from         ..219 
Tinea     circinata,    general 
account  of    . .        .249 
. .  I'l'.' 


540 


249 


ing 


249 


■  seborrhoea  distinguish- 

ed from      . .         . .   ' 

■  syphilides  distinguish- 


248 

-  scales  in         . .         . .  602 
versicolor,   chloasma  si- 
mulating       . .         . .  250 

-  colour  of 

-  distribution  o 

-  eczema  scborrhceicum 

simulating  . . 


250 


vMicn 


251 


Tinea    versicolor,    general 
account  of  •  •  250 

leprosy  simulating    . .   250 

macules  in      . .  . .   383 

microsporon  furfur  in  250 

pigmentation  from  . .  529 

pityriasis  rosea  simu- 
lating . .  . .    250 

-  -  scales  in  250,  529,  601,  602 
syphilides    simulating 

250,  384 
Tingling,  as  an  aura  of  epi- 
lepsy   . .  . .  . .     67 

-  from  peripheral  neuritis 

465,  607 

-  sensation  from  miliaria    755 

-  in  tabes 009 

-  from  tinea  circinata  . .  249 
Tinkling, metailic. .  ..  168 
TINNITUS 722 

-  deafness  and      . .  . .  723 

-  with  facial  paralysis      ..103 

-  nftrr  Ihisliirif,'      ..  ..    241 

-  ifiinLri;nii:ilniiinnurwith723 
Tinnitus,  list  of  causes  of. .  723 


Mr 

from 


incdii 


165, 


■  otosclerosis 
.  plethora 

syphilis  of  internal  < 

■  telephone  ear    . . 


Tiredness,  from  phthisis. .  572 
Toadstools,      hiumoglobin- 

uria  from  . .  284 

Toast,  in  test  meal  ..    31!) 

Tobacco,   amblyopia   from  759 

-  central  scotoma  from  . .   760 

-  colour    blindness     from 

759,  760,  762 

-  rouifh  from         . .  . .    148 

-  ,|r,ifMc-^s  from  ..  ..  166 
,|\^|..-|,siafrom  ..  ..319 
III  r  .uiu'ina  pectoris  from  434 
fiirnil  tongue  from       . .     43 

-  ifimtritis  from     ..        43.  317 

-  headache  from  . .  . .   295 

-  heart,    heartburn    simu- 

lating   297 


43 


from 

..   41K 
484,  485 


-  orthopiii.i:-;L  from 

-  palpitation  from 

-  pulse-rate  and   . .         . .  -4?^" 

-  tachycardia  from      703,  704 

-  tinnitus  from     . .  . .   723 

-  tremor  from       . .         . .  724 
~  variable  incidence  of  ill 

effects  of        . .         . .  485 

-  vertigo  from      . .  . .    752 

-  vomiting  from  . .         . .   764 
Toe,  abraded,  cellulitis  from  410 

-  big,  exostosis  of  ..  671 

in  peroneal  atrophy  . .  513 

plantar      ffesed,       in 

Tooth's        peroneal 
palsy  . .         . .     60 

-  melanotic  sarcoma  start- 


ing 


I  the 


381 


(see   Paini 
Toe) 
Toe-nail,  ingrowing  . .  438 

Toes,  athetosis  of  .  -  131 

-  cheiropompholyx  of     , .   756 

-  clubbed,  with  congenital 

heart  disease  157,  215,  720 

patent  interventricular 

septum       . .  . .  215 
pulmonary  stenosis  91,  217 

-  cyanotic,   in  Raynaud's 

disease  . .      162,  441 

-  dead,  in  swimmers       . .  162 
~  dragging  of,   in    spastic 

monoplegia    . .         . .  496 

-  gangrene    of    (see  Gan- 

grene) 

-  hyperextended,  in  talipes  112 

-  pallor  of,  in  Raynaud's 


441 


-  position  in  tetany 

-  Raynaud's  disease  affect- 

ing      ..162,  256,  441 

—  scabies  of 

—  sore,    femoral    abscess 

from    . . 


glands  fn 


effect 


250 


Tokelau  ringworm 

Toluyleuedianiine, 

on  dogs  . ,       ,  . .  .i.i 

-  jaundice  from  . .  325,  33 
Tomato  tumoui-s  of  skin  ..  73 
Tomatoes,  oxalate  from  . .  42 

-  oxaluria  after  . .  . .  28 
Tongue,   absence  of  deep 

tenderness  in,  in  tabes  51 
Tongue,  acute  sdema  of, 
causes  of 


of. 
L   ]AUU) 


698 

l.-.N 


-  angeioneurotic      oedema 

of          ..         411,  698,  699 

-  angiosarcoma  of           . .  69!i 

-  ataxy  of 5ii 

-  atrophy    of,    in    bulbar 

paralysis        197,  493,  627 

from      12th        nerve 

jmralysis    . .         . .  63 

-  bald,  in  scarlet  fever    ,.  617 

-  biting,  in  convulsions  . .  1  i:i 
epilepsv           ..      594.  *>'.)>' 

Tongue,  bleeding  nsvl  of 


(Plafr  .wfn. 


292 

71 


i-llii 


■,M.t..^ 


Tongue,  chancre  of 


.rrtinihti: 

irU-t  fuvei 

of,    ii 


..    15 


cornot- 


-  cramp 

playpi-s  ..  ..   i.>i 

-  dark  "red.  In  dlftbote.H    ..   261 

-  dermatitis  hor|>otiformi8 

allocting         . .         . .     7-i 

-  drv,     in     acute    yellow 

atrophy  . . "    273,  831 


300 

TONGUE    — 

TREMOR 

Tongue,  drit,  contd. 

Tongue,  contd. 

Tooth's  peroneal  atrophy,  coritii. 

To.rcemia,  contd. 

-  with  anuria    . .          . .     42 

-  ulcer  of  (see  Ulceration 

anterior  cornual  cells 

-  from  parasites  . .       223. 

-  (mm  lipllailonna       ..   705 

of  the  Tongue) 

affected  in         . .     61 

-  parenchymatous  cardiac 

iriiiii          ..              ..       -10 

-  wasting    of,    in    bulbar 

big  toe  in    . .         . .  513 

changes  from. . 

r|.iilirli,.i ■  (see   Car- 

paralvsis        . .         . .  543 

flexed  in          . .     60 

-  from  plumbism. . 

iniiini.i  1)1    I'uliSUe) 

Tonic  versus  tetanic         ,.   137 

distinguished     from 

-  of    pregnancy,    polycy- 

.  1  1  in.ii.:iljiillosumaflect- 

Toii-i!.     r.h-:.-P-     of     (see 

infnntjle  paralysis  113 

tbfemia  from. . 

74 

<,Mliii-\  1 

f,'niiilvlus(orvin512,513 

-  from  quinine     . . 

'  1  M  ,  r  contractions  in  135 

Tnii-i'ilr.inim  .  ,ir;ith  from  382 

(Fn,.s\  I'll  .,11,1  21)  ..      60 

-  salicylates 

!'■  ill  iiion  of,  in  bulbar 

-  .■.Hih-i-  .1  liv          ..   218 

Tooth's  peroneal  atrophy, 

-  tetany  from 

|.il  1 627 

-  |.,ir.il\  -1-   ni    p;il;itp  after  589 

general  account  of    -.513 

Toxic  conditions,   anicmia 

1    ui.'.i,    l( i-omegaly  237 

-  stulii.^    IVinpli;itii-u^    :itm1   382 

heredity  in. .          . .    113 

from 

M 1  in  iFirj.    119)  237 

Tonsillitis,   acute,   bacteria 

lesion  of     . .          ..   513 

dementia  from 

ii.iiii  Mi.lulK              ..   739 

causing                     .613 

limping  from          . .   362 

noises  in  the  head  in 

Imixd,  liuui  .iL-nte  con- 

-    :i.nN 1 inliliv    uilli    I'll 

after  measles       60,  513 

Trachea,     aneurysm     ruii- 

gostiou  ol  liver           .  .   334 

-  -    '■!  '.    ........                .  .    379 

muscle  wasting  in. .     61 

tured  through       120, 

-  alcoliol            . .         . .     43 

...    542 

myopathy  simulating 

-  compression  of,  no  pain 

-  alveolar  abscess        . .  683 

Tonsillitis,   .iculf.   types  of  613 

60,  113 

with 

-  appendicitis   . .          . .  677 

1   ■  ■ .    ■    .  Ill    iii  ni 

paralysis  of  hands  in     GO 

-  displaced,     by     thyroid 

-  catarrhal  jaundice    . .  329 

'         "      '""      1U5^  211,   G14 

legs  in    . .         . ._    60 

gland  enlargement   . . 

-  aortic  disease  after       . .  209 

paraplegia  from    . .'  510 

-  distoraa  in 

-  in  cirrhosis    . .        51,  371 

-  bacteriological  diagnosis 

plantar  reflex  in    . .     68 

-  epithelioma  of  . .        184, 

-  from  defective  teeth. .     43  _ 

of        379 

B.D.  in  60,  61,  113,  513 

-  invadpri  by  carcinoma  of 

-  in  fevers         . .         . .  705 

-  bacteriuria  from            . .     69 

reflexes  in  . .         . .  513 

thvroid" 

-  foul  taste  from          . .  705 

-  chronic,    adenoids    with  015 

simulating  infantile 

f|.itlM-lioma     .  . 

-  from  gastritis          43,  267 

in  children      . .          . .   G15 

paralysis             . .     60 

Trachea,  irruption  of  caseous 

-  peritonitis      . .      388,  705 

-  and  diphtheria,  relative 

symmetry  of         . .  113 

gland  into      . .     650, 

-  pneumonia     .  .          . .   705 

pyrexias  of     . .          . .   574 

talipes  in     60,  113,  513 

Trachea,  obstruction  of,  by 

-  septicajmia     . .         . .  705 

-  earache  from     . .         . .  202 

thenar  atrophy  in. .   113 

aneurysm 

-  serum  injections       . .  223 

Tonsillitis,  follicular  {Plate 

after  whooping-cough 

--caseous     gland      157, 

-  taste  loss  from           . .  705 

XXVP)          ..          ..6(0 

60,  513 

(Fi'j^.  <;8)  15S. 

-  from  tobacco             . .     43 

albuminuria  from      ..      1'; 

'r-nrlnrlir. 4^2 

(.v:i,io-~i-  In.rn 

-  in  typhoid  fever        . .  705 

diphtheria  and           , .    'ill 

.il\  riii.ir  abscess  and    . .  683 

Trachea,  obstruction  of.  list 

glazed,    with     pyelone- 

leucocYtnsis  in           . .    :;i.ii 

M  ilnii:!  of  face  with     . .  410 

of  causes  of  418.  650. 

T'hi-iti^              •■          ..   S76 

-  _  ^vpdili-  -iinnliiting    ..   till 

Tuuih-brnsh,  bleeding  gums 

hv     incdiasliiial     new 

•iiiiiiiK.   .if         :'.79,  698,  739 

-  -  \  jiMTiiC-'  ;iiiL'i!ia  simu- 

from     .  .          .  .          72,  73 

■growth         .. 

.i-ir  Ironi           ..   705 

l-n,ML-            ..           ..614 

-  retraction  of  gums  from  589 

orthopncea  from 

iriihiMlirT  into       698,  699 

-   fniit  iMi'.Ml,  lr..ni               ..       87 

Tooth-plate,  aorta  opened 

stridor  from  . . 

h,.,|M.-  ,it              ..          ..   754 

_     jiMll'r'    II |,„..,pliti'^          "U 

l>v        267 

-  syphilitic  stenosis  of    . . 

iiiiniiiril     ,~rii-:ition    in, 

-      (ll      l,M    ■.        ..!           .      II   1       i|r-|.    ,.,.           II 

Mir.i.M-.' dueto..         ..     73 

~  ulceration  of     . .       287, 

Hill  11.  rvo  lesion  706 

-      II    !,    .    1          ,,!■■■                    ■  ,  1    1               t,   1   - 

ill    ;  111  /.  ptyalism  from  542 

Tracheotomy,     for     acute 

III. 1.  III. '.1  ,.i   .'.l^'cs,  from 

-    |,, ; ;ii;.      i;,        |ii.;,    |l.  1 

.1     i|ii  .iLralstenosisfrom 

laryngitis       . .      158, 

iuiue     luiiKCStion     of 

-    JifllU-lT     llu  Ulu.lll.  .1     ajnl    ,".."fl. 

1^14.  (Fig.  91)  195 

-  in  angioneurotic  cedema 

liver    ..          ..          ..334 

-  pyre.Ma  from     . .         . .     34 

-  ir^M),li,,L'u.p.Tinnitedby  267 

-  for  laryngeal  obstruction 

-  by   teeth,   from   gas- 

- rheumatic          . .       14,  379 

-  ill  .r^.i|ilMjii-.  )iyupneu- 

paralysis 

tritis           ..         ..   267 

fever  and       . .         . .  337 

ii...(irji.;,t.iiii!ii  from     652 

-  stenosis  after    . . 

large,  in  acromegaly   . .  237 

-  rigor  from          . .          . .  595 

-  stump    uiKk-r,    ptyalism 

-  stridor  after 

-  diabetes          . .         . .  264 

-  in  scarlet  fever  . .         . .  614 

from 542 

-  subcutaneous       emphy- 

- Mongolism  (Figs.  118, 

-  spondylitis      deformans 

-  tongue  swollen  from     . .    698 

sema  from     . . 

119)  237 

from 714 

-  ulcer  of  tongue  from    . .   198 

-  tube,  hffimoptysis  from 

leukoplakia  of  . .         . .  73!) 

-  stiff  neck  from  . .         . .  647 

Torsio  testis                    . .  696 

ulceration   of  trachea 

like  a  bag  of  worms       ..   135 

-  submaxillary  glands  in- 

 abscess  from  . .          . .   622 

from 

niBviof    ..          ..'        ..283 

flamed  from  ..         ..379 

in  horse  riders           . .   480' 

Trachoma,  entropion  from 

normal    protrusion    dis- 

-  trismus  simulated  by    . .    729 

operation  in  diagnosing  480 

-  (Plate  Xir,       . . 

t:im-c  of             .,            ..    738 

-  (nml  p.-o  ^^orc-Tliroat) 

strangulated       hernia 

-  pannus  from      . .      231, 

|.:ii:ih   1     ..r   i-pe   Para- 

Ton-il-i,  .■liiii.iv  on            ..    615 

simulating  . .          . .   682 

-  trichinsis  from  . . 

\\    1    .it  'r. ..'■-'lie) 

-  f.|il,iiv...|,   :i. I.I. ...ids  with  615 

Torticollis,   asymmetry  of 

-  ptosis  from         .  .      231, 

|..ni|iliiLii-  ..iT.'.'fing      . .      74 

-  -  111  .lulili.  11      ..      613,  615 

face  with        . .          . .   142 

-  ulcer  with 

ongue,    pigmentation   of. 

fruiii          In  [icrtrophic 

-  clonus  with        . .         . .  137 

Trades    (see    Occupations) 

in    Addison's   disease 

rhinitis  ■     ..          ..179 

—  congenital           . .          . .   142 

Train  giddiness      . . 

(Phil,  .V.v/i  . .         . .  526 

-  -  insonmia  from           . .   321 

-  contracture  in   . .          .  .    139 

-  sickness,  headache  from 

protrude.l.    in   .■ii'liMi..iii  234 

-  -  in  Ivmphatism           .  .    382 

Torticollis,  general  account 

Training,    lack    of,    tachy- 

- mongolisni   I'Jii,  (/■'(;/*■. 

-  -  iitelVmnro  anil           ..   4112 

of                             -.142 

cardia  from   . .      703, 

lis,  119)  237,  238 

-  -  s..rr  Ihn.iit  uith         ..    613 

-    fi-M...    1-   -I-.  1       .  .              ..141 

Traiirc.  bradypncea  in     84 

Raynaud's  disease  affect- 

 .^I.rlor  fniTii    .  .           .  .    i;47 

-    I.Hi  1    .:   .    ,1        :■.!,     Uith.  .     (M7 

-  cpifliral    abscess    simu- 

ing       .  .          .  .      286,  699 

Tonsils,  epithelioma  Of     ..  615 

-  1\  i.i|.li.,.|.  ■.,;.      iiiiiilatiii^  112 

iDtiriLT 

snrcomn   of         .  .       ii9S.  699 

-  L-iiiiiiiiii   u£          ..       613,  615 

-  i-la'Uia.U.uin>u.-Ui;,simu- 

-.  _  tiir.iniir  •^imiila.tinir    .  . 

ongue,    sensory   areas  ot 

-  mil. ■oils    patches   on,    in 

lutiiiH 142 

skin  corresponding  to  449 

syi.liilis            ..          ..618 

-  scoliosis  from    153,  154,  647 

Trance,  dcnpral  arrount  of 

sore.   Ill   [u.lliiL,'tii                 .  .     --•"' 

-  i.liiiiviiL'eal,       inflamed, 

-  spnsmodic           . .          . .   648 

-  hr.i:           ■,     .;      1   .        iiMll.k- 

-  svi.liiliilw  and            ..    .51:11 

sMoriiig  due  to           . .  613 

_  _  v.-trMtp.l  )iM,l  from..   589 

111 

-  in  syphilis       . .          .  .    491 

-  sarcoma  of         .  .        285,  615 

-  >\-r   .1  -   -Minilating     142 

-  hysterical            . .      118, 

stomatitis  afliecting      . .     74 

-  syphilis  affecting  383, 616, 739 

-  ^M  1      !            '  '  iii-i  leandl42 

-  respiratory  tests  in 

strawberry,  in  erythema 

-  tubercle  ot        . .          . .  615 

-  M,;;  ■ .  .          ..   647 

-  simulating  death 

scarlatiuiforme      . .   227 

-  ulcere  on,  ill  syphilis     ..   383 

-  fruiu  ,--(ri;M-iii.,,-.tuid  rup- 

- thermometer    in      dia- 

- scarlet  fever  . .      227,  562 

Tonsils,  various  affections 

ture  at  birtli  . .          . .   142 

gnosing 

swelling    of    in    angina 

Of        613 

-  stiff  neck  with  . .          . .   647 

Transfusion,  oedema  from 

Ludovici          ..      198,  699 

Toiiu-,  .l..|iiiilioii  of          .,    137 

Tonila!  in  urine     . .          . .   261 

412. 

-  angioneurotic    oedema  699 

Tonus,  how  maintained    ..    137 

-  vomit 115 

TransiUnmination    of    an- 

- from  bee-sting           . .   198 

Too!        ||'   ■    ■ 1              ..      96 

Tottering   gait   in   general 

trum    

-  carcinoma       . .          .  .    198 

T...I'                      ii.liajmo- 

paralysis         ..          ..726 

-  -  in  diagnosis  of  tumour 

-  dysphagia  from          .  .   198 

1    ;    .      .          :■•!..                             .  .      287 

Toxaemia,  in  acute  fevers    214 

Transitional     lymphocytes 

-  from  elossifis              ..    198 

-  .'.11111,1-  t-...   t  .aiL'.-,,  Den- 

-  from  alcoholism            . .   406 

{Plate  II) 

ongue.  swelling  of,  list  of 

l.iii 

—  arsenic    . .          . .          . .   406 

Translucencv  test,  for  cysts 

causes  of                   .698 

-  fxtni.'tion,         excessive 

-  aspirin 400 

-  -  hydrocele        . .      481. 

lili-.-dinc'    after,    from 

-  brachial  neuralgia  and . .  442 

Transposition      of      great 

-  sloiiiiif iti-'        .  .         74,  699 

l,:.'T,M.pl,ili-.     ,  .           ..273 

—  from  constipation          . .   406 

vessels 

-    l;;.yn:iii.l'~  ilisease    .  .'  699 

_  iii.|.  1.  1 ,  1  1'  1-  t,  simii- 

-  convulsions  from           . .   146 

-  liver        

ongue.  syphilis  of           . .  739 

.11        1.     .     1     '     138,  730 

-  dilatation  of  heart  from  214 

-  viscera    . .         . .      157, 

loiilli-iiiiirko.l,     in    dys- 

;,,    ;i.u       .iNiil;itedby729 

-  from  drugs         . .          . .   406 

dysphagia  lusoria  and 

pep.sia              . .       267,  698 

-  iiih.ika.     ^aii^'iciie      of 

-  erythema  from  . .         . .  226 

Traiisvei-se     myelitis    (see 

tremulous,  from  alcohol 

lung  from      . .       259,  260 

-  hemoglobinuria  from  . .    2S  J 

Alvi'ljiis,     Transveree) 

51,  726 

-  in  larynx           . .         . .  157 

-  headache  from  . .         . .  2'm: 

Ti:i[nvni-.p;nv^isof        .. 

-  cirrhosis          . ,       51,  371 

-  septic,  alveolar   abscess 

-  infantilism  from            ..   ISH 

Traube's  space 

-  general  paralysis  146,  726 

from 683 

-  intestinal            189,  406,  410 

Trauma  (-rr  Injury) 

-  from  lead       . .          . .  726 

Tooth's  jieroneal  atropliy. 

-  from  iodide  of  potassium  406 

Treadler's  cramp  . . 

tuberculosis  ot  540,  698,  739 

age  incidence            . .     60 

-  noises  in  the  head  from  406 

TREMOR    

Trunor,  conl'l. 

rremor,  from  alcohol  no, 

S33,  726 
rremor.  ataxia  and  .  ■  727 

-  from  cerebtnl  embolism  133 

-  ill  chorea 


!she.1f 


TREMOR      - 

Trichocephahts  dispar,  contd 

-  -  ovum    iFig.    28)     80, 

520,  (Fi(t.  219)  i) 

no  symptoms  from  . .   5. 

'  Trichophyton  acuminatum   24 

-  crat€riforme 


TUBERCULOSIS 


rremor.     coarse,     general 

account  of  .  ■  727 

rremor.  from  drugs         -  ■  726 
rremor,  fine,  general  account 
of  724-7 

-  after  flashinpr     . .  . .   -Ml 

-  in  general  paralysis      . .  14G 

-  Graves's 


247 


29,  703,  72 


726,  770 
134,  727 


-  after  hemipl^ia 

-  in  hysteria      '  . .      J.34,  i 

-  infantile  hemiplegia     . . 

-  intention,  from  cerebellar 


ataxy  . .         -  -  728 

tumour       . .         . .  517 

-  cerebral  diplegia    724,  729 

-  -  disseminated   sclerosis 

148,  307,  496,  517,  724 

-  -  Fripdreich';:       disease 

140,  512,   728 
rremor,  intention,  general 
account  of  - .  728 

rremor,     intention,     from 
mid-brain  lesions      . .  729 

-  -  iieur.istheni:(  . .  .  .    l'^^ 

-  of   iris,   from   dislocated 


rii>  u-]-id  area,  bruits  in      92 
.iflinition  of  . .  .  -     92 

-  regui^itation,  from  alco- 

holism ..  ..214 

-  -  bruit  of  . .        92,  211 

without  bruit  . .      92 

from  dilatation  of  right 

ventricle  . .  . .  92 
dullness    to    right    of 

sternum  in. .  . .      92 

from  emphysema      . .   217 

liver  eniaiged  from  . .     92 

from  mitral  regui^ita- 

tion  ..  ..211 

ffidema  of  legs  from  . .      93 

pulsatile  liver  from  92,  368 

pulsation  of  neck  veins 

in 92 


Tropics,  could. 

-  cheiropompholyx  in     ..  97 

-  cluronic  diarrhcea  in      . .  172 

-  chylous  ascites  in         . .  50 

-  cbyluria  in         . .          . .  pO 

-  congestion  of  liver  in  334,  369 

-  eczema    marginatum    in  250 

-  elephantiasis  in           28,  695 

-  filaria  in              . .          . .  109 

-  hepatic  abscess  in      291, 

332,  3G9 

-  hypotliermia  after  resi- 

dence in          . .         . .  312 
loss  of  weight  after  fevers 


from  lead 


726 


rremor.  list  of  causes  of  ■  •  724 

-  from    mercury      33,  65,  726 

-  mid-brain  tumour        . .   727 

-  nervousness       . .         . .  726 

-  in  peripheral  neuritis  65,  256 

-  with  professional  cramps  151 

-  rates  of  . .  . .  . .    724 

-  of    tongue,    in    chronic 

alcoholism      ..  ..51 

-  cirriiosis  . .  . .     51  I 

rremor,  unilateral  .  •  727 

Ir.-Ti.-li  feet  . .  .  .    224 

rre|>liiiiing,  for  meningeal 

hifimorrhagc  ..  ..   118 

Preponema   pallidum   (see 

Spirochieta  Pallida) 
rriceps.  nerve  supply  of. .  505 

-  pseudo-hypertrophy     of  513 

-  r«ot  innervation  of      . .  509 
rriceps-jerk,  increased,  in 

hnichial  monoplcgi 


clos 


traclir 


blood 


231 


Triohinellaj,  in  stools 
Trichinosis,  cholera  simu- 
lated by         . .  . . 

-  embryos  in  blood 

-  eosinophilia  in  401, 

-  epidemic 

-  erythema  in 


frot 


geographical  distribution 


of 


11..  ..   461 

simulating  464 


-  pork  find  . .      w\,  7*J!t 

-  pyrexia  from  . .  . .  729 
rfiftmiatism  Himulalcd  by  464 
-utllini^'  of  muscles  in  . .  101 
f.iiiliriiesa  of  spine  from  713 
iM>  liii.ellffi  in  stools  In..  161 
t  II  iriiis  from  . .  . .  729 
lyplioid  sinndaleii  by..    464 

Trichocephalus  dispar      ..  520 

I,..  I.lix.d  -lifimjes  with      26 
ill  .•<>I<.ii  (Fit/.  218)  520 

-  -  rommonne**  of  . .   :.2<» 

eo^inophilin  rare  from 

no    eosinopliilia    from 


-  -  thrill  with      . .  . .   721 

-  stenosis,  ascites  with    . .   694 
~  -  lividity  with  . .  . .   694 

-  -  with  mitral  stenosis. .   694 

-  -  nutmci?  liver  with     ..   694 

-  ~  rpdeni.i  ot  leL'S  with  . .    694 

-  -  orthoi.ncpa  with         ..    694 

presystolic  thrill  with  721 

pulsating  liver  with  . .   694 

Trigeminal      nerve      (see 

Nerve,  Fifth) 

-  neuralgia  (see  Neuralgia, 

Trigeminal) 
Trigone,  affections  of,  pain 

at  tip  of  penis  from  . .  471 
Triplegia,  spastic  infantile  132 
Trinitrotoluol,  acute  yellow 

atrophy  from  . .   334 

-  jaundice  from    . .       325,  334 
Trional,  tradypncpa  from    84 

-  coma  from         . .         . .  118 

-  cyanosis  from    . .  . .   157 

-  erythema  from..         ..  222 

-  hfemoglobiimria  from  . .  284 

-  methaemoglobinuria  after  157 

-  reducing    substances    in 

urine  after  . .  . .  157 
TRISMUS 729 

-  from  alveolar  abscess  . .  683 

-  catalepsy  . .  . .   729 

-  iivdrophobia      . .  . .    730 

-  hVsteria  ..  ..      138,  417 

-  nialiiigering  of  . .  . .   729 

-  from  strychnine  .  -    730 

-  simulated    by    alveolar 

abscess  . .  . .  729 
angina  ludovici  . .   729 

-  -  epithelioma    . .  . .  729 

facial  neuralgia  . .    729 

hysteria  . .  . .  729 

impacted  wisdom 

tooth  ..  ..729 

mumps  . .         . .  729 

myositis  od^cans    . .  729 

odontoma       . .         . .  729 

quinsy  . .  .  -   729 

teniporomaxillary  arth- 
ritis ..         ..729 

-  in    tetanus     138,     152, 

417,    649,    729 

-  tetany     . .  . .  . .    "30 

-  trichinosis  . .  . .   729 
Triple  phosphate   • .        . .  524 

-  -  crystals  of      (Fiij.  221)  524 
Trochanter,  trreat.  bedsore 

over 2.''7 

Trommer's  test  ..261 

Trophic  chaiitres.  atrophy 

of  testis  from. .         ..     66 

in  hair  and  skin,  in  tic 

douloureux  . .  147 

nails    . .  . .  400 

in  syringomvelia   110,  257 

-  ulcer,  fintjer  a'ffected  by  240 
'froithu'denia,      liereilitarv 

(Fiff.  177)  411 
Tropical  liver  . .  369 

-  Medicine,  London  School 


-  malaria  in  . .         -  -  632 
Trousers,    ill-fitting,    pria- 
pism from       . .  . .   538 

Trousseau's  sign  in  tetany 

3,  151,  152 
Truflles,      hremoglobiniu'ia 

from    . .  .  -  . .    284 

Trunk,  chromidrosis  of    . .   655 

-  leprosy  erythema  of     ..  383 

-  hchen         scrofulosorum 

affecting         . .         . .  488 

-  oedema   of,    fi'om    renal 

growth  . .  . .        7 

-  pigmentation  of  . .  527 

-  seboiThcea  affecting     . .  602 

-  syphilis  roseola  on        . .  383 

-  syphiloderms  of  . .  490 

-  vaccinia  affecting  . .    757 
Truss,    atrophy    of    testis 

from    . .  . .  . .     66 

-  glands  enlarged  from   . .  679 

-  psoriasis  affecting         . .  603 

-  spermatic  cord  compres- 

sion by  . .         . .     66 

Trypanosoma      eambiense 

(Plat^XXVni,  Fig.  G)  614 

in   cerebrospinal   fluid  305 

_  _  ,^l,;,rn.-t,..-^  of..  ..      28 


:.d    28 


23,   226 


Trypanosomiasis    . . 

-  L-;.l..i^L'.i  1;,  ii;i  h'^^lauds 

-  erythema  from 

-  gland  pimcture  in   dia- 

gnosing . .         . .     28 

-  kala-azar  due  to  •  -     29 

-  parasites  in  blood  in     . .     27 
Tryptic  activity  of  motions  328 
Tubal    abortion    (see    Abor- 
tion) 

-  gestation     (see    Ectopic 

Gestation  ) 

-  mole        . .  .  -  - .    ^93 
Tube  casts,  in  acute  neph- 
ritis    . .            14,  42,  281 

from    albuminuria   . .  537 

arteriosclerosis  . .  537 

bacteria  in     . .  . .       6 

bacteriuria     . .         . .     70 

in  blood  diseases      . .       7 

in  Bright's  disease 

y,  105.  412 

from     carcinoma     of 

rectum        . .         . .       7 

cerebral    hmmorrhage 

and  ..         ..119 
in  chronic  nephritis 

11,  76,  212,  274,  298,  408 

peritonitis  . .     47 

chyluria  . .         . .  109 

from  cystic  kidney   . .  037 

-  -  disintegration  of    6,  10, 13 
in  fungftting  endocar- 
ditis        '  . .  . .       7 
Tube  casts,  general  account 

of  (Phile  I) 


Tube  casCSy  conid. 

with  suppurative  nepli- 

ritis  .  .         .  .  I 

in  unemia       . .        85,  -) 

from  uterine  causes  . . 

varieties  of    . . 

Tube  casts,  various  causes 


of 


from        vena        cava 

tlirombosis 
Tubercle  bacilli,  antiformin 
process  in  detecting   . . 
458,  0 

in  ascitic  fluid 

cases  of  cough  . .   1 

caustic  potash  in  ex- 
amining for  . .  C 

cerebrospinal  fluid  305,  S 

cystitis  due  to 

in  eye  discharge        . .  7 

-  -  f^es    . .  76,  385,  4 
guinea-pig  inoculation 

in  detecting  . .  1 

from  gums     . . 

hiemoptysis  and        . .   '. 

from  hernia  testis     . .  ( 

in  liver  pus    . .         . .  - 

meningitis  from         . .   1 

nephritis  due  to 

from  nipple    . .         . .  1 

in  otitis  media  . .  • 

-  -  iPlaJe  XXVIIf)       ..    ( 

pyelonephritis  due  to 

sore  throat  due  to     . .   < 

from  scrotal  tistula    . .   ■ 

Tubercle  bacilli  in  sputum 

l.v.t.  ]'.•'.•.  ■-■ss,  15S,  641,  ' 
in  iiiihi.'M/.;.  ..   i 


Tubercle  bacilli  in  sputum, 
no  proof  that  phthisis 
is  advancing  . .         . .   i 


Tubercle  bacilli,  staining  for  C 

from  tuberculous  tonsiH 

ulcer  of  palate  - .  I 

ureteritis  due  to 

-  -  hi  urine  279,  282,  355, 
460,  4 

with    tuberculous 

bhulder   . .      397, 
471, 


kidn 


117,  . 


iilar  kidn 


537 


with   high  blood-pi 


!19 

.20     Tropi 


of 


iikylostomum  in     81 


212.  435 
insignidcance  of  single  6 
in  tardaceous  disease  8,  5.17 
mucus  simulating  . .  399 
.  with  nephritis  109,  420 
from  new  growth  of 
kidney  . .  . .  ' 
•  with  Q'dcma  of  legs  . .  412 

■  in  pyelitis      ..  ..578 

-  pyelonepliritis  . .   578 

-  from  renal  growth    . .        7 

-  -  infan-tion  ..  7.  283 

■  from  renal  thrombosis 


Tubercles  in  the  choroid  ..417 


Tuberculides,  general  ac- 
count of  .  •  '''■'>9 

Tuberculin  injection,  diag- 
nostic . .         . .  677 

in  obscure  pyrexia   . .   573 

phthisis  . .         .  ■   768 

-  -  tuberculosis  566.  669.  7Ii> 

-  reaction     in     Addison's 

disease  - .         ■  ■     •'! 

_-  (Plafo.'i  XXXVI, 

XXXVIJ)..       768,   770 

eosinophilia  from      ..    219 

Tuberculosis,  abdominal, 
pigmentation  of  skin 
in        528 

-  acet-onuria  from  ..        I 

-  acute  miliary,  leucopcnia 

-  albuminuria  in  , .         . .     13 

-  amenorrhoea  in..         ..     18 

-  anajmia  from      . .  32.  33 

-  anorexia  in         . .        43,  566 

-  associated  with  svphilis  293 

-  atrophy  of  testis  from  66,  67 

-  axillarv   glands   affected 

by    ' 3S.I 

abscess  fmni  . .  . .  6i;i; 

Tuberculosis     of     bladder 

(lUatc  XV)     ..  -.282 

aching     in     perineum 

I  from    . .  . .         ..171 

age  incidence  of  282, 

397,  471 

Ttilhnrzia  simulating 

282,  172 
oalrulus  sinnilating  . .  579 


902 


TUBERCULOSIS 


Tuberculosis  oj  bladder,  contd. 
cystoscope      in      dia- 
gnosing       . .      471,  579 

epitlieUomasimuliiting 

282",  579 

frequent      micturition 

from    171.  :.;:i,  .">::>.  712 
Tuberculosis     of     bladder, 
general  account  of 

282.  471.  579 

-  -  liECmaturia   from    L'7o, 

282,  397.  471,  579 

-  -  pain  in  penis  from 

397,  471,  579 

Other  parts  afEected  in  397 

prostate  affected  with 

282,  471,  579,  620 

pyuria  from  282,  397, 

471,  575,  579 

rectal  examination  in 

diagnosing  . .   471 
renal    tubercle    simu- 
lating         282,  471,  579 

-  -  secondary  to  kidney. .   579 

-  -  seminal  vesicles  affected 

with  282,  471,  473,  579 

strangury  fTom  . .   649 

tabes  simulating       . .  650 

testes  affected  with 

282.  471.  479. 


tuhf 


Mlli 


-  1-'- 


■ith 


'by 


677 
458 
lii4)        ..  ..458 

Tuberculosis     of     cscum, 
general  account  of    . .  458 

-  -   I;qiarotoniv      in      dia- 

gnosing^     ..  ..677 

pain  in  iliac  fossa  from 

454;  458 

-  -  from  plirln^is  ..   458 


snniil  1:    .     .1  |M  ■    I'.'itis; 

-  -  swelling'  in  iliac  fossa 
from  . .      458, 

tubercle      bacilli      in 

fteces  with  . . 

Tuberculosis,  cervical  glands 
enlarcred  from 


-YA  ) 


of  colon,  abscess  from..  1 

-  blood  in  stools  from. .  1 

-  cachexia  from  . .  1 

-  carcinoma     simulated 

by    . .  . .       125,  ' 

-  obstruction  from       . ,  1 

-  tenesmus  from  . .  ( 

-  tumour  in  hypochon- 


TiihercuIosiSj  contd. 

-  from    cow's    milk    308, 

379,  385,  631,  7G8 

-  deep-seated,  obscure  py- 

rexia from 


573 


Tuberculosis  of  kidney,  confd. 

guinea-pig  inoculation 

in  diagnosing         . .   57 
htematuria   from    275, 


Tuberculosis  of  bone,  gene- 
ral account  of       668.  669 


ar-niy-  m  .li  i-ih.mm-.  .   669 

-  bony  swelling  from       ..   667 

-  of  bowel,  bladder  opened 

by        582 

diarrhtra  from  . .   458 

-  lKBni;ituri;i  from         ..    275 

-  hyiiiT|il;i-(ii- colon  from  661 
Tuberculosis  of  bowel,  Inci' 

dence  of  ..  458 

-  -  pneumoperitoneum 

from  . .  . .   652 
pyuria  from  . .         . .  575 

-  of     breast.       carcinoma 

simul;ited  bv  ISl,  tiKi; 

-  -  mastitis  simulated  hy  OSt; 
Tuberculoslsof  breast,  notes 

..  686 


from  nipple  with  181 
simulating  carcinoma  181 

-  cachexia    from     4,     13, 

33,  413,  415 

-  of   cieciim,    appendicitis 
lated  by. 


of  < 


hli.lv 


Tuberculosis  of  epididymis, 
notes  on 

with  tuberculous  blad- 


into  bladder  579 


I  i.tiiii  ■-,  -iii>'  I  hroatfrom 
■  iiL'.T  (-.■,.    Miictylitis) 
oiieral.  in  children 

choroidal  tubercles  in 

in  guinea-pigs 

headache  in   . . 

hyperpyrexia  in 
kidney  involved  in  . . 
no  leucocytosis  in     . . 
liver  enlarged  in 
lumbar    puncture 

diagnosing . . 
of    lungs,     bronchitis 

simulated  by 

-  broncliopneumonia 

simulated  by  310, 

-  hyperpyrexia  from 
after  measles. . 


.    37 


-  meningitis  in. .         . .  ( 

-  optic  neuritis  in       . .  f 

-  purpui"a  in     . .      553,  ' 

■  -  relatively  slow  pulse  in  t 

■  -  no     renal    symptoms 

with  '. .         ,.  t 

■  -  spleen  enlarged  in  632,  i 

■  -  typhoid  simulated  by 

63G,  e 

■  -  vomiting  in    . .         . .  ( 

■  general  wasting  from  . . 

■  generalized  lymph-gland 

enlaigement  in  . .  l 

■  giant  cells  in       . .  . .  4 
of  L'lands.  lymphadenoma 

HI, ml  ,[M,.'         ..  ..     'c 

'  I  :         li  idation  in 


Tuberculosis  of  hip-joint  ■■ 

'with T  , 

-  of  ileo-caecal  valve      . .  ■ 

-  influenza  simulating     . .   i 
~  intestinal,   acute   ascites 

albumosuria  with     . . 

perforation  in 

suppurative  peritonitis 

-  jaundice  in         . .  , ,   ; 

-  of  joints  (see  Arthritis, 

Tuberculous) 

-  of  kidney,  aching  in  loin 

from  . .      279,  { 

age  incidence  of    277,  ; 

albuminuria    from    7, 

279,  i 

anuria  with     . .         40, 

calculus  simulated  by  : 

Cheyne-Stokes  breath- 
ing from     . .         ..  '. 

colic  from       . .      117,  i 

cystoscope      in      dia- 
gnosing    282,     355, 

Tuberculosis  of  kidney, 
cystoscopic  appear- 
ance   in   iPhfe   -YP)  ; 

empyema  from  . .   1 

frequent     micturition 

from  277,  279,  282, 
355,  393.  577,  I 
Tuberculosis    of    kidney, 
general  account  of 

279,  355,  I 


kiJiiey  crilai-ged  from 


pain  in  iiiac  fossa  from 

452,  454 

loin  from    . .  , .   460 

penis  from  . .  . .   579 

part  of  general  tuber- 
culosis       . .         . .  577 

perinephritis  from    . .  106 

pleurisy  from  . .  106 

polyuria  from  . .  577 

prostate  affected  in 

280,  355 

pyonephrosis  from  ..  576 

pyrexia  with  . .         . .   117 

pyuria  from  117,  279, 

282,  355,  460,    575, 

577.  579 

rectal  examination  in 

280,  282,  355,  577 

renal  colic  from        . .  279 

tube  casts  due  to . .       7 

seminal     vesicles     af- 

I  fected  in     . .      280,  355 

simulating  calculus 

\  117,  577 

tuberculous  bladder 

282,  471 

; strangury  from  . .   649 

I tenderness  in  loin  with  579 

testes  affected  in      . .  355 

' secondary  to  . .  479 

' thickened  ureter  seen 

!  with  cystoscope    . .  576 

'■ tubercle  bacilli  in  urine 

with  117,  279,  355, 

460,  577 

tuberculosis  elsewhere 

I  with  ..         ..577 

I tuberculous   bladder 

from  . .  . .   579 

I simulated  by     . .   579 

with  tuberculous  perito- 
nitis . .         . .     48 

tvphoid  simulated  by  566 

-  -  uramia  from         lol  146 

ureter  felt  per  rectum 

j  with  . .  . .   579 

infected  from         . .   473 

I ureteritis  from  . .   277 

' vaginal  examination  in 

280,  355 

wasting  with..  ..   117 

2;-rays  in  diagnosing 

279,(J^ij7. 134)280,  577 
;  -  of    knee.    Baker's    cyst 


Tuberculosis,  contd. 

-  orbital     . .  . .       229,  230 

-  orchitis  from     . .  . .     66 

-  pain  in  limbs  with       . .   465 

-  of  palate,  lupus  and    . .  588 

perforation  due  to  . .  588 

phthisis  and  . .         . .  588 

sore  throat  from       . .   613 

-  pancreatitis  in  , .         . .   100 

-  of  penis   ..  ..      617,  619 

-  periostitis  in      ..         .,   707 

-  peripheral  neuritis  from    465 

-  of  peritoneum  (see  Perito- 

nitis, Tuberculous) 

-  without  physical  signs. .  5r.(; 

-  polyorrhomenitis  from. .   Iu7 

-  of  portal  glands         45,  330 

-  portal  glands  enlai^ed  in 

51,  325 

-  prolonged  pyrexia  from  563 

-  of  prostate         . .      184,  697 

abscess  from  . .         . .  581 

aching     in     perineum 

from  . .  . .  474 
diflSculty  in  micturition 

with  . .  . .    395 

hjematuria  from    275,  5S1 

nodules  in  epididymis 

with  . .         . .  582 


linal 


rith 


nth 


-  lachrymal     glands 
I  Iari,'ed  in         .  .  ..   695 

i  Tuberculosis    of     larynx, 

notes  on  199.  293,616,  617 

;  -  -  piiilii-i-  :ui.[  ..  ..615 
j  -  -  s.iiv  tliroat  due  to     ..    613 

I tonsil  atTected  with  . .   615 

I ulceration   of..  ..   293 

voice  change  with     . .   150 

I  -  latent,  loss  of  weight  from  768 
j  —  leucocytosis  rare  in  . .  360 
I  -  lichenscrofulosorum  with  488 
i  -  of  liver 375 

Tuberculosis      of      lymph 
I  (ilands      I  '  ■      under 

'  '.lands) 


473,  582 
no   pain   during   mic- 
turition with         ..  470 

perineal  sinus  from  . .  620 

rectal  examination  and 

479.  630 

with  renal  tubercle  280, 355 

testis  involved  with 

620,  622 

secondary  to         . .  479 

tuberculous      bladder 

with  282,  397,  579,  620 

simulated  by     . .   471 

kidney  with        280,  577 

-  pulmonary,  acute,  rigor  in  594 
elastic  fibres  in  sputum 

in 598 

febricula  representing  4G4 

miliary,    no    tubercle 

bacilli  in  sputum..   643 

pain  in  the  limbs  in. .   463 

l)rolonged  pyrexia  from  566 

rigors  from     . .      595,  598 

Tuberculosis,    pulmonary, 
sputum  in  ..641 

typhoid  simulating  . .   565 

r.apid   .  .  . .  . .    549 

-  -  (and  see  Phthisis) 

-  of     rectum,     carcinoma 
simulated  by  ,  .  585 

-  of     rib,     submammarv 
abscess  from  . .         . .  686 

-  salivary  glands  enlarged 
in         695 

-  of  seminal  vesicles  184,  697 
aching  in  perineum 

from        . .  ..   474 

enlargement  in     . .  587 

nodules  in  epididymis 

with        ..         ..473 
rectal    examination 

and  ..  ..   479 

secondary  to  testis  587 

testis  involved  with  622 

tuberculous  bladder 

with        282,  397,  '>7'.t 

simulated  by. .   471 

kidnev  with   280, 

355,  577 
prostate  with    . .   582 

-  simulated  by  paratyphoid  565 
iTi-cted  by  435  I  -  of  spine  f see  Spinal  Caries) 

..    668  I  -  sl<M.i:ititi>  Ironi..  ..    :>l-' 


692 


Miculicz's  syndrome  in     695 

Tuberculosis  of  testis 

696 

miliary,  choroid  tubercles 

Tuberculosis  of  testis,  gene- 

in           417 

ral  account  of       479. 

G22 

-  prolonged  pyrexia  from  566 

Tuberculosis  of  testis,  hernia 

—  rigor  in             . .          .  .595 

testis  from      . .      n---. 

623 

milk  and            . .         . .   768 

morning  pyrexia  with  .  -  631 

Witll 

fc'- 

of  nails 400 

primary 

47'.l 

nose        179 

prostate  involved  with 

620 

obscure  cases  of            . .  385 

with  renal  tubercle  . . 

355 

occipital  glands  enlarged  378 

scrotal  fistula  from  621 

622 

oedema  of  legs  from  413,  415 

secondary  to  bladder 

479 

opsonic  index  in  diagnosing 

kidney 

479 

479,  677 

prostate 

479 

\, 


TUBERCULOSIS 


■TYPHOID   FEVER 


"iiherculosis,  coHtd. 

Tumour,  cbntd. 

ruplmkl  jmr.  mnUl. 

Tijphoid  fever,  eoiitd. 

-  seminal  vesicles  infected 

-  green,  in  chloroma 

39 

Typhoid  fever,  arthritis  in 

osteitis  of  femur  after 

34U 

witli 

587 

-  phantom  (see  Phantom 

340, 

341 

pain  in  the  eyes  in   . . 

446 

-  simuiatins  neoplasm 

4S0 

Tumours) 

atrophy  of  testis  from 

06 

iliac  fossa  from  454, 

459 

tubercnlous  bladder 

471 

-  pulsatile    (see  Swelling, 

bacteriiemia  in 

597 

pancreatitis  in 

100 

uberculosis     of      testis. 

Pulsatile) 

blanching  in  . .      120, 

574 

paraplegia  from 

516 

syphilitic  testis  distin- 

-  rfi[:il   (sr-e   Kidney,    Eii- 

bleeding  gums  in 

72 

paratyphoid  simulating 

guislieti  from         4^o. 

622 

liip'f'b 

blood-count     in     dia- 

565, 

636 

iiiIh-ivii1,.iis        l.IadilLT 

TUMOURS  OF  THE  SKIN 

730 

gnosing 

636 

perforation  in  47,  389, 

will. 

5711 

Tuning-fork  with  foot-piece 

culture  in  diagnosing 

574,  595, 

053 

-  -  kidney  with 

577 

(.Fig.  74) 

164 

564, 

036 

first  sign  of 

459 

-  ulceration  of  scrotum 

-  tests        

164 

per  anum  in 

76 

periosteal  abscess  from 

070 

from 

621 

Tunnels,  workers  in,  anky- 

-  -  carriers  of      . . 

254 

periostitis  in..      595, 

707 

-  wasting  with  . . 

409 

lostomum  in  . . 

81 

character  of  pyrexia  in 

636 

of  rib  after. . 

686 

tongue     . .         540,  698, 

739 

Turkish     bath,     capillary 

Cheyne-Stokes  breath- 

 peripheral  neuritisfrom 

of  tonsil 

615 

pulsation  during 

93 

ing  in 

108 

61 

04 

tuberculin  tests  in  506, 

Turner,    Dr.,   temperature 

cholangitis  from 

333 

peritonitis  in. .      254, 

595 

573,- 677,  738, 

740 

charts     supplied     by 

coated  tongue  in 

705 

pleurisy    complicating 

595 

typhoid  simulated  by  . . 

566 

(^Figs.  268,  269)  638, 

639 

coma  in 

117 

pneumonia       compli- 

ulceration of  bowel  from 

283 

Turpentine,  anuria  from  40 

,  41 

constipation  in      564, 

595 

cating 

595 

opening  into  bladder  575 

-  bullte  from 

90 

contractures  after    . . 

114 

simulating  ... 

037 

-  of  larynx  from 

158 

-  dermatitis  from 

755 

cramps  in 

152 

pneumoperitoneum 

-  nose  from 

220 

-  eri'thema  from  .  . 

222 

date  of  rash  in 

636 

from             . .      652, 

653 

-  tongue  from  . . 

738 

-  hajmaturia  from 

275 

deafriess  from 

106 

polyuria  after        535, 

536 

of  ureter             . .      355, 

472 

—  haimoglobinuria  frnm  . . 

284 

deep-seated    suppura- 

 prolonged  pyrexia  fron 

-  cystoscope      in      dia- 

- leucocytosis  from 

360 

tion  simulating     . . 

301 

563, 

564 

gnosing 

473 

-  nephritis  from   .  . 

9 

delirium  in    . .        76, 

109 

pulse  relatively  slow  ill 

-  frequent     micturition 

-  priapism  from   .  . 

538 

diarrhoea   in  76,  171, 

171,  564, 

038 

from 

473 

-  strangurv  from          649, 

650 

239, 

564 

pulse-respiration  ratio 

-  kidney  tender  with  . . 

473 

Twelfth  nerve  (sec  Serve, 

diazo-reaction  in 

173 

in     . . 

036 

-  pain  in  iliac  fossa  from 

454 

Vagus) 

dilatation  of  heart  in 

214 

-  -  purpura  in     . . 

553 

penis  from. .      471, 

473 

Twins,  detection  of      200, 

201 

diphtheria  simulating 

037 

pus  in  stools  in 

567 

-  rectal  examination  in 

-  dystocia  from    . . 

200 

empyema      of      gall- 

 pyiemia  simulating  . . 

.596 

diagnosing  277,471, 

TwiU-hings.  with  anuria. . 

42 

bladder  from     254, 

333 

pyelitis  in 

576 

473, 

579 

-  hemiplegia  preceded  by 

134 

epididymitis  from    . . 

66 

—  pylephlebitis       simu- 

- secondary  to  kidney . . 

473 

-  due   to   incre:ised   intra- 

 epididymo-orchitisfrom 

lating 

507 

-  simulating  tuberculous 

cranial  pressure 

590 

478, 

696 

pyosalpinx  simulating 

301 

471 

-  muscular,  from  alcohol 

726 

cpistaiis  in     76,  221, 

636 

rnrity  of  purpura  in. . 

554 

-  tubercle  bacilli  in  urine 

in  chorea 

136 

fatty  heart  from 

212 

-  -  rlionctii  in 

636 

with 

473 

delirium   tremens     . . 

130 

fatty  stools  in 

239 

Typhoid  fever,  rigors  In  . . 

595 

-  vaginal  examination  it 

579 

from  fatigue  . . 

136 

febrictUa  representing 

464 

-  -   -  rarv  in 

595 

of  urethra 

184 

in  general  paralysis. . 

1.36 

foul  breath  in 

86 

Typhoid  fever,  rose  spots  of 

uteri,    carcinoma   simu- 

 Graves's  disease 

138 

taste  in      . . 

705 

636 

lating  

391 

hysteria 

130 

frontal  headache  in.. 

604 

_  .    .     

r,:!7 

-  erosion  simulating   . . 

391 

from      nervous      cx- 

gall-bladder  enlarged  ii 

_     -     -rill  ■.     r -iiiimI    II  !•   1 

rii;5 

-  metrorrhagia  from  390 

391 

hau-stiou     . . 

136 

253, 

254 

-  -  <i>i  I'll-  aiiunirnnal  Jiain 

-  microscopical  diagnosis 

391 

overwork 

130 

rupture  in  . . 

254 

in 

574 

of  uvula,  sore  throat  f  ron 

613 

-  from  URcmia     . . 

40 

-"  -  gall-stones  after 

254 

sloughs  in  stools  in  . . 

636 

of  vas  deferens. . 

097 

Two-glass  test 

183 

gangrene  from 

255 

small  lymphocytes  in 

361 

with        tuberculous 

in  gonorrhoea 

182 

gastric    HCl   deficient 

small-pox  simulating 

637 

bladder  .. 

397 

urethritis 

581 

in     . . 

270 

softening  of  cord  from 

visceral,  multiple  benign 

Tympanic  membrane,  per- 

Typhoid     fever,      general 

510, 

617 

sarcoid  witli  . . 

405 

forated            . .      202, 

422 

account  of     . ■ 

564 

sordes  in        , .         7- 

,   86 

uberculosis,  von  Pirquet's 

hearing  good  in  spite 

general  peritonitis  from  388 

speech  loss  in 

623 

test  for  ■■■t.  :;-■..  v.'j. 

of 

165 

tuberculosis     simu- 

— spinal    coi-d    changes 

I7<i.    .".i;i;,    .•.7:;,   i;:;i. 

-  -  niptured,  from  a  blow 

lating      .  .      636, 

640 

after 

715 

liii'.i,    ii'.ii;.    ;:is,   ri". 

on  ear 

421 

wasting  from 

59 

thrombosis  from  . . 

516 

768, 

769 

htemorrhage  from  ear 

hfemoglobimiria  from 

284 

spiTif   after 

71.-. 

vulval  swelling  from    . . 

699 

due  to     . . 

421 

-  -  haimorrhagc  in 

574 

Typhoid  fever,  spleen  en- 

weakness from  . . 

506 

Tympanites      (and       see 

-  -  headache  in    70,  566, 

larged  in  ;i;.  171.  y^<^. 

yaws  distinguished  from 

403 

Moteorism) 

572.  630, 

640 

636 

uberculous    glands    (see 

-  abdominal       distention 

-  -  lii].-i,.ihi  -liiT  after  .. 

340 

spondylitis  deformans 

Lymphatic       Glands) 

from 

418 

-        Im.riarrM:,    in      309, 

574 

from 

71  1 

nodule  in  brain,  hemian- 

- with  acute  peritonitis  . , 

592 

Ill  |inlli.rnii.i    after    .. 

311 

—  streptococci     compli- 

opsia from 

301 

-  from  carcinoma  coli     . . 

330 

-        ilal.lihil.-  ..iK.-t  of     .. 

636 

cating 

311 

ubular     breathing     (see 

-  witti  <irr!io-i' 

371 

iiidicatmria  from 

314 

stridor  after  . . 

660 

Bronchial    Brejithing) 

108 

-    in  i-ij  h.i.     ill-i   i^r 

171 

infective  parotitis  in 

694 

submammary   abscess 

■umour  (see  under  Swell- 

Tympanites, distinction  fron 

influenza  simulated  by 

.505 

after 

080 

ing) 

ascites 

44 

simulating  . .      564, 

639 

sudden  drop  of  tem- 

umour. abdoini[ial,  from 

-  heart    impulse   displaced 

intestinal  haimorrhagc 

perature  in         389, 

574 

aneurysm 

331 

by       ..-,.. 

299 

in     . . 

120 

rise  of  pulse-mte  in 

389 

-  from     c:irfinonul      of 

-  from  nirschsprung's  dis- 

jaundice  in   325,  320, 

335 

suppurative       perito- 

(luo.kMiuni . . 

272 

c:isc 

130 

—  "knee-jerks  exaggeratet 

nitis  in 

47 

stomach      270,  271. 

-  on  hn|.iiii'  1   l'r'<irri 

418 

after 

358 

-  -  sweats  in 

695 

317, 

318 

-    |Ml|<if  .If  lull    Initii 

485 

la.ssltudc  in   . . 

630 

talipes  from    . . 

114 

-  constipation  from     . . 

127 

-    frrilii      |i  ri,   r.'  il  ili^ 

594 

leucocytosis  rare  in.. 

360 

-  -  temperature  chart  in 

665 

-  distended  bladder  caits 

-     -lliiill   If  r     ■      1    .    ir.'S 

44 

no  leucocytosis  in     . . 

640 

tenderness  of  chest  in 

707 

,   "'«, 

45 

Tyniiiany.  thor.nric 

611 

leucopenia  in  76,  171, 

testicular  abscess  in . . 

622 

-  from  diverticulitis    . , 

453 

'i'\  1  ■                    ■  '  ."ilii-.ln  in 

117 

335,  301, 

636 

-  -  tetany  from   . . 

151 

-  gastric  ulcer  . . 

318 

'l\  1                                imni 

61^3 

low  inilse-ratio  in    . , 

335 

-  -  throinbosis  in 

411 

-  heart  impulse  displaced 

■-    Ji.ini    in     1  1  '1,1     i||:ii-    fossa 

lymphocytes  in 

030 

thyroid  gland  enlarged 

by 

299 

fr.irri 

116 

-  -  malignant  endocarditis 

in     . . 

722 

-  mtussusccptioii    caus- 

Typhoid    bacillus     (see 

simulated  b.y 

605 

tinnitus  from. . 

723 

ing  ..           78,  115, 

127 

Hacillus  Typhosus) 

simulating 

607 

to.vaimia  in    . . 

214 

-  linep  albicJlntcs  from 

305 

-  fever,    abdominal    full- 

—  Mediterranean     fever 

trichinosis  simulating 

404 

-  liver  pushed  up  by  . . 

367 

nesj*  in 

76 

simulating  . . 

566 

tuberculosis  sinuilntini. 

-  multiple,  malignant.. 

47 

—  abscess  from  . . 

459 

memory  defects  after 

20 

565, 

50(> 

tuberculous  47,  IK, 

1.TO 

—  mmtfl  o.scitcs  In 

47 

menorrlmgia  from    . . 

386 

—  tuberculous       menin- 

- from    ovarian    dise-tse 

19 

agglntlnntion  test  in 

171 

mental  dullness  in    . . 

70 

gitis  siimiluted  by 

.565 

-  palpitation  from 

485 

albuminuria  in 

13 

moteorism  in . . 

389 

siimilnting  . , 

666 

-  from  iireghJuicv 

19 

nlbuniosiirin  in 

16 

middle  -  car      disease 

-  -  typhus     distinguished 

-  simulated  by  hysteria 

390 

ambulatory    type     . . 

459 

complicating 

695 

from 

336 

-  simulating  jis«-itos     . . 

44 

-  -  anorexia  in    . . 

036 

necrosis  of  jaw  from. . 

083 

ulceration  of  bowel  In 

657 

appendicitis  simulated 

nephritis  from 

42 

laiynx  In  199,  287, 

omentum    .. 

48 

by 

459 

-  -  nodes  from    . . 

670 

292,  419, 

050 

-  with  tuberculous  peri- 

 appendicular     abscess 

a'dcma  of  le^.'s  after. . 

414 

-  -  ulcerative  colitis  simu- 

tonitis        . .         48 

I. 30 

simulating  . . 

.361 

-  -  orchitis  from.. 

06 

lating 

70 

TYPHOID  FEVER    —    UMBILICUS 


Tifplioid  fever,  confd. 

weak  first  sound  ia  . .  214 

-  -  Midal's  test  in  64,  76,  ■ 

254,  335,  459,  564, 

572,  636  I 
Typhoid  spine      340,  714,  715 
teiulerness  of  spine  froiii713  | 

-  state        638 

Typhus   fever,    blood    in-  i 

■  ■  •      ..         ..  161  ' 


chills  i 


..637 
..117 

-  -  crisis  in         (Fuj.  269)  639 

-  -  cyanosis  in     . .  . .   161 
diazo-reaction  in       . .   173 

-  -  dilatation  of  lieart  in  214 

dirt  and  . .  ..   335 

distinction    from    ty- 
phoid . .  . .   335 

-  -  hyperpyrexia  in        . .   309 

-  -  jaundice  in     . .      325,  335 


leucocvtosis  i 

-  -  lice  and 


Typhus  fever,  notes  on  637.  638 

-  -  pain  in  the  eyes  in  . .   446 

photophobia  in  . .   525 

prolonged  pyrexia  from  563 

-  -  prostration  in  . .   637 

-  -  purpura  in      . .      553,  554 

-  -  rash  of  . .      335,  638 
retention    of  urine  in  638 

-  -  rigor  in  . .  . .   594 

-  -  in  Servia         . .  . .   335 

-  -  spleen  enlarged  in  632,  637 
temperature  churts  of 

638,  639 
tennination  by  crisis    335 

-  -  toxeemia  in    . .         . .  214 

-  -  vomiting  in    . .  . .   638 

weak  first  sound  in  . .  214 

Typists'  cramp      ..       151.  445 
Tyrosin,  alkaptonuria  and  746 

-  crystals  (Fig.  148)  333 

-  in  urine,  in  acute  yellow 

;itro[ihy      ..  273,  333.    705 


UFFELMANN'S  test,  for 
lactic  acid   . .         . .  320 

Uganda,  sleeping  sickness  in    28 

-  trypanosomes  in  . .     28 
Ulcer,  anal,  dyschezia  from  128 

-  pain     on     defaecation 

from  . .         .  •  585 
spasm  of  sphincterfronil28 

-  carbolic  acid  in  treating  746 

-  of  cornea  {Plate  JT//)  . .    232 

-  cutaneous,  from  syphilis  304 

-  duodenal  (see  Duodenal 


T"lce 
-  epith. 


731 


(Fig.  298)  737 
microscope    in    dia- 
gnosing      . .         . .  381 

-  Mooren's  . .         . .  734 

-  of  neck,  from   epitheli- 

omatous  glands        . .  380 
tuberculous    . .         . .  379 

-  perforating     735,     (Fig. 

297)  736,  737 

in  diabetes    ..         ..  737 

~  -  in  tabes  . .      257,  515 

-  rodent  (see  Ulcer,  Rodent) 

-  sarcoma  starting  from. .   731 

-  tuherculous,  diagram  of 

(Fig.  299)  737 

-  in    the      mouth,     from 

stomatitis       . .  . .      74 

-  on  tonsils,  in  syphilis  . .    3S3 
Ulceration  of  bladder,  from 

appendicitis   . .  . .   582 
from     carcinoma     in- 
vading bladder     . .  582 

-  -  from  cystitis  . .      578,  580 

epithelioma    . . 

-,  -  injury 

pyuria  from  . . 

simple,  cystoscope  in 

diagnosing  . .  . .   580 
frequent  micturition  580 


580 


I'lnnin.Hi    nf  hia.hhr.    n»,M. 

Ulceration  of  bladder, 
simple,  general  ac- 
count of  . .  580 

hsematuria  from  . .  580 

pain  Qn  micturition 

with         ..  ..580 
subcutaneous  emphy- 
sema from . ,  . .   203 
from  tuberculosis     . .  580 

-  of   bowel,  arthritis  from  339 

acute  peritonitis  from  592 

dysenteric,        stenosis 

fi-om  . .  . .   125 

from  dysentery         . .  283 

hsematuria  from    275,  283 

malignant,  pus  in  stools 

from  . .  . .  557 
opening  into   bladder  .'>75 

-  -  pyuri;rfroni  ..  ..575 

Ulceration  of  bowel,  tuber- 
culous . .      •■^S?>,  458 

:dl.iniiosiiria  with..      16 

-  -    -  M i  pi'ianumfrom 

76,  657 


I  tro 


1  fro 


painin  ahdomenfrora   76 

.with  phthisis         . .      76 

pus  in  stools  from. .   557 

stenosis  from         . .  125 

tenderness     in     ab- 
domen from       . .      76 

tubercle    bacilli    in 

fteces  in  . .         . .     76 

typhoidal,  pus  in  stools  557 

venereal,  pus  in  stools  557 

(and  see  Colitis,  Ulcer- 
ative) 

-  bronchus,      lijemoptysis 

from 287 

varieties  of     . .  . .    287 

—  ccecum,  stercoral  . .  459 
cutaneous  emphysema 

from  . .  . .   203 

tuberculous,  simulating 

125 


-  clieek,       from       actino- 

mycosis ..  ..   458 

-  clu'sr  wall,  actinomycotic  458 
ULCERATION     OF     THE 

CORNEA  -.733 

adhesions  of  iris  from  733 

anterior  polar  cataract 

from  ..  ..733 

from  conjunctivitis  . .   231 

epiphora  in    . .  . .   220 

fluorescin  in  detecting  733 

from  gonorrhoeal  con- 
junctivitis . .         . .  231 
hypopyon  from     231,  733 

-  -  (Plate  XII)    . .  . .   232 

iridocyclitis  from,      . .  733 

iritis  from       . .  . .   733 

from     lachrymal    sac 

suppuration  . .  220 

lachrymation  from   . .   733 

opaque  cornea  after. .  733 

in  ophthalmia  neona- 
torum        . .         . .  231 

pain  in  eye  from  445,  733 

perforation  from       ..   733 

photophobia  from  524,  733 

prolapse  of  iris  from. .  733 

]inpil  irregular  from. .   551 

-  -   \Mfh  r..-;.(-<-;i    ..  ..734 

Ulceration  of  cornea,  various 
causes  of        .  -      733.  734 

ULCERATION     OF     THE 

FACE 735 

-  finger,  cau.ses    . .         . .  240 

in   Raynaud's  disease  162 

trophic  . .  . .   240 

ULCERATION     OF     THE 

FOOT  .735 

perforating   257.    735, 

(Fiq.    297)  736,   737 

in  diabetes  . .   737 

ia  tabes      257,  515, 

735,    (Fig.     297) 

736,  737 
with  talipes  ..         ..  112 

-  fnenumlinguaj  in  whoop- 

ing-cough      . .         . .  739 

-  hand  over  chondroma. .  671 

-  jaw,  from  actinomycosis  458 

-  larynx,  due  to  angioma  293 


Ulceration  of  the  larynx,  confd. 

carcinoma       ..  ..   19i 

after  cut  throat        . .  28'i 

decubital        . .         . .  199 

-  -  diphtheritic    . .      287,  : 

earache  from. .  . .   202 

hsemoptysis  from     . .  : 

histological  diagnosis     199 

from  injury    . .      199,  292 

-  -  intubation      . .      287,  292 
simulating     laryngeal 

paralysis     . .         . .  494 

-  -  leprous  158,  199,  287,  292 

-  -  lupoid    158,  199,  287, 

293,  419 


malifii 

■  cedem. 


no,  650 

mm  419 
.  .    650 


-  -  stridr.i    irum    . 

-  -  syphilitic        J 

287,  293,  419,  650 

traumatic       158,  419,  650 

tuberculous    158,  199, 

287,  293,  419,  650 

typhoid  199.  287,  292, 

419,  650 
Ulceration  of  larynx,  varieties 


of 


199 


iolons        158,  199. 

ULCERATION     OF     THE 

LEG 736 

from  anthrax  . .  737 

.atheroma        . .  . .   737 

-  -  in  Bazin's  disease  404,  738 

from  cold       . .         . .  737 

from  deficient  innen-a- 

tion  ..  ..737 

elephantiasis  . .         . .  737 

epithelioma    . .  . .   738 

fracture  . .  . .   737 

-  -  glandei-s         ..         ..   737 

injury  . .  . .   737 

-.  -  after  phlegmasia       . .   737 

from  pressure  . .   737 

rodent  ulcer  . .         . .  738 

sarcoma  . .  . .   738 

Ulceration    of    leg,    from 

syphilis  . .     40.H,  737 
tubercle           . .      737,  738 

-  -  varicose  . .  . .    736 

-  -  -  epithelioma  from  . .   738 
from  yaws      . .  . .   403 

-  in  leprosy  . .        63,  257 

-  of  neck   ." 379 

nose,    epistaxis    from. 

220,  221 

leprous  . .  . .   220 

malignant       . .  . .   220 

from  syphilis . .         . .  220 

tuberculous    . .         . .  220 

-  cesophagus,  subcutaneous 

emphysema  from       . .   203 

-  palate,  microscope  in  dia- 

gnosing nature  of     . .  588 
spirochseta  pallida  from  588 

-  -  syphilitic         . .      210,  588 
therapeutic     test     of 

nature  of    . .         . .  588 

tubercle  bacilli  from     588 

Wassermann  test  and  588 

-  penis  from  balanitis     . .   617 

chancre  . .      617,  618 

epithelioma    . .      617,  619 

gumma  . .      617,  619 

-  -  herpes  617,  618,  754 

-  -  soft  sore  . .      617,  618 

tubercle  . .         . .  617 

(and  see  Sores,  Penile) 

-  perineum     (see     Sores, 

Perineal) 

-  pharynx,  earache  from    202 
in  syphilis      . .         . .  615 

-  rectum,      beai-ing-down 

pain  from       . .  . .   426 
from  carcinoma         . .   585 

-  -  proctoscope     in    dia- 

gnosing      . .         . .  129 

simple  . .         . .  129 

subcutaneous    emphy- 
sema from  .  .  ; .   203 

traumatii 

simulated  by 

-  -  venereal 
distinction  fro) 


vphi 


Vfaraiion,  contd. 
Ulceration  of  scrotum  479, 

621,   690 

-  skin  in  Bazin's  disease. .   404 

from  epithelioma      . .   731 

in  Jacquet's  erythema  401 

Kaposi's  disease       ..   731 

leprosy  . .      404,  601 

from  lupus     . .  . .  402 

-  -  sarcoma         . .         . .  731 

in  scrofulodermia     . .   403 

serpiginous,   syphilitic  40S 

from  yaws  . .         . .  402 

syphilitic,  Wassermann 's 

test  and      . .         . .  40S 
therapeutic  test  of  . .  40? 

-  small  intestine,  bladder 

opened  by      . .  . .   58i 

dysenteric  . .  . .   58* 

fulioivnlons  ..   58l 

-  Thrn;,r  ,HT  Sore  Throat) 
ULCERATION     OF     THE 

TONGUE  ..   73( 

Iv-pi,;,.'i..   fn.iu  ..    i;i; 

73f 

'arieties  of     . .  . .    19J 

~  tonsil,  malignant  . .   6K 

tuberculous    . .         . .  61." 

in  Vincent's  angina  . .   61- 

-  trachea,  by  carcinoma  of 

thyroid  . .  ..72; 

hfBmoptysis  from       . .  28' 

varieties  of    . .         . .'  28' 

-  at  umbilicus,  malignant  48; 
microscope    in    dia- 
gnosing nature  of. .   48: 

tuberculous    . .         . .  48: 

-  of  urethra,  behind  stric- 

ture    . .  . .  . .  47) 

from  calculus  . .  47; 

epididymo-orchitis 

from             . .          . .  47) 
from  syphilis. .         . .  IS- 

-  vagina,  from  prolapse. .  IS; 

-  vulva,  from  chancre    . .  70i 
-•—  epithelioma    . .         . .  701 

sj-philitic         . .  . .  70! 

T'lcerative  colitis  (see  Colitis) 

T'lcus  serpens        . .  . .  73- 

Ulna,  chronic  periostitis  of 

(Fig.  278)  66J 

-  node  on,  from  j-aws     . .  40; 

-  sarcoma  of,  skiagram  of  67' 
Ulnar  ancesthesia,  in  tabes  60S 

-  deflection  in  osteo-arth- 

ritis      ..  ..  ..   34i 

rheumatoid     arthritis 

(Fig.   154)  342,  34: 

-  nerve  (see  Nerve,  Ulnar) 

-  paralysis  (see  Paralvsis, 

Ulnar) 
Umbilical  cord,  infection  of, 

bleeding  due  to         . .      7* 
short,  dystocia  from. .   20( 


teta 


nfecti( 


Umbilical    region,    organs 
contained  in  ■  ■         ■  ■  66( 

Umbilical   Region) 
Umbilicus,  abscess    at,    in 

tuberculous  peritonitis  481 

-  altered  by  ascites        43,  42; 

-  dilated  veins  at. .         . .     4: 
in  cirrhosis  51,  37] 

-  eczema  intertrigo  of    . .  48; 

-  fistula    at    (see"  Fistnla, 

Umbilical) 

-  fixed  bv  carcinoma      . .     4J 

-  glands  draining..  ..   67* 

-  hajmatidro^is   of  . .   6Di 
-  htemorrhagc  from,  from 

congenital  obliteration 
of  bile-ducts  . .  . .  32J 

-  hernia    at    (see    Hernia, 

Umbilical) 

-  inflamed,  in  fat  persons    65( 

new-born        . .  . .   65f 

from  perigastric  abscess  65f 

tuberculous  peritonitis  65( 

-  lipomatosis  round         . .   41C 

-  malignant  deposits  at 

317,  656,  65^ 

-  reddened  in  tuberculous 

peritonitis  43,  48,  425,  48^ 


UMBILICUS  • 


URINE 


iibilicus,  coukl. 
jvarian  cyst  and 
icabtes  of  . .         . .   ' 

leptic,  prolonged  pyrexia 
from    . .         . .  . .   ' 

-  septicaemia  from       . .  ; 
welling  at  (see  Swelling 

in  Umbilical  Region) 
jlceration  at     . .         . .  - 
cinate     gyrus     lesions, 

anosmia  from  . .  ( 

-  tumour    of,    olfactory 

aura  with   . . 

-  taste  loss  fi-oni  . .  ' 
consciousness  (see  Coma) 
derground  workers,.pallo 


21 


pardonable  sfn 
reality,  sense  of,  as  an 

aura  of  epilepsy        . .  67 

acliur;,  carcinoma  in    . .  49 

■ysr  of   ..          6G5,  66G,  691 

nalignant  nodules  in  . .  G57 

ite  of     . .          . .          . .  605 

£mia,  acetonuria  in    . .  4 
icute,      with      chronic 

nephritis        . .          . .  11 

rom  acute  nephritis    . .  108 

85,  146, 

315,  417,  594 

:.llmminuria   ..  315 

amaurosis  in  759,  761 


I  ascending  nephritis    ■ 

108,  146 
ma  simulated  by  . .  535 
Id-ki's  sign  in        . .     69 


Sievn 


rom  chronic  nephritis. .  108 
oma     in     40,   83,   117, 

144,  146,  447 
first  sign  of  . .  . .  118 
onvulsions     in    40,    85, 

137,  144.  146,  417,  594 
rom  cystic  kidneys  42,  108 
eh'riimi  in  . .  40,  169 
rnw^iness  in  . .  40,  296 
f  ,   t.H.L'i...  in    ..  ..40 

I from  ..         ..  296 

n    .  I  [  iiL'cd  prostate     146 

■  (.  f     i. 315 

emia.  general  account  of    40 


igh  blood-pressure  in 

85,  146,  315 

yporr.vrcxia  in         309,  574 

vi>otl,.'niii:L  ill            4*1,  :ill 

Mil  -.-hoM  ,iiiiul.itr<]  hy  :Jir, 
emia.     latent,     general 

account  of                 . .  40 

■M.,,     ..  |,i,rif,is  ..  ..42 

.,(h  of  kidney..  108 


I    I'rcemin,  cotitd. 

-  tube  casts  in     . .        85,  417 

-  from  tuberculous  kidney 

108,  146 

-  urea  in  blood  in  . .     85 
cerebrospinal  fluid  in 

85,  304 

-  uridrosis  in        . .         . .  655 

-  venesection  for  . .         . .  118 

-  vomiting  from  296,  315,  764 
Urate   dfposit.   pink   from 

unxTvtl.rin     ..  -.743 

URATE       DEPOSIT       IN 
URINE  .740 

-  of  sodium  in  bursa       . .   344 

cartilage         . .         . .  344 

joint    . .         . .         . .   344 

-  -  on  knuckles  (Fig.  158)  345 

skiagram  of    . .         . .  346 

3--rays  in  detecting   . .  345 

Urates,  after  biliary  colic  451 

-  cleared  up  by  heating. .  574 

-  r.rTst:.lsof  ..  ..740 


Urates,  significance  of     ..  740 

-  tests   Inr 740 

-  white 740 

-  white  ring  from. .  . .  5 
Urea     in      acute     yellow 

atrophy  . .  . .    273 

-  in  blood  in  unBmia       . .      85 

-  cerebrospinal  fluid  . .  304 
in  unemia  . .  . .     85 

-  decomposed    by   fuming 

nitric  arid       . .  - .        5 

-  diminished       in       acute 

yellow  atrophv  . .   333 

--nephritis         .".  ..10 

-  nitrate,  white  ring  from  5 
--  in  phosphorus  poisoning  33G 
Ureometer  in  fermentation 

test 262 

Ureter,    appearance    with 

tidierculous       kidney 

(Phite  XV)     ..  .'.    282 

Ureter,  blood  coming  from 

(Platp  XV)    ..         . .  282 

-  calculus  in  (see  Calculus, 

Ureteric) 

-  kinking  of,  from  movable 

kidney  . .         . .       7 

-  lymphatics  round,  pyelo- 

nephritis and. .  ..  576 

-  obstnicted  by  aneurysm       7 

-  -  bladder  growth      277,  281 

carcinoma      . .        41    472 

fibroids  . .         . .     41 

hydronephrosis  from 

41,  35G 

-  pain  over  (sec  Pain) 

-  patulous,    with    dilated 

renal  pelvis    . .         . .  576 

-  pouting  of,  in  pyelitis  . ,  576 

-  psoas    abscess    openhig 


into 


582 


-  papilloma  of       . ,  , .   278 
Ureter,   pus  coming  from 

(Plnfr  XV)      ..  ..282 

from,     seen      through 

cystospope       .  .  . .    576 

-  thickened     by*  tubercle 

280,  576 

-  tuberculous  fsee  Tuher- 

fulnsis  of  TVeter) 

Ureteritis,    acute,     general 
account  of  . .  455 


-  P''i 


152.    l.-.l 

-  apjiendicitissinudated  by  155 

-  Ti.  coli  with       ..        69,   172 

-  -  pvo.-v«neii«  with        .  .      69 

-  nnl.-nhw     .In.nlito.l      hv  455 

-  frnr I.  I.  ..  .Miiri-.        ,".    455 

^ing  473 


>i      iniMlutpil  in       . .  .'i!!! 

fr.Mi,.      ■•     I:.  1  .1,,  from -172 

1  -      ..f  hreitli  from     87 

-   In.    1    ...i.  i'    I.I.  illii^ivith  K» 

n;h,,i    after    severe 

-  froiri  1,1. h,,.,   luLi-iviilnsIs  277 

:U:iee  ..         ..120 

-  (»)"■'" ' li  i..'!insin(?  4.')5 

-•    cerebral  nb- 

-  pa ..■-„     1 171,  472 

S.l 

-  riitiiiu....«,u.-  uitli       ..     09 

1.- rrliiij-c            ..      «.1 

-  stMpliyli»'oci'u.<  wilh  no,  478 

iiiiM.Mjr       ..          ..     xr, 

-  strpptocorcim  with       . .     fll) 

1  i''  I'-v         ..        ..lie. 

-  tuhcrtle  lwcillu.s  witb  . .     no 

rn     (rirlillnnr  lni.|liru    Mr, 

-  tuberculous        . .         . .  472 

tila.  symptoms  of     40,  42 

-  veaicfil  lesions  simulnted  472 

niliH  from     .  .          .  .    "L'^i 

Urcthm.    nbsecsa    openinc 

mor  from                  . .   721 

into r,81 

Crcfhra,   cnnhl. 

~  E.  xerosis  in  normal    . .      69 

-  bacteria  in  normal       . .     09 

-  blood-drops  from,  calcu- 

lus causing    . .         . .  39G 

-  calculus  in  (see  Calculus, 

Urethral) 

-  carcinoma  of  (see   Car- 

cinoma of  Urethra) 

-  canmcle  of  (see  Caruncle) 

-  catheter    in,     discharge 

due  to  . .         . .  181 

-  congenital  deficiency  in  394 
Urethra,    discharge    from 

(see  Bischarge,  Urethral) 

-  epithelioma  of  (see  Car- 

cinoma of  Urethra) 
URETHRA,  F>ECES  PASSED 

BY 238 

from  cai-cinoma  recti  582 

-  fistula   of   (see    Fistula, 

Urethral) 

-  flatus    passed    through, 

from  carcinoma  recti     582 

-  foreign  bodies  in        181,  184 
Urethra,  gas  passed  through 

529.  530,  582 

-  gonococci  in  female     ..   185 

-  graiuilar  areas  in  . .   183 

-  herjies  of  . .  . .   184 

-  injections  into,  discharge 

due  to  . .  . .  181 
epididymo-orchitisfrom478 

-  iniury  of  (see  Injurv  of 

Urethra) 

-  instrumentation  of.  epi- 

didynio-orchitis  from     478 

-  lacei'atet.i.  from  fractured 

pelvis 470 

-  ntevus  in  . .       275,  283 

-  obstructed,    by   bladder 

growth             .  .          . .  396 

l>y  calculus     .  .           .  .  396 

chronif  nephritis  from  7 

papilloma  of  bladder  472 

-  paiiillomata  of  . .          . .  184 

-  parts  of,   in  relation  to 

gonorrhosa     . .         . ,  182 

-  pigmentation     of,     in 

Addison's  disease     . .   528 

-  polypus  in.  dischai-gedue 

to         183 

Urethra,  prolapse  of    too.  702 

-  rectum  opening  throucrh 

{Fig.  249)  586 

-  rupture  of  . .         . .  278 
aching    in     perineum 

from  . .  . .  474 

-  slaphylococci  in  normal    69 

-  streptococci  in  normal,.     69 

-  stricture    of   (see    Stric- 

ture   of    I'rcllirn) 

Urethra,  syphilitic  lesions  of  184 


-  til 
uU- 


1S| 


rntliritis,   contd.     ' 

-  due  to  micrococcus  catar- 

rhalis  . . 

-  non-gonococcal . .      181,  1 
cystitis  from  . .         . .  1 

-  -  epididymitis  from     . .   1 
--  pm.l./fiti.'  fv,„„  ..    1 

-  pain   ..     ; I(;0,   4 

-  (111.-  I..  I      .  '.■ II-    .. 

-  post(.i  iiii .  ill  .    .11. -I-  i)f .  .   5 

-  probtaui     ..l..-t...-.^    Irum 

182,  470,  5 
affections  from         . .  3 

-  prostatitis  from  470,  578,  5 

-  pyuria  from       .  .      575,  5 

-  retention  of  urine  from    fi 

-  from  rlieumatism         . .  1 

-  septic,  epididymo-orchitis 

from    . .         . .         . .  4 

from  leucorrhcea       . .  4 

prostatitis  from        . .  4 

-  staphylococcal    70,  182,  5 

-  strangury  from . .  . .  G 

-  due  to  streptococcus    . . 

-  with  stricture    . .         . .  5 

-  two-glass  test  in  . .  5 

-  uric  acid  and      .  .  .  .   7 

-  v.aginismus  from  . .  1 

-  vesiculitis  from .  .  . .   4 

-  fand  see  Gonorrhosa) 
Urethroscopy  . .   I 

-  in    diagnosing    urethral 

TTrcthrotomy,  anuria  after 
T'rir  arid  fsfr  Arid.  TTricI  2 
URIC   ACID    DEPOSIT   IN 

THE   URINE..  -.   7 

Uridrosis 6 

URINE.  ABNORMALCOLOR 

ATION  OF     ..  .7 

-  acetone  in  (see  Aceton- 

Urlne,  acidity  of.  general 
account  of  . .  5 

-  albumin     ir.     (sr-r    .\lliu- 


■d  in 


of     ..        ISj.l 

Urctlirnl  crises  in  tabes  ..  .IIS 

-  glands,  infection  of     . .  183 
Urethritis,  abscess  of  testis 

from fi22 

-  from  bacillus  coli         . .  182 

-  bacteriological  diagnosis 

of         . .  . .      47S,  581 

-  I'vstitjB  from      . .  . .  581 

-  -  sinnilalpd  by.  .  .  .  579 

-  dvsii.ircunia  from  ..  193 

-  .-ir.-rl  <if  idrobol  on       ..  184 

iiislrnnicntation  on  ..  184 

-  -  irrihinl  inic-ctinns  on  181 
Urethritis,     endoscope     In 

detecting  . .  183 

-  epididvnio-oreidtis    from 

4  78,  nno 

-  fistula  from        . .  . .  (120 

-  from    gonococci           70,  182 
Urethritis,  oonorrhoai  182,  581 

-  goutv       ..  ..      181,  742 

priapism  from  . .  538 

pyuria  from  . ,         . .  575 

-  hmmaturia  from        275,  282 

-  from  iniuiy        ..         ..181 

-  instillntions  in  treating  478 
-from    instrumentation..  182 

-  irritant  Inieclions         . .  181 

-  leueocytosis  in  . .         . .  .300 

-  from  leucorrha»n  . .  182 

-  levator  aru  spasm  from  193 


-  (and  see  Anuria) 

-  increased,    in   chronic 

nephritis     . .  10, 

from  cystic  disease 

B.  coli  in  '        ..         69, 

-  paratyphosus  in 


URINE.  BACTERIA  IN  .. 
Urine,    bacteriological   ex- 
amination of  . .         69, 

-  Boncc-.Tonoss'    albumose 

in,  tests  for    .  . 

-  bile  pigment  in,  from  car- 

cinoma of  the  bile-duct 

pancreas 

from  gall-stones    . . 

Urine,    bile    pigment    In, 

general  account  of  . .  ' 

-  -    .-    IV..TM    I 
(iMid     , 


bilh: 


.dice) 


bilirubin   in         ..      74.3, 

-  I.ilivenlin   ill       ..      743, 
Urine,  blacl<        713,  744, 

-  in  aclllr.  iiepbrilis     .. 

-  -  alk^iplonuria  ..      7I.-|. 

-  -  cnilxilliria       .  .      7f.'i, 

~  ~  drugs  

hicmatojmri'hyriiiuria 

~  -  hnamaturia     . .         . . 
bmmoglohinuria     284, 

-  -  imllcanurin     . . 

-  -  jniindico         . .      324, 
melanuria 

-  blood-red.   from   hromo- 

globimiria       .. 

-  blotting-paperstiuncd by 

jaundiced 

Urine,  blue 

-  bromides  in 


906 

Urine,   coniH. 
Urine,  brown 

ill  acute  nephriti? 

hsemoglobiiiuria 

jaandice 

-  -  ring  in,  witli  nitric 


URINE 


UTERUS 


URINE,  CAMMIDGE'S  RE- 
ACTION  IN    ..  ..100 

-  carbolic    acid    in.    ferric 

cliloride  reaction  witli  170 

Urine  changes  in  acute 
nephritis      9,    10,    14,  42 

yellou-  ati'opliy      .,   27iJ 

Urine  changes  in  bacteri- 
uria 


'itli  c 


-  -   CVr||.',;l    \MMMM1,-        ..    3S-1 

-  -    Cysrtr   .h^.M-r  .,        I'J 

Urine  changes  in  cystitis..  578 

-  -  dialH.ir-  MiHInu-       ..    53tj 

Urine  changes  with  kidney 

new  growth    . .  7 

Urine  changes  in  lardaceous 
disease  8 

witli  ]>olvcvstic  kidneys 

42,  357 
Urine  changes,  in  pyelitis    578 

pyelonephritis  . .   576 

stricture  . .  . .        8 

-  chlorides  absent  in  pneu- 

monia ..      160,  335 

diminished  in  uepliritis     10 

phosphorus  poison- 
ing ..  ..   336 

-  i-tiylous  (see  Chyluria) 
Urine    cloud    on    boiling, 

causes  of       . .  4 

-  clots  in 276 

type  with  new  growth  278 

-  colourless  . .  . .    743 

-  copaiba   in,   white  ring 

from    . .         . .         . .       5 

-  cystin  in  . .  . .   161 

-  dark,  from  alkapton    . .   261 
brown,    from     liaenio- 


261 


Urine,  in  diabetes  . . 

-  diacetic  acid  in. . 

-  dribbling,  from  enlarged 

prostate  . .         . .  394 

fractured  spine  . .   398 

hffimorrhai|;e  into  spinal 

meninges    .,  ..398 

myelitis  ..  ..   398 

paralysis  of  bladder. .  398 

paraplegia      . .  . .    398 

retention         , .  . .   395 

retroverted         gravid. 

uterus  . .  . .   689 
stricture          39,  394,   470 


-  effects  of  acetanilide  on    157 

sulphonal  on  . .         . .  157 

trional  on       , .  . ,   157 

veronal  on     . .         . .  157 

-  effervescence  with  acetic 

acid     . .         . .         . .       4 

nitric  acid       . .  . .       5 

-  epithelial  cells  in  9,  10, 

575,  742 
14 
314 

-  exercise  and       . .         . .  534 

-  extravasation   of      278, 

470,  621 

-  fa?culent  . .  . .   283 

-  fdaments  in,  from  gleet  183 

-  fluorescent,  from  eosin. .   745 

-  fragments  of  growth  in 

7,  276,  580 

-  free  heemoglobin  in,  in 

nephritis         . .  . .     10 

-  Friedlander's  bacillus  in     09 

-  gas  in  (see  Pneumaturia) 

-■-  gonococcus  in    . .  69,  70 

-  cravel  in,  after  renal  colic  451 
Urine,  green  . .  747 

-  ereeTiish-brown,    from 

jaundice  . .  .  .   324 


ntd. 


hiBmatoporphyrin  in  (see 
Haematoporphyrinuria; 

haemoglobin  in  (see 
Haemoglobinuria) 

high-coloured  from  acute 


t;Li.l.< 


Of  ii^ 


-  incontinence  of  (see  In- 

continence of  Urine) 

-  indican  in    (see  Indican, 

and  Indicanuria) 

brown  ring  witli  nitric 

acid  from   . .         . .       5 

-  iodides  in  . .  73,  98 

-  iodine  co-efficient  of      . .    100 
Urine,  jaundice  and  changes 


in 


324 


-  lead 

-  leakageintovagina,from 

carcinoma       . ,  . .   582 

-  leucin  in  . .  . .   705 

in  acute  yellow  atrophy  273 

--  \i-\ir,\i-y[v<    in,   ill  acute 


I  'yuria) 


vith 


424 


Urine,  orange-coloured    ..  743 
Urine    outflow,   causes   of 
obstruction  to  . .       7 

changes  from         . .        S 

-  ova  in,  in  bilharaiasis  . .   472 

-  painful     and     frequent 

desire    to    pass    (see 
Strangury) 

-  pale      abundant,      after 

angina  pectoris     . .   433 

in  diabetes     . .         . .  261 

lardaceous  disease    . .       8 

-  passed  through  vagina. .  283 

-  phosphates  in,  diminished 

in  nephritis    . .         . .     10 
(and  see  Phosphaturia) 

-  pigment  granules  in,  in 

malaria  . ,  . .      31 

Urine,  pink  . .     743,  744 

from  drugs    . .         . .   745 

745 


14 


-  salicylates       in,       ferric 

chloride  reaction  witli 

-  salol  in,  ferric  chloride 

reaction  with . . 

■  sleep  and  . .         . .  , 

-  smoky,  in  acute  nephritis 

■  specific    gravity    of,    in 

diahptes  '.  .        261.   , 


■ lardaceous  disease 

■  spermatozoa     in,     with 

oxaluria  . .  , .   . 

■  spontaripouw  coat^nlation 

of  


-  micn-rnr,-ii-r:,i,,,-,h.ili^in    70 
inclit-'tisis  ill  .  .  .  .      09 

-  milky,  from  chyluria    ..    108  . 
Urine,   milky,  from  phos- 
phates ..     los,  524 

Urine,  mucus  in  . .        . .  399  : 
from  cystitis. .        194,  578  ; 

-  in  myxcedema  ..  ..     38 

-  nitrogen,   diminished   in 

phosphorus   poisoning  336 

-  normal  amount  of    393,  534 

-  nucleo-albumin  in,  white 

ring  from        . .  . .        5 

Urine,  nucleo-proteid  in  . .  4,  5 
..     10  , 


Urine  stream,  changes  in. .  394 
Urine  stream,  sudden  stop- 
page in  . .        . .  394 

-  streptococci  in  . .         G9,  70 

-  sugar    in    (see    Glycos- 


6     Urotropine,  strangury  from 

649,  ( 
5      Frticaria,  age  incidence  of  ' 

-  angioneurotic        oedema 

simulated  by. .         . .  i 

-  from  aspirin       . .         . . 
70     -  bullous 

70     -  in     dermatitis     lierpeti- 
34  formis 

9     -  dermatitis  herpetiformis 
simulated  by. .         . .   ; 


.ifun 

bullosa  related  to 
haamoglobinuria    with  2! 

-  lingers  affected  by       . .  -2'. 

-  from  fish  . ."         , .  c, 

-  giant,  from  serum         . .  i\\ 

-  from  hydatid  disease  . . 

-  itching  in  489,  540, 

-  from  jelly-fish  stings  .. 
-  I  i  I 's  affected  by . . 


ul;e 


tube  c:i,sts  in   (see  Tube 

Casts) 
tubercle  bacilli  in  69,  70, 

279,  282 
tnrhi.I.  from  plic^plmtf-;  183 
Tvn.-.n   in  ..    705 


■273 


-  pneumococcus   in  69,  70 

-  porter  coloured,  in  acho- 

hu-ic  jaundice  . .   335 

-  port-wine  coloured       ..  744     Urol)ihi 

-  powdered-wig  appearance 


DcpuMt  in   LnuL-) 

-  ui-ea   in,    diminished  in 

nephritis        . .         . .     10 

nitrate  in,  white  ring 

from  . .         . .       5 

-  uric  acid   in   (see  Acid, 

Uric) 

-  urobilin  in  (see  Urobilin) 

-  urochromo  of  normal  . .   743 

-  weather  and      . .         . .  534 

-  white  precipitate  in,  from 

oxalates         . .         . .  423 

riii;;  in.  from  albumns:p 

i:.,   16 
Urine,    white    rings    with 

nitric  acid  In.  causes  of      5 
Urine,  yellow  ■ .  743 

Urinometer,  in  measuring 

specific  gravity  of  blood  534 
Urobilin  with  cholangitis..  101 

-  in  fajces 743 

-  fluorescent    test     for 

(Plate  XXXIV)  748 

-  with  gall-stones  . .  101 

-  jaundice  . .  . .   101 

-  red,  with  corrosive  sub- 
limate ..         . .  170 


■  of 


■St    f( 


423 

-  prostatic  threads  in     . .  183 

-  pus  in  (see  Pyuria) 

-  reaction     of,    -in    acute 

nephritis         . .  . .        9 

bacteriuria      . .  . .      70 

Urine,  red 744 

-  red  corpuscles  in,  in  acute         I 

nephritis         . .  . .      14  I 

cystic  kidneys       . .     12  i 

insignificance         of 

occasional  . .        6 
(and  see  Hsematuria)  [ 

-  reducing  power  of,  with  i 

alkapton         . .  . .   746 

substances    in,     after 

di-ugs  . .         , .  157  ; 

-  reduction,  life  in; 


in  detecting  743 

( Fig.  36)     80 

r     .  ..325 

743 


743 


UlXii'.lKiUlla,   .;.  t.'ilTh0Sis 

371,  743 

-  fluorescence  from         . .  325 

-  from    intestinal    putre- 

faction           ..         . .  743 

-  in  malaria          . .          . .  31 
Urobilinuria,  notes  on     ■ .  743. 

-  in  pernicious  anjemia 

—^^274,  324,  743 

-  spectroscope      in      dia- 

gnosing           . .      324,  325 

Urochrome             . .          . .  743 

rrnpiTthrin            ..      740,  743 


iiydruncplirosis)  ..  578 
Urotropine,  for  gall-stones  650 
-  haimoglobinuria  from  . .  284 


37( 


39 

ici 

01 


2J 

■  iKipuIar  form  . .  487,  77] 
parts  affected  by         . .  4ii'. 

■  pemphigus  related  to  . .     9! 

■  -  simulated  by,.  ..  77] 
pigmentosa,  itching  in. .  73i 
-  wheals  in        . .  . .   73i 

■  -  xanthoma  simulating  73i 
from  pork  . .  . .  671: 
prurigo  simulating  . .  48J 
in  rat-bite  fever  . .  59J 

fiOi 


-  scarlet  fever  simulated  by  771 

-  from  serum         ..      223,  55-1 

-  shell-lish  poisoning  and      9!: 

-  tache  c6r6brale  in         . .  70'j 

-  from  strawberries         . .  22.' 

-  wheals  in  . .  . .   77J 
Uterus,  absence  of,  sterility 

from     . .  . .      645,  64e 

-  affections  of,  pain  in  the 

back  from       . .  . .   42S 

-  anteversion      of,      from 

pendulous  belly        . .  200 

-  carcinoma  of  (see  Carci- 

noma of  Uterus) 

-  cervix    of    (see    Cervix 

Uteri) 
Uterus,  casts  of  .193 

-  chorion-epithelioma     of 

390,  391,  688 

-  cochleate,  sterility  from 

645,  616 

-  cnn-p-Hnn  of,  drsmenor- 

rlnr.a    l-runi      '.  .  ..    192 
mriinnlia-ia  from  386,  3S7 

Uterus,  congestion  of,  sym- 
ptoms of  . .  387 


esof, 


vith 


-  displaced,   bearing-down 

pain  from       . .         . .  4'_'6 

chronic  neplu'itis  from  7,  8 

renal  tube  casts  due  to      7 

simulating  cauda  equina 

tumour        . .  . .     63 
sterility  from  . .  646 

-  distended  with  blood  18,  6S8 

-  double,   with   retention, 

amenorrhcea  with     . .     18 

-  drawn    up,    by   ovarian 

cyst     . .  . .  . .     45 

-  enlai-ged,   bv  carcinoma  391 

fibromyoma    .,      386,  391 

pregnancy      - .  . .   393 

rectal  examination  in 

detectiiii::    -.         ..  5S7 
from  sarcoma  . .   391 

-  felt  per  rectum  . .  . .   587 

-  fibromyoma       of       (see 

Fibromyoma) 

-  gravid  (see  Pregnancy) 

-  hour-glass  contraction  of  201 
dystocia  from        . .  200 

-  hyperinvolution  of,  ster- 

ility from       . .  . .   645 

-  impacted     tumour     of, 

backache  from  . .  468 
pain  in  thigh  from    468 


UTERUS 


VEINS 


ertia  of.  flv^toi-i;i  from 
US.  infantile    . .         - .  i 

'■'I-'  ,.p  ihi.ea  from     . . 

from         645,  > 
us.  inversion  of        ..  . 

b:;.i.i  .Liul  examination 


I  A/ACCINAL  ERUPTIONS  757 
V       Vaccine,    for   actino- 
mycosis . .  . .   45S 
-  treatment   in   fungating 

endocarditis  . .         . .     3-4 
Vaccinia,  anthrax  simulated 


fibroid  simulating 
haemorrhage  from 
simulating  prolapse..  < 
sound  in  diagnosing. .   ; 
vulval   swelling   from 
ros,  lesions  of,  cachexia 
rith 


by 

539     _  small-pox  simulated  bv 
5G2 


chloasma  from  . .  i 

pain  in  legs  from 
tenderness    of     spine 

from  (Fi(f.  294)  ' 

-US,    normal    secretion 

from 

.>lvpu.  of  fsee  I'olypus 
of  Uttrus) 
Kition  in  ascites 
ozzi's   cochleatp,    dys- 
menorrhoea  with 
-niiT'^n  of  (see  Prolapse 

'"I  of,  dysmen- 

.■.!       dy; 


.  iiTiia  from  193, 
>  .  .  H  tritis  with  . . 
us.  retroverted  gravid, 
bearing     down      pain 


-  dtlliciihy  on  mictu- 

rition with        ..  S 

-  distended      bladder 

from       . .        45,  6 

-  frequent      micturi- 

rition  from       . .  3 

-  retention    of    urine 

with         . .        39,  C 

-  strangury  from     . .  (1 

-  tenesmus  from      . .   1 

-  vaginal      examina- 

tion in  diagnos- 
ing ..  ..  ? 
levator  an!  spasm  from  ] 
menorrhagia  from  38G,  c 
pfiin  in  the  pelvis  from  ■! 
rus,  retroveiied,  preg- 
nancy in  ..  C 

rftil    r-\.imination    in 

.lit.vtini;     ..  ..    : 

sciatica  simulated  by  ■! 
vaginismus  from  ". .  ] 
vomiting  from  . .  "i 


I  !     irthritis  from    J 
V,  hi-  i.-u'  from  ..  ■! 

nail  ai  lull,  sterility  from 
(iV,,  f 

jbinvolution  of  3Si>, 
387,  ; 

rus,  superlnvolution  of 

anM-riorriin-H  from     18. 
■ii.I.TrM-^  of      ..  ..    1 

^'h  i  'iiiMi^     ..     3iiii, : 

II  Ml.  unicmia  from 
'  iifphritis  from 

I  >u    !    I-  from  ..  : 

rus.  tumour  of,  kidney 
simulated  by  . .         . .  i 


•  of 


i  I  I  i.k  urine  from  ' 
I'  ■!  iM  I  from  . .  i 
ill.  ■  iiriiioma  of,  sore 
thniiii  from  . ,  . .  i 
phthrria  membrane  on  ■ 
immii  of,  sore  throat 
from I 


im, 

ibprculou.-j.  son-  tliroiit 
from   . . 


.   074 


Vagabond's    disease,    pig- 
mentation in  . .         . .  527 
Vagina,  absence  of  . .     18 

; amenorrhoea  from    . .     18 

dyspareunia  from     . .  193 

sterility  from  . .   645 

-  bullous    dermatoses    af- 

fecting . -  . .      99 

'  Vagina,  casts  of   ••        ..186 

-  closed,  sterility  from    , .  64G 

-  closure  of,  after  fevers. .     18 

-  dermatitis  herpetiformis 

affecting  . .  . .      74 

VAGINA.     DISCHARGE 

FROM 185 

(;ina    ^ee     Dischar^'e, 

V:.-inal) 

-  discoloration     in     preg- 

nancy . .  . .  . .      19 

-  distention     with    blood 

(see  HoBmatocolpos) 

-  epithelioma  of  (see  Car- 

cinoma of  Vagina) 

-  erythema  bullosum   af- 

fecting . .  ..71 

-  extroversion  of  bladder 

throncrh  . .         . .  540 

-  fibroid  of  .  .        539,  700 

-  growths  of,  dystocia  from  200 

-  hypcrtrophied  cervix  pro- 

"  jecting  through         . .   539 

-  imperforate,  amenorrhcea 

from    . .  . .         . .     18 

cry  ptomenoiThoea  from    17 

-  kraurosis  adectin?     194,  701 
1  -  new  trrowth  of,  felt  per 

rectum  . .         .  -  587 

Vagina,    normal   secretion 
of  .185 

i  -  pemphigus  affecting     . ,      74 

-  polvpns  projecting 

through  ..  ..   539 

;  -  rigid,  rlystocia  from      . .   200 

-  sepsis  of,   arthritis  from  339 

-  short,  in  pseudo-herma- 

phroditism     . .         . .  fi4fl 
!  -  stenosis  of         . .         17,  194 

-  tumour    of,    simidating 

prolapse  . .  . .   539 

-  ulceration  of,  from  pro- 

lapse . .         . .  . .   185 

,  -  urine    leaking    througli, 

I  from  carcinoma        . .  582 

I pa.'^sed  through         . .   283 

Vaginal    examination,    in 


-  bladder  prowth  and . 
■  calculus  in  ureter  felt 


■  in 


of 


41 


Varihml  examination,  contd. 

ovarian  cyst  and     45, 

for  pelvic  tumour 


ureteric  calculus  felt  on  \ 

Vaginismus 

-  sterility  from     .  .  . .    i 
Vaginitis,   aching   in   peri- 

neimi  from     . .  . .   ■ 

-  characters   of   discharge 

-  membranous,      due      to 

bacillus  coli    . .         . . 

casts  from 

due      to      diphtheria 

bacilli 

-  from  ,.— M-i^o    ., 
Vaginitis,  senile  adhesive 


bladder 

uteri        .-. .         . .     41 

in    cases    of  bearing- 
down  pain  . .  427 

CRdema  of  one  leg. .  411 

pus  in  stools         . .   557 

rauda  equina  tumour    C3 

chyluria  . .  . .   101) 

cystic  kidney  felt,  on    354 

' in  diagnosing  cause  of 

frequent  micturition  39 1 

swelling    in    iliao 

fossa    . .         . .  fifi5 

diverticulitis  . .  453 

fibroid         . .      353,  394 

I obtumtor  hernia  .,  081 

I ovarian  cyst      353,  394 

inflammation      . .  45fi 

tumour    . .      331,  631 

pelvic  tumour        .,  394 

pyosalpin.T  582.  587,  678 

renal  tuberculosis..  355 

retroverted     gravid 

utenm     . .         . .  394 

RulpinKltIs  ..         ..  456 

tuberculous  kidney    280 

—  himhtufo         . .         " .  429 


Vein,  jugular,  contd. 

compressed  by  thyroid 

g-land     enlargement  722 
thrombosed   . .       lOG,  597 

-  iliac,  obstructed  by  pelvic 

tumour  . .         . .  411 

-  -  thrombosed      8,  lOG,  411 

-  innominate,     obsfructed  750 
by  mediastinal  new 

irrowth    ..       381.  419 

-  -  throiiit.nspd    .  .  ..751 

-  poplit.il.  .>h~tMi.-r.-d  hy 

aii.-iiiv-ni         ..  .'.    411 

Vein,  portal,  obstructed  (see 

Portal  VL-iii  Ulj^tructiou) 

pressure     on,     ascites 

from  . .  . .   272 

haimatemesis    from 

365,  272 

I jaundice  from        . .  272 

thrombosed  (see  Throm- 

j  bosis  of  Portal  Vein  ; 

'  and  Pylephlebitis) 

-  pulmonary,     anemysni 

ruptured  into  . .  434 

-  renal,  invaded  by  growth     7 
retinal,  thrombosed  (see 


Vagus    nerve    (see    ^'erve. 

Tlu-ombosis,  Retinal) 

Vagus) 

-  rupture  of,  purpura  from  553 

Valerian,  eiythema  from. . 

222 

-  saphenous          . .         . .  675 

-  fnul  ta'^to  from. . 

705 

-  splenic,  thrombosed  (see 

Valvular  disease  (see  Heart) 

Thrombosis,  Splenic) 

Vmiilin.  cryttiema  from.. 

222 

-  subclavian,  obstructed  by 

Vanilla,  dciinatitis  from.. 

755 

carcinoma      . .         ...  259 

Varicella  (see  Chicken-pox) 

-  superficial  circumflex  iliac, 

Varicocele,  aching  in  testis 

congested,  in  appendi- 

from   . . 

482 

citis     454 

-  atrophy  of  testis  from. . 

(iG 

Veins,  abdominal  distended. 

-  bng-of-worm^  f-rl  nf 

:mi 

witli  ascites    ..         ..44 

-  with  enlarL'i   1   '     ]    > 

from  portal  obstruc- 

- hernia  simni.i.  ,  i      i  - 

tion         . .          . .   272 

-    impulse    OTI     n.u     mh-     III 

I-'.' 

-  diastolic  collapse  of,with 

-  with  kidney  ^^ilamI.      .. 

;-;-"•  1) 

adherent  pericardium     90 

-  of  vulva. .          . .       70U, 

701 

-  of    forearm,    distended. 

Varicose  ulcer,  epithelioma 

from  axillary  aneuiysm  6G  7 

from    . . 

738 

-  frontaU  engorged,  from 

Varicose  ulcer  of  leg 

736 

cavernous  sinus  throm- 

- veins   (see   Veins,    Vari- 

bosis     229 

cose) 

-  ofneck,diastoliccollapse 

Variola  (see  Small-pox) 

of,  with  adherent  peri- 

Varix.    saphena,     general 

cardium          ..         ..213 

account  of    ..      675, 

nsn 

distended,  from  aneur- 

Varnish,   aeroplane,    com- 

ysm            (Fiff.  99)  20S 

position  of     . . 

331 

-  -  pulsation       of,      with 

-  builai  from 

9(> 

tricuspid  regurgitation    92 

-  erythema  from  . . 

222 

from  obstructed  vena 

Vas  ftberrans  of  Haller,  cyst 

cava         ..          ..   208 

from    . . 

481 

-  obstnictcd,  by  aneurysm  410 

deferens,  uodular,  from 

glands              . .          ..   410 

tubercle     . .      479, 

G97 

oedema  from  , .         . .  410 

thickened,    from    epi- 

by  tumours    . .         . .  410 

didymo-orchitis. . 

478 

-  ophthalmic,     engorged. 

with    tuberculous 

from  cavernous  sinus 

testis       . . 

G9C 

thrombosis     . .         . .  229 

(and     sec     Spermatic 

-  pelvic,  pressure  on,  oedema 

Cord) 

of  yulv:.,  fiMiM             ..    701 

Vasa  brevia.   largo  spleen 

-  prec.M.liil.  .IIlii,..!.   with 

obstmcting    . . 

272 

:.ill. .iinni  213 

Vasodilators    in    relieving 

-  pnU.i                   .           il    ..    369 

angina  abdominalis  . . 

31 G 

VEINS.     VARICOSE     AB- 

Vaaomot-or disturbance  from 

DOMINAL                  ..748 

cervical  rib    , , 

110 

from  cirrhosis        . .  75u 

in  syringomyelia 

no 

(Fia.  303)  749 

—  neuroses. . 

413 

from  vena  caval  ob- 

 :ill.iiiiiiiniil.i    III 

13 

struction            . .  749 

,.|.-,  It;     .1     1  !■ us    in 

584 

thrombosis        8,  52 

-  -    li;<  .1,,,    !-,■   n.ui     .       with 

284 

—  gastric,    from    portal 

in     1;   i\  1,  ii|.  1         :||    r;iSO 

1G3 

obstruction            . .  272 

Vatci'.  iinii.uM  1  -1  1    ■■•■  Am- 

in  nose,  fipistax  is  from  220 

oedema  of  leg  fmm  . ,  41m 

Vcgc-t;il.i'    .  .  II      ■-     ., 

520 

oesophageal,  from  cir- 

Vetlfl:'!'!---    -Ni'-v  iiir-'dbV 

39 

riiosis          ..         ..  2G7 

-  -  from  hu-k  of  .  .          .* 

536 

hnomatcmatis  from 

Vein,  axillary,  obstructed 

2G5,  2G7 

by  cjirclnoma 

259 

from  portal  obstruc- 

- cerebral,  rupture  of,  from 

tion          ..      207,  272 

passion 

113 

orbital.     Int^nnittent         ' 

in  wlinopinL'-cout.'h 

113 

exophthalmos  from  23il 

-  -  thnimho-^is   of 

113 

pain  in  the  \osi  from. .  43S 

Vein,  direction  of  flow  In, 

-  -  phlebitis  in     . .          ..   43S 

method  of  testing     ■ . 

749 

pigmentation  round..  551 

-  emissary  fronica\crnous 

jiopliteal          . .          . ,   692 

sinuses 

229 

from  popliteal  aneur- 

 miwloid 

229 

ysm             ..         ,.692 

-  -  to  nose 

220 

purpum  round           ..   551 

-  jugular,  bniit  de  diabic 

-  -  rupturo.1,  vulval. .well- 

in bulb  of      . . 

723 

ing  from                 . .   700 

VEINS    —    VIPER   BITE 


Vein.t,  vark-osc,  contAl. 

Venereal  ulcer  of  rectum. .     79 

Veronal,  conld. 

Vesicles,  conld. 

—  subcutaneous  nodules 

Venesection,     leucocytosis 

-  coma  from        •. .         . .  lis 

-  with  malignant  pustule 

from            . .          . .  404 

after 360 

—  cyanosis  from    . .          . .   157 

-  in  meningitis     . . 

-  miliarial  . .          . .      753, 

VEINS,  VARICOSE  THOR- 

- for  unemia        . .         . .  118 

-  erythema  from  . .          . .    222 

ACIC   750 

Ventilation,  bad,  appetite 

-  haimoglobinuria  from  . .   284 

-  occupations  causing     . . 

-    -  -  lidrii      :irictir\'sm 

bad  from        .  .          . .   321 

-  methaimoglobinuria  after  157 

-  in  scabies,  562,  600,  753, 

ib'ia-  99)  208 

headache  from       295,  321 

-  polycythjemia  from      . .  533 

-  from  serum  injections.. 

cliroiiio  mcdiastiiiitis  435 

-  -  insomnia  from      321,  322 

-  purpura  from    . .          . .   553 

-  in  small-pox      554,  560, 

mediastinal   growth 

irritabilitv  from        . .  321 

-  reducing   substances    in 

616, 

104,  308,  419 

-  5ore  throat  .and . .          . .   616 

urine  after     . .         . .  157 

-  from  splint  pressure    . . 

new  growth  in  chest 

Ventricle,  left,  dilated,  from 

-  urticaria  from  . .         . .  771 

-  in  strophulus     . . 

104,  290 

aortic  disease         211,  212 

Verruca  necragenica,  fingere 

-  syphilis    . .         560,  562, 

new  growth  indicated 

aortic  regurgitation 

affected  by     . .          . .   240 

-  syphiloderms     . . 

by           ..         ..751 

94,   95 

-  plana  juvenilis  . .          . .   488 

-  vaccinia  . . 

vena  cava  obstruc- 

- ■■  -  arteriosclerosis       .  .   211 

papule  of        . .          . .   487 

-  varicella  . .          , .       753, 

tion         . .      208,  413 

iiark-|itt  — IMr  clYrrl .. 

-  MiL-ahs 488 

-  variola 

—  ulcer  of  ies  from      . .  736 

lit,                         ,  .    :'  1  1' 

\>.,n.i.nu  (see  Spine) 

-  on  wheals 

-  -  vauirial,  dystocia  from  200 

I'nitM  III 1  iiiMi-i .  ,   ■.*! :; 

VERTIGO 751 

—  from  .T-rays 

^'eiKi  cav:i  inferior  invaded 

—  .-  -   LTiiiiul.ir    l',iil'ii-\      .  .    "J  1  1 

■   III  .iriiic  cerebellar  ataxy     58 

Vesiculaa  seminales,  affec- 

l>y new  t,'rovv-tfi          . .        7 

-   -   -    liiL'li     lilniiii   pir  —  iMi'    L'l  I 

-     1 1  ""1  idi-ith-il        .  .            ,  .    752 

tions  of,  pain  in  the 

—  -  olistrueted,olbumin- 

Ventricle,     left,    dilatated. 

-    .■  .--ii 1  M.les         ..    751 

back  from 

nri:i   from            13,  52 

mitral       regurgitation 

- 1 1-    ..       752,  753 

felt  per  rectum 

-  -  -  -  ;isi-itc.s  from       . .     52 

from        90.  -li.  -jlj.  2!is 

-   ■■"■'^y  "l'l 58 

gonococcal  infection  of 

by  ascites          . .  416 

I'li-i^i irinilmm  95 

-  on  hont 752 

182, 

b.v  carcinoma  of 

-  bradypncea  wi  h            . .     84 

not  normally  palpable 

kidney            . .  750 

iMiiM              1  lirniiie 

-  cerebellum  and..          ..   751 

tuberculous  (see  Tuber- 

Vena   cava    inferior,    ob- 

1 iriL'ht  ■-  ili-iM-f.  .    212 

-  from  cerebral  abscess  . .  752 

culosis) 

structed,  causes  of  . .  749 

\\\'j,\\     hloocl-jires- 

lesions             . .          . .      84 

Vesicular  murmur,  absent. 

I.v  enl.irL,'cd  medi- 

sure     ..          ..212 

tumour            . .          . .   752 

over  empyema 

nsfinal  plands     381 

mitral  regui^itation 

-  on  cliff  edge       . .         . .  752 

pleuritic   effusion 

-  -  -  -  intrattioraeic  new 

from    .  .          . .   212 

-  from  diplopia    . .          . .   752 

20G, 

srowtli             ..      52 

enlai^ed     from     alco- 

- dyspepsia            . .          . .   753 

pneumothorax 

-  -   -  -  nieiliastinalsrowth  4(1 

holism         . .          . .   206 

-  ear  lesions         . .         . .  408 

432, 

navliastinitis        46,  52 

from  aortic  disease    206 

-  in  epilepsy         . .         , .  752 

from  stenosis   of 

iiew  Krowth        . .   415 

nrteriosclerosis       . .   206 

-  from  facial  palsy           . .   493 

bronchus 

cedenia     of     le^s 

Ventricle,     left,    enlarged, 

-  foreign  body  in 'ear       ..    752 

deficient,  from   aneu- 

from    52,  414,  415 

causes  of                    .206 

-  after  fractured  base     . .   752 

rysm 

after  jihlebitis  . .  414 

frnnii,'r;Miiil:ir-kiiliit>vL'()n 

-  from  [gastric  disturbance  752 

bronchus     obstruc- 

 reversal  of  blood 

(■;i-;ivf's-s  disease     .:  200 

-  L.'<.nt         753 

tion 

flow  in  surface 

hard  work  . .          . .    206 

'-  lu.'l,    i>I.M>.|-pi-(.ssure     ..  752 

emphysema  160, 167, 

veins  from     . .    749 

site  of  impulse  with  206 

1  ')■■  1     .   .1    -|..i-rn             ..    752 

over     fibroid     lung 

by  thrombosis  (see 

failure  of.  risht  ventricle 

■■   :■          -  ..          ..   407 

168,  206,  292, 

Ttirombosis) 

eiilarized  from        . .   215 

~  M,  M.iM.  u--~  disease  752,768 

pleuritic  effusion  . . 

renal     Krowth     in- 

hypertrophied  in  aortic 

-  nuL-raine               . .           . .    752 

pneumothorax 

vadiriir     ..          ..750 

reffurtritation          . ,     94 

-  nephritis 752 

pulmonary     infarct 

-   -  superior,    aneurysm 

stenosis  . .          . .     92 

-  noises  in  the  head  with  407 

Vesiculitis,  aching  in  peri- 

openiut,' into,  acute 

site  of  impulse  with  299 

-  nystagmus  with        408,  751 

neum  from 

dyspmpa  from       .  .      92 

Ventricle,  left,  hypertrophy 

-  optic  neuritis  and         . .   752 

-  prostatitis  with. . 

■-  bruit  of          ..92 

and  dilatation  of      ..211 

-  from  otitis  media    423, 

—  from  urethritis  . . 

c.y.-inosis  from       92 

fiuininiliiiln-.L'urgi- 

752,  753 

Vestibule,    auditory   nerve 

cedcma  of  face 

tinn       ..           ..210 

-  otosclerosis         . .          . .   753 

ending  in 

and  ai-ms  from  92 

-  rate  of  iiulependcut  beat 

-  pjvrrdiiiL'    i'crehral    hsi- 

Vibices       

obstructed  . .         . ,  750 

of         545 

Vibrios,  cholera     . . 

by  aneui-ysm  158, 

-  ri^ht.    dilated,    pain    in 

-  iiMniianin.iMir  poisoning  752 

Vicarious  menstruation  . . 

159.  413,  415,  073 

epien.^ttiuiii  fnun       .  .    4.36 

-  -.tNi.M.iil  !!■   .-anals   and  751 

blood  per  anum  from 

Iilnali-d  lariesfr.ini  158 

-    -    -    tM.'ll-|i:ii      n-Mll  -ll:!- 

■    1 1  i'li;   ■  >  !  ir    NIL'  ear       .  .    753 

Villous  tumour  of  bladder, 

Vena    cava    superior,    ob- 

■■ i.'ii       ..'    Kiii-mal   ear  752 

kidney  enlarged  by  . . 

structed,  causes  of    . .  751 

-    -    ^    :ili    1       ■    ■    1    '   :     ...-.1,11  .1, 

...1.  ■■    ..                ..          ..    752 

cystoscope    in  'dia- 

~ -  -        r\ari(isi-;  ti'inii 

td.m         ti,:l  i.il         ir- 

11. MM    n.,:,1li,i-..          ..   752 

gnosing   . .      281, 

1.'.7,  159 

L'Uivitatioii           ..    210 

-  wax  in   ear          ..       421,   752 

detected  per  rectum 

by  enlarged  medi- 

enlareed,   from   bron- 

- (and  see  Giddines.s) 

frequent  micturition 

chitis          ..         -.215 

Vesicants,  bullae  from     QG,  97 

from 

Iiv  growth  of  lung  159 

cardiac  impulse  dis- 

- pigmentation  from       . .   527 

haematuria  from 

giunma   . .         . .  413 

placed  from       . .   215 

-  various 97 

275,  281, 

hiemorrhage   into 

from  emphysema 

dermatitis  from         . .   755 

hjemoglobinuria 

intrathoracic  sar- 

215, 217 

VESICLES 753 

simulating 

coma  ,.         ..  1.59 

episastric  pulsation 

-  in  anthrax         . .          . .   674 

pain  in  kidney  from 

mediastinum  . .  159 

from         . .      20G,  215 

-  from  bites         . .         . ,   757 

penis  from 

' thymus           . .  159 

from  failure  of  left 

-  bromides             . .          . .    757 

retention    of    urine 

mediastinal  fibrosis 

ventricle              . .   215 

-  burning  from     . .          . .   753 

from 

159,  415,  673 

from  fibroid  luiitr  . .   215 

-  in   cerebrospinal  menin- 

 stoppage    of    urine 

gumma           . .  415 

Ventricle,    right,    enlarged. 

gitis     591 

stream  by 

-  -■ new  growth  416,  419 

general  account  of    . .  2(5 

-from  chancroid..          ..   (118 

ureter       obstructed 

mediastinitis      . .  413 

-  in  cheiropompholj^x     . .    756 

by 

-  new  growth  102, 

t;itioM       .  .    ^      "  .    206 

-  chicken-pox        . .          . .   616 

Vincent's   angina,   bacteri- 

104, 290,  413,  673 

stenosis   .  .          .  .   215 

-  cmsts  from        . .          . .   753 

ology  in  diagnosing  . . 

iTdcma  from      . .   416 

pulmonary  incompe- 

- in  dermatitis      . .          . .   755 

diphtheria     simulated 

of  face  from  . .   673 

tence    ■   ..          ..215 

herpetifoi-mis  710,  753,  755 

by 

and  arms  froml59 

stenosis   . .      215,  217 

-  in  eczema  487,  488,  600, 

-  -  follicular     tonsillitis 

neck  and  arms 

site  of  impulse  with  206 

753,  754 

simulatin-r  . . 

from        . .  413 

hypertrophied.  in  con- 

- erythema        multiforme 

foul  breath  from      S7, 

by  thrombosis  . .  413 

genital  heart  disease     91 

227,  489,  756 

fusiform  Imcilli  in     . . 

varicose   thoracic 

from  emphj-sema  . .   299 

-  from  frostbite    . .          . .   757 

Vincent's  angina,   general 

veins  from       ..   413 

fihroid  hint;            . .   216 

-  in  glanders         . .          . .   559 

account      of       {Plaie 

opened  bv  anenrvsm  159 

see-saw  impulse  with    54 

-  herpes      ..         477,  600,  753 

XXVII)        ..      BI2,  ( 

cyanosis  from     159 

strain    of,    from    hmg 

progenitalis    . .         . .  618 

neck  glands  and 

dyspnoea    from  159 

affections    . .          . .   4S5 

-  -  zoster  . .         431,  460,  754 

organisms     of     {Plate 

swelling  of  face  169 

palpitations  from..   485 

-  hidrocystoma  ■   . .          . .   753 

XXVIII)       ..          ..   * 

stenosed  bv  aneur- 

- single 157 

-  impetigo. .          . .      558,  562 

sore  throat  hi           . .  f 

ysm         \Fia.  99)  208 

Vermiform    appendix    on 

contagiosa      . .          . .   755 

spirilla  in        . .          . .   ( 

evanosis  from    . .    208 

left  side          . .          .  .    152 

-  from  iodides      . .          . .   757 

-  -  ulceration  in  . .         . .  t 

-    ■;.■,!,       irins      dis- 

Vermin    d..-^i  n.^  rr.    ^n\.|,. 

iii'liini,--  from      . .          . .   753 

Violin    playing,    deterioiu- 

li  ii.l,-.l  1  /■■;,/.  !I9)   208 

ninr  |.'.i   '>iiMi.'   IrolM          I  1  7 

l'l  .iii([uet's  erythema. .   401 

lion  in  quality  of,  in 

\;iihi>-r     llinracic 

Veronal.    i.i  i.h  |.m.i..i    iti.ni     >  i 

li.hrii  ]ilanus     . .          . .   756 

general  paralysis       . .   ' 

\riiK    Wi.l.   99)  208 

-  bullae  Irniu                         ,.      !•.; 

urti.-atus          .  .           .  .    756 

Violinists'  cramp  .  .          . .    1 

-   -    -  -  thronit'osis      (see 

-  Clievne-Sfnkrs  hi-oatliin;,' 

-  lynipliaiigioma     circimi- 

Viper  bite,  general  account 

Thrombosis) 

from .108 

pcriptimi         . .          . .    756 

of         3 

VIRGINIA   CREEPER 


WARTS 


■ginia  creeper,  rbus  toxi- 

codundrou  instead  ot     224 
!ceroptosis  (Fiff.  50)  127 

ibdorainal  outline  in  . .  426 
;olon  ill  {Fiff.  183)  426 

jeneral  abdominal  pain 

from 426 

tidney  displaced  in  . .  426 
iver  displaced  in.  , .  426 
loises  in  the  head  in  . .  406 
r-r;ivs      in      diagnosing 

(Fi(;.  183)  426 
;ihl^  peristalsis  (-ee  Peri- 


758 


;ion,  colour  -  •  758 

um^Mirric  limitation  of. 
in  .li>>erainated  scler- 

510N,  DEFECTS  OF  '.'.  757 

-  irora  choroiditi?       . .  416 

Jiniiiess  of  from  diabetes  260 
luuble  (see  Diplopia) 

i.Tv.M,;itIis  of  (/■'(>/.  U?)  300 
ilon,     normal,     general 

account  of     ■  ■      757,  758 

..■nj>li.-r:t!  ..  ..  758 

lion,  red  ■ .  ■ .  762 

lion,  yellow       ■  -      3-'l,  762 

-iiiH-,  i>yrL-\ia  from      ..  573 

iual  acuity  ..  757 


;ortex     lesion,     crossed 

amblyopia  from 
—  hemianopia  from  . . 
ield,  concentric  limita- 


of 


-  constriction    of,   from 
choroido-retinitis  760,  761 

-  functional   . .  . .  761 

-  -  glaucoma    760,  761,  762 

-  -  in  hysteria  . .   (UO 

-  optic  atrophy        . .    760 

-  retinitis  pigmentosa 

760,  761 

-  spiral  contraction  of  759 
word  centre  (Fig.  266)  624 
isual,'  deflnition  of  a  625 
tiligo,  pitjment-iition  witli  521) 
treous,  hremorrhage  into 


hftzy,  in  glaucoma 

701 

particles  in 

71 

cfti  cords,  ataxy  of 

au 

-  epithelioma  (see  Carci- 

noma of  Larynx) 

-  fibroma  of     . .      635, 

C3I) 

-  paralysis  of  (see  Para- 

Ivsis,  Laryngeal) 

nrtiim-      (see    Tactile 

\  .M  ,1    Fremitus) 

1  .       ;'.n.i,  with  larvn- 

1  1  mtlysisloO,  -191 

495 
150 
l.'Il 

n      h  1  tinainewgrowt 

1    :(  Ml.  irom  cerebellar 

517 

<li    .  iiiiiiated  sclerosis 

517 
517 

n     I.I.  ii-orn  laryngitis.. 

(ilG 

(uhI  ~vf-  Aphonia) 

nonotniioiLS,  in  paralysis 

agituns 

725 

nasal,  after  diplithcrin 

64,  154,  512,  589, 

(i27 

-  in  myasthenia   gravis 

(i27 

from  i)aresis  of  palate 

51 2 

soundK.  absence  of,  over 

cmj)yema 

in:i 

—  with  fibroid  lung  . . 

(!.13 

—  plcuml  elTuRion     . . 

2!lfl 

—  pneumothorax  432, 

530 

-  deficient,  with  fibroid 

lung..          ..      206, 

292 

—  pleuritic  etTugion  . . 

l(i8 

—  pneumothorax 

168 

-  increased,    from    em- 

physema    . . 

217 

Ices,  hearing  of.. 

723 

-  as  an  aum  of  epilepsy 

07 

-  iu  i.,s:inlty     .. 

105 

Ii'  urgoii  hy 

1115 

■    1  .  Itidliii  from  . . 

91! 

Ml  li.rri:i   from 

222 

lluiiiiin's             imralysifl 

(Fi,j.  58) 

Ml 

Volkmwin's  parali/sts,  contd. 

-  -  of  leg 114 

nerve  paralysis  simu- 
lated by     . .  . ,  506 

fi-om  splint     . .        61,  506 

Volvulus,  carcinoma   caeci 

simulated  by..         ..  459 

-  distention  of  cajcum  from  459 

-  intestinal     obstruction 

from    . .         130,  388,  459 

-  pain  in  right  iliac  fossa 

from    . .         . .         . .  459 

-  sigmoid,  abdominal  dis- 

tention from  . .  . .  452 
general         peritonitis 

from  . .  . .  452 
Hirsclisprung's  disease 

and 654 

immediate     operation 

for 452 

pain      in      left     iliac 

fossa  from  . .         . .  452 

visible  peristalsis  from  452 

Vomit,  bile  in       . .         . .   766 

-  black,     in     phosphorus 

poisoning        . .  . .   336 

-  -  in  yellow  fever      273,  336 

-  cofFee-ground,  from  gas- 

tric carcinoma  . .  269 
ulcer  . .  . .   268 

-  fiukes  in  . ,  . .   32S 

-  occult  blood  in. .        030,  767 


pus 


766 


reaction  of         . .  . .   766 

-  round-worm  in  . .         . .   767 

-  torulai  in  . .  . .    115 

-  Cand  see  Gastric  Contents) 
VOMITING 763 

-  with    undue    abdominal 

aortic  pulsation        . .  543 

-  from    acute    congestion 

of  liver  . .  . .  334 

pancreatitis    . .  . .   661 

peritonitis      . .         . .  767 

yellow  atrophy       273,  333 

-  in  Addison's  disease  33, 

526,  765 

-  from  alcohol      . .         . .   726 
768 


gastric  ulcer  simulated 

by 36 

Vomiting,  ansemic,  general 
account  of       .        36,  412 

-    iiftrf    ;iiK.'.li.cti.'>  ..         4 


115,  316 
--  aTigioneurotic  oedema  . .  220 

-  appendicitis       454,  665, 

677,  767 

-  from  arsenic,  64,  73,  78, 

171,  268,  717 

-  anterioscierosis  . .         . .  295 

-  hacteriuria         . .         . .     70 

-  biliary  colic       . .     110,  767 

-  bnidypnroa  with  ..     84 

-  from  carcinoma  coli     . .   330 

of  duodenum..      661,  662 

stomacli,      270,      316, 

436,  630,  678,   707 

-  cerebellar  abscess        . .  597 

tumour  . .         . .  517 

Vomiting,  cerebial  8 1,  295, 

315,  767 

-  from     cerchnil     abscess 

147,  3U6.  502,  597,  620,  768 
liminorrlinge  , .         . .  768 

-  -  tumour,  147,  264,  302, 

306,  315,  429,  502, 
525,  537,  626,  711,  768 

-  in  chronic  alcoholism  . .     51 
peritonitis 


nrrlu 


51 


763 


-  with  colic  114,  115 

-  from  r-olitis 
!  -  colliipsi;  from  scvi-n-     . 

Vomiting,  conditions  simu- 
lating . . 

-  copious  dark,  from  acute 

dilatation  of  stomach  173 

-  from  corrosives. .      267,  76(1 

-  cough  and  . .  . .    150 

-  from  i-ryptnuicnorrhcta       17 
Vomiting,  cyclfcal.  of  cliil- 

dren  >,  :tH[.  761,  765 


idosi 


381 


-.717 
tetany  from  . .         . .   151 

-  from   dilatation    of   the 

heart 36 

stomach  . .  . .    522 

-  in  disseminated  sclerosis  295 

-  from  distoma  heiiaticum  328 

-  diverticulitis      . .         . .  453 

-  duodenal  ulcer  . .        75,  271 

-  eclampsia  . .  . .  140 

-  encephaUtis       120,  502, 

511,  525 

-  after  enema       . .         . .   767 

-  from  errors  of  diet      . .  384 

-  in  exhaustion  of  labour    201 

-  foecal.  from  acute  perito- 

nitis      767 

appendicitis   ..         ..767 

gastro-colic  fistula    . .   766 

hysteria  . .  . .   768 

intestinal  obstruction 

131,  388,  760,  707 

-  from  food  . .  . .     99 

-  fermentation      . .  . .  241 

-  aft-er  Hushing     . .         . .  241 

-  from  gall-stones . .         ..  327 
gastric  ulcer,   36,  75, 

268,  269,  317,  437,   767 

-  gastritis  . .  267,  317,  766 

-  general  peritonitis        . .   388 

-  glaucoma  . .       233,  761 

-  headache  with  . .  . .   768 

-  ill  Henoch's  purpura  7  ', 

343,  556,  767 

-  from  hour-glass  stomach  766 

-  hypertrophic  stenosis  of 

pylorus  ..       384,  766 

-  hypothermia  after  severe  311 

-  hysterical  315,  467,  768 
~  due  to  increased  intra- 
cranial pressure       . .  590 

-  in  influenza       . .  . .   405 

-  from  intestinal  obstruc- 

tion    115,    131,    315, 

430,  522,  593,  767 

-  intussusception  .  .      663,  678 

-  irritant  poison  . .  . .    706 
Vomiting,  list  of  causes  of 

764,  765 
Vomiting,  mechanism  of..   764 

-  M-'.i.  .         .     .       :5-_',  :t;8 


515,  525,  59(1,  768 

-  migraine. .         760,  7()2,  768 

-  morning,  from  alcohol  51.  207 

-  -  c'utIk.^is         ..         . .   :;7l 

Vomitino,  nausea  and  765.  766 
Vomiting  from  oesophageal 
lesions  ■  ■  763 

pouch  . .        . .         . .   190 

-  after  operations  . .       4 

-  optic  neuritis  with       . .   76S 

-  from  otitis  media        . .  202 

-  pachymeningitis  . .  525 
-pancreatitis        ,.      594,707 

-  in  pelljigra        ..  ..  225 

-  from  pericolic  abscess..  663 

-  peritonitis  115,  435,  592 

-  in  phosphorus  poisoning  336 

-  phthisis 315 

-  pituitary  infantilism    . .   190 

-  plumbism  . .         . .     34 

-  poliomvolitis      . .      110,  509 

-  witli   |.'i>ly«ystic  kidneys     42 

-  fr'oiii    I'l'i  til    nli-t  nictton   272 

-  pi. M  l:.,  ;il5,  393 


■  jiyicmia  . . 

■  pyloric  obstruction   115, 

174,  245,  318, 

■  in  renal  colic       ..       451, 

•  scarlet    fever   224,   227, 

614, 

•  from  sea-cat  prick.s 

•  senim  injc<'lIons 

-  severe,       polycythcomla 

from    . . 

•  -  in  pregnancy . . 

-  from  sick  headache     . . 

•  jsimpio  colitis     .. 


Vomiting^  contd. 

-  sinus  "thrombosis       120, 

511,  597,  'i 

-  in  small-pox      . .  . .  i 

-  from  snake-bite  . .   i 

-  strangulated  hernia      . .   ( 

-  suppurative  nephritis  . .   i 

-  tabes       . .  . .      315,  I 
-from  teti-achlorethane. .  J 

-  thirst  from         . .  . .    1 

-  in    tuberculous    menin- 

gitis    . .  . .      574,  ( 

-  typhus ( 

-  uremia   ..  40,  296,  l 

-  urate  deposit  due  to  . .  1 

-  urgent,  in  tabes. .  . .   • 

-  wasting  from      . .  . .   i 

-  from  weever-fish   pricks  i 

-  whooping-cough         150,  ^ 

To!!  Biisedow's  disease  (see 

Graves's  Disease) 
Von  Graefe's  sign  . .  ' 

in    Graves's    diseaso 

21  r>.  : 
Von       Jal(5ch's      disease 

(/■'///.  \:\)  ;!7.  ( 

\'on    I'u.iii.r^    n-;i.-tiu,i    in 

Von     Pirquet's      reaction, 
general  account  of  768,  ' 

{J'/(ife  AAAT//).  .    ' 

not  trustwortliy    . .   ) 

in  tuberculosis,  385, 

459,  479,  566,  573, 
631,  669,  696,  7.S8, ' 
Von  Pecklingliausen's  dis- 
pjtsp.   fibroma  moUus- 
rmn  siinulatinir         ..   : 
,,,.,;,..   iln.l..-,.'a  in  ■ 


affections  of  701 


Add 


I'S  di£ 


of. 


-  prin'itus  of 

-  pspndo-L'le|)hantiasis     of 

-  ri'i-lUTn  opi'iiing  llirongh 

(/•■/-,.  251) 
Vulva,  soft  sores  of 

-  sniv'oii.  iiill;iiiifil  inguiiml 

l.'liiii,ls  frr.iii    ,  .    "      .  . 

Vulva,   swellings  affectino 

the,  list  of     . .     699, 

-  svpliilnilcnn  iif  .  . 


Viih 


I 
Wiilk 


1         rurjl-l 


.   -189 
I'l.  ,  ..   510 

-  intmnitlcntdiiiKlicntioll 

UIKl Ml 

Walshiim,  Dr.  HukIi,  skln- 

uninis  hy      ..         (i(18-7:i 

Wandering  liver   . .         . .  368 

\V;ir,  livii.li  fi.ct  ill  ..    221 

ivpliiis  t,-vrr  mill  ..   335 

Willis,    iyiomii   (listiii- 

Kilislicil  fmni..  ..    190 

-  opiliiolioiim  from       021,  731 


llimtii 


WASH-LEATHER  SLOUGH    —    WRIST-DKOP 


Wasli-lcatlu 


slo 


:ropar- 


^Vasherwo^lcn , 

Eestliesia  ir_     _  _ 

-  dead  fingere  in  . . 

-  nail  clianges  iu  . . 

-  sore  lingers  in    . . 
Wasp  sting,  tongue  swollen 

from    . . 
AVassei-niaiin  reaction, 

;iiiriii-\Ma  and       .430, 
ill   r:i-.-.   (if  noises  in 

-    -  I Ill  shoulder    . . 

in  cerebrospinal  fluid 


120,  . 

chancre  and  618,  G19, 

G20,  I 

iu  congenital  syphilis 

235,  385,  ) 

cranial  nerve  paralyses  . 

in   diagnosing   natiu-e 

of  ulcer  of  tongue. .    '■ 

for  digital  chancre    . .   . 

in    familial    acholuric 

jaundice      . .      332,  i 

general  paralysis   120,  : 

gumma  of   liver  and 

253,  ; 

in  lisemoglobinuria  . .  ! 

leprosy  . .  . .   ■ 

miner's  phthisis       . .  : 

negative  in  tabes     . .  ; 

in  obscure  nerve  cases  ; 

pachymeningitis  and     i 

in  prolonged  pyrexia  i 

spinal  meningitis      . .  • 

stomatitis       . .  . .   ! 

svphilides  and        559,  ! 

-  -  ill  svi-hilis,  33,  52,  63, 
71.  7:J.  il3,  179,  184, 
11)7,  1SI9,  210,  292, 
304,  377,  403,  480, 
491,  541,  568,  604, 
B15,  622,  679,  696, 
735,  ' 

of  bone       ..  ..   ( 


ulcer 

tabes   . .  . .      116, 

ulcer  of  palate 

von    Jaksch's   disease 

Wasting  (and  see  Atrophy) 

-  from  carcinoma  of  bowel 

-  -  duodenum 


373, 


rectum 

-  -  stomacli  . .  . .   I 

-  chronic  pancreatitis     . .  : 

-  cirrhosis  . .         . .         59,  ; 

-  above      clavicle,      from 

piitiii^i-        ..        ..  : 

-  from  .■,,■!,  ,r  ,iiM.,-,.       ..    : 

-  diabetes  . .  . .  -13.  59,  : 

-  diseases,  enophthalmos  in  : 

fatty  heart  from       . .   : 

Wasting,  general   (and  see 

AVeight,  Loss  of)      . . 

-  in  Graves's  disease     .. 

-  from  liypertrophic  sten- 

osis of  pylorus  . .   ' 

-  with  liver  abscess       59,  : 

-  fi'om  pancreas  growth. .   ^ 
disease  . .  . .   ; 

-  in  plithisis     159,  (Fiff. 

195)  : 

-  from  starvation  59,  ; 

-  of     tongue,     in     bulbar 

paralysis         . .  . .  i 

-  from  tiiIi.'ivuloii>  kidney  ; 

-  ulcer:ni\r  rnlili^             59^ 
Watclini.>krr^  rr.,in}.       ..  : 
Watch  tr~i.  inrti.-aniiLT    ..  : 
Water,  an^emca!  contamin- 
ation of          . .          . .  ' 

-  deficient     ingestion    of, 

constipation  from     . . 

-  pellagra  and      . .  . .   : 
Waterbi'ash,    burning     in 

throat  from  . .         . .  : 

-  with  heartburn  . .  - 

-  huskiness  from  . .         . .  ' 

-  note  on  . . 

-  relation  to  heartburn  . .  : 


AA'^ater-hammer    pulse    in 

aortic  regurgitation  93, 

94.  207,  20«, 

AVax  in  ear,  cough  from  . . 

deafness  from  164,  lUo, 

earaclie  from. . 


SIX 


i-i-jL, 


tinniti 

vertigo  from  . .     421, 

Waxy  casts 

Weakness,  from  alcohol  . . 

-  carcinoma  of  bowel     . . 

-  cerebral  softening 

-  chronic  nephritis 

-  diabetes  . .         . .     2G0, 

-  malaria  . . 

-  muscular,     in     general 


-  from  neurasthenia 

-  from  phthisis     . . 

-  progressive,     from    new 

growth  of  lun^ 
in  pellagra      . .  . . 

-  from  pyloric  obstruction 

-  tremor  from      . .      724, 

-  fi'om  tuberculosis  . .  . 
Weasels,  fever  from  bite  of  . 
Weather,  effect  on  tabetic 

pains  . .         . .         , . 

-  rheumatic  pains  and    . . 

-  sore  throat  and . .         . .  i 

-  urine  amount  and 
AVeber's  test         . .  . .  : 
Weeping     . .         . .         . .  ; 


Weever-fish    pricks,    ery- 
thema from    . .      222,  i 

festering  sores  from. .  t 

headache  from         . .   '. 

oedema  from  . .         . .  : 

vomiting  from  , .   : 

Weichselbamn.  diplococcus 
of  (see  Meningococci) 

meningitis  from       . .  ] 

Weight-carrying,    arthritis 
from    . .         . ,         . .  4 

atrophy     of     muscles 

from  . .         . .   ] 

brachial  plexus  change 

from  . .         . .   ] 

dead  fingere  from     . .  ] 

—  headache  from  . .  i 

kyphosis  from  . .  ] 

pain  in  arm  from      . .    1 

shoulder  from       . .  ] 

in  scoliosis  from    153,  ] 

WEIGHT.  LOSS  OF        ..  1 

in  Addison's  disease. .    ', 

from  alcohol  . .         . .  1 

alcoholic  neiu-itis 

alkalies   . . 

aneurysm       . .      258,  ' 

anorexia  nervosa      . .   'i 

atheroma       . .         , ,  : 

bacilluria        . .  , .    ' 

with   cachexia 

from  carcinoma     126, 

129,   270,  271,   316, 
330,  585,  768,  ' 

cirrhosis  . .         . ,  ', 

colitis  . .  . .  ( 

diabetes  . .      768,  : 

drugs  . .  . .  . .   ', 

Graves's  disease     215,  1 

hysterical 

with  joint  infectious    ' 

in  leukaemia  . . 

with  liver  lesions      . .  ' 

from  mah'gnant   peri- 
tonitis 
new  growth  ni  lim-.. 


in  phosphatir  .|i;ttp._>t.  s  :.i'J 

progeria  . .      . .  , .    liU 

pyaemia  . .  . .    335 

Still's  disease  , .     35 

from  tuberculous  bowel   76 

Weight,     loss    of,     minor 
causes  of  ..  769 

-  -  ill  oM  ;.-.■       ..  ..770 


769 


peripheral  neuritis 

periproctitis   . .  . .   719 

pernicious  aniemia  24,  770 


M'eight,,  loss  of,  contd. 

'phthisis      .      ..      288, 

rheumatoid  arthi-itis 

sleeplessness  . . 

starvation      . .  . . 

tabes  . .         . .         . .  I 

after  ti'opical  infec- 
tions . .         . . 

(and  see  Marasmus) 

-  sense  of,  from  acute 
congestion  of  liver   . .  i 

in    epigastrium,  from 

gastritis      . .         . .  ; 


pil..-s 


Weir-Mitchell      treatment 


Welders,      electric      steel, 

photophobia  in 
West     Coast     of     Africa, 

malaria  on      . . 

\\v<\  Iiiili.'^.y.'llow  fever  in 
Wet  -.;]iii|  ill  li:iu' sensation 
in. in    ..i.-t.-i.i-arthritis. . 
WHEALS 771 


771 


Wheals,  drugs  causing    ..  771 

-  in  lichen  urticatus       . .   756 

-  strophulus  . .  . .    771 

-  urticaria  . .  . .  771 
pigmentosa     . .  . .    732 

-  (and  -see  Urticaria) 
Werdnig-Hoffmann     para- 

■     lysis 135 

Werlhof,  morbus  maculosus 

of         ..          ..      553,  556 
"Whetstone  crystals         . .  741 
Whooping-cough,  asphyxia 
in         145 

-  Bordet-Gengou  bacilli  in  645 

-  bronchitis  simulating  . .  645 

-  cerebral  vein  rupture  iiTT-lS 
~  a  cold  simulating         . .   645 

-  convulsions  from      144,  145 

-  cough  after       . .         . .   149 

-  hemoptysis  from       286,  289 

-  hernia  of  lung  from     . .  169 

-  leucocytosis  in  . .  . .   3G0 

-  oedema  of  face  from    , .  413 

-  orthopncea  from  . .  418 

-  paroxysmal  cough  in  . .  420 

-  peroneal  atrophy  after. .  513 

-  serum  reaction  for       . .   645 

-  subcutaneous  emphysema 

from 203 

-  talipes  from      . .         . .  113 

-  Tooth's   peroneal   palsy 

after 60 

-  ulcerof  frsenumlingusein  739 

-  violent    coughing    bouts  289 

-  vomiting  from  150,  420,  765 
Whip-worms  {Fig.  218)  520 
Whiskers,  pediculosis  pubis 

affecting         . .  . .   401 

Whispered  voice  test  ..  164 
Wln-tir.  i;;droirs  (/-ij?.  75)  165 
Wlii^ilifiL'  f,ni~.-  ill  ear  ..  723 
"\\  \\\\ r       iiii'iiiisi'les      (see 


fro 


-  due  to  bacillus  coli 

-  diphtheritic 

-  cow-pox  causing 

-  epitrochlear    gland 

larged  fi'om   . . 

-  fingere  affected  by 

-  leucocytosis  witli 

-  limping  from 

-  pain  in  foot  from 

-  septicaemia  from 

-  in  syringomyelia 

-  thrombosis  of 


pyr 


5) 


atei 


ifro 


Mediterranean  fever. .  5i 

negative  in  ulcerative 

colitis         . .         . .     7 

paratyphoid  fever  and  65 

in  typhoid  fever,  64, 

76,    254,    335,    459, 

564,  572,  6? 
Willis,  paracusis  of         . .  1( 
Wilson,  Dr.  S.  A.  K.,  on 
cervical  rib  paresis  . .  5C 

illustrations    lent 

by,  (Figs.  234-7) 

491,    li!. 
Wind,  from  gail-stones    ..    31' 

Wind,  general  account  Of..  24! 

-  per  rectum  ..  241,  24( 
Win.',  i.olyuria  from     534,  53i 

-  priapism  from  ..  ..  53) 
AVinged  scapula  . .  . .  50( 
Winking,      defective,      in 

Graves's  disease       . .  23( 

paralysis  ggitans      . .  23' 

AVinter,  bronchitis  in  . .  16 
AVisdom  tooth,  impacted, 

tetanus  simulated  by  73- 

trismus  simulated  by  72' 

Wolf     bite,     hydrophobia 

from 731 

Women,  borborygmi  in  . .     8: 

-  dyschezia  in      . .         . .   12! 

-  fibrous  stricture  of  rectum 

in        12! 

-  gall-stones  in     . .         . .   13( 


Wool,  anrhnix  from      559,  67' 

Word-blindness,       general 
account  of  ..  t. 

I,rini.nin|,.i;(    with       ..    6i 

-    Ill  [/'/?.  266)  62 
■  1     :  K  oansing    62i 

Word-deafness.       general 

account  of  ..  ..62! 
AA'^ork,  bard,  heart  changes  li 
large  from  . .  . .     5- 

—  manual,    aneurvsm    and 

196,  29] 
Worms,  appetite  increased    4' 

-  convulsions  from  . .   14 


21 


frequent  micturition  from  39 
grinding  of  teeth  from. .  26" 
leucocytosis  from  ..   57 

jdt.'^i  in.il  -M-^i  simulating  3 


-  under  skin,  sense  as  of, 

from  cocaine  . .  . .   6 

-  tape    (see   Tape-worms) 

-  tenesmus  from  . .         . .   7 

-  vomiting  from  . .      765,  7 

-  (and  see  Parasites) 


-  til?  ilouloureux  and  ..  ' 
Wound,  diphtheria  of      . .   ' 

-  gangrene  of   lung  from 

259,  : 

-  pyaemia  after    . .      335,  i 

-  septicaemia  from  . .  ) 

-  tetanus  from  138,  417,  I 
Wriggling,  in  chorea  . .  : 
AA'rinkting  of  forehead,    in 

tabes  (Fui.  lir.)  : 

Wrist-drop  from  diphtheria 

(Fig.  22) 

-  hysterical  . .  . .   i 

-  from  plumbism    34.  65,  J 

-  musculospiral     paralysis 
Wrist-drop,    plumbic,   dis- 
tinction from  musculo- 
spiral paralysis 

-  Saturday  nii^lit  palsy  . . 


WRIST    —    ZYGOMATIC   PROCESS 

911 

•oat  of      . . 

345 

X-rai/s  and  hismutfi,  contd. 

X-rays  in  Jia'jnoxiiuj,  contd. 

X-rays,  conftl. 

iks.    increased,    in 

ill   diagnosing  gastric 

fracture      . .          152,  707 

-  photopliobia  from        . .   524 

Iiiil    liioiioplegia 

302 

ulcer        ..          ..   2G9 

of  jaw         . .          . .    683 

-  pigmentation  from       . ,   223 

303 

gastroptosis 

spine           . .         . .   715 

-  in  pyelography  . .         . .  354 

•i  ■     .  1^  of         '.'. 

131 

iFig.   1-14)  318 

fusiform  aneurysm  . .  210 

~  in  seeing  immobility  of 

\     Ml  :narcs  on  . . 

540 

hernia  of  stomach     652 

gall-stone    116,    {Fig. 

diaphragm     . .     "    . .  432 

MX-.U  ^rtliritis  of. . 

340 

Hirechsprung's    dis- 

146) 327 

-  spleen  reduced  by        . .     25 

in  ricltets  (fiy.  85) 

186 

ease       ..         ..     390 

gas  in  stomach        . .   245 

-  sterility  from     , .          . .     67 

planus  altecting. . 

603 

hour-glass   stomach 

gastric  ulcer  from  car- 

- in  tachycardia  . .          . .   704 

lie   Ijeiiign  sarcoid 

318,  7G6 

cinoma       ..         ..174 

-  vesiculation  from         . .   223 

•Ihvj 

405 

idiopathic  dilatation 

gout 345 

Xylol,  oiearing  with         ..   391 

nll.iili-   of 

347 

of  cesophagus     . .    IflS 

growth  of  bone        . .   243 

-1     .it    (see  Para- 

ileoc;t!c:iI  kink        ..    157 

lung             ..       105,  159 

-  .11  hI  W  ristrdrop) 

intestinal      obstruc- 

 spine            . .      154,  484 

-VT-AWjN^NG,     movenxent 
A      of  paralyzed  arm  in    503 

on  in  tetany 

2 

tion          . .          . .    459 

hoiu--glass  stomach  . .  174 

nary    arthropathy 

cesopha^us  obstruc- 

 hydatid  cyst  . .       291,  476 

Yaws,  bony  swellings  from  403 

352 

tion  (Fig.  95)  195,  TCS 

hydronephrosis     {Fig. 

-  framba-sial  excrescences 

s  affecting'      .101, 

pyloric    obstruction 

166)  356 

in         403 

540, 

736 

174,  241,  653 

injmy  to  joint         ..  476 

Yaws,  general  account  of    403 

2uIous  disease  of. . 

347 

subdiaphragmatic 

intercostal  neuralgia     436 

Yaws,    raspberry    granula- 

tor's cramp  simu- 

abscess    . .         . .  532 

internal  glands         . .  570 

tions  in                     . .  601 

ited  by     . . 

151 

visceroptosis          . .  426 

intrathoracic     growth 

Yo;i-^t-.      Iri-nit/iit.itiiiii      in 

cramp    .  ■ 

151 

duodena!  ulcer  and  . .  272 

52,  {Fig.  42)  105 

bladder  from             . .   530 

ataxy  exhibited  or 

56 

in  outlining  stomach    663 

ivory  exostosis         . ,  230 

-  in  gastric  contents  241, 

ivc.      in      general 

-  burn  from        ,,.         ..223 

large  bronchial  gland    376 

318,  320.  766 

alysis        .. 

120 

-  in  case  of  paiu  in  the 

-  -  liver  abscess  . .         . .  370 

-  sugar  testing     . .         . .  262 

Ity  in,  from  supra- 

back 428 

mediastinal  fibrosis  ..   159 

Yellow  atrophy,  acute  (see 

[lular  nerve  palsy 

506 

-  chest  lesions      . .         . .     33 

lesions         . .          . .   708 

Acute  Yellow  Atrophy) 

f  power  of 

626 

-  cicatrix,         epithelioma 

new  growth  G3,  102, 

-  fever,  acute  yellow  atro- 

k  (see  Torticollis) 

starting  from             . .    731 

41  1,  419,435,461,  476 

pliy  simulating         . .   336 

-  congenital  heart  disease 

necrosis  of  jaw         . .  683 

-  -  albimiinuria  in        13,   273 

and 91 

new  growth  in  chest. .  150 

-  -  anuria  in        . .         . .     42 

MELASMA    palpe- 

-  in  deciding  whether  pus 

of  spine  . .         . .  477 

black  vomit  in         . .   273 

arum 

324 

is  above  or  below  dia- 

odontoma      . .         . .  684 

bleeding  gums  in      . .   27:> 

n   . . 

324 

l)hragm          ..         ..103 

orbital  periostitis     . .  230 

blood  inspissated  in..   161 

[istiin 

324 

-  dermatitis  fi'om. .         ..  223 

periostitis       . .         . .  668 

-  -  chill  ui           . .          . .   27;i 

bases,  list  of 

742 

-  in  determining  position 

-  -  phthisis  103,  104,  150, 

-  -  coma  in          ..          ..117 

.'icid  from 

742 

of  heart         ..         ..   299 

287,  288,  458,  476, 

-  -  cvanosis  in     . .          . .    161 

,  Fchling's  solution 

size  of  stomach        . .  244 

677,   768 

-  ~  <U'UL'\U'  simulating    ..    336 

ured  by     . . 

2G1 

-  diagnosing  acromegaly..  537 

pneumothorax     432, 

Tia  diabeticorum.. 

732 

aerophagy      . .          . .   245 

{Fig.  226)  531 

-  -■   LMnL'triir    iftiin            . .    255 

es  ill 

383 

aneurj'sm"   63,    92,  93, 

pyloric    obstruction 

Yellow  fever,   general  ac- 

.1. s 

732 

150,    159,    195,    208, 

124,  245 

count  of         . .     273.  336 

48- 

209,  21(1,  2;i().    291, 

--  renalcalcniusin,  279, 

geographical  distribu- 

na planum,  general 

411,    419,  4-';i,  435. 

357.  451,  536 

tion 273 

ouni  of 

732 

437,    llil,  47(5,  681, 

rheumatoid   artliritis     343 

Iiasmatemesis  in        . .   265 

r M  -  Iriijn 

732 

708,  714,  720 

?alivarv  calculus      . .  695 

hiematnria  in             ..   275 

n  action    in 

atony  of  bowel        . .  123 

sarcoma        668,  684,  693 

hajmoglohiiinria  from     28-1 

.  .1  lluid    .. 

304 

—  bone  disease  . .         . .  341 

of  bone      . .         . .  672 

headache  in   . .          . .    273 

sia 

762 

growth        {Fig.  62)  152 

sciatica           . .      438,  439 

liyperpyrexia  in        . .   309 

MI'l.ii.l'         .    , 

:;lM 

tubercle      . .          . .   069 

short  tibia      . .         . .  114 

jaundice  in     ..      273,  325 

mla    piomentosum 

383 

-  -  calculus          . .         . .  577 

spastic  constipation      124 

-  -  loss  of  weight  after  . .   770 

mia,  general  account 

in  ureter     . .         . .     41 

spina!  arthritis         . .  461 

malaria  simulated  by  273 

488 

—  caries  of  bone           . .   243 

caries  116,  154,  364, 

pain  in  back  in         ..   273 

1  .'.  rskin  in  '.'. 

488 

—  caseous           bronchial 

429.    161,   477 

limbs  in      . .      273,  463 

734 

glands  85,  {Fig.  61)  149 

new  growth  151.  ICl,  184 

pernicious        aniemia 

'   i  '  '   1 1'om 

763 

glands        . .         . .  308 

—  spine  of  os  ci\\v\<     . .    i;i9 

simulating  . .          ..   336 

1    '  '■  hiiia  cases  , . 

535 

mediastinal  gland     704 

spondylitis  deformans 

-  -  petechiie  in    . .         . .  273 

i.v  .)(  ti-siis  from  U( 

,  67 

—  cause    of    intercostal 

461,   714 

pulse-rate  slow  in    . .  273 

arium.  in  diagnos* 

pain 707 

—  stenosis  of  bowel      . .  125 

purpura  in     . .         . .  553 

constipation       . . 

122 

subacromial  bursitis     476 

—  snbdiaphagmatic    ab- 

 pyrexia  in      . .         . .  273 

rigor  in          . .         . .  594 

^a«tic  constipation 

245 

limping       . .          . ,   363 

nacli    examination 

(edema  of  one  arm    411 

scess  451,  532,  652, 

Yellow  spot,  cones  in      . .   75S 

ith 

244 

" pain  in  arm           . .   442 

658,  659 

choroiditis  alTecting. .  759 

miquc  of  . . 

122 

heel         ..         ..671 

from  emp3'cma..  658 

nystagmus  from  lesion 

smuth,  in  diagnos- 

shouMc-r              ..   476 

tuberculous  iliac  glands  459 

of 759 

cfl^'al  distention. . 

457 

p:.r:ih-i-   •■{  ■  1.-  499 

kidney        279.  280,  577 

retinitis  affecting     . .   75;i 

ircinoma  coli    77, 

null'  111  '1    .It  Hi    [.  iiti  444 

-  --  unonipted  molar      . .  462 

role  in  vision..         ..   7.'>s 

(Fig.      53)      125, 
(Fig.  54)  126,  330, 

354 

li;-.M  /■■-;..  l^'..  IS7J  ' 

ureteral  calculus  281, 

{Fig.  192)  455.  4  72,  578 

Yellow.vislon       . .     324,  762 

of  iL'SophaguslOG, 

4i;i,  4  14,   508 

—  vertebral  lesions       . .  461 

(Fig.  97)  197, 

461 

—  congenital  dislocation 

vesical  calculus     282,  580 

yiEHL-NEELSEN   stain, 
^^     technique  of            . .  G4I 

of   Btomach    271, 

of  hip         ..          ..   156 

-  cpididvmltis  from        . .     66 

liSO, 

767 

constipation  from  kink  126 

-  .•pillic'lioma  from          ,.   223 

Zinc    ULetule,    in    urobilin 

mse  of  gastric  suc- 

dyschezia       ..          ..  128 

i-i  \  1  Ik'Hm    Imiri.  .        222   223 

test 325 

cussioii    . . 

653 

-  -  enlarged     mediastinal 

-   in   -■■-..  IikIii  ■•   .iiii'iUTSm     551 

-  sulpliate,  vomiting  from  705 

intestinal  obstruc- 

Klands        ..         ..381 

Ml- .1  .li.n.se     ..    4.'*2 

Zimmerlin.  myopathy  of     135 

tion     ..      211, 

316 

enlarged  thymus  {Fig. 

.llr,  t    in    Iruk^iMnJU          ..       25 

/,nii:i    ('<ov    Hcrpi-sl 

latation  of  colon 

654 

180),  419 

-  linger  alTccU-d  by         ..   210 

ZVL'.'r.i.ihr    niii-rl..s,    weak, 

of   stomach    115, 

-  -  exostosis         . .      201,  671 

-  orchitis  from      . .          . .     66 

111     iia.i   iN.^Mia    i;ravis  235 

.117,  522, 

678 

-  -  foreign  body  in  oeso- 

-  patent     ductus     arterio- 

istric tumour 

(1611 

Ithngus        . .          . ,   267 

sus  iind                        ..91 

.■'  1 ■.mI>     .  .      *      .  .    237 

PROPER    NAMES    ASSOCIATED    WITH    DISEASES,    I  tc. 


AdliiSON'S      anamia     (see 

Erb's  palsy 

.507 

Pernicious  Aiiasmia) 

Erb's  sign 

3, 

152 

Addison's  disease  18,  33, 

34,      64,      82,    117, 

Fehling's    solution 

157. 

172,    219,    296.    311, 

17S,    201.   263, 

304. 

526,    527,    528,    722, 

743, 

74(1 

Klumpke's  palsy  . .     507 

Kopllk's  spots     . .         178,  228 
Korsakow's  syndrome    20,  465 


764, 


Aran-Dudienne 

amyotrophic     lateral 

sclerosis 
Argyll    Robertson    pupil 

116.    236.    302,     31- 


Fehling's  test 

Flint's  murmur  ■ .  95. 

Fordyces   disease        365, 


4211,    444.    466,    514, 

Friedreich's  ataxy  57,  6ii, 

551.    651..    719,    726, 

6s.     11:;,    138.    1311, 

760,  761,  762 

768 

140.     15  1,     251,    4117, 

Astley    Cooper,     irritable 

51".    512.    513.     727,    71 

breast  of 

431 

Frohlich's  syndrome             1 

Babinski's  sign    .  ■ 

68 

Gaerther's  bacillus        384,  5 

l'.;iki'r's  <v-t 

692 

Galton's  whistle  {Fig.  75)     1 

Bang's    method    of    esti- 

Gaucher's disea,se  631,  633,  6 

mating  sugar 

263 

Gell^i's  test           . ,          . .     1 

llaiiir.-   ,1-r:,.,.      ..            37 

111 

Giemsa's  stain      .  .          .  .      7 

Barlow's  disease  .'i'*,  72,  99 

556 

GiralOes,  ort-.m  of            ..      4 

Bazin's  disease 

404 

GltMiMriT-  'li-prise              ,  .      6 

Bell's  palsy 

494 

lillirllli'-      Ir-I                                                 7 

Bence-lones's     albumo- 

(H.«M.   -|. il. .,. Ma  media  oi    1- 

suria  . .         . .         4. 

.   16 

Graves's   disease    13,    18, 

Bial's  test 

261 

."■J,    s7     ',ii     i(«t     l;^M, 

l:ii.l"s  lir.Mtliiiiu'  .  . 

107 

172.     L'liii.     215.     22II, 

I'.ni-.'K.  i iL'ii  sarcoid  of 

405 

229.    236,    -6  1.    :;ii'.'. 

|-„.nlci-(;cii._-..ii  hacillus  .. 

645 

323.    :;sN.    111...    isi. 

Bottger's  test 

262 

486,     5l'7,     51:;,    i;'.l4, 

Braun's  sign  of  pregnancy 

393 

702,    703.     721,     722, 

Bright's  disease  9.  46.  17, 

724,  726,  734,  7 

5".    54.    55.    '.17.     In.-,, 

1"7,    l:.-j,    (58,    166, 

I'.ll,     -JlL',     266,     2S3, 

Haldane-Gowers     lirenio- 
plobinometer 

41J,     ii:;,    411,    420. 

Haller.  vas  aberrans  of    . .     4 

Cammidge's  test  ■  -        100, 
Charcot's  disease  of  joints 

l/v.;.  161')  ■-■57,319,  515. 

516, 

i'liari'Ot.    lateral    sclerosis 

of        

Charcot-Leyden  crystals 


Curschmann's  spirals     . . 

Dalryniple's  sign .  . 
De'erine.  inyopath.v  of  . . 
-  oli\n-io!itiiie  atrophy  of 
Dercum's  disease 

1118.  410,  431, 
Dietl's  crises 

115.    117.  280.  605,  • 

I :■]::-'-    |...u.'l.  ..       i 

Duchenne's  palsy  ■ .     1 

Ouhrjng's  disease  99,  : 

Dupuytren's  contracture 


Boson's  reaction 
Eberth's     bacillus     (see 
Bacillus  Typhosus) 
El-b's  myopathy  .  . 


Hanot's  cirrhosis  . .     372 

Harrison's  sulcus 

145,  167,  187,  635 
HeberJcn's  nodes  . .     346 

Hebra.  prurigo  ferox  of  .  .  489 
He^ar's  sign  of  pregnancy  393 
Heller's  test  . .  . .  5 
Henoch's  chorea  electrica 

134,  137,  144 
Henoch's  purpura  76.  2S1. 
:;i:;,    :;6-,    :;6:;,    556, 


Hirschsprung's  disease 
126.    l-'7.    l:io,    389. 

Ills,  buiiillc  (.1       .. 
UoilL-.-u-s   .plint    .. 

Hodgkin's  disease  13,  18, 

23,    25,    37,     16,    55. 

61,  64,  72,   101;.  -Jfin. 

274,    292,    329.    :i76. 

(Pig.    168)  377.   378. 

379,    380,    413.    415. 

627,    563,    569,    570. 
632,  635, 
Hofmeister's  test 
Holmsren's  test  . . 
Huntingdon's  chorea 
Huppert's  test 
Hutchinson's  teeth 


235 

Jacksonian  epilepsy 

137,  144.  147 

Jacquet's  erythema  . .    400 

Jaffa's  te-st            .  .  .  .      314 

Jenner's  stain      . .  . .       21 


Kirkh.n.r-  .ii^ra.,e  615,    616 

Klcli^-Lorlllvi's    bacillus 

154,  196,  589 


La. 


ftallic      tin- 


of 


168 


Lindry's  _ 
Legal's  test 

Lcishman-Donovan  bodies  033 
Leishnian's  stain  21,28,31,568 

Levaditi's  stain  . .         . .  701 

Levden.  myopathy  of     . .  135 

Little's  disease      132.  139,  729 
Ludovlc's  angina  108,  413, 

115.    5  1L',    651,    699,  72g 

McBurney's  spot  451,  454 
McCall  Anderson,  psori- 
asis rupioides  of  . .  601 
Madura  foot  . .  . .  736 
Magnan's  sign  611 
Marie.   spond,ylose   rhi7.o- 

melique  of   . .         714,  715 

Marsh's  test           .  .           .  .  78 

.Mckrl's  ,liv,.riiculum     .  .  130 

Meige's  disease    . .       226,  414 
Meniere's  disease 

166,  723,  752,  765,  768 
Miculicz's  syndrome  (Fia. 

3)  25,  695 

Milroy's  disease  (Fig.  179)  414 

Montgomery's  gland       . .  430 
Moore's  test                  .262 

Mooren  ulcer                 . .  734 

Morgagni.  bydiitid  of     . .  481 

Morgan's    bacilhis          384,  717 

Morton's  disease            . .  439 

Morvan's  disease     62,  97,  257 

^"ei,-iL•r■^  ataia      .  .         157,  614 

Nylander's   reagent         . .  746 

Nylander's  test    . .        . .  262 

Obermeyer,  spirochsete  of  28 
Oppler-Boas'   bacilli 

316,  3-20,  766,  767 

Paget's  disease    ..       204,  730 
Paikirison's    disease    (see 
I'aralysis  Agitans) 


Payy's  solution   .  . 

Pavy's  test 

Pawlik's  grip 

Perl's  test 

Peyer's  patches  . .         382,  I 

Pfeiffer's  bacillus  465,  i 

Politzer's  acoumeter  (Fig. 

73): 

Pott's  curvature      89,  304,  I 
Pott's  fracture     . .  . .     '. 

Pozzi.  cochleate  uterus  of    < 
Pozzi.  syndrome  of         ..     i 


^^     Quincke's  disease 


Raynaud's  disease  13,  $1, 
96,  97.  117.  162,  103, 
203,  223,  240,  255, 
256,  257,  259,  284, 
413,  414,  415,  441, 
444,  584,  698, 

Kciiisch's  test      .  . 

Rledel's  lobe  252.  353,  366. 

Rigq's  disease      ■ .  73, 


.Sahli's  capsules    .  . 

Schonleln's  disease 

Scliott's   Xaulieim    tri     - 

Slierrin.gton,     decerebra .  e 

rigidity  of     . . 
Shiga's  dysenter,y  bacillus 
Shrapuell's  membrane 
Siegle's  speculum 
Skene's  tubes 
Skut^i's  pelyimeter 
Snellen's  type 
Spreugel's  shoulder 
St.lhva^.s  si-n        215,  J  '0, 
St.-.i>i.n-.  ilnrt      .. 
Still's  disease  :;5.  302.  377, 
Stokes-Adams's    disease 

83,  118,  144,  146,  486, 


ocytn- 

Thomsen's  disease  .       58 

Tooth's  peroneal  atrophy 

60,    61,   6S.    Uu.    362, 

510.  51 
Traube's  space    ..  ..      61 

Trommer's  test    . .        .26 

Trousseau's  sign      3,  151.    15 

32 


Uffelmann's  test . 


Vater,    ami.ulla    of    loo. 

325.  330.  59 
Vincent's  angina  87.  6I3. 

614,  37 
A  olfcmaun's      contracture 

114.  141,  50 
Von     Basedow's     disease 


Von  Graefe's  sign  215. 229,  72 

V.Mi.lak.rl,-,-,|i.|.ase(/'l». 

!:;•-.  ..  37.  63 

Von  Moebius's  sign       215.  ?2l 
Von  PIrquet's  reaction  34. 

385,      1511,     1711.     566, 
573.     631.      6611.    677, 
696.    738.    7  Hi.    768.     76! 

Von     Recklinghausen's 

disease  ilo.  73: 

Wassermann's    test     52, 

63.    71.    73.  93,  116. 

120,    179,    184,    197. 

199,    210,    235.    24.S. 

253,    285,    288,    292. 

304,    305,    309,    332. 

334,  -348,    372,    377. 

379,    381,    385,    403. 

404,    407,    435i    440. 

477,    480,    491,    499. 

516,    541,    542.    559. 

560,    568,    588,    6IU. 

615,    618,    619,    62", 

022.    634,    635,    66I1. 

074.    679,    696,     714. 

735.   73f 
Weber's  test         . .  .  ,      16! 

Weil's    disease    13,    325. 

326.  336,  5.53.  594 
"Weir  Mitchell  treatment       771 
Werdnig-Hoffmann  para- 
lysis   135 

Werlhof,    morbus    macu- 

losus  of         . .         553.  556 
Widal's  test  64.  76,  254, 

336,    459,    563.    564. 

560,  572,  636.  O.l? 
Willis,  paracusis  of         . .     165 


/?C7/ 

'^<iX\ 

K88 

• 

